Timing of steroid treatment is important for cerebral protection during cardiopulmonary bypass and circulatory arrest: minimal protection of pump prime methylprednisolone.

OBJECTIVES: The contact of cardiopulmonary bypass surface and patient's blood activates systemic inflammatory response which aggravates ischemia-reperfusion injury. This study evaluates the effects of cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) on cerebral protection using different steroid administration protocols. METHODS: Eighteen (n=6/group) 4 week-old piglets were divided in three groups. Methylprednisolone (30 mg/kg) was administered intravenously 4 h prior to CPB in Group I, or added in pump prime in group II. Group III received no steroid. All animals were cooled to 15 degrees C followed by 100 min of DHCA, then rewarmed over 40 min and sacrificed 6 h after CPB. Post-operative weight gain, bioelectrical impedance, colloid oncotic pressure (COP) and interleukin-6 (IL-6) were evaluated. Determination of cerebral trypan blue and immunohistochemical assays of transforming growth factor (TGF)-beta1 and caspase-3 activities were performed. RESULTS: Post-operative % weight gain (13.0+/-3.8 (I) versus 26.4+/-9.9 (II) versus 22.6+/-6.4 (III), P=0.02); % bioimpedance reduction (14.5+/-8.0 (I) versus 38.3+/-13.3 (II) versus 30.5+/-8.0 (III), P=0.003); mean COP (mmHg) (14.9+/-1.8 (I) versus 10.9+/-2.0 (II) versus 6.5+/-1.8 (III), P=0.0001) and systemic IL-6 levels (pg/ml) (208.2+/-353.0 (I) versus 1562.1+/-1111.4 (II) versus 1712.3+/-533.2 (III), P=0.01) were significantly different between the groups. Spectrophotometric analysis of cerebral trypan blue (ng/g dry weight) was significantly different between the groups (0.0053+/-0.0010 (I) versus 0.0096+/-0.0026 (II) versus 0.0090+/-0.0019 (III), P=0.004). TGF-beta1 scores were 3.3+/-0.8 (I) versus 1.5+/-0.8 (II) versus 1.5+/-0.5 (III), P<0.05, groups I versus II and I versus III. Remarkable perivascular caspase-3 activity was observed in groups II and III. CONCLUSION: Different timing of steroid administration results in different inflammatory mediator response. Steroid in CPB prime is not significantly better than no steroid treatment, while systemic steroid pre-treatment significantly decreases systemic manifestation of inflammatory response and brain damage.

Prospective comparison of 3-dimensional volume rendered computerized tomography and conventional renal arteriography for surgical planning in patients undergoing laparoscopic donor nephrectomy.

PURPOSE: We prospectively assessed the accuracy of 3-dimensional (3-D) volume rendered computerized tomography (CT) and conventional renal arteriography to visualize renovascular anatomy in patients undergoing laparoscopic donor nephrectomy. MATERIALS AND METHODS: A total of 60 consecutive patients undergoing laparoscopic donor nephrectomy (left side in 46 and right side in 14) prospectively underwent 3-D CT and renal angiography. A short videotape of 3-D CT was prepared using volume rendering software that demonstrated the anatomical location, number, anomalies and spatial interrelationships of the renal arteries and veins. These 3-D videotapes and arteriogram findings were directly correlated with intraoperative surgical findings at laparoscopy and during ex vivo bench preparation of the harvested kidney. The perceived intraoperative value of 3D-CT to delineate renovascular anatomical detail was scored subjectively by the laparoscopic surgeon for each case on a 10-point scale of 0--completely inaccurate to 10--completely accurate. RESULTS: There were no complications related to the 3-D CT protocol and volume rendering was successful in all patients. Three-D CT accurately identified the number of renal arteries in 59 patients (98%). In 1 patient with 3 renal arteries 3-D CT and arteriogram each identified only 2. In the 46 patients undergoing left donor nephrectomy 3-D CT accurately identified the number of veins and venous anomalies in 45 (98%), including 2 with a circumaortic left renal vein. Another case of circumaortic vein was misdiagnosed as 2 renal veins. On the right side in 14 patients 3-D CT accurately identified the renal veins in 13 (94%) and missed 1 vein in a patient with 2 renal veins. Angiography correctly identified the number of renal veins in only 52 cases (87%). Furthermore, it misdiagnosed all 3 cases of circumaortic left renal vein. The laparoscopic surgeon believed that 3-D CT accurately identified the location and anatomical interrelationship of the renal vessels with precision. Mean subjective score +/- SEM was 8.5 +/- 1 for the arterial system, 8.6 +/- 1.1 for the venous system and 9.2 +/- 0.5 for any vascular anomalies. CONCLUSIONS: Three-D CT accurately identifies renal vascular anatomy in a manner that may facilitate renal hilar dissection during laparoscopic donor nephrectomy, especially during the initial surgeon experience. This imaging modality integrates essential information from angiography, venography and excretory urography into a single study, and it can obviate the need for more invasive vascular imaging in most cases.

Orthotopic neobladder and subsequent renal transplantation.

Continent urinary diversion has become an attractive alternative to traditional conduits after cystectomy in select patients, including those awaiting renal transplantation. We report a case of a surgically anephric dialysis patient who underwent radical cystoprostatectomy with orthotopic ileal neobladder for recurrent superficial transitional cell carcinoma of the bladder and subsequent living-related renal transplantation 7 months later. We also discuss the perioperative adjuncts paramount to successful outcomes in such patients.