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PubMed1988

Nephrectomy-induced alterations in the synthesis of catecholamines in the sympathetic nervous system and central nervous system.

Reduction in renal function is a key factor to the development of salt-dependent hypertension; however, the mechanism is obscure. To examine the role of the sympathetic nervous system (SNS) and central catecholaminergic neurons in this predisposition to the development of hypertension, the activity of tyrosine hydroxylase (TH) was determined in SNS and in several brain regions. In another group of unilaterally nephrectomized rabbits, cardiovascular responsiveness to norepinephrine was determined. A unilateral nephrectomy increased the activity of TH in the midmedulla, a brain region important in the baroreflex regulation of blood pressure, and in the adrenal gland, the major source of circulating catecholamines. The activity of TH was decreased in the pons-upper medulla region. No alterations were found in the proximal and distal mesenteric arteries, lower medulla, midbrain or hypothalamus. No alteration in blood pressure or cardiovascular responsiveness to norepinephrine was found. This study indicates that a unilateral nephrectomy produces long-lasting effects on central catecholaminergic neurons and the sympathetic nervous system without an effect on blood pressure or cardiovascular responsiveness.

Adrenal Glands↗

PubMed2004

Late pulmonary metastasis of renal cell carcinoma resected 25 years after nephrectomy.

A 50-year-old male underwent a left nephrectomy for clear cell type renal cell carcinoma (RCC) in February 1978. A right pulmonary metastasis was resected in February 1994. At that time, chest computed tomography revealed the presence of three small nodules in the left lung, but these were followed up as inflammatory lesions. In January 2002, a right pleural metastasis, which showed rapid growth, was detected and it was resected in June of the same year. A gradual growth was observed in the left lung nodules, and the patient underwent wedge resection of the left lung in March 2003, 25 years after nephrectomy. These nodules were diagnosed as metastatic RCC. Currently, the patient is doing well with no signs of recurrence, 8 months after the third metastasectomy.

Adenocarcinoma, Clear Cell↗

PubMed1998

Role of the peripheral renin profile in predicting blood pressure control after bilateral nephrectomy in renal-transplanted patients.

BACKGROUND: The unregulated renin release by native kidneys is one of the factors responsible for the high incidence of hypertension after renal transplantation but, even after three decades of transplantation, there is still a lack of a method to identify it as the major cause of hypertension. METHODS: We investigated whether or not peripheral renin activity, before and 90 min after 25 mg of captopril, can play this role. One hundred and five consecutive patients with SCr less than 2 mg/dl were studied 18 +/- 8 months after renal transplantation. Forty-seven of them were considered hypertensive and 58 normotensive. All hypertensive patients were submitted to the captopril test to analyse the peripheral renin activity profile. RESULTS: In the hypertensive group, 17 patients (36%) were considered Renin-pos and 30 (64%) Renin-neg. All Renin-pos (stimulated renin = 19.1 +/- 6.4 ng/ml/h) patients were submitted to bilateral nephrectomy (bNx) and re-evaluated 6 months later. All of them normalized renin activity (4.4 +/- 3.0 ng/ml/h, P = 0.0001) and 10 of 17 (60%) became normotensive and off drugs. The remaining seven (40%) decreased the number of hypotensive drugs from 2.2 +/- 0.5 to 0.5 +/- 0.7/pt/day. There was a correlation between b-Renin and dBP (r = 0.47, P < 0.05) which was lost after bNx. An 'in situ' renal-cell carcinoma was found in two cases. Serum creatinine did not change. CONCLUSIONS: This study shows that the unregulated renin-angiotensin system from the native kidneys plays a major role in the maintenance of hypertension in some patients with normal graft function and that peripheral renin activity can identify those who will benefit from bilateral nephrectomy.

Adult↗

PubMed2004

Laparoscopic living-donor nephrectomy.

