The development of a laparoscopic donor nephrectomy program in a de novo renal transplant program: Evolution of technique and results in over 200 cases.

BACKGROUND AND OBJECTIVES: In 1999, our institution began a kidney transplant program with collaboration between the departments of General Surgery/Transplantation and Urology. From the onset, donor nephrectomies were performed laparoscopically and are currently the domain of Urology, which had no prior laparoscopic experience before this undertaking. We reviewed our experience. METHODS: A database of our experience was kept prospectively from June 1999 to November 2004. Records of both donors and recipients were reviewed. Special attention was directed toward our changes in technique and their relationship to outcomes, with emphasis on graft extraction and overall complication rates. RESULTS: We reviewed the records of 205 consecutive procedures. We report excellent donor outcomes, including mean operative time (112 minutes), estimated blood loss (120 mL), and length of stay (2.3 days). Complication (14.1%) and open conversion (1.5%) rates were low. For the recipients, early (98.0%) and 1-year (94.7%) graft survival, and ureteral ischemia (2.4%) rates were also appropriate with contemporary experience. CONCLUSIONS: We report our results on laparoscopic donor nephrectomy in a de novo renal transplant program. Because of this experience, we have ventured into other horizons of urologic laparoscopy and currently produce enough volume to support a laparoscopic fellowship. We feel that a productive donor nephrectomy program can enhance urologic laparoscopic programs and should be taken advantage of when available.     

Pretransplant bilateral hand-assisted laparoscopic nephrectomy in adult patients with polycystic kidney disease.

Laparoscopic procedures continue to gain popularity over traditional open procedures for a number of abdominal and pelvic surgeries. With increasing experience, the application of this technique is rising because it provides an alternative, less invasive, approach to various surgical procedures. Herein, we report our experience with adult patients with polycystic kidney disease, requiring bilateral laparoscopic nephrectomy before renal transplantation.     

Routine postoperative chest x-ray following laparoscopic nephrectomy.

PURPOSE: To determine whether a routine postoperative chest x-ray is required following uneventful laparoscopic nephrectomy to rule out pneumothorax. METHODS: From June 1999 to May 2003, 308 laparoscopic nephrectomy cases were performed by 5 different surgeons. This consisted of 121 radical nephrectomies, 106 donor nephrectomies, 29 simple nephrectomies, 29 partial nephrectomies, and 23 nephroureterectomies. Of the 308 procedures, 186 postoperative chest x-ray s were obtained in the recovery room: 183 routinely and 3 for known intraoperative diaphragmatic injuries. Routine chest x-rays were not obtained in 122 cases due to the individual surgeon's preference. Of these 122 patients, 15 underwent chest x-ray performed while hospitalized secondary to pulmonary issues or fever. RESULTS: Of the 308 cases, 4 pneumothoraces were identified on chest x-ray. Three were identified in the patients who had intraoperative identification of diaphragmatic injury. The fourth pneumothorax was identified in a patient who did not have a routine postoperative chest x-ray but did have a chest x-ray obtained due to postoperative shoulder pain. The pneumothorax in this patient resolved spontaneously. No incidental findings existed of pneumothorax in any patient who underwent routine postoperative chest x-ray. CONCLUSION: In our series, a pneumothorax was identified either intraoperatively or based on postoperative clinical findings. None of the 183 routine postoperative chest x-rays changed patient management. Routine postoperative chest x-ray is not necessary in uncomplicated laparoscopic nephrectomy.     

