Anterior-interrupted and posterior-continuous suture technique improved the success rate of kidney transplantation model in rats.

PURPOSE: This study aimed to introduce and evaluate two new microvascular anastomosis techniques compared to the conventional method in a rat renal transplant model. METHODS: Using a Fisher-to-Lewis rat kidney transplantation model, the renal artery anastomosis was performed using the interrupted (I) suture technique, Y-shaped continuous (Y) suture technique, and anterior-interrupted and posterior-continuous (I-C) suture technique. The rats were then divided into three groups: I group, Y group, and I-C group. Parameters such as arterial anastomosis time, warm ischemia time, seven-day survival rate of the rats, and vessel histopathology were assessed. RESULTS: The mean arterial anastomosis time, blood leakage scores, and warm ischemia time were significantly reduced in groups Y and I-C compared to group I. Moreover, the seven-day survival rate was significantly higher in the I-C group compared to the other two groups. Arterial histopathology demonstrated vessel wall recovery without damage in all three groups, suggesting the safety of both Y and I-C techniques. CONCLUSIONS: The anterior-interrupted and posterior-continuous suture method is particularly beneficial for small artery reconstruction in organ transplantation.

En Bloc Simultaneous Liver-Kidney Transplantation Compared to the Traditional Technique: Results From a Single Center.

BACKGROUND: Simultaneous liver-kidney transplantation is indicated for patients with concomitant end-stage liver disease and end-stage renal disease. The traditional technique involves separate implantations of the liver and the kidney. In the en bloc approach, the liver is recovered en bloc with the right kidney and the donor renal artery is anastomosed to the donor splenic artery. We aimed to compare the outcomes of the traditional and en bloc techniques for simultaneous liver-kidney transplantation in a single center. METHODS: This single-center retrospective study involved all adult patients who underwent simultaneous liver-kidney transplantation from brain-dead donors from January 2017 to December 2022. RESULTS: A total of 15 patients were included: 10 transplanted with the traditional technique and 5 with the en bloc approach. Patients in the en bloc group presented higher body mass index, shorter kidney cold and total ischemia times, shorter overall surgical time and longer kidney warm ischemia time (29.07 kg/m2vs 23.20 kg/m2 [P = .048]; 560 minutes vs 880 minutes [P = .026]; 615 minutes vs 908 minutes [P = 0.025]; 405 minutes vs 485 minutes [P = .046]; 46 minutes vs 33.5 minutes [P = 0.027], respectively). Ureteroneocystostomy was performed in 2 patients of the en bloc group and ureteroureterostomy in the remaining 3 patients. One patient in the en bloc group presented stenosis of renal artery anastomosis and underwent percutaneous angioplasty. This same patient eventually developed late urinary fistula. In the traditional technique group, there were 2 cases of renal vein thrombosis and 1 of ureteral stenosis. CONCLUSIONS: Compared with the traditional technique, the en bloc approach is feasible and safe, reducing kidney total ischemia time and overall surgical time.

Robotic-Assisted Endovascular Treatment for Transplant Renal Artery Stenosis: A Feasibility Study.

PURPOSE: To describe a single-center experience with robotic-assisted endovascular treatment for transplant renal artery stenosis. MATERIALS AND METHODS: This is a single-center, retrospective, feasibility study of 4 consecutive cases of robotic-assisted endovascular surgery for transplant renal artery stenosis from October 2021 to August 2022. RESULTS: All lesions were identified, and stenting was performed with no complications. Conversion to manual control was not necessary. The mean fluoroscopy time was 25.25 min (range 12-60.9). A control Doppler ultrasound was routinely performed, demonstrating no residual lesions in all cases. There was no reintervention during the follow-up period. The operator learning curve was felt to be acceptable. CONCLUSION: Robotic-assisted endovascular treatment is a feasible technique for transplant renal artery stenosis.

Efficacy and Safety of Radiofrequency-Based Renal Denervation on Resistant Hypertensive Patients: A Systematic Review and Meta-analysis.

