Laparoscopic nephrectomy in patients with renal exclusion secondary to urolithiasis. Which factors can predispose conversion to open surgery?

BACKGROUND: The prevalence of urolithiasis is 7-10% and has increased over the past years. Simple nephrectomy is, therefore, indicated when renal exclusion is associated with recurrent urinary tract infections and/or chronic pain. OBJECTIVE: The aim of the study was to describe the surgical experience of laparoscopic nephrectomy (LPN) due to urolithiasis in Mexican South-east and which factors can predispose conversion to open surgery. METHODS: This was a retrospective study including patients with renal exclusion secondary to urolithiasis, who underwent laparoscopic simple nephrectomy between 2016 and 2019. RESULTS: Forty simple LPN for renal exclusion due to urolithiasis was performed between 2016 and 2019. Mean age was 47 ± 10.8 and 82.5% were female. The mean BMI was 30.2 ± 5 kg/m2, mean operative time was 165.2 ± 64. Conversion rate was 12.5% (n = 5). Conversion was significantly associated with abnormal hilum vascular anatomy (p = 0.001), hilum adherences (p = 0.001), and hydronephrosis (p = 0.001). CONCLUSION: LPN is a safe surgical technique for renal exclusion due to urolithiasis. Hydronephrosis, abnormal vascular anatomy, and the adherences that involved de hilum are the factors that could predictive conversion to open surgery.

INTRODUCCIÓN: La prevalencia the urolitiasis es del 7-10% sin embargo a presentado un incremento del numero de casos en los ultimos años. La nefrectomia simple laparoscopica esta indicada en pacientes con exclusión renal asociado a cuadros repetitivos de infecciones en el tracto urinario y o dolor cronico a nivel fosa renal. OBJETIVO: Describir la experiencia de nefrectomia simple laparoscopica en pacientes con exclusion renal secundario litiasis en un hospital del sur de México, y que factores pueden predisponer la conversión a cirugia abierta. MATERIALS Y METODOS: Estudio restrospectivo que incluyo pacientes con exclusion renal secundario a urolitiasis durante el periodo comprendido entre 2016 y 2019. RESULTADOS: Se realizaron 40 nefrectomias simples laparoscopica durante el periodo comprendido 2016 y 2019 en paciente con exclusion renal asociada a litiasis. La media edad 47 ± 10.8 años, el 82.5% de los pacientes fueron del sexo femenino. La media de Indice de masa corporal fue de 30.2 ± 5 kg/m2, La tasa de conversion fue del 12.5% (n = 5), los factores que se asociaron a conversion a cirugia abierta fueron anormalidades dependientes del hilio vascular renal (p = 0.001)., adherencias dependientes del hilio renal (p = 0.001). e hidronefrosis (p = 0.001). CONCLUSIÓN: La nefrectomia simple laparocopica es un procedimiento seguro en pacienres con exclusion renal secundaria a urolitiasis. Hidronefrosis, anormalidades dependientes del hilio vascular renal y adherencias que involucren el hilio renal son factores que pueden predisponer conversion a cirugia abierta.

Reparación de aneurisma complejo de arteria renal izquierda: nefrectomía laparoscópica, reconstrucción en banco y autotrasplante heterotópico / Repair of complex left renal artery aneurysm: laparoscopic nephrectomy, ex vivo reconstruction and heterotopic autotransplantation

Los aneurismas de la arteria renal son entidades clínicas poco frecuentes. Si bien la mayoría de casos son asintomáticos y se detectan incidentalmente, su rotura se asocia a elevadas tasas de mortalidad y de pérdida del riñón, lo que afecta a los supervivientes. Aunque la mayoría de estos aneurismas pueden tratarse mediante técnicas de reparación endovascular o in situ, esto puede no ser posible en pacientes con aneurismas complejos, como aquellos localizados en la bifurcación arterial. Presentamos el caso de un aneurisma renal complejo tratado satisfactoriamente mediante nefrectomía laparoscópica, reconstrucción vascular en banco y autotrasplante heterotópico.(AU)

renal artery aneurysms are rare clinical entities. While most cases are asymptomatic and detected incidentally, rupture is associated with high mortality rates and loss of the aff ected kidney in survivors. although most of these aneurysms can be treated by endovascular or in situ repair techniques, this may not be possible in patients with complex aneurysms, such as those located at the arterial bifurcation. We present a case of complex renal aneurysm successfully treated by laparoscopic nephrectomy, ex vivo vascular reconstruction, and heterotopic autotransplantation.(AU)

