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At least 163 records · Page 9Linked to original sources

PubMed2005

Is routine postoperative chest radiography needed after open nephrectomy?

OBJECTIVES: To assess whether routine postoperative chest radiography (CXR) is required after open nephrectomy for the detection and possible management of a pneumothorax. It has become the standard of care by many urologists to obtain routine postoperative CXRs after open nephrectomy to assess for the presence of a pneumothorax. However, at our institution, very few patients have developed a pneumothorax postoperatively, and, furthermore, the CXR findings almost never affected the clinical management. METHODS: Retrospective data were collected on the last 150 open nephrectomies performed by two urologists at our institution. All laparoscopic nephrectomies and thoracoabdominal nephrectomies were excluded from analysis. RESULTS: A total of 150 patients underwent open nephrectomy between 1998 and 2003. The procedure was performed with an anterior subcostal, 11th rib, 12th rib, midline, and 10th rib incision in 60 (40%), 51 (34%), 18 (12%), 20 (13.3%), and 1 (0.67%) patient, respectively. Of the 150 patients, 92 (61.3%) underwent postoperative CXR and 58 (38.7%) did not. Of the 150 patients, 92 of whom had undergone postoperative CXR, 4 (2.7%) had a postoperative pneumothorax. One of these patients (0.67%) received a chest tube. Of the 4 patients with a pneumothorax, 3 had had a recognized pleural tear that was repaired at nephrectomy and the fourth had had an unrecognized pleural injury. CONCLUSIONS: Routine postoperative CXRs are not needed after open nephrectomy. Obtaining a selective CXR when a recognized intraoperative pleural tear has occurred, a central line is placed, the physical examination reveals an abnormality (ie, decreased breath sounds), or the patient experiences respiratory difficulties in the postoperative period is safe, cost-effective, and decreases the radiation exposure to patients.

Adult↗

PubMed1998

The risk of nephrectomy during local control in abdominal neuroblastoma.

METHODS: Eight hundred sixty-eight children presenting from 1981 to 1991 were treated on five multiagent chemotherapy protocols by members of the Pediatric Oncology Group for advanced-stage neuroblastoma with large primary tumors crossing the midline or distant metastasis. Of these children, 696 had abdominal (adrenal or paravertebral) primary tumors. One hundred sixteen children underwent greater than 50% surgical resection of these abdominal primary tumors before chemotherapy, and 233 underwent similar surgery after induction chemotherapy. RESULTS: Among the 349 who underwent surgical resection, 52 children (14.9%) had nephrectomy or renal infarction during surgery for local control. There was a 25% incidence among those with initial resection (29 patients) and a 9.9% incidence in the postchemotherapy resections (23 patients). Reasons for nephrectomy given by the surgeons included direct involvement of the kidney by adjacent tumor (17 children), clinical impression that the tumor was a Wilms' tumor (11 children), renal vessels could not be separated from the tumor (10 children), extensive tumor surrounding the kidney (8 children), postoperative renal infarction (4 children), marked decrease in unilateral renal function after chemotherapy (1 child), and position of the tumor posterior to the kidney and vena cava making resection without nephrectomy impossible (1 child). Of the patients undergoing nephrectomy, four children had an upper pole nephrectomy in conjunction with their adrenalectomy and resection of the tumor. Pathological review of the resected tumor available in 47 cases demonstrated direct involvement of the renal parenchyma in 18 cases (38% of the nephrectomies) and in 5.2% of those undergoing resection. In children undergoing initial resection, the risk for nephrectomy (as calculated by the methods described by Gart) was more than twice compared with those undergoing resection after chemotherapy (P = .012; odds ratio, 2.32; 95% confidence interval of 1.23 to 4.42). CONCLUSIONS: This review confirms that renal parenchymal involvement does occur in a significant number of children with abdominal neuroblastoma. It also suggests that preoperative chemotherapy may decrease the number of nephrectomies required to achieve a total or subtotal resection.

Abdominal Neoplasms↗

PubMed1998

Changes in regional renal blood flow after unilateral nephrectomy using the techniques of autoradiography and microautoradiography.