INTRODUCTION: New therapies for resistant hypertension (RH), including renal denervation (RDN), have been studied. AIM: Access the safety and effectiveness of radiofrequency-based RDN vs pharmacological treatment for RH. METHODS: A thorough literature search was conducted across PubMed, EMBASE, and the Cochrane databases, focusing on studies that compared the effects of radiofrequency-based RDN versus pharmacological treatment for RH. Treatment effects for binary and continuous endpoints were pooled and used, respectively, odds-ratio (OR) and mean differences (MD) with 95% confidence intervals (CI) to analyze continuous outcomes. RESULTS: In the 10 included studies, involving 1.182 patients, 682 received radiofrequency-based RDN. The follow-up period ranged from 6 to 84 months. Analysis revealed that the RDN group had a significant reduction in office systolic blood pressure (BP) (MD - 9.5 mmHg; 95% CI - 16.81 to - 2.29; P = 0.01), office diastolic BP (MD - 5.1 mmHg; 95% CI - 8.42 to - 2.80; P < 0.001), 24 h systolic BP (MD - 4.8 mmHg; 95% CI - 7.26 to - 2.42; P < 0.001). For 24 h diastolic BP RDN did not have a significant reduction (MD - 2.3 mmHg; 95% CI - 4.19 to - 0.52; P = 0.012). The heterogeneity between the studies was high, visible in the funnel and Baujat plots. The OR was non-significant for non-serious adverse events, but also clinically significant for hypertensive crises and strokes for the RDN group. CONCLUSIONS: While the pharmacological regimen of 3 or more anti-hypertensive, including a diuretic, still be the first-line option for RH treatment, our results support that radiofrequency-based RDN is superior in reducing global BP and is safe.

Robot-assisted partial nephrectomy for large complex renal cancer: step-by-step segmental artery unclamping.

INTRODUCTION: Main renal artery clamping and selective arterial clamping are two conventional devascularization methods for robot-assisted partial nephrectomy (RAPN) (1, 2). Decreasing warm ischemic (WI) time (3, 4) and improving clear surgical visualization (5) are the main surgically modifiable factors for RAPN, especially in large complex renal cancer (6). In this study, we described our surgical technique, focusing on gradual segmental artery unclamping on patients with large renal tumors. MATERIAL AND METHODS: Two patients (R.E.N.A.L score 10 and 11) underwent RAPN with gradual segmental artery unclamping (Figures 1 and 2). The unclamping included five key steps. First, all renal segmental arteries were identified as tumor feeding vessel(s) and the vessels for normal kidney parenchyma under the guidance of CT angiography (CTA) 3-division (3D) reconstruction. Second, all segmental arteries were isolated, and the feeding one(s) should be blocked before other arteries were blocked. Third, the tumor was resected outside the pseudocapsule, and the deep resection bed was sutured for initial hemostasis. Fourth, the segmental arteries were reopened except for the tumor feeding one(s), and normal kidney parenchyma restored blood supply. And fifth, the resection bed was completely sutured, and the feeding vessel supplying the tumor was opened after the suture. Warm ischemia time (WIT) was defined as the time measured between clamping and unclamping of the renal artery. WIT1 was the time for normal kidney parenchyma and WIT2 was the time for resection area. Patient demographics, perioperative variables, and warm ischemic time were included in our study. And we presented the details of gradual segmental artery unclamping in the video. RESULTS: In both cases, the total operation times were 215 and 130 mins for patient 1 and patient 2, respectively. WIT1 and WIT2 for patient 1 were 15 min and 33 min., and WIT1 and WIT2 for patient 2 were 21 min and 32 min, respectivelly. The maximum diameters of the masses resected were 10.8 and 7.3 cm, and surgical margins were negative. No patient had complications after operation. Preoperative and postoperative eGFR did not change significantly. Pre- and postoperative eGFR were 111 and 108 mL/min for patient 1, 91 and 83 mL/min for patient 2, respectively. Key hints for outcomes optimization during RAPN on patients with large complex renal tumors: 1) Each segmental renal artery is precised clamped before we excise the tumor, and an excellent surgical vision is essential for precising excision and shortening clamping time, 2) Other segmental renal arteries are unclamped except tumor feeding branch after suturing deep layer of parenchyma, and most normal parenchyma restores blood supply, 3) Preoperative high-resolution computed tomography angiography (CTA) and 3D reconstructive renal structure serve as a guide to clear the approach to find the tumor and segmental arteries (7, 8). CONCLUSIONS: Gradual segmental artery unclamping is feasible and efficient to excise large complex renal cancer. Compared with main renal artery clamping, it can shorten the warm ischemic time of normal parenchyma; On the other hand, compared with selective segmental arterial clamping, the technique can reduce bleeding from the deep resection bed, keep a clear surgical vision, and decrease the incidence of positive margin.

