Retroperitoneoscopic nephrectomy and nephroureterectomy for benign nonfunctioning kidneys: a single-center experience

Systematic review and meta-analysis of the incidence of incisional hernia in urological surgery

PURPOSE

To evaluate the incidence of incisional hernia in patients undergoing direct access to the abdominal cavity in urological surgery.

METHODS

We conducted a systematic review in Pubmed, Embase, and Cochrane Central from 1980 to the present according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Eighty-four studies were selected for inclusion in this analysis, and meta-analysis and meta-regression were performed.

RESULTS

The total incidence in the 84 studies was 4.8% (95% CI 3.7% - 6.2%) I2 93.84%. Depending on the type of incision, it was higher in the open medial approach: 7.1% (95% CI 4.3%-11.8%) I2 92.45% and lower in laparoscopic surgery: 1.9% (95% CI 1%-3.4%) I2 71, 85% According to access, it was lower in retroperitoneal: 0.9% (95% CI 0.2%-4.8%) I2 76.96% and off-midline: 4.7% (95% CI 3.5%-6.4%) I2 91.59%. Regarding the location of the hernia, parastomal hernias were more frequent: 15.1% (95% CI 9.6% - 23%) I2 77.39%. Meta-regression shows a significant effect in reducing the proportion of hernias in open lateral, laparoscopic and hand-assisted compared to medial open access.

CONCLUSION

The present review finds the access through the midline and stomas as the ones with the highest incidence of incisional hernia. The use of the lateral approach or minimally invasive techniques is preferable. More prospective studies are warranted to obtain the real incidence of incisional hernias and evaluate the role of better techniques to close the abdomen.

Technical and Anatomical Aspects of Retroperitoneoscopic Renal Surgery: A Summary of Tribulations and Resolutions Encountered at a Tertiary Care Institute of North India

INTRODUCTION

Kidneys are a retroperitoneal organ but the widely practiced laparoscopic approach to renal surgery is transperitoneal due to the advantages of greater working space at the cost of entering the peritoneal cavity, risk of injury to intraperitoneal organs, and the increased risk of postoperative bowel complications. The classic open approach to kidney procedures has been the flank approach without violating the peritoneal cavity instead of the retroperitoneal approach to renal surgery with the advantages of direct access to the renal hilum, especially the renal artery. Being a technically challenging procedure, the retroperitoneoscopic approach is less practiced and needs an experienced surgical team. Through this study, we have tried to unveil the myths and illustrate the exact position of ports, which is the decisive initial step in retroperitoneoscopic surgery.

MATERIAL AND METHODS

This retrospective study was conducted at a developing tertiary center in northern India with novice staff mainly to determine the technical and anatomical caveats pertaining to the retroperitoneoscopic approach for renal surgeries, the challenges faced, and their resolutions. The decision for the site of incision for primary or camera port was taken only after a proper anatomical study of the cadavers and ongoing retroperitoneal surgical experience while treating various patients suffering from renal diseases. The study comprised eight patients, during the period from June 2023 to March 2024. Various parameters, such as demographic variables, diagnosis, mean operative time, estimated blood loss, technical difficulties encountered and their resolution, complications, and reasons for conversion were studied. A total of 15 cadavers were dissected during the above time period to study finer anatomical details of port positioning and other details.

RESULTS

After an elaborate study of 15 cadavers and thereafter performing surgery on eight patients during the above time period, surgery was successfully performed on six patients, and two patients needed conversion to open procedure due to dense adhesions and non-progression while complications occurred in two patients (peritoneal rent and renal vein injury), which were managed laparoscopically.

CONCLUSION

 Nonetheless, restrictions of surgical space make retroperitoneoscopic space a challenging procedure but with elaborate experience, which we gained through cadaveric study, and surgical results obtained during the initial few cases such as the exact site of the primary port and technical intricacies, and handling of complications if and when faced, we hope our study will certainly make retroperitoneal space more amicable to urologists.

Perioperative outcomes and risk factors for major complications associated with nephrectomy for Xanthogranulomatous pyelonephritis: a multicenter study

PURPOSE

To determine the risk factors associated with major complications in patients with histologically confirmed Xanthogranulomatous pyelonephritis (XGP) who underwent nephrectomy.

METHODS

A multicenter retrospective study was performed including patients who underwent nephrectomy between 2018 and 2022 with histopathological diagnosis of XGP. Clinical and laboratory parameters at the initial presentation were evaluated. Data on extension of XGP was recorded as per the Malek clinical-radiological classification. Characteristics of nephrectomy and perioperative outcomes were obtained. The primary outcome was major complications, defined as a CD ≥ grade 3 and the need for intensive care unit (ICU) admission. Secondary outcomes included the comparison of complications evaluating the nephrectomy approach (transperitoneal, retroperitoneal, and laparoscopic). A sub-analysis stratifying patients who needed ICU admission and Malek classification was performed.

RESULTS

A total of 403 patients from 10 centers were included. Major complications were reported in 98 cases (24.3%), and organ injuries were reported in 58 patients (14.4%), being vascular injuries the most frequent (6.2%). Mortality was reported in 5 cases (1.2%). A quick Sepsis-related Organ Failure Assessment (qSOFA) score ≥ 2, increased creatinine, paranephric extension of disease (Malek stage 3), a positive urine culture, and retroperitoneal approach were independent factors associated with major complications.

CONCLUSION

Counseling patients on factors associated with higher surgical complications is quintessential when managing this disease. Clinical-radiological staging, such as the Malek classification may predict the risk of major complications in patients with XGP who will undergo nephrectomy. A transperitoneal open approach may be the next best option when laparoscopic approach is not feasible.

Retroperitoneoscopic nephrectomy: current status

The classic retroperitoneal open surgical access to the kidney has been duplicated while performing laparoscopy but is less common than transperitoneal laparoscopy. We reviewed minimally invasive retroperitoneoscopic nephrectomy as a part of the international consultation on urological diseases and European Association of Urology international consultation on minimally invasive surgery in urology. A Pubmed/Medline search was performed to identify studies assessing the feasibility, safety and efficacy of laparoscopic and robotic retroperitoneoscopic nephrectomy. The articles were reviewed to assess outcomes after simple, radical and donor nephrectomy and comparative trials between retroperitoneoscopic versus the open and transperitoneal route were evaluated. Retroperitoneoscopic nephrectomy is feasible for most cases of benign non-functioning kidneys. Retroperitoneoscopic radical nephrectomy is also feasible for most tumours and may be better suited for posteriorly located tumours. Both retroperitoneoscopic and transperitoneal nephrectomy have similar outcomes but the operative time may be shorter for the former. The data are insufficient for robotic retroperitoneoscopic nephrectomy probably because of limited space and lack of benefit of a robot in ablative surgeries.