Nephrectomy during operative management of retroperitoneal sarcoma

Background: Complete resection of a retroperitoneal sarcoma often requires removal of adjacent organs. In this study we evaluated the role of nephrectomy during operation for retroperitoneal sarcoma. Methods: Between July 1982 and July 1995, 75 of the 371 (20%) patients who underwent resection of retroperitoneal sarcoma at MSKCC underwent concommitant nephrectomy. Data concerning the reasons for nephrectomy, degree of sarcomatous renal involvement, and survival were retrospectively analyzed. Results: Fifty-four patients (72%) underwent nephrectomy during the initial resection, and 21 (28%) during a resection of a recurrent or persistent tumor. The most common reason for nephrectomy was total encasement by sarcoma (n=40; 53%), followed by dense adherence of the tumor to the kidney (n=21; 28%), and the direct invasion of the kidney by tumor (n=2; 3%). Pathology demonstrated an absence of kidney invasion in the majority of cases (55 of 75; 73%). Renal capsular invasion was present in 11 of 75 (15%), renal parenchymal invasion in 7 of 75 (9%), and renal vein invasion in 2 of 75 (3%) of cases. There were no significant differences in survival based on degree of sarcoma involvement of the kidney, tumor grade, or whether the resection was for primary or recurrent disease. The 53 patients who underwent a complete gross resection of all tumor had a significantly improved long-term survival compared to the 20 patients who did not (50% versus 20% DFS at 5 years, respectively; p<0.001). Conclusions: Decisions for concomitant nephrectomy during resection of retroperitoneal sarcoma should be based on whether this maneuver will provide a complete resection of all gross tumor, in which case the long-term disease-free survival of 50% is comparable to the reported 5-year survival of all patients with retroperitoneal sarcoma who are completely resected. Presented at the 49th Annual Cancer Symposium of the Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.     

手辅助腹腔镜取肾的实验研究

目的　探索和运用手辅助腹腔镜技术切除供肾并行肾移植术 ,了解该方法的优缺点及临床应用的可行性。方法　用成年狗作动物实验进行手辅助腹腔镜供肾切除术并移植 ,观察并记录手术时间 ,供肾热缺血时间 ,移植肾功能恢复情况及供者的康复情况等。结果　实验狗术后均存活 ,供肾切除手术时间平均 13 2min ;肾热缺血时间平均 83s ,移植肾再灌注后排尿时间平均 74s。结论　手辅助腹腔镜活体供肾切除术易于掌握 ;手术时间短 ;供肾热缺血时间短 ,质量好 ;供肾者手术创伤小 ,术后恢复快 ;是临床值得推广应用的一种活体供肾切除方法     

From laparoscopic training on an animal model to retroperitoneoscopic or coelioscopic adrenal and renal surgery in human

So far, laparoscopic approaches to kidney and adrenal have been limited because of their retroperitoneal location. We here report eight renal and adrenal endoscopic procedures performed in seven patients: two adrenalectomies for hyperaldosteronism, one adrenalectomy for isolated metastasis from an adenocarcinoma of the lung; two nephrectomies for end-stage infected hydronephrosis, two partial nephrectomies for small circumscribed lesions of the kidney, and one endoscopic resection for pain relief of a voluminous cyst at the kidney. The approach was transperitoneal in two cases and retroperitoneal in five cases using the retropneumoperitoneum insufflation technique. One patient was operated by a combined approach using the retro- and transperitoneal routes. All procedures were successfully completed endoscopically. The retroperitoneoscopic approach of the kidney is safe and does not interfere with the peritoneal organs. Its working space is tenuous, but allows a direct access on the kidney with good exposure of its pedicle. For adrenal surgery, the retroperitoneoscopic dissection is more difficult, because movements of instruments are often impaired by the closeness of the costal margin and the iliac crest. However, in case of difficulties we found it very convenient to switch from a retroperitoneal endoscopic approach to a combined coelioscopic and retroperitoneoscopic operation. Far from excluding each other, both approaches are complementary, particularly for difficult situations (i.e., previous peritoneal or retroperitoneal surgery).     

