Does previous standard percutaneous nephrolithotomy impair retrograde intrarenal surgery outcomes?

ABSTRACT Purpose: The objective of this study is to evaluate the impact of a previous standard percutaneous nephrolithotomy (PCNL) on the outcomes of retrograde intrarenal surgery (RIRS). Materials and Methods: Outcomes of RIRS performed from January 2017 to January 2020 in adult patients with residual stone fragments ≤20mm after a standard PCNL (Post-PCNL) and symptomatic adult patients with kidney stones ≤20mm (Control) were prospectively studied. Stone-free rate (SFR) was evaluated on a postoperative day 90 non-contrast computed tomography. Surgical complications based on Clavien-Dindo classification during the 90 days of follow-up were recorded. Results: Outcomes of 55 patients and 57 renal units of the post-PCNL group were compared to 92 patients and 115 renal units of the control group. SFR was lower in post-PCNL group than in control (28/57, 49.1% vs. 86/115, 74.8%, p <0.001). Overall complications were more frequent in post-PCNL group (p=0.004). Infundibula strictures were identified and incised with laser in 15/57 (26.3%) renal units of the post-PCNL group. Thirteen renal units had infundibulum stricture at the site of previous percutaneous tract (13/15; 86.7%, p=0.004) and one renal unit had three infundibula strictures. Postoperative complications were not affected by the treatment of infundibula strictures (p=0.198). Conclusions: Previous standard PCNL significantly impairs the outcomes of RIRS. Infundibula strictures can be found in 26.3% of the patients with residual stone fragments after standard PCNL for large burden kidney stones. The main site of infundibulum stricture after standard PCNL is the infundibulum of the entry calyx.

Mini-percutaneous nephrolithotomy in a child with multiple urogenital anomalies and a solitary duplex kidney

ABSTRACT Purpose: To report a case of successful removal of right staghorn renal calculi in a 3-year-old girl with Arnold-Chiari malformation and multiple urogenital anomalies. Case report: A 3-year-old female child with the diagnosis of Arnold-Chiari type 2 malformation was referred to our clinic due to presence of 9 kidney stones with a total volume of 10743mm3. The total of the longest diameters of all stones was calculated as 11.4cm. The patient had a urogenital septum, bifid bladder, and duplicated collecting system on the right side. An 18F Amplatz sheath was placed and mini-percutaneous nephrolithotomy was performed successfully by laser and pneumatic lithotripter. Any residual urinary tract stones or urinary tract infection were not detected during the 6th-month follow-up. Conclusion: Urolithiasis requires a thorough understanding of the underlying causes, as well as an effective and minimally invasive treatment. It is important for urologists to understand the complexity of the optimal stone management in pediatric patients in order to maximize treatment efficacy and minimize morbidity. We conclude that it is essential to treat urolithiasis in a single session in children with urogenital anomalies and accompanying congenital anomalies who have past surgical history.

Techniques of orthotopic renal transplantation in pigs. One donor to two recipients via inverted grafting

ABSTRACT Purpose Although transplanting two kidneys from a single donor to two recipients has some advantages, the right and left kidneys are not anatomically identical; thus, a surgical procedure considering the anatomical features of the donor kidneys is needed when transplanting them into the opposite renal fossae. Based on vast experience, the surgical details of pig orthotopic kidney transplantation from one donor to two recipients was reported. Methods When the right kidney was transplanted to the left renal fossa, the graft was inverted upside down, not backwards, thus ensuring that the anteroposterior relationship of the renal vessels was maintained and anatomically natural vascular anastomosis could be performed. Results Using this technique, we could have developed a pig experimental model that is safe and has a high success rate, even for researchers in the middle of their training. This technique of inverting the graft upside down was reported in human kidney transplantation to make vascular anastomosis easier. Conclusions In pig orthotopic kidney transplantation from one donor to two recipients, an anatomically natural vascular anastomosis could be performed via inverted grafting when the right kidney was transplanted into the left renal fossa.

