Bench Surgery Research Articles

Bench Surgery With Renal Autotransplantation for Angiomyolipoma of Renal Sinus

BackgroundThe treatment of angiomyolipomas (AML) of the renal sinus is challenging and often requires nephrectomy. In this study, we report on 5 patients who underwent extracorporeal AML resection and subsequent renal autotransplantation (RA) for renal sinus AML. MethodsAs of May 2013, 5 patients had undergone extracorporeal AML resection and RA for renal sinus AML at our institute. Separation of the AML in renal sinus is performed by combined sharp and blunt dissection. Tissue between AML and renal sinus is ligated where blood vessels cannot be excluded. When complicated with AML of the renal parenchyma, the AMLs were resected using ultrasound guidance. ResultsRenal nuclear scan showed that kidney grafts were perfused uniformly without evidence of segmental infarction at day 7 posttransplantation in all patients. No significant deterioration in renal function and tumor recurrence was noted over a median follow-up of 3 months (range: 1 to 6 months). All patients presented with normal blood pressure values. No intraoperative complications occurred. ConclusionsBench surgery and subsequent RA method, due to its advantage of kidney preservation, is a valuable option for renal sinus AML treatment.

V47 An experimental model for training in renal transplantation surgery with human cadavers preserved with W. Thiel embalming technique

RESULTS: Overall, 9 cadavers were used with 17 grafts transplanted. Kidney procurement in human cadavers preserved using Thiel’s embalming technique was performed following the conventional protocol; en bloc nephrectomy with the trunk of aorta and inferior vena cava. Bench surgery was performed, perfusing artery with saline and checking vascular permeability. Once suitability is established, RT was performed as is done in clinical practice. This embalming method enables tissue dissection that is comparable to the living body and provides suitable conditions for realistic RT simulation; handling human tissues and vessels in the same surgical field as the clinical scenario. This experimental model approximates to in vivo RT, providing a realistic and interesting learning to inexperienced surgeons. Overall, participants held a positive view of the cadaver sessions, believed them to be useful in their daily practice, and

Anaesthesia for autotransplantation after extracorporeal nephron sparing surgery for bilateral giant renal angiomyolipoma

Extracorporeal ‘work bench surgery’ with subsequent autotransplantation is a challenge from both anaesthetic and surgical point of view when performed bilaterally or in a solitary kidney. A 28-year-old female with bilateral giant angiomyolipoma of kidneys was taken up for renal autotransplantation. Patient had a huge tumour, which was the largest reported exophytic tumour to be excised by this technique. Both kidneys were operated at an interval of 1 month, under combined general and epidural anaesthesia. Anaesthetic challenges faced during the procedure were maintenance of adequate perfusion of the grafted kidneys, containment of massive blood loss and coagulopathy during the perioperative period. Patient recovered in due course with functioning autotransplanted kidney. A careful pre-operative preparation with intraoperative maintenance of adequate blood volume and blood pressure is the key for graft survival.

A new veno-venous bypass type for ex-vivo liver resection in dogs

Ex-vivo liver resection is a procedure in which the liver is completely removed, perfused and after bench surgery, the liver is autotransplanted to the original site. Ex-vivo liver resection is an important treatment for unresectable liver tumors. This surgical procedure requires long operation time, during which blood flow must be carefully maintained to avoid venous congestion. An effective veno-venous bypass (VVB) may meet this requirement. The present study was to test our new designed VVB device which comprised one heparinized polyvinylchloride tube and three magnetic rings. The efficacy of this device was tested in five dogs. A VVB was established in 6–10 minutes. There was no leakage during the procedure. Hemodynamics was stable at anhepatic phase, which indicated that the bypass was successful. This newly-developed VVB device maintained circulation stability during ex-vivo liver resection in our dog model and thus, this VVB device significantly shortened the operation time.