Spontaneous renal artery dissection: angioplasty with stent implantation in one-year follow-up.

Spontaneous renal artery dissection is an unusual and idiopathic condition in most cases. In young, mildly symptomatic patients, diagnosis may be difficult, frequently culminating in delay in treatment. This report presents the case of a 40-year-old male patient, with severe hypertension of sudden onset, and difficult management of oral medication. In etiological investigation, Echo-Doppler of renal arteries showed signs of hemodynamically relevant right renal artery stenosis. Arteriography showed presence of double-lumen and thrombus in the vessel lumen, indicating dissection. The proposed treatment was endovascular approach after failure of isolated medical treatment, option which included the aspiration of the thrombus by Penumbra System® device and balloon angioplasty, followed by right renal artery stenting. Improvement of immediate sonographic control of peak systolic velocity and renal-aortic ratio was shown, with a consequent reduction of systemic arterial blood pressure and stabilization of renal function. Within the following year, the patient presented in-stent stenosis and was successfully treated with balloon angioplasty.

Denervação de artéria renal em paciente com hipertensão arterial refratária / Renal denervation in patient with refrataryarterial hypertension

Caso clínico de uma paciente com quadro de hipertensão arterial refratária, sendo inicialmente atribuída como etiologia a displasia de artéria renal. Os níveis pressóricos mantiveram elevados após a angioplastia de artéria renal, mantendo descontrole pressórico apesar do uso de 10 classes de anti-hipertensivos. Foi indicada a denervação de artéria renal e após tal, foi possível redução das medicações e êxito no controle de seus níveis tensionais. Destaca-se a importância do adequado diagnóstico de hipertensão arterial refratária, a exclusão de hipertensão secundária, somado à otimização terapêutica e indicação de procedimentos quando necessário, tendo como objetivo o melhor controle pressórico e consequente redução de lesões de órgãos-alvo e eventos cardiovasculares graves (AU).

It will be explained the patient clinical case of with refractory hypertension, which was initially attributed to renal artery dysplasia, but after the renal artery angioplasty, remained with high blood pressure levels despite adequate anti-hypertensive drugs administration. Renal denervation was indicated and after medications was reduced, with adequate blood pressure level control. It emphasizes the importance of secondary hypertension diagnosis, therapeutic optimization and specific therapies, if necessary, with the aim to take blood pressure control and the consequent reduction of target-organ damage and severe vascular events (AU).

Denervação simpática renal no tratamento da hipertensão arterial resistente: relato de caso / Renal sympathetic denervation in the treatment of resistant arterial hypertension: case report

Introdução: A hipertensão arterial sistêmica (HAS) pode levar a consequências cardiovasculares graves quando não tratadas adequadamente. No entanto, alguns indivíduos, mesmo realizando tratamento recomendado, a pressão arterial (PA) se mantém elevada, passando a ser chamada de hipertensão arterial refratária (HAR). A denervação simpática renal (DSR) é uma terapia amplamente estuda e com resultados promissores que surgiu como alternativa para controlar a PA em pacientes resistentes ao tratamento convencional. Relato de caso: Participante da pesquisa, sexo masculino, 67 anos, com queixa de cefaleia e elevação dos níveis pressóricos. Avaliação cardíaca com alteração apenas da PA (182x113 mmHg), demais sistemas sem variações. Diagnosticado com HAS estágio 3, realizou todas as etapas do tratamento medicamentoso, porém resistente as terapias propostas. Diante do caso, foi diagnosticado com HAR. Sendo realizado DSR que mostrou resultados satisfatórios de redução progressiva da pressão arterial central e periférica. Conclusão: A DSR mostrou-se eficaz no controle gradual e sustentado da PA do participante da pesquisa. Contudo, somente através de estudos clínicos mais amplos e rigorosos será capaz de comprovar a eficácia da DSR no tratamento da PA alta persistente (AU).