Level of evidence: 3a

Comparison of modified hand-assisted retroperitoneoscopic laparoscopic nephrectomy and open nephrectomy in patients with benign inflammatory non-functioning kidney diseases

Background

To assess the validity and feasibility of the modified hand-assisted retroperitoneoscopic laparoscopic nephrectomy (MHARLN) in patients with benign inflammatory non-functioning kidney diseases.

Methods

We retrospectively compared the data of 223 patients who underwent an MHARLN (n=142) or an open nephrectomy (ON) (n=81) with benign inflammatory non-functioning diseases between January 2014 and October 2019 at our hospital. Patients' demographic data, perioperative outcomes, preoperative and postoperative inflammatory data, and postoperative complications were reviewed.

Results

The basic demographic data of patients were similar between the 2 groups. The mean operative times for the MHARLN and the ON were 135 and 143 minutes (P=0.181), respectively. The first time at which postoperative ambulation occurred, the visual analog pain scale (VAS) score before discharge and the postoperative complication rate were similar in both groups. However, compared to the MHARLN, the ON was associated with a more severe inflammatory response on the first day after surgery (P=0.045), higher estimated blood loss (309.8 vs. 139.6 mL; P=0.036), more peritoneal ruptures (19.8% vs. 9.2%; P=0.024), higher intraoperative transfusion (14.82% vs. 4.93%; P=0.011), higher VAS scores 24 hours after surgery (5.9 vs. 5.2; P=0.002), additional analgesic use (35.8% vs. 21.8%; P=0.024), and longer hospital stays (5.3 vs. 4.6 days; P=0.048). Before a liquid diet was commenced in the MHARLN and ON groups, the mean time was 1.2 and 1.5 days, respectively (P=0.004).

Conclusions

When performed by a skilled laparoscopic surgeon, the use of the MHARLN in patients with benign inflammatory non-functioning kidney diseases is reliable and safe. The MHARLN may help to treat challenging cases and result in less trauma successfully.

Hernia after retroperitoneoscopic adrenalectomy, case report

We report the first case of a previously undocumented complication after posterior retroperitoneal adrenalectomy (PRA). Extensive diagnostic procedures for persisting abdominal pain led to diagnosis of an incisional hernia (IH) approximately 2.5 years after surgery for a pheochromocytoma of the right adrenal gland. Thus, IHs need to be recognized as a potential complication after PRA, particularly if the symptoms are non-specific. The differential diagnosis of an IH after PRA includes a type of spontaneous lumbar hernia due to a pre-existing weakness of the abdominal wall however the treatment for both type of hernias is similar by mesh repair. A possible risk factor for IH after PRA might be obesity, due to different factors including difficulties in closing the fascia in depth under subcutaneous tissue.

Comparative Study of Retroperitoneal Laparoscopic Versus Open Ipsilateral Nephrectomy After Percutaneous Nephrostomy: A Multicenter Analysis

Purpose: To investigate the feasibility of retroperitoneal laparoscopic ipsilateral nephrectomy of a benign nonfunctional kidney after percutaneous nephrostomy, and to compare this method with open surgery. Materials and Methods: Data from 70 patients who underwent simple nephrectomy from January 2014 to October 2018 at three large centers were retrospectively analyzed. All patients underwent percutaneous nephrostomy because of renal or ureteral calculi with severe hydronephrosis or pyonephrosis. Simple nephrectomy was performed via retroperitoneal laparoscopic surgery (retroperitoneal laparoscopic group; n = 33) or open surgery (open group; n = 37). The retroperitoneal laparoscopic and open groups were compared regarding preoperative variables (age, sex, location of surgery, hypertension, diabetes, BMI, preoperative serum creatinine level, American Society of Anesthesiologists (ASA) grade, fistula duration, fistula size, number of fistulae, and urinary tract infection), and perioperative variables (operation time, intraoperative blood loss, postoperative drainage volume, catheter indwelling time, gastrointestinal function recovery time, duration of bedrest, duration of postoperative hospitalization, postoperative hemoglobin decline, perioperative transfusion, and postoperative complications). Results: The retroperitoneal laparoscopic group included more patients with hydronephrosis, while the open group included more patients with pyonephrosis. There were no significant differences between the two groups in age (P = .813), sex (P = .729), location of surgery (P = .345), hypertension (P = .271), diabetes (P = .394), BMI (P = .798), preoperative serum creatinine level (P = .826), ASA grade (P = .820), fistula duration (P = .108), fistula size (P = .958), number of fistulae (P = .925), urinary tract infection (P = .111), or operative time (P = .851). The retroperitoneal laparoscopic group had significantly lesser intraoperative blood loss (P = .007), postoperative drainage volume (P = .008), shorter catheter indwelling time (P = .002), gastrointestinal function recovery time (P < .001), duration of bedrest (P < .001), and duration of postoperative hospitalization (P < .001), and lesser postoperative hemoglobin decline (P = .035) compared with the open group. Conclusions: Retroperitoneal laparoscopic ipsilateral nephrectomy is feasible for a benign nonfunctional kidney after percutaneous nephrostomy. The surgical method should be selected based on the surgeon's experience and the specific situation of the patient.

Laparoscopic nephrectomy in xanthogranulomatous pyelonephritis

Introduction

The aim of this article was to report our experience with laparoscopic and retroperitoneoscopic nephrectomy in patients with xanthogranulomatous (XPG) pyelonephritis.

Material and methods

Between November 2002 and September 2010, 27 patients, with a mean age of 61.1 years (range 43–85), underwent laparoscopic nephrectomy for a unilateral nonfunctioning kidney, because of xanthogranulomatous pyelonephritis. Patient's data was collected retrospectively and included patient age, gender, intraoperative conversion rate, operative time, estimated blood loss, length of hospital stay, perioperative transfusion rate, renal function pre- and postoperatively and postoperative complications.

Results

Laparoscopic nephrectomy was successful in 26 patients. It was transperitoneal in 15 patients, retroperitoneal in 11 patients and in one patient the operation was initiated as retroperitoneal and converted to transperitoneal. One conversion to open surgery was needed. The mean operative time was 193.6 minutes (range 123–340). The mean estimated blood loss was 223.5 ml (range 30–1000). The mean hospital stay was 4.8 days (range 3–12). The transfusion rate was 29.6%. Serum creatinine was 1.3 mg/dl the day before and the day after the operation. Major complications occurred in patients (11.1%).

Conclusions

Laparoscopic nephrectomy should be considered as an initial approach for XGP. The indications for laparoscopic nephrectomy should be extended to these patients.