Kidneys From Donors With Incidental Renal Tumors

The increase in the prevalence of end-stage renal disease in developed countries and the shortage of deceased donors has made it necessary to increase the graft pool by means of several strategies, such as live donation, non-heart-beating donors, and expanded criteria donors. Frequently, and because of the increasing acceptance of older donors, we find a higher percentage of incidental renal masses in these donors as a result of the inherent epidemiology of this disease. These kidneys can be considered suitable grafts after bench surgery to remove the tumor. Retrospective analysis of donors with a diagnosis of incidental small renal mass before implantation and their corresponding recipients was performed between January 2007 and September 2012. All cases underwent an ex vivo tumorectomy with a preoperatory pathologic analysis. Recipients were followed up according to our standard renal tumor protocol. Eight donors with incidental renal mass were detected (four live and four deceased donors). The mean age was 47.8 years. Eleven transplantations were performed. Eight cases received the kidney after tumor exeresis, and three, the contralateral one. The recipient mean age was 53.8 years.The mean tumor diameter was 14.8 mm, with pathologic stages pT1a in seven cases and pT1b in one case (five clear cell renal carcinoma, two chromophobe type, and one lipoma). Surgical margins were negative. Mean follow-up was 32.34 months; none of the patients presented tumor recurrence, and all had correct renal function. Kidneys with small incidental tumors can be considered an option for kidney transplantation in selected patients.

Standard liver volume estimation in Indian population: Need for an accurate formula

Abstract Background Liver transplantation is the most durable treatment option for ESLD. Due to acute shortage of cadaveric organs Living donor liver transplantation has gained momentum especially in Asian countries. Size of the liver graft or the remnant liver is often expressed as a percentage of the standard liver volume (SLV) of the patient. Various formulas for SLV have been derived but only Chandramohan formula is derived for Indian population. Our aim was to carry out a study to validate the Indian formula based on the actual liver volumes (ALV) that we got from the cadaveric donor livers. Material and methods This prospective study included 33-brain dead cadaveric donor of either sex. Body surface area was calculated by Mosteller's formula. Graft weight was measured after the bench surgery. Standard liver volume was calculated by formula derived by Chandramohan et al and compared with actual liver weight. Result Chandramohan formula underestimates actual liver weight in Indian population. With our data we derived a formula for standard liver volume for Indian population. Conclusion No accurate formula of SLV for Indian population. We attempted to derive a formula for SLV for Indian population. However our data is very limited needs larger cohort for proper estimation.