BACKGROUND: In order to increase the number of renal donors, laparoscopic live-donor nephrectomy (LLDN) was first performed 8 years ago. Today, LLDN is a routine procedure in many centres worldwide. We reviewed the literature with regard to extend the use of this method, the feasibility and safety for donor, graft and recipient. Laparoscopic and open-donor nephrectomy are compared, and the impact of LLDN on donors' willingness is evaluated. METHODS: Literature search (PubMed, DIMDI, Medline) for the period from 1995 to 2003. RESULTS: More than 200 centres worldwide perform LLDN. It is a feasible and safe surgical procedure. For the donor, LLDN has numerous advantages, while graft and recipient outcome are the same as with the open approach. The learning curve on the way to performing this operation safely is long, and surgeons planning to integrate LLDN into their programme must be trained thoroughly. There are some indications that with LLDN the number of donors willing to donate a kidney can be increased. CONCLUSIONS: LLDN is widely used and will spread further. It is of the utmost importance to undergo thorough laparoscopic training in general urology prior to performing this procedure.

Clinical Competence↗

PubMed1999

Transesophageal echocardiographic detection of gas embolism and cardiac valvular dysfunction during laparoscopic nephrectomy.

UNLABELLED: We used transesophageal echocardiography (TEE) to monitor venous gas embolism, cardiac performance, and the hemodynamic effects of positioning and pneumoperitoneum in 16 healthy kidney donors undergoing laparoscopic nephrectomy. A four-chamber view was used continuously, except at predetermined intervals, when a complete TEE examination for cardiac function was performed. Other clinical variables recorded include systolic, diastolic, and mean arterial blood pressure; heart rate (HR), pulse oximetric saturations; and end-tidal CO2. Baseline valvular incompetence was seen in 13 of the 16 patients when supine and asleep. After positioning for surgery and induction of pneumoperitoneum, TEE revealed valvular incompetence with regurgitation more pronounced from baseline in 15 of the 16 patients. In one patient, during renal vein dissection, gas entered the right atrium from the inferior vena cava, worsening tricuspid regurgitation. Hemodynamic variables and ejection fraction were tested by using repeated-measures analysis of variance for significance (P < 0.05). Pneumoperitoneum increased (P < 0.05) systolic blood pressure (from 102.8 +/- 3.89 to 120.8 +/- 3.88 mm Hg) and HR (from 68.9 +/- 3.19 to 75.6 +/- 2.62). Ejection fraction was unchanged. The high incidence of valvular incompetence indicates that further studies are needed to assess these effects during laparoscopic nephrectomy with cardiac disease. IMPLICATIONS: Laparoscopic surgery has gained popularity as a procedure for the removal of donated kidneys. Although the insufflation of gas necessary for this relatively simple approach poses a low risk of venous air embolism, it may increase the risk of changes in valvular competency.

Adult↗

PubMed1999

Pleural bupivacaine for pain treatment after nephrectomy.

UNLABELLED: The efficacy of pleural analgesia after nephrectomy is controversial. We therefore evaluated i.v. opioid requirements in patients with and without pleural bupivacaine. Patients undergoing elective nephrectomy were randomly assigned to receive postoperative i.v. piritramid alone (n = 18) or piritramid combined with pleural bupivacaine (n = 19). In the patients assigned to receive pleural analgesia, boluses of 20 mL of 0.25% bupivacaine were given at 6-h intervals via an pleural catheter that was inserted in the medial axillary line at the sixth intercostal space. Pain scores (10-cm visual analog scale) and opioid requirements were recorded over the first 2 postoperative days. One hour after pleural puncture, a chest radiograph was performed. The catheter was removed 48 h after insertion. Patient characteristics were similar in each group, as was the duration of surgery. Pain scores were similar in each group: 3.0 +/- 2.5 in those given pleural bupivacaine and 3.1 +/- 2.7 in those given piritramid alone. However, the piritramid requirement was significantly less in those given pleural bupivacaine (23 +/- 3 mg) than in those given piritramid alone (45 +/- 6 mg). Furthermore, the time from completion of surgery until the first opioid request was significantly longer in the patients who received bupivacaine (4.7 +/- 1.0 vs 2.8 +/- 1.0 h). One patient had a small pneumothorax that resolved without treatment. These data indicate that pleural analgesia is effective and provides a significant opioid-sparing effect. IMPLICATIONS: We conclude that pleural analgesia significantly prolongs the time until postoperative opioid was first requested and halves the total required dose. These data indicate that pleural analgesia is effective and provides a significant opioid-sparing effect.