Techniques of orthotopic renal transplantation. II. Size-matched porcine grafts in monkey recipients

ABSTRACT Purpose As a classical xenotransplantation model, porcine kidneys have been transplanted into the lower abdomen of non-human primates. However, we have improved upon this model by using size-matched grafting in the orthotopic position. The beneficial aspects and surgical details of our method are reported herein. Methods Donors were two newborn pigs (weighting 5 to 6 kg) and recipients were two cynomolgus monkeys (weighting, approximately, 7 kg). After bilateral nephrectomy, kidneys were cold-transported in Euro-Collins solution. The porcine kidney was transplanted to the site of a left nephrectomy and fixed to the peritoneum. Results Kidneys transplanted to the lower abdomen by the conventional method were more susceptible to torsion of the renal vein (two cases). In contrast, early-stage blood flow insufficiency did not occur in orthotopic transplants of theleft kidney. Conclusions Size-matched porcine-primate renal grafting using our method of transplanting tothe natural position of the kidneys contributes to stable post-transplant blood flow to the kidney.

Three dimensional nephrometry system for partial nephrectomy: Our initial exploration / 北京大学学报(医学版)

OBJECTIVE@#To construct a preoperative evaluation system for partial nephrectomy using CT three-dimensional visualization technology and to explore its practical value.@*METHODS@#The clinical data of the patients who underwent partial nephrectomy for renal tumors in Department of Urology, Peking University First Hospital were collected retrospectively. At the same time, the homogenized standard data of patients who underwent partial nephrectomy for renal tumors were collected in 16 clinical centers in China. The CT three-dimensional visualization system was applied (IPS system, Yorktal) to evaluate tumor anatomy, blood supply, perirenal fat and other information. The parameters were summarized to build a three-dimensional nephrometry system, on the basis of which virtual surgery design and intraoperative navigation were completed.@*RESULTS@#A three-dimensional visualization image was established based on the enhanced CT urography. The nephrometry system included the longest diameter and volume of the tumor, proportion volume of tumor invading the parenchyma, maximum depth of the tumor invading the parenchyma, contact surface area, flatness of the tumor surface, renal segment where the tumor was located, vascular variation, and perirenal fat. The average two-dimensional diameter of the tumor was (2.78±1.43) cm, the average three-dimensional maximum diameter was (3.09±1.35) cm, and the average postoperative pathological size was (3.01±1.38) cm. The maximum tumor diameter in the three-dimensional image was significantly related to the prolonged renal artery clamping time and intra-operative blood loss (r=0.502, P=0.020; r=0.403, P=0.046). The three-dimensional and pathological tumor volume were (25.7±48.4) cm3 and (33.0±36.4) cm3, respectively (P=0.229). The tumor volume was significantly related to the intraoperative blood loss (r=0.660, P < 0.001). The proportion volume of the tumor invading into renal parenchyma was significantly related to the prolongation of renal artery clamping and the occurrence of postoperative complications (r=0.410, P=0.041; r=0.587, P=0.005). The tumor contact surface area and the presence of vascular variation did not show correlation with the perioperative data and postoperative complications. While the preoperative evaluation was completed, the reconstructed three-dimensional image could be zoomed, rotated, combined display, color adjustment, transparency, and simulated cutting on the Touch Viewer system. The process generally consisted of showing or hiding the tissue, adjusting the transparency of the interested area, rotating and zooming the image to match the position of the surgical patient. Together, these functions met the requirements of preoperative virtual surgery plan and intraoperative auxiliary navigation.@*CONCLUSION@#Three-dimensional images can provide a more intuitive anatomical structure. The CT three-dimensional visua-lization system clearly displays tumor anatomical parameters, blood supply and perirenal fat. The three-dimensional nephrometry system for renal tumors can help predict the difficulty of partial nephrectomy and perioperative complications. Importing the reconstructed three-dimensional visualization image into the specified program or robot operating system can complete virtual surgery and intraoperative navigation, helping the surgeon to better grasp the surgical process. The indexes included in the nephrometry system and the score weights of each index need to be confirmed and perfected by multi-center study with large samples.

Anatomical background of ovine kidney for use as animal model: analysis of arterial segmentation, proportional volume of each segment and arterial injury after cranial pole partial nephrectomy

