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PubMed2005

Retroperitoneoscopic living donor nephrectomy: a safe and minimally invasive procedure for the donor.

A living kidney donor surgery must be safe and minimally invasive. In addition the removed kidney must be in good condition. Retroperitoneoscopic nephrectomy has the advantage that it does not risk intra-abdominal organ injuries and provides direct access to the renal artery/vein despite the small working space. An abdominal wall-lifting method combined with the pneumoretroperitoneum provides sufficient space to use a hand skillfully in retroperitoneoscopic surgery. Introduction of hand-assisted retroperitoneoscopic living donor nephrectomy with the abdominal wall-lifting method yielded safer and easier operations as well as shorter warm ischemia (mean: 3 minutes; 7 seconds) and operative times (mean: 3 hours; 28 minutes) in the current 10 cases. The procedure is a useful alternative to procure a kidney graft.

Adult↗

PubMed2005

Alterations in the practice of open and laparoscopic live donor nephrectomy at renal transplant centers in the UK and Ireland.

Live kidney donor (LKD) activity has increased over recent years. In response, the British Transplantation Society (BTS) has issued guidelines for best practice. This study involved two questionnaires sent to all renal transplant centers in the UK and Ireland to examine practice for the years 2000 and 2002. Findings were compared to BTS guidelines. There was a 100% response rate from 28 centers for both years. Twenty-seven centers performed LKD in the year 2000, falling to 24 in 2002. Consultants reported 356 procedures in 2000, representing 19% of all kidney transplants, and 403 in 2002, representing 23% of all kidney transplants. Three centers offered laparoscopic donor nephrectomy in 2000, and five did so in 2002. The majority of centers organize donor and recipient operations synchronously, and most have a consultant anaesthetist present for the donor procedure. There were variations in the use of thromboprophylaxis, and in donor follow-up. There is widespread practice of live kidney donation in the UK and Ireland, but BTS guidelines are not closely adhered to. Laparoscopic donor nephrectomy is offered at a small number of centers, but many have plans to introduce it.

Graft Rejection↗

PubMed2005

Laparoscopic versus open donor nephrectomy in Germany: impact on donor health-related quality of life and willingness to donate.

INTRODUCTION: Laparoscopic living donor nephrectomy (LDN) offers multiple advantages to the donor. Since 1999 LDN has become the only surgical approach for living kidney donation in our department. To our knowledge a donor health-related quality of life (QoL) has not yet been performed with standardized and validated questionnaires to compare laparoscopic with open nephrectomy. We therefore performed a study with two questionnaires (SF-36/GBB-24) and one set of open questions for all donors in our department. METHODS: Questionnaires were sent out to all donors between 1983 and 2001 with at least a 1-year follow-up. To exclude a bias a maximum response rate was sought; donors who did not answer were recontacted as well as their recipients or their physicians to motivate them for participation. RESULTS: The response rate was (89.8%). Except for less limb pain in the laparoscopy group, no difference could be detected for donors QoL with respect to the surgical method. Willingness to donate again was not affected by the surgical method. Nevertheless if asked again today, most donors want laparoscopic kidney retrieval. CONCLUSIONS: Donors health-related QoL is not affected by the surgical method when queried retrospectively. Nevertheless, most donors today would favor laparoscopy, if they could chose again. How laparoscopy affects a reluctant donor to step forward must be determined in a prospective study.

Attitude↗

PubMed2005

The effect of anesthetic technique on early postoperative renal function after donor nephrectomy: a preliminary report.

General and regional anesthesia may both be used successfully in donor nephrectomy although the use of regional anesthesia is rare. We compared the remaining kidney function during general (n = 10) versus combined spinal-epidural (n = 10) anesthesia for donor surgery. Blood biochemistry data were collected preoperatively and postoperatively, while renal function was assessed by scintigraphy and urine levels of microalbumin, creatinine, Na, K, Ca and creatinine clearance rate were measured/calculated in 24-hour urine samples collected preoperatively and on postoperative day 2. There were no differences preoperatively and on postoperative day 2 with respect to glomerular filtration rate, microalbuminuria, or creatinine clearance rate (P > .05 for all). There were also no differences between the groups with respect to other scintigraphic findings preoperatively and on postoperative day 2 (P > .05 for all). The results suggest that general or combined spinal-epidural anesthesia for donor nephrectomy have similar effects on the remaining donor kidney function.

Anesthesia, Epidural↗

PubMed2005

The effect of graft nephrectomy on long-term graft function and survival in kidney retransplantation.

