The Harbin Medical University nephrectomy score: a quantitative system for evaluating the complexity of laparoscopic retroperitoneal simple nephrectomy

ABSTRACT Background: Laparoscopic retroperitoneal simple nephrectomy (LRSN) has been widely accepted as a mainstay option for benign non-functioning kidney. The complexity of the procedure, however, differs and remains a subject of controversy. Objective: To develop a standardised Harbin Medical University nephrectomy score (HMUNS) system for evaluating LRSN complexity. Subjects and methods: A total of 6 variables with different factors comprising primary diseases, history of upper urinary tract surgery, body mass index (BMI), surgeon's learning curve, kidney volume, and Mayo Adhesive Probability (MAP) scores were included in the HMUN score. 95 consecutive patients who underwent LRSN at our institution were divided into low (2 to 6 points) and high (7 to 17 points) complexity groups with HMUNS and investigated the differences of operative time (OT), estimated blood loss (EBL), postoperative hospitalisation time (PHT), rate of intraoperative conversion to open surgery, and the Clavien-Dindo classification (CDC) between both groups. Results: Longer mean operative times (193.2±69.3 min vs. 151.9±46.3 min, p <0.05), more median estimated blood loss (100.0mL vs. 50.0mL, p <0.05), and higher rates of conversion to open surgery (1.2% vs. 25%, p <0.05) were observed in the high-complexity group (n=12) than in the low-complexity group (n=83). However, there were no remarkable differences between the two groups related to the baseline characteristics, post-surgical hospitalisation times, and postoperative complications. Conclusions: The HMUNS can effectively reflect LRSN complexity, thus providing a quantitative system for risk estimation and treatment decisions. Because of some limitations, further well-designed studies are necessary to confirm our findings. Patient summary: The HMUNS, including primary diseases, history of upper urinary tract surgery, BMI, surgeon's learning curve, kidney volume, and MAP score, can provide an effective quantitative tool to evaluate the complexity of LRSN.

Living donor nephrectomy

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

National nephrectomy registries: Reviewing the need for population-based data

Nephrectomy is the cornerstone therapy for renal cell carcinoma (RCC) and continued refinement of the procedure through research may enhance patient outcomes. A national nephrectomy registry may provide the key information needed to assess the procedure at a national level. The aim of this study was to review nephrectomy data available at a population-based level in Australia and to benchmark these data against data from the rest of the world as an examination of the national nephrectomy registry model. A PubMed search identified records pertaining to RCC nephrectomy in Australia. A similar search identified records relating to established nephrectomy registries internationally and other surgical registries of clinical importance. These records were reviewed to address the stated aims of this article. Population-based data within Australia for nephrectomy were lacking. Key issues identified were the difficulty in benchmarking outcomes and no ongoing monitoring of trends. The care centralization debate, which questions whether small-volume centers provide comparable outcomes to high-volume centers, is ongoing. Patterns of adherence and the effectiveness of existing protocols are uncertain. A review of established international registries demonstrated that the registry model can effectively address issues comparable to those identified in the Australian literature. A national nephrectomy registry could address deficiencies identified in a given nation's nephrectomy field. The model is supported by evidence from international examples and will provide the population-based data needed for studies. Scope exists for possible integration with other registries to develop a more encompassing urological or surgical registry. Need remains for further exploration of the feasibility and practicalities of initiating such a registry including a minimum data set, outcome indicators, and auditing of data.

The final stage of the laparoscopic procedure: exploring final steps

Despite significant advances in laparoscopic technique and technologies, laparoscopic Urologic surgery remains technically demanding regarding various surgical steps including the challenge of specimen retrieval and extraction, whether to install a drainage system and the best option for wound closure. Laparoscopic specimen entrapment and extraction occurs at what is falsely considered the "end of the procedure". During open surgery, after the specimen has been mobilized, the specimen is simply lifted out of the larger incision which has been made to achieve the surgical objectives. In contrast, significant laparoscopic skill is required to entrap and safely extract laparoscopic specimens. Indeed, the Urologist and surgical team which are transitioning from open surgery may disregard this important part of the procedure which may lead to significant morbidity. As such, it is imperative that during laparoscopic procedures, the "end of the procedure" be strictly defined as the termination of skin closure and dressing placement. Taking a few minutes to focus on safe specimen entrapment and extraction will substantially reduce major morbidity. The following review focus on the technology and technique of specimen entrapment and extraction, on the matter of whether to install a drainage system of the abdominal cavity and the options for adequate closure of trocar site wounds. This article's primary objectives are to focus on how to minimize morbidity while maintain the advantages of a minimally invasive surgical approach.