Recomendaciones en la analgesia perioperatoria para la nefrectomía laparoscópica / Recommendations in perioperative analgesia for laparoscopic nephrectomy

Resumen: La nefrectomía laparoscópica se ha convertido en el enfoque quirúrgico estándar en muchos centros de tratamiento quirúrgico para los tumores renales, así como de otras patologías. Los estudios que comparan la nefrectomía abierta y laparoscópica reportaron que la nefrectomía laparoscópica facilitó una recuperación más rápida con una menor morbilidad perioperatoria, menor pérdida sanguínea y produjo menos dolor. Sin embargo, algunos pacientes sometidos a una nefrectomía laparoscópica todavía experimentan dolor postoperatorio que requiere el uso de opiáceos parenterales. Dado que el abordaje es frecuentemente lumboscópico, la distensión y el dolor interno en ese sitio quirúrgico, las incisiones de los puertos, la nocicepción de los órganos y los cólicos ureterales en conjunto con las molestias urinarias asociadas al catéter urinario contribuyen al dolor postoperatorio. A pesar de que esta cirugía ha llegado a ser menos invasiva, el dolor se reporta de moderado a intenso (visita http://www.painoutmexico.com para obtener la versión completa del artículo y el diagrama de recomendaciones).

Abstract: Lumboscopic nephrectomy has become the standard surgical approach in many surgical treatment centers for renal tumours as well as other pathologies. Studies comparing open and laparoscopic nephrectomy reported that laparoscopic technique facilitated a faster recovery with lower peri-operative morbidity, lower blood loss, and produced less pain. However, some patients undergoing laparoscopic nephrectomy still experienced postoperative pain requiring parenteral opioids. Due to the surgical approach is often lumboscopic, the distension and pain at the inner surgical site, laparoscopic port sites and incision, organ nociception, and ureteric colic together with urinary tract discomfort associated with urinary catheter contributed to the postoperative pain. So even though this surgery has become less invasive, pain is reported from moderate to intense (visit http://www.painoutmexico.com to see the full article and recommendations).

Laparoscopic living donor right nephrectomy: Assessment of outcome and association of BMI to length of right renal vein. / Nefrectomía laparoscópica derecha de donante vivo: evaluación del resultado y asociación del IMC con la longitud de la vena renal derecha.

AIMS: The aim of this study was to describe outcomes of laparoscopic living donor right nephrectomy (LLDRN) and study factors affecting the length of right renal vein from the donors. MATERIAL AND METHODS: This study was conducted in 60 donors (48 males and 12 females) from January 2016 to December 2017. We performed a retrospective review of consecutive patients who underwent transperitoneal right laparoscopic living donor nephrectomy at our unit. RESULTS: LLDRN was successfully performed in all subjects by the same surgeons. Among 60 cases, 47 donors had single renal artery and vein, 2 cases had one artery and 2 veins, and 5 donors had 2 arteries and one vein, and the rest had 2-3 arteries with 1-3 veins. Operative time was 142.60±33.73min. Warm ischemic time was 2.64±0.76min. The mean hospital stay was 6.69±0.63 days. The median length of right renal vein was 1.92±0.41cm. All transplanted kidneys showed immediate function. No graft losses were recorded. Almost no gender differences were found in study variables except BMI and warm ischemic time, that was higher BMI but shorter warm ischemic time in female versus male donors. Further analysis showed a negative correlation between BMI and right renal vein (r=-0.282, P<0.05), but a positive correlation between operative time and estimate blood loss (r=0.37, P<0.01). CONCLUSIONS: LLDRN is a feasible safe procedure, less traumatic approach, and provides good outcomes kidney for recipients. Notably, in the study group the higher BMI was associated with resulting more difficult LLDRN and kidney transplantation.