ABSTRACT Objective To study the arterial segments of ovine kidney, present a proportional volume analysis of each kidney arterial segment, and analyze arterial injuries caused by simulated partial nephrectomy of cranial pole. Materials and Methods Forty-eight ovine kidneys injected with polyester resin into the renal arteries and collecting system were used in this study. Eighteen kidneys were used to study the arterial segments and the proportional volume of each renal segment. Other 30 kidneys were submitted to superior pole resection at a distance of 1.0cm, 0.5cm, or exactly at the cranial hilar edge, just before the resin hardening. These endocasts were used to evaluate the arterial injuries caused by these different resection planes. Results Ovine renal artery divided into two (ventral and dorsal) or three segmental arteries. Dorsal segment presented higher proportional volume than ventral segment. For kidneys with three segments, the third segment was on the caudal region (caudo-ventral or caudo-dorsal segment) and presented the lowest proportional volume. None of the resected kidneys (at 1.0, 0.5 or at the cranial hilar edge) presented injury of arterial branches that irrigate non-resected region. Conclusion The segmental distribution of renal artery, the proportional volume of each segment and arterial injuries after cranial pole resection in ovine kidneys are different from what is observed in human kidneys. Meanwhile, ovine kidneys show a primary segmental division on anterior and posterior, as in humans, but different from swine. These anatomical characteristics should be considered when using ovine as animal models for renal experimental and/or training procedures.

Image-guided study of swine anatomy as a tool for urologic surgery research and training

Abstract Purpose: To describe the anatomy of the swine urinary system using computed tomography and to discuss the role of this animal as an experimental model for urological procedures. Methods: Three male Landrace pigs underwent computed tomography and the anatomy of the urinary system and renal circulation was analyzed and described. Results: In all animals, 2 kidneys, 2 ureters and one bladder were identified. Each kidney presented a single renal artery vascularization, with a mean diameter on the right of 4.45 and 5.31 mm on the left (p < 0.0001) and single renal vein drainage, with a mean diameter on the right of 5.78 and 5.82 mm on the left (p = 0.0336). The average renal length was 9.85 cm on the right and 10.30 cm on the left (p < 0.0001). The average renal volume was 113.70 cm3 on the right and 109.70 cm3 on the left (p < 0.0001). The average length of the ureter was 19.78 cm on the right and 22.08 cm on the left (p < 0.0001). The average bladder volume was 423.70 cm3. Conclusions: The data obtained show similarities with human anatomy, suggesting the viability of the swine model for planning preclinical trials, basic research, refinement in experimental surgery and surgical training for urological procedures.

Clinicopathological characteristics of surgically treated localized renal masses in patients previously exposed to chemotherapy

ABSTRACT Purpose: To explore the potential association between renal mass characteristics and a history of chemotherapy. Materials and methods: A retrospective review of records of patients surgically treated for a localized renal mass between 2000 and 2012 was undertaken following an institutional review board approval. Patients age and sex, renal mass clinical characteristics (radiological size and mode of presentation) and pathological characteristics (diagnosis, renal cell carcinoma subtype, Fuhrman grade and stage) were compared between patients with and without a history of chemotherapy, using Fisher's exact test, Student's t-test and Wilcoxon rank sum test. A multivariate logistic analysis was performed to evaluate the independent association of chemotherapy and tumor pathology. Results: Of the 1,038 eligible patients, 33 (3%) had a history of chemotherapy. The distribution of clinical stage, renal mass diagnosis, renal cell carcinoma subtype, Fuhrman grade, pathological stage, sex and median age were similar between the general population and the chemotherapy group. However, the latter had a higher rate of incidental presentation (P = 0.003) and a significantly smaller median radiological tumor size (P = 0.01). In a subset analysis of T1a renal cell carcinoma, the chemotherapy group presented an increased rate of high Fuhrman grade (P = 0.03). On multivariate analysis adjusted for radiological tumor size, sex and age the chemotherapy cohort had a 3.92 higher odds for high Fuhrman grade. Conclusion: Patients with a history of chemotherapy typically present with smaller renal masses that, if malignant, have higher odds of harboring a high Fuhrman grade and thus may not be suitable for active surveillance.

Personalized 3D kidney model produced by rapid prototyping method and its usefulness in clinical applications

ABSTRACT Background: Three-dimensional (3D) printing has been introduced as a novel technique to produce 3D objects. We tried to evaluate the clinical usefulness of 3D-printed renal model in performing partial nephrectomy (PN) and also in the education of medical students. Materials and Methods: We prospectively produced personalized renal models using 3D-printing methods from preoperative computed tomography (CT) images in a total of 10 patients. Two different groups (urologist and student group) appraised the clinical usefulness of 3D-renal models by answering questionnaires. Results: After application of 3D renal models, the urologist group gave highly positive responses in asking clinical usefulness of 3D-model among PN (understanding personal anatomy: 8.9 / 10, preoperative surgical planning: 8.2 / 10, intraoperative tumor localization: 8.4 / 10, plan for further utilization in future: 8.3 / 10, clinical usefulness in complete endophytic mass: 9.5 / 10). The student group located each renal tumor correctly in 47.3% when they solely interpreted the CT images. After the introduction of 3D-models, the rate of correct answers was significantly elevated to 70.0% (p < 0.001). The subjective difficulty level in localizing renal tumor was also significantly low (52% versus 27%, p < 0.001) when they utilized 3D-models. Conclusion: The personalized 3D renal model was revealed to significantly enhance the understanding of correct renal anatomy in patients with renal tumors in both urologist and student groups. These models can be useful for establishing the perioperative planning and also education program for medical students.

