Mean Postoperative Serum Creatinine Research Articles

Modified robot-assisted laparoscopic dismembered pyeloplasty for adult patients with horseshoe kidney: techniques and medium-term outcomes.

The aim of this study was to report our technique and medium-term outcomes of modified robot-assisted laparoscopic dismembered pyeloplasty (RALDP) in the Lithotomy Trendelenburg position for treating adult ureteropelvic junction obstruction (UPJO) with horseshoe kidney (HSK). Between March 2021 and March 2023, 11 adult patients with UPJO and HSK underwent modified RALDP in the lithotomy Trendelenburg position. Patient demographic characteristics, perioperative parameters, and follow-up outcomes were collected prospectively and analyzed. A detailed description of the technique and medium-term outcomes were reported. The median (range) age was 33 (23-50) years. The mean preoperative serum creatinine and preoperative estimated glomerular filtration rate (eGFR) were 74.72±16.20 μmol/L and 100.4±16.5 mL/min/1.73 m2, respectively. One patient (9.1%) required an additional right pyelolithotomy. The mean operative duration was 208±70 min. The median (range) estimated blood loss was 20 (20-100) mL. The median (range) drainage-tube removal time was 3 (2-4) days postoperatively. The median (range) postoperative hospitalization period was 5 (3-6) days. No open conversions or intraoperative complications occurred. Postoperative urinary tract infections (Clavien-Dindo grade II) occurred in two patients, managed with oral antibiotics. The median (range) follow-up of 25 (12-36) months achieved an overall success rate of 100%. The mean postoperative serum creatinine and postoperative eGFR were 74.96±17.43 μmol/L and 98.14±18.39 mL/min/1.73 m2, respectively. Our medium-term outcomes indicate that the modified RALDP in the Lithotomy Trendelenburg position was safe and feasible for adult HSK patients. Further prospective studies of larger sample sizes and randomized controlled trials are warranted.

Modified percutaneous nephropexy for nephroptosis: Technical description and short-term results

Abstract Objectives Percutaneous nephropexy (PCN) has been demonstrated as a feasible method for treating nephroptosis. This study describes an improved technique for PCN that better addresses the issue of nephroptosis. Materials and methods We reviewed 4 patients who underwent the improved PCN procedure between January 2021 and January 2023. These patients were diagnosed with nephroptosis, with 1 case having both a narrow ureteropelvic junction and nephroptosis due to a kidney stone, and 3 cases having simple nephroptosis. Patient characteristics, perioperative data, and follow-up results were collected. Surgical success was determined by symptom relief (subjective success) and the absence of kidney descent by intravenous pyelography (objective success). Results Preoperative computed tomography urography showed that all patients had hydronephrosis, with severe hydronephrosis in 75% (3/4) and moderate hydronephrosis in 25% (1/4) of cases. The mean operative time was 63.8 minutes (range, 45–95 minutes), and the mean blood loss was 5 mL (range, 5–50 mL). The mean length of hospital stay was 4.5 days (range, 3–6 days). The mean time to removal of the nephrostomy tube was 2 months (range, 1–4 months). No serious complications (Clavien-Dindo grade ≥3) occurred during or after the procedure. The mean postoperative serum creatinine level was 54.75 μmoI/L (range, 43–65 μmoI/L). The mean follow-up time was 6.25 months (range, 4–8 months). The objective and subjective success rates were both 100%. Conclusions The improved PCN procedure that was used in this study is feasible and provides a good option for treating nephroptosis.

The Outcome of Posterior Urethral Valves among Children in Tertiary Care Hospital–A Prospective Study