An assessment of immunoreactive epidermal growth factor in urine of patients with urological diseases

To examine the excretion of urinary epidermal growth factor (EGF) in urological diseases and the relationship of EGF urine levels with transitional cell carcinoma (TCC), we measured the concentration of EGF by radioimmunoassay. The series comprised patients with active TCC (n=50), others in tumor-free status (n=29) and with non-neoplastic inflammatory diseases (n=43), and normal controls (n=50). Urinary EGF values were lower in patients with urological diseases of different etiologies than in normal controls (P<0.005). Mean EGF levels of patients who had previous bladder tumor resection (n=21) were not statistically different from normal controls (P=0.2). For patients with active TCC, EGF urine levels showed a significant inverse relationship to increasing tumor grade (P=0.02). In addition, subjects who had received nephrectomy for pelvic carcinoma (n=8) showed significantly lower mean EGF values than those with intact kidneys (n=21), irrespective of sex (P<0.05). Immunostaining of EGF on non-neoplastic kidney (n=9) revealed reactivity in the distal convoluted tubules and thick ascending limbs of Henle. Our results suggest that the kidney is the major source of urinary EGF. Its excretion in urine is decreased in both inflammatory and neoplastic diseases of the urinary tract. EGF may play an important part in the biological activity of TCC. Further study is indicated to investigate the monitoring of EGF urine levels as a marker of recurrence for EGF receptor-positive TCC.     

大鼠双侧肾切除后肾上腺皮质球状带细胞苯二氮受体的量变

用选择性作用于外周型苯二氮(艹卓)受体的标记配体[~3H]PK11195检测了Wistar大鼠分离的肾上腺皮质球状带细胞上苯二氮(艹卓)受体的结合动力学参数,结果表明Wistar大鼠在双侧肾切除后36小时、其球状带细胞苯二氮(艹卓)受体结合[~3H]PK11195的最大容量(B_(max))显著高于假手术组和正常对照组的相应数值,三组的B_(max)分别为12.1±1.1、6.6±1.3和5.6±1.8(pmol/10~6cells),三组的K_D值则无显著差异。     

Unusual case of urothelial carcinoma disguised as xanthogranulomatous pyelonephritis and causing reno-colic fistula: Case report and review of literature

Xanthogranulomatous pyelonephritis is a rare and aggressive form of chronic pyelonephritis, it can occur at all age groups but is more common in women than in men, supposedly relating to the increased incidence of urinary tract infections and chronic nephrolithiasis in woman. Computed tomography (CT) findings are very helpful in making the correct diagnosis, but the definitive diagnosis is still based on histology, as there are many differential diagnoses such as renal cell carcinoma and renal tuberculosis. The complications of this type of pyelonephritis are due to the involvement of adjacent organs. The most frequent ones are Psoas abscess, perinephric abscess, and sepsis. Nephrocutaneous and renocolic fistulas are less common. We report a case of a 61-year-old male, who presented to emergency for left-sided lumbar pain for whom radiological investigations confirmed a renocolic fistula complicating xanthogranulomatous pyelonephritis. The diagnosis of XGP was proven by histopathological examination of the nephrectomy specimen slides, but there was also association with an underlying malignant squamous differentiation consistent with urothelial carcinoma, which was not evident on CT. XGP is a rare variant of chronic pyelonephritis with known imaging features. The treatment of choice is nephrectomy and histopathological examination is required for final diagnosis, as there may be associated renal malignancy.     

后腹腔镜在肾切除术中的应用分析

目的探讨后腹腔镜在各类肾切除中的应用及疗效分析。方法回顾性分析136例经腹膜后腹腔镜行肾切除术治疗的各类肾脏疾病患者的临床资料,其中肾结核肾切除术10例、肾癌根治性肾切除术56例、无功能肾切除术34例、肾上腺切除术24例、巨大肾积水肾切除术12例。结果 136例手术均获成功;手术时间76～198min,平均(162±10)min;术中出血量15～280mL,平均(47±12)mL;术后并发症(包括皮下气肿、腹膜损伤、皮下淤血、漏尿等)发生率为11.3%,其中腹膜损伤立即缝合,漏尿予留置尿管、半卧位引流5～7d后恢复,皮下气肿、皮下淤血术后自行吸收。术后恢复良好,5～7d后可下床活动。56例肾恶性肿瘤患者随访3～9个月,均未发现复发或转移。结论经腹腔镜行肾切除术治疗安全可行,具有创伤小、术后恢复快、并发症少及住院时间短等优点。但对肾恶性肿瘤中远期疗效尚需进行长期随访及进一步观察研究。