Evaluating the learning curve for retroperitoneoscopic adrenalectomy in a high-volume center for laparoscopic adrenal surgery.

BACKGROUND: Laparoscopic adrenalectomy is an effective method for benign adrenal tumor removal. In the literature, both lateral transperitoneal (TLA) and posterior retroperitoneoscopic (RPA) approaches are described. Since 2007, the number of patients increased significantly in our center. Therefore, RPA was introduced in 2011 because of its potential advantages in operating and recovery times. The learning curve of RPA is now evaluated. METHODS: All data of patients undergoing laparoscopic adrenalectomy from 2007 until 2014 were prospectively collected. Patients were eligible for RPA with a tumor <7 cm, with BMI < 35 kg/m2, and with low suspicion of malignancy. The learning curve of RPA was measured by operating time. Furthermore, blood loss, preoperative complications and hospital stay were analyzed. Descriptive statistics were performed using SPSS 20.0. RESULTS: In the study period, 290 patients underwent surgery, of whom 113 underwent RPA. After starting with RPA, operating times decreased significantly (median 100 min in the first 20 patients to 60 min after 40 patients, p < 0.05). There was a significant difference in operating times (median 108 vs. 62 min, p < 0.05) and hospital stay (median 4 vs. 3 days, p < 0.05) in unilateral surgery in favor of RPA, compared to TLA. Also in bilateral surgery, operating times were significantly shorter (median 236 vs. 117 min, p < 0.05). In both groups, few major complications occurred. CONCLUSION: After the introduction of RPA, a short learning curve was seen for a single surgeon with extensive experience in laparoscopic adrenal surgery. Compared to TLA, RPA has significant advantages in operating times and hospital stay. Therefore, RPA may be the preferred approach for patients with BMI < 35 kg/m2 and small benign adrenal tumors (<7 cm).

Low-pressure pneumoperitoneum during laparoscopic donor nephrectomy to optimize live donors' comfort.

Nowadays, laparoscopic donor nephrectomy (LDN) has become the gold standard to procure live donor kidneys. As the relationship between donor and recipient loosens, it becomes of even greater importance to optimize safety and comfort of the surgical procedure. Low-pressure pneumoperitoneum has been shown to reduce pain scores after laparoscopic cholecystectomy. Live kidney donors may also benefit from the use of low pressure during LDN. To evaluate feasibility and efficacy to reduce post-operative pain, we performed a randomized blinded study. Twenty donors were randomly assigned to standard (14 mmHg) or low (7 mmHg) pressure during LDN. One conversion from low to standard pressure was indicated by protocol due to lack of progression. Intention-to-treat analysis showed that low pressure resulted in a significantly longer skin-to-skin time (149 ± 86 vs. 111 ± 19 min), higher urine output during pneumoperitoneum (23 ± 35 vs. 11 ± 20 mL/h), lower cumulative overall pain score after 72 h (9.4 ± 3.2 vs. 13.5 ± 4.5), lower deep intra-abdominal pain score (11 ± 3.3 vs. 7.5 ± 3.1), and a lower cumulative overall referred pain score (1.8 ± 1.9 vs. 4.2 ± 3). Donor serum creatinine levels, complications, and quality of life dimensions were not significantly different. Our data show that low-pressure pneumoperitoneum during LDN is feasible and may contribute to increase live donors' comfort during the early post-operative phase.

Poor early graft function impairs long-term outcome in living donor kidney transplantation.

BACKGROUND: Poor early graft function (EGF) after living donor kidney transplantation (LDKT) has been found to decrease rejection-free graft survival rates. However, its influence on long-term graft survival remains inconclusive. METHODS: Data were collected on 472 adult LDKTs performed between July 1996 and February 2010. Poor EGF was defined as the occurrence of delayed or slow graft function. Slow function was defined as serum creatinine above 3.0 mg/dL at postoperative day 5 without dialysis. RESULTS: The incidence of slow and delayed graft function was 9.3 and 4.4%, respectively. Recipient overweight, pretransplant dialysis and warm ischemia were identified as risk factors for the occurrence of poor EGF. The rejection-free survival was worse for poor EGF as compared to immediate graft function with an adjusted hazard ratio (HR) of 6.189 (95% CI 4.075-9.399; p < 0.001). Long-term graft survival was impaired in the poor EGF group with an adjusted HR of 4.206 (95% CI 1.839-9.621; p = 0.001). CONCLUSIONS: Poor EGF occurs in 13.7% of living donor kidney allograft recipients. Both, rejection-free and long-term graft survivals are significantly lower in patients with poor EGF as compared to patients with immediate graft function. These results underline the clinical relevance of poor EGF as phenomenon after LDKT.

The use of mannitol in partial and live donor nephrectomy: an international survey.

PURPOSE: Animal studies have shown the potential benefits of mannitol as renoprotective during warm ischemia; it may have antioxidant and anti-inflammatory properties and is sometimes used during partial nephrectomy (PN) and live donor nephrectomy (LDN). Despite this, a prospective study on mannitol has never been performed. The aim of this study is to document patterns of mannitol use during PN and LDN. MATERIALS AND METHODS: A survey on the use of mannitol during PN and LDN was sent to 92 high surgical volume urological centers. Questions included use of mannitol, indications for use, physician responsible for administration, dosage, timing and other renoprotective measures. RESULTS: Mannitol was used in 78 and 64 % of centers performing PN and LDN, respectively. The indication for use was as antioxidant (21 %), as diuretic (5 %) and as a combination of the two (74 %). For PN, the most common dosages were 12.5 g (30 %) and 25 g (49 %). For LDN, the most common doses were 12.5 g (36.3 %) and 25 g (63.7 %). Overall, 83 % of centers utilized mannitol, and two (percent or centers??) utilized furosemide for renoprotection. CONCLUSIONS: A large majority of high-volume centers performing PN and LDN use mannitol for renoprotection. Since there are no data proving its value nor standardized indication and usage, this survey may provide information for a randomized prospective study.

