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A review of 158 consecutive nephrectomies is presented. The pathological findings are listed and compared to other author's findings. In the present series a very low rate of nephrectomy necessitated by stone and infection is noted. Surprisingly, 14 normal kidneys were removed. The specific diagnostic problems in each case are discussed, and better diagnostic procedures in the future are mentioned.
In 30 patients with kidney cancer the serum concentrations of immunoglobulins IgG, IgA and IgM were determined. Blood was sampled before embolization and then before and 14, 30, 90, 180 and 360 days after nephrectomy, respectively. Statistically significant increases of IgG and IgM concentrations were found immediately after nephrectomy and were more evident later on. Only a minimal increase of IgA concentration was found. Our findings may be explained by the regression of tumour due to embolization. Persisting elevation of IgG and IgM may join the stimulation of the B-cell system by cancer antigen. Such a clinical procedure may be recommended because it may favourably influence the immunological system.
Recombinant human erythropoietin (rHuEPO) was purified from the conditioned media of Chinese hamster ovary cells with a transfected human erythropoietin gene. We investigated the effects of the rHuEPO in rats with renal anemia induced by partial nephrectomy. Five-sixth nephrectomy resulted in renal failure with anemia. Twenty-five days after the operation plasma urea nitrogen was increased about 2.5 times, and the red blood cell count, hematocrit, and hemoglobin concentration fell to 85% of normal. The reticulocyte count and plasma erythropoietin level did not change such as they do in patients with anemia due to chronic renal failure. Both total red blood cell volume and the plasma iron turnover rate were depressed in five-sixth nephrectomized rats compared with normal rats. The five-sixth nephrectomized rats were injected with rHuEPO (60 IU/kg) intravenously every second day for a total of six injections. After three injections of rHuEPO, circulation volume of total red blood cells was increased from 9.9 ml to 14.6 ml, and the plasma iron turnover rate was increased from 1.03 mg/kg/day to 2.12 mg/kg/day, and the reticulocyte count was also increased. After six injections, a marked increase of the red blood cell count, hematocrit, and hemoglobin concentration were observed. Plasma urea nitrogen and the creatinine levels as indications for renal function did not change after rHuEPO administration in both normal and five-sixth nephrectomized rats. In conclusion rHuEPO has a potent erythropoietic action and it is possible to cure the anemia caused by renal failure.
CONCLUSION: Pancreatic metastasis from renal cell carcinoma is extremely rare. The average time between nephrectomy and the diagnosis of metachronous metastases is reported to exceed 10 yr. Therefore, the initial diagnosis may be neglected in the cases of prolonged disease-free interval. When it does occur simultaneously or metachronously, aggressive surgical resection, when possible, seems to be the most effective treatment for this metastatic lesion. BACKGROUND: An 81-yr-old female patient, who 8 yr previously had undergone right radical nephrectomy for renal cell carcinoma, presented with solitary pancreatic metastasis, which was successfully treated with a distal pancreatectomy. Only 66 cases of clinically diagnosed renal cell carcinoma metastatic to the pancreas are reported in the world literature and 49 of the patients (including ours) underwent a definitive surgical resection. Our case, treated by distal pancreatectomy, and a review of the relevant literature including all reported cases of renal cell carcinoma metastatic to the pancreas, are presented. RESULTS: The patient was well without any evidence of recurrence at 22 mo after the operation.
The nephropathy induced by mercuric chloride was assessed in unilaterally nephrectomized (NPX) and sham-operated (SO) rats using histological and urinalysis techniques. This assessment was carried out in order to test whether or not rats are more susceptible to the nephrotoxic effects of mercuric chloride after unilateral nephrectomy and a period allowing for compensatory renal growth. Twelve days after surgery both NPX and SO rats were given a single 1.5, 2.0 or 2.5 mumol/kg dose of mercuric chloride (i.v.). Twenty-four hours after the 1.5 or 2.0 mumol/kg dose of mercuric chloride was administered, cellular and tubular necrosis in the pars recta segments of proximal tubules in the outer medulla was more severe in NPX rats than in SO rats. Moreover, the urinary excretion of a number of cellular enzymes (e.g. lactate dehydrogenase) and plasma solutes (e.g. albumin) was greater in NPX rats than in SO rats. At the 2.5 mumol/kg dose of mercuric chloride, renal tubular damage was quite extensive in both groups of rats; to such an extent that possible differences in renal tubular damage between the NPX and SO rats could not be determined histologically. However, the urinary excretion of alanine aminopeptidase was greater in the NPX rats than in the SO rats. Therefore, based on the aforementioned findings, rats that have undergone and adapted to a reduction in renal mass (i.e. unilateral nephrectomy) appear to be more vulnerable to the nephrotoxic effects of mercuric chloride than rats with two normal kidneys.