Laparoscopic donor nephrectomy versus open donor nephrectomy: Outcomes from a single transplant center. / Nefrectomía laparoscópica del donante vivo en comparación con nefrectomía abierta del donante vivo.

OBJECTIVES: Laparoscopic donor nephrectomy (LDN) is currently replacing open donor nephrectomy (ODN) across the world. Its advantages in terms of patient recovery are well known. We sought to compare surgical outcomes, particularly renal function during the post-nephrectomy period, for renal grafts procured by LDN versus ODN in our center. METHODS: We retrospectively analyzed all cases of living donor nephrectomies performed from 2004 to 2014 at Hospital Universitario La Paz. We compared demographic data; medical background, operative times, post-operative complications, and renal function follow up at 6, 12 and 18-month controls. RESULTS: A total of 114 living donor nephrectomies were performed: 85 LDN and 29 ODN. Demographic characteristics and medical background were similar among both groups, except mean donor age; 41.4 vs 47.4 years (p = 0.009) in the LDN and ODN groups respectively. LDN was used predominantly for left kidneys (83 out of 85), and ODN for right kidneys (28 out of 29). Although not significantly, mean operative time was shorter for the LDN group (169.37 vs 181.46 minutes; p = 0.2). Mean warm ischemia time was shorter for the ODN group (2.92 vs 2.36 minutes; p = 0.28). Differences between post-operative complications were not statistically different between both groups (p = 0.19). There were no conversions from LDN to ODN, and no re-admissions were registered. Length of stay was slightly shorter in LDN but not different (4.29 vs 4.92 days; p = 0.43). Renal function follow-up, measured with serum creatinine levels showed no difference over time (p = 0.67). CONCLUSIONS: Data from our series demonstrate that outcomes and renal function follow up over time were similar among both groups. In expert hands, this altruistic procedure can be performed with a minimally invasive approach without an increased complication rate or compromising renal function in donors.

OBJETIVOS: La nefrectomía laparoscópica del donante vivo (NLDV) está reemplazando actualmente a la nefrectomía abierta (NADV) en todo el mundo. Sus ventajas en términos de recuperación del paciente son bien conocidas. Comparamos los resultados quirúrgicos, particularmente función renal durante el periodo postnefrectomía, para los injertos obtenidos en nuestro centro por NLDV o NADV. MÉTODOS: Analizamos retrospectivamente todos los casos de nefrectomía del donante vivo realizados entre 2004 y 2014 en el Hospital Universitario La Paz. Comparamos los datos demográficos, antecedentes médicos, tiempo operatorio, complicaciones postoperatorias y funcion renal a los 6, 12 y 18 meses de seguimiento. RESULTADOS: Se han realizado un total de 114 nefrectomías del donante vivo: 85 NLDV y 29 NADV. Las características demográficas y antecedentes médicos eran similares entre ambos grupos, excepto la edad media del donante: 41,4 vs 47,4 años (p = 0,009) en los grupos de NLDV y NADV, respectivamente. La NLDV se utilizó preferentemente para riñones izquierdos (83 de 85) y la NADV para los riñones derechos (28 de 29). Aunque no fue significativo, el tiempo medio de operación del grupo de NLDV fue menor que el de NADV (169,37 vs 181,46 minutos; p = 0,2). El tiempo medio de isquemia caliente era menor en el grupo de NADV (2,92 vs 2,36 minutos; p = 0,28). No hubo diferencias estadísticamente significativas en las complicaciones postoperatorias entre ambos grupos (p=0,19). No hubo conversión a cirugía abierta en ninguna NLDV y no se registró ningún reingreso. La estancia hospitalaria fue ligeramente menor en la NLDV pero la diferencia no fue estadísticamente significativa (4,29 vs 4,92 días; p = 0,43). La función renal en el seguimiento, medida con los niveles de creatinina sérica no mostró diferencias con el tiempo (p = 0,67). CONCLUSIONES: Los datos de nuestra serie demuestran que los resultados y función renal en el seguimiento eran similares entre ambos grupos. En manos expertas, este procedimiento altruista puede ser realizado con un abordaje mínimamente invasivo sin aumento de la tasa de complicaciones o compromiso de la función renal del donante.