We retrospectively evaluated the long-term results of 53 (3.5%) recipients who received second allograft among 1486 kidney transplants between November 3, 1975 and June 30, 2004. Two study groups were patients in Group 1 (n = 21) who underwent allograft nephrectomy and those in Group 2 (n = 32) who did not. We assessed demographic features, rejection rates throughout the follow-up period, and serum creatinine levels at 12 months as well as graft and patient survival rates, postoperative complications, time interval between transplantations, and HLA matches. Forty-three patients who underwent retransplantation received kidneys from living-related donors and the remaining 10 from cadaveric donors. Mean serum creatinine levels of Group 1 versus Group 2 were 1.8 mg/dL (range, 0.8 to 6.6 mg/dL) versus 2.1 +/- 1.1 mg/dL (range, 1.1 to 7.1 mg/dL). HLA-AB and HLA-DR mismatches were 1.9 +/- 1.1 versus 1 +/- 0.6, respectively (P = .01). Acute rejection rates were not significantly different between Groups 1 (9/21, 43%) and 2 (12/32, 38%) (P < .05). The average intervals between the first and the second transplantations were 62 +/- 26 months in Group 1 (P = .02) and 32 +/- 11 months in Group 2. One-, 3-, and 5-year graft survival rates in Group 1 versus Group 2 were 83% versus 89% (P > .05); 64% versus 79% (P > .05), and 45% versus 68% (P = .04), respectively. In conclusion, we did not observe any advantage of graft nephrectomy before retransplantation. The length of the interval between the first and the second transplantations may have a negative correlation with second graft survival.

Adolescent↗

PubMed2005

Results and complications of 50 laparoscopic nephrectomies for live donor renal transplantation.

Living donors represent 30% of kidneys for renal transplantation. Laparoscopic nephrectomy is the best surgical procedure due to its clear advantages: low morbidity, less blood transfusion requirements, and shorter donor hospitalization. From March 2002 to August 2004, we performed 50 laparoscopic nephrectomies for transplantation to recipients who were prescribed tacrolimus (0.1 mg/kg bid), mycophenolate mofetil (1 gr bid), and prednisone (0.5-1 mg/kg per day PO from 48 hours before transplantation). Mean surgery time was 170 minutes (120-260); warm ischemia time, 3.1 minutes (1.5-10); and cold ischemia time, 1.27 hours (0.85-4). Mean bleeding was 270 cc (100-900), and mean donor hospitalization was 5.5 days (3-9). Four cases required conversion of the laparoscopic procedure to open surgery because of bleeding. Seventy-two hours posttransplantation, the mean plasma creatinine was 170 micromol/L. None of the patients suffered delayed graft function. Eighteen percent experienced acute rejection episodes. Donor and recipient survivals were 100% at 1 year, and graft survival, 94% (kidney losses were due to acute rejection, severe acute pancreatitis, and surgical complications).

Employment↗

PubMed2006

Interventional stenting for ruptured iliac aneurysm following transplant nephrectomy.

Surgical removal of a failed kidney graft may lead to a variety of postoperative complications, development of an aneurysm being a relatively rare complication. We report the case of a 34-year-old man who developed an iliac aneurysm 13 years after transplant nephrectomy. Interventional stenting was performed upon the rupture of the aneurysm. Postintervention the function of the contralateral transplanted kidney was stable and the patient recovered. An endoleak was diagnosed after 1 week, which was also stented. No operative procedure was necessary. In conclusion, even in an emergency situation interventional stenting of a false iliac aneurysm after transplant nephrectomy may be a therapeutic option.

Adult↗

PubMed2006

Postoperative outcome of open donor nephrectomy under epidural analgesia: a descriptive analysis.

PURPOSE: Patients subjected to open donor nephrectomy with epidural analgesia were analyzed to determine whether there was a relation between catheter placement site and the appearance of complications and satisfactory analgesia and to determine whether this factor had an impact upon recovery and return to preoperative life. METHODS: A cohort of 36 open donor nephrectomies were performed with postoperative epidural analgesia. Two groups were analyzed: thoracic (22 patients) and lumbar catheters (14 patients). There was a 72-hour evaluation followed by phone contact. Besides detecting related complications pain was evaluated using a visual analog scale (VAS 0 to 10) in the postanesthesia care unit and at 6, 24, 48 and 72 hours postoperatively. Satisfactory analgesia was defined as a VAS of 3 or less. RESULTS: In all cases the analgesic solution was composed of bupivacaine 0.125% with an opioid in 97%. Patients showed complications in 72% (26/36); the only significant association was motor blockade in the lumbar group (21% vs 0% in the thoracic, P = .023). Patients had a mean VAS of 2.83 +/- 1.77. There was a larger proportion of pain-free patients (VAS 0) in the thoracic group; in addition, there was no VAS of 10 in this group. Ambulation was resumed in less than 24 hours in 57% of patients, having a mean VAS of 2.1 +/- 1.5 compared with 3.2 +/- 1.6 among those who ambulated after 24 hours (P = .04). There was no association between perioperative pain control and the interval to normal activities. CONCLUSIONS: Without a control group, we can hardly evaluate the impact of epidural analgesia on perioperative outcome. Notwithstanding, the obtained pain control may justify its use in these patients. An important issue is to maintain a low VAS (<3), especially in the first 24 hours, which may make a clinically important difference for early ambulation.