The number of patients suffering from terminal renal failure awaiting kidney transplantation has continued to increase. Since the number of available cadaver donor kidneys has largely remained unchanged, a special publicity campaign achieved that almost one-half of the kidneys transplanted in Basle come from live donors. We performed a laparoscopic live donor nephrectomy in 14 patients between March 1998 and August 1999. Despite good experience regarding transplant function and patient satisfaction, the hand-assisted technique was introduced in 1999 because of the long average operating time of 230 min (200-270) and warm ischemia time of 7.5 min (4-9). In the 33 operations performed up to now, the average operating time and warm ischemia time could be significantly reduced to 185 min (135-240) and 2.4 min (1.5-4), respectively. Most recently, the technique of retroperitoneoscopic live donor nephrectomy was successfully employed in 4 patients and could possibly represent the method of choice for the future.
Since in the absence of clinically overt metastatic disease tumorous lesions within the adrenal gland are found in only 2-10% of cases, the majority of renal cell cancer patients are overtreated by adrenalectomy as an integral part of nephrectomy. The medical records of 847 patients undergoing adrenalectomy in combination with nephrectomy irrespective of the local extent of the primary tumor or the clinical stage at first diagnosis were reviewed to determine the reliability of currently available imaging modalities regarding the prediction of adrenal gland metastases. Several patient and tumor characteristics correlated with the presence of intra-adrenal metastases, and their prognostic value was determined by a multivariate logistic regression model. Metastatic spread into the adrenal gland was observed in 27 of 847 (3%) patients. In only three of eight patients in whom the adrenal was identified as the only metastatic site, preoperative abdominal CT scans were interpreted as false negative. During multivariate statistical analysis, only the presence of distant metastases, vascular invasion within the primary tumor, and multifocal growth of renal cell cancer within the tumor-bearing kidney were identified to independently predict the likelihood for the presence of intra-adrenal metastases. None of the patient or tumor characteristics evaluated reliably predicted the likelihood for the presence of adrenal metastases in patients without evidence of disseminated metastatic spread. As we believe and as the current investigation demonstrates, routine adrenalectomy should not be recommended in cases of preoperatively normal radiological examinations.
Living donor kidney transplantation is one possibility to meet the growing demand for organs in patients with chronic renal failure. In 1995 the first laparoscopic living donor nephrectomy (LDN) was performed in the United States. More than 100 transplant centers worldwide perform LDN. The expectations of a larger number of willing organ donors were fulfilled due to the less traumatic operation. Meanwhile, several techniques exist to retrieve a kidney laparoscopically, including the trans- or retroperitoneal, strictly laparoscopic, or hand-assisted approach. From February 1999 to September 2002, 63 strictly laparoscopic, transperitoneal LDNs were performed at the Department of Urology of the Charité University Hospital, Berlin. Warm ischemic time was 148 s (105-360) and operating time was 203 min (110-305). Intraoperative complications were due to insufficient closure of the vessels in four patients. Mean postoperative hospital stay was 5.7 days (3-9). One year after LDN, renal function as well as creatinine levels of the recipient showed no difference compared to the organs harvested via the approach at our department prior to implementation of LDN. Strictly laparoscopic transperitoneal donor nephrectomy is a safe method for kidney retrieval and ensures excellent graft function.
In urology, renal cell carcinoma is the third most frequently diagnosed malignancy. Localized, non-metastatic tumors are generally cured by radical tumor nephrectomy. Since the 1960s, this procedure has routinely included removal of the kidney together with the perirenal fat, Gerota's fascia, and ipsilateral adrenal gland. In recent years, improved diagnostic methods have led to the detection of tumors at earlier stages. These methods widen the scope for organ-sparing surgical strategies and have consequently sparked controversy over adrenal gland removal. Despite this, radical tumor nephrectomy that includes adrenal gland removal is still strongly advocated. This is the only suitable surgical approach for the cure of patients with direct tumor infiltration of the adrenal gland. In the case of adrenal involvement, minimal tumor dimension and the predisposing localization of the primary tumor have to relevance. The imaging procedure for diagnosis is also difficult to assess, especially in slim patients with upper role tumors. Finally, to date, no justifiable disadvantages of adrenalectomy have been described.
