A Case of Pelviureteric Obstruction and Renal Stones with Transitional Cell Carcinoma. Beware of Tumor in Gross Hematuria

Presenting an interesting case report of a patient with gross hematuria. On contrast CT evaluation was found to have pelvicureteric obstruction with multiple secondary calculi. Since he was on anticoagulants and antiplatelets, these were thought tobe the cause of hematuria. On the table when laparoscopic pyeloplasty and stone removal procedure was on, incidental tumorin lower calyx was detected. Pyeloplasty was converted to laparoscopic nephrectomy after discussing with patients’ kin. Thishighlights the importance of suspecting tumor in patients presenting with gross hematuria.

Recomendaciones en la analgesia perioperatoria para la nefrectomía laparoscópica / Recommendations in perioperative analgesia for laparoscopic nephrectomy

Resumen: La nefrectomía laparoscópica se ha convertido en el enfoque quirúrgico estándar en muchos centros de tratamiento quirúrgico para los tumores renales, así como de otras patologías. Los estudios que comparan la nefrectomía abierta y laparoscópica reportaron que la nefrectomía laparoscópica facilitó una recuperación más rápida con una menor morbilidad perioperatoria, menor pérdida sanguínea y produjo menos dolor. Sin embargo, algunos pacientes sometidos a una nefrectomía laparoscópica todavía experimentan dolor postoperatorio que requiere el uso de opiáceos parenterales. Dado que el abordaje es frecuentemente lumboscópico, la distensión y el dolor interno en ese sitio quirúrgico, las incisiones de los puertos, la nocicepción de los órganos y los cólicos ureterales en conjunto con las molestias urinarias asociadas al catéter urinario contribuyen al dolor postoperatorio. A pesar de que esta cirugía ha llegado a ser menos invasiva, el dolor se reporta de moderado a intenso (visita http://www.painoutmexico.com para obtener la versión completa del artículo y el diagrama de recomendaciones).

Abstract: Lumboscopic nephrectomy has become the standard surgical approach in many surgical treatment centers for renal tumours as well as other pathologies. Studies comparing open and laparoscopic nephrectomy reported that laparoscopic technique facilitated a faster recovery with lower peri-operative morbidity, lower blood loss, and produced less pain. However, some patients undergoing laparoscopic nephrectomy still experienced postoperative pain requiring parenteral opioids. Due to the surgical approach is often lumboscopic, the distension and pain at the inner surgical site, laparoscopic port sites and incision, organ nociception, and ureteric colic together with urinary tract discomfort associated with urinary catheter contributed to the postoperative pain. So even though this surgery has become less invasive, pain is reported from moderate to intense (visit http://www.painoutmexico.com to see the full article and recommendations).

Resultados del trasplante renal con donante vivo: análisis comparativo entre arteria renal única y múltiple / Outcome in Living Donor Kidney Transplant: Comparative Análisis of Single and Multiple Renal Arteries

Objetivos: Realizar un análisis comparativo de los resultados funcionales y complicaciones en trasplantados renales y sus respectivos donantes vivos con arteria renal única versus múltiple. Materiales y métodos: Trabajo retrospectivo analítico de una base de datos confeccionada prospectivamente de pacientes sometidos a trasplantes renales con donante vivo en nuestra institución entre mayo de 2010 y julio de 2014. Según el número de arterias presentes en la angiotomografía preoperatoria se confeccionaron dos grupos: grupo 1 (arteria renal única) y grupo 2 (arteria renal múltiple). Resultados: De los 91 pacientes incluidos, el 37% (n=34) presentaba arterias renales múltiples. Se realizó una nefrectomía laparoscópica al 63% (n=36) y el 41% (n=14) de los donantes del grupo 1 y el grupo 2, respectivamente (p=0,05). Tiempos promedio de isquemia total (grupo 1: 55,6 min; grupo 2: 56 min; p=0,931), de anastomosis (grupo 1: 29,6 min; grupo 2: 29,7 min; p=0,982) y de "cirugía de banco" (grupo 1: 23,5 min; grupo 2: 23,8 min; p=0,948). Transfusión de glóbulos rojos en los receptores (grupo 1: 7%; grupo 2: 14%; p=0,23). Porcentaje de hemodiálisis en la primera semana (grupo 1: 5,2%; grupo 2: 5,8%; p=1). No se hallaron diferencias significativas entre grupos a nivel de tasa de complicaciones y días de internación. Ambos grupos presentaron una sobrevida del injerto del 100% a los 35,6 meses de seguimiento promedio. Conclusiones: La presencia de multiplicidad arterial no debe ser considerada una contraindicación para el donante vivo, ya que el implante de estos injertos logra resultados funcionales similares a los injertos renales con arteria única, sin aumentar la morbilidad del procedimiento. (AU)