Introduction: Posterior Urethral Valve (PUV) is the most common cause of lower urinary tract obstruction in male children. This obstruction in posterior urethra could lead to severe dilatation of upper urinary tract and functional impairment of one or both kidney. The presentations are not always same for all patients. Early diagnosis and appropriate treatment may reduce the progressive damage and helps in recovery. Aim of the Study: The aim of this study was to find out the presentation and to assess the short term functional outcome after fulgaration of the patients with PUV. Methods: This prospective study was conducted at Pediatric urology department, Bangladesh Shishu Hospital and Institute, Dhaka. We included fifty patients with Posterior urethral valve, who were treated at the pediatric urology department from Jan, 2019 to Nov, 2021. Result: Total 50 patients enrolled in the study. In our study we found 50% of our patients were aged between 1 month to 1 year, followed by 36% were more than 1 years old and 14% were less than 1 month old. 76% patients were presented with dribbling of urine. 40%,26%,10% and 6% patients had UTI, poor stream,, retention of urine and palpable bladder respectively. 45 patients had bilateral hydronephrosis ( HDN) at presentation and only 5 had unilateral hydronephrosis in USG. At follow up MCU, 14% patients had unilateral VUR and 10% patients had bilateral VUR. Mean postoperative serum creatinine was 0.585 mg/dl. We found residual Valve in 11(22%) patients during follow up who required repeat Valve ablation. Conclusion: In our study, we found that Cystoscopic valve ablation and follow up is the treatment of choice for PUV patients which may arrest the progressive damage of renal function and facilitate the improvement. Further multicenter study and long term follow up is necessary for understanding the ultimate outcome.

Segmental Ureterectomy Versus Radical Nephroureterectomy in Older Patients Treated for Upper Tract Urothelial Carcinoma.

The world population is ageing and surgical procedures for older patients are associated with higher perioperative morbidity and mortality rates than in younger patients. Segmental ureterectomy (SU) has been proposed as an alternative to radical nephroureterectomy (RNU) for selected upper tract urothelial carcinomas (UTUC), to reduce post-operative morbidity, and preserve renal function. The aim of this study was to compare RNU and SU in terms of post-operative complications, functional outcomes, and overall survival (OS) in older patients treated for UTUC. Data of patients aged 75 years or older and treated for UTUC were included. The primary outcome was to compare RNU versus SU according to post-operative complications, the estimated glomerular filtration rate (eGFR) variation, and OS. Complications were defined according to the Clavien-Dindo classification. eGFR was calculated according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. Un-adjusted OS curves were plotted using the Kaplan-Meier method. Overall, 177 patients (150 RNU and 27 SU) were eligible for the analysis. Pre- and post-operative characteristics were similar between the 2 groups. RNU patients showed higher incidence of post-operative complications (34.0% vs. 7.4%, P=.011). The mean post-operative serum creatinine was lower in SU patients in comparison with the RNU ones (1.23 vs. 1.69 mg/dL, P=.046), but no differences were found in terms of eGFR variation (P=.258). At 3 years of follow-up, the OS was comparable between the two surgical techniques (P=.129). In older patients diagnosed with UTUC, SU could offer lower rates of post-operative complications without affecting survival.

Evaluating the Effect of Acetazolamide on the Prevention of Post-operative Acute Kidney Injury after Coronary Artery Bypass Grafting Surgery: A Randomized, Open-labeled Clinical Trial.

Acute kidney injury (AKI) is a common complication after coronary artery bypass grafting (CABG) surgery and can be linked to the increased morbidity and mortality. Therefore, in the present study, the effect of preoperative administration of acetazolamide was evaluated to investigate whether it could prevent occurrence of post-operative AKI after CABG surgery. In this randomized controlled clinical trial, 130 patients who were candidates to undergo elective CABG surgery from January 21, 2020 to February 8, 2021 were randomly allocated to intervention group (receiving 500 mg of acetazolamide orally 2 h preoperatively) and control group. The patients were evaluated for AKI based on the kidney disease- improving global outcomes (KDIGO) criteria based on their serum creatinine (SCr) level and urine output until 7 days postoperatively. There was no significant difference in baseline demographics between the two groups. The total incidence of AKI was measured as 43%. Analysis of post-operative AKI incidence showed no statistically significant difference between the two groups (P = 0.860). Mean post-operative SCr level on day 1 was significantly higher in the acetazolamide group (P = 0.036). A significant difference was found in length of hospitalization stay between the groups, which was higher in the control group (P = 0.006). Our results did not demonstrate a significant protective effect of acetazolamide on incidence of post-operative AKI in the patients undergone elective on-pump CABG surgery.

Robotic kidney transplantation: one year after the beginning.