Adult↗

PubMed2006

Laparoscopic donor nephrectomy: short learning curve.

INTRODUCTION: The learning curve of laparoscopic donor nephrectomy (LDN) may represent a great technical challenge at centers with low volume of living donors. The number of LDNs required to overcome the learning curve is still unclear. Here we report the modality of approach to LDN at a low-volume living donor transplant center. MATERIALS AND METHODS: We reviewed the records of two groups of donors operated by two different surgeons between January 2002 and October 2005. We compared donor hospital stay, operative time, presence of multiple renal arteries, blood loss, operative details, and complications. RESULTS: The first six operations (group A) were performed by a well-trained laparoscopic surgeon (A.P.) with a consolidated experience in the LDN procedure, attended by our training surgeon (R.D.V.) who conducted the other six cases (group B). No conversion to an open procedure was necessary and there were no major minor complications. Mean operative time was 267.5 (+/-55.9) minutes in group A and 300 (+/-43.4) minutes in group B (P = .28). Mean warm ischemia time was 125 (+/-61.6) seconds in group A and 189.2 (+/-18.6) seconds in group B (P = .035). Mean hospital stay was 5.3 days in group A and 5.6 days in group B. CONCLUSIONS: LDN can be performed safely and efficiently in transplant centers with initial experience. A collaborative approach to this difficult procedure with a surgeon skilled in donor nephrectomy minimizes the risk to the donor and reduces the learning curve.

Female↗

PubMed2007

High intensity ultrasound clamp for bloodless partial nephrectomy: In vitro and in vivo experiments.

In some patients at risk of disease recurrence of renal cancers, maximum conservation of the kidney is possible through partial nephrectomy. However, bloodless surgery is difficult to achieve. The article describes an ultrasonic clamp, which optimises energy deposition and monitors lesion development with an echo-based technique. Using this novel apparatus, coagulation necroses have been obtained in vitro on substantial thicknesses (23 to 38 mm) over exposure durations ranging from 10 s to 130 s, and with acoustic intensities of less than 15 W/cm(2) per transducer. When used for coagulation purposes, two transducers situated on opposite arms of the clamp are driven, while for monitoring, only one is used. Lesions are monitored in real time by analysing the echo signal returned by the opposite arm of the clamp. The presence of a lesion is evaluated on the basis of energy changes and echo phase as a function of time. Both kidneys of two pigs (30 to 36 mm thick) were treated in vivo with the clamp, and the partial nephrectomies performed proved to be bloodless.

Animals↗

PubMed2004

Laparoscopic versus open donor nephrectomy: ureteral complications in recipients.

OBJECTIVES: To describe our experience with laparoscopic donor nephrectomy (LDN) and open donor nephrectomy (ODN) regarding ureteral complications. LDN has proved to be safe and to offer significant benefits to the donor compared with ODN. Of major importance is the effect of the surgical technique on the graft. Studies have shown an increased incidence of ureteral complications in recipients of laparoscopically procured kidneys. Operative reconstruction results in additional morbidity for the recipient. METHODS: Living donors and their recipients, who underwent surgery from January 1994 to April 2002, were included in this retrospective study. A total of 122 LDN and 77 ODN recipients were included. RESULTS: Of the 122 LDN and 77 ODN recipients, 15 (12%) and 10 (13%), respectively, required percutaneous nephrostomy drainage. In total, 5 LDN (4.1%) and 5 ODN (6.5%) recipients required reconstruction of the ureter because of obstruction of the ureter or urine leakage (P value not statistically significant, excluding reconstruction required for technical errors). The operating time, warm ischemia time, and serum creatinine were comparable between recipients with or without ureter complications requiring reconstruction. CONCLUSIONS: In our experience, LDN was not associated with an increased incidence of ureteral complications in the recipient compared with ODN.

