Nephrectomy For Benign Renal Disease Research Articles

263 Minimally Invasive Non-Radical Nephrectomy for Benign Renal Disease: A Single Centre Experience Comparing Two Surgical Approaches

Abstract In our high-volume tertiary centre for renal disease, we perform in excess of 150 nephrectomies for benign or malignant disease per annum. In this study we compare outcomes between laparoscopic and retroperitoneoscopic minimally invasive (MI) approaches. We retrospectively reviewed our database of all patients who underwent MI non-radical nephrectomy over a 3-year period. Indication for surgery, conversion rate, operative time, blood loss, length of stay and post-operative complications were examined. A total of 61 MI nephrectomies were performed by three experienced minimal access surgeons. Indications for surgery included chronic infection, stone disease, tuberculosis, and obstruction associated with pain. Mean age was 51 years (range 22–89), 72% were female. The approach was laparoscopic in 62% and retroperitoneoscopic in 38%. Median operative time 137 minutes. The overall conversion rate was 3% (2 patients). Median blood loss 50ml's with 1.5% transfusion rate. Median length of stay was 2 days (1–69). There was no significant change in the renal function (P=0.32). Four patients developed Clavien-Dindo grade 3 complication. There was no recorded mortality in our series. We acknowledge this is a retrospective study that may be subject to selection bias, however our experience of this procedure in high volume centre with experienced operators shows that both laparoscopic and retroperitoneoscopic approaches are safe in performing MI non-radical nephrectomy with very low conversion rate.

Prechemotherapy laparoscopic nephrectomy for Wilms' tumor

Laparoscopic radical nephrectomy is emerging as the treatment of choice for localized renal malignancies in adults. Despite the widespread use of laparoscopic nephrectomy for benign renal disease in infants and children, the laparoscopic approach has not been employed for pediatric Wilms' tumor except following systemic chemotherapy. We report the results of laparoscopic radical nephrectomy for removal of unilateral Wilms' tumor prior to the administration of systemic chemotherapy in two patients.

Transitional Cell Carcinoma in a Remnant Ureter after Retroperitoneoscopic Simple Nephrectomy for Benign Renal Disease

A 70-yr-old man presented with painless gross hematuria. He underwent right nephrectomy for benign disease 9 yr ago. Computed tomography and cystoscopy showed a mass in the distal region of the right ureteral stump. He underwent right ureterectomy and bladder cuff resection. Pathological examination showed T1 and WHO grade 2 transitional cell carcinoma. At 6 months postoperatively, the patient is alive without any evidence of recurrence.

Outcome and Complications of Laparoscopic Nephrectomy in Patients with Previous Renal Surgery

The aim of this study was to evaluate the technical difficulties, limitations, outcome, and complications of laparoscopic nephrectomy in patients with previous ipsilateral renal surgery. Eighteen patients with a history of epsilateral renal surgery underwent laparoscopic simple nephrectomy for benign renal disease at our center between November 2001 and March 2005. All patients were informed about the details of the laparoscopic procedure, and an informed consent was obtained that included the possibility of an emergency laparotomy. All procedures performed were carried out through a transperitoneal approach. A separate table with a laparotomy set was available in the room and ready for open conversion. The procedure was completed in 13 patients. Excluding the cases converted to open surgery, the operative time ranged from 120 to 210 minutes, with a mean of 170 +/- 32.9. The intraoperative blood loss ranged from 30 to 400 cc, with a mean blood loss of 100. Complications included minor visceral injury (liver) in 1 patient, minor bleeding in 2, major bleeding (open conversion) in 1, technical failure (open conversion) in 4, postoperative bleeding (reexploration) in 1, and postoperative renal bed collection in 1. Laparoscopic nephrectomy is an alternative to the open nephrectomy for the removal of nonfunctioning kidneys in benign diseases and results in less morbidity and a shorter hospital stay. A higher conversion to open and complication rate should be expected in patients with previous open or endoscopic renal surgery and postinflammatory conditions.