Kidney transplantation (KT) is the preferred treatment for patients with end-stage renal disease (ESRD). To reduce the morbidity of the open surgery, a robotic-assisted approach has been recently introduced. Our aim is to evaluate surgical and functional results on 17 cases of robotic-assisted kidney transplantation (RAKT) performed at the same institution. From July 2015 to June 2016, we performed 17 cases of RAKT from living donors in pre-emptive patients, who underwent laparoscopic nephrectomy. A prospective pilot study was made at Fundació Puigvert (Barcelona), evaluating functional and surgical outcomes. In this series, we considered the functional results, surgical outcomes and complications rates. Seventeen patients successfully underwent RAKT, in particular surgical console time was 181min (150-200) with vascular suture time 42min (32-48), and estimated blood loss <70ml. Overall ischemia time was 98.9min (84-140). No patient was converted to open transplantation. No major surgical intra-operative complications were observed. The mean post-operative serum creatinine level 160μmol/L (81-479). We reported a case of delayed graft function (DGF), one case of graft arterial thrombosis and one case of intraperitoneal hematoma. No anastomosis revision and wounds infections occurred. RAKT with regional hypothermia appears to be a safe surgical procedure in a properly selected group of patients. The potential advantages of RAKT are related to the quality of the vascular anastomosis, the possible lower complication rate and the shorter recovery of the recipients.

Mini-flank incision for open partial nephrectomy for renal tumor with Zhongshan score≥8

Objective To evaluate the effect and feasibility of mini-flank approach for open partial nephrectomy (MI-OPN) in complex renal tumors with high Zhongshan Score(ZS Score ≥8). Methods Between January 2012 and December 2014, the data from 25 patients with renal tumors, including 18 male and 7 female patients, were retrospectively reviewed.The average age was 50.2 years(range 26-75 years)and the average body mass index was 24.5 kg/m2(range 21.3-30.1 kg/m2). The initial symptom included asymptom in 17 cases, hematuria in 6 cases and other presentation in 2 cases.Bilateral renal tumors were found in 4 cases.Fifteen cases suffered with contralateral urinary stone, renal cyst or hydronephrosis.The preoperative serum creatinine level was 76.9 μmol/L(range 47-132 μmol/L) and the preoperative estimated glomerular filtration rate (eGFR) was 103.8 ml/(min·1.73 m2)(range 36.5-173.9). The ZS Score was 8 in 11 cases, 9 in 3 cases, 10 in 5 cases, 11 in 2 cases, 12 in 2 cases, and 13 in 2 cases.Mean maximum tumor size was 4.9 cm (range 2.5-8.1 cm) in CT scan.The average length of incision was 8.0 cm(7.5-10.0 cm). During the operation, the mass and around normal renal tissue were exposed after opening the Gerota fascia.Along the dorsal of kidney, the renal artery was dissected and clamped.Then, the mass was completely removed along margin of 0.5-1.0 cm normal renal tissue.The vascular end was closed by 3-0 absorbable suture.The entire wound of kidney was U shaped closed by 2-0 absorbable suture.The operative time, ischemia time, estimate blood loss, pathology parameters, operative and short-term (2-3 months) postoperative complications were recorded.Renal function was recorded 2-3 months after operation. Results MI-OPN was successfully performed in 23 cases.Radical nephrectomy was performed in 1 cases due to the tumor invasion into the renal pelvis and ureteropelvic junction.Another radical nephrectomy was performed for suspection of positive margin.Mean operative time was 100.2 min(range 75-150 min), mean warm ischemia time was 28.3 min(range 21-39 min) and mean estimated blood loss was 63.6 ml(range 10-400 ml). Only 1 case accepted blood transfusion.Mean postoperative hospital stay was 6.6 days (range 5-9 days). Postoperative complications were found in 1 patient, who was found the fluid in surgical region and relieved after the drainage. The pathological diagnosis included clear cell carcinoma in 21 cases, papillary carcinoma in 3 cases and chromophobe cell tumor in 1 case. The mean postoperative serum creatinine level was 88.9 μmol/L(range 61-189 μmol/L) and the mean postoperative eGFR was 86.3 ml/(min·1.73 m2)(range 34.0-149.6). There was significant difference between pre and postoperative renal function (P<0.01). During the average follow-up period of 13.7 months (range 6-24 months), no local recurrence or metastasis occurred. Conclusion MI-OPN is an innovation of traditional OPN and suitable for the complex renal tumors with high ZS score. Key words: Kidney neoplasms; Nephron sparing surgery; Mini-incision; Zhongshan score