Contemporary Analysis of Calculous Nephrectomy Utilization and Outcomes in the United States

Introduction: Calculous nephrectomy was a mainstay of treatment of complex upper tract stone disease up until the 1970s, but data on its contemporary utilization in the current era of rising rates of stone disease are lacking. We characterized the nationwide utilization and outcomes for calculous nephrectomy in the United States. Patients and Methods: The National/Nationwide Inpatient Sample databases for 2001 to 2014 were queried for adults with a principal diagnosis of upper urinary tract calculi (UUTCs), who underwent nephrectomy as well as other inpatient surgeries for UUTCs. Per-population trend in utilization of calculous nephrectomy was analyzed using negative binomial regression. The proportion of calculous nephrectomy as a fraction of all inpatient surgical procedures for UUTCs was analyzed using the Cochran-Armitage test. Patient demographics, hospital characteristics, perioperative outcomes, and complications were analyzed using appropriate statistical tests. Results: Of almost 1.42 million inpatient UUTC procedures performed over the study period, 9232 (0.65%) were calculous nephrectomies. Per-population utilization rate for calculous nephrectomy decreased significantly over time (incidence rate ratio = 0.82; 95% confidence interval = 0.73-0.91, p < 0.001). The proportion of calculous nephrectomy as a fraction of all inpatient surgical procedures for UUTC also decreased significantly over time (p < 0.0001). Majority of the procedures were performed in females, in urban teaching hospitals, and in the Southern United States. The overall complication rate was 38.3%, most commonly hemorrhage requiring transfusion (15.6%). Older age, female gender, and nonprivate insurance or lack of insurance were significant predictors of increased risk of complications, whereas hospitalization in urban hospitals was a predictor of lower risk. Conclusions: Despite increasing prevalence of stone disease in the United States in the contemporary era, utilization of calculous nephrectomy is low and is declining. Inpatient complication rates are moderately high and influenced by patient sociodemographic and hospital characteristics.

Trocar Site Hernia After Retroperitoneal Laparoscopic Partial Nephrectomy: A Case Report and Literature Review

Trocar site hernia is a rare complication after laparoscopic surgery. The incidence of trocar hernia is rarer in retroperitoneal approach of urologic laparoscopy. We report a case of trocar site hernia after retroperitoneal laparoscopic partial nephrectomy.

This challenging procedure has successful outcomes: Laparoscopic nephrectomy in inflammatory renal diseases

In prospective study from November 2011- November 2013, we performed 44 laparoscopic nephrectomies for benign non-functioning kidney diseases. Twenty eight patients underwent laparoscopic transperitoneal nephrectomies (63.6%), ten were laparoscopic assisted (22.7%) and six (13.6%) were converted to open. Patient's age, gender, laterality and etiology of renal failure were noted. Outcomes were measured as operative time, intraoperative and post operative complications, blood loss, pain score and hospital stay. Patients were followed up at one, three and 12 weeks and 6 monthly thereafter. Of the 44, ten (22.7%) were 15-24 years old, 32 (72%) between 25-50 years and two were more than 50 years old. Females were 54.6%. 22 patients had either right or left nephrectomy. Pelviureteric-junction (PUJ) obstruction was the commonest cause, 26 cases (59.0%). Operative time: less than two hours in 30 (68.2%) patients, more than two hours in 14 cases. Blood loss: less than 100 ml in 12 (27.3%), 100-200 ml in 20 (45.4%) and more than 200 ml in 12 (27.3%) patients. All four major complications were converted to open, two had injury to mesocolic veins and two had vascular stapler malfunction. Post-operative complications: surgical site infection (SSI), paralytic ileus and mild grade fever in six cases each and non infected benign intra abdominal collection in two cases. Maximum pain score on POD-1: four in 20 cases (45.7%), two in 24 (54%). Two had pain score between 3-4 three weeks after surgery. Oral intake started by POD-2 in 30 (68.2%) and by POD-4 in 100% cases. 22 (50%) patients were ambulating by POD-2, 16 (36.7%) by POD-4. Our study and randomized and non-randomized published literature report acceptables complication and conversion rates. In conclusion, laparoscopic nephrectomy for benign non functional kidney is a better alternative to open nephrectomy.

Have we overcome the complications of laparoscopic nephrectomy? A prospective, cohort study using the modified Clavien-Dindo scale

INTRODUCTION

Apart from the complexity of procedure and surgeon's experience, surgical complication rates depend on case definition and method of recording data. We prospectively evaluated the complications of laparoscopic nephrectomy (LN) in a current cohort of patients, graded on the modified Clavien-Dindo (CD) scale and compared them with historical cohorts.

METHODS

In the Institutional Review Board approved protocol, all patients undergoing LN over a 30-month were enrolled in the study. Clinical parameters, operative data, inhospital course, and 30-day follow-up were recorded prospectively in an electronic database by a resident who did not perform any of the surgeries. The complications were analyzed using the CD scale.

RESULTS

A total of 103 patients (age 14-80 years) underwent LN (30 radical, 73 simple) during the study period. Forty-three of these procedures were for inflammatory conditions (stone disease or tuberculosis). Six procedures were converted to open surgery due to vascular injury (2), bowel injury (1), and adhesions (3). There were 45 (46%) complications in the 97 procedures completed laparoscopically including 34 low-grade (CD grade 1, 2) and 11 high-grade (CD grade 3, 4) complications. There was no mortality. Complications were similar in patients undergoing surgery for inflammatory or noninflammatory conditions.

CONCLUSIONS

LN continues to be associated with postoperative complications in 46% of cases. However, the complication rates appear to be higher than historical series, possibly due to the more rigorous case-definition and prospective recording.

Clinical analysis of retroperitoneoscopic nephroureterectomy for renal tuberculosis

OBJECTIVES

To explore the feasibility and safety of retroperitoneoscopic nephroureterectomy for kidney tuberculosis.

METHODS

Forty-eight retroperitoneoscopic nephroureterectomies and thirty-five nephroureterectomies for kidney tuberculosis procedures were performed from June 2008 to December 2014. The patients consisted of 53 males and 30 females with a mean age of 36 years (range: 26-51 years). The patients' data were reviewed and analyzed.

RESULTS

The retroperitoneoscopic nephroureterectomy procedures were completed successfully in 48 cases with no conversions to open surgery. The mean operating time was 170 minutes (range: 121-258 minutes), the mean blood loss was 110 ml (range: 70-250 ml), and the mean hospital stay was 5.70 days (range: 5-14 days); these were all much less than nephroureterectomy procedures (P < 0.05). A total of five minor complications (10.4%) occurred, injury to the peritoneum was observed in three patients, and infection at the incision site was observed in two patients, there were no obvious difference between the two surgical methods (P > 0.05). Seventy-five patients were followed up, and the average follow-up time was 12.5 months (range: 6-20 months). All the patients recovered without any lesions remaining.

CONCLUSIONS

The results of this study indicate that retroperitoneoscopic nephroureterectomy is a feasible, safe, effective, and less invasive treatment modality for treating renal tuberculosis.

Comparison of transperitoneal laparoscopic nephrectomy outcomes in atrophic and hydronephrotic kidneys

OBJECTIVE

To compare the results of transperitoneal laparoscopic nephrectomy in patients with atrophic and hydronephrotic kidneys.