A two-center experience with the exclusive use of laparoscopic transperitoneal nephrectomy for benign renal disease in children

This study aimed to evaluate a two-center experience with pediatric transperitoneal laparoscopic nephrectomy, specifically focusing on the outcome parameters of operative time, complication, analgesic requirement, and postoperative stay. This ambispective study was conducted over a 4-year period between May 2001 and May 2005 in two tertiary pediatric surgical centers. Data were prospectively recorded from an in-house expanded medical audit system (EMAS) and a Microsoft Excel database. Information on patient demographics, operative time, complications, analgesic requirement, and length of hospital stay were retrieved and analyzed. A total of 30 consecutive patients with a mean age of 4.43 years (range, 3 months to 15 years) underwent laparoscopic nephrectomy. All the patients underwent unilateral nephrectomy/nephroureterectomy for multidysplastic kidney (n = 12), reflux nephropathy (n = 13), pelvicoureteric junction obstruction (n = 4), or cystic disease of indeterminate cause (n = 1). The mean operative time was 93 +/- 30 min. The principal hemostatic devices used were the Harmonic Scalpel (20 cases), liga clips (5 cases), and hook diathermy and endoshears exclusively (4 cases). There were no conversions, but the intraoperative complications of bleeding (n = 2), difficult location (n = 1), difficult extraction (n = 1), and requirement for a liver retractor (n = 2) were encountered. An additional five patients had problems in the immediate postoperative period, two of whom went on to have long term difficulties with recurrent urinary tract infections resulting from a residual ureteric stump, which required surgery. Nearly one-third of the patients required morphine for analgesia in the immediate postoperative period, with the figure falling to 20% by day 1. The median postoperative hospital stay was 1 day (range, 0-16 days). At this writing, all the patients remain under surveillance with a mean follow-up period of 2.88 years, and no patients have experienced complications secondary to intraabdominal adhesions. Transperitoneal laparoscopic nephrectomy is technically feasible in most cases of benign renal disease. The intraoperative complications are minimal, and recovery for most is robust. Two-thirds of the patients are discharged within 24 h. In this study, narcotic analgesics were prescribed in about a one-third of all the cases for a limited period. Further problems may be seen when refluxing ureters are incompletely excised. However, the transperitoneal approach does not mitigate against complete excision because the exposure to the pelvis is adequate. At the midterm follow-up assessment, adhesive obstruction was not encountered, confirming this approach as a tenable alternative to other laparoscopic approaches for nephrectomy.

Follow‐up after unilateral nephrectomy in children: is an estimate of glomerular filtration rate necessary?

To determine the need for an estimate of glomerular filtration rate (GFR) in the follow-up of children undergoing unilateral nephrectomy for benign renal disease. Forty-four children (21 girls and 23 boys) undergoing unilateral nephrectomy for benign renal disease over a 3-year period were reviewed for the underlying diagnosis and indication for nephrectomy, imaging before and after surgery, postoperative GFR and final outcome. The follow-up included ultrasonography (US) of the contralateral kidney at 3 and 12 months and an estimate of GFR before discharge at > or = 1 year. All children were aged > 2 years when the GFR was measured. The criteria for discharge were normal imaging of the contralateral kidney before and after surgery and a normal GFR afterward. Spearman's correlation coefficient was used to determine the relationship between age, GFR and contralateral renal length after surgery. The median (range) age at surgery was 2.5 (0.67-16) years. The indications for nephrectomy included reflux nephropathy in 18, multicystic dysplastic kidney in 12, a congenital obstructive uropathy in eight, congenital renal dysplasia in four and miscellaneous in two. All patients had a normal contralateral kidney before surgery on US and functional imaging, and normal US at the follow-up, with evidence of compensatory hypertrophy in all. The median (range) corrected GFR for the 44 children was 109 (81-140) mL/min/1.73 m2, with no correlation between age and GFR, or between renal length and GFR. After unilateral nephrectomy for benign renal disease, provided there is a structurally and functionally normal contralateral kidney before surgery, with no abnormality on US, a routine estimate of GFR is unnecessary before discharge from follow-up. There was no correlation between GFR and age or renal length.

