Percutaneous Nephrostomy as a Procedure in the Treatment of Urinary Tract Obstruction - Experiences in the University Clinic of Urology in Skopje.

INTRODUCTION: Obstructive uropathy encompasses various urinary tract obstructions, leading to changes in urine flow, kidney pressure, and impaired kidney function. Predicting renal recovery from obstructive uropathy, can be challenging and necessitates treatment, as in percutaneous nephrostomy (PNS) drainage. The choice of drainage method depends on patient-specific factors and local expertise. According to the data for the Republic of North Macedonia, in the register of the European Renal Association, in the last few years, there has been an increase in the percentage of patients with obstructive nephropathy from 7.6% to 8.9% who end up on a chronic hemodialysis program. Prompt relief from urinary tract obstruction is essential to preserve renal function and prevent complications. The aim of this study is to present our initial data analysis of recent experience in the use of nephrostomies as a method for temporary or long-term resolution of obstructive nephropathy, in terms of safety and success in preserving kidney function and reducing the number of patients on hemodialysis. MATERIALS AND METHODS: This study analyzed the medical records of 24 patients with obstructive uropathy who underwent PNS placement. Data were collected for the type and degree of obstruction from the ultrasonographic examination. A pig tail nephrostomy was used, with a dilator, guided under ultrasound and controlled with contrast and fluoroscope. Obstructive nephropathy was defined as an elevation of the serum creatinine > 109 µmol/L, before the intervention. Glomerular filtration rate (GFR) was calculated according to the formula CKD epi in ml/min. Each placement of the PNS was considered as an individual procedure and the data of 38 placed nephrostomies were analyzed. We compared the laboratory analyses from the day before (D0) PNS placement and on the seventh day (D7) after PNS placement. The reduction of values for red blood cells (RBC) and hemoglobin (Hb) baseline values from D0 to D7 and the need for transfusion after the procedure were defined as a complication-bleeding. The increase in total counts of the white blood cells (WBC) and C-reactive protein (CRP) from the baseline values from D0 to D7 were defined as a complication-infection. Standard statistical methods were used for data processing. RESULTS: Most patients, 17 (70%), had malignant disease as the cause of obstruction. Unilateral obstruction was more common, detected in 24 (63%) of procedures, with a high degree of hydronephrosis. Obstructive nephropathy, marked by elevated serum creatinine, was observed in 23 (60%) cases before PNS placement. Complications included bleeding and infection but did not result in any fatalities. When comparing the laboratory analysis before PNS placement (D0) and seven days later (D7), a statistically significant decrease in serum creatinine (225±161 vs. 162±145, p=0.005) and an increase in GFR (47±39 vs.59±34, p= 0.005) were observed. CONCLUSION: Percutaneous nephrostomy is a safe and effective treatment option for urinary tract obstruction, especially in patients with malignancies. Continuous monitoring is essential to assess long-term complications and the longevity of PNS functionality. This procedure offers a significant benefit in preserving renal function and minimizing the need for hemodialysis in these patients.

Laparoscopic Donor Nephrectomy in the Republic of North Macedonia.

Introduction: Hand-assisted laparoscopic living donor nephrectomy has become the technique of choice for living donor kidney donations. Since 2018, 30 procedures have been performed at our clinic using this technique. The goal of this comparative analysis was to determine how surgical technique, specifically, hand-assisted laparoscopic living donor nephrectomy with hand assistance may affect early graft function when compared to open classical nephrectomy. Material and methods: Retrospective analyses were performed, comparing the two techniques of kidney donation. Kidney transplantation was performed with the open standard technique in both groups. The primary outcome was early graft function, and levels of urine output, and plasma creatinine were analyzed at three time points. A secondary outcome was the quality of the operative technique, which was determined by the time of warm ischemia, blood loss, and duration of surgery. Additionally, we noted all complications, length of hospital stay, and patient satisfaction. Results: In terms of warm ischemia time, there was no statistically significant difference between donors in both groups. It is important to note that in 2 recipients from Group II we did not observe diuresis at the conclusion of the operation. The recipients' diuresis was 515 ml ± 321SD in group I and 444 ml ± 271SD in group II. At 3, 12, and 36 hours postoperatively, there were statistically significant differences in the average serum creatinine values (p 0.05) in favor of group I. Similar results were observed in the second time measurement at 12 h and the third time measurement at 36 h for serum urea levels in recipients. The difference in serum urea values between the recipients in the groups at the first measurement (3h) following surgery was not statistically significant. Conclusion: Hand-assisted laparoscopic donor nephrectomy is recognized as a safe and effective treatment. Donors in this situation have a different profile from other surgical patients; hence, they do not undergo surgery due to their own medical condition but for an altruistic reason, and with hand-assisted living donor nephrectomy. Such patients receive all the advantages of minimally invasive surgery. The two main objectives of a donor nephrectomy are to give the recipient the best possible kidney and to ensure the donor's complete safety.