Introduction: Systemic arterial hypertension (SHT) can lead to severe cardiovascular outcomes when not properly treated. However, in some individuals, even with recommended treatment, blood pressure (BP) remains high, and is now referred to as Resistant hypertension (RHTN). Renal sympathetic denervation (RDn) is a widely studied and promising therapy that has emerged as an alternative to control BP in patients resistant to conventional treatment. Case report: Research participant, male, 67 years old, complaining of headache and elevated blood pressure. Cardiac assessment with only BP alteration (182x113 mmHg), other systems without variations. Diagnosed with stage 3 hypertension, performed all stages of drug treatment, but resistant to the proposed therapies. Given the case, was diagnosed with RHTN. Being performed RDn that showed satisfactory results of progressive reduction of central and peripheral blood pressure. Discussion: Sympathetic hyperactivity of the renal nervous system releases catecholamines that raise BP. Based on this, the RDn uses a catheter connected to the radiofrequency device that through the femoral artery goes to the two renal arteries and emits energy in the sympathetic fibers attached to the walls of these arteries, destroying them. RDn has been the target of several clinical studies, the best-known being Simplicity HTN-1, 2 and 3 which brought significant and questionable results regarding the efficacy of the procedure. Conclusion: RDn proved to be effective in gradually and sustained BP control of the research participant. However, only through broader and more rigorous clinical studies will it be able to prove the efficacy of RDn in combating persistent high BP (AU).

Multilayer stents affect the final diameter of aortic aneurysms and maintain renal artery patency for a short time in a swine experimental model.

OBJECTIVES: We sought to analyze the hemodynamic effects of the multilayer flow-modulated stent (MFMS) in Thoracoabdominal aortic aneurysms (TAAAs). METHODS: The hemodynamic effects of MFMS were analyzed in aortic thoracoabdominal aneurysms in experimental swine models. We randomly assigned 18 pigs to the stent or control groups and underwent the creation of an artificial bovine pericardium transrenal aneurysm. In the stent group, an MFMS (Cardiatis, Isnes, Belgium) was immediately implanted. After 4 weeks, we evaluated aneurysm sac thrombosis and renal branch patency by angiography, duplex scan, and morphological analysis. RESULTS: All the renal arteries remained patent after re-evaluation in both groups. Aneurysmal sac thrombosis was absent in the control group, whereas in the stent group it was present in 66.7% of aneurysmal sacs (p=0.061).The mean final aneurysm sac diameter was significantly lower in the stent group (mean estimated reduction, 6.90 mm; p=0.021). The proximal neck diameter decreased significantly in the stent group (mean difference, 2.51 mm; p=0.022) and grew significantly in the control group (mean difference, 3.02 mm; p=0.007). The distal neck diameter increased significantly in the control group (mean difference, 3.24 mm; p=0.017). There were no significant findings regarding distal neck measurements in the stent group. CONCLUSION: The MFMSs remained patent and did not obstruct the renal arteries within 4 weeks. In the stent group, the device was also associated with a significant decrease in aneurysmal sac diameter and a large proportion (albeit non-significant) of aneurysmal sac thrombosis.

The bovine kidney as an experimental model: Simulated partial nephrectomy of the cranial pole and proportional analysis of the arterial segments.

Previous studies have shown that the pig kidney is not a good model for some procedures. This study aimed to describe the relationship between the collecting system and the intrarenal arteries, the arterial segments, and to evaluate the bovine kidney as an experimental model for partial nephrectomy of the cranial pole. Polyester resin endocasts of the kidney collecting system together with the intrarenal arteries were prepared. Thirty-two kidneys were used to evaluate the relationship between the collecting system and the intrarenal arteries, while 25 kidneys were transversally sectioned at different points to simulate partial nephrectomy of the cranial pole. Polyester resin of different colors was injected into each segmental artery of the 24 kidneys to evaluate the arterial segments proportionally. The renal artery was divided into cranial and caudal primary branches in 75% of the cases. The cranioventral branch curved on the cranial pole and ran toward the ventral mid-zone in 56.3% of the cases, resembling the retropelvic artery of the human kidney. The kidney was divided into two (25%) or three (75%) arterial segments. The caudal arterial segment had the highest proportional volume (62%). The cranioventral branch was damaged in 28.6% of the kidneys sectioned 1 cm inside the hilum. The arterial branching pattern, the arterial segmentation, and the impairment of the arterial supply after the simulated partial nephrectomy of the cranial pole are quite different from those found in humans. Thus, all differences should be taken into account when using the bovine kidney as a model.