Objectives: TTo compare functional outcomes and complications in patients with a single artery versus multiple arteries undergoing living donor nephrectomy. Materials and methods: Retrospective analysis of a prospective collected database of living donor kidney transplantations performed at our institution between May 2010 and July 2014. According to the number of arteries present in preoperative angiotomography, two groups of patients were organized: group 1 (single artery) and group 2 (multiple arteries). Results: TNinety-one living donor kidney transplantations were performed during this period. A total of 34 patients (37%) had multiple renal arteries. Mean total ischemia time (single: 55.6 min; multiple: 56 min; p=0.931), anastomosis time (single: 29.6 min; multiple: 29.7 min; p=0.982), bench surgery time (single: 23.5 min; multiple: 23.8 min; p=0.948). Blood transfusion rate was 7% and 14% for group 1 and group 2, respectively (p=0.23). Three patients in group 1 (5.2%) and two patients in group 2 (5.8%) needed dialysis during the first postoperative week (p=1). Overall, recipient complication rate and hospital stay were similar between group 1 and 2. Both groups had a 100% graft survival with a mean follow-up of 35.6 months. Conclusions: The presence of multiple renal arteries should not be considered a contraindication for the living donor nephrectomy, since these grafts achieve similar functional results to single artery renal grafts, without increasing the morbidity of the procedure. (AU)

A Clinical Experience of Laparoscopic Nephrectomy in Primary Hospital / 昆明医科大学学报

Objective To investigate the clinical value and the experience of retroperitoneal laparoscopic nephrectomy in primary hospitals. Methods A retrospective analysis of 20 cases of retroperitoneal nephrectomy performed in the people's hospital of Jianshui from July 2014 to December 2017 and 23 cases of open nephrectomy in the same period as the control group, the two groups of surgery and postoperative recovery were analyzed and compared. Results The two groups of patients were operated successfully. The surgery time of the laparoscopic group was (110.14 ±15.63) min and the control group was (100.33 ±10.58) min. There was no statistical difference between the two groups (P＞0.05). No complications occurred during the follow-up period between the two groups, and the difference was not statistically significant. The intraoperative blood loss in the two groups was (40.63 ±22.21) ml and (80.45 ±38.31) m L respectively, and the difference was statistically significant (P＜ 0.05).The indwelling time of drainage tube in the two groups was (2-3) days and (6-7) days respectively. The difference was statistically significant (P＜ 0.05), and the hospitalization time was (3.2 ±2.2) days and (6.4 ± 3.3) days respectively, the difference was statistically significant (P＜0.05). Conclusions Laparoscopic nephrectomy has the advantages of less trauma, faster recovery and shorter hospital stay. With the improvement of operation technique, it will bring more advantages and be worth popularizing.

Post-operative pain after ultrasound transversus abdominis plane block versus trocar site infiltration in laparoscopic nephrectomy: a prospective study / Dor no período pós-operatório de nefrectomia laparoscópica com bloqueio do plano transverso abdominal guiado por ultrassom versus infiltração do sítio do trocarte: um estudo prospectivo