Long-Term Follow-Up of Ureteral Stump Tumors after Nephrectomy for Benign Renal Disease

The occurrence of primary carcinoma of the ureteral stump after nephrectomy is rare. In this study, we evaluated the clinical characteristics of ureteral stump tumors after nephrectomy for benign renal disease. During a 16-year period, 318 consecutive patients underwent simple nephrectomy for benign renal disease (216 cases) or for donation (102 cases). Eight of these 318 patients diagnosed as having an ureteral stump tumor were treated by ipsilateral ureterectomy with cuff excision of the bladder. Pathologic findings, tumor stages, and clinical characteristics were analyzed. The eight ureteral stump tumors comprised; 6 transitional cell carcinomas (TCCs) and 2 squamous cell carcinomas (SCCs). The mean interval between nephrectomy and ureteral stump tumor diagnosis was 76.5 months. Six of the 8 patients had pyonephrosis and two renal tuberculosis as original renal diseases. Four of the 6 TCCs were stage T1 and 2 stage T2. There was no concomitant bladder tumor at stump tumor diagnosis. Hematuria was the major presenting symptom in 3 of the 8 patients and 4 patients were diagnosed by follow-up imaging study. Two of the 6 ureteral stump TCC patients developed bladder TCC during follow-up. The 5-year survival rate of patients with ureteral stump tumor was 37.5%. T1G1 TCC was associated with a better survival than T2 or G2 TCC. No ureteral stump tumor occurred in cases of donor nephrectomy. This study demonstrate, that long-term closed observation is needed to detect ureteral stump tumor, particularly in patients that have undergo nephrectomy for a long-standing inflammatory renal disease such as pyonephrosis or tuberculosis. Hematuria is a major presenting symptom of ureteral stump tumor. However, a follow-up imaging study is also important for ureteral stump tumor detection. The prognosis is poor in cases developing ureteral stump SCC, bladder tumor recurrence, or a high-grade ureteral tumor.

Laparoscopic live donor nephrectomy: the single surgeon technique.

The worldwide shortage of cadaveric kidneys available for transplantation has led surgeons to seek out alternate sources for organs. After Clayman and associates first demonstrated the ability to perform laparoscopic native nephrectomy for benign renal disease in 1991, transplant surgeons began to assess this minimally invasive technique for live donor nephrectomies. The laparoscopic procedure has reduced donor fear concerning postoperative pain, length of recovery, and increased the number of individuals donating by as much as 25% at some institutions. Several different techniques have been used for donor nephrectomy, ranging from the method Ratner and associates initially described in 1995 to hand-assisted devices that reduce the learning curve in this technically demanding procedure. To date, all of these techniques require a second surgeon or assistant. We present our method of live laparoscopic donor nephrectomy, which is unique, in that it involves only a single surgeon.

Laparoscopic Nephrectomy for Benign Disease

Nearly 10 years of experience with laparoscopic nephrectomy for benign renal disease has shown that the procedure can be performed safely with a complication rate comparable with open surgery. Improvements in the skill, instrumentation, and technique of the laparoscopist have expanded the indications for the procedure to include larger (polycystic kidneys) and in some cases more complex (xanthogranulomotous pyelonephritis) specimens. Continued demonstration of reduced postoperative pain, shorter hospital stay, and more rapid recovery along with decreasing operative times have made laparoscopy the preferred approach for the surgical removal of benign kidneys.

Laparoscopic nephrectomy for nonfunctioning tuberculous kidney.

Although laparoscopic nephrectomy for benign renal disease has been widely accepted, use of the operation for tubercular pyelonephritic kidney is relatively contraindicated because of difficulties in dissecting the dense fibrotic adhesions and the risk of spillage of caseous materials with subsequent dissemination of the disease. However, with the accumulation of experience, laparoscopic surgery is expanding its applications. In this study, we tried to evaluate the efficacy and safety of the laparoscopic nephrectomy for renal tuberculosis. At three centers, 13 laparoscopic nephrectomies were performed between April 1996 and March 1999. The patients consisted of eight men and five women with a mean age of 44.8 years (range 37-51 years). All patients had known renal tuberculosis with a nonfunctioning kidney and underwent nephrectomy after at least 3 months of chemotherapy with four antituberculous drugs. Nine patients underwent the transperitoneal approach and four patients, the retroperitoneal approach. The follow-up was from 2 to 35 months with a mean of 15.8 months. Kidneys were removed laparoscopically in 12 patients (92%). The mean operative time was 268 minutes (range 190-500 minutes), and the mean estimated blood loss was 227 mL. Although there had been some difficulties releasing the adhesions, no significant intraoperative and postoperative complications were observed. Conversion to open surgery was needed in only one patient. The mean hospital stay was 4 days, and the patients returned to normal activity within 10 days. Neither local recurrence nor distant dissemination of the disease was observed during the follow-up period. Laparoscopic nephrectomy for renal tuberculosis was safe and effective with minor complications. Therefore, tuberculosis should not be a contraindication to a laparoscopic approach.