Analgesics, Opioid↗

PubMed1990

Measurement of inactive renin in rat plasma: effect of nephrectomy and sialoadenectomy on the plasma concentration.

In this paper we describe a routine method of measuring inactive renin in rat plasma. The activation was performed by trypsin, at optimal concentration and incubation conditions. The trypsin treatment formed an interfering and high-performance liquid chromatography-verified tetradecapeptide-like material, which was removed before the assay by a simple batchwise use of a cation-exchange resin. The concentration of activated inactive renin was measured by an antibody-trapping method after the addition of exogenous angiotensinogen. Angiotensinogen was added in order to compensate for the trypsin destruction of angiotensinogen and in order to measure the parameter of renin concentration. The inactive renin concentration in plasma of conscious male rats was 0.48 +/- 0.13 Goldblatt units (GU) per litre (n = 38). This corresponds to 66% (range 42-92%) of the total renin concentration. Physiological experiments in conscious rats were initiated, demonstrating that nephrectomy decreased the inactive renin concentration from 0.45 +/- 0.14 to 0.27 +/- 0.05 GU/l after 24 h (n = 21; P less than 0.01). Submandibular sialoadenectomy decreased the plasma inactive renin concentration from 0.45 +/- 0.11 to 0.34 +/- 0.06 GU/l (n = 12; P less than 0.05) after 7 days. Combined sialoadenectomy and nephrectomy decreased the plasma inactive renin concentration from 0.45 +/- 0.11 to 0.24 +/- 0.06 (n = 12; P less than 0.01).

Angiotensinogen↗

PubMed1992

The effect of chronic bilateral nephrectomy on plasma and brain angiotensin.

OBJECTIVE: To prove the independence of local tissue renin-angiotensin system (RAS) in brain from classical kidney RAS, we measured local angiotensin levels in bilaterally nephrectomized rats which had been dialyzed with a dialysis technique to greatly prolong survival time. DESIGN: Two groups of animals were used: (1) bilaterally nephrectomized rats with intraperitoneal dialysis, where both kidneys were surgically removed; and (2) controls with intact kidneys and dialysis. By using this protocol, we were able to study plasma and brain angiotensins 5 days after nephrectomy (no longer periods have been attempted). METHODS: Plasma sodium, potassium and pH were monitored while rats were dialyzed four times a day. Plasma samples and brain areas were obtained and angiotensin II measured by radioimmunoassay and high-pressure liquid chromatography (HPLC). RESULTS: Plasma angiotensin II was significantly diminished in the nephrectomized rats but was still detectable, the levels being above the minimal detectable value. The identity of angiotensin I and angiotensin II detected by radioimmunoassay was confirmed by HPLC. In the brain, angiotensin II content was significantly increased in all areas studied. The highest increments were in hypothalamus and brain stem. CONCLUSIONS: Our results demonstrate that: (1) brain angiotensin II is regulated independently of peripheral angiotensin II; and (2) a reduced plasma angiotensin II persists 5 days after bilateral nephrectomy. We conclude that the angiotensin II in the plasma was derived from non-renal tissue and the results support the conclusion that tissue RAS has paracrine and autocrine functions independent of the endocrine function of circulating plasma angiotensin.

Angiotensin II↗

PubMed1995

Nephrectomy combined with lower abdominal extraperitoneal ureteral bladder augmentation in the treatment of children with the vesicoureteral reflux dysplasia syndrome.