The preoperative stratification of patients based on renal scan data is unable to predict the functional outcome after partial nephrectomy

ABSTRACT Introduction: eGFR-categories are used to predict functional outcome after partial nephrectomy (PN); no study categorized patients according to preoperative renal scan (RS) data. Aim of the study was to evaluate if stratification of patients according to RS is a reliable method to predict minor/major loss of renal function after PN. Materials and Methods: We considered patients who underwent PN and RS pre-/post-PN for T1 tumor in our Institution (2007-2017). Demographics, perioperative and specifically functional data were analysed. On the basis of the baseline Split Renal Function (SRF), patients were stratified into risk-categories: 1) baseline operated-kidney SRF range 45-55%; 2) baseline operated-kidney SRF <45%. Risk categories were analysed with postoperative functional outcome: postoperative operated-kidney SRF decrease below 90% of baseline was considered significant loss of function. Contingency tables and univariate/multivariate regression were analysed looking for independent factors of postoperative functional impairment. Results: 224 patients were analysed, 125 (55.8%) maintained >90% of their baseline function. Worse probability of maintaining ≥90 baseline renal function was found in patients with Charlson's Comorbidity Index (CCI≥3) (p=0.004) and patients with PADUA score ≥8 (p=0.023). After stratification by baseline renal function, ischemia was the only independent factor: no effect on patients with poorer baseline renal function. Patients with baseline SRF 45-55% who did not experience ischemia had the highest probability to maintain ≥90% baseline SRF (p=0.028). Ischemia >25 minutes was detrimental (p=0.017). Conclusions: Stratification of patients by SRF before PN is not a reliable predictor of renal functional outcome. Ischemia seems to scarcely influence patients with poorer renal function.

An unusual presentation of urethral duplication presenting with chronic bladder retention, left scrotal transposition and left renal agenesis

ABSTRACT Introduction and objective Urethral duplication is a rare congenital anomaly, with roughly 200 cases reported in the literature (1). It is more frequent in males, with few cases reported in females. The clinical presentation differs according to the anatomical variant present. The duplication most commonly occurs in the sagittal plane with one urethra located ventrally and the other dorsally (2). Usually the ventral urethra is the more functional of both. Duplications occurring in the coronal plane are quite rare and they are usually associated with bladder duplication (3). The purpose of this paper was to present a video of a boy with an unusual urethral duplication form. Materials and Methods Patient was born premature due to oligohydramnios at 7 months-gestational age and he has initial diagnosis of hypospadia. Since then, he presented at least 7 febrile UTI and mother complained of difficult micturition and a presence of a mass at lower abdomen. Patient was referred to our institution and we identified urethral duplication with a glandar and scrotal meatus, palpable bladder and left penile-hemiscrotum transposition. US and CT-scan showed left kidney agenesis and overdistended bladder. VCUG and retrograde urethrography showed duplication, presence of contrast in the seminal vesicles and complete catheterizing of both urethras was not possible. Results The topic urethra was dysplastic and not patent to a 4Fr plastic tube so we were unable to access it endoscopically. We performed initially a Mitrofanoff procedure to allow CIC and treat chronic retention. Six months later, we assessed both urethras surgically and concluded that dorsal urethra was dysplastic after 3cm still in the penile area and scrotal urethra was not possible to be catheterized. We excised the ventral urethra because of dribbling complaints up to bulbar area and reconstructed the scrotal transposition, keeping the topic urethra for cosmetic issues. Patient had excellent outcome, performs CIC every 4 hours and has not presented further UTI episodes. Discussion and conclusion The urethral duplication is an anomaly that has multiple anatomical presentations. There are several theories about the etiology, but none can explain all types of presentations. There is also more than one rating available, and the Effmann classification is the most detailed. The case exemplifies this varied spectrum of anatomic urethral duplication. It resembles the urethral duplication type IIa-Y, however, ventral urethra meatus was located in penoscrotal area and both urethras were at least partially hypoplastic/dysplastic associated with obstruction and bladder retention. In determining how to best manage a patient with Y-type urethral duplication, the caliber and quality of the orthotopic urethra must first be assessed. Published reports suggest that best outcomes are those using the ventral duplicated urethra for the reconstruction (4). In this case, none of urethras were functional and a supravesical outlet channel had to be provided. The treatment of this condition requires an individualized planning and a vast technical knowledge of reconstructive surgery.