V1079 BILATERAL EX-VIVO NEPHRON SPARING SURGERY AND AUTOTRANSPLANTATION FOR GIANT BILATERAL RENAL ANGIOMYOLIPOMA

You have accessJournal of UrologyRenal Oncology1 Apr 2013V1079 BILATERAL EX-VIVO NEPHRON SPARING SURGERY AND AUTOTRANSPLANTATION FOR GIANT BILATERAL RENAL ANGIOMYOLIPOMA George Abraham, R Krishnamohan, Avinash Siddaiah, Datson George, Jisha Abraham, Oppukeril Thampan, and Krishanu Das George AbrahamGeorge Abraham Kochi, India More articles by this author , R KrishnamohanR Krishnamohan Kochi, India More articles by this author , Avinash SiddaiahAvinash Siddaiah Kochi, India More articles by this author , Datson GeorgeDatson George Kochi, India More articles by this author , Jisha AbrahamJisha Abraham Kochi, India More articles by this author , Oppukeril ThampanOppukeril Thampan Kochi, India More articles by this author , and Krishanu DasKrishanu Das Kochi, India More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.670AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Management of large bilateral renal tumors generally involves bilateral nephrectomy followed by renal transplantation at later date bridging the waiting period with hemodialysis. These treatment options are associated with problems like critical shortage of kidney donations suitable for transplantation, significant reduced quality of life, high morbidity and mortality and high cost involved in these procedures. In view of these drawbacks there is resurgent interest in bench dissection and autotransplantation in recent years. In exceptional situations, bench surgery followed by autotransplantation may be indicated. We present video demonstration of bilateral ex-vivo nephron sparing surgery and autotransplantation for giant bilateral renal angiomyolipoma. METHODS Twenty eight old female patient presented with bilateral flank mass associated with intermittent pain of 5 years duration. Per abdomen examination revealed bilateral large lumbar mass extending up to iliac region. Renal parameters were normal. Computerised tomography scan revealed bilateral large angiomyolipoma. Treatment options were discussed with the patient. Angioembolisation was not feasible in view of large size, multiple vessels supplying tumor and poor demarcation between tumor and normal renal parenchyma in the imaging. After explaining risk and outcome, bilateral nephrectomy, bench dissection and autotransplantation was planned. First, left nephrectomy, bench dissection with nephron sparing surgery and autotransplantation was conducted. After 4 weeks interval procedure was repeated on the right side. Operative, postoperative and follow up details were recorded. RESULTS Total operation duration was 6 and 8 hours, blood loss was 200 and 230 ml, tumor size was 30x15 cms and 26x18 cms, tumor weight was 3 and 2.8 kilograms for left and right tumors respectively. Orals started after 24 hours, hospital stay was 5 days following both surgeries. Serum Creatinine was 1.4 and 1.5 mg/dl on 5th postoperative day and at 1 month follow up respectively.Follow up magnetic resonance imaging with angiogram showed good perfusion of left autotransplanted remnant kidney. CONCLUSIONS Ex-vivo nephron sparing surgery and autotransplantation for large renal angiomyolipoma is feasible with satisfactory renal functional outcome. Morbidity, poor quality of life and high cost involved in renal replacement therapy can be avoided with this procedure in selected cases. However this surgically challenging procedure should be regarded as the last resort. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e443 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information George Abraham Kochi, India More articles by this author R Krishnamohan Kochi, India More articles by this author Avinash Siddaiah Kochi, India More articles by this author Datson George Kochi, India More articles by this author Jisha Abraham Kochi, India More articles by this author Oppukeril Thampan Kochi, India More articles by this author Krishanu Das Kochi, India More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Uso de los cianoacrilatos en el sellado de las biopsias renales en la cirugía de procuración del trasplante renal

Introduction and objectiveCyanoacrylate surgical glues have been widely used for sealing and hemostasis in distinct surgical specialties and interventions. In urology, these glues are highly useful in sealing surgical sutures to prevent bleeding and urinary extravasation in urinary tract surgery. We describe a new application of cyanoacrylate surgical glue: sealing renal graft biopsy during bench surgery in renal transplantation. MethodsWe applied several drops of Glubran ®2 surgical glue (N-butyl-2-cyano-acrylate and methacryloxysulfolane) over the orifice of the graft biopsy at bench surgery. The glue was left to set for 90s until completely polymerized, leaving the biopsy cavity completely sealed. ResultsWe have used this procedure successfully since 2010. Cyanoacrylate polymerizes rapidly on contact with the renal tissue and is therefore ideal to reduce cold ischemia time. Among the 194 kidney transplantations performed, there was no active bleeding at the biopsy site on graft reperfusion, nor in any of the subsequent Doppler ultrasound follow-up examinations. ConclusionsRenal biopsies are usually closed using a cruciate suture pattern. In our center, we prefer sealing with cyanoacrylate adhesive. This method avoids parenchymal laceration and bleeding after reperfusion. In our experience, this alternative is safe and effective.

Video Clip for Continuous Medical Education(Cme) of Operation Theater Nurse in the Field of Living Donor Liver Transplatation

Continuing medical education(CME) for nursing activity in operating theater has important role to enhance the safety of patient as well as work efficiency. For CME, various types of program including lecture, test, publication, etc can be employed. However, well-made video clip can provide much enlightenment about the surgical procedure. It is an additional advantage of video clip in CME that it can be used for self-learning program. In our institution, annual more than 300 cases of living donor liver transplantation(LDLT) have been performed. Therefore, the number of nurse requiring education about became more and more. For the CME of operating theater nurse, we made video clip containing motion picture describing detail procedure of LDLT. In 2007, we made the video clip of LDLT for donor at first. The clip for donor contains motion picture and animation which is divided into 7 steps including preparation of instrumental table, the procedure of hepatectomy, bench surgery, thawing of cryopreserved allograft vessel, measures for patient safety and the management of equipment. The running time was 43 minutes. In 2010, the video clip of recipient surgery was made. The running time is also 43 minutes. It contains preparation of instrumental table, the procedure of recipient hepatectomy, implantation procedure and handling of extra-corporeal bypass pump machine. We handed out this video clip to operating theater nurses and visiting nurse from foreign country. During 4 years, we have got feed-back from users of this video clip and plan to update contents. And we anticipate that this video clip will contributes to enhance the actual quality of nursing activity in operating theater.