MP57-14 INTRAOPERATIVE MOLECULAR DIAGNOSTIC IMAGING CAN IDENTIFY RENAL CELL CARCINOMA DURING NEPHRECTOMY

open surgery. Only 1 patient in PCA group required a reintervention performed by radiological embolization. Both groups had a comparable mean postoperative serum creatinine and eGFR was stable over time in both groups. According to Clinical Practice Guideline for Acute Kidney Injury (AKI) only 5% of patients had an acute compromise renal function (AKI Stage 1) which resolved in a few days. At Univariate and Multivariate analysis predictors of Recurrence Disease (RD) included PADUA Score 8 (HR 1⁄4 9.99) and ASA risk 4 (HR 1⁄4 11.23). Limitations of our study are: limited follow-up, oncologic outcomes based only on radiographic criteria and lack of pathologic data in some cases. CONCLUSIONS: Our multicentric analysis shows that oncologic outcomes and complication rate in PCA treatment and LCA treatment have no statistical difference. Both treatments are safe and effective is the management of cT1 solid renal masses in patients who are poor candidates for conventional surgery. Longer follow-up is required to truly interpret oncologic outcomes after cryoablation.

1827 IMPACT OF SILENT URETERAL STONE TREATMENT ON RENAL FUNCTION

INTRODUCTION AND OBJECTIVES: The prevalence of nephrolithiasis is increasing worldwide. The purpose of this paper is to report our experience managing silent ureteral stones and to expose its’ true influence on renal function. METHODS: We prospectively analyzed 506 patients who underwent ureteroscopy for ureteral stone removal between January 2005 and May 2010. Silent ureteral stone definition: ureteral stone found in a patient without any specific or subjective ureteral stonerelated symptom. 27 (5,3% Global Cohort) patients met those criteria. All patients were assessed postoperatively with Dimercaptosuccinic Acid scintigraphy (DMSA). We considered abnormal a kidney relative function 45%. Pre and postoperative comparative DMSA analysis was electively obtained for 9 (34%) patients (Renal Function Cohort). We used the T-test for numerical variables and Chi-Square Test or Fisher’s Exact Test for categorical variables. Two-tailed values of P 0.05 were considered statistically significant. RESULTS: Demographic data is exposed on table 1. There were no statistically significant differences between Global Cohort and Renal Function Cohort. Primary therapy was ureteroscopic lithotripsy in 88%. Double J insertion was required in 90% and mean time to retrieval was 39 (7–100) days. Stone was considered impacted in 70%. Mean follow-up time was 23 (3–54) months. Overall ureteral stone-free rate after one and two procedures were 96% and 100%. Ureteral stenosis was seen in 2 patients during ureteroscopy and 2 after stone treatment. In the global Cohort, mean postoperative serum creatinine was not different from preoperative levels (p 0,39). Mean postoperative kidney relative function on DMSA was 31% (0–77%). In 17 (63%) patients, postoperative DMSA revealed impaired renal function. Hydronephrosis improvement was seen in 19 and stabilization in 7 patients, with one case showing worsening. In the Renal Function Cohort, all patients presented with impaired renal function preoperatively. There was no difference between pre and postoperative DMSA (22 12,1; vs. 20 11,8; p 0,83) and Cr (0,8 0,13; vs. 1,0 0,21; p 0,45). CONCLUSIONS: Silent ureteral stones are associated with decreased kidney function already at diagnosis. Although hydronephrosis tends to diminish after stone removal, renal function is likely to remain unaltered. Source of Funding: None

Renal Hilar Control During Laparoscopic Partial Nephrectomy: To Clamp or Not to Clamp

To decrease intraoperative and perioperative morbidity that is associated with laparoscopic partial nephrectomy (LPN), clamping of the renal hilum has been advocated. It has been suggested, however, that renal hilar control is not necessary in all patients. We compared the perioperative and pathologic results of 21 consecutive patients who underwent LPN with or without renal hilar clamping at our institution. Twenty-one patients underwent LPN over a 24-month period. Of these, 11 LPNs were completed without hilar control while 10 needed hilar clamping. Renal hilar control was deemed necessary if the depth of tumor invasion was greater than 50% of the renal parenchyma on CT or MRI. Only the artery was clamped. We retrospectively analyzed the intraoperative, perioperative, and the pathologic results. The mean tumor size was 2.6 cm (range 0.8-4.2 cm) in the nonclamped group and 2.3 cm (range 1.5-3 cm) in the clamped group. The mean operative time was 174 minutes (range 95-270 min) in the nonclamped group and 232 minutes (range 180-270 min) in the clamped group. The mean ischemia time was 29 minutes (range 21-45 min) in the clamped group. The mean postoperative serum creatinine level was 1.1 mg/dL (range 0.7-2.0 mg/dL) in the nonclamped and 1.1mg/dL (range 0.7-1.8 mg/dL) in the clamped group. Postoperative transfusion was not needed. In one patient in the nonclamped group and in three patients in the clamped group, urine leak occurred. In the nonclamped group, 7 of the 11 procedures were for benign tumors while only 2 of the 10 lesions in the clamped group were benign. LPN can be performed safely in selected patients without clamping the hilum. Tumors that need cross-clamping of the renal hilum were more likely to be malignant. We suggest that the decision to clamp the hilar vessels should be made based on each patient's characteristics and radiologic findings.