Obturator Nerve Block for Transurethral Resection of Bladder Tumors.

Background: Bladder tumors are identified and treated using a surgical procedure called as transurethral resection of bladder tumors (TUR-BT). During TUR-BT resection, stimulation of the obturator nerve may cause violent adductor muscle spasms. The "obturator reflex," as this disorder is known, generally causes the legs to move inadvertently (leg jerking). Since this condition can cause several complications, it is preferable to avoid it. Objective: In this study, we investigated the effectiveness of spinal anesthesia combined with obturator nerve block or general anesthetic without muscle relaxant in preventing adductor muscle spasm during TUR-BT procedures. Methods: Forty consecutive patients were enrolled in a prospective observational evaluation and divided into two groups. Patients in Group I underwent spinal anesthesia along with an obturator nerve block, while those in Group II underwent general anesthesia without a neuromuscular relaxant. The following details were recorded: time for obturator block performance, the severity of the motor blockade, the length of the procedure in both groups because a probable adductor spasm might make it more difficult. The level of the surgeon's pleasure was noted throughout the surgery. Additionally, the patient's satisfaction and any issues that may have arisen were documented (the incidence of vascular puncture, hematoma, nerve damage, and visceral injury was noted). Results: Block performance time in Group I was 4.8±0.5 minutes, whereas it was 5.0±0.3 minutes in Group II. The ease of access for the two groups was the same. Group I demonstrated increased patient and surgeon satisfaction with a general anesthesia without neuromuscular relaxants and an obturatorius nerve block. Mean surgical time did not differ between the groups.There were no complications in either group. Conclusion: During such operations, routine use of ONB in combination with spinal anaesthetic or general anesthetic without a neuromuscular blocker can enhance oncological outcomes for patients, reduce complication rates, and extend the period of time spent living without disease.

Solitary Fibrous Tumor of Adrenal Gland and Review of the Literature.

Solitary fibrous tumor (SFT) is a rare and still controversial entity. This type of tumor first appeared in the literature as a pleural lesion, but, over the last decades, it has been reported in many extrathoracic sites. As a tumor of the adrenal gland, SFT is still rare and very uncommon, thus extensive research among the English language literature has been performed. We present here a case report of an adrenal SFT which is compared to 11 other known cases. Our case report is from a patient with SFT on the left adrenal gland, followed by mild symptoms of abdominal discomfort and hypertension. Physical examination, laboratory, and radiological tests were performed. The patient underwent surgery and the material was sent for histopathologic analysis for a definite diagnosis. Regular follow up appointments were performed over the course of two years. No recurrence of the tumor has been detected. We explain the symptoms, diagnosis, treatment, and additionally we describe the results and implications of the findings reported in the literature. Correct diagnosis is mandatory for optimal management of solitary fibrous tumor patients.

Acute fulminant hepatatis in kidney transplant recipient after repeated sevoflurane anesthesia--a case report and literature review.

INTRODUCTION: A liver dysfunction induced by halogenated volatile anaesthetics is considered as a significant diagnostic problem. The aim of our report was to describe the first case of lethal hepatic failure in a female patient undergoing kidney transplantation (KTx) from a living donor after repeated sevoflurane anaesthesia. CASE PRESENTATION: A 47-year-old hypertensive and diabetic female patient received kidney from her 70-year-old mother. There was an immediate graft function and around 800 ml of blood loss on the abdominal drains, which gradually decreased after the erythrocyte and fresh frozen plasma (FFP) substitution. On the first postoperative (p.o.) day she gradually became anuric and overweighed at the next day undergoing dialysis. Because of prolonged hypotension and somnolence she required reintubation. The second day transaminases increased (AST&ALT>700, LDH>1200 U/L). On the third p.o. day she was urgently reoperated because of a sudden excessive bleeding. However, there was a rather slow flow of tears from the whole operative field that was even more excessive after the operation with signs of a consumptive coagulopathy. She was adequately substituted until the bleeding stopped more than 24 hrs after its onset. The new laboratory results showed further increase in transaminazes (3300 U/L-ALT, 5100-AST, 8900-LDH) and ultrasound investigation confirmed an extensive toxic hepatic lesion. On the fourth p.o. night the patient was stable, diuresis rate was at 100 ml/hour, but in the morning she became hyposaturated because of an increased bronchial secretion. The dialysis could not improve the cardio-respiratory insufficiency and she died 30min later. CONCLUSIONS: This case report suggests that sevoflurane can lead to a severe hepatotoxicity in at-risk individuals with repeated sevoflurane anaesthesia, having renal failure, in those with a preoperative known history of cardiovascular disorders, as well as in those with excessive extracellular volume. A particular precaution should be considered in cases of an elective surgery including organ transplantation.