The Use of Iliac Y-Graft for Arterial Revascularization in Simultaneous Double-Kidney Transplantation

Double-kidney transplantation (DKT) has gained popularity because of results comparable with single-kidney transplantation when applied to marginal old-age donors, aiming at expanding the donor’s pool (1). Initially, the surgical technique of DKT consisted of placing the kidneys by two separate surgical incisions in the right and left iliac groin and performing vascular anastomosis on both the right and left iliac vessels (2, 3). Thereafter, Ekser et al. (4) described the monolateral access, transplanting both kidneys in the right iliac groin with a single surgical incision, and using the right iliac vessels for double venous and arterial anastomoses. The monolateral access has comparable results for graft function, with clear advantages for shorter operative time and leaving the left side untouched for an eventual retransplantation (5). However, this approach always requires two separate arterial anastomoses on the same iliac vessel to provide blood inflow to both grafts. Because well-known patients with chronic kidney disease are affected by severe and diffuse atherosclerotic lesions and many recipients of DKT are older than single-transplant recipients on dialysis for many years before, performing double arterial anastomoses, with two arteriotomies, on the same iliac artery can be risky and challenging because of the high probability of encountering severe atherosclerotic damage (6, 7). To overcome this problem, we developed a new technique of arterial anastomosis adopted from the experience of pancreas transplantation, using a donor’s interposed iliac Y-graft anastomosed during back-table surgery to the renal arteries of both grafts in an end-to-end fashion. This technique allowed performing a single anastomosis on the recipient’s external iliac artery, avoiding additional arterial anastomosis and thereby theoretically reducing the risk of vascular complication on the recipient’s atherosclerotic vessels. Moreover, another advantage of this approach could be the reduction of cold ischemia time of the second kidney and the possibility to revascularized simultaneously both grafts. Finally, also in the presence of more than one renal artery on a separate patch, the additional artery can be anastomosed to the bifurcation of the internal iliac artery of the Y-graft, providing a careful retrieval of the Y-graft including the internal iliac artery. A single venous anastomosis was performed on the external iliac vein of the recipient; in all cases, the left renal vein was reimplanted on the vena cava during bench surgery in the same way as previously described by Nghiem (8). Since now, we applied this approach without encountering any problem or complications related to back-table reconstruction of the renal arteries on the Y-graft (Fig. 1). The only limitation to the widespread use of this technique is the availability of the Y-graft not affected by atherosclerotic lesions, easily and safely usable for back-table reconstruction, which is not always possible in old-age marginal donors.FIGURE 1: Arterial anastomosis using a donor’s iliac y-graft.

2273 FATE OF THE ACCESSORY RENAL ARTERIES OF GRAFTS WITH MULTIPLE RENAL ARTERIES DURING LIVE-DONOR RENAL ALLO-TRANSPLANTATION