Estudos anteriores demonstraram que o rim do porco não é um bom modelo para alguns procedimentos. O objetivo deste estudo foi descrever a relação entre o sistema coletor e as artérias intrarrenais, os segmentos arteriais, e avaliar o rim bovino como modelo experimental para a nefrectomia parcial do polo cranial. Foram confeccionados moldes de resina de poliéster do sistema coletor renal associado às artérias intrarrenais. Para a avaliação da relação entre o sistema coletor e as artérias intrarrenais foram utilizados trinta e dois rins, enquanto outros trinta e cinco rins foram cortados transversalmente em diferentes regiões para simular a nefrectomia parcial do polo cranial. Resina de poliéster de diferentes cores foi injetada em cada segmento arterial de 24 rins para avaliar proporcionalmente os segmentos arteriais. A artéria renal se dividiu em ramos primários cranial e caudal em 75% dos casos. O ramo cranioventral contornou o polo cranial e seguiu para a região média ventral em 56,3% dos casos, lembrando a artéria retropiélica do rim humano. O rim estava dividido em dois (25%) ou três (75%) segmentos arteriais. O segmento arterial caudal apresentou o maior volume proporcional (62%). O ramo cranioventral foi lesionado em 28,6% dos rins seccionados 1 cm internamente ao hilo. O padrão da ramificação arterial, os segmentos arteriais, e o dano ao suprimento arterial após a nefrectomia simulada parcial do polo cranial são bem diferentes daqueles encontrados em humanos. Então, todas as diferenças devem ser levadas em consideração quando se usa o rim bovino como modelo.

Resultado imediato do tratamento endovascular com stents paralelos do aneurisma roto justarrenal / Immediate outcome of endovascular treatment of ruptured juxtarenal aneurysm with parallel stents

Resumo A ruptura do aneurisma de aorta abdominal é um evento com alta mortalidade, e o seu tratamento nesses casos é uma emergência médica. O tratamento endovascular desses aneurismas tem se estabelecido como uma alternativa minimamente invasiva à cirurgia aberta clássica, tornando-se a opção de primeira escolha. Contudo, 20 a 50% dos pacientes portadores de aneurisma de aorta abdominal não apresentam anatomia favorável para o tratamento endovascular devido à presença de colo curto ou pelo acometimento de ramos viscerais pelo aneurisma. Relatamos um caso de uma paciente de 70 anos submetida à correção endovascular de aneurisma roto justarrenal com implante de stents paralelos para as renais (técnica de chaminé). São apresentados dados clínicos e detalhes do procedimento. O sucesso técnico foi obtido e não houve relato de complicações pós-operatórias.

Abstract Rupture of an abdominal aortic aneurysm is an event with a high mortality rate and treatment is a medical emergency. Endovascular treatment of these aneurysms has become established as a minimally invasive alternative to classical open surgery and is now the first-choice option. However, 20 to 50% of patients with abdominal aortic aneurysms do not have anatomy favorable for endovascular treatment because of a short aneurysm neck or because visceral branches are involved by the aneurysm. We report the case of a 70-year-old patient who underwent endovascular repair of a ruptured juxtarenal aneurysm with deployment of parallel stents in the renal arteries (in a chimney technique). Clinical data and details of the procedure are reported. Technical success was achieved and there were no postoperative complications.

Multilayer stents affect the final diameter of aortic aneurysms and maintain renal artery patency for a short time in a swine experimental model

OBJECTIVES: We sought to analyze the hemodynamic effects of the multilayer flow-modulated stent (MFMS) in Thoracoabdominal aortic aneurysms (TAAAs). METHODS: The hemodynamic effects of MFMS were analyzed in aortic thoracoabdominal aneurysms in experimental swine models. We randomly assigned 18 pigs to the stent or control groups and underwent the creation of an artificial bovine pericardium transrenal aneurysm. In the stent group, an MFMS (Cardiatis, Isnes, Belgium) was immediately implanted. After 4 weeks, we evaluated aneurysm sac thrombosis and renal branch patency by angiography, duplex scan, and morphological analysis. RESULTS: All the renal arteries remained patent after re-evaluation in both groups. Aneurysmal sac thrombosis was absent in the control group, whereas in the stent group it was present in 66.7% of aneurysmal sacs (p=0.061). The mean final aneurysm sac diameter was significantly lower in the stent group (mean estimated reduction, 6.90 mm; p=0.021). The proximal neck diameter decreased significantly in the stent group (mean difference, 2.51 mm; p=0.022) and grew significantly in the control group (mean difference, 3.02 mm; p=0.007). The distal neck diameter increased significantly in the control group (mean difference, 3.24 mm; p=0.017). There were no significant findings regarding distal neck measurements in the stent group. CONCLUSION: The MFMSs remained patent and did not obstruct the renal arteries within 4 weeks. In the stent group, the device was also associated with a significant decrease in aneurysmal sac diameter and a large proportion (albeit non-significant) of aneurysmal sac thrombosis.