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)

Post-operative pain after ultrasound transversus abdominis plane block versus trocar site infiltration in laparoscopic nephrectomy: a prospective study / Dor no período pós-operatório de nefrectomia laparoscópica com bloqueio do plano transverso abdominal guiado por ultrassom versus infiltração do sítio do trocarte: um estudo prospectivo

Abstract Background Transversus abdominis plane (TAP) block is useful in reducing post-operative pain in laparoscopic nephrectomy compared to placebo. The purpose of this work is to compare post-operative pain and recovery after TAP block or trocar site infiltration (TSI) in this surgery. Methods A prospective, single blinded study on patients scheduled for laparoscopic nephrectomy. Patients were assigned to two groups: TSI Group: trocar site infiltration at the end of surgery; TAP Group: unilateral ultrasound-guided TAP block after induction. Sevoflurane and remifentanil, in a target controlled infusion mode, were used for maintenance of general anesthesia. Before the end of surgery paracetamol, tramadol and morphine were administered. Visual analogue scale (VAS 0-100 mm) at rest and with cough was applied in three moments: in recovery room (T1 at admission and T2 before discharge) and 24 h after surgery (T3). Pain scores with incentive spirometer were also evaluated at T3. In recovery, morphine was administered as a rescue drug whenever VAS > 30 mm. Time to oral intake, chair sitting, ambulation and length of hospital stay were evaluated 24 h after surgery. Statistical analysis: Student's t-test and Chi-square test, and linear regression models. A p-value < 0.05 was considered significant. Data are presented as mean (SD). Results Forty patients were enrolled in the study. The primary outcome variable, VAS pain scores did not show a statistical significant difference between groups (p > 0.05). VAS at rest (TAP vs. TSI groups) was: T1 = 33 ± 29 vs. 39 ± 32, T2 = 10 ± 9 vs. 17 ± 18 and T3 = 7 ± 12 vs. 10 ± 18. VAS with cough (TAP vs. TSI groups) was: T1 = 51 ± 34 vs. 45 ± 32, T2 = 24 ± 24 vs. 33 ± 23 and T3 = 20 ± 23 vs. 23 ± 23. VAS with incentive spirometer (TAP vs. TSI groups) was: T3 = 21 ± 27 vs. 21 ± 25. Intraoperative remifentanil consumption was similar between TAP (0.16 ± 0.07 mcg.kg-1.min-1) and TSI (0.18 ± 0.9 mcg.kg-1.min-1) groups. There were no differences in opioid consumption between TAP (4.4 ± 3.49 mg) and TSI (6.87 ± 4.83 mg) groups during recovery. Functional recovery parameters were not statistically different between groups. Conclusions Multimodal analgesia with TAP block did not show a significant clinical benefit compared with trocar site infiltration in laparoscopic nephrectomies.