MATERIAL AND METHODS

Clinical data were collected from 35 patients who had undergone laparoscopic nephrectomies for atrophic or hydronephrotic non-functioning kidneys between January 2010 and March 2014. Comparative analysis was carried out between the two groups examining demographic characteristics, imaging modalities, etiology, operative times, port numbers, conversion to open surgery, complications, pre-and post-operative hemoglobin and creatinine values, transfusion rates and length of hospital stays.

RESULTS

Laparoscopic nephrectomy was performed for atrophic kidneys in 20 (57%) patients and for hydronephrotic kidneys in 15 (42%) patients. In the atrophic group, 3 patients (15%) required transfusion because of bleeding but none of the patients required conversion to open surgery. In the hydronephrotic group one patient (6.6%) required transfusion and conversion to open surgery because of bleeding. Both of the groups were similar in terms of postoperative hospital stay but compared to the atrophic kidneys, hydronephrotic ones were associated with a longer total operative times (90.1 min vs. 73.6 min, p=0.03). Any serious complication (except for bleeding) and mortality were not encountered in both groups.

CONCLUSION

Laparoscopic nephrectomy is a safe and effective minimally invasive technique that can be used in atrophic and hydronephrotic non-functioning kidneys.

Lateroconal fascia suspension for management of peritoneal tear and "curtain" effect during retroperitoneal laparoscopic operations

PURPOSE

To describe the method of lateroconal fascia suspension for the management of peritoneal tear and curtain effect during retroperitoneal laparoscopic operations.

MATERIALS AND METHODS

Between May 2013 and October 2014, we performed lateroconal fascia suspension in 30 cases of retroperitoneal laparoscopic operations. Peritoneal tear occurred and retroperitoneal space collapsed in 18 cases of them during the operation, and free edge of the lateroconal fascia caused curtain effect and sheltered the field of view in another 12 cases after the lateroconal fascia was incised longitudinally.

RESULTS

The curtain effect of lateroconal fascia was eliminated successfully, and the sheltered field of view got normal in all the 12 cases. The collapsed retroperitoneal space due to peritoneal tear got enlarged effectively and was sufficient for the following operations in 15 patients of the overall 18 cases, while the collapsed retroperitoneal space did not get enlarged significantly in the other three cases. After the insertion of an extra 5-mm trocar into peritoneal space, the collapsed retroperitoneal space got enlarged eventually. Finally, retroperitoneal laparoscopic operations were continued and completed successfully in all these 30 patients. It took 4 min to complete the suspension procedure, and no related complications occurred during the whole suspension process.

CONCLUSION

Lateroconal fascia suspension method could manage most peritoneal tears and curtain effect effectively during retroperitoneal laparoscopic operations.

Retroperitoneal Laparoscopic Nephroureterectomy for Tuberculous Nonfunctioning Kidneys: a single-center experience

PURPOSE

To present our surgical techniques and experiences of retroperitoneal laparoscopic nephroureterectomy for the treatment of tuberculous nonfunctioning kidneys.

MATERIALS AND METHODS

From March 2005 to March 2013, a total of 51 patients with tuberculous nonfunctioning kidney underwent retroperitoneal laparoscopic nephroureterectomy at our medical center. The techniques included early control of renal vessels and dissection of the diseased kidney along the underlying layer outside the Gerato's fascia. The distal ureter was dissected through a Gibson incision and the entire specimen was removed en bloc from the incision. Patient demographics, perioperative characteristics and laboratory parameters as well as postoperative outcome were retrospectively reviewed.

RESULTS

Retroperitoneal laparoscopic nephroureterectomy was successfully performed in 50 patients, whereas one case required conversion to open surgery due to non-progression of dissection. The mean operating time was 123.0 minutes (107-160 minutes) and the mean estimated blood loss was 134 mL (80-650 mL).The mean postoperative hospital stay was 3.6 days (3-5 days) and the mean return to normal activity was 11.6 days (10-14 days). Most intra-operative and post-operative complications were minor complications and can be managed conservatively. After 68 months (12-96 months) follow-up, the outcome was satisfactory, and ureteral stump syndrome did not occur.

CONCLUSIONS

Retroperitoneal laparoscopic nephroureterectomy as a minimally invasive treatment option is feasible for treatment of tuberculous nonfunctioning kidneys.

Nephrectomy for benign disease in the UK: results from the British Association of Urological Surgeons nephrectomy database

OBJECTIVE

To summarize the practice of UK urologists with regard to nephrectomy for benign disease, documenting the indications, procedural techniques and outcomes.

METHODS

All patients undergoing nephrectomy for a benign condition in 2012 were identified from the British Association of Urological Surgeons (BAUS) nephrectomy database. Recorded variables included the technique of surgery, the type of minimally invasive procedure, operating time, blood loss, transfusion rate, conversion rate, intra- and postoperative complications and mortality rate. Cases were also sub-analysed according to their pathologies to determine the differences in complication rate between stone disease, pyelonephritis, non-functioning kidney and other benign lesions. To contextualize procedural complexity, the simple nephrectomy data were compared with those obtained from the BAUS stage T1 radical nephrectomy audit.

RESULTS

A total of 1 093 nephrectomies were performed (537 non-functioning kidneys, 142 stone disease, 129 nephrectomies secondary to pyelonephritis and 285 cases with other benign conditions). Of these, 76% were performed laparoscopically. Blood loss >500 mL was noted in 74 cases with a 4.8% blood transfusion rate. The intra- and postoperative complication rates were 5.2 and 11.9%, respectively. Of the 847 minimally invasive procedures, the conversion rate was 5.9%. Patients with stone disease have the highest intra- and postoperative complications (9.9 and 23.9%, respectively) compared with other benign pathologies. The total number of T1 radical nephrectomies performed was 1 095. In comparison with T1 radical nephrectomy, simple nephrectomy carries an increased risk of conversion to an open procedure (1.8 times), a higher rate of blood transfusion (4.8 vs 2.8%), and a higher risk of intra- and postoperative complications (5.2 vs 3.7% and 11.9 vs 10%, respectively).

CONCLUSION

The present study reports the largest series of nephrectomies performed for benign disease and the resultant data now support the bespoke preoperative counselling of patients. Furthermore, it confirms the commonly held view that simple nephrectomy can be more difficult than its radical counterpart. The authors suggest that the term 'simple nephrectomy' is changed to 'benign nephrectomy'.