Complex Aortic, Visceral and Renal Arteries Reconstruction with a Four-Branch Dacron Graft for Middle Aortic Syndrome Secondary to Takayasu's Arteritis.

The middle aortic syndrome (MAS) is an uncommon clinical expression as a result of isolated stenosis or complete occlusion of the descending thoracic and/or abdominal aorta; Takayasu's arteritis (TA) is a rare vasculitis and a recognized etiology of MAS. We herein present the case of a 52-year-old woman with refractory renovascular hypertension and progressive bilateral lower extremity claudication; she had known history of TA. A computed tomography angiography demonstrated an aortic occlusive lesion compromising the origin of the celiac trunk, superior mesenteric, and bilateral renal arteries. The patient underwent a complex aortic reconstruction with visceral and renal vessels revascularization utilizing a back-table hand-crafted 4-branch Dacron graft through a left thoracoabdominal approach. The patient recovered uneventfully and was discharged on postoperative day 5, and at 36 months from her surgery, she remains symptoms-free and without antihypertensive agents.

Experiencia de embolización de la arteria renal previa a nefrectomía / Experience of Renal Artery Embolization Prior to Nephrectomy

Resumen Objetivo: Describir la evolución perioperatoria de pacientes sometidos a nefrectomía con y sin embolización de la arteria renal (EAR) prequirúrgica, en un hospital de alta complejidad de Medellín, Colombia. Materiales y Métodos: Observacional descriptivo retrospectivo; se incluyeron pacientes de 18-90 años con diagnóstico de tumor renal, sometidos a nefrectomía con y sin EAR prequirúrgica. Las variables cualitativas se expresaron por medio de frecuencias y proporciones, y las cuantitativas mediante medidas de tendencia central y dispersión. Resultados: Se incluyeron 71 pacientes con una media de edad de 58,1 (DE: 10,6) años, 41 eran mujeres y el 69% tenía diagnóstico de carcinoma de células claras. La media del volumen de sangrado intraoperatorio fue de 540,8 cc, y 19,7% requirió transfusión. El tiempo quirúrgico promedio fue de 2,6 horas y el 38% presentó alguna complicación, con una mortalidad total del 4,2%. Al observar comparativamente los pacientes con EAR (15 pacientes) versus aquellos sin ella (56 pacientes), se identificó un mayor volumen de sangrado intraoperatorio y la necesidad de transfusión en los primeros. Conclusión: Los pacientes sometidos a EAR presentaron un mayor volumen de sangrado, mayor frecuencia de transfusión y complicaciones postoperatorias, siendo necesario un consenso sobre su real pertinencia terapéutica.

Abstract Aim: To describe the perioperative outcomes of patients undergoing nephrectomy with and without preoperative Renal Artery Embolization (RAE) in a high-complexity hospital in Medellín, Colombia. Materials and Methods: Retrospective, descriptive and observational study; 18-90 years old patients with renal tumor diagnosis, submitted to nephrectomy with and without preoperative RAE were included. Qualitative variables were expressed by measures of frequencies and proportions, and quantitative variables were expressed by measures of central tendency and dispersion. Results: 71 patients with a media age of 58,1 (SD: 10,6) years were included, 41 were women and 69% were diagnosed with clear cell carcinoma. The blood loss volume media was 540.8 cc, and 19.7% required transfusion. The operative time media was 2.6 hours and 38% had any complication, with a total mortality of 4.2%. Comparatively observing patients with RAE (15 patients) versus patients without RAE (56 patients), a higher intraoperative blood loss and transfusion requirements were identified in the first ones. Conclusion: Patients submitted to RAE presented greater volume of bleeding, greater frequency of transfusion and post-operative complications, requiring a consensus on its real therapeutic relevance.

Antioxidants as Renoprotective Agents for Ischemia during Partial Nephrectomy.

Small renal masses have been diagnosed increasingly in recent decades, allowing surgical treatment by partial nephrectomy. This treatment option is associated with better renal function preservation, in comparison with radical nephrectomy. However, for obtaining a bloodless field during surgery, occlusion of renal artery and veins is often required, which results in transitory ischemia. The renal ischemia-reperfusion injury is associated with increased reactive oxygen species production leading to renal tissue damage. Thus, the use of antioxidants has been advocated in the partial nephrectomy perioperative period. Several antioxidants were investigated in regard to renal ischemia-reperfusion injury. The present manuscript aims to present the literature on the most commonly studied antioxidants used during partial nephrectomy. The results of experimental and clinical studies using antioxidants during partial nephrectomy are reported. Further, alimentary sources of some antioxidants are presented, stimulating future studies focusing on perioperative antioxidant-rich diets.

