Prior Renal Surgery Research Articles

The not so 'simple' laparoscopic nephrectomy: Experience with 3D laparoscopy from a tertiary care centre.

Laparoscopic simple nephrectomy (LSNx) is among the gold standard options for management of selected poorly functioning and most non-functioning kidneys (PFK/NFKs). Our objective was to audit our patients who had undergone LSNx for benign causes and assess their perioperative outcomes and analyse the factors correlating with these outcomes. We reviewed our prospectively collected data of patients with PFK/NFKs due to benign causes who underwent a LSNx on a three-dimensional (3D) system via a transperitoneal approach between January 2017 and June 2023. Details on clinical profile, radiological findings and peri-operative details were recorded and analysed. A total of 302 patients underwent LSNx in the study duration. Urolithiasis was the most common cause of PFK/NFKs in 66.5% of patients followed by pelvi-ureteric junction obstruction in 14.9%. Rate of conversion to open surgery was 5.3%. Final histopathology revealed chronic pyelonephritis in 82% patients and Xanthogranulomatous pyelonephritis (XGPN) in 14%. Multivariate analysis revealed presence of pre-operative fat stranding on imaging, larger kidney size, presence of XGPN and pyonephrosis to be significantly associated with longer operation times. Prior renal surgery, positive urine culture, presence of XGPN and a higher body mass index was associated with a longer hospital stay and increased rate of post-operative complications. LSNx is commonly employed for management of PFK/NFKs from various aetiologies, the most common of which is urolithiasis in our experience. Multiple clinico-radiological factors as described correlated with longer operative times and prolonged hospital stay, which aids in surgical planning and patient counselling.

Impact of CT-determined low kidney volume on renal function decline: a propensity score-matched analysis

ObjectivesTo investigate the relationship between low kidney volume and subsequent estimated glomerular filtration rate (eGFR) decline in eGFR category G2 (60–89 mL/min/1.73 m2) population.MethodsIn this retrospective study, we evaluated 5531 individuals with eGFR category G2 who underwent medical checkups at our institution between November 2006 and October 2017. Exclusion criteria were absent for follow-up visit, missing data, prior renal surgery, current renal disease under treatment, large renal masses, and horseshoe kidney. We developed a 3D U-net-based automated system for renal volumetry on CT images. Participants were grouped by sex-specific kidney volume deviations set at mean minus one standard deviation. After 1:1 propensity score matching, we obtained 397 pairs of individuals in the low kidney volume (LKV) and control groups. The primary endpoint was progression of eGFR categories within 5 years, assessed using Cox regression analysis.ResultsThis study included 3220 individuals (mean age, 60.0 ± 9.7 years; men, n = 2209). The kidney volume was 404.6 ± 67.1 and 376.8 ± 68.0 cm3 in men and women, respectively. The low kidney volume (LKV) cutoff was 337.5 and 308.8 cm3 for men and women, respectively. LKV was a significant risk factor for the endpoint with an adjusted hazard ratio of 1.64 (95% confidence interval: 1.09–2.45; p = 0.02).ConclusionLow kidney volume may adversely affect subsequent eGFR maintenance; hence, the use of imaging metrics may help predict eGFR decline.Critical relevance statementLow kidney volume is a significant predictor of reduced kidney function over time; thus, kidney volume measurements could aid in early identification of individuals at risk for declining kidney health.Key points• This study explores how kidney volume affects subsequent kidney function maintenance.• Low kidney volume was associated with estimated glomerular filtration rate decreases.• Low kidney volume is a prognostic indicator of estimated glomerular filtration rate decline.Graphical

Cardiac damage following renal ischemia reperfusion injury increased with excessive consumption of high fat diet but enhanced the cardiac resistance to reperfusion stress in rat

Renal ischemia-reperfusion (IR) injury inflicts remote cardiac dysfunction. Studies on rats fed with a high-fat diet (HD) showed contradictory results: some demonstrated increased sensitivity of the heart and kidney to IR injury, while others reported resistance. In this study, we examined cardiac dysfunction and compromised cardiac tolerance associated with renal IR in HD and standard diet (SD) fed rats. Male Wistar rats fed with HD or SD diet for 16 weeks were subjected to either renal sham or IR protocol (bilateral clamping for 45 min and reperfusion for 24 h). The hearts isolated from these rats were further subjected to normal perfusion or IR procedure to study cardiac response. Renal IR surgery negatively affected cardiac function with substantial changes in the cardiac tissues, like mitochondrial dysfunction, elevated oxidative stress, and inflammation. HD-fed rat hearts exhibited hypertrophy at the end of 16 weeks, and the consequential impact on the heart was higher in the animals underwent renal IR surgery than with sham surgery. However, the IR induction in the isolated heart from renal sham or renal IR operation showed significant tissue injury resistance and better physiological recovery in HD-fed rats. However, in SD-fed rats, only hearts from renal IR-operated rats showed resistance to cardiac IR, whereas hearts from renal sham-operated rats were more susceptible to IR damage. The augmented IR resistance in the heart with prior renal surgery was due to preserved mitochondrial bioenergetics function, reduced oxidative stress, and activation of the PI3K/AKT signaling axis.

Transperitoneal Laparoscopic and Robotic Partial Nephrectomy for Renal Cancer in Patients with Previous Abdominal Surgery: a Single Centre Experience

Patients with previous abdominal surgery are at an increased risk of peritoneal adhesions, which may complicate transperitoneal surgery. The objective of this article is to report single centre experience with transperitoneal laparoscopic and robotic partial nephrectomy for renal cancer in patients with previous abdominal surgery. We evaluated data from 128 patients who underwent laparoscopic or robotic partial nephrectomy from January 2010 to May 2020. Patients were divided into three groups according to the localization of main previous surgery: in the upper contralateral abdominal quadrant, in the upper ipsilateral abdominal quadrant or in the middle line, in lower abdominal quadrants. Each group was divided into two subgroups (laparoscopic/robotic partial nephrectomy). We separately analysed data of indocyanine green-enhanced robotic partial nephrectomy. Our study did not find significant difference in the rate of intraoperative or postoperative complications between any of the groups. The type of partial nephrectomy (robotic or laparoscopic) affected the surgery time, blood loss, and length of stay in hospital, but did not significantly influence the frequency of complications. Partial nephrectomy in group of patients with prior renal surgery led to a higher rate of intraoperative low-grade complications. We did not observe more favourable results for indocyanine green-enhanced robotic partial nephrectