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At least 1,513 records · Page 84Linked to original sources

PubMed2005

Potassium-titanyl-phosphate laser laparoscopic partial nephrectomy without hilar clamping in the survival calf model.

PURPOSE: Laparoscopic partial nephrectomy (LPN) with hilar clamping represents the various challenges associated with warm ischemia. We tested the feasibility, and acute and chronic outcomes of LPN using a potassium-titanyl-phosphate (KTP) laser without vascular hilar clamping in the survival calf model. MATERIALS AND METHODS: Six Jersey calves weighing 76 to 94 kg underwent a total of 12 staged bilateral transperitoneal laser LPNs of the mid/lower pole using an 80 W KTP laser, including left kidney chronic LPN with 1-month followup in 6 and right kidney acute LPN with immediate sacrifice in 6. Two techniques (ablative vaporization in 5 subjects and wedge resection in 7) were evaluated. Renal parenchymal resection and hemostasis were achieved only with the laser without any adjunctive hemostatic sutures or bioadhesives. Retrograde pyelography, renal arteriography and histological analyses were performed. RESULTS: All 12 procedures were successful performed laparoscopically without open conversion and 11 (92%) were done without hilar clamping. Mean total operative time was 2.9 hours (range 1.5 to 5) and mean blood loss was 119 cc (range 25 to 300). Mean lasing time was 56 minutes (range 20 to 100) with an average energy use of 54 kJ. Mean preoperative and postoperative hemoglobin (10.38 and 10.52 gm/dl) and serum creatinine (0.46 and 0.4 gm/dl, respectively) were similar. At 1-month followup there was no evidence of urinary leakage or arteriovenous fistula. CONCLUSIONS: This initial study of laparoscopic KTP laser partial nephrectomy without hilar clamping confirms its technical feasibility in most cases and good short-term outcomes. This success of laser LPN in the robust survival calf model with its human-sized kidney holds promise for future clinical application.

Animals↗

PubMed2005

Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: patient selection and perioperative outcomes.

PURPOSE: We compared the results of transperitoneal (T) and retroperitoneal (R) approaches to laparoscopic partial nephrectomy (LPN) in regard to perioperative outcomes and technical considerations, thereby, identifying patient selection guidelines for each approach. MATERIALS AND METHODS: The choice of approach was dictated primarily by tumor location, that is TLPN for anterior or lateral lesions and RLPN for posterior or posterolateral lesions. The approaches differed primarily by the hilar control technique. During TLPN en bloc hilar control was achieved with a Satinsky clamp, while during RLPN individual vessel control was obtained with bulldog clamps. RESULTS: In a 3-year period 100 TLPNs and 63 RLPNs were performed for renal tumor. Of posterior tumors 77% were managed by RLPN, whereas 97% of anterior tumors were managed by TLPN. TLPN was associated with significantly larger tumors (3.2 vs 2.5 cm, p <0.001), more caliceal suture repairs (79% vs 57%, p = 0.004), longer ischemia time (31 vs 28 minutes, p = 0.04), longer operative time (3.5 vs 2.9 hours, p <0.001) and longer hospital stay (2.9 vs 2.2 days, p <0.01) than RLPN. Blood loss, perioperative complications, postoperative serum creatinine, analgesic requirements and histological outcomes were comparable between the groups. CONCLUSIONS: We perform TLPN for all anterior or lateral tumors as well as for large or deeply infiltrating posterior tumors that require substantive resection (heminephrectomy). The limited retroperitoneal space makes RLPN technically more challenging but provides superior access to posterior and particularly posteromedial lesions. When feasible, we prefer to perform laparoscopic partial nephrectomy by the transperitoneal approach because of its larger working area and superior instrument angles for intracorporeal renal reconstruction.

Adolescent↗

PubMed2005

Laparoscopic partial nephrectomy for hilar tumors.

PURPOSE: Partial nephrectomy for hilar tumors represents a technical challenge not only for laparoscopic, but also for open surgeons. We report the technical feasibility and perioperative outcomes of laparoscopic partial nephrectomy (LPN) for hilar tumors. MATERIALS AND METHODS: Between January 2001 and September 2004, 25 of 362 patients (6.9%) undergoing LPN for tumor, as performed by a single surgeon, had a hilar tumor. We defined hilar tumor as a tumor located in the renal hilum that was demonstrated to be in actual physical contact with the renal artery and/or renal vein on preoperative 3-dimensional computerized tomography. En bloc hilar clamping with cold excision of the tumor, including its delicate mobilization from the renal vessels, followed by sutured renal reconstruction was performed routinely. RESULTS: Laparoscopic surgery was successful in all cases without any open conversions or operative re-interventions. Mean tumor size was 3.7 cm (range 1 to 10.3), 4 patients (16%) had a solitary kidney and the indication for LPN was imperative in 10 patients (40%). Pelvicaliceal repair was performed in 22 patients (88%), mean warm ischemia time was 36.4 minutes (range 27 to 48), mean blood loss was 231 cc (range 50 to 900), mean total operative time was 3.6 hours (range 2 to 5) and mean hospital stay was 3.5 days (range 1.5 to 6.7). Histopathology confirmed renal cell carcinoma in 17 patients (68%), of whom all had negative margins. In 2002 or earlier hemorrhagic complications occurred in 3 patients (12%). No kidney was lost for technical reasons. CONCLUSIONS: LPN can be performed in select patients with a hilar tumor. The technical feasibility reported further extends the scope of LPN. To our knowledge the initial experience in the literature is reported.

Adult↗

PubMed2005

Multi-institutional validation study of neural networks to predict duration of stay after laparoscopic radical/simple or partial nephrectomy.

PURPOSE: We developed models to predict post-laparoscopic radical or simple nephrectomy (LapNx) and post-laparoscopic partial nephrectomy (LapPNx) hospital duration of stay (DOS). MATERIALS AND METHODS: We performed a retrospective review (design group) of all 726 patients (July 1997 to April 2004) who underwent LapNx or LapPNx at the Cleveland Clinic Foundation (CCF). Preoperative findings were recorded. Neural network algorithms were designed to predict the DOS before surgery. The models were then tested on a separate 252 patients from 6 different institutions, namely Tulane University Medical School, University of Arkansas for Medical Sciences, Cedars-Sinai Medical Center, University of Iowa, Mayo Clinic at Scottsdale and CCF. RESULTS: In the CCF design groups, the LapNx model accuracy was 73% to 74% and the LapPNx model 73% to 83%. Overall accuracy in the test groups at all 6 institutions was 72% (area under ROC 0.6 to 0.7) for the LapNx model and 52% to 81% (ROC 0.5 to 0.7) for the LapPNx model. CONCLUSIONS: The LapNx model provides 72% accuracy in predicting the DOS at all 6 institutions. The LapPNx model provided fair accuracy only at CCF and Tulane University Medical School. These models may streamline the delivery of care and continued testing will allow for further refinement.

Algorithms↗

PubMed2006

Hemostatic techniques during laparoscopic partial nephrectomy.

PURPOSE OF REVIEW: To review the current techniques and technologies being used for hemostatic control during laparoscopic partial nephrectomy. RECENT FINDINGS: Laparoscopic nephron-sparing surgery has become more common for the treatment of renal masses. With increasing experience, the indications for nephron sparing are increasing. Despite the increased use of these techniques in high-volume centers, however, more widespread application has been limited because of the need for advanced laparoscopic skills including the laparoscopic control of intraoperative renal bleeding. As a result, many techniques have been developed to achieve hemostasis, including conventional suture repair, tissue sealants, radiofrequency ablation, lasers, water dissection, and microwave tissue coagulation. SUMMARY: Laparoscopic partial nephrectomy is a technically challenging procedure. Many promising techniques are being developed currently, most geared toward improved hemostasis and collecting system repair. These techniques and products have made, and will continue to make, the procedure less demanding and more universally accepted.

Adhesives↗

PubMed2005

Hand-assisted laparoscopic radical nephrectomy: comparison of the transperitoneal and retroperitoneal approaches.

Transperitoneal and retroperitoneal approaches have been introduced to perform hand-assisted laparoscopic radical nephrectomy. The efficacy and convalescence of both approaches were compared. Of 26 patients with renal cell carcinoma, 14 patients were treated by the transperitoneal approach and 12 by the retroperitoneal approach at the same institution. The mean operative time by transperitoneal approach was significantly shorter than retroperitoneal approach (236.4 and 280.0 minutes, respectively, P < 0.05), but there is a steeper learning in retroperitoneal approach. A significant increase in operative time was required with an increase in specimen weight (r = 0.591, P < 0.05). There were no differences in patient demographic, operative, and convalescence data between the both groups. Hand-assisted laparoscopic radical nephrectomy is safe by either the transperitoneal or the retroperitoneal approach. Making enough retroperitoneal space for the hand and instrument enables us to use the retroperitoneal approach readily. Patients with abundant fatty tissues around the kidney should be treated by the transperitoneal approach.

Aged↗

PubMed2003

The economic impact of laparoscopic living-donor nephrectomy on kidney transplantation.

BACKGROUND: End-stage renal disease accounts for $17.9 billion annually in direct medical costs in the United States. This study assessed the flow of expenditures from a Medicare perspective for laparoscopic donor nephrectomy compared with living and cadaveric transplantation and continued dialysis. METHODS: This study involved a nonrandomized, retrospective investigation of patients with end-stage renal disease and charges using institutional and physician/supplier charges from the United States Renal Data System. The subjects were classified as laparoscopic living-donor transplant, living-donor transplant, cadaveric transplant, or dialysis patients. The first treatment date was set as the index date, and monthly charges were plotted from 12 months before and up to 48 months after the index date. RESULTS: There were 230,769 dialysis patients and 44,063 transplant patients (181 laparoscopic living-donor, 11,466 living-donor, and 32,416 cadaveric). Monthly institutional charges were similar in the year preceding the index date, but they were higher for transplantation in the month after the index date and lower in subsequent periods. Two-year post-index cumulative charges were as follows: Monthly institutional charges were similar for the living-donor ($191,374) and laparoscopic living-donor ($192,053) transplant patients, followed by the cadaveric transplant ($229,449) and dialysis ($250,348) patients, whereas physician/supplier charges were highest for the laparoscopic living-donor transplant ($104,583) patients, followed by the dialysis ($73,730), cadaveric transplant ($70,369), and living-donor transplant ($65,897) patients. The break-even points for the living-donor, laparoscopic living-donor, and cadaveric transplant patients compared with the dialysis patients were 10, 14, and 18 months, respectively. CONCLUSIONS: The laparoscopic procedure may be a beneficial alternative to the conventional open donor nephrectomy procedure and cadaveric transplantation, and it provides considerable benefits compared with dialysis.

Cadaver↗

PubMed2004

A systematic review of laparoscopic live-donor nephrectomy.

BACKGROUND: A systematic review was undertaken to assess the safety and efficacy of laparoscopic live-donor nephrectomy (LLDN) compared with open live-donor nephrectomy (OLDN). METHODS: Literature databases were searched from inception to March 2003 inclusive. Comparative studies of LLDN versus OLDN (randomized and nonrandomized) were included. RESULTS: There were 44 included studies, and the quality of the available evidence was average. There was only one randomized controlled trial and six nonrandomized comparative studies with concurrent controls identified. In terms of safety, for donors, there did not seem to be any distinct difference between the laparoscopic and open approaches. No donor mortality was reported for either procedure, and the complication rates were similar although the types of complications experienced differed between the two procedures. The conversion rate for LLDN to an open procedure ranged from 0% to 13%. In terms of efficacy, LLDN seemed to be a slower operation with longer warm ischemia times than OLDN, but this did not seem to have resulted in increased rates of delayed graft function for recipients. Donor postoperative recovery and convalescence seemed to be superior for LLDN, making it a potentially more attractive operation for living donors. Although in the short-term, graft function and survival did not seem to differ between the two techniques, long-term complication rates and allograft function could not be determined and further long-term follow-up is required. CONCLUSIONS: LLDN seems to be at least as safe and efficacious as OLDN in the short-term. However, it remains a technique in evolution. Further high-quality studies are required to resolve some of the outstanding issues surrounding its use, in particular, long-term follow-up of donor complications and recipient graft function and survival.

Humans↗

PubMed2004

Retroperitoneoscopic living donor nephrectomy: a retrospective comparison to the open approach.

A purely retroperitoneoscopic approach in living kidney donation is used by only a few centers worldwide. Data from 28 consecutive purely retroperitoneoscopic living donor nephrectomies (RLDN) were compared to the most recent 30 open living donor nephrectomies (OLDN). Right-sided donation was performed in 12 cases (43%) of the RLDN and 11 cases (37%) of the OLDN. Comparison of the results between the two groups showed a shorter operation time and hospital stay for the RLDN group (P < 0.001). Warm ischemia time was significantly shorter in the OLDN group (P < 0.02). The rate of complications did not differ significantly between the groups. No significant difference in terms of renal graft function was detected within 30 days after surgery. As a result of the direct access, RLDN is superior in terms of operation time, even to the open access on our series, while maintaining the advantage of minimal invasiveness.

Adolescent↗

PubMed2005

The effect of laparoscopic and open donor nephrectomy on the long-term renal function in donor and recipient: a retrospective study.

Pneumoperitoneum, as used in laparoscopic donor nephrectomy (LDN), may result in negative effects on renal function in donor and recipient. This study compares long-term serum creatinine in donor and recipient after laparoscopic and open donor nephrectomy (ODN). A retrospective analysis of 120 LDN and 100 ODN donors and their recipients was performed. Serum creatinine of donor and recipient was recorded and analyzed. The follow-up period posttransplantation was 3 years. Serum creatinine in the recipients was significantly higher in the LDN groups the first week after transplantation. Serum creatinine in the donor was significantly higher in the LDN group at 1 day, 3 months, and 1 year posttransplant. Finally, creatinine levels remained 40% higher compared to preoperative values in both donor groups. LDN results in higher short-term serum creatinine levels in donor and recipient. Long-term serum creatinine levels were comparable after LDN or ODN in donor and recipient.

Adult↗

PubMed2005

Hand-assisted retroperitoneoscopic live donor nephrectomy: experience from the first 75 consecutive cases.

BACKGROUND: The two major life-threatening complications associated with laparoscopic live donor nephrectomy are sudden severe bleeding and intestinal injury. A combined technique-hand-assisted and retroperitoneoscopic (HARS)-reduces the risk of these life-threatening complications. In this study, we report on our experience from the first 75 consecutive HARS operations. METHODS: The data has been collected prospectively according to intention to treat and includes all consecutive donors operated with the HARS technique. Warm ischemia time, operating time, and blood loss were recorded. Complications, convalescence, and allograft outcome were followed postoperatively with a mean follow-up of 701 (range 60-1438) days. RESULTS: The mean operating time was 138 (range 85-260) minutes and the mean warm ischemia time 175 (85-510) seconds. The operative time was significantly longer in male donors. The mean bleeding was 176 (50-700) ml. There were no conversions to open surgery. Major complications comprised one pulmonary embolus and one donor required 2 units of blood transfusion. One donor was reoperated due to suspicion of trocar hernia. Nine patients experienced minor complications (fever, n=4; urinary tract infection, n=2; chylous ascites, n=1; orchialgia, n=1; subcostal pain, n=1). All except two kidneys had immediate onset of function. Neither of these could, however, be attributed to the donor operation. One recipient experienced urinary leakage and one a stenosis. Recipient and graft survival were 99% and 96%, respectively. CONCLUSIONS: We conclude that HARS facilitates the procedure by enabling short operating times and at the same time significantly reducing the risks associated with endoscopic live donor nephrectomy.

Adult↗

PubMed2006

Donor nephrectomy: mini-incision muscle-splitting open approach versus laparoscopy.

BACKGROUND: The introduction of laparoscopic donor nephrectomy (LDN) has encouraged the development of less invasive open techniques. Aim of the present study was to compare short-term outcomes between contemporary cohorts of donors who underwent either mini-incision open or laparoscopic kidney donation. METHODS: From May 2001 to September 2004 data of all living kidney donations and transplantations were prospectively collected. Fifty-one donors underwent mini-incision, muscle-splitting open donor nephrectomy (MIDN) and 49 donors underwent LDN. RESULTS: Baseline characteristics of donors and recipients in the study groups were comparable except for donors' gender. Median incision length in MIDN was 10.5 cm. In two patients LDN was converted to open. MIDN resulted in significantly shorter warm ischemia and operation time (2.5 vs. 6.5 min and 157 vs. 240 min respectively). During MIDN, donors had more blood loss (200 vs. 120 ml, P=0.02). Disposables used for MIDN were cheaper (328 vs. 1784 Euros). In the LDN group 4 (8%) major intraoperative and 2 (4%) major postoperative complications occurred versus no major complications in the MIDN group. Morphine requirement, pain and nausea perception, and time to dietary intake did not significantly differ between the groups. Following MIDN, donors were discharged later (4 vs. 3 days, P=0.02). Transplantation of kidneys procured by either approach led to a similar decline in serum creatinine throughout the first year. One-year graft survival was 100% following MIDN and 86% following LDN (P=0.005). CONCLUSION: MIDN and LDN both lead to satisfactory results. Both techniques can be used to expand living donor programs.

Adult↗

PubMed2006

Psychosocial and physical impairment after mini-incision open and laparoscopic donor nephrectomy: A prospective study.

BACKGROUND: The aim of the present study was to prospectively investigate how mini-incision donor nephrectomy (MIDN) and laparoscopic donor nephrectomy (LDN) affected the donor's quality of life and fatigue. METHODS: Forty-five donors underwent MIDN and 55 donors underwent LDN. Quality of life and fatigue were recorded preoperatively and four times during one year follow-up on the Short-Form 36 (SF-36) and Multidimensional Fatigue Inventory-20 (MFI-20), respectively. RESULTS: One-year response rates were 89% and 95% following MIDN and LDN, respectively. After MIDN, all dimensions of the SF-36 significantly declined. Most dimensions returned to preoperative values at three months except for "vitality" (six months) and "bodily pain" (12 months). After LDN, the scores of the SF-36 dimensions returned to preoperative values at three months, except for "vitality" and "role physical" (both six months). Between-groups analysis revealed significantly better scores of the SF-36 dimensions "physical function" (P = 0.03) and "bodily pain" (P = 0.04) following LDN at one month postoperatively. Fatigue scores did not significantly differ between the groups at any point in time. General and physical fatigue (MFI-20) remained affected up to one year after either type of surgery. After MIDN, 4% of the donors had returned to work at four weeks postoperatively versus 28% after LDN (P = 0.04). Return to preoperative activity level was not significantly different between groups. CONCLUSIONS: Both procedures clearly impact quality of life and fatigue. The beneficial effect on the quality of life and the earlier return to work encourage us to advocate LDN as the surgical approach to be preferred.

Adult↗

PubMed1990

The role of lipids in the pathogenesis of glomerulosclerosis in the rat following subtotal nephrectomy.

Similarities between atherosclerosis and glomerulosclerosis suggest that hyperlipidaemia may contribute to glomerular injury. Dietary supplementation with 4% cholesterol + 1% cholic acid was administered to rats 4 weeks after 1 1/3 nephrectomy and continued for 7 weeks. There was a significant increase in serum cholesterol (peak = 11.52 +/- 1.09 mmol l-1 vs. 4.73 +/- 0.31 on control diet, P less than 0.001) and triglyceride concentrations (peak = 2.31 +/- 0.27 mmol l-1 vs. 1.41 +/- 0.29, P less than 0.05) and a marked increase in beta-migrating lipoproteins. The severity of hypercholesterolaemia was significantly correlated with proteinuria (control diet: r = 0.600, cholesterol diet: r = 0.672, P less than 0.0001) as was hypertriglyceridaemia (control diet: r = 0.544, cholesterol diet: r = 0.678, P less than 0.0001). The percentage of glomeruli containing lipid deposits was increased from 21% to 60% (P less than 0.05). The kidney total cholesterol content was increased from 29.2 +/- 0.8 to 47.7 +/- 3.3 mumols g-1 dry weight (P less than 0.0001), with esterified cholesterol increasing from 7.5 +/- 0.4% to 14.5 +/- 2.1% of total (P less than 0.01). Serum cholesterol concentration was significantly correlated with both glomerular lipid deposition (rs = 0.7195, P less than 0.0001) and tissue total cholesterol content (rs = 0.6053, P less than 0.001). Lipid vacuolation was prominent in the paramesangium and within mesangial cells. Despite these changes hypertension, uraemia, proteinuria and glomerulosclerosis were not significantly increased on the cholesterol diet. Cholesterol deposition in the glomeruli occurs secondary to hyperlipidaemia in rats following subtotal nephrectomy but over 7 weeks no exacerbation of glomerulosclerosis is detectable.