Abstract Background Transversus abdominis plane (TAP) block is useful in reducing post-operative pain in laparoscopic nephrectomy compared to placebo. The purpose of this work is to compare post-operative pain and recovery after TAP block or trocar site infiltration (TSI) in this surgery. Methods A prospective, single blinded study on patients scheduled for laparoscopic nephrectomy. Patients were assigned to two groups: TSI Group: trocar site infiltration at the end of surgery; TAP Group: unilateral ultrasound-guided TAP block after induction. Sevoflurane and remifentanil, in a target controlled infusion mode, were used for maintenance of general anesthesia. Before the end of surgery paracetamol, tramadol and morphine were administered. Visual analogue scale (VAS 0-100 mm) at rest and with cough was applied in three moments: in recovery room (T1 at admission and T2 before discharge) and 24 h after surgery (T3). Pain scores with incentive spirometer were also evaluated at T3. In recovery, morphine was administered as a rescue drug whenever VAS > 30 mm. Time to oral intake, chair sitting, ambulation and length of hospital stay were evaluated 24 h after surgery. Statistical analysis: Student's t-test and Chi-square test, and linear regression models. A p-value < 0.05 was considered significant. Data are presented as mean (SD). Results Forty patients were enrolled in the study. The primary outcome variable, VAS pain scores did not show a statistical significant difference between groups (p > 0.05). VAS at rest (TAP vs. TSI groups) was: T1 = 33 ± 29 vs. 39 ± 32, T2 = 10 ± 9 vs. 17 ± 18 and T3 = 7 ± 12 vs. 10 ± 18. VAS with cough (TAP vs. TSI groups) was: T1 = 51 ± 34 vs. 45 ± 32, T2 = 24 ± 24 vs. 33 ± 23 and T3 = 20 ± 23 vs. 23 ± 23. VAS with incentive spirometer (TAP vs. TSI groups) was: T3 = 21 ± 27 vs. 21 ± 25. Intraoperative remifentanil consumption was similar between TAP (0.16 ± 0.07 mcg.kg-1.min-1) and TSI (0.18 ± 0.9 mcg.kg-1.min-1) groups. There were no differences in opioid consumption between TAP (4.4 ± 3.49 mg) and TSI (6.87 ± 4.83 mg) groups during recovery. Functional recovery parameters were not statistically different between groups. Conclusions Multimodal analgesia with TAP block did not show a significant clinical benefit compared with trocar site infiltration in laparoscopic nephrectomies.

Resumo Justificativa O bloqueio do plano transverso abdominal (TAP) é útil para reduzir a dor no pós-operatório de nefrectomia laparoscópica comparado com o placebo. O objetivo deste estudo foi comparar a dor no pós-operatório e a recuperação após bloqueio TAP ou infiltração do sítio do trocarte (TSI) nesse tipo de cirurgia. Métodos Estudo prospectivo e cego com pacientes agendados para nefrectomia laparoscópica. Os pacientes foram divididos em dois grupos: Grupo TSI: infiltração do sítio do trocarte ao final da cirurgia; Grupo TAP: bloqueio TAP unilateral guiado por ultrassom após a indução. Sevoflurano e remifentanil administrado em perfusão alvo-controlada foram usados para a manutenção da anestesia geral. Paracetamol, tramadol e morfina foram administrados antes do fim da cirurgia. Escala analógica visual (VAS 0-100 mm), para avaliar a dor em repouso e durante a tosse, foi aplicada em três momentos: na sala de recuperação [na admissão (T1) e antes da alta (T2)] e 24 horas após a cirurgia (T3). Os escores de dor com espirômetro de incentivo também foram avaliados em T3. Durante a recuperação, morfina foi administrada como medicamento de resgate, sempre que VAS > 30 mm. Os tempos até a ingestão oral, sentar em cadeira, deambulação e de permanência hospitalar foram avaliados 24 horas após a cirurgia. Análise estatística: teste t de Student, teste do qui-quadrado e modelos de regressão linear. Um valor de p < 0,05 foi considerado significativo. Os dados foram expressos em média (DP). Resultados Quarenta pacientes foram incluídos no estudo. Os escores do desfecho primário e da VAS não apresentaram diferença estatística significativa entre os grupos (p > 0,05). Os escores VAS em repouso (TAP vs. TSI) foram: T1 = 33 ± 29 vs. 39 ± 32; T2 = 10 ± 9 vs. 17 ± 18 e T3 = 7 ± 12 vs. 10 ± 18. Os escores VAS durante a tosse (TAP vs. TSI) foram: T1 = 51 ± 34 vs. 45 ± 32; T2 = 24 ± 24 vs. 33 ± 23 e T3 = 20 ± 23 vs. 23 ± 23. Os escores VAS com espirômetro de incentivo (TAP vs. TSI) foram: T3 = 21 ± 27 vs. 21 ± 25. O consumo de remifentanil no intraoperatório foi semelhante entre os grupos TAP (0,16 ± 0,07 mcg.kg-1.min-1) e TSI (0,18 ± 0,9 mcg.kg-1.min-1). Não houve diferença no consumo de opioides entre os grupos TAP (4,4 ± 3,49 mg) e TSI (6,87 ± 4,83 mg) durante a recuperação. Os parâmetros funcionais de recuperação não foram estatisticamente diferentes entre os grupos. Conclusões A analgesia multimodal com bloqueio TAP não mostrou benefício clínico significativo comparado com a infiltração do sítio do trocarte em nefrectomia laparoscópica.