Partial nephrectomy for renal tumors using selective parenchymal clamping

To describe our experience with partial nephrectomy using selective parenchymal clamping for the treatment of renal tumors. Between 2003 and 2005, seven patients with solid renal tumors underwent partial nephrectomy with selective parenchymal clamping at our Institution. In five, the tumor was in the right kidney and in two the tumor was in the left. Only one patient had a tumor within a solitary kidney. The tumor was located in the upper pole in 2 patients and in the lower pole in 5. Partial nephrectomy was performed with the DeBakey aortic clamp without occlusion of renal vessels. Mean operative time was 236 min (range 175-298 min). Mean intraoperative blood loss was 485 ml with only one patient requiring blood transfusion. There were no major complications. Mean preoperative serum creatinine level was 0.74 mg/dl (range 0.58-1.26 mg/dl) and mean postoperative serum creatinine level was 0.81 mg/dl (range 0.69-1.21 mg/dl) with no patient requiring dialysis. Mean hospital postoperative stay was 5 days (range 4-7 days). Mean tumor size was 2.9 cm (range 1.3-4.0 cm). Pathologic analysis detected renal cell carcinoma in 5 patients, angiomyolipoma in 1 and fibrosis with chronic hemorrhage in 1, all with negative surgical margins. After a mean follow-up of 18 months (range 3-32 months), all patients are free of disease recurrence. Partial nephrectomy with selective parenchymal clamping allows resection of solid masses without damage to normal renal tissue, avoids the risk of renal failure and offers an excellent local cancer control.

Carbon dioxide digital subtraction angiography–assisted endovascular aortic aneurysm repair in the azotemic patient

This report analyzes the safety and efficacy of carbon dioxide digital subtraction angiography (CO(2)-DSA) for EVAR in a group of patients with renal insufficiency compared with a concurrent group of patients with normal renal function undergoing EVAR with iodinated contrast angiography (ICA). Between 2003 and 2005, 100 consecutive patients who underwent EVAR using ICA, CO(2)-DSA, or both were retrospectively reviewed, and preoperative, intraoperative, postoperative, and follow-up variables were collected. Patients were divided into two groups depending on renal function and contrast used. Group I comprised patients with normal renal function in whom ICA was used exclusively, and group II patients had a serum creatinine >or=1.5 mg/dL, and CO(2)-DSA was used preferentially and supplemented with ICA, when necessary. The two groups were compared for the outcomes of successful graft placement, renal function, endoleak type, and frequency, and the need for graft revision. Comparisons were made using chi(2) analysis, Student t test, and the Fisher exact test. A total of 84 EVARs were performed in group I and 16 in group II. Patient demographics and risk factors were similar between groups with the exception of serum creatinine, which was significantly increased in group II (1.8 mg/dL vs 1.0 mg/dL P < .0005). All 100 endografts were successfully implanted. Patients in group II had longer fluoroscopy times, longer operative times, and increased radiation exposure, and 13 of 16 patients required supplemental ICA. Mean iodinated contrast use was 27 mL for group II vs 148 mL in group I (P < .0005). Mean postoperative serum creatinine was unchanged from baseline, and 30-day morbidity was similar for both groups. No patient required dialysis. No patients died. Perioperatively, and at 1 and 6 months, the endoleak type and incidence and need for endograft revision was no different between groups. CO(2)-DSA is safe, can be used to guide EVAR, and provides outcomes similar to ICA-guided EVAR. CO2-DSA protects renal function in the azotemic patient by lessening the need for iodinated contrast and associated nephrotoxicity, but with the tradeoff of longer fluoroscopy and operating room times and increased radiation exposure.

