Comparison of videolaparoscopic versus open surgery for benign renal diseases in children

Introduction: Laparoscopic nephrectomy in children has become a reasonable alternative to open nephrectomy and has replaced open surgery for many renal diseases. The purpose of our study is to evaluate transperitoneal videolaparoscopic procedures in renal benign diseases in comparison to an open surgery approach. Patients and methods: 34 children aged between 17 days and 15 years old (mean 6.14) were divided into two groups in order to be submitted to nephrectomy. The first one underwent transperitoneal videolaparoscopic nephrectomy and was composed by 21 patients aged from 2 months to 15 years (mean 7.42), from which 12 were females and 9 males. The second group was submitted to open nephrectomy and was composed by 13 patients aged from 17 days to 11 years (mean 3.91), 6 females and 7 males. The groups were compared regarding anesthesic time, operative time, length of hospital stay, postoperative pain and time of reintroduction of oral intake. Short and long term complications were also evaluated. Statistical analysis was performed by Student t-test with the level of significance set at P < 0.05. The study was previously approved by the Committee on Ethics in Research of our institution. Results: Significant statistical difference was observed only for the variable length of hospital stay. No laparoscopy group case was converted to open surgery. There was no immediate or late complication. Blood loss was negligible and no transfusion was required. Conclusions: In our experience, transperitoneal videolaparoscopic nephrectomy has similar results to open nephrectomy, except for time of hospitalization. (C) 2009 AEU. Published by Elsevier Espana, S.L. All rights reserved.

Living kidney donors - a prospective study of quality of life before and after kidney donation

Although the safety of living kidney donation has been well established, prospective studies examining the physical and psychosocial aspects of the donor's quality of life are still scarce. Thus, the purpose of this prospective work was to assess the quality of life of 50 consecutive donors before and after kidney transplantation. All donors were asked to respond to both a donor questionnaire and the short-form 36-item health survey (SF-36). Interviews were individually conducted before, three months after, and over one yr after transplantation. Donation was considered a positive experience by all patients and had no impact on any physical or psychosocial aspect of the donor's life. Improved self-esteem and better quality of life after donation were reported in 52% of the cases. All donors would donate again and encouraged donation. SF-36 data indicated improvement in post-donation mental and physical scores among living donors closely related to recipient. Overall, most donors had a positive experience, felt no changes in quality of life, experienced enhanced self-esteem, would donate again, and recommended donation. © 2012 John Wiley & Sons A/S.

Urogenital manifestations in Wegener granulomatosis: a study of 11 cases and review of the literature

We describe the main characteristics and treatment of urogenital manifestations in patients with Wegener granulomatosis (WG). We conducted a retrospective review of the charts of 11 patients with WG. All patients were men, and their median age at WG diagnosis was 53 years (range, 21-70 yr). Urogenital involvement was present at onset of WG in 9 cases (81%), it was the first clinical evidence of WG in 2 cases (18%), and was a symptom of WG relapse in 6 cases (54%). Symptomatic urogenital involvement included prostatitis (n = 4) (with suspicion of an abscess in 1 case), orchitis (n = 4), epididymitis (n = 1), a renal pseudotumor (n = 2), ureteral stenosis (n = 1), and penile ulceration (n = 1). Urogenital symptoms rapidly resolved after therapy with glucocorticoids and immunosuppressive agents. Several patients underwent a surgical procedure, either at the time of diagnosis (n = 3) (consisting of an open nephrectomy and radical prostatectomy for suspicion of carcinoma, suprapubic cystostomy for acute urinary retention), or during follow-up (n = 3) (consisting of ureteral double J stents for ureteral stenosis, and prostate transurethral resection because of dysuria). After a mean follow-up of 56 months, urogenital relapse occurred in 4 patients (36%). Urogenital involvement can be the first clinical evidence of WG. Some presentations, such as a renal or prostate mass that mimics cancer or an abscess, should be assessed to avoid unnecessary radical surgery. Urogenital symptoms can be promptly resolved with glucocorticoids and immunosuppressive agents. However, surgical procedures, such as prostatic transurethral resection, may be mandatory in patients with persistent symptoms.

