Neurologic Complications in Percutaneous Nephrolithotomy

PURPOSE: Percutaneous nephrolithotomy (PCNL) has been the preferred procedure for the removal of large renal stones in Iran since 1990. Recently, we encountered a series of devastating neurologic complications during PCNL, including paraplegia and hemiplegia. There are several reports of neurologic complications following PCNL owing to paradoxical air emboli, but there are no reports of paraplegia following PCNL. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients who had undergone PCNL in 13 different endourologic centers and retrieved data related to neurologic complications after PCNL, including coma, paraplegia, hemiplegia, and quadriplegia. RESULTS: The total number of PCNL procedures in these 13 centers was 30,666. Among these procedures, 11 cases were complicated by neurologic events, and four of these cases experienced paraplegia. All events happened with the patient in the prone position with the use of general anesthesia and in the presence of air injection. There were no reports of neurologic complications in PCNL procedures performed with the patient under general anesthesia and in the prone position and with contrast injection. CONCLUSIONS: It can be assumed that using room air to opacify the collecting system played a major role in the occurrence of these complications. Likewise, the prone position and general anesthesia may predispose to these events in the presence of air injection.

Effects of stem cells and granulocyte colony stimulating factor in reperfusion injury

Bone marrow-derived stem cells have a potential capacity to differentiate and accelerate recovery in injured sites of body. Also, factors like granulocyte colony stimulating factor [GCSF] can promote their mobilization to the injured sites. We aimed to investigate the role of GCSF as an alternative therapeutic option instead of mesenchymal stem cells [MSCs] in reperfusion injury. Twenty-nine rats with induced reperfusion injury were divided into 3 groups to receive MSC, GCSF, or nothing [control]. Kidney function was assessed by blood urea nitrogen and serum creatinine levels. Histological grading was performed to evaluate the extent of tubular injury and the rate of recovery. All the rats reached recovery after 14 days. Rats in the MSC group reached early functional and histological recovery compared to the controls on the 7th day of the study [P = .01 and P = .02, respectively]. Compared to the control group, the GCSF group showed a more significant histological recovery on the 7th day [P = .04], but kidney function was ameliorated on the 14th day [P = .04]. Both the GCSF and control groups had a significant number of CD34+ cells, which were detected by flow cytometry on the 7th day after reperfusion injury. We found therapeutic effects following administration of both MSC and GCSF which was more evident with MSC in the setting of reperfusion injury. More investigation is required to find optimal time, dose, and route of administration as well as other possible contributing factors

Transperitoneal laparoscopic partial nephrectomy using a new technique

We report our experience with a new technique for transperitoneal laparoscopic partial nephrectomy with the kidney turned upside down intraoperatively. Laparoscopic partial nephrectomy was performed in 10 patients with upper pole lesions through a transperitoneal approach. Once complete mobilization of the kidney was achieved, it was rotated 180 degrees around the horizontal axis, so that the upper pole was positioned inferiorly. After performing partial nephrectomy, the resection bed was sutured by 2-0 polyglactin sutures and application of Hem-o-Lok clips. Then, the kidney was returned into its normal position and fixed to the abdominal wall. We performed laparoscopic partial nephrectomy on 9 patients with a contrast-enhancing upper pole kidney mass and 1 patient with a nonfunctioning upper pole. The median tumor size was 58 mm [range, 41 mm to 92 mm]. The median operative time was 206 minutes [range, 114 to 262 minutes] and the mean warm ischemia time was 30 minutes [range, 22 to 35 minutes]. One patient underwent surgical exploration due to bleeding 6 hours after the operation. Prolonged urine leakage [more than 7 days] was observed in 1 patient, which responded to ureteral stent insertion. Surgical margins were negative in all of the patients. Renal cell carcinoma was histologically diagnosed in patients with a kidney tumor. Laparoscopic upper pole partial nephrectomy had acceptable results while the kidney was turned upside down intraoperatively, in terms of operative time and complications. This approach facilitates the procedure by achieving a better field of vision

established rat model of inducing reversible acute tubular necrosis

Acute tubular necrosis [ATN] is a challenging problem that still requires to be studied in animal models. Our aim was to prepare an established experimental model of inducing reversible ATN in rats by determining the optimum duration of ischemia induction to the kidney. Twenty-four hour after nephrectomy of the right kidney and clamping the pedicle of the left kidney for durations ranging from 10 to 55 minutes, the kidney function and the histologic changes were evaluated. Accordingly, the optimum duration of clamping was determined and in the next step, it was considered for induction of reversible ATN in another group of rats. This group was followed up for 14 days and the pathologic course and function of the kidney were observed. Reversible ATN developed by 47-minute clamping of the renal pedicle. Blood urea nitrogen and serum creatinine levels were elevated up to threefold within 24 hours after the induction of ischemia and they decreased to their reference ranges after 12 and 6 days, respectively. In the histologic study of the kidneys, the least extend of injury was noted by the 14th day following the ATN induction. Even on the 14th day of the follow-up, some signs of ATN remained indicating that the tissue regeneration was not complete yet. To integrate the experimental models of ATN, a rat model with 47-minute clamping of the renal pedicle for induction of ischemia seems appropriate. The resultant ATN remains for a long duration, while kidney function is alleviated