Resumo Justificativa O bloqueio do plano transverso abdominal (TAP) é útil para reduzir a dor no pós-operatório de nefrectomia laparoscópica comparado com o placebo. O objetivo deste estudo foi comparar a dor no pós-operatório e a recuperação após bloqueio TAP ou infiltração do sítio do trocarte (TSI) nesse tipo de cirurgia. Métodos Estudo prospectivo e cego com pacientes agendados para nefrectomia laparoscópica. Os pacientes foram divididos em dois grupos: Grupo TSI: infiltração do sítio do trocarte ao final da cirurgia; Grupo TAP: bloqueio TAP unilateral guiado por ultrassom após a indução. Sevoflurano e remifentanil administrado em perfusão alvo-controlada foram usados para a manutenção da anestesia geral. Paracetamol, tramadol e morfina foram administrados antes do fim da cirurgia. Escala analógica visual (VAS 0-100 mm), para avaliar a dor em repouso e durante a tosse, foi aplicada em três momentos: na sala de recuperação [na admissão (T1) e antes da alta (T2)] e 24 horas após a cirurgia (T3). Os escores de dor com espirômetro de incentivo também foram avaliados em T3. Durante a recuperação, morfina foi administrada como medicamento de resgate, sempre que VAS > 30 mm. Os tempos até a ingestão oral, sentar em cadeira, deambulação e de permanência hospitalar foram avaliados 24 horas após a cirurgia. Análise estatística: teste t de Student, teste do qui-quadrado e modelos de regressão linear. Um valor de p < 0,05 foi considerado significativo. Os dados foram expressos em média (DP). Resultados Quarenta pacientes foram incluídos no estudo. Os escores do desfecho primário e da VAS não apresentaram diferença estatística significativa entre os grupos (p > 0,05). Os escores VAS em repouso (TAP vs. TSI) foram: T1 = 33 ± 29 vs. 39 ± 32; T2 = 10 ± 9 vs. 17 ± 18 e T3 = 7 ± 12 vs. 10 ± 18. Os escores VAS durante a tosse (TAP vs. TSI) foram: T1 = 51 ± 34 vs. 45 ± 32; T2 = 24 ± 24 vs. 33 ± 23 e T3 = 20 ± 23 vs. 23 ± 23. Os escores VAS com espirômetro de incentivo (TAP vs. TSI) foram: T3 = 21 ± 27 vs. 21 ± 25. O consumo de remifentanil no intraoperatório foi semelhante entre os grupos TAP (0,16 ± 0,07 mcg.kg-1.min-1) e TSI (0,18 ± 0,9 mcg.kg-1.min-1). Não houve diferença no consumo de opioides entre os grupos TAP (4,4 ± 3,49 mg) e TSI (6,87 ± 4,83 mg) durante a recuperação. Os parâmetros funcionais de recuperação não foram estatisticamente diferentes entre os grupos. Conclusões A analgesia multimodal com bloqueio TAP não mostrou benefício clínico significativo comparado com a infiltração do sítio do trocarte em nefrectomia laparoscópica.

[Post-operative pain after ultrasound transversus abdominis plane block versus trocar site infiltration in laparoscopic nephrectomy: a prospective study]. / Dor no período pós­operatório de nefrectomia laparoscópica com bloqueio do plano transverso abdominal guiado por ultrassom versus infiltração do sítio do trocarte: um estudo prospectivo.

BACKGROUND: Transversus abdominis plane (TAP) block is useful in reducing post-operative pain in laparoscopic nephrectomy compared to placebo. The purpose of this work is to compare post-operative pain and recovery after TAP block or trocar site infiltration (TSI) in this surgery. METHODS: A prospective, single blinded study on patients scheduled for laparoscopic nephrectomy. Patients were assigned to two groups: TSI Group: trocar site infiltration at the end of surgery; TAP Group: unilateral ultrasound-guided TAP block after induction. Sevoflurane and remifentanil, in a target controlled infusion mode, were used for maintenance of general anesthesia. Before the end of surgery paracetamol, tramadol and morphine were administered. Visual analogue scale (VAS 0-100mm) at rest and with cough was applied in three moments: in recovery room (T1 at admission and T2 before discharge) and 24h after surgery (T3). Pain scores with incentive spirometer were also evaluated at T3. In recovery, morphine was administered as a rescue drug whenever VAS>30mm. Time to oral intake, chair sitting, ambulation and length of hospital stay were evaluated 24h after surgery. STATISTICAL ANALYSIS: Student's t-test and Chi-square test, and linear regression models. A p-value<0.05 was considered significant. Data are presented as mean (SD). RESULTS: Forty patients were enrolled in the study. The primary outcome variable, VAS pain scores did not show a statistical significant difference between groups (p>0.05). VAS at rest (TAP vs. TSI groups) was: T1=33±29 vs. 39±32, T2=10±9 vs. 17±18 and T3=7±12 vs. 10±18. VAS with cough (TAP vs. TSI groups) was: T1=51±34 vs. 45±32, T2=24±24 vs. 33±23 and T3=20±23 vs. 23±23. VAS with incentive spirometer (TAP vs. TSI groups) was: T3=21±27 vs. 21±25. Intraoperative remifentanil consumption was similar between TAP (0.16±0.07mcg.kg-1.min-1) and TSI (0.18±0.9mcg.kg-1.min-1) groups. There were no differences in opioid consumption between TAP (4.4±3.49mg) and TSI (6.87±4.83mg) groups during recovery. Functional recovery parameters were not statistically different between groups. CONCLUSIONS: Multimodal analgesia with TAP block did not show a significant clinical benefit compared with trocar site infiltration in laparoscopic nephrectomies.