Adult↗

PubMed2004

Prognostic value of body mass index in patients undergoing nephrectomy for localized renal tumors.

OBJECTIVES: To identify whether the body mass index (BMI) has any adverse effect on the prognosis of patients with established renal cell carcinoma, given the increasing prevalence of obesity and the rising incidence of renal cell carcinoma in the United States. METHODS: We reviewed the records of patients who underwent nephrectomy for localized disease between 1985 and 1998 at our institution. Patients were grouped according to BMI as normal (less than 25 kg/m2), overweight (25 to 30 kg/m2), or obese (more than 30 kg/m2). Cox regression analysis was used to determine the significant predictors of metastasis and survival. RESULTS: A total of 400 patients met the inclusion criteria. On univariate analysis, normal BMI (P = 0.018), pathologic stage (P <0.0001), Fuhrman grade (P = 0.007), maximal tumor size (P = 0.005), and time to recurrence (P <0.0001) were significant predictors of disease-specific death. On multivariate regression analysis, the time to metastasis (P <0.0001) was the best predictor of disease-specific death, followed by BMI (normal versus overweight or obese; P = 0.006) and pathologic stage (P = 0.007). Patients with a normal BMI who had pathologic Stage pT3 or greater and developed metastasis within 19 months of surgery had the worst prognosis, with a disease-specific death rate of 52.0%. CONCLUSIONS: Our findings suggest that overweight and obese patients with renal cell carcinoma have a more favorable prognosis than patients with a normal BMI. If others confirm our finding that a high BMI confers a survival advantage to patients undergoing nephrectomy, BMI may prove to be an important prognostic factor in renal cell carcinoma.

Adult↗

PubMed2004

Laparoscopic radical nephrectomy in obese patients: outcomes and technical considerations.

OBJECTIVES: To review our technique and experience with laparoscopic radical nephrectomy (LRN) in the obese patient population. Obesity has been considered a potential risk factor for poor outcomes in a variety of surgical procedures and has been considered a relative contraindication to laparoscopy. Since 1996, with increased experience and technical modifications, obesity has not been considered a contraindication for laparoscopy at our institution. METHODS: Retrospective data were obtained for all patients who underwent LRN from January 1997 to December 2000. A body mass index (Quetelet's index) greater than 30 was used to define obese patients. Technical modifications included slightly greater insufflation pressures and a lateral shift in trocar sites. The obese laparoscopic group was compared with the nonobese laparoscopic group. RESULTS: Of 101 patients who underwent LRN, 69 were not obese and 32 were obese. No statistically significant differences were observed in any of the analyzed operative data between the nonobese laparoscopic group and obese laparoscopic group, including a mean operative time of 220 and 242 minutes, respectively. Other factors assessed were the time to ambulation, length of hospital stay, conversion rate to an open procedure, and complication rate, which also demonstrated no statistically significant difference. Only one conversion to an open procedure was required in both the obese and the nonobese laparoscopic groups. CONCLUSIONS: With minor technical modifications, LRN can be safely performed in obese patients. Proper trocar site selection and greater insufflation pressures were critical for success. The differences in the intraoperative and postoperative course of LRN in obese and nonobese patients were not statistically significant. Obesity should not be considered a contraindication to laparoscopic nephrectomy.

Aged↗

PubMed2004

Laparoscopic partial nephrectomy in patients with neoplasia in a solitary kidney.

OBJECTIVES: To assess the renal function and describe our operative experience with laparoscopic partial nephrectomy (LPN) in patients with solitary kidneys. METHODS: The medical records were analyzed to find patients with a solitary kidney and renal neoplasms who underwent LPN. Demographic, operative, pathologic, and follow-up data were obtained. RESULTS: Four patients were identified with solitary kidneys who had undergone LPN. The mean operative time was 251 minutes, mean warm ischemic time 15 minutes, mean estimated blood loss 395 mL, and mean hospitalization stay 3 days. The mean preoperative creatinine was 1.5 mg/dL and the mean peak creatinine 2.0 mg/dL. All patients returned to their baseline creatinine levels in the follow-up period. The final pathologic finding was Stage pT1 in 1, pT3a in 2, and angiomyolipoma in 1 patient. All surgical margins were negative. No cancer recurrence developed in the patients, with a mean follow-up of 17 months (range 3 to 35). CONCLUSIONS: LPN in patients with a solitary kidney is feasible and a reasonable treatment alternative to open partial nephrectomy.

Blood Loss, Surgical↗

PubMed2004

Long-term survival of patients with unilateral sporadic multifocal renal cell carcinoma according to histologic subtype compared with patients with solitary tumors after radical nephrectomy.