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery II1 Apr 20122273 FATE OF THE ACCESSORY RENAL ARTERIES OF GRAFTS WITH MULTIPLE RENAL ARTERIES DURING LIVE-DONOR RENAL ALLO-TRANSPLANTATION Ahmed Harraz, Ahmed Shokeir, Ibrahim Shalaby, Shady Soliman, Ahmed El-Hefnawy, Mohamed Kamal, Ahmed Kamal, and Mohamed Ghoneim Ahmed HarrazAhmed Harraz Mansoura, Egypt More articles by this author , Ahmed ShokeirAhmed Shokeir Mansoura, Egypt More articles by this author , Ibrahim ShalabyIbrahim Shalaby Mansoura, Egypt More articles by this author , Shady SolimanShady Soliman Mansoura, Egypt More articles by this author , Ahmed El-HefnawyAhmed El-Hefnawy Mansoura, Egypt More articles by this author , Mohamed KamalMohamed Kamal Mansoura, Egypt More articles by this author , Ahmed KamalAhmed Kamal Mansoura, Egypt More articles by this author , and Mohamed GhoneimMohamed Ghoneim Mansoura, Egypt More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2451AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Donor grafts with multiple arteries are accepted alternative with equivalent outcome to grafts with single renal arteries. We aim at determining the effect of occlusion of the accessory artery on early graft function and delineating factors predicting occlusions of the accessory artery. METHODS A retrospective review of 731 consecutive live-related renal transplants was conducted between November 2002 and January 2011. A total of 105 consecutive grafts with multiple renal arteries were identified. The patency of the accessory artery was evaluated using Doppler US and MRA done at postoperative period. The frequency of patency was correlated with renographic clearance to delineate the effect on graft function. Factors predicting occlusion of the accessory artery were studied using univariate and multivariate analyses. RESULTS Doppler US diagnosed occlusion of the accessory arteries in 11 (10.5%) out of 105 grafts at a mean and median (range) of 8 and 9 (1-21) days post-transplantation, respectively. Mean ± SD and median (range) of renographic clearance of grafts with occluded accessory arteries were 50.5 ± 26 and 40 (21-92) ml/min while those of grafts with patent accessory arteries ware 68.6 ± 18.9 and 67.2 (21-117) (p<0.01). The percentage change of renographic clearance before and after transplantation has increased for grafts with patent arteries and decreased for grafts with occluded arteries (p=0.03). On multivariate analysis, factors predicting the occlusion of the accessory artery were delayed graft function (OR= 9.9, 95% CI= 1.6-58.6, p=0.01) and upper polar location of the accessory artery (OR=8.9, 95% CI= 1.8-43.4, p<0.01). On the other hand, the site of anastomosis (to major or inferior epigastric arteries) or anastomosing the artery to the main artery (bench surgery) had not affected the patency. Further analysis showed that the mean ± SD of the diameter of the upper polar arteries was 0.14 ± 0.09 cm and those of the hilar and lower polar arteries were 0.2 ± 0.06 and 0.2 ± 0.08, respectively (p=0.03). CONCLUSIONS Occlusion of the accessory renal artery has a negative impact on the early graft function. When considering grafts with accessory arteries, grafts with upper polar arteries should be paid the greatest attention and efforts should be exerted to avoid delayed graft function. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e917 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Harraz Mansoura, Egypt More articles by this author Ahmed Shokeir Mansoura, Egypt More articles by this author Ibrahim Shalaby Mansoura, Egypt More articles by this author Shady Soliman Mansoura, Egypt More articles by this author Ahmed El-Hefnawy Mansoura, Egypt More articles by this author Mohamed Kamal Mansoura, Egypt More articles by this author Ahmed Kamal Mansoura, Egypt More articles by this author Mohamed Ghoneim Mansoura, Egypt More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Third and Fourth Kidney Transplant: Still a Reasonable Option