Potential Renal Protective Benefits of Intra-Operative BNP Infusion During Cardiac Transplantation

Background Recombinant BNP (nesiritide) is known to reduce endothelin levels, cause afferent arteriole vasodilation, and increase natriuresis and diuresis. We hypothesized that intraoperative infusion of BNP may benefit renal function in cardiac transplant patients. Methods From June 2003 to September 2005, 22 consecutive heart transplant patients received BNP at a dose of 0.01 μg/kg/min before initiation of cardiopulmonary bypass (group A). BNP infusion was continued for a mean of 3.3 ± 1.9 days. Hemodynamics, urine output, and serum creatinine levels were prospectively collected and compared with 22 consecutive patients who underwent heart transplantation between May 2002 and June 2003 following the identical transplant protocol, but without BNP infusion (group B). Results At 24 hours postoperatively, mean blood pressure was comparable between groups (87 ± 11 mm Hg vs 89 ± 17 mm Hg, P = .7), but pulmonary artery pressure (18 ± 5 mm Hg vs 24 ± 5 mm Hg, P = .001) and central venous pressure (12 ± 5 mm Hg vs 16 ± 4 mm Hg, P = .01) were lower with BNP infusion, whereas cardiac index was augmented (2.8 ± 0.5 vs 2.4 ± 0.6, P = .03). Requirement of low-dose inotropic and vasopressor support was equally distributed between groups ( P ≥ .72). Postoperative urine output for the initial 24 hours was higher in group A (84 ± 15 vs 55 ± 36 mL/h, P = .01). None of the patients with BNP infusion required additional diuretics or renal replacement therapy during the first week after transplantation. Mean postoperative serum creatinine levels as compared with preoperative values remained unchanged within group A ( P = .12), but increased significantly in group B ( P < .001). Conclusions Intraoperative BNP infusion in heart transplant recipients was associated with favorable postoperative hemodynamics, significantly improved urine output, and stable serum creatinine levels. A prospective, randomized, multicenter trial is warranted to evaluate the potential renal protective benefits of intraoperative BNP infusion in this patient population.

Technique of percutaneous, CT-guided radiofrequency ablation of small renal lesions under conscious sedation

RESULTS: From July 2001 to July 2005 we ablated 27 tumors in 23 patients with a mean follow-up of 24 months. The mean patient age was 74 years with a mode ASA score of 3. The mean renal mass size was 2.71 cm. The mean preoperative serum creatinine was 1.34, and the mean postoperative serum creatinine was 1.46, yielding a change which was not statistically different(p 0.46). Follow-up imaging revealed a 70%(16/23)initial success rate and a 17%(4/23)initial failure rate. Two of these failures underwent successful repeat ablation, 1 is on watchful waiting and 1 patient was a true failure. Our only complication was a large perinephric hematoma which resolved spontaneously.

Laparoscopic Radical versus Partial Nephrectomy: Assessment of Complications

We evaluated the short-term morbidity and complications of laparoscopic radical nephrectomy (LRN) compared with laparoscopic partial nephrectomy (LPN). From May 1998 to May 2002, 114 patients were identified with a single unilateral sporadic renal tumor and a normal contralateral kidney. These individuals had undergone LRN (35) or LPN (79). The LRN and LPN groups were analyzed for age, sex, American Society of Anesthesiologists score and body mass index. Mean tumor size in patients undergoing LRN and LPN was 2.8 +/- 1.2 (range 0.9 to 4.5) and 2.5 +/- 1.0 cm (range 1 to 4.5), respectively (p = 0.17). There were no differences between the 2 groups in terms of mean hospital stay, blood transfusion or surgical complications. There was no difference in mean preoperative and postoperative serum creatinine in patients in the LPN group. Mean postoperative serum creatinine was significantly higher than the mean preoperative level in patients in the LRN group (1.51 +/- 0.22 vs 1.18 +/- 0.37 mg/ml, range 0.6 to 2.4, p = 0.02). In each group 1 case was converted to open surgery due to bleeding. LPN is associated with similar postoperative convalescence and complications compared with LRN. The increase in serum creatinine noted in patients undergoing radical extirpation supports the use of LPN when clinically indicated.