Deleterious influence of prolonged warm ischemia in living donor kidney transplantation.

BACKGROUND: Recent studies investigating early graft function (EGF) after living donor kidney transplantation (LDKT) identified prolonged warm ischemia time (WIT) as a risk factor for the occurrence of poor EGF. The latter is associated with long-term graft loss; therefore the question arises whether prolonged WIT affects long-term outcomes in LDKT. METHODS: Data were collected on 472 consecutive adult LDKTs. Patients were divided according to the total WIT into 3 groups with short (<30 minutes), intermediate (30-45 minutes), or prolonged (>45 minutes) WIT. RESULTS: Of all patients, 193 (40.9%) experienced short, 249 (52.8%) intermediate, and 30 (6.4%) prolonged WIT. Prolonged WIT was a significant risk factor for the occurrence of poor EGF with an adjusted odds ratio of 4.252 (95% confidence interval [CI), 1.914 -9.447). Long-term graft survival was impaired in patients with prolonged WIT, with an adjusted hazard ratio of 3.163 (95% CI, 1.202-8.321). Multivariate analysis revealed determinants of prolonged WIT, including laparoscopic procurement, recipient overweight, right donor kidney, and multiple renal arteries. CONCLUSION: Prolonged WIT impairs long-term graft survival in LDKT. This finding underlines the need to develop strategies to avoid the occurrence of prolonged WIT in LDKT.

[The practice guideline 'Urolithiasis' (first revision) from the Dutch College of General Practitioners; a response from the perspective of urology]. / De standaard 'Urinesteenlijden' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de urologie.

The Dutch College of General Practitioners has made a useful revision of its practice guideline 'Urolithiasis', in which new imaging techniques and medical treatment modalities are implemented. Sonography is useful but CT has now become the gold standard imaging technique. CT images should be examined by both the radiologist and the urologist. Therefore, requests for CT should preferably be made by urologists. This guideline should focus more on the differential diagnosis of urolithiasis in the acute phase, and in particular on aortic aneurysm in the elderly patient. Complaints of irritative micturition should be considered to indicate a distal localization ofa ureteral stone rather than a urinary tract infection. When prescribing selective alpha-1 blocking agents, the doctor should inform the patient that both retrograde ejaculation and orthostatic hypotension are side effects.

Endocrine approaches in the therapy of prostate carcinoma.

At present, the management of non-organ confined prostate cancer, whether it is a recurrence or metastasis, continues to evolve based on prostate cancer detection using prostate-specific antigen and the development of medications as alternatives for the classical orchiectomy, which induced irreversible implications for quality of life. Diethylstilbestrol therapy was associated with cardiovascular side-effects; GnRH agonists were able to create a castration level, but again considerable side-effects were described. Combination therapies using antiandrogens and GnRH agonists do not improve survival and have additional toxicity. GnRH antagonists, which also suppress FSH, represent the latest class of agents introduced for hormonal treatment, but phase III studies with survival data are not yet available. In spite of all these achievements, hormonal manipulation has resulted in only modest improvements during recent decades and new targets are needed to improve the clinical outcome. Selectively modifying the androgen receptor is currently one of the most promising developments.

High energy transurethral thermotherapy in the treatment of benign prostatic hyperplasia: criteria to predict treatment outcome.

In this study we analyzed the individual value of baseline parameters to predict the outcome of high energy transurethral microwave thermotherapy in the treatment of patients with lower urinary tract symptoms and benign prostatic hyperplasia. Two hundred and forty-seven patients with symptomatic benign prostatic hyperplasia were treated with high energy microwave thermotherapy using the software 2.5 (Prostatron). Mean age at the time of treatment was 66.3 (s.d. 8.2) y, the mean prostate volume 57.0 (s.d. 25.2) cc and the mean energy applied was 159 (s.d. 40) KJ. Multi variable analysis on baseline parameters was performed to evaluate their predictive value for response using the WHO-response evaluation criteria for IPSS, maximum flow and urodynamic obstruction (linPURR). At 1 y follow-up a 57% increase in maximum flow and a 59% decrease in symptom score was noticed following high energy transurethral thermotherapy. The percentage of good responders varies between 12% and 34% depending on the stratification (IPSS, Q(max) and linPURR), the percentage of intermediate responders in these categories varies between 17% and 60% and the percentage of poor responders varies between 20% and 49%. Independently predictive baseline parameters for poor response were patients' age, prostate size and grade of bladder outlet obstruction (BOO). The total amount of energy delivered during treatment is also correlated with response. For the case selection for high energy transurethral microwave thermotherapy three baseline parameters can be identified which predict response for at least one response evaluation criterium: age, prostate size, grade of bladder outlet obstruction (BOO) and total amount of TUMT-energy. Especially the total amount of TUMT-energy is strongly predictive for all three response evaluation criteria, which suggests an important contribution of other mechanisms such as vascularisation and tissue composition to the outcome of high energy TUMT treatment.