Ureterocystoplasty is a novel procedure well suited for treating children with megaureters and small or noncompliant bladders. It combines the benefits of enterocystoplasty without many of its drawbacks. We performed nephrectomy through a posterior approach with extraperitoneal ureteral augmentation in 6 patients with bladder neck obstruction and reflux into a nonfunctioning kidney (the vesicoureteral reflux dysplasia/vesicoureteral reflux nonfunctioning kidney syndrome). In all patients capacity increased significantly. Bladder pressure at capacity decreased in patients who were evaluated by urodynamics postoperatively, and continence was achieved or preserved. There were no complications and hospital stay was short. Nephrectomy via a posterior approach with extraperitoneal ureteral augmentation is an appropriate procedure for children with the vesicoureteral reflux dysplasia syndrome. It should be considered for all such patients before nephroureterectomy is done and irreversible loss of valuable compliant native urothelium occurs.

Adolescent↗

PubMed1999

Metastatic renal cell carcinoma with concurrent inferior vena caval invasion: long-term survival after combination therapy with radical nephrectomy, vena caval thrombectomy and postoperative immunotherapy.

PURPOSE: We report our experience using aggressive multimodal therapy in a high risk group of patients with metastatic renal cell carcinoma and concurrent inferior vena caval extension. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients in our kidney cancer database who had metastatic renal cell carcinoma and tumor thrombus extension into the inferior vena cava at the initial diagnosis. Patients were included in the study if they underwent radical nephrectomy and inferior venal caval thombectomy, and immunotherapy was planned for the postoperative period. Tumor size and grade, metastatic sites, level of vena caval extension, surgical complications and overall survival were obtained from the medical records. The primary end point analyzed was overall survival. RESULTS: We identified 31 cases of metastatic renal cell cancer with extensive disease and vena caval extension. Of the patients 23% had an isolated lung metastasis, and 53% had metastasis in the lung and at other sites. The remaining patients had involvement primarily at nonpulmonary metastatic sites, including lymph node in 38%, soft tissue in 13%, liver in 29% and bone in 10%. Average blood loss during nephrectomy was 3,200 cc (median 2,100) and the rate of major complications was 12%. Of the patients 80% underwent the full course of surgery and postoperative immunotherapy. At a mean followup of 18 months (34 for survivors) 26% of the patients are alive. Actuarial overall 5-year survival of the group was 17%. Tumor thrombus level did not correlate with overall survival, while immunotherapy, tumor grade and metastatic site provided significant prognostic information. In patients with an isolated pulmonary metastasis the 5-year survival rate was 43%, while in those with low grade tumors it was 52%. CONCLUSIONS: In contrast to the poor results of surgery only in patients with renal cell carcinoma and concurrent inferior venal caval invasion, reasonable 5-year survival may be achieved after combined aggressive surgery and immunotherapy. Patients in whom metastasis was limited to the lungs and those with grade 1 to 2 tumors had a better prognosis. With careful planning and experienced immunotherapists therapy may be completed in the majority of this high risk group of patients.

Adult↗

PubMed2001

Use of bipolar electrocautery during laparoscopic donor nephrectomy.

PURPOSE: We describe a technique enabling easier placement of the endoscopic linear stapling device on the renal vein during laparoscopic nephrectomy. MATERIALS AND METHODS: Bipolar electrocautery rather than a clip applier was used in 20 laparoscopic donor nephrectomy cases to coagulate the renal vein branches before transection. Warm ischemia time of the specimens and the number of surgical clip applier devices used were compared with those in the 20 immediate preceding cases in which bipolar electrocautery was not used. RESULTS: Using bipolar electrocautery no clips were placed on the specimen side of the renal vein before stapling. Average warm ischemia time for the 20 kidneys in which bipolar electrocautery was performed was 2 minutes 13 seconds compared with 3 minutes 1 second for the previous 20 (p = 0.157). Significantly fewer clip applying devices were used in the 20 bipolar electrocautery cases (p = 0.005). CONCLUSIONS: Bipolar electrocautery of the renal vein branches enables easier placement of the endoscopic linear stapling device on the renal vein and the use of fewer surgical clip appliers during laparoscopic surgery. Because the bipolar electrocautery device is reusable, it decreases operative costs.

Electrocoagulation↗

PubMed1994

Review of 333 living donor nephrectomies.

We reviewed the operative complications in 333 living related donor nephrectomies done at our institution over the past 12 years. The overall complication rate was 17.1%; only three patients (0.9%) had major complications, and none died. The major complications were a delayed splenectomy because of bleeding, an adrenalectomy, and acute renal failure in one patient in the immediate postoperative period. We concluded that donor nephrectomy done through a flank incision results in minimal morbidity.

Adolescent↗

PubMed1997

Nephron-sparing surgery compared with radical nephrectomy for renal tumors: current indications and results.

BACKGROUND: Small asymptomatic solid renal masses are being found more often through the frequent use of abdominal ultrasonography and computed tomography. Nephron-sparing renal surgery is being done more often to treat these small lesions. A retrospective review was done to determine the effectiveness of this treatment. METHODS: Patients who had nephron-sparing renal surgery (group 1-35 patients) were compared with those who had radical nephrectomy (group 2-71 patients) for renal cell carcinoma smaller than 5 cm. RESULTS: The two groups had only small differences in fall in hematocrit, transfusion rates, operative time, and hospital stay. Major surgical complications were more frequent in group 1. After a median follow-up of 3.1 years, there has been no recurrence of tumor and there were no surgery-related or cancer-related deaths in either group. CONCLUSION: Nephron-sparing renal surgery appears to be a safe and effective alternative to radical nephrectomy for localized small renal tumors.

Adult↗

PubMed1999

Laparoscopic versus open donor nephrectomy: comparing ureteral complications in the recipients and improving the laparoscopic technique.

BACKGROUND: Laparoscopic live donor nephrectomy (LDN) is a recently developed procedure, the performance of which needs to be studied. Given the reported advantages in the donors, this study looks at graft outcome and ureteral complications in recipients of kidneys procured by open donor nephrectomy (ODN) versus LDN. METHODS: The LDN recipients consisted of 193 patients since 3/27/96. A total of 168 ODN recipients from 1991 to 1998 served as controls. Immunosuppression protocols were similar for both groups. RESULTS: Two-year graft survival for LDN and ODN was 98% and 96%, respectively. Two-year patient survival for LDN and ODN was 98% and 97%, respectively. The incidence of delayed graft function and mean serum creatinine at 3 and 12 months was similar in both groups. However, the number of ureteral complications that required operative repair was significantly higher for LDN recipients compared to ODN recipients, 7.7% (n=15) vs. 0.6% (n=1) respectively (P=0.03). Ureteral stenting was required in an additional 3.1% (n=6) of LDN and 2.4% (n=4) of ODN (P=NS). There was, however, a learning curve with time. For the first 130 LDN patients, a total of 20 ureteral complications were recorded, whereas only one occurred in the more recent 63 patients (P=0.03). CONCLUSIONS: The higher ureteral complication rate in LDN recipients has improved over time as technical causes have been identified. We have noted significant improvement in ureteral viability by using the endogastrointestinal anastomosis instrument on the ureter and peri-ureteral tissue. LDN is therefore an excellent alternative to ODN. Identification of hazards unique to this technique is critical before its broader application.

Adult↗

PubMed2000

Laparoscopic donor nephrectomy increases the supply of living donor kidneys: a center-specific microeconomic analysis.

BACKGROUND: A tenet of microeconomics is that new technology will shift the supply curve to the right. Laparoscopic donor nephrectomy (LDN) is a new technique for removal of living donor kidneys. Centers performing this procedure have noted an increased number of patients presenting for donor evaluation. This has not been previously studied. METHODS: The records of all LDN performed from May 1998 to February 1999 were reviewed. The following variables were examined: sex, age, related vs. unrelated donation, estimated blood loss, i.v. analgesia, length of stay, and time out of work. Donors undergoing traditional open donor nephrectomy during January 1997 to May 1998 served as the control group. A composite cost index was constructed. RESULTS: LDN significantly decreased length of stay, pain, and time out of work; the supply function shifted to the right. Telephone interviews revealed that 47% donated solely because of the LDN procedure. CONCLUSIONS: LDN increases the supply of living donor kidneys.

