Comparison of continuous intravenous lidocaine versus transversus abdominis plane block for kidney transplant surgery: a randomized, non-inferiority trial.

BACKGROUND AND OBJECTIVES: Transversus abdominis plane (TAP) blocks are associated with an improvement in postoperative analgesia following kidney transplant surgery. However, these blocks carry inherent risk and require a degree of expertise to perform successfully. Continuous intravenous lidocaine may be an effective alternative. In this randomized, non-inferiority study, we hypothesized that a continuous lidocaine infusion provides similar postoperative analgesia to a TAP block. METHODS: Subjects presenting for kidney transplant surgery were randomized in a 1:1 ratio to either an ultrasound-guided unilateral, single-injection TAP block (TAP group) or a continuous infusion of lidocaine (Lido group). The primary outcome of this non-inferiority study was opioid consumption within the first 24 hours following surgery. Secondary outcomes included pain scores, patient satisfaction, opioid-related adverse events, time to regular diet, and persistent opioid use. RESULTS: One hundred and twenty subjects, 59 from the TAP group and 61 from the Lido group, completed the study per protocol. Analysis of the primary outcome showed a cumulative geometric mean intravenous morphine equivalent difference between the TAP (14.6±3.2 mg) and Lido (15.9±2.4 mg) groups of 1.27 mg (95% CI -4.25 to 6.79; p<0.001), demonstrating non-inferiority of the continuous lidocaine infusion. No secondary outcomes showed clinically meaningful differences between groups. CONCLUSIONS: This study demonstrates that a continuous infusion of lidocaine offers non-inferior postoperative analgesia compared with an ultrasound-guided unilateral, single-injection TAP block in the first 24 hours following kidney transplant surgery. TRIAL REGISTRATION NUMBER: NCT03843879.

The Benefit of an Enhanced Recovery Program for Living Kidney Donors.

In our efforts to continue to evolve the care of living kidney donors, the application of enhanced recovery after surgery guidelines appears to offer expedited recovery and decrease the incidence of readmission.

Renal Autotransplantation: 27-Year Experience at 2 Institutions.

PURPOSE: Renal autotransplantation is an infrequently performed procedure. It has been used to manage complex ureteral disease, vascular anomalies and chronic kidney pain. We reviewed our 27-year experience with this procedure. MATERIALS AND METHODS: This is a retrospective, observational study of 51 consecutive patients who underwent renal autotransplantation, including 29 at Oregon Health and Science University between 1986 and 2013, and 22 at Virginia Mason Medical Center between 2007 and 2012. Demographics, indications, operative details and followup data were collected. Early (30 days or less) and late (greater than 30 days) complications were graded according to the Clavien-Dindo system. Factors associated with complications and pain recurrence were evaluated using a logistic regression model. RESULTS: The 51 patients underwent a total of 54 renal autotransplants. Median followup was 21.5 months. The most common indications were loin pain hematuria syndrome/chronic kidney pain in 31.5% of cases, ureteral stricture in 20.4% and vascular anomalies in 18.5%. Autotransplantation of a solitary kidney was performed in 5 patients. Laparoscopic nephrectomy was performed in 23.5% of cases. Median operative time was 402 minutes and median length of stay was 6 days. No significant difference was found between preoperative and postoperative plasma creatinine (p = 0.74). Early, high grade complications (grade IIIa or greater) developed in 14.8% of patients and 12.9% experienced late complications of any grade. Two graft losses occurred. Longer cold ischemia time was associated with complications (p = 0.049). Of patients who underwent autotransplantation for chronic kidney pain 35% experienced recurrence and 2 underwent transplant nephrectomy. No predictors of pain recurrence were identified. CONCLUSIONS: The most common indications for renal autotransplantation were loin pain hematuria syndrome/chronic kidney pain, ureteral stricture and vascular anomalies in descending order. Kidney function was preserved postoperatively and 2 graft losses occurred. At a median followup of 13 months pain resolved in 65% of patients who underwent the procedure. Complication rates compared favorably with those of other major urological operations and cold ischemia time was the only predictor of postoperative complications.

Timing, incidence and risk factors for venous thromboembolism in patients undergoing radical cystectomy for malignancy: a case for extended duration pharmacological prophylaxis.

PURPOSE: Patients undergoing radical cystectomy for bladder cancer are at high risk for venous thromboembolism. Recent data have demonstrated that the risk of venous thromboembolism often extends beyond hospital discharge in nonurological surgical populations. To our knowledge the timing of venous thromboembolism in patients who have undergone radical cystectomy during a 30-day postoperative period has not been assessed. Therefore, we evaluated the timing, incidence and risk factors for venous thromboembolism for patients undergoing radical cystectomy for malignancy. MATERIALS AND METHODS: In this descriptive, observational, retrospective study data from 1,307 patients who underwent radical cystectomy for malignancy from 2005 to 2011 were collected using the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) database. Venous thromboembolism occurrences were evaluated by postoperative day and whether they occurred while an inpatient or after discharge home. Univariate and multivariate Cox regression and logistic regression models were used to evaluate risk factors associated with venous thromboembolism. RESULTS: Of 1,307 patients 78 (6%) were diagnosed with venous thromboembolism. The mean time to venous thromboembolism diagnosis was 15.2 days postoperatively. Of all venous thromboembolism events 55% were diagnosed after patient discharge home. The 30-day mortality rate from venous thromboembolism was 6.4%. Risk factors for the development of venous thromboembolism on multivariate analysis were age (p = 0.024), operative time (p = 0.004) and sepsis or septic shock (p = 0.0001). CONCLUSIONS: More than half of all venous thromboembolisms (55%) in patients undergoing radical cystectomy for malignancy occurred after discharge home and the mean time to venous thromboembolism diagnosis was 15.2 days postoperatively. It is reasonable to consider extended duration pharmacological prophylaxis (4 weeks) in this high risk surgical population.