Comparison of perioperative outcomes with or without renorrhaphy during open partial nephrectomy: A propensity score-matched analysis

ABSTRACT Purpose: Renorrhaphy in partial nephrectomy may damage intraparenchymal vessels and compress the renal parenchyma, which may lead to the formation of renal artery pseudoaneurysms or vascularized parenchymal volume reduction. Using propensity score matching, we compared surgical outcomes following non-renorrhaphy and renorrhaphy techniques for open partial nephrectomy (OPN) for T1a renal tumors. Materials and Methods: We retrospectively analyzed data from 159 patients with normal contralateral kidneys who underwent OPN for T1a renal tumors and pre- and postoperative enhanced computed tomography between 2012 and 2015. Patient variables were adjusted using 1:1 propensity score matching between the two Groups: renorrhaphy (inner and outer layer sutures) and non-renorrhaphy (inner layer sutures only). Postoperative complications and renal function were compared between the two groups. Results: We matched 43 patients per Group. Operative time, estimated blood loss, cold ischemic time, and postoperative hospital stay were not significantly different between the two Groups. Urine leakage (Clavien-Dindo grade ≥3) occurred in 0 renorrhaphy cases and 2 non-renorrhaphy cases (0% versus 4.6%, P=0.49). Renal artery pseudoaneurysm (RAP) occurred in 6 renorrhaphy cases and in 0 non-renorrhaphy cases (13% versus 0%, P=0.02). Conclusions: The non-renorrhaphy technique may result in a lower risk of RAP but a greater risk of urine leakage. This technique needs further refinement to become a standard procedure for OPN.

Initial experience with the use of fractional flow reserve in the hemodynamic evaluation of transplant renal artery stenosis.

OBJECTIVE: To describe and standardize an original protocol for fractional flow reserve (FFR) pre and postangioplasty in an initial series of patients with clinically manifested transplant renal artery stenosis (TRAS). BACKGROUND: There is no data in the literature about the use of FFR in TRAS. METHODS: Patients with TRAS detected in a noninvasive study were referred to diagnostic angiography and stenosis considered visually severe (≥ 60%) were included. After selective cannulation, a PressureWire 0.014" (Certus™-St. Jude Medical) was advanced to the distal portion of the vessel. Resting Pd/Pa ratio (ratio of mean distal to lesion and mean proximal pressures) and translesional systolic pressure gradient were obtained and FFR and hyperemic translesional systolic and mean pressure gradients (HSG and HMG) were registered after papaverine induced maximum hyperemia-pre and poststent implantation. Creatinine levels and office blood pressure measurements were registered at the baseline, 6 and 12 months after intervention. RESULTS: Ten consecutive patients had successful stent implantation and were included. After treatment, significant increase in FFR (0.76 ± 0.09 vs. 0.96 ± 0.04, P < 0.001) and reduction in systolic hyperemic gradients (-41.40 ± 19.18, P < 0.001) and mean (-24.00 ± 11.65, P < 0.001) were observed. A strong negative correlation was observed between FFR and percent stenosis diameter-%SD (r = -0.89, P < 0.001) and HSG (r = -0.9, P < 0.001) as well as a strong positive correlation between FFR and baseline Pd/Pa ratio (r = 0.9, P < 0.001). CONCLUSION: FFR was a well-tolerated, valid and reproducible tool during percutaneous intervention for TRAS. Good correlation was observed between FFR and others hemodynamic parameters of lesion severity.

Comparison of perioperative outcomes with or without renorrhaphy during open partial nephrectomy: A propensity score-matched analysis.