OBJECTIVES: To determine the pathologic features, including histologic subtype and tumor size, associated with multifocal renal cell carcinoma (RCC) and the impact of multifocality on survival after radical nephrectomy, about which controversy exists. METHODS: We studied 2373 patients who underwent radical nephrectomy for RCC from 1970 to 2000. Histologic subtype, stage (2003 TNM), nuclear grade, tumor size, and multifocality, defined as the presence of more than one ipsilateral RCC tumor of the same histologic subtype, were evaluated. Associations of multifocality with ipsilateral and contralateral recurrence and death from RCC were evaluated using Cox proportional hazards models. RESULTS: The incidence of sporadic histologically concordant multifocality was greater in papillary RCC (29 of 266; 10.9%) compared with clear cell RCC (40 of 1934; 2.0%; P <0.001) and chromophobe RCC (2 of 104; 1.9%; P = 0.005). Patients with solitary clear cell and papillary RCC had larger tumors compared with multifocal clear cell and papillary RCC (P <0.001 and P = 0.024, respectively). Patients with multifocal clear cell RCC were more likely to have a contralateral recurrence than were patients with solitary clear cell RCC (risk ratio 2.91, P = 0.142). Multifocality was not significantly associated with ipsilateral recurrence or death from RCC in patients with clear cell or papillary RCC. CONCLUSIONS: The incidence of multifocality was significantly greater among patients with papillary RCC than among patients with clear cell or chromophobe RCC. Patients with multifocal clear cell RCC were more likely to experience a contralateral recurrence. Multifocality was not significantly associated with ipsilateral recurrence or death from RCC. In addition, multifocality was not associated with larger and higher stage tumors, as previously reported.

Adenocarcinoma↗

PubMed2004

Laparoscopic versus open partial nephrectomy.

OBJECTIVES: To compare, retrospectively, the results of laparoscopic partial nephrectomy (LPN) to open partial nephrectomy (OPN) using a tumor size-matched cohort of patients. Limited data are available comparing LPN to OPN in the treatment of small renal tumors. METHODS: Between September 2000 and September 2003, 27 LPNs and 22 OPNs were performed to treat renal masses less than 4 cm. Patient demographics and tumor location and size (2.4 +/- 1.0 cm versus 2.9 +/- 0.9 cm, respectively; P = not statistically significant) were similar between the LPN and OPN groups. RESULTS: Although the mean operative time was longer in the LPN than in the OPN group (210 +/- 76 minutes versus 144 +/- 24 minutes; P <0.001), the blood loss was comparable between the two groups (250 +/- 250 mL versus 334 +/- 343 mL; P = not statistically significant). No blood transfusions were performed in either group. The hospital stay was significantly reduced after LPN compared with after OPN (2.9 +/- 1.5 days versus 6.4 +/- 1.8 days; P <0.0002), and the postoperative parenteral narcotic requirements were lower in the LPN group (mean morphine equivalent 43 +/- 62 mg versus 187 +/- 71 mg; P <0.02). Three complications occurred in each group. With LPN, no patient had positive margins or tumor recurrence. Also, direct financial analysis demonstrated lower total hospital costs after LPN (4839 dollars+/- 1551 dollars versus 6297 dollars+/- 2972 dollars; P <0.05). CONCLUSIONS: LPN confers several benefits over OPN concerning patient convalescence and costs, despite prolonged resection times at our current phase of the learning curve. Long-term results on cancer control in patients treated with LPN continue to be assessed.

Adult↗

PubMed2004

Simultaneous thoracoscopic wedge resection of a solitary lung nodule and laparoscopic partial nephrectomy for a renal mass.

Approximately 33% of patients with renal cell carcinoma will present with metastases. Patients have a reported 35% 5-year survival rate in instances in which nephrectomy and surgical resection of a solitary metastasis have been performed. Laparoscopic partial nephrectomy has become an increasingly viable option in the treatment of some renal cancers. We report a case in which a patient had a solitary lung nodule in the workup for a renal mass. This patient underwent combined thoracoscopic and laparoscopic resection of both the lung nodule and the renal mass in the same setting.

Adenocarcinoma, Clear Cell↗

PubMed2004

Renal cell cancer in solitary kidney after donor nephrectomy.

The occurrence of renal cell carcinoma in the solitary remnant kidney after donor nephrectomy is rare and, to our knowledge, has not been previously reported. We encountered 2 such patients in whom cancer occurred 19 and 40 years after the donation. Both patients underwent successful partial nephrectomy for the tumor using two different techniques.

Carcinoma, Renal Cell↗