Natural history of chronic renal insufficiency after partial and radical nephrectomy

Objectives. To compare the incidence of newly developed chronic renal insufficiency after partial nephrectomy (PN) and radical nephrectomy (RN). Elective PN for renal tumors is intended to preserve renal function; however, studies of transplant donors suggest normal renal function is also maintained after unilateral nephrectomy. Methods. We retrospectively compared all patients undergoing PN or RN for renal tumors 4 cm or less in the presence of a normal contralateral kidney from 1989 to 2000. Creatinine failure was defined as a serum creatinine value greater than 2.0 mg/dL. Risk factors for renal insufficiency, including diabetes, hypertension, American Society of Anesthesiologists score, age, preoperative creatinine, and history of smoking tobacco, were compared between the two groups. We compared the two groups using the chi-square and Mann-Whitney U tests and the creatinine failure rates using the Kaplan-Meier method. Results. One hundred seventy-three patients met the criteria for analysis after RN and 117 did so after PN (median follow-up 25 months). The 5-year freedom from recurrence rate was 96.4% and 98.6% for PN and RN, respectively ( P >0.05). The mean preoperative serum creatinine was 1.0 mg/dL (range 0.4 to 1.4) and 0.98 (range 0.6 to 1.5) for RN and PN, respectively ( P = 0.4, not significant). The incidence of risk factors for renal insufficiency did not differ between the two groups. The mean postoperative serum creatinine in the RN and PN groups was 1.5 mg/dL (range 0.8 to 3.8) and 1.0 mg/dL (range 0.5 to 1.9), respectively ( P <0.001). The chance of creatinine failure over time was significantly greater in the RN group ( P = 0.008). Conclusions. When controlled for preoperative risk factors for renal insufficiency, patients undergoing RN are at a greater risk of chronic renal insufficiency than a similar cohort of patients undergoing PN.

Conservative surgery for renal cell carcinoma: A single-center experience with 100 patients

From January 1956 March 1987., 100 patients underwent a conservative (parenchymasparing) operation as curative treatment for renal cell carcinoma at our clinic. This series includes 56 patients with bilateral (28 synchronous and 28 asynchronous) and 44 with unilateral renal cell carcinoma; in the latter category the contralateral kidney was either absent or nonfunctioning (17 patients), functionally impaired (17), involved with a benign disease process (6) or normal (4). The pathological tumor stage was I in 75 patients, II in 9, III in 10 and IV in 6. A nephron-sparing operation was performed in situ in 86 patients and ex vivo in 14. Postoperatively, 93 patients experienced immediate function of the operated kidney, while 7 required dialysis (4 temporary and 3 permanent). The incidence of dialysis was greater after ex vivo than in situ surgery (p equals 0.0005). The mean postoperative serum creatinine level in 97 patients with renal function was 1.7 mg. per dl. (range 0.9 to 4.6 mg. per dl.). The over-all actuarial 5-year patient survival rate in this series is 67 per cent including death of any cause and 84 per cent including only deaths of renal cell carcinoma. Survival was improved in patients with stage I renal cell carcinoma (p less than 0.05). Survival also was improved in patients with unilateral renal cell carcinoma (p less than 0.05) and fewer patients in this category had recurrent disease postoperatively (p less than 0.0005). Nine patients (9 per cent) had local tumor recurrence postoperatively and 5 of these were rendered free of tumor by secondary surgical excision. Conservative surgery provides effective therapy for patients with localized renal cell carcinoma in whom preservation of renal function is a relevant clinical consideration.

Nephron-sparing surgery for renal angiomyolipoma

Objectives. Angiomyolipoma (AML) is a benign renal tumor that may require treatment because of associated local complications. The present study was undertaken to evaluate the efficacy of nephron-sparing surgery (NSS) in the management of renal AML, with respect to the long-term preservation of renal function and absence of tumor recurrence. Methods. From 1980 to 1997, 27 patients underwent NSS for treatment of renal AML. The clinical presentation, surgical approach, and outcome in these patients were analyzed. Surgical treatment for renal AML was indicated because of associated symptoms, size of 4.5 cm or greater, and/or suspicion of renal malignancy. Results. In symptomatic patients (52%) the most common presenting signs or symptoms were pain (50%), retroperitoneal hemorrhage or shock (43%), hematuria (36%), hypertension (7%), palpable mass (7%), and anemia (7%). Two patients had tuberous sclerosis. Fifteen patients had a solitary functioning kidney (group I), 6 patients had an impaired contralateral kidney (group II), and 6 patients had a normal contralateral kidney (group III). All operations were performed in situ. There were no operative deaths. All operated kidneys functioned postoperatively, and no patient required dialysis. The mean postoperative serum creatinine level in groups I, II, and III was 1.81, 0.98, and 0.97 mg/dL, respectively. No patients have developed recurrent AML, related symptoms, or required dialysis with follow-up to 177 months (median 39). Conclusions. When surgical treatment for renal AML is indicated, NSS can be performed with a high success rate even in patients with a very large tumor involving a solitary kidney.