Childhood nephrectomy indications: a changing profile

To assess the changing profile of children's nephrectomy indications in the south of Tunisia during the last two decades. There were 94 children who underwent nephrectomy between 1982 and 2007. They were classified into two groups. The first group included 55 out of 511 hospitalized children between 1982 and 1994, the second included 39 Out of 382 hospitalized children between 1995 and 2007. K2 [Chi-squared] test was used for this statistical analysis. A P value of<0.05 was considered statistically significant. The average was 7. Pathologies leading to nephrectomies were dominated in both groups by 3 main aetiologies: urolithiasis [42.5%],Wilm's tumors [21.3%] and pelvi-ureteric junction [13.8%]. While in the first group, urolithiasis was found to be the major indication of nephrectomy [54.5%, p<0.05], in the second group, kidney tumors had become the major indication [33%, p<0.05] followed by urolithiasis [25.6%]. So, the rate of nephrectomies performed due to urolithiasis had clearly decrease [P=0.005], but there were no statistical differences observed between the rates of nephrectomies performed due to tumors or upper urinary tract malformations in the two groups. The profile of children's nephrectomy indications in Tunisia stretches currently to be similar to the one of the industrialized countries, with regression of evolved kidney lithiasis leaving place to the tumorous pathologies,because of early detection, improvement and appropriate treatment of urinary lithiasis

Lymph node dissection during the surgical treatment of renal cancer in the modern era: [review]

The increasing use of routine CT scan, along with advances in imaging technology, have facilitated the early diagnosis of incidental renal masses. This has resulted in the reduction in the rate of metastatic disease diagnosis. Although surgery remains the mainstay in the treatment of renal tumors, the decreasing incidence of lymph node involvement has created controversy regarding the importance and the ideal extent of lymph node dissection, formerly considered mandatory at the time of radical nephrectomy. In this review, we critically assessed the role of lymph node dissection at the time of radical nephrectomy. To date, randomized trials have failed to show a benefit of lymph node dissection when broadly employed. This is likely due to the low prevalence of lymph node metastasis at the time of presentation, the unpredictable pattern of lymph node metastasis from renal tumors, and the continued downward stage migration of the disease. As a result, lymph node dissection for renal cancer is currently not recommended in the absence of gross lymphadenopathy. In high risk patients, lymph node dissection may be considered, but it remains controversial and more clinical evidence is warranted. Extended lymph node dissection is still recommended in individuals with isolated gross nodal disease or those with lymphadenopathy at the time of cytoreductive surgery prior to systemic therapy. A practical approach is summarized in an algorithm form.

Retroperitoneoscopic renal biopsy in children

OBJECTIVE: We present our experience in a series of 17 consecutive pediatric patients submitted to retroperitoneal laparoscopic renal biopsy. MATERIALS AND METHODS: Retroperitoneal laparoscopic renal biopsy (LRB) was performed in 5 boys and 12 girls. Mean age was 8.1 years and age range from 2 to 12. Two or three trocars were used to expose the inferior pole of the kidney, remove enough cortical parenchymal specimen and fulgurate the biopsy site. Assessment included surgical time, estimated blood loss, hospitalization period, analgesia requirements, complications and number of glomeruli present in the specimen. RESULTS: LRB was successfully performed in all 15 patients (88 percent). In two cases, LRB was not possible to be performed. One patient was converted to a transperitoneal laparoscopy due to tear in the peritoneum. The other patient had had previous abdominal surgery and, during retroperitoneal balloon dilation, the peritoneum was opened and the open biopsy was performed. A third patient had postoperatively a perirenal hematoma, which was solved spontaneously. Complication rate was 17.6 percent (3/17 cases). Mean operative time was 65 minutes, while mean estimated blood loss was 52 mL, mean hospital stay was 2.2 days and mean analgesic requirement was 100 mg of tramadol. The mean number of glomeruli present in the specimen was 60. CONCLUSION: Retroperitoneal laparoscopic renal biopsy in children is a simple, safe. Bleeding is still the most common complication. However, direct vision usually allows a safe control of this drawback. In our institution, laparoscopic approach is the chosen procedure in pediatric patients older than one - year - old.

Traumatismo renal: nefropreservación o nefrectomía / renal traumatism: nefropreservation or nefrectomia

Objetivo: Evaluar las causas que llevaron a la nefrectomía y señalar las indicaciones actuales de la cirugía conservadora en el riñon traumatizado. Material y Métodos: De febrero de 1997 a febrero de 2003 se realizaron 1143 laparotomías exploradoras por traumatismos abdominales; 89 presentaron lesión renal. Se determinó la tasa de compromiso renal según corresponda a traumatismos cerrados o abiertos, así como su etiología. Se usó la clasificación de la American Association for the Surgery of Trauma Renal Injury Scaling. Se registró evolución y complicaciones por las lesiones renales. Se realizó la reconstrucción renal, en ausencia de inestabilidad hemodinámica persistente y de coagulopatía. Resultados: De los 89 casos tratados, en 50 se realizó nefrectomía (56%) y en los 39 restates (43,8%) cirugía conservadora. De los pacientes nefroctomizados (50 casos), el 54% (27 casos) no presentaron "shock" y las lesiones eran grado III (5 casos) y grado IV (22 casos), en 9 de estos últimos las lesiones estaban localizadas a nivel mesorrenal. El 71,9% presentó lesiones asociadas. Discusión: El tratamiento quirúrgico tiene 2 principios básicos: control de la hemorragia y preservación del tejido renal. La indicación absoluta de exploración se aplica a pacientes con trauma externo y sangrado renal persistente. La exploración emergente surge de la inestabilidad hemodinámica persistente; el hematoma en expansión, y la hemorragia activa con posibilidad de lesión renal de alto grado. Conclusiones: Los traumatismos renales penetrantes siempre obligan a efectuar exploración. El método de reconstrucción renal está dictado por el grado y la localización de la lesión y no por la asociación de lesiones intraabdominales. Son indicación de nefrectomía: el estallido renal, las lesiones grado V irreparables, las lesiones graves del péndulo vascular principal, la hemorragia descontrolada y el estado hemodinámico inestable.