Open partial nephrectomy in renal cancer: a feasible gold standard technique in all hospitals

Introduction. Partial nephrectomy (PN) is playing an increasingly important role in localized renal cell carcinoma (RCC) as a true alternative to radical nephrectomy. With the greater experience and expertise of surgical teams, it has become an alternative to radical nephrectomy in young patients when the tumor diameter is 4 cm or less in almost all hospitals since cancer-specific survival outcomes are similar to those obtained with radical nephrectomy. Materials and Methods. The authors comment on their own experience and review the literature, reporting current indications and outcomes including complications. The surgical technique of open partial nephrectomy is outlined. Conclusions. Nowadays, open PN is the gold standard technique to treat small renal masses, and all nonablative techniques must pass the test of time to be compared to PN. It is not ethical for patients to undergo radical surgery just because the urologists involved do not have adequate experience with PN. Patients should be involved in the final treatment decision and, when appropriate, referred to specialized centers with experience in open or laparoscopic partial nephrectomies

Laparoscopic nephrectomy outside gerota fascia for management of inflammatory kidney

Background and Purpose: A nonfunctioning inflammatory kidney is a challenging surgical condition for urologists. Some investigators recommend open surgery because of the surgical difficulties caused by the inflammatory process, whereas others try to apply the advantages of a ""simple"" non-hand-assisted laparoscopic approach. We report our experience with simple laparoscopic nephrectomy for inflammatory kidney management. Patients and Methods: From July 2002 through December 2006, 50 pure laparoscopic nephrectomies were performed for inflammatory kidney ( 43 because of pyelonephritis, 5 for xanthogranulomatous pyelonephritis (XGP), and 2 for pyonephrosis). Histopathologic analysis was the criterion used for inflammatory kidney diagnosis. Pain or recurrent urinary tract infection associated with a nonfunctioning excluded kidney was the eligibility criterion for the procedure. Preoperatively, all patients underwent complete image and functional renal assessment. Morcellation was used to remove surgical specimens. Conversion index, surgical difficulties, operative time, and postoperative complications were evaluated. Results: Conversion was performed in 14 of 50 (28%) patients, including two with XGP and one with pyonephrosis. Adhesions, vascular (two inferior vena cava) lesions, and intestinal lesions (two colon) were the main causes of conversion. Acute pancreatitis developed in one patient, and one patient had a wound infection. Reoperations were unnecessary, and no deaths occurred. Conclusion: Pure laparoscopic nephrectomy was successful in 72% of patients with inflammatory kidneys. The laparoscopic dissection was useful even in those cases converted to open surgery. This is a high-risk procedure, however, and both surgeon and patient must be aware of that before the decision is made for this approach.

Néphrectomie par laparoscopie: aspects techniques [Laparoscopic nephrectomy: technical aspects]

The laparoscopic approach has emerged as a valid option for surgical management of kidney cancer, as well as a few benign pathologies. The immediate benefits of laparoscopy are well established and include less estimated blood loss, decreased pain, shorter perioperative convalescence, and improved cosmesis. Long-term oncologic outcomes of patients treated laparoscopically for kidney tumors are similar to those of open surgery.