PURPOSE: Renorrhaphy in partial nephrectomy may damage intraparenchymal vessels and compress the renal parenchyma, which may lead to the formation of renal artery pseudoaneurysms or vascularized parenchymal volume reduction. Using propensity score matching, we compared surgical outcomes following non-renorrhaphy and renorrhaphy techniques for open partial nephrectomy (OPN) for T1a renal tumors. MATERIALS AND METHODS: We retrospectively analyzed data from 159 patients with normal contralateral kidneys who underwent OPN for T1a renal tumors and pre- and postoperative enhanced computed tomography between 2012 and 2015. Patient variables were adjusted using 1:1 propensity score matching between the two Groups: renorrhaphy (inner and outer layer sutures) and non-renorrhaphy (inner layer sutures only). Postoperative complications and renal function were compared between the two groups. RESULTS: We matched 43 patients per Group. Operative time, estimated blood loss, cold ischemic time, and postoperative hospital stay were not significantly different between the two Groups. Urine leakage (Clavien-Dindo grade ≥3) occurred in 0 renorrhaphy cases and 2 non-renorrhaphy cases (0% versus 4.6%, P=0.49). Renal artery pseudoaneurysm (RAP) occurred in 6 renorrhaphy cases and in 0 non-renorrhaphy cases (13% versus 0%, P=0.02). CONCLUSIONS: The non-renorrhaphy technique may result in a lower risk of RAP but a greater risk of urine leakage. This technique needs further refinement to become a standard procedure for OPN.

Resultados del trasplante renal con donante vivo: análisis comparativo entre arteria renal única y múltiple / Outcome in Living Donor Kidney Transplant: Comparative Análisis of Single and Multiple Renal Arteries

Objetivos: Realizar un análisis comparativo de los resultados funcionales y complicaciones en trasplantados renales y sus respectivos donantes vivos con arteria renal única versus múltiple. Materiales y métodos: Trabajo retrospectivo analítico de una base de datos confeccionada prospectivamente de pacientes sometidos a trasplantes renales con donante vivo en nuestra institución entre mayo de 2010 y julio de 2014. Según el número de arterias presentes en la angiotomografía preoperatoria se confeccionaron dos grupos: grupo 1 (arteria renal única) y grupo 2 (arteria renal múltiple). Resultados: De los 91 pacientes incluidos, el 37% (n=34) presentaba arterias renales múltiples. Se realizó una nefrectomía laparoscópica al 63% (n=36) y el 41% (n=14) de los donantes del grupo 1 y el grupo 2, respectivamente (p=0,05). Tiempos promedio de isquemia total (grupo 1: 55,6 min; grupo 2: 56 min; p=0,931), de anastomosis (grupo 1: 29,6 min; grupo 2: 29,7 min; p=0,982) y de "cirugía de banco" (grupo 1: 23,5 min; grupo 2: 23,8 min; p=0,948). Transfusión de glóbulos rojos en los receptores (grupo 1: 7%; grupo 2: 14%; p=0,23). Porcentaje de hemodiálisis en la primera semana (grupo 1: 5,2%; grupo 2: 5,8%; p=1). No se hallaron diferencias significativas entre grupos a nivel de tasa de complicaciones y días de internación. Ambos grupos presentaron una sobrevida del injerto del 100% a los 35,6 meses de seguimiento promedio. Conclusiones: La presencia de multiplicidad arterial no debe ser considerada una contraindicación para el donante vivo, ya que el implante de estos injertos logra resultados funcionales similares a los injertos renales con arteria única, sin aumentar la morbilidad del procedimiento. (AU)

Objectives: TTo compare functional outcomes and complications in patients with a single artery versus multiple arteries undergoing living donor nephrectomy. Materials and methods: Retrospective analysis of a prospective collected database of living donor kidney transplantations performed at our institution between May 2010 and July 2014. According to the number of arteries present in preoperative angiotomography, two groups of patients were organized: group 1 (single artery) and group 2 (multiple arteries). Results: TNinety-one living donor kidney transplantations were performed during this period. A total of 34 patients (37%) had multiple renal arteries. Mean total ischemia time (single: 55.6 min; multiple: 56 min; p=0.931), anastomosis time (single: 29.6 min; multiple: 29.7 min; p=0.982), bench surgery time (single: 23.5 min; multiple: 23.8 min; p=0.948). Blood transfusion rate was 7% and 14% for group 1 and group 2, respectively (p=0.23). Three patients in group 1 (5.2%) and two patients in group 2 (5.8%) needed dialysis during the first postoperative week (p=1). Overall, recipient complication rate and hospital stay were similar between group 1 and 2. Both groups had a 100% graft survival with a mean follow-up of 35.6 months. Conclusions: The presence of multiple renal arteries should not be considered a contraindication for the living donor nephrectomy, since these grafts achieve similar functional results to single artery renal grafts, without increasing the morbidity of the procedure. (AU)