Relative motion theory in retroperitoneal laparoscopic partial nephrectomy: Clinical application and experience / 第二军医大学学报

Objective To investigate the feasibility and advantages of five skills summarized by relative motion theory in reducing difficulty of suturing the kidney during retroperitoneal laparoscopic partial nephrectomy. Methods We retrospectively analyzed the clinical data of 89 patientsundergoing retroperitoneal laparoscopic partial nephrectomy in the Department of Urology of Changhii Hospital, Second Military Medical University between Jan. 2014 and May 2016. There were 42 cases in the control group and 47 cases in the skill group. Five skills including “move, add, push, pull, and shitt” were strictly applied to reconstruct the kidney in the skill group, but not fully used in the control group. Warm ischemic time, operation time, intra-operative blood loss, renal function and complications were compared between the two groups during and after operation. Results The operations were successfully completed in all the 89 cases. The average warm ischemic time was (22. 4 ± 4. 9) min and the operation time was (96. 0±11. 6) min in the skill group; while those in the control group were (24. 5 ± 4. 8) min and (102. 0 ± 13. 7) min, respectively, and the differences between the two groups were statistically significant (P<0. 05). There were no significant differences in the intra-operative blood loss, blood transfusion or artery injury between the two groups. No complications such as urine leakage or post-operative bleeding were observed in either groups. Conclusion The five skills summarized by relative motion theory are clinically feasible and safe in retroperitoneal laparoscopic partial nephrectomy, and can shorten operation time and renal warm ischemic time.

Nefrectomía laparoscópica de donante vivo: experiencia de 75 casos consecutivos / Live donor laparoscopic nephrectomy: experience in 75 cases

Background: Live Donor Laparoscopic Nephrectomy (LDLN) has substantial benefits when compared with open nephrectomy such as shorter hospital stay, prompt return to work, less post-operative pain, better cosmetic results, less blood loss and less surgical wound infections. It is the mode of choice for safely harvesting a kidney for organ transplantation. Aim: To describe the surgical results of LDLN in a pioneer renal transplant center in Chile. Material and Methods: Review of clinical records of 75 subjects aged 27 to 60 years (37 males) subjected to a LDLN in a public hospital between 1998 and 2013. Information about clinical and surgical data and perioperative complications was retrieved. Results: No subject died. All kidneys were satisfactorily implanted in their receptors. The mean operative time was 116 minutes. Mean hospital stay was 1.6 days, warm ischemia time was 6.8 minutes, and cold ischemia time was 31.5 minutes. Operative adverse events occurred in 8 percent. The conversion and reoperation rates were 4 and 1.3 percent, respectively. Among receptors, 1.5 percent evolved with Acute Tubular Necrosis and 2.2 percent required graft excision. Conclusions: LDLN is a safe and pioneering surgical technique in Chile. Its results are satisfactory and comparable to those obtained with classic lumbotomy.

Introducción: El trasplante renal es en la actualidad el tratamiento de elección de la Insuficiencia Renal Crónica Terminal. La Nefrectomía Laparoscópica del Donante Vivo (NLDV) tiene ventajas sustanciales en relación a la Nefrectomía Clásica. Entre estas se destacan una menor estancia hospitalaria, pronto regreso a la actividad laboral, disminución del dolor post-operatorio, mejores resultados cosméticos, menor pérdida de volumen sanguíneo y una disminución de infecciones de heridas operatorias, consolidándose como la primera prioridad como forma de obtener un órgano para trasplante renal. El presente trabajo tiene como objetivo mostrar la casuística y complicaciones en el Hospital Barros Luco-Trudeau (HBLT), como centro pionero en NLDV en nuestro país. Material y Método: Estudio retrospectivo de corte transversal. Se realiza una revisión de registros clínicos de 75 NLDV realizadas entre 1998-2013, seleccionando datos demográficos, clínicos y quirúrgicos de donantes y receptores, con un especial énfasis en relación a complicaciones peri-operatorias. Resultados: Sin mortalidad. Todos los riñones fueron implantados satisfactoriamente en sus respectivos receptores. Cirugía con duración promedio de 116 min, estadía hospitalaria promedio de 1,6 días, isquemia caliente promedio de 6,8 min e isquemia fría promedio de 31,5 min. Incidentes operatorios 8 por ciento y 4 por ciento conducentes a conversión. Tasa de reoperación de 1,3 por ciento. En cuanto a receptores, un 1,5 por ciento desarrolla Necrosis Tubular Aguda. 2,2 por ciento requiere transplantectomía. Discusión: La NLDV representa una técnica segura, que ha llegado a constituir el 100 por ciento de las nefrectomías de donantes vivos realizadas durante los últimos tres años. Los resultados son satisfactorios y plenamente comparables a los resultados obtenidos por lumbotomía clásica y de otros centros de alto volumen laparoscópico a nivel internacional.