PURPOSE: To determine alterations in regional renal blood flow following unilateral nephrectomy using an autoradiographic technique. The role of prostaglandins and the sympathetic nervous system in the mediation of these changes was assessed. MATERIALS AND METHODS: C-14 iodoantipyrine was used as a tracer to measure intrarenal blood flow in anaesthetised rats at multiple time points following nephrectomy. Autoradiographs were produced from tissue sections. C-14 concentrations were measured from standards thus allowing blood flow values to be calculated. RESULTS: Base line values for cortical and medullary blood flow were 806 +/- 63 and 373 +/- 39 ml./100 gm./min. (mean +/- SEM) respectively. At 2 hours post nephrectomy blood flow to both the cortex and medulla increased significantly (1152 +/- 54 and 594 +/- 37; p < 0.05). Blood flow had returned to control levels by 24 hours and was maintained at 5 days post-nephrectomy. Multiple discrete regions of high blood flow within the cortex were observed. Microautoradiography defined the morphological location of these discrete regions of higher blood flow as periglomerular vasculature. Diclofenac administration did not inhibit the augmentation in cortical blood flow post-nephrectomy, while medullary blood flow fell below base line values at both 30 minutes and 2 hours following nephrectomy. Sympathetic denervation did not affect the changes in cortical blood flow seen following nephrectomy, but did ameliorate the changes in medullary blood flow. CONCLUSIONS: Significant, transient changes in regional renal blood flow occur in the residual kidney following unilateral nephrectomy. The interaction between vasoactive mediators and the autonomic nervous system which produces changes in cortical blood flow is complex. It is evident, however, that medullary blood flow is dependent on local prostaglandin production and is also influenced by sympathetic nervous supply.

Animals↗

PubMed1997

Nephrectomy before interleukin-2 therapy for patients with metastatic renal cell carcinoma.

PURPOSE: The management of metastatic renal cell carcinoma remains challenging and controversial. There is some evidence of improved response to interleukin-2 (IL-2) based immunotherapy in patients who undergo nephrectomy before systemic treatment. However, recent reports have suggested that surgery prior to immunotherapy may not be an efficient strategy, since many patients will not be able to receive systemic treatment after nephrectomy. We describe our criteria for determining which patients are candidates for nephrectomy before immunotherapy and present our series of patients treated with this approach. MATERIALS AND METHODS: Based on our initial experience with IL-2 based immunotherapy we developed certain inclusion criteria for treatment with initial nephrectomy followed by systemic immunotherapy, including greater than 75% debulking of tumor burden possible, no central nervous system, bone or liver metastases, adequate pulmonary and cardiac function, and Eastern Cooperative Oncology Group performance status of 0 or 1. In addition, patients in whom biopsies show other than predominantly clear cell type histology are excluded. From 1991 through 1996, 28 patients met these criteria and were treated with this approach. Patients were followed to determine the number receiving immunotherapy as well as overall response and survival rates. RESULTS: Radical nephrectomy was performed in all patients. One patient died of respiratory failure from disease progression 1 month after nephrectomy. Another patient had poor pulmonary function and, therefore, was treated with an alternative cytokine therapy. The remaining 26 patients (93%) received at least 1 course of IL-2. Median interval between nephrectomy and initiation of immunotherapy was 1.5 months (range 1 to 3). Overall response rate was 39% with 5 complete (18%) and 6 partial (21%) responses. Actuarial median survival of the entire group was 20.5 months (range 1 to 66) from the initiation of treatment. Currently 13 patients are alive, including 8 who are disease and/or progression-free. CONCLUSIONS: Using these strict criteria nephrectomy can be effectively performed before immunotherapy without compromising the likelihood that patients will receive systemic treatment. The activity of IL-2 in patients treated with this approach is encouraging and justifies its consideration in properly selected patients.

Adult↗

PubMed2000

Retroperitoneal laparoscopic radical nephrectomy: the Cleveland clinic experience.