Tumor fibroso solitario y síndrome Doege-Potter / Solitary fibrous tumor and Doege-Potter syndrome

El tumor fibroso solitario es raro. Si bien su localización más frecuente es la pleura, han sido informados algunos casos de ubicación retroperitoneal. Es difícil diferenciarlo imagenológicamente de otras neoplasias, por lo que casi siempre el diagnóstico es histológico. Dado que los tumores fibrosos solitarios tienen presentaciones clínicas muy diversas, una mejor compresión de la ubicación y sus características imagenológicas ayudaría a abreviar la lista de diagnósticos diferenciales. Comunicamos un tumor fibroso solitario de localización retroperitoneal cuyo diagnóstico fue confirmado por examen histológico.

The solitary fibrous tumor is uncommon. Even though it frequently locates in the pleura, a few cases have been reported in the retroperitoneum. Differentiation from other neoplasms is difficult, and therefore the diagnosis is always attained through histological examination. Although solitary fibrous tumors have variable clinical behaviors, a better comprehension of the location and its imaging characteristics would help to decrease the list of differential diagnoses. We report a solitary fibrous tumor located in the retroperitoneum whose diagnosis was confirmed by histological examination.

Digital Videoscopic Retrograde Intrarenal Surgeries for Renal Stones: Time-to-Maximal Stone Length Ratio Analysis

PURPOSE: To investigate 100 consecutive cases of videoscopic retrograde intrarenal surgery (RIRS) by a single surgeon and to evaluate factors associated with stone-free status and the learning curve thereof. MATERIALS AND METHODS: We analyzed the results of videoscopic RIRS in 100 patients who underwent primary treatment for renal stones from January 2015 to August 2016. Videoscopic RIRS were performed with URF-V and URF-V2 flexible video uteroscopes (Olympus) or a Flex-Xc flexible ureterorenoscope (KARL STORZ). Non-contrast computed tomography was taken at 3 months postoperatively to confirm the absence of stones. The stone characteristics included the location, maximal stone length (MSL), stone heterogeneity index (SHI), and mean stone density (MSD). Fragmentation efficacy was calculated as operative time (min) divided by removed MSL (mm), and was evaluated in the sequential order of operations. RESULTS: The mean age of the total patient was 60.0±14.0 years. The mean MSL was 13.1±6.2 mm. The average MSD was 734.2±327.6 Hounsfield unit (HU) and the SHI was 241.0±120.0 HU. The mean operation time was 65.1±45.7 min considering each renal unit. The stone-free rate at 3 months post-surgery was 87%. The estimated cut-off of the time-to-MSL ratio below 5 min/mm was 50. Multivariate analyses indicated a lower MSD [odds ratio (OR): 0.998; 95% confidence interval (CI): 0.996–0.999; p=0.047) and the last 50 cases (OR: 5.408, 95% CI: 1.337–30.426; p=0.030) as independent predictors of stone-free status after videoscopic RIRS. CONCLUSION: Low MSDs and the last 50 cases were significant predictors of stone-free rate in videoscopic RIRS.

Supervivencia de receptores de trasplante renal en Colombia, 2008-2012 / Survival in renal transplant recipients in Colombia, 2008-2012