Laparoscopic nephrectomy for xanthogranulomatous pyelonephritis: are there predictive factors for success?

OBJECTIVES: Laparoscopic nephrectomy for xanthogranulomatous pyelonephritis is currently associated with great operative difficulty and surgical complications. Herein, we report on our single-center experience and describe predictive factors for successfully accomplishing this procedure. METHOD: Between March 1998 and April 2010, 66 patients (27 men and 39 women) underwent laparoscopic nephrectomy for the treatment of a unilateral nonfunctioning kidney. These patients had previous diagnoses of renal chronic inflammation associated with calculi and previous pyonephrosis. All of the nephrectomies were performed using the transperitoneal approach, and a similar technique was used for radical nephrectomy. RESULTS: Laparoscopic nephrectomy for the treatment of renal chronic inflammation was successful in 58/66 cases (87.9%). Eight cases were converted to the open technique because of difficulty in progression, which was related to the discovery of dense adhesions in the hilar or perirenal region. One major (colonic lesion) and two minor (wound infection) complications occurred in the conversion group. A diagnosis of xanthogranulomatous pyelonephritis was confirmed pathologically for all of the specimens. Of the factors examined, a longitudinal renal length greater than 12 cm (laparoscopy group - 7.2±1.8 cm, versus open group - 13.6±1.5 cm; p<0.05) and time to access the renal vessels (laparoscopy group - 32±18 min, versus open group - 91±11 min; p<0.05) were associated with a higher conversion rate. Although the number of patients in the conversion group was small, the majority of these patients received right-sided nephrectomy. CONCLUSIONS: Laparoscopic nephrectomy for the treatment of xanthogranulomatous pyelonephritis is feasible and associated with low levels of morbidity. Factors including the time required to control the renal vessels, renal length and right-sided nephrectomy were associated with higher chances of conversion into an open procedure.

Una alternativa de extensión de la vena renal derecha en donante vivo laparoscópico / An alternative for enlargement of right renal vein in laparoscopic living donor nephrectomy

El manejo de la vena renal derecha en la nefrectomía laparoscópica del donante vivo puede en ocasiones representar un problema como consecuencia de la longitud limitada de este vaso. El caso clínico que se presenta muestra una técnica de extensión de la vena renal utilizando la vena gonadal del donante.

Vascular management of the right renal vein during laparoscopic living donor nephrectomy is still an unsolved problem. This short vessel has limited the use of right kidneys. However, the right kidney should be harvested in some instances. A renal vein enlargement technique using the donor gonadal vein is presented which may facilitate the use of right kidneys in this setting.

Hand-Assisted Laparoscopic Live Donor Nephrectomy / 대한비뇨기과학회지

PURPOSE: Hand-assisted laparoscopic live donor nephrectomy (HALDN) are being performed at our institution in an attempt to make live donor more attractive to the potential donor. We review the results of HALD N retrospectively and compare them with those obtained using the standard open approach. MATERIALS AND METHODS: 9 consecutive HALDN were performed from February 2000 through June 2000. The control group consisted of the 22 open donor nephrectomy at the same institution from January 1999 through December 1999 immediately before the initiation of HALDN. Live donors were considered candidates for HALDN if they possessed left normal renal anatomy with single renal vessels and ureter. Among 9 HALDN patients, one patient had two main renal arteries and another one patient had a polar artery. We evaluated sex, age, body weight, BMI (Body Mass Index) basically. And we evaluated renal ischemic time, operation time, to normal activities, postoperative serum creatinine level, and postoperative complications. RESULTS: There was no significant difference in male-female ratio, age distribution and weight-height ratio between two groups. Warm ischemic time for HALDN group was 3 to 4 min and it was not different with open surgery. Operation time was prolonged in HALDN group (284.4+/-72.8 min) compared to open group (193.1+/-26.7 min) (p