Recently, laparoscopic liver-donor nephrectomy has been developed in order to increase organ donation. In this study we compare and review the records of 10 donors operated by open extraperitoneal approach and of 10 donors operated by a laparoscopic transperitoneal approach (LSC). Results show less use of postoperative parenteral narcotics in the LSC group (109 mg vs 272 mg; P < 0.0005) than in the extraperitoneal group. Morbidity was similar in both groups. There was no difference in postoperative stay. Allograft kidney function was similar in both groups until 6 months after donation. The use of disposable laparoscopic material bears an extra cost of 900 US$. We can thus conclude that laparoscopic live-donor nephrectomy is a safe procedure that significantly reduces postoperative pain, and is not detrimental to the allograft. The total cost of the laparoscopic procedure will be lower than that of the open approach if the length of postoperative stay is cut by 3 days.
There are few reported cases of renal cell carcinoma (RCC) arising in kidney allografts. Whether these tumours occur due to post-transplant malignant transformation or are present at the time of transplantation is unclear. The influence of immunosuppression must be considered in their development, progression and treatment. We report a case of a RCC presenting asymptomatically in a functioning live donor renal allograft 173 months after transplantation. In an attempt to avoid return to dialysis treatment, a partial nephrectomy was carried out. To optimise the procedure, and to assure cancer clearance, combined intraoperative ultrasound and frozen section analysis were used. Our patient remains disease free and dialysis independent at 22 months follow up. To our knowledge, this patient represents the only live donor organ transplant tumour reported to be treated using nephron-sparing surgery and remain dialysis independent. Partial nephrectomy should be considered as a treatment option in such cases.
BACKGROUND: We investigated whether the left adrenal vein could be consistently localized on three-dimensional (3D) real-time volume-rendering computed tomographic angiographic (CTA) mapping in a group of living renal donors before laparoscopic nephrectomy. METHODS: Sixty-six consecutive potential renal donors were referred for CTA vascular mapping before laparoscopic donor nephrectomy. Thirty-three patients were examined on a single-detector helical CT scanner and the other 33 were examined on a multidetector unit. In each patient, arterial phase and venous phase volumetric data sets were acquired after the intravenous injection of 150 cc of non-ionic contrast material. Three radiologists reviewed the data sets at a free-standing workstation after the application of 3D volume-rendering software and reached a consensus on whether the left adrenal vein was visualized and, when seen, its position relative to the abdominal aorta. RESULTS: The left adrenal vein was found in 92.5% of the 66 donors (91% in the single-detector group and 94% in the multidetector group). The junction of the left adrenal vein and left renal vein averaged 5.2 mm (range = 0-13 mm) from the left lateral wall of the abdominal aorta. CONCLUSION: Three-dimensional real-time volume-rendering CTA with single-detector and multidetector scanners permits consistent localization of the left adrenal vein in more than 90 % of prospective living renal donors.
Retroperitoneal laparoscopic nephrectomy (RLN) is a relatively recent technique whose performance needs to be firmly established. The aim of this study was to compare the results of RLNs in 19 patients with retrospective results for 10 cases of open surgery. Ten of the RLN patients had transplanted kidneys. We used a slightly modified, already published technique with only three trocars that did not require balloon dilatation of the retroperitoneal space. It was successful in patients with and without transplants. The average operative times of RLN and open surgery were 115 and 110 minutes, respectively. In no instance did the laparoscopic procedure need to be converted to open surgery. There were no peri- or postoperative complications that could be related to the RLN technique. The average length of hospitalization after RLN was considerably shorter (3.8 days) than after open surgery (7.9 days). In conclusion, our experience shows that RLN is a safe, reproducible technique that reduces recovery time. It has become our first-line approach for simple nephrectomy, nephroureterectomy for ureteral tumors, and removal of the native kidney in transplant recipients.
An approach to carboplatin dosing in children with bilateral nephrectomy using a renal function-based dosing formula with a glomerular filtration rate of zero was investigated in the current study. Carboplatin exposure was determined in a total of nine courses of chemotherapy in four patients with Wilms' tumour. Carboplatin exposures following initial dosing were less than 50% of the defined target area under the plasma concentration-time curve (AUC) in all four patients studied, with actual AUC values of between 31% and 45% of the target exposures. The use of real-time pharmacokinetic monitoring to guide dosing within a course of carboplatin treatment resulted in exposures within 15% of the target AUC in all patients. Using this information to guide dosing on additional courses of treatment in the same patient resulted in consistent exposures without the need for further monitoring or dose adjustment. These results indicate that real-time pharmacokinetic monitoring of carboplatin treatment plays a key role in ensuring that an appropriate exposure to carboplatin is achieved in children with bilateral nephrectomy. Carboplatin dosing based on patient body weight, or use of a fixed dose of carboplatin, would both be predicted to result in individual patients receiving unsatisfactory drug exposures. Further studies are warranted to further elucidate the relationship between non-renal clearance of carboplatin and patient body weight in this and other patient subpopulations where there remains concern about the optimal way to use this anticancer drug.