Laparoscopic horseshoe kidney isthmusectomy: four case reports

Horseshoe kidney is a congenital defect of the urinary tract that occurs in 0.25% of the general population. The indications for division of the isthmus of horseshoe kidney are controversial, and if done, it is during the concomitant removal of additional defects accompanying horseshoe kidney. The aim of this study was to evaluate the results of isthmusectomy of horseshoe kidney using laparoscopy. This paper presents cases of 4 patients who underwent isthmusectomy, dismembered pyeloplasty, and stone removal using laparoscopy. All patients were operated on by a transperitoneal approach using 4 trocars. In 3 patients, we cut the renal isthmus by means of bipolar scissors and then we closed the renal parenchyma using two continuous hemostatic Vicryl 1-0 stitches. In 1 patient, an endostapler was used for isthmusectomy. The total operative time ranged from 4.5 h to 5.5 h including simultaneous dismembered pyeloplasty in 3 patients. Blood loss ranged from 40 ml to 300 ml. Use of the endostapler greatly facilitated the procedure. There were no complications either during or after the procedure. In all patients, mobilization and oral nutrition were included on the first or second day. On the third day, all patients were ready to be discharged from the hospital. Long-term follow-up after treatment showed good results in all patients. Laparoscopy is an alternative to open surgery, particularly in the correction of congenital defects of the urinary tract. Although the indications for division of the isthmus of horseshoe kidney are controversial, laparoscopic technique in isthmusectomy is safe for patients, as shown by our results.

Retroperitoneal renal laparoscopy

The retroperitoneal laparoscopic approach to the kidney offers a minimally invasive access that mimics the open surgical techniques of renal surgery. It allows renal surgery without violation of the peritoneal cavity with its attendant complications such as bowel injury and ileus. Over the last two decades, all renal surgery has been shown to be feasible through this technique. This includes complicated procedures such as a donor nephrectomy and radical nephroureterectomy for upper tract transitional cell cancers. We began performing retroperitoneoscopic renal surgery in the early 1990s and have developed a number of modifications to existing techniques so as to make this surgery easy and cost effective. In this review, we discuss the evolution of retroperitoneoscopic renal surgery, the indications, techniques and outcome of all types of retroperitoneoscopic renal surgery.

Application of the Hem-o-lok ligation system in laparoscopic nephrectomy

BACKGROUND

The Hem-o-lok polymer clip has become the preferred method to control large vessels during operation. We explored the advantages of application of the Hem-o-lok ligation system in laparoscopic nephrectomy.

METHODS

From January 2004 to May 2009, 116 laparoscopic nephrectomies were performed using Hem-o-lok clips to control renal artery and vein, including 22 simple nephrectomies, 63 radical nephrectomies, and 31 nephroureterectomies. Operative time, estimated intraoperative blood loss, recovery time of intestinal function, postoperative hospital day, as well as complication rate were recorded and studied retrospectively. The number and cost of Hem-o-lok clips were analyzed.

RESULTS

All 116 laparoscopic nephrectomies using Hem-o-lok clips for renal pedicle control were accomplished successfully without conversion to open surgery. No intra/postoperative vascular complications or other clip-related complications occurred. Laparoscopic operating time was 14-275 min (average 146.5 min). Estimated blood loss was 25-600 ml (average 159.2 ml). Mean recovery time of intestinal function was 30.4 h (range 16-72 h). Postoperative hospital stay was 4-22 days, with an average of 7.3 days. The mean number of Hem-o-lok clip used per operation was 5.3 (range 4-8).

CONCLUSIONS

Use of the Hem-o-lok ligation system to control renal pedicle is safe and reliable for laparoscopic simple/radical nephrectomy.

Retroperitoneoscopic nephrectomy for pyonephrotic nonfunctioning kidney

OBJECTIVES

To review the feasibility and outcome of retroperitoneoscopic nephrectomy (RPN) for pyonephrotic nonfunctioning kidneys.

METHODS

RPN for pyonephrotic nonfunctioning kidneys was used in 52 patients from July 2001 to May 2007. Percutaneous nephrostomy drainage was instituted in 46 patients because of sepsis before being referred to our institute. However, the remaining 6 patients underwent RPN without previous diversion. The mean patient age was 46.4 years (range 22-72). The etiology was stone disease in 29 patients, ureteropelvic junction obstruction in 18, and genitourinary tuberculosis in 5; 32 patients had diabetes mellitus as a comorbid condition.

RESULTS

RPN was performed successfully in 46 patients (88.5%); 6 patients required conversion to open surgery (1 emergently because of colonic injury and 5 electively because of nonprogression of the procedure). In 6 patients, subcapsular nephrectomy was required. The mean operating time was 110 minutes (range 90-180). The mean blood loss was 95 mL (range 80-300), and the mean analgesic requirement was 150 mg (range 50-400) of tramadol. Five patients had Clavien grade I, 7 had grade II, and 2 had grade IIIb complications. One patient required blood transfusion. The mean hospital stay was 3.6 days (range 2-8), and the mean return to normal activity was 14.2 days (range 11-21).

CONCLUSIONS

RPN, although challenging, is safe, reliable, and successful for treatment of pyonephrotic nonfunctioning kidneys.

Not so "simple" laparoscopic nephrectomy: outcomes and complications of a 7-year experience

INTRODUCTION

Laparoscopic radical nephrectomy has quickly evolved as an oncologic standard of care. The "Simple" nephrectomy implies an easier procedure than perhaps its radical counterpart and one that budding laparoscopists may approach with more confidence. Though, strict indications for simple nephrectomy are few, these cases tend to have infectious or inflammatory pathology sometimes making the procedure more difficult than its radical counterpart.

METHODS

A retrospective review of our experience with laparoscopic simple nephrectomy (LSN) over a 7-year period was performed. A total of 42 patients (12 males/ 30 females) with a mean age 47.5 years underwent LSN: 25 retroperitoneal (RP), 17 transperitoneal (TP). Indications for nephrectomy included poorly functioning kidneys associated with pain+/-hydronephrosis, recurrent infections, renal arterial stenosis induced malignant hypertension, XGP with stones.

RESULTS

Forty-two of 45 attempted simple nephrectomies were completed laparoscopically. Three patients had open conversions: two for non-progression and one endovascular stapler malfunction. Three patients were converted from RP to TP due to severe scarring (two having prior nephrostomy tubes). Median operative time was 202.5 minutes (98-399). Eight patients were discharged within 23 hours with no complications, all having RP approaches and morcellated specimens. Mean post-operative oral intake was 17.8 hours and bowel function return was 1.3 days. Median estimated blood loss 100 ml (30-4500). Creatinine levels did not alter significantly. Median specimen weight was 88.9 grams (28-672). Fourteen complications occurred in nine patients (21.4%): five minor (flank ecchymosis and mild ileus) and nine major (re-intubation, flank hernia, wound opening requiring readmission, retroperitoneal infections, trocar fistula formation, bleed requiring transfusion). Four patients were transfused: one for post-op bleed from the ureteral stump, two for chronic anemia with minimal intraoperative blood loss, and one for intraoperative blood loss.

CONCLUSIONS

Laparoscopic simple nephrectomy has few indications and includes a complicated patient population. The results show its efficacy and overall safety despite a moderate complication rate. Utilizing a retroperitoneal approach with specimen morcellation can reduce hospital stay. One should approach a laparoscopic nephrectomy for non-malignancy with caution for infectious or inflammatory indications.

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.