PURPOSE: Laparoscopic radical nephrectomy is usually performed by the transperitoneal approach. At our institution the retroperitoneoscopic approach is preferred. We confirm the technical feasibility of retroperitoneoscopic radical nephrectomy, even for large specimens, and compare its results with open surgery in a contemporary cohort. MATERIALS AND METHODS: A total of 47 patients underwent 53 retroperitoneoscopic radical nephrectomies. Data from the most recent 34 laparoscopic cases were retrospectively compared with 34 contemporary cases treated with open radical nephrectomy. RESULTS: For the 53 retroperitoneoscopic radical nephrectomies mean tumor size was 4.6 cm. (range 2 to 12), surgical time was 2.9 hours (range 1.2 to 4.5) and blood loss was 128 cc. Mean specimen weight was 484 gm. (range 52 to 1,328), and concomitant adrenalectomy was performed in 72% of patients. Mean analgesic requirement was 31 mg. morphine sulfate equivalent. Average hospital stay was 1.6 days, with 68% of patients discharged from the hospital within 23 hours of the procedure. Minor complications occurred in 8 patients (17%) and major complications occurred in 2 (4%) who required conversion to open surgery. Various parameters, including patient age, body mass index, American Society of Anesthesiologists status, tumor size (5 versus 6.1 cm.), specimen weight (605 versus 638 gm.) and surgical time (3.1 versus 3.1 hours), were comparable between patients undergoing laparoscopic (34) and open (34) radical nephrectomy. However, laparoscopy resulted in decreased blood loss (p <0.001), hospital stay (p <0.001), analgesic requirements (p <0.001) and convalescence (p = 0.005). Complications occurred in 13% of patients in the laparoscopic group and 24% in the open group. CONCLUSIONS: Retroperitoneoscopy is a reliable, effective and, in our hands, the preferred technique of laparoscopic radical nephrectomy. At our institution retroperitoneoscopy has emerged as an attractive alternative to open radical nephrectomy in patients with T1-T2N0M0 renal tumors.

Adult↗

PubMed2006

Hand pain during hand assisted laparoscopic nephrectomy--an ischemic event?

PURPOSE: The etiology of hand discomfort during hand assisted laparoscopic nephrectomy may be ischemic in nature. We determined if pneumoperitoneal pressure sustained to the hand during hand assisted laparoscopic nephrectomy poses an occupational risk, contributing to local hand hypoxia and resultant extremity pain. MATERIALS AND METHODS: A total of 442 measurements of hand oxygen saturation were made during hand assisted laparoscopic nephrectomy. A Nellcor OxiMax Max-1 oxygen sensor was attached to the left index finger of each surgeon and hand assisted laparoscopic nephrectomy was performed using a LapDisc at 15 mm Hg pneumoperitoneal pressures. Local hand oximetry readings and a numerical pain distress scale (range 0 to 10) were recorded every 2 minutes. To control for motion artifact oximetry readings were taken during hand motion and at rest. The Student t test was used to compare differences in local hand oxygen saturation and hand pain in and between study groups. RESULTS: A history of hand pain during hand assisted laparoscopic nephrectomy was significantly associated with local hypoxia during operative motion and at rest (p = 0.023 and 0.012, respectively), even with an adequate fascial incision and standard pneumoperitoneal pressures. During hand assisted laparoscopic nephrectomy hand pain was most significantly associated with local hypoxia after 24 minutes (p = 0.0002), when local oxygen saturation was 56% to 88%. CONCLUSIONS: A cohort of urologists is predisposed to ischemic hand pain during hand assisted laparoscopic nephrectomy. The etiology of this pain may be hypoxic in nature, attributable to pneumoperitoneal pressure decreasing perfusion and causing venous congestion or regional local ischemia. Circumferential antebrachial constriction from the LapDisc does not seem to be a significant contributing factor in the presence of an adequate fascial incision. Hand pain secondary to ischemia is most significant after 24 minutes at 15 mm Hg. Future studies in more subjects are called for to validate these findings to elucidate which surgeons are predisposed to this potential occupational hazard and what perioperative measures can be taken to avoid hand pain during hand assisted laparoscopic nephrectomy.

Adult↗

PubMed1991

Intraoperative renal ultrasonography: a useful adjunct to partial nephrectomy.

Several evolutionary changes in ultrasonographic instrumentation, including miniaturization of transducers and marked improvement in resolution, have made intraoperative renal ultrasonography a valuable adjunct for intrarenal surgery. We investigated its use in 6 patients undergoing partial nephrectomy for treatment of renal cell carcinoma. In addition, 14 kidneys with renal tumors were scanned immediately after radical nephrectomy and the specimens were subjected to simulated partial nephrectomy. Transverse and longitudinal real-time sonographic images were obtained with a 5 MHz. sector scanner or a 7.5 MHz. convex array transducer. With ultrasonography to define tumor extent and location, negative surgical margins were obtained in all 6 individuals undergoing partial nephrectomy. A negative surgical margin was obtained in 13 of the 14 radical nephrectomy specimens subjected to simulated partial nephrectomy. A small satellite lesion was not identified and not resected in 1 of the radical nephrectomy specimens. We found that intraoperative renal ultrasonography helps to identify the location and extent of deep intraparenchymal lesions. It also provides a guide for a more accurate nephrotomy, which facilitates the attainment of negative resection margins during partial nephrectomy.