Adult↗

PubMed2000

Laparoscopic live donor nephrectomy--is it safe?

BACKGROUND: Laparoscopic live donor nephrectomy (LDN) is a less invasive alternative to open nephrectomy (ODN) for living kidney donation. Concerns have been raised regarding the safety of LDN, the short and long term function of kidneys removed by LDN, and a potential higher incidence of urologic complications in LDN transplant recipients. METHODS: Between October 1997 and May 1999, 80 LDNs were performed at our center. All patients were followed longitudinally with office visits and telephone interviews. These LDNs were compared with 50 ODN performed from January 1996 to October 1997. RESULTS: LDN procedures took significantly longer than ODN (4.6 vs. 3.1 hr). However, LDN was associated with significant reduction in i.v. narcotic use, a rapid return to diet, and shorter hospital stay. Of the 80 LDN procedures, a total of 75 (94%) were completed laparoscopically. Five patients were converted to laparotomy: three for hemorrhage and two for complex vascular anatomy. ODN conversion was associated with large donor body habitus and/or obesity. Seven LDN patients had minor complications and 4 had major complications. All major complications consisted of vascular injuries (2 lumbar vein injuries, 1 renal artery, and 1 aortic injury). All patients made complete recoveries. All LDN kidneys functioned immediately posttransplant. We have observed 100% patient and 97% 1-year actuarial graft survival in LDN transplant recipients. There have been no short-or long-term urologic complications in this series. CONCLUSION: With increasing experience and standardization of technique, LDN is a safe and effective procedure. Patients undergoing LDN demonstrate clinically significant, more rapid postoperative recoveries and shorter hospital stays than ODN patients. Excellent initial graft function and long-term graft survival have been observed with LDN kidneys. Urologic complications can be avoided. LDN has become the preferred surgical approach for living kidney donation at our center.

Adult↗

PubMed2003

Maximizing renal artery length in right laparoscopic donor nephrectomy by retrocaval exposure of the aortorenal junction.

Laparoscopic donor nephrectomy (LDN) has become the standard of care at increasing numbers of renal transplant programs worldwide. As in open donor nephrectomy, the left kidney has remained the preferred organ for LDN because of the greater renal vessel lengths. Currently, the overwhelming majority of donor operations are performed on the left kidney. This disparity may be due to an unfamiliarity with the technique of right LDN and technical difficulties encountered in obtaining adequate arterial and venous vessel lengths. Modifications in the laparoscopic technique have increased the length of the renal vein obtained from either side; however, further techniques are needed to maximize the length of the right renal artery in LDN. Herein the authors present a technique to provide exposure of the right aortorenal junction that provides maximal length of the right renal artery. This technique has currently been used in 20 consecutive right LDN operations without vascular complications or technical graft losses.

Aorta↗

PubMed1999

Is open surgery for partial nephrectomy an obsolete surgical procedure?

During the past few years, the indications for laparoscopic surgery in urology have extended from simple ablative procedures towards more complex reconstructive and organ-preserving interventions. Among them, transperitoneal and extraperitoneal laparoscopic partial nephrectomy have been successfully performed for both benign and malignant lesions. However, this approach raises specific problems because in contrast to other laparoscopic procedures the techniques and tools used during open surgery can not be simply transposed to laparoscopy. The absence of surface hypothermia, the lack of manual palpation, difficulties of vascular control and reconstruction of the collecting system necessitate new solutions readily adaptable to laparoscopic surgery. However, the available series comprise only a few cases, and there are differences in techniques and instrumentation in almost every operation. In these circumstances, it is too early to consider this new approach as reproducible and ready to be used elsewhere than in specialized centres. Although the feasibility and good results of partial nephrectomy for benign conditions and small exophitic tumours is now well documented, the development of new surgical tools and standardization of methodology are required for more complex cases within the scope of well conceived prospective studies.

Blood Loss, Surgical↗