PEDIATRIC RETROPERITONEOSCOPIC NEPHRECTOMY USING 2 MM. INSTRUMENTATION

We describe several modifications of the retroperitoneoscopic approach to nephrectomy for benign renal disease, including the use of 2 mm. instrumentation and prone patient positioning. A total of 14 children underwent retroperitoneoscopic nephrectomy in the prone position. An inflatable dissecting device was inserted into the retroperitoneum after a small muscle splitting incision was made at the lateral border of the sacrospinalis muscle approximately 1 cm. below the costovertebral angle. After inflation the dissecting device was replaced with a 5 mm. cannula and pneumoretroperitoneum was maintained with carbon dioxide insufflation. Two 2 mm. trocars were then placed under endoscopic guidance. Dissection was performed using 2 mm. instrumentation and the specimen was retrieved through the largest port site. Nephrectomy was performed in 9 girls and 5 boys 3 months to 9.8 years old. The preoperative diagnosis included chronic pyelonephritis with minimal renal function, reflux with a nonfunctioning kidney, multicystic dysplastic kidney, an upper pole dysplastic moiety with an associated ureterocele and a dysplastic kidney with a vaginal ectopic ureter. Mean operative time for retroperitoneoscopic nephrectomy was 142 minutes with an estimated blood loss of less than 15 ml. Contralateral ureteral reimplantation was performed after retroperitoneoscopic dissection in 5 patients. Overall average hospital stay was 2 days and there were no complications. Several modifications of the retroperitoneal approach, including the use of prone patient positioning and 2 mm. instrumentation for visualization and dissection, may improve the safety and efficacy of this technique in children.

Nefrectomia laparoscopica: Nostra esperienza

In this work we report our experience in the use of laparoscopie nephrectomy for benign renal disease. From September 1995 to April 1997, 10 patients, with age range from 36 to 67 years, underwent laparoscopie nephrectomy (4 for hydronephrosis, 4 contracted kidneys, 1 staghorn stone with excluded kidney, 1 tubercular contracted kidney). The average operating time was 150’. Average blood loss was about 200 cc. The patients resumed oral intake and started walking within 1 day, while just 1 patient required 500 ml of autologous blood. The average post-operative hospital stay was 4 days. Although laparoscopie operating times (average: 150’) are longer than those for traditional surgery, we achieved a considerable reduction in pain, post-operative hospital stay and in the time taken to resume normal activities. We therefore consider that laparoscopie nephrectomy may be a good alternative to traditional surgery for selected patients.

Laparoscopic nephrectomy.

Since the first clinical operation in June 1990 laparoscopic nephrectomy for benign renal disease has become widely accepted. Although the laparoscopic operation takes much longer than open surgery, there are considerable reductions in the length of postoperative hospital stay and the time taken to return to normal activities and to full recovery. Major complications were relatively common in early operations, but with more experience morbidity has been reduced. Laparoscopic nephrectomy for malignant renal disease is still controversial, largely because of the fear of release of malignant tissue into the abdominal cavity during the morcellation and retrieval of the diseased kidney. To prevent this, the kidney is removed intact through a 5-7 cm incision. Long term follow up is needed, however, before we will know whether the laparoscopic procedure is effective in preventing recurrence of cancer. New developments have improved various technical aspects of the operation, but stringent assessment of new techniques is necessary so that the medical community can decide which procedures should become routine practice.

Laparoscopic Nephrectomy: Review of the Initial 10 Cases

Laparoscopic nephrectomy is a new procedure in which the kidney is removed via a laparoscopic approach using a surgical entrapment sack and a high-speed 10-mm electrical tissue morcellator. Herein, we report the initial clinical experience with this procedure in 10 consecutive patients. The average operating room time was 5.5 hours. The hospital stay averaged 4.9 days, and convalescence occurred over 12 days. Two patients received a blood transfusion(s). At present, laparoscopic nephrectomy is our method of choice for patients requiring a nephrectomy for benign renal disease. The technology developed for this procedure may be helpful to surgeons in other disciplines, as the method of organ entrapment and morcellation can be applied to the removal of other intra-abdominal or pelvic organs.