Ex-Vivo Ultransonographic Control Of Resection Margin During Partial Nephrectomy

Introduction & Objectives: Surgery remains the treatment of choice for localized renal cell neoplasia. While radical nephrectomy was long considered as gold standard, partial nephrectomy (PN) has widened its indications over the past twodecades and has shown oncological results equivalent to radical nephrectomy for small tumors. Moreover, it is considered superior to radical nephrectomy in terms of non-cancer related mortality. The role of negative surgical margin has been widely debated. Intraoperative frozen section analysis has been shown to be unreliable, expensive, time-consuming and not well correlated to final pathology. The goal of the present study was to assess the correlation of intraoperative exvivo ultrasonographic (US) evaluation of resection margin to definitive pathology in patients undergoing PN.Materials & Methods: An observational study was carried out in ours 2 institutions from February 2008 to October 2010. Patients undergoing PN for T1-T2 renal tumors were included. Ex vivo US evaluation was performed. Considering availability of US engine, not all consecutive eligible patients were included. PN was undertaken either by open surgery or laparoscopic access in a standardized technique. The "minimal healthy tissue margin" technique was applied. Once resected, the specimen was kept in a saline solution and US determination of tumor margins was performed. Sequential images were captured in order to evaluate the whole capsule.Results: Twenty-two patients (9 women, age 63±11 years[46-78]) were included in the present analysis. Open or laparoscopic PN was performed in 19 and 3 patients, respectively. Intraoperative ex-vivo US showed negative surgical margin in all cases except one, needing a complementary renal parenchyma resection. US duration ranged from 1 to 4 minutes, with a median time of 1 minute. Definitive histological analysis confirmed the presence of 3 angiomyolipoma, 15 clear cell carcinoma (11 pT1a,3 pT1b,1 pT2), 3 chromophobe carcinoma (1 pT1a,1 pT1b,1 pT2) and 1 pT1a type II papillary tumor. Mean tumor size was 3,4±2.1 cm [0,6-7,2]. Final pathology revealed R0 margins in all cases.Conclusions: Intraoperative ex-vivo US evaluation of resection margin in patients undergoing PN is feasible, time-efficient, well correlated to definitive pathological examination, and should be evaluated in further prospective trials.

Robotic-assisted laparoscopic partial nephrectomy: initial experience in Brazil and a review of the literature

CONTEXT AND PURPOSE: Partial nephrectomy has become the standard of care for renal tumors less than 4 cm in diameter. Controversy still exists, however, regarding the best surgical approach, especially when minimally invasive techniques are taken into account. Robotic-assisted laparoscopic partial nephrectomy (RALPN) has emerged as a promising technique that helps surgeons achieve the standards of open partial nephrectomy care while offering a minimally invasive approach. The objective of the present study was to describe our initial experience with robotic-assisted laparoscopic partial nephrectomy and extensively review the pertinent literature. MATERIALS AND METHODS: Between August 2009 and February 2010, eight consecutive selected patients with contrast enhancing renal masses observed by CT were submitted to RALPN in a private institution. In addition, we collected information on the patients' demographics, preoperative tumor characteristics and detailed operative, postoperative and pathological data. In addition, a PubMed search was performed to provide an extensive review of the robotic-assisted laparoscopic partial nephrectomy literature. RESULTS: Seven patients had RALPN on the left or right sides with no intraoperative complications. One patient was electively converted to a robotic-assisted radical nephrectomy. The operative time ranged from 120 to 300 min, estimated blood loss (EBL) ranged from 75 to 400 mL and, in five cases, the warm ischemia time (WIT) ranged from 18 to 32 min. Two patients did not require any clamping. Overall, no transfusions were necessary, and there were no intraoperative complications or adverse postoperative clinical events. All margins were negative, and all patients were disease-free at the 6-month follow-up. CONCLUSIONS: Robotic-assisted laparoscopic partial nephrectomy is a feasible and safe approach to small renal cortical masses.Further prospective studies are needed to compare open partial nephrectomy with its minimally invasive counterparts.

A systematic review of laparoscopic live-donor nephrectomy

Background. A systematic review was undertaken to assess the safety and efficacy of laparoscopic live-donor nephrectomy (LLDN) compared with open live-donor nephrectomy (OLDN). Methods. Literature databases were searched from inception to March 2003 inclusive. Comparative studies of LLDN versus OLDN (randomized and nonrandomized) were included. Results. There were 44 included studies, and the quality of the available evidence was average. There was only one randomized controlled trial and six nonrandomized comparative studies with concurrent controls identified. In terms of safety, for donors, there did not seem to be any distinct difference between the laparoscopic and open approaches. No donor mortality was reported for either procedure, and the complication rates were similar although the types of complications experienced differed between the two procedures. The conversion rate for LLDN to an open procedure ranged from 0% to 13%. In terms of efficacy, LLDN seemed to be a slower operation with longer warm ischemia. times than OLDN, but this did not seem to have resulted in increased rates of delayed graft function for recipients. Donor postoperative recovery and convalescence seemed to be superior for LLDN, making it a potentially more attractive operation for living donors. Although in the short-term, graft function and survival did not seem to differ between the two techniques, long-term complication rates and allograft function could not be determined and further long-term follow-up is required. Conclusions. LLDN seems to be at least as safe and efficacious as OLDN in the short-term. However, it remains a technique in evolution. Further high-quality studies are required to resolve some of the outstanding issues surrounding its use, in particular, long-term follow-up of donor complications and recipient graft function and survival.