Carcinoma, Renal Cell↗

PubMedDate not supplied

[Hand-assisted laparoscopic nephrectomy].

INTRODUCTION AND OBJECTIVES: To present the number of cases of hand-assisted laparoscopic nephrectomy. This study evaluates our results and difficulties of starting a progresive programme of laparoscopy. MATERIAL AND METHOD: Between november 2003 and november 2005, 35 hand-assisted laparoscopic nephrectomies were carried out, of a total of 45 laparoscopic nephrectomies. 22 radical nephrectomies, 3 simple nephrectomies and 10 nephroureterectomies. The average age of patients was 66 years (47-89). On average, they were overweight (IMC 28,3), with approximately 38% being obese. ASA 2.3 (1-4). The tumors measured 4.8cm on average, and 80% of these were T1. In 28.6% of the cases, they had previously undergone abdominal surgery. RESULTS: One was undertaken in 2003, 17 in 2004, and 17 in 2005. The surgery time was 140 minutes, 130 minutes (80-210) in radical nephrectomies, 135 minutes (120-150) in simple nephrectomies and 163 minutes (80-240) in the nephroureterectomy. Patients began an oral diet 1.7 days later, and were able to get up 1.7 days later. In the case of obese patients, they began an oral diet 2.3 days later and were able to get up (2.4 days) later than those non obese cases. (1.5 and 1.4 days respectively). The average stay has been 5.8 days (3-15). The average stay of the cases without complications was 4.2 days and those that encountered complications 9.7 days. In no cases was there a need for a blood transfusion. In 11.4% we had major complications with an average stay of 11.7 days. In 5.7% of cases there were reconversions, and 5.7% of cases were reoperated. 17.1% had minor complications, with an average stay of 8.8 days CONCLUSIONS: The advantage of hand-assisted nephrectomy is that it allows one to begin a laparoscopy, with a reduced learning time, and with satisfactory results, allowing the incorporation of laparoscopy surgery in hospitals with a reduced annual volume.

Aged↗

PubMed2002

The role of initial immunotherapy as selection for nephrectomy in patients with metastatic renal cell carcinoma and the primary tumor in situ.

OBJECTIVE: A prospective pilot study in patients with metastatic renal cell cancer and the primary in situ to assess the feasibility of immunotherapy prior to nephrectomy and to evaluate the rationale for a future randomized trial to define the role of response to upfront immunotherapy as selection for cytoreductive surgery. PATIENTS AND METHODS: Sixteen patients with synchronous multiple metastases were treated with the primary tumor in place and were evaluated with regard to age, sex, sites of extrarenal disease, morbidity, response, nephrectomy rate, time to progression and overall survival. Immunotherapy consisted of 2 courses low-dose IL-2 4MIU/m(2), subcutaneous GM-CSF 2.5 microg/kg and interferon-alpha (IFN-alpha) 5MU flat on day 1-13 and 22-34. Patients with either partial remission (PR) or stable disease (SD) underwent nephrectomy followed by a third and fourth course. RESULTS: No response was seen in the primary tumors. With regard to extrarenal sites SD was noted in nine cases, PR in two and progressive disease (PD) in five. Eleven patients underwent nephrectomy. No surgical complete response (CR) could be achieved. All patients with PD died after a median overall survival of 3 months versus 11.5 months (range 4-22) in those who underwent nephrectomy. Four patients are still alive at 10, 12, 18 and 19 months. Median duration of response was 6 months (range 2-10). One patient with SD following nephrectomy developed CR after two additional cycles, which is currently maintained for >10 months. CONCLUSIONS: Absence of progression at metastatic sites following immunotherapy may be used as a selection for nephrectomy in this selected group. Non-responding patients can be spared from surgery. A randomized study is needed to assess the timing of nephrectomy in combination with immunotherapy with regard to morbidity, overall survival and quality of life.

Adult↗

PubMed2002

Pathological spectrum of nephrectomies in a general hospital.