Resumen Introducción. La Red Nacional de Donación y Trasplantes del Instituto Nacional de Salud reportó que durante 2014 se realizaron en Colombia 1.059 trasplantes de órganos, de los cuales 761 fueron de riñón y, de estos, 643 (84,5 %) correspondieron a órganos provenientes de cadáveres. Objetivo. Describir las características sociodemográficas de los pacientes con trasplante renal y los resultados en términos de supervivencia. Materiales y métodos. Se hizo un estudio observacional y retrospectivo de cohorte mediante el análisis de la base nacional de datos de receptores de trasplante renal. Se estimó la supervivencia global con el método de Kaplan-Meier, se compararon las curvas según sexo, edad, tipo de donante, tipo de régimen de afiliación al sistema de salud y tiempo en lista de espera mediante la prueba de hipótesis de Mantel-Cox (log rank) y una regresión de Cox. Resultados. De los 3.980 pacientes incluidos en el estudio, 338 fallecieron según el Registro Único de Afiliados. Con una mediana de seguimiento de 49 meses, la supervivencia global fue de 6,35 años (IC95% 6,30-6,40), la supervivencia al año del trasplante fue de 97,2 %, a los tres años, de 93,2 %, y a los cinco años, de 90,8 %. La supervivencia fue mayor en los pacientes menores de 50 años receptores de trasplante con donante vivo y con menos de seis meses en lista de espera. Conclusiones. Los resultados reflejaron el panorama de los pacientes con trasplante renal en el país en términos de supervivencia, lo cual sirve de base para estudios prospectivos con seguimiento estricto.

Abstract Introduction: The Red Nacional de Donación y Trasplantes of the Colombian Instituto Nacional de Salud reported that in 2014, 1,059 organ transplants were performed, of which 761 were kidney transplants, and 643 (84.5%) of these were from cadaveric organ donors. Objective: To describe the socio-demographic characteristics of patients who received renal transplants, as well as their outcomes in terms of survival. Materials and methods: National kidney transplants were analyzed through an observational retrospective cohort study. Overall survival was estimated using the Kaplan-Meier method. The survival curves by sex, age, type of donor, type of insurance, and time on the waiting list were compared utilizing the log rank hypothesis and a Cox regression. Results: A total of 3,980 patients were included, of whom 338 died according to the Registry of Affiliates. The median follow-up time was 49 months, overall survival was 6.35 years (95% CI: 6.30 to 6.40), the one-year survival following transplantation was 97.2%, the three-year survival, 93.2%, and the five-year survival, 90.8%. The survival rate was higher in patients under 50 years of age, receptors of living donor transplants, and with less than six months on the waiting list. Conclusions: The results obtained serve as the basis for future studies with strict monitoring of survival among kidney transplant recipients in Colombia.

The relationship between renal warm ischemia time and glomerular loss. An experimental study in a pig model

Abstract Purpose: To investigate the glomerular number after different warm ischemia times. Methods: Thirty two pigs were assigned into four groups. Three groups (G10, G20, and G30) were treated with 10, 20, and 30 minutes of left renal warm ischemia. The sham group underwent the same surgery without renal ischemia. The animals were euthanized after 3 weeks, and the kidneys were collected. Right kidneys were used as controls. The kidney weight, volume, cortical-medullar ratio, glomerular volumetric density, volume-weighted mean glomerular volume, and the total number of glomeruli per kidney were obtained. Serum creatinine levels were assessed pre and postoperatively. Results: Serum creatinine levels did not differ among the groups. All parameters were similar for the sham, G10, and G20 groups upon comparison of the right and left organs. The G30 group pigs' left kidneys had lower weight, volume, and cortical-medullar ratio and 24.6% less glomeruli compared to the right kidney. A negative correlation was found between warm ischemia time and glomerular number. Conclusions: About one quarter of glomeruli was lost after 30 minutes of renal warm ischemia. No glomeruli loss was detected before 20 minutes of warm ischemia. However, progressive glomerular loss was associated with increasing warm ischemia time.

Relación entre gravedad de arteriosclerosis y progresión de enfermedad renal en pacientes nefrectomizados / Relation between severity of atherosclerosis and progression of renal disease in nephrectomized patients

