Step-by-Step robotic heminephrectomy for duplicated renal collecting system

Introduction A duplicated renal collecting system is a relatively common congenital anomaly rarely presenting in adults. Aim In this video we demonstrate our step-by-step technique of Robotic heminephrectomy in a patient with non-functioning upper pole moiety. Materials and Methods Following cystoscopy and ureteral catheter insertion the patient was placed in 600 modified flank position with the ipsilateral arm positioned at the side of the patient. A straight-line, three arm robotic port configuration was employed. The robot was docked at a 90-degree angle, perpendicular to the patient. Following mobilization the colon and identifying both ureters of the duplicated system, the ureters were followed cephalically toward, hilar vessels where the hilar anatomy was identified. The nonfunctioning pole vasculature was ligated using hem-o-lok clips. The ureter was sharply divided and the proximal ureteral stump was passed posterior the renal hilum. Ureteral stump was used as for retraction and heminephrectomy is completed along the line demarcating the upper and lower pole moieties. Renorrhaphy was performed using 0-Vicryl suture with a CT-1 needle. The nonfunctioning pole ureter was then dissected caudally toward the bladder hiatus, ligated using clips, and transected. Results The operating time was 240 minutes and blood loss was 100 cc. There was no complication post-operatively. Conclusions Wrist articulation and degree of freedom offered by robotic platform facilitates successful performance of minimally invasive heminephrectomy in the setting of an atrophic and symptomatic renal segment. .

Cicatrização renal após nefrectomia parcial laparoscópica sem fechamento do sistema coletor em porcos / Kidney healing after laparoscopic partial nephrectomy without collecting system closure in pigs

Introdução: Embora alguns estudos tenham descrito as semelhanças e diferenças anatômicas entre o rim humano e o rim suíno, pouco é conhecido sobre a cicatrização renal neste animal. O conhecimento da cicatrização do rim do porco é especialmente importante em procedimentos cirúrgicos que incisem o tecido renal e o sistema coletor, como é o caso da nefrectomia parcial. O objetivo do presente trabalho é estudar a cicatrização renal em porcos após nefrectomia parcial laparoscópica sem o fechamento do sistema coletor. Materiais e Métodos: Quatorze porcos machos com peso médio de 30 kg foram submetidos à nefrectomia parcial laparoscópica esquerda, removendo 25% do comprimento renal no pólo caudal (n=7) ou no pólo cranial (n=7). A técnica cirúrgica empregada envolveu acesso laparoscópico transperitoneal, clampeamento em bloco dos vasos renais, excisão do tecido renal com tesoura a frio e aplicação de energia monopolar para hemostasia do parênquima, deixando o sistema coletor aberto. Os animais foram avaliados clinicamente por 14 dias e então foram mortos. Níveis séricos de creatinina e uréia foram obtidos antes e em diferentes momentos após a cirurgia. São relatados ainda os achados de necropsia, pielografia retrógrada ex vivo e aspectos histológicos dos pólos renais operados. Resultados: Os níveis séricos de uréia e creatinina tiveram leve aumento inicial retornando aos valores pré-operatórios durante o período avaliado. Durante a necropsia verificou-se que não houve extravasamento de urina a partir do rim operado e que este se cobriu com tecido fibroso, aderindo-se aos tecidos adjacentes. Nas pielografias retrógradas não foi verificado nenhum extravasamento de contraste pelos pólos operados. Os achados histológicos mostraram grande deposição de colágeno tipo I sobre o pólo renal operado, vedando-o completamente. Conclusão: O rim suíno não é um bom modelo para pesquisas ou treinamento cirúrgico em que a cicatrização do sistema coletor seja um aspecto importante.

Introduction: Although some studies have described similarities and diferences between human and pig kidney anatomy, little is known regarding renal healing in this animal model. The knowledge of pig kidney healing is especially important in surgical procedures which incise the renal parenchyma and collecting system, such as partial nephrectomy. The aim of this study is to access kidney in pigs after laparoscopic partial nephrectomy without closuring of the collecting system. Materials and Methods: Fourteen male pigs with mean weight of 30 kg were submitted to left partial laparoscopic nephrectomy, removing 25% of the kidney length at caudal pole (n=7) or at cranial pole (n=7). Briefly, the surgical technique involved a transperitoneal laparoscopic access, en bloc vascular clamping of renal artery an vein, tissue excision with cold scissor and monopolar energy parenchyma hemostasis, leaving the collecting system opened. The animals were clinically evaluated during fourteen days, and afterwards were killed. Serum levels of creatinine and urea were assessed prior and at different moments after surgery. Necropsy findings, retrograde ex vivo pyelogram and histological aspects of operated renal poles are also described. Results: Serum creatinine and urea showed a slight initial increase with a gradual return to preoperative levels during the evaluated period. At necropsy, no signs of urine leakage were found and kidneys were covered by a fibrous tissue with adherences to adjacent organs. Also, in the retrograde pyelograms obtained, we did not find contrast medium leakage by operated poles. Histological findings showed great deposition of type I collagen over operated renal pole, sealing it completely. Conclusion: The pig kidney is not an adequate experimental model for research and training of surgery on which collecting system healing is an important aspect to be considered.

Collecting duct carcinoma associated with oncocytoma

Collecting duct carcinoma (CDC) is a rare, highly aggressive malignant neoplasm that arises from the collecting duct epithelium of the kidney. CDC was reported to coexist with renal cell and transitional cell carcinomas. We report a rare case of CDC associated with oncocytoma, confirmed by the characteristic histological appearance and immunohistochemistry. We also review the epidemiological, histological and immunohistochemical criteria for diagnosis, in addition to the genetic and cytogenetic aberrations reported in the literature. Identification and reporting CDC is important for the establishment of treatment strategies and monitoring prognosis.

Duplicación ureteral: implicaciones diagnósticas y terapéuticas / Ureteral duplication: diagnostic and therapeutic implications

Se revisaron retrospectivamente los resultados del tratamiento de 34 niños de doble sistema colector, entre los que predominó la duplicación completa de 82 por ciento. La anomalía acompañante más frecuente el reflujo vesicoureteral en 47 por ciento de los casos, seguido del ureterocele en 24 por ciento y uréter ectópico en 12 por ciento. Sus manifestaciones clínicas más frecuentes fueron infección de vías urinarias, tumoración abdominal e incontinencia, en orden de frecuencia. El diagnóstico se logró mediante urograma excretor en 80 por ciento de los casos, y se complementó con ecosonograma, uretrocistograma y gammagrama renal. Los procedimiento quirúrgicos realizados consistieron en reimplantación ureteral de tipo de Cohen, heminefrectomía y ureteroureteroanastomosis con resultados satisfactorios en 90 por ciento de los casos. Las complicaciones más frecuentes ocurrieron en los casos de reimplantación, con 9 por ciento por estenosis. Se concluye que la conducta quirúrgica definitiva depende de la individualización de cada caso según el tipo de anomalías, y del grado de funcionalidad de los segmentos renales implicados