Nefrectomía laparoscópica de donante vivo: experiencia de 75 casos consecutivos / Live donor laparoscopic nephrectomy: experience in 75 cases

Background: Live Donor Laparoscopic Nephrectomy (LDLN) has substantial benefits when compared with open nephrectomy such as shorter hospital stay, prompt return to work, less post-operative pain, better cosmetic results, less blood loss and less surgical wound infections. It is the mode of choice for safely harvesting a kidney for organ transplantation. Aim: To describe the surgical results of LDLN in a pioneer renal transplant center in Chile. Material and Methods: Review of clinical records of 75 subjects aged 27 to 60 years (37 males) subjected to a LDLN in a public hospital between 1998 and 2013. Information about clinical and surgical data and perioperative complications was retrieved. Results: No subject died. All kidneys were satisfactorily implanted in their receptors. The mean operative time was 116 minutes. Mean hospital stay was 1.6 days, warm ischemia time was 6.8 minutes, and cold ischemia time was 31.5 minutes. Operative adverse events occurred in 8 percent. The conversion and reoperation rates were 4 and 1.3 percent, respectively. Among receptors, 1.5 percent evolved with Acute Tubular Necrosis and 2.2 percent required graft excision. Conclusions: LDLN is a safe and pioneering surgical technique in Chile. Its results are satisfactory and comparable to those obtained with classic lumbotomy.

Introducción: El trasplante renal es en la actualidad el tratamiento de elección de la Insuficiencia Renal Crónica Terminal. La Nefrectomía Laparoscópica del Donante Vivo (NLDV) tiene ventajas sustanciales en relación a la Nefrectomía Clásica. Entre estas se destacan una menor estancia hospitalaria, pronto regreso a la actividad laboral, disminución del dolor post-operatorio, mejores resultados cosméticos, menor pérdida de volumen sanguíneo y una disminución de infecciones de heridas operatorias, consolidándose como la primera prioridad como forma de obtener un órgano para trasplante renal. El presente trabajo tiene como objetivo mostrar la casuística y complicaciones en el Hospital Barros Luco-Trudeau (HBLT), como centro pionero en NLDV en nuestro país. Material y Método: Estudio retrospectivo de corte transversal. Se realiza una revisión de registros clínicos de 75 NLDV realizadas entre 1998-2013, seleccionando datos demográficos, clínicos y quirúrgicos de donantes y receptores, con un especial énfasis en relación a complicaciones peri-operatorias. Resultados: Sin mortalidad. Todos los riñones fueron implantados satisfactoriamente en sus respectivos receptores. Cirugía con duración promedio de 116 min, estadía hospitalaria promedio de 1,6 días, isquemia caliente promedio de 6,8 min e isquemia fría promedio de 31,5 min. Incidentes operatorios 8 por ciento y 4 por ciento conducentes a conversión. Tasa de reoperación de 1,3 por ciento. En cuanto a receptores, un 1,5 por ciento desarrolla Necrosis Tubular Aguda. 2,2 por ciento requiere transplantectomía. Discusión: La NLDV representa una técnica segura, que ha llegado a constituir el 100 por ciento de las nefrectomías de donantes vivos realizadas durante los últimos tres años. Los resultados son satisfactorios y plenamente comparables a los resultados obtenidos por lumbotomía clásica y de otros centros de alto volumen laparoscópico a nivel internacional.