Empirical reconstruction of the renal artery: long-term outcome.

Unequivocal indications for renal artery reconstruction remain the presence of significant underlying renal insufficiency or severe hypertension. Thus surgical intervention for renal artery stenosis in the absence of this clinical picture may well be considered empirical and, as a consequence, treatment recommendations are ill-defined. Our experience with reconstruction of the minimally symptomatic or asymptomatic renal artery lesion in association with primary aortic repair over a 10-year period was reviewed. Thirty-two patients who had atherosclerotic renal artery stenosis > or = 70% underwent prophylactic renal revascularization between 1982 and 1992. The patients' median age was 63 years (range, 44 to 79 years); 23 (72%) were men and nine (28%) were women. All had preoperative serum creatinine levels < or = 1.7 mg/dl (1.29 +/- 0.24 mg/dl) and were receiving either no antihypertensive medication (22%) or only a single agent (78%). Aortoiliac occlusive disease was present in 38% of this population, and aortic aneurysmal disease either alone or in combination with occlusive disease was found in 62%. Operative management included unilateral renal artery repair in 21 patients (66%) and bilateral renal revascularization in the remaining 11 (34%). The median decrease in postoperative serum creatinine level (> or = 7 days after operation) was 0.81 +/- 0.05% (mean postoperative serum creatinine level 1.27 +/- 0.07 mg/dl). The 30-day operative mortality rate was 3.1% (1 of 32). Late follow-up was available for 96% of patients (30 of 31; median, 64 months). Kaplan-Meier life table analysis revealed a 5-year probability of survival of 90.2% (95% confidence interval, 0.802 to 1.00). Stability of renal function was assessed by modeling the change in serum creatinine level over time with the intraclass correlation model. A serum creatinine level (mg/dl) = 1.3348 + 0.0011 x time (months) demonstrated minimal deterioration of excretory function during the observation period. Furthermore, the blood pressure of the majority of patients (75%) remained normal either with a single agent or without medication. Recurrent stenosis in one patient required treatment by percutaneous transluminal angioplasty. Adjunctive repair of the renal artery may be an appropriate option in selected patients who undergo simultaneous aortic surgery, even in the absence of severe hypertension or renal insufficiency. Surgical intervention can be accomplished with acceptable perioperative morbidity rates, and stability of renal function is sustainable in the majority of patients.

Management of small unilateral renal cell carcinomas: Radical versus nephron-sparing surgery

Objectives. There is controversy concerning the management of small unilateral renal cell carcinomas. The present study was undertaken to evaluate the relative efficacy of radial nephrectomy versus nephron-sparing surgery in such patients. Methods. Patients with a single, small (less than 4 cm), localized, unilateral, sporadic renal cell carcinoma (IRCC) were identified from an institutional registry. From 1975 to 1992, 88 patients fulfilling these criteria were treated with either radical nephrectomy (n = 42) or nephron-sparing surgery (n = 46). The mean postoperative follow-up interval is 48 ± 29 months. Results. The radical and nephron-sparing surgical groups were well matched for patient age, sex, renal function, diabetes, hypertension, tumor size, tumor location, and tumor stage. All patients in both groups had low pathologic stage RCC. There was no difference between the two groups in terms of the mean hospital stay, the requirement for blood transfusions, or the occurrence of surgical complications. There was no difference in the mean preoperative and postoperative serum creatinine levels for patients in the nephron-sparing surgery group. However, the mean postoperative serum creatinine levels were significantly higher than the mean preoperative levels for patients in the radical nephrectomy group ( P < 0.001). A single patient in each group developed recurrent RCC postoperatively. The cancer-specific 5-year survival rate for patients in the radical and nephron-sparing surgical groups is 97% and 100%, respectively. Conclusions. Radical nephrectomy and nephron-sparing surgery each provide safe and effective curative treatment for patients with a single, small, unilateral localized RCC. The long-term renal functional advantage of nephron-sparing surgery in this setting is not established.