Retroperitoneoscopic Nephrectomy for Pyonephrotic Kidneys

PURPOSE

To assess the feasibility and efficacy of retroperitoneoscopic nephrectomy for pyonephrotic kidneys.

PATIENTS AND METHODS

From July 2003 to December 2005, 67 patients underwent retroperitoneoscopic nephrectomy for nonfunctioning pyonephrotic kidneys. The patients were assessed for operative time, blood loss, analgesic requirement, conversion rate, and hospital stay.

RESULTS

Retroperitoneoscopic nephrectomy could be accomplished in 58 patients (86.5%). The mean operative time and blood loss were 168 minutes and 101 mL, respectively. The mean postoperative analgesic requirement was 100 mg of diclofenac sodium. The mean hospital stay was 3.4 days.

CONCLUSION

Retroperitoneoscopic nephrectomy can be accomplished successfully and safely in the majority of patients with pyonephrosis and may be considered as the primary treatment. However, this is a difficult procedure, and experience in routine retroperitoneal nephrectomy is recommended prior to doing a case.

Reconstructive Surgery for the Management of Genitourinary Tuberculosis: A Single Center Experience

PURPOSE

We evaluated the role of surgery for genitourinary tuberculosis with special emphasis on reconstructive procedures.

MATERIALS AND METHODS

Case records of 241 patients with genitourinary tuberculosis who underwent surgery at our center during a period of 17 years were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied.

RESULTS

There were 129 males and 112 females with a mean age of 34.6 years. The most common presentation was irritative voiding symptoms. Azotemia was seen in 54 (22.4%) cases. The most commonly involved organ was the kidney in 130 (53.94%) cases. Preoperative bacteriologic diagnosis was confirmed in 70 (29%) cases. All patients received antitubercular drug therapy for 9 months. A total of 248 procedures, including 33 endoscopic, 87 ablative and 128 reconstructive, were performed with some patients requiring more than 1 procedure. Early complications, which mainly involved the bowel, were seen in 19 (7.88%) cases. Bacteriologic cure was achieved in all culture positive cases. Renal functional parameters stabilized or improved in 44 of 54 patients (81.5%) in whom they were deranged at presentation.

CONCLUSIONS

Genitourinary tuberculosis is common in developing countries. Diagnosis is often delayed because of late presentation and many patients present with cicatrization sequelae. A combination of antitubercular drug therapy and judicious surgery achieves satisfactory results in the majority of cases. With improved antitubercular drug therapy and experience with the use of bowel segments in the urinary tract, more reconstructive procedures are being performed with satisfactory outcomes. In patients who undergo reconstructive procedures, a rigorous and prolonged followup is necessary.

Methods of training using pelvic trainers

During the past decade, the clinical applications of laparoscopic surgery in urology have been growing steadily. The laparoscopic version of various procedures, such as nephrectomy, is becoming the standard of care. This has led to an increased need for laparoscopic training in urology and focused the attention on the various modalities for laparoscopic skill acquisition. The common training modalities for laparoscopy are box trainers, animal and cadaveric laparoscopy, and virtual reality simulators. Each modality carries its own benefits to the practicing surgeon. The box trainers are the first practiced and are basic training simulators. They were first designed to help with training in basic laparoscopic skills and to assist surgeons in getting acquainted with instruments. However, these simple boxes are being upgraded constantly by tissue- and organ-specific models, allowing the surgeon to train in a convenient and cost-effective environment. This article describes the ways to work with box trainers, from basic skills to advanced laparoscopic tasks, and discusses the contribution of these trainers to real surgery as well as their role in defining criterion levels of surgical performance.

Laparoscopic nephrectomy in inflammatory renal disease: proposal for a staged approach

INTRODUCTION

The present study shows and discusses the preliminary experience of customized and staged approach in the minimally invasive treatment of inflammatory renal diseases, using either pure laparoscopic surgery or the hand-assisted technique.

MATERIALS AND METHODS

We prospectively assessed 17 patients with inflammatory renal diseases operated by laparoscopic approach. Mean age was 41 years and the surgical indication was repeated pyelonephritis in 8 cases, pyonephrosis in 4 cases and renal exclusion due to staghorn stone in 5 cases. The staged laparoscopic approach was chosen based on kidney size and on the presence or not of tomographic findings showing significant perirenal infiltration. Thus, retroperitoneal access was chosen in cases where the kidney was smaller than 12 cm or in the absence of signs of significant perirenal infiltration on the computerized tomography. For the remainder, transperitoneal access was employed.

RESULTS

Of the 17 patients, 11 underwent laparoscopic nephrectomy by retroperitoneal access, and all cases were successful. Mean surgical time was 160 minutes. In 6 cases where the nephrectomy was performed by laparoscopic transperitoneal access, the use of hand assistance was required. Four surgeries were successfully completed with mean time of 190 minutes and 2 were converted to open surgery with mean time of 220 minutes.

CONCLUSION

The laparoscopic nephrectomy for inflammatory renal disease is feasible, but presents a high degree of complexity, requiring a customized approach. The use of hand assistance is an attractive option when the inflammatory process is intense, and can avoid conversions, maintaining the advantages of minimally invasive treatments.

Laparoscopic nephrectomy for benign non functioning kidneys

Laparoscopic nephrectomy has been established as the standard of care for the management of benign non-functioning kidneys and has gained worldwide popularity over the past decade. In this article, we have reviewed the current literature to elucidate the indications, contraindications, surgical techniques, results and complications of laparoscopic nephrectomy.

Retroperitoneoscopic Decortication of Symptomatic Renal Cysts

PURPOSE

To determine the safety and efficacy of retroperitoneoscopic decortication of symptomatic renal cysts.

PATIENTS AND METHODS

A total of 24 patients with symptomatic 6- to 14-cm (mean 10.9-cm) simple renal cysts, right sided in 13 and left sided in 11, underwent retroperitoneoscopic decortication for pain relief at our center between January 1997 and December 2002. The diagnosis was based on an ultrasonogram and contrast-enhanced CT. Symptom severity, assessed using a visual analog pain scale, averaged 7.2/10 (range 6.5-9). The mean duration of symptoms was 4 months. Operative and follow-up data were collected prospectively and analyzed for symptomatic and objective evidence of improvement.

RESULTS

The mean operating time was 95 minutes, and no major complications were observed. The average hospital stay was 2.9 days (range 2-7 days). At a mean follow-up of 2.8 years (range 1.5-5 years), pain relief was reported by 22 patients (change of pain score from 7.2 to 1.4). One patient had worsening of pain at 6 weeks postoperatively. Asymptomatic recurrence of the cyst was seen in two patients on the follow-up ultrasound scans.

CONCLUSIONS

Retroperitoneoscopic renal-cyst decortication is a safe, minimally invasive, and efficacious procedure for the treatment of painful renal cysts, with a durable response.