Selective approach for transperitoneal and extraperitoneal endoscopic nephrectomy in children

Purpose: From the experience of a large combined series of transperitoneal. (TP) and retroperitoneal (RP) endoscopic complete and partial nephroureterectornies in children, we present a logical selective endoscopic approach to benign renal pathology. Materials and Methods: During a 5-year period 122 complete nephrectomies and nephroureterectomies (bilateral 2, invisible ectopic 8) and 63 partial nephroureterectomies for duplex (52 upper, 8 lower) or singleton polar disease (xanthogranulomatous pyelonephritis 1, cyst 2) were performed. Of the partial nephrectomies, ureterectomy, bladder repair and lower moiety reimplantation were performed in 8. Patient age ranged from 2.7 months to 14 years (mean 2.9 years). Preoperative weight ranged from 2.7 to 98 kg (mean 12.3). The position of the renal remnant, the presence or absence of a refluxing ureter and the need for ureterectomy were the major determining factors affecting choice of endoscopic approach. Results: A total of 179 (96.7%) procedures were successfully completed endoscopically. The 6 open conversions (3.2%) occurred early in our experience. The operating time reflected the complexity of the excision and lower urinary reconstruction (lateral and posterior RP 25 to 145 minutes [mean 921) TP with ureterocelectomy and bladder neck repair 105 to 355 minutes [mean 153]. Hospital stay for RP and simple TP was 1.5 days (mean 1 to 4) and for complicated TP 2 to 8 days (mean 3.5). Conclusions: We suggest a posterior retroperitoneal approach with isolated renal excision without extended ureterectomy. The lateral retroperitoneal approach allows complete ureterectomy as well as better exposure to horseshoe and pelvic kidneys and, therefore, avoids exposure to intraperitoneal. structures. Finally, the transperitoneal approach is recommended when complete moiety excision with lower urinary reconstruction is anticipated.

Comparison between the 1% and 2% ibopamine provocative test in primary open-angle glaucoma patients: sensitivity, specificity and tolerability

PURPOSE: To compare intraocular pressure (IOP) rise in normal individuals and primary open-angle glaucoma patients and the safety and efficacy of ibopamine eye drops in different concentrations as a provocative test for glaucoma. METHODS: Glaucoma patients underwent (same eye) the ibopamine provocative test with two concentrations, 1% and 2%, in a random sequence at least 3 weeks apart, but not more than 3 months. The normal individuals were randomly submitted to one of the concentrations of ibopamine (1% and 2%). The test was considered positive if there was an IOP rise greater than 3 or 4 mmHg at 30 or 45 minutes to test which subset of the test has the best sensitivity (Se)/specificity (Sp). RESULTS: There was no statistically significant difference in any of the IOP measurements, comparing 1% with 2% ibopamine. The IOP was significantly higher at 30 and 45 minutes with both concentrations (p<0.001). The best sensitivity/specificity ratio was achieved with the cutoff point set as greater than 3 mmHg at 45 minutes with 2% ibopamine (area under the ROC curve: 0.864, Se: 84.6%; Sp:73.3%). All patients described a slight burning after ibopamine's instillation. CONCLUSION: 2% ibopamine is recommended as a provocative test for glaucoma. Because both concentrations have similar ability to rise IOP, 1% ibopamine may be used to treat ocular hypotony.