OBJECTIVES: To first categorize a series of nephrectomies according to underlying pathology, as practised in a major general hospital in the north of Jordan, and then compare the results with published figures for Western countries. Also, to create standards for future evaluation of nephrectomies performed by laparoscopy. METHODS: The hospital and pathological records of 423 consecutive nephrectomies performed at Princess Basma Teaching Hospital in the north of Jordan during the period of 1991 to 2000 were reviewed. RESULTS: Benign disease led to surgery in 298 cases, of which 161 were secondary to infection-related conditions. Malignancy resulted in the removal of 125 kidneys. The rate of nephrectomy for benign conditions has declined during the last few years in comparison with that for malignant conditions. Patients operated on for benign diseases were younger [mean age, 38.4 years] than those with malignant tumours [mean age, 46.7 years]. CONCLUSIONS: The mean age of patients undergoing surgery for benign and malignant disease was lower than in publications from Western countries. The frequency of nephrectomy performed for tuberculosis, hydatid disease, and xanthogranulomatous pyelonephritis is still higher than the rates published in Western countries. There is a remarkably low frequency of upper urothelial carcinoma compared with Western countries, probably due to environmental differences and genetic susceptibilities. Malignant renal tumours tend to affect people at a remarkably young age in Jordan, which is thought to be a reflection of the high proportion of young people. Nephrectomy for malignant disease had a higher rate of complications (16.8%) than for benign conditions [9.4%; p less than 0.0228]. The re-operation rate was 3.1% for all patients who underwent nephrectomy. The overall 30-day mortality rate was 0.9%. Both screening and education programmes are needed to decrease the rate of nephrectomy for preventable conditions.

Adolescent↗

PubMed2000

Laparoscopic live donor nephrectomy: pre-operative assessment of technical difficulty.

Laparoscopic live donor nephrectomy decreases disincentives to live kidney donation. Thus, many centers are interested in adopting this procedure. However, the high stakes involved for both the donor and the recipient, and the technical difficulties of the operation, have tempered the enthusiasm of some surgeons. Ideally, if early in their series, surgeons could select patients that would be the least challenging technically, it would facilitate the dissemination of this operation. The purpose of this study is to determine if anatomic or radiologic parameters can accurately assess pre-operatively the degree of technical difficulty of laparoscopic live donor nephrectomy for any individual patient. Abdominal spiral three-dimensional CT scanning was performed prior to laparoscopic donor nephrectomy. CT scans were reviewed for six radiographic anatomic parameters. Seven clinical anatomic measurements relating to body habitus were recorded upon induction anesthesia at the time of surgery. Demographic data for gender, age, race, weight, height, and smoking history were collected. Following laparoscopic live donor nephrectomy, the following six component parts of the operation were graded on a scale of 1-4 (1 = easy, 4 = very difficult) for technical difficulty: a) mobilization of the colon; b) mobilization of the upper pole; c) dissection of the renal vein; d) dissection of the renal artery; e) division of the adrenal vein; and f) dissection of the ureter. Also, operative time, estimated blood loss, and intra-operative fluid requirements were recorded as surrogate markers of operative difficulty. Forty-one patients were included in the study. Laparoscopic donor nephrectomy was successfully completed in all cases. The sum of the difficulty scores was 9.9+/-3.1 (mean) (range, 6-18). No anatomic, demographic, or radiologic parameters were predictive of the total operative difficulty score. Of the surrogate markers, only operative time correlated with total difficulty score (R = 0.47, p = 0.003). Donor weight and abdominal girth correlated with operative time (R = 0.50, p = 0.002; R = 0.38, p = 0.019) but not with total difficulty score (R = 0.10, p = 0.51; R = -0.02, p = 0.90, respectively). When the easiest cases and the hardest cases (< or = 25th percentile and > or =75th percentile total difficulty score, respectively) were segregated out, again no anatomic, demographic, or radiologic parameters were predictive of operative technical difficulty. In conclusion, laparoscopic live donor nephrectomy technical difficulty could not be predicted by body habitus from the variables examined in this study. Hence, it was equally likely that performing laparoscopic live donor nephrectomy using a heavy donor would be technically easy, as using a thin donor would be difficult. Although, in general, operative time increased with donor size and weight, it appears that laparoscopic live donor nephrectomy operative technical difficulty is dependent upon such factors as amount of laparoscopic working space, quality of tissue planes, and retractability of the colon and mesocolon; factors that, to date, are not quantifiable.