To compare the efficacy, safety and oncological completeness of retroperitoneoscopic radical nephrectomy (RPRN) and nephroureterectomy (RPRNU) with that of the open retroperitoneal approach for radical surgery for localised renal cell carcinoma and upper tract transitional cell carcinoma. Eighteen patients of RPRN, nine of RPRNU, 11 of open radical nephrectomy (ORN) and five patients who underwent open radical nephroureterectomy (ORNU) were evaluated. The groups were similar to each other. The mean operative times in the laparoscopic group were longer (147 and 188.7 min for RPRN and RPRNU vs 127.7 and 184 min for ORN and ORNU, respectively); however, the mean analgesic requirement (203.3 and 275 mg for RPRN and RPRNU vs 400 and 650 mg pethidine for ORN and ORNU, respectively), hospital stay (3.2 and 5.1 days for RPRN and RPRNU vs 7.6 and 9.2 days for ORN and ORNU, respectively) and return to normal activities (2 and 2 weeks in RPRN and RPRNU vs 4.3 and 4.6 weeks for ORN and ORNU, respectively) were lower in the retroperitoneoscopic group. Tumour-free margins could be achieved in all the cases. The mean duration of follow-up for RPRN and RPRNU was 17.7 and 15.0 months and for ORN and ORNU were 32.5 and 19.0 months, respectively. There was no port site or local recurrences. Distant metastasis developed in one case of RPRN and in two cases of RPRNU. The retroperitoneoscopic approach for a localised malignancy of the upper urinary tract appears to be effective and safe. An oncologically complete removal of the tumour is possible as in open surgery. The retroperitoneoscopic approach is associated with less morbidity and faster recovery.
One of the historic landmarks in urology is the first planned nephrectomy performed in 1869 by Gustav Simon of Heidelberg (1824-1877). In the history of medicine the reflections and considerations of the specialized surgeon reveal distinguished analyses of the "case" and, thus, the beginning of a modern scientific discussion of a patient's quality of life. Available primary and secondary sources were screened to present a differentiated aspect of this milestone in the history of urology. The analysis of the first German indicated nephrectomy shows the introduction of scientifically orientated thinking in urology, especially in Germany during the middle of the nineteenth century, and parallels the rise of urology and general surgery.
A 70-year-old Japanese woman was admitted to our hospital because of anasarca. At 32 years of age, she had undergone nephrectomy for renal tuberculosis. A continuous abdominal bruit was heard. The chest X-ray showed cardiomegaly and dilatation of the pulmonary artery. Abdominal three-dimensional computed tomography scanning clearly revealed an arteriovenous fistula. Cardiac catheterization disclosed cardiac output of 9.2 l/min and a step-up of oxygen saturation at the renal vein level of the inferior vena cava. Surgical closure of the fistula promptly decreased her cardiac output and improved the heart failure. This is a rare case of an arteriovenous fistula developing long after nephrectomy and causing high-output heart failure.
BACKGROUND: As compared with open donor nephrectomy (OpenDN), laparoscopic donor nephrectomy (LapDN) offers donors more rapid recovery and recipients equivalent graft function, but LapDN costs remain greater. This study compared LapDN and OpenDN with cost-utility analysis. METHODS: Utilities were assessed with time trade-off, probabilities derived from systematic review of the literature and the costs derived from 27 OpenDN and 34 LapDN patients treated contemporaneously. A societal perspective was taken. Lost employment costs were included. An incremental cost-effectiveness ratio (ICER) was calculated with best- and worst-case scenarios for confidence intervals. Sensitivity analyses assessed robustness. RESULTS: LapDN costs are lower (11,170.71 dollars vs 12,631.91 dollars), whereas quality of life (QOL) is superior (0.7247 vs 0.6585 quality-adjusted life years [QALY], rendering LapDN a dominant strategy. The model was robust to all variables, and LapDN remained dominant from a payer perspective. In a worst-case scenario, the ICER for LapDN was at most 2,231.61 dollars per QALY. CONCLUSIONS: LapDN offers improved QOL at lower costs, despite the fact that this analysis included patients treated during the learning curve of LapDN at our institution. By potentially increasing organ donor rates, LapDN may be further cost saving by decreasing the number of patients receiving dialysis.