Oncological outcome of 100 laparoscopic radical nephrectomies for clinically localized renal cell carcinoma

BACKGROUND

Laparoscopic renal surgery is now accepted within the urological community and its indication is extended to oncological operation. The oncological outcome and survival of patients undergoing laparoscopic radical nephrectomy for clinically localized renal cell carcinoma were evaluated.

METHODS

From October 1998 to July 2003, 100 patients underwent laparoscopic radical nephrectomy for clinically localized renal cell carcinoma. All operations were performed by transperitoneal approach with early vascular control. Perioperative events and pathological data were recorded prospectively. Patients were followed up by clinical examination, chest radiograph, ultrasonography and/or computed tomography where appropriate.

RESULTS

The median age of patients was 61 years. Median operating time was 120 min and blood loss was 100 mL. There were five open conversions. There was no perioperative mortality but 11 patients had complications. Resection margins were clear in all but one patient. The median tumour size was 4.6 cm. The median follow-up time was 30 months. All patients survived up to the date of review. No patient developed port-site recurrence but two patients had recurrence at the renal bed 1 year after the operation. Five patients developed distant metastases involving liver, lung and bone.

CONCLUSION

Laparoscopic radical nephrectomy is a safe and efficacious treatment option for clinically localized renal cell carcinoma. The intermediate-term oncological outcome appears favourable.

Laparoscopic nephrectomy for infected, obstructed and non-functioning kidneys

Since laparoscopic nephrectomy was introduced by Clayman et al, it has been doubted whether it should be employed in patients with extensive perirenal fibrosis. In this series, 20 consecutive patients underwent laparoscopic nephrectomy for obstructed, infected, non-functioning kidneys. Preoperative assessment included urine cultures, abdominal sonography, intravenous pyelography, computerized tomography and a renal scan. Laparoscopic nephrectomies were performed using either the transperitoneal or the retroperitoneal approach.Patients' mean age was 52 years (range 20-77, SD = 15.2). Three patients underwent previous open surgery on the same kidney and 15 had percutaneous nephrostomies. The etiology of obstruction was stone disease in 15 cases, uretero-pelvic junction obstruction (3), iatrogenic ureteral injury (1), and infected multicystic kidney (1). Mean operative time was 224 minutes (range 140-325, SD = 57). Conversion to open surgery was necessary in one patient due to splenic injury. Mean hospital stay was 3 days (range 2-6, SD = 1). Laparoscopic nephrectomy was feasible in cases of severe perirenal fibrosis, with an acceptable rate of complications, and may be considered in patients with obstructed, infected, and non-functioning kidneys.

Laparoscopic nephrectomy: the new gold standard?

Laparoscopic nephrectomy has lesser blood loss, quicker recovery and return to work, shorter hospital stay, lesser post operative pain and analgesia requirement associated with it compared to open nephrectomy along with having oncological equivalence to open nephrectomy for T1, T2 renal tumours and for level 1 renal vein invasion by tumour thrombus. It has assumed the status of the New Gold Standard.

Retroperitoneoscopic heminephrectomy of a horseshoe kidney for calculus disease

Retroperitoneoscopic management of complications of a horseshoe kidney provides a feasible and effective alternative to conventional management. We describe a patient who had presented with multiple calculi and a poorly functioning left moiety of a horseshoe kidney, in whom we performed a retroperitoneoscopic left heminephrectomy. Most of the previous reports of laparoscopic nephrectomy have been described via the transperitoneal route. Division of the isthmus was done using ultrasonic shears. The patient had an uneventful recovery and was discharged within 24 hours.

Should retroperitoneoscopic nephrectomy be the standard of care for benign nonfunctioning kidneys? An outcome analysis based on experience with 449 cases in a 5-year period

PURPOSE

Laparoscopic nephrectomy has become a routine procedure at specialized centers with the advantages of less postoperative pain, minimal scars, rapid recovery and short convalescence. We report our experience with the establishment of retroperitoneoscopic nephrectomy as the standard of care for benign nonfunctioning kidneys.

MATERIALS AND METHODS

We retrospectively compared the records of patients who underwent simple nephrectomy retroperitoneoscopically or by open surgery from January 1998 to October 2003 at our center.

RESULTS

A total of 351 simple nephrectomies were done retroperitoneoscopically, while 83 were done as an open procedure. Mean operative time was significantly longer in the retroperitoneoscopic group. However, mean blood loss, complication rate, hospital stay and convalescence were significantly less in the retroperitoneoscopic group.

CONCLUSIONS

Retroperitoneoscopic nephrectomy has become a standardized procedure. It should be offered as the primary treatment modality to patients with benign renal disease scheduled for elective nephrectomy except in those in whom it is contraindicated.

Bilateral laparoscopic nephrectomy with simultaneous peritoneal dialysis: a new era

Peritoneal dialysis is the treatment of choice in children with end-stage renal failure who are awaiting renal transplantation. Traditionally patients requiring bilateral nephrectomy spent time on haemodialysis prior to being converted to peritoneal dialysis during a separate operation. Bilateral synchronous retroperitoneoscopic nephrectomy with the initiation of or return to peritoneal dialysis in the immediate postoperative period was performed on three patients with end-stage renal failure in our unit. The indications for bilateral nephrectomy were persistent heavy proteinuria in two children and difficult to control hypertension in the third. Bilateral laparoscopic nephrectomy was performed with the patients in the prone position. Two of the children were then placed in a supine position and a tunneled peritoneal dialysis catheter was inserted in the standard open fashion. The postoperative complications included a peritoneal catheter line breach requiring intraperitoneal antibiotics and a fever that was culture negative and settled spontaneously. This technique allows for immediate peritoneal dialysis, with the added benefit of reduced postoperative pain and improved cosmetic appearance.

The effect of verapamil on the prevention of ischemia/reperfusion injury in the experimental retroperitoneoscopic donor nephrectomy model

BACKGROUND

This study investigated the effect of intravenous administration of verapamil in prevention of the injury caused by free oxygen radicals generated in a rabbit retroperitoneoscopic donor nephrectomy model.

METHODS

Twenty-four adult New Zealand rabbits were divided into four groups. In group I, balloon dissection of the left retroperitoneal space was performed. In group II, CO2 at 10 mmHg was applied for 3 hours after the balloon dissection. In group III, laparotomy was performed, the left renal pedicle was clamped for 3 min, and the clamp was removed 5 min before nephrectomy. In group IV, 2 min before the attempt 0.2 mg/kg verapamil was given intravenously, and the same procedure was employed as in group III. Nephrectomy was performed after each experiment. The concentrations of malonyl dialdehyde (MDA), reduced glutathione (GSH), and protein carbonyl content were measured in renal tissue samples as markers of oxidative stress.

RESULTS

Pneumoretroperitoneum (Prp) promoted oxidative stress in renal tissues, with an increase of MDA and protein carbonyl content. The verapamil- pretreated group (group IV) showed statistical significantly lower values of MDA and protein carbonyl content when compared with group II and III (p < 0.05), whereas tissue GSH concentrations were unchanged in all groups.