Bilateral nephrectomy of huge polycystic kidneys associated with a rectus abdominis diastasis and umbilical hernia / Nefrectomia bilateral para doença renal policística gigante associada à diástase do reto abdominal e hérnia umbilical

BACKGROUND: Patients with end-stage renal failure due to huge autosomal dominant polycystic kidney disease usually have an umbilical hernia and rectus abdominis diastasis, which are very troublesome. Pretransplant bilateral nephrectomy techniques does not manage the umbilical hernia and rectus abdominis diastasis. We report our experience in performing bilateral nephrectomy and repairing the rectus abdominis diastasis and umbilical hernia through the one, small incision. METHODS: Four patients aged 37 to 43 years with huge polycystic kidneys, an umbilical hernia, and a rectus abdominis diastasis underwent bilateral pretransplant nephrectomy through a midline supraumbilical incision including the umbilical hernia defect. The kidneys were removed through this incision. The incision was closed with the transposition of rectus abdominis muscle, pants-over-vest-style, to correct the diastasis and the umbilical hernia. RESULTS: The average operative time was 160 minutes (range, 130-180); the average larger kidney size was 33 cm (range, 32-34 cm); no major complications occurred; one patient who had preoperative low hemoglobin required blood transfusion. Patients were discharged from the hospital on postoperative day 7 with an esthetically pleasing belly, no rectus abdominis diastasis, and no umbilical hernia. One to two months after bilateral nephrectomy, the patients received a live donor kidney with an uneventful outcome. CONCLUSION: A midline supraumbilical incision is an excellent approach for bilateral nephrectomy of huge polycystic kidneys. In addition, an umbilical hernia and rectus abdominis diastasis may be successfully repaired through same incision with good cosmetic results.

INTRODUÇÃO: Pacientes com insuficiência renal terminal por Doença Renal Policística Autossômica Dominante geralmente apresentam hérnia umbilical e diástase de músculo reto abdominal, que são muito problemáticas. Técnicas de nefrectomia bilateral pré-transplante não dão atenção à hérnia umbilical e à diástase do músculo reto abdominal. Relatamos nossa experiência com nefrectomia bilateral e correção da diastase de músculo reto abdominal e hérnia umbilical através de uma única pequena incisão. MÉTODOS: Quatro pacientes com idade entre 37 a 43 anos com Doença Renal Policística Autossômica Dominante gigante, hérnia umbilical e diástase do múculo reto abdominal foram submetidos à nefrectomia bilateral pré-transplante através de incisão mediana supra-umbilical incluindo o defeito herniário umbilical. Os rins foram removidos através da pequena incisão mediana. A incisão foi fechada com transposição do músculo reto abdominal tipo jaquetão para corrigir a diastase e a hernia umbilical. RESULTADOS: O tempo operatório médio foi 160 minutos (130-180); o tamanho médio do maior rim foi 33cm (32-34); não ocorreram grandes complicações; um paciente, que tinha baixo nível de hemoglobina pré-operatório e precisou de transfusão sangüínea. Pacientes receberam alta hospitalar no 7° pós-operatório com abdome de boa aparência, sem diástase de músculo reto abdominal e sem hérnia umbilical. Os pacientes receberam enxerto renal de doador vivo um ou dois meses após a nefrectomia bilateral, sem intercorrências. CONCLUSÃO: A incisão mediana supra-umbilical é uma abordagem excelente para nefrectomia bilateral de rins policísticos gigantes. Além disso, a hernia umbilical e a diastase de músculo reto abdominal podem ser corrigidas com sucesso pela mesma incisão, com bons resultados cosméticos.

Actuación del cirujano general ante el traumatismo renal y de las vías urinarias / The general surgeon's in the initial management of renal and urinaries lesions

Se señala el papel del cirujano general en el manejo inicial de las lesiones renales y de vías urinarias, mediante un conocimiento adecuado de la normatización diagnóstica y terapéutica de estas lesiones. Para ello es preciso efectuar diagnóstico oportuno y dejar en algunos casos, eventualmente, el tratamiento definitivo para el especialista. Los comunicantes confirman esta aseveración con su experiencia de 116 pacientes con lesiones renales y de vías urinarias, de los que se operaron 98 en un período de 15 años. El 42.05%fueron lesiones renales puras, 7%ureterales, 26%vesicales, 11%uretrales y el resto combinación de ellas. La morbilidad general fue del 27.44%y la específica del 13.17%. La mortalidad, por complicación de lesiones asociadas, fue del 13.72%, no observándose mortalidad específica