Introduction At present, a second kidney transplant is considered an established therapeutic option for patients who have lost a previous graft. Second transplants show similar graft survival as first transplants. A debate exists about the benefit of submitting the patient to a third or fourth renal transplant, or to maintain dialysis. Objective We sought to analyze graft and patient survivals as well as associated variables and surgical complications of third and fourth transplantations. Material and Methods From July 1985 to December 2008, we performed 74 third and 8 fourth transplantations among 2763 cases. We prospectively collected the variables of age, gender, graft origin, hyperimmunization, time on dialysis, location, bench surgery, acute rejection episodes, graft survival, and operative complications. Results Third and fourth trasplantations were performed in 49 men and 33 women, with an overall mean age of 40.26 years who were on dialysis for an average of 126.89 months before transplantation. Mean graft survivals of their first and second grafts were 35.6 and 50.1 months, respectively. Acute or chronic rejection was reason for renal failure in 71% and 75% of cases, respectively. Patient survivals at 1 and 5 years were 92.7% and 90.6%, for third and both 85.7% for the fourth transplantation. The third and fourth transplantations showed 1- and 5-year graft survivals of 88% and 76.4% and 71.4% and 42.9%, respectively. Sixty-eight cases underwent cadaveric donor and 14 living donor (mean age, 42.1 years) transplantations. Nine patients were hyperimmunized. In 60 cases, we used the left kidney. Orthotopic kidney transplantation was performed in 15 cases; heterotopic transplant to the right iliac fossa in 40 and in the left iliac fossa in 17 cases. Arterial bench surgery was necessary in 6 cases and venous in 3. We performed 3 hepatorenal and 1 cardiorenal transplantation. The complications included 29 cases (35.4%) of postoperative acute tubular necrosis, 14 of acute rejection episodes (17.1%); 12 of perirenal hematoma (14.6%); 1 urinary fistula (1.2%); 4 lymphocele (4.9%); 2 ureteral stenosis (2.4%); variables arterial kink requiring surgery (1.2%), and 1 venous thrombosis with graft loss (1.2%). The 4 patients who died in the perioperative period succumbed to intravascular disseminated coagulation ( n = 1) cardiac failure ( n = 2), and septic shock ( n = 1). Induction antibody therapy, hyperimmunized status, or operative complications were not independent prognostic factors for patient or graft survival. Conclusions Third or fourth renal transplantations constitute a valid therapeutic option with reasonable short- and long-term patient and graft survivals. Although orthotopic kidney transplantation was used in selected patients, we preferred an iliac fossa approach for most.

Bench Surgery in Right Kidney Transplantation

The problems deriving from the anatomic differences between the two harvested kidneys make the bench surgery necessary to solve some technical difficulties in transplantation. This condition is particularly real in the case of right kidney transplantation, especially in presence of arterial anomalies. In this study, we focused our attention on venous reconstruction in cases of short renal right veins. In 3 years, we performed 55 consecutive cadaveric renal transplants in patients with an end-stage chronic renal insufficiency. The right kidney was used in 30 patients, eight of whom had two or more arteries attached to a single aortic patch, and 22 had a single artery. In these right transplanted kidneys, the elongation of renal vein was performed end-to-side to the external iliac vein, reconstructing a “T-patch” (angular reconstruction) in 28 patients and a “linear” one in two cases. The vascular anastomoses had no thrombotic problems. We have followed the progress of the patients for more than 2 years; no one has lost the graft due to chronic rejection or other complications. In conclusion, elongation of the right renal vein with a T-patch constitutes a feasible, physiological procedure without vascular complications or apparent reverberations for graft blood flow.

Editorial Comment on: Assessing the Impact of Ischaemia Time During Partial Nephrectomy