CONCLUSIONS

Our study showed that Prp causes increased oxidative stress in renal tissue. Warm ischemia lasting 3 min did not exert an additive effect on Prp-associated oxidative stress. Verapamil reduces the oxidative stress markers caused by Prp.

Videoendoscopic surgery by extraperitoneal access

Laparoscopic surgery in urology is definitely incorporated to the techniques of minimally invasive treatment for urogenital diseases. Though the classic access to organs in the urinary tract is extraperitoneal, this access has not been prioritized when the videoendoscopic technique is used. In Brazil, few groups use this approach and little has been discussed about its true practical applicability. The authors intended to discuss the main technical aspects and criteria for indication, reported though the improvement achieved in a 5-year period with 150 operated cases. A review of the literature shows that the worldly acceptance of the extraperitoneal endoscopic approach is increasing. Nevertheless, there are no evidences that the extraperitoneal access is superior to the transperitoneal route. Thus, the choice depends basically on the surgeon's preference. Major advantages are the immediate access to the renal hilum and isolation of peritoneal structures. Employing this access is useful when one suspects that significant peritoneal adherences could prevent the surgical act or when one wishes to preserve the integrity of the peritoneal cavity.

Laparoscopy for the diagnosis and treatment of radiologically occult but symptomatic hypoplastic kidneys

OBJECTIVES

To evaluate the efficacy of different imaging modalities for visualization of small poorly functioning hypoplastic and dysplastic kidneys and to assess the role of laparoscopy in localization and treatment.

METHODS

Between 1998 and 2002, 10 female patients who presented with urinary incontinence, flank pain, or hypertension secondary to small, poorly functioning hypoplastic or dysplastic kidneys were treated at our institute. We reviewed the results of the imaging studies, cystoscopy, and evaluation under anesthesia for these patients. After the diagnosis, all patients were treated with laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy.

RESULTS

Intravenous urography and ultrasonography failed to visualize the affected renal units in all 10 cases. Computed tomography could locate small dysplastic renal units in only 5 patients (50%). Dimercaptosuccinic acid renal scintigraphy was diagnostic in all 10 cases (100%). Magnetic resonance urography was done in 2 cases only, and the affected renal units were identified in both. Cystoscopy and vaginoscopy were inconclusive in all but 2 cases. Laparoscopy efficiently located the offending renal units in all 10 cases. In 9 cases, the affected renal units were located in the lumbar region, and in 1 case it was situated ectopically in the pelvis. All 10 patients underwent laparoscopic retroperitoneal or transperitoneal nephroureterectomy or nephrectomy and were asymptomatic after surgery.

CONCLUSIONS

Dimercaptosuccinic acid scintigraphy is an accurate and specific imaging modality for visualization of small hypoplastic renal units that are not visualized by conventional radiologic imaging techniques. Laparoscopy can be recommended as the ideal method of management, because it provides a minimally invasive technique for detecting the kidney and simultaneously correcting the problem.

Multiple intravesical linear staples identified during surveillance cystoscopy after laparoscopic nephroureterectomy

Laparoscopic nephroureterectomy has faced technical criticism secondary to the unknown effects of urine-exposed intravesical or intraureteral staples. Although not reported, staples exposed to urine theoretically create a nidus for encrustation and stone formation. We present a case of a 66-year-old man after left laparoscopic ureterectomy for ureteral malignancy. Surveillance cystoscopy at 6 months revealed a nearly complete intravesical titanium staple line without encrustation. Successful transurethral removal of all staples with standard cystoscopic graspers revealed no immediate, or delayed, sequelae.

Pretransplant native nephrectomy in patients with end-stage renal failure: assessment of the role of laparoscopy

OBJECTIVES

To evaluate the outcome and morbidity of laparoscopic nephrectomy in patients with end-stage renal disease.

METHODS

Between August 1991 and September 2001, 64 laparoscopic nephrectomies were carried out for the native kidneys of 62 patients with end-stage renal failure. The procedures were performed in preparation for renal transplantation. The indications were vesicoureteral reflux with persistent or recurrent urinary tract infection in 26 renal units, uncontrolled hypertension in 15, chronic pyelonephritis or hydronephrosis with urinary tract infection in 8, renal calculi in 13, heavy proteinuria in 1, and small renal tumor in 1. The left side was removed in 52 procedures and the right side was removed in 12. Forty-eight and 16 renal units were removed through the retroperitoneal and transperitoneal approach, respectively.

RESULTS

Sixty procedures were successfully performed (94%). Four patients required open exploration (6%). Four major complications were recorded: pneumothorax in 1, large hematoma in 1, colonic injury in 1, and bleeding in 1. No mortality related to the procedures or their complications occurred. The patients received allograft transplantation shortly after the procedure, with a mean of 26 days. Both transperitoneal and retroperitoneal approaches were effectively used with satisfactory outcome.

CONCLUSIONS

Laparoscopy should be considered as the procedure of choice for pretransplant nephrectomy. The high success rate, low morbidity, early recovery, and short duration between nephrectomy and transplantation all are considered as real advantages for this patient population.

Retroperitoneoscopic extirpation for adult multicystic calcified dysplastic kidneys with contralateral ureteral abnormalities mimicking genitourinary tuberculosis

PURPOSE

To identify adult multicystic calcified dysplastic kidneys (AMCDK) with contralateral ureteral abnormalities mimicking urinary tuberculosis and to evaluate the feasibility and efficacy of retroperitoneoscopic extirpation in their management.

PATIENTS AND METHODS

We retrospectively identified a group of adult patients who were referred to us as having unilateral nonfunctioning kidney containing calcified cystic masses with a contralateral normally functioning kidney along with segmental dilation of ureter. Two patients had histories of treatment elsewhere with antitubercular drugs on the basis of imaging studies, before being referred to our center for retroperitoneoscopic nephrectomy with a diagnosis of nonfunctioning left kidneys and urinary tuberculosis. The other two cases with similar findings on imaging studies were detected incidentally while the patients were undergoing investigations for vague abdominal symptoms.

RESULTS

All these patients had AMCDK on the left side and a contralateral normally functioning kidney with ureteral abnormality. Retroperitoneoscopic extirpation of the nonfunctioning left renal unit was carried out uneventfully with a mean operating time, blood loss, and hospital stay of 124 minutes, 80 mL, and 3 days, respectively. There were no complications. The dissection in these cases was difficult, as the dysplastic calcified kidney was plastered in the retroperitoneum.

CONCLUSION

Unilateral AMCDK with contralateral segmental dilation of the ureter may be separate entity or a coincidental finding, and it should not be confused with urinary tuberculosis unless there is microbiological and radiologic or histopathologic evidence of infection. Minimally invasive surgery in the form of retroperitoneoscopic extirpation is feasible, safe, and effective in such cases, although difficult, and it requires skills as well as experience.