Animals↗

PubMed2004

A systematic review of hand-assisted laparoscopic live donor nephrectomy.

We provide a systematic review of hand-assisted laparoscopic live donor nephrectomy (HALDN), a relatively new procedure. Medline search of HALDN between 1995 and 2002 was conducted. Published studies were scored by two independent assessors using a modified form of 11 generic questions. All questions required one of three responses: 0--criterion not reported, 1--criterion reported but inadequate, 2--criterion reported and adequate. The studies were placed according to their scores in category A (score 20-22), category B (17-19) and category C (16 or less). Higher scores indicate better quality of studies. Where possible, statistical analysis of comparative data was performed. Most reports of HALDN are expert series, some comparative and a few prospective. There was good correlation between the assessors (r = 0.91), and of the seven published series on HALDN, two fell into category B and five into category C. At present, there is only one published randomised-controlled trial of HALDN vs. open donor nephrectomy; this is the only such trial in laparoscopic urology. HALDN allows kidneys to be harvested with short operating and warm ischaemia times and fewer ureteric complications. HALDN is a relatively new and effective technique, designed to make kidney donation more attractive and minimally invasive without affecting recipient outcomes. More prospective data of this technique is needed, and wide variation in reported outcome parameters need to be standardised to allow meaningful comparison.

Humans↗

PubMed2006

Option of pre-emptive nephrectomy and renal transplantation for Bartter's syndrome.

Bartter's syndrome (BS) is an incurable genetic disease, with variable response to supportive therapy relating to fluid and electrolyte management. Poor control or therapy non-compliance may result in frequent life threatening episodes of dehydration, acidosis and hypokalemia, with resultant adverse effects on patient quality of life (QOL). We report, for the first time, pre-emptive bilateral native nephrectomies and successful renal transplantation, prior to the onset of ESRD, for severe, clinically brittle, neonatal BS, resulting in correction of metabolic abnormalities and excellent graft function. We propose that fragile BS should be considered as a possible indication for early native nephrectomies and pre-emptive renal transplantation, procedures that results in a 'cure' for the underlying disease and significant improvements in patient QOL.

Bartter Syndrome↗

PubMed2005

Chylous ascites as a complication of laparoscopic donor nephrectomy.

Laparoscopic living donor nephrectomy (LLDN) is a minimally invasive technique for kidney procurement and was developed with the hope of reducing the disincentives associated with live renal donation. Compared with open donor nephrectomy (ODN), this alternative has many advantages including less postoperative pain and earlier return to work. Unfortunately, these benefits are sometimes negated by postoperative complications. Among these, chylous ascites (CA) is a rare but serious problem that is usually managed conservatively. We report the case of a living donor who developed CA refractory to initial conservative management and surgical treatment. We also discuss the role of surgery in the treatment of CA following LLDN.

Chylous Ascites↗

PubMed2006

Routine left robotic-assisted laparoscopic donor nephrectomy is safe and effective regardless of the presence of vascular anomalies.

The classic approach to donor nephrectomy consists of preferential procurement of the kidney without vascular anomalies. We studied the effect of routine procurement of the left kidney regardless the presence of multiple arteries on the outcomes of robotic-assisted laparoscopic living donor nephrectomy (LLDN) with particular reference to the incidence of urological complications. From August 2000 to July 2005, 209 left LLDNs were performed. We analyzed the outcomes of donors and recipients in relation to the presence of multiple vessels versus normal anatomy. We divided the patients into two groups: group A (n = 148) with normal vascular anatomy and group B (n = 61) with vascular anomalies. In the donors, no significant difference in conversion to open surgery rate, blood loss, length of stay, was noted between the two groups; operative time and warm ischemia time were slightly higher in group B. One-year patient survival was 98% in both groups while the 1-year graft survival was 96.6% in group A and 96% in group B. Only one urological complication was noted in the group with normal anatomy (0.7%) versus none in the group with multiple arteries. Left kidney procurement using robotic-assisted laparoscopic technique is safe and effective, even in the presence of vascular anomalies.

Adolescent↗