[51] Lane BR, Gill IS. 5-year outcomes of laparoscopic partial nephrectomy. J Urol 2007;177:70–4. [52] Porpiglia F, Renard J, Billia M, et al. Is renal warm ischemia over 30 minutes during laparoscopic partial nephrectomy possible? One-year results of a prospective study. Eur Urol 2007;52: 1170–8. [53] Shekarriz B, Shah G, Upadhyay J. Impact of temporary hilar clamping during laparoscopic partial nephrectomy on postoperative renal function: a prospective study. J Urol 2004;172:54–7. [54] Nguyen MM, Gill IS. Halving the ischemia time during laparoscopic partial nephrectomy. J Urol 2008;179:627–32. [55] Bollens R, Rosenblatt A, Espinoza BP, et al. Laparoscopic partial nephrectomy with ‘‘on-demand’’ clamping reduces warm ischemia time. Eur Urol 2007;52:804–10. [56] Baumert H, Ballaro A, Shah N, et al. Reducing warm ischaemia time during laparoscopic partial nephrectomy: a prospective comparison of two renal closure techniques. Eur Urol 2007;52: 1164–9. [57] Gill IS, Abreu SC, Desai MM, et al. Laparoscopic ice slush renal hypothermia for partial nephrectomy: the initial experience. J Urol 2003;170:52–6. [58] Steffens J, Humke U, Ziegler M, Siemer S. Partial nephrectomy with perfusion cooling for imperative indications: a 24-year experience. BJU Int 2005;96:608–11. [59] Humke U, Uder M. Renovascular hypertension: the diagnosis and management of renal ischemia. BJU Int 1999;84:555–69. [60] Kemmer H, Siemer S, StockleM. Nephrectomy, work bench surgery, and autotransplantation: a case of a solitary left kidney with an extensive centrally located renal cell carcinoma and a tumour thrombus entering the vena cava. Eur Urol 2007;52:1518–20. [61] Janetschek G. Laparoscopic nephron sparing surgery: ischemic renal damage. Curr Opin Urol 2006;16:45–6. [62] Janetschek G, Abdelmaksoud A, Bagheri F, Al-Zahrani H, Leeb K, Gschwendtner M. Laparoscopic partial nephrectomy in cold ischemia: renal artery perfusion. J Urol 2004;171:68–71. [63] Landman J, Rehman J, Sundaram CP, et al. Renal hypothermia achieved by retrograde intracavitary saline perfusion. J Endourol 2002;16:445–9. [64] Landman J, Venkatesh R, Lee D, et al. Renal hypothermia achieved by retrograde endoscopic cold saline perfusion: technique and initial clinical application. Urology 2003;61:1023–5. [65] Orvieto MA, Zorn KC, Mendiola F, et al. Recovery of renal function after complete renal hilar versus artery alone clamping during open and laparoscopic surgery. J Urol 2007;177:2371–4.

Arteriovenous fistula in an autotransplanted kidney segment: Successful angiographic management

Autotransplantation is a management option in complex renal or ureteral diseases. This report describes a case of bilateral renal cell carcinoma treated with partial nephrectomy using bench surgery followed by a contralateral total nephrectomy. This procedure was complicated by an arteriovenous fistula in the transplanted segment that was successively embolized angiographically.

Successful Ex-Vivo Repair of an Intrahilar Renal Artery Aneurysm with Autotransplantation

Renal artery aneurysm (RAA) is an unusual vascular disease. Few vascular surgeons have extensive experience with clinical management of RAA.Considerable confusion persists concerning its incidence, cause, and clinical importance. Due to lack of controlled clinical data, controversy also persists regarding the indication for treatment of asymptomatic RAA.We report the case of 46-year-old gentlemen who was found to have a 3.4cm aneurysm of the left renal artery during the course of ultrasonography for non-specific abdominal pain and to have hypertension on routine examination. The aneurysm was successfully repaired by ex-vivo bench surgery and auto-transplantation.

In Situ Elongation Patch in Right Kidney Transplantation

Background A short right renal vein complicates transplantation causing traction and difficulties during anastomosis. When we perform a kidney transplantation from a cadaveric donor, this problem may be resolved by using the vena cava to create a venous duct. This elongation technique is proposed to be performed during bench surgery. We propose a small change in the technique: execution of an “elongation patch” during harvesting and under cold perfusion. Materials and Methods From January 2004 to June 2006, we performed 12 in situ (during the harvesting procedure) vena cava elongation patches. In these cases, the right renal vein was too short. The elongation patch was used in only 8 transplantations. In the other 4 cases we sacrificed the patch to perform a direct venous anastomosis due to favorable recipient anatomical characteristics. Results The 8 transplantations performed with the elongation patch did not show vascular complications and the venous anastomosis was easy to perform. Conclusions The “extension patch” was not associated with a greater incidence of vascular complications. Using the elongation patch during the harvest showed some advantages: performed during cold perfusion with a reduction in bench ischemia; the anatomical relationships are preserved so we can perform a calibrated suture; the perfusion of the organ allows us to observe the integrity of the anastomosis. This technique did not significantly increase the harvesting time.