Nefrectomía radical se asocia a disminución progresiva de función renal. Los parámetros en insuficiencia renal post-nefrectomía están identificados, no así la importancia de la histopatología vascular en la pieza de nefrectomía. Nuestro objetivo fue evaluar si la gravedad de la aterosclerosis en tejido renal no neoplásico puede predecir la evolución del filtrado glomerular en pacientes con nefrectomía total. Se incluyeron 31 pacientes con nefrectomía radical unilateral, no donantes. Edad promedio 68.5 ± 11.8 años, 80% tenían antecedentes de hipertensión, 64% sobrepeso, 51% fumadores. Se estimó tasa de filtración glomerular preoperatoria, postoperatoria y a 6, 12 y 24 meses de cirugía. Se determinó grado de arteriolosclerosis según porcentaje de estrechamiento de luz vascular (grado 0: sin estrechamiento vascular; grado 1: menos del 25%; grado 2: 25-50%; grado 3: más del 50%). Los 10 pacientes con arteriolosclerosis grado 0 tuvieron mayor tasa de filtración glomerular basal (75 ± 13 ml/min/1.73 m²) que los 8 con grado 2 y 3 (55 ± 22 ml/min/1.73 m2) (p 0.0886). En la última evaluación, la tasa de filtrado glomerular fue 60 ± 13 ml/min/1.73 m² (grado 0) y 39 ± 11 ml/min/1.73 m² (grados 2 y 3) (p = 0.05). La disminución del filtrado glomerular fue mayor en grados más graves de ateroesclerosis (sin significación estadística). El análisis histológico de piezas quirúrgicas de nefrectomía permitiría identificar aquellos con mayor riesgo de progresión de enfermedad renal según gravedad de las lesiones vasculares ateroscleróticas.

Radical nephrectomy is associated with a progressive decline in renal function. Clinical parameters in post-nephrectomy insufficiency were described but the impact of histopathologic vascular findings in the non-neoplastic kidney of nephrectomy specimen, has been poorly studied. Our aim was to evaluate whether the severity of atherosclerosis in non-neoplastic renal tissue predicts the evolution of glomerular filtration rate in patients undergoing total nephrectomy. Thirty-one non-donor patients with unilateral radical nephrectomy were included. Average age was 68.5 ± 11.8 years, 80% had a history of hypertension, 64% overweight and 51% were smokers. The glomerular filtration rate was estimated preoperatively, postoperatively and at 6, 12 and 24 months after surgery. Arteriolosclerosis was scored based on degree of narrowing of the vascular lumen (stage 0: no vascular narrowing; stage 1: less than 25%; stage 2: 25-50%; stage 3: more than 50%). Ten patients in stage 0 had higher basal glomerular filtration rate (75 ± 13 ml/min/1.73 m²) than eight patients in stage 2 or 3 (55 ± 22 ml/min/1.73 m²) (p 0.0886). At the last postoperative evaluation, the glomerular filtration rate was 60 ± 13 ml/min/1.73 m² (stage 0) and 39 ± 11 ml/min/1.73 m² (stage 2 or 3) (p = 0.05). The decrease in glomerular filtration rate was higher in patients with more severe degrees of atherosclerosis but the difference was not statistically significant. The histological evaluation of the severity of arteriosclerosis in the whole kidney allows the identification of patients with a greater risk of decreased glomerular filtration rate after a post radical nephrectomy.

Tratamiento quirúrgico conservador en paciente monorrenal con esclerosis tuberosa y angiomiolipoma complicado: presentación de caso y revisión bibliográfica / Conservative surgical treatment in monorrenal patient with sclerosis and complicated tuberous angiomyolipom: case report and literature review

Los angiomiolipomas renales son formaciones renales que se presentan de forma aislada o asociadas con otras patologías como esclerosis tuberosa o enfermedad de Von Hippel Lindau. Los angiomiolipomas renales se pueden presentar clínicamente con un shock hipovolémico por lesión de uno de sus vasos o con dolor abdominal por efecto masa debido a su tamaño. La resolución de los angiomiolipomas puede ser de manera programada o de urgencia, siendo las vías elegidas la nefrectomía parcial o la embolización arterial selectiva, dependiendo siempre de los recursos que se tengan y la experiencia del equipo quirúrgico.

Renal angiomyolipomas are kidney formations presented in isolation or associated with other diseases such as tuberous sclerosis or Von Hippel Lindau disease. Renal angiomyolipoma may present clinically with hypovolemic shock due to injury of one of its vessels or with abdominal pain due to mass effect because of its size. Angiomyolipomas can be resolved on scheduled basis or emergency, where the chosen ways are partial nephrectomy or selective arterial embolization, always depending on the resources you count on and the experience of the surgical team.