Adult↗

PubMed2005

Evaluation of hydrogel tissue sealant in porcine laparoscopic partial-nephrectomy model.

BACKGROUND AND PURPOSE: Laparoscopic partial nephrectomy (LPN) is technically challenging with a steep learning curve, primarily because techniques used to control bleeding on the cut surface of the kidney can be ineffective, inconsistent, or challenging. Hemostatic techniques can include intracorporeal suturing, vascular coagulation (argon-beam coagulator, bipolar cautery, laser), and application of various tissue sealants. There is no uniformity of opinion regarding which hemostatic technique is optimal for this application. CoSeal, a hydrogel (Baxter Healthcare Corp, Deerfield, IL), has been effective following vascular surgery but has not been applied to a partial-nephrectomy model. We evaluated the effectiveness of this hydrogel in controlling bleeding and sealing the collecting system by comparing it with intracorporeal suturing and fibrin sealant (Tisseel; Baxter) in a porcine laparoscopic partial-nephrectomy model. MATERIALS AND METHODS: Bilateral synchronous upper-pole partial nephrectomies were performed in two groups of 18 farm pigs, and the three hemostatic techniques (suturing, Tisseel, CoSeal) were applied. In the first group, partial nephrectomies were performed and the pigs sacrificed 3 days postoperatively (acute group). In the second group, the pigs were euthanized 6 weeks postoperatively (chronic group). In both groups, weight, blood pressure, estimated blood loss, weight of the partial and completion nephrectomy specimen, presence/ absence of urinary leak on retrograde study, histopathologic findings, and complications were recorded. RESULTS: The mean weight, blood pressure, estimated blood loss, histopathology findings, and weight of the partial and completion nephrectomy specimens were similar in the three groups. CoSeal did not adhere well to the renal parenchyma compared with Tisseel. All three animals in the acute CoSeal group and three of the six pigs in the sutured group had small urinary leaks during retrograde ureteral study, whereas none of the pigs in the fibrin-glue cohort had urinary leaks. There was one complication (urinary leak) in the CoSeal group, necessitating sacrifice of the animal on postoperative day 8 because of sepsis. CONCLUSIONS: CoSeal is not as effective as fibrin glue in adhering to the cut renal surface and sealing the collecting system during laparoscopic partial nephrectomy.

Animals↗

PubMedDate not supplied

Laparoscopic radical nephrectomy: long-term outcomes.

BACKGROUND: Although more than a decade of experience with laparoscopic radical nephrectomy indicates it is an alternative to open surgery for localized renal-cell carcinoma (RCC), the long-term oncologic effectiveness of this procedure remains to be established. MATERIALS AND METHODS: A thorough MEDLINE and PubMed literature research on long-term outcomes of laparoscopic radical nephrectomy was performed, and all pertinent articles were reviewed in detail. This review was formulated on the current cancer indication, the oncologic basis, the oncologic efficacy, and the longterm oncologic effectiveness of the procedure, including laparoscopic cytoreductive nephrectomy, with regard to metastasis, port-site tumor recurrence, and the relation to laparoscopic partial nephrectomy. Furthermore, the authors' previous report on the intermediate-term efficacy of laparoscopic radical nephrectomy was updated. RESULTS: With increasing experience, the indications for laparoscopic radical nephrectomy continue to expand. There were many reports of intermediate-term, two reports of long-term, and our up-to-date outcomes analyzing the management of localized RCC that showed effective cancer control with no statistically significant difference between laparoscopic and open radical nephrectomy in the true 5- and 10-year survival analysis. CONCLUSION: Long-term data, critical in the evaluation of any treatment for cancer, are currently available with respect to laparoscopic radical nephrectomy for localized RCC.

Adult↗

PubMed2001

Laparoscopic nephrectomy in young-old, old-old, and oldest-old adults.