Una alternativa de extensión de la vena renal derecha en donante vivo laparoscópico / An alternative for enlargement of right renal vein in laparoscopic living donor nephrectomy

El manejo de la vena renal derecha en la nefrectomía laparoscópica del donante vivo puede en ocasiones representar un problema como consecuencia de la longitud limitada de este vaso. El caso clínico que se presenta muestra una técnica de extensión de la vena renal utilizando la vena gonadal del donante.

Vascular management of the right renal vein during laparoscopic living donor nephrectomy is still an unsolved problem. This short vessel has limited the use of right kidneys. However, the right kidney should be harvested in some instances. A renal vein enlargement technique using the donor gonadal vein is presented which may facilitate the use of right kidneys in this setting.

Complicaciones de la nefrectomía laparascópica, experiencia del Hospital del Salvador / Complications in laparoscopic radical nephrectomy: the Hospital del Salvador experience

Introducción: La cirugía laparoscópica ha experimentado un auge progresivo durante los últimos años. En la medida que aumenta el número de procedimientos, también aumentan las complicaciones. Objetivo: Presentar la incidencia de complicaciones y la tasa de conversiones de la nefrectomía laparascópica durante su realización por diversas indicaciones, analizando los métodos que ayudarían a prevenirlas.Material y Métodos: Entre junio de 2002 y julio de 2006, se realizaron 95 nefrectomías laparoscópicas, 16simples, 33 radicales y 46 nefrectomías para donante vivo. Se revisaron las fichas clínicas de los pacientessometidos a estas intervenciones para evaluar las complicaciones y analizar los factores relacionados a conversión a cirugía abierta. Resultados: Complicaciones mayores ocurrieron en 6 pacientes (6,32 por ciento). De estas complicaciones 4 fueron de manejo quirúrgico y 1 de manejo médico. La complicación mayor predominante fue sangramiento que requirió conversión a cirugía abierta. La tasa global de conversión fue 3.16 por ciento (3 pacientes). Diez pacientes experimentaron problemas post quirúrgicos menores como retención de orina, infección urinaria e infección de herida operatoria. La mortalidad de la serie fue 0 por ciento. Conclusión: La cirugía renal laparoscópica es cada vez más común en la práctica urológica, pero a pesar de ser una técnica mínimamente invasiva, puede llevar a complicaciones serias. Estas complicaciones pueden prevenirse en el tiempo, con la repetición y experiencia. El conocimiento de estas es esencial paralos urólogos en entrenamiento en cirugía laparoscópica, ya que podría ayudar a disminuir la curva de aprendizaje.

Purpose: We present the incidence of complications and conversions during laparoscopic nephrectomy performed for various indications and discuss methods to prevent future complications. Material and methods. From June 2002 to July 2006 95 laparoscopic nephrectomy cases were performed at our institution,consisting of 27 simple nephrectomies, 33 radical nepherectomies, 33 radical nephrectomies and 46 donor nephrectomies. We reviewed the surgical data of patients who underwent laparoscopic nephrectomy to examine complications and analyze factors related to conversión to an open surgical procedure. Results: Major complications occurred in 6 patients (6.32 percent). Major complications were surgical in 4 patients and medical in 1. The predominant major surgical complication was bleeding requiring conversión to open surgery. Overall conversion rate was 3.16 percent (3 patients). The remaining 10 patients experienced minorsurgical or postoperative medical problems, such as urinary retention or wound infection. No mortality was observed. Conclusions: Laparoscopic renal surgery is becoming a routine procedure in the armamentarium of many urologists. Complications unique to laparoscopy still occurred but they willdecrease with time and experience. We have learned many different precautions and procedures that should help decrease the risk of future complications associated with laparoscopic renal surgery.