Kidneys from patients with small renal tumours: a novel source of kidneys for transplantation

To report the use of a novel donor source as a further option to increase the number of patients who might be able to receive a renal transplant. Between May 1996 and July 2007, 43 kidneys were transplanted using kidneys obtained from patients with small (<3 cm diameter) incidentally detected tumours. After bench surgery to excise the tumour, they were all successfully transplanted into patients who were elderly or had significant comorbidities. Apart from four patients who died from unrelated illnesses, all grafts continued to function with a median and mean follow-up of 25 and 32 months. The follow-up, which included 3-monthly renal ultrasonography and chest X-rays, showed only one case of tumour recurrence, which occurred 9 years after transplantation; the patient remains stable under observation after 18 months. From our experience we consider that where nephrectomy is used for small, localized, incidentally detected renal tumours, the kidney should be considered for transplantation into carefully selected patients. Such patients with numerous medical comorbidities might benefit from renal transplantation, but not survive the waiting period if they are dependent on a deceased donor graft. Paradoxically the use of these marginal kidneys has the potential to increase the quality and length of life of these patients, despite the apparent contradiction of an intuitive principle of organ transplantation and immunosuppression.

Enucleación extracorpórea y autotransplante en paciente con riñón único con cáncer renal multicéntrico de células claras

To demonstrate that "bench surgery" and autotransplantation are still alternatives in the treatment of complex renal cancer cases. 58 y/o female with history of radical nephrectomy due to renal cancer who asked for medical attention because of back pain. Renal masses were found during her evaluation and she was referred to our service. Lumbar incision was the preferred approach. After removal, the kidney was irrigated with EuroCollins solution and bench surgery was performed. Cold ischemia time was 63 minutes. The kidney was transplanted into the right pelvic region. Diuresis was immediately achieved after vascular anastomosis. Lich-Gregoir ureteral implant was carried out. During the first 48 hrs no complication was reported, urine output was about 80 cc/hour. She eventually developed renal failure and after 6 sessions of hemodialysis recovered to void in the previous volume range. She had a urinary leak that was resolved with CFT-guided percutaneus drainage. Twelve months after the procedure, she has no complaints; serum creatinine is 1.6 mg/dl and CT scan shows no evidence of recurrences. Bench surgery is still a therapeutic alternative for the treatment of complex renal cancer cases in order to avoid dialysis.

Autotrasplante renal: Una alternativa válida en la resolución de casos complejos

To analyze the current indications for renal autotransplantation, as well as the technical features, complications and long-term follow-up of the technique. From 1990 to 2005 we have performed autotransplantation in 10 patients, 7 adults and 3 children. The indication was established due to vascular pedicle pathology in 8 cases and ureteral lesion in 2. The cause of vascular pathology was: atherosclerotic stenosis (4), dysplastic stenosis (2), Takayasu's disease stenosis (1), and renal artery aneurysm (1). The patients with ureteral lesion had ureteral stenosis secondary to Crohn's disease in one case, initially solved by ureteral stent and subsequently obstructed by lithiasic encrustation, and ureteral avulsion in the other case. The vascular grafts employed in the 8 cases with vascular reconstruction were: hypogastric artery 7 cases, and sophena vein in one case. Ureteral reimplantation was necessary in 5 cases after bench surgery; in other five cases vascular reconstruction was performed without ureteral division. All grafts were perfused with 4 degrees C lactate ringer or Wisconsin solution and protected with surface cold ischemia. Ischemia times ranged from 42 to 89 minutes. Nine kidneys (90%) functioned after autotransplantation, 8 of them had immediate function, and one had delayed graft function after a six-day period of acute tubular necrosis. The kidney with arterial stenosis secondary to Takayasu's disease never functioned. The cause of graft loss was renal vein thrombosis. Postoperative mortality was zero. After a mean follow-up of 72+/- 13 months mean serum creatinine is 1.6+- 0.4 mg/dl (1.1-2.4) and 70% (7/10) of the patients have normal blood pressure without antihypertensive medication. Currently, renal autotransplantation, with or without extracorporeal vascular reconstruction, is a complex technique with exceptional indications, but it allows recovering renal units with vascular pathology not amenable to angioplasty or in situ revascularization. It is also a valid alternative to ileal ureteral substitution in cases of extensive ureteral lesion.