BACKGROUND: This study reports findings for laparoscopic nephrectomy in comparison with open nephrectomy in geriatric patients. METHODS: Since 1993, a total of 249 patients have undergone nephrectomy for benign disease at the Medical University of Lübeck, Germany. In 11 patients older than 65 years, a laparoscopic nephrectomy was performed (in the majority via a transperitoneal approach), and 42 patients older than 65 years underwent an open-flank nephrectomy. Clinical parameters were evaluated in comparison with both groups and stratified according to age groups. RESULTS: With respect to operative results (operative duration and pre- and postoperative hemoglobin levels), no relevant differences were observed between the laparoscopy group and the open-nephrectomy group, even when stratified according to patient age. However, patients in the laparoscopy group demonstrated a significant advantage concerning blood loss and the number of required blood transfusions, regardless of age. In addition, patients after laparoscopy showed advantages in the postoperative course. Benefits were proven for the analgesic consumption, hospital stay, and convalescence parameters. Although complication rates were comparable in both groups, an increase was observed in both groups for patients aged between 75 and 84 years. CONCLUSIONS: Laparoscopic nephrectomy offers comparable operative results (with reduced blood loss and less need for blood transfusions) when compared with open surgery. Significant advantages can be demonstrated in the postoperative course, and especially geriatric patients benefit from these aspects of the minimally invasive approach. Laparoscopy should be regarded as the primary therapeutic option for nephrectomy for benign disease in these patients.

Age Factors↗

PubMed2006

The current practice of live donor nephrectomy in Europe.

BACKGROUND: The increasing number of live kidney donors in the last decade has stimulated interest in the surgical technique of donor nephrectomy. In this study, we evaluated the current status of the surgical approach in European transplant centers. METHODS: A questionnaire was sent to 131 centers in 12 European countries. Questions included the number of donors, the technique used, and the inclusion and exclusion criteria for a technique. RESULTS: Ninety-two replies (70%) were included. In the responding centers, approximately 1450 live donor nephrectomies were performed in 2004 (more than 80% of all live kidney donations in these countries). The number of living donors ranged from 0 to 95 per center. Nineteen institutions (21%) removed kidneys using endoscopic techniques only. Twenty-two centers (24%) performed both open and laparoscopic donor nephrectomy. Vessel length, difficult anatomy and right-sided donor nephrectomy were common reasons to choose an open technique. Twelve centers had performed laparoscopic donor nephrectomy but quit their program for various reasons. In 51 centers (55%), only open donor nephrectomy was carried out. Lack of evidence that endoscopic techniques provide better results was the main reason for these centers to stick to an open approach. Incisional hernias occurred after all types of open surgery in up to 30% of the donors per center. Twenty-nine clinics still carry out the classic flank incision. CONCLUSION: The surgical technique of live donor nephrectomy varies greatly between transplant centers in European countries. To define the optimal surgical approach a European registration of donor nephrectomies would be helpful.

Europe↗

PubMed2004

Laparoscopic and partial nephrectomy.

Radical nephrectomy is the gold standard curative operation for patients with localized renal cell carcinoma (RCC). Since its introduction in 1990, laparoscopic radical nephrectomy is being increasingly done at numerous institutions worldwide. In the hands of experienced laparoscopic urological surgeons and with adherence to established principles of open radical nephrectomy, laparoscopic radical nephrectomy is now a standard of care for patients with T1-3a N0 M0 RCC. Intermediate-term outcome data indicate equivalent cancer-free survival to open radical nephrectomy in such cases. Nephron-sparing surgery (NSS) is now an established approach for patients with localized RCC when there is a clinically relevant need to preserve renal function. NSS is also indicated in patients with a single, small, unilateral, localized RCC when the opposite kidney is completely normal. The technical success rate with NSS for RCC is excellent, and long-term patient survival free of cancer is comparable with that obtained after radical nephrectomy. We recently reviewed the results of NSS in 107 patients with localized sporadic RCC treated at the Cleveland Clinic before 1988 who were followed up for a minimum of 10 years. Long-term preservation of renal function was achieved in 93% of patients, and the 10-year cancer specific survival rate was 73%. Although open surgical partial nephrectomy remains the gold standard for nephron-sparing treatment of RCC, laparoscopic partial nephrectomy is now available in selected cases. The optimal indications for laparoscopic NSS are in patients with a relatively small and peripheral renal tumor. In such cases, laparoscopic NSS is proving to be an effective, minimally invasive therapeutic approach with respect to renal functional outcome, with additional advantages of reduced postoperative narcotic use, earlier hospital discharge, and a faster convalescence. The laparoscopic approach is associated with longer warm renal ischemia time, more major intraoperative complications, and more postoperative urological complications. Continued efforts are required to develop laparoscopic renal hypothermia techniques and to facilitate intrarenal suturing while minimizing the warm ischemia time.