Effects and Mechanisms of Radiofrequency Ablation of Renal Sympathetic Nerve on Anti-Hypertension in Canine / Efeitos e Mecanismos da Denervação Simpática Renal por Radiofrequência na Anti-Hipertensão em Cães

Abstract Background: Radiofrequency ablation of renal sympathetic nerve (RDN) shows effective BP reduction in hypertensive patients while the specific mechanisms remain unclear. Objective: We hypothesized that abnormal levels of norepinephrine (NE) and changes in NE-related enzymes and angiotensinconverting enzyme 2 (ACE2), angiotensin (Ang)-(1-7) and Mas receptor mediate the anti-hypertensive effects of RDN. Methods: Mean values of systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were assessed at baseline and follow-up. Plasma and renal norepinephrine (NE) concentrations were determined using highperformance liquid chromatography with electrochemical detection, and levels of NE-related enzyme and ACE2-Ang(1-7)- Mas were measured using real time PCR, Western blot and immunohistochemistry or Elisa in a hypertensive canine model fed with high-fat diet and treated with RDN. The parameters were also determined in a sham group treated with renal arteriography and a control group fed with normal diet. Results: RDN decreased SBP, DBP, MAP, plasma and renal NE. Compared with the sham group, renal tyrosine hydroxylase (TH) expression was lower and renalase expression was higher in the RDN group. Compared with the control group, renal TH and catechol-o-methyl transferase (COMT) were higher and renalase was lower in the sham group. Moreover, renal ACE2, Ang-(1-7) and Mas levels of the RDN group were higher than those of the sham group, which were lower than those of the control group. Conclusion: RDN shows anti-hypertensive effect with reduced NE and activation of ACE2-Ang(1-7)-Mas, indicating that it may contribute to the anti-hypertensive effect of RDN.

Resumo Fundamentos: A denervação simpática renal por radiofrequência (DSR) mostra redução eficaz da pressão arterial (PA) de pacientes hipertensos, ainda que os mecanismos específicos permaneçam obscuros. Objetivo: Fizemos a hipótese de que níveis alterados de noradrenalina (NA) e mudanças nas enzimas relacionadas à NA e enzima conversora de angiotensina 2 (ECA-2), angiotensina (Ang)-(1-7) e receptor Mas são mediadores dos efeitos antihipertensivos da DSR. Métodos: Foram avaliados os valores médios de pressão arterial sistólica (PAS), pressão arterial diastólica (PAD) e pressão arterial média (PAM) no início e durante o seguimento. Foram medidas as concentrações plasmática e renal de noradrenalina (NA) por cromatografia líquida de alta eficiência com detecção eletroquímica, e os níveis de enzima relacionada à NA e ECA2-Ang-(1-7)-Mas através de PCR em tempo real, Western blot e imunohistoquímica ou Elisa em um modelo canino de hipertensão que recebeu ração rica em gordura e foi tratado com DSR. Os parâmetros também foram determinados em um grupo de cirurgia simulada submetido à arteriografia renal e em um grupo controle que recebeu dieta normal. Resultados: DSR causou diminuição da PAS, PAD, PAM e das concentrações plasmática e renal de NA. Em comparação ao grupo placebo, a expressão da tirosina hidroxilase (TH) renal foi menor e a da renalase foi maior no grupo DSR. Em comparação ao grupo controle, os níveis de TH renal e de catecol-o-metil-transferase (COMT) foram maiores e os de renalase foram menores no grupo cirurgia simulada. Além disso, os níveis renais de ECA2, Ang-(1-7) e Mas foram maiores no grupo DSR do que no grupo cirurgia simulada, que, por sua vez, foram menores do que no grupo controle. Conclusões: A DSR mostra efeitos anti-hipertensivos com redução da NA e ativação da ECA2-Ang-(1-7)-Mas, o que indica que pode contribuir com o efeito anti-hipertensivo da DSR.

Anesthetic management of nephrectomy in a chronic obstructive pulmonary disease patient with recurrent spontaneous pneumothorax / Controle anestésico de nefrectomia em paciente com doença pulmonar obstrutiva crônica e pneumotórax espontâneo recorrente

Abstract Nephrectomies are usually performed under general anesthesia alone or in combination with regional anesthesia and rarely under regional anesthesia alone. We report the management of a patient with chronic obstructive pulmonary disease with a history of recurrent spontaneous pneumothorax undergoing nephrectomy under regional anesthesia alone.

Resumo Geralmente, as nefrectomias são feitas sob anestesia geral, isoladamente ou em combinação com anestesia regional, e raramente sob anestesia regional sozinha. Relatamos o tratamento de um paciente com doença pulmonar obstrutiva crônica e história de pneumotórax espontâneo recorrente submetido à nefrectomia sob anestesia regional isolada.