Carcinoma, Renal Cell↗

PubMed1988

Pharmacologic treatment of hyperlipidemia reduces glomerular injury in rat 5/6 nephrectomy model of chronic renal failure.

The role of lipid abnormalities in the pathogenesis of focal glomerulosclerosis was investigated in the rat remnant kidney model of chronic renal failure. Rats subjected to right nephrectomy and two-thirds segmental infarction of the left kidney (5/6 nephrectomy) were treated for 10 weeks with the lipid-lowering agent clofibric acid. Both serum cholesterol and urine albumin excretion were significantly reduced by clofibric acid. At 10 weeks, the percent of glomeruli with focal glomerulosclerosis was 5 +/- 2% in clofibric acid-treated and 24 +/- 5% in untreated 5/6 nephrectomy rats (p less than 0.01). Inulin clearance was greater in clofibric acid-treated than in untreated 5/6 nephrectomy rats (0.28 +/- 0.02 versus 0.22 +/- 0.02 ml/min 100 g body wt, p less than 0.05). Body weight, kidney weight, and systemic blood pressure were not significantly altered by clofibric acid. Micropuncture studies, performed in separate groups of clofibric acid-treated and untreated 5/6 nephrectomy rats, demonstrated elevated single nephron glomerular filtration rates and glomerular capillary pressures 4 weeks after surgery. However, clofibric acid did not significantly alter single nephron glomerular filtration rates (95 +/- 2.1 nl/min in treated versus 97.0 +/- 6.2 nl/min in untreated, p greater than 0.05) or glomerular capillary pressures (56.6 +/- 1.5 mm Hg in treated versus 57.8 +/- 0.8 mm Hg in untreated, p greater than 0.05) in 5/6 nephrectomy rats. In a separate set of experiments, 5/6 nephrectomy rats were treated with the specific cholesterol synthesis inhibitor, mevinolin. Mevinolin improved serum lipid levels and reduced albuminuria in 5/6 nephrectomy rats without causing significant alterations in blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed2002

Effect of unilateral nephrectomy on the pharmacokinetics of amikacin in humans.

As unilateral nephrectomy is not a rare surgical procedure, it gives rise to the question whether drugs predominantly eliminated through the urinary tract can be handled effectively by the remaining kidney. Amikacin is predominantly excreted via glomerular filtration with only a small fraction undergoing tubular reabsorption, and can be used as a model drug of glomerular elimination. The study was carried out in 28 subjects, 10 one month and 10 one year after unilateral nephrectomy, as well as in 8 healthy subjects. The pharmacokinetics of amikacin was investigated after a 1-h infusion of 5 mg kg(-1) amikacin. Blood samples were collected for 24 h after the end of infusion. Pharmacokinetic parameters of amikacin were calculated using a one-compartment open model for intravenous administration. Amikacin concentrations were significantly elevated in nephrectomized patients as compared with control subjects, both 1 month and 1 year after the surgery, and were similar at these two time-points following unilateral nephrectomy. Pharmacokinetic parameters of amikacin in patients subjected to unilateral nephrectomy were significantly different from those observed in the control subjects. As compared with the controls, an increase in AUC (area under the serum concentration-time curve) by 81% (P < 0.001) and 63% (P < 0.01) 1 month and 1 year after nephrectomy was observed, respectively. The lambda(z) (elimination rate constant) was reduced by 39% (P < 0.001) after 1 month and by 38% (P < 0.001) 1 year after the operation and t 1/2 was prolonged by 70% (P < 0.001) and by 43% (P < 0.01) at the respective time-points following unilateral nephrectomy. CLT (total body clearance of the drug from plasma) and CL(BW) (clearance per kg body weight) were both significantly decreased in unilaterally nephrectomized subjects in comparison with the controls. CLT and CL(BW) were reduced by 53% (P < 0.001) and 42% (P < 0.01) 1 month after nephrectomy, and by 45% (P<0.001) and 42% (P<0.01) 1 year after the surgery, respectively. No significant differences among studied groups were found in C0 (initial serum drug concentration) and Vd (apparent volume of distribution). The results suggest that unilateral nephrectomy impairs elimination of amikacin, and possibly other drugs predominantly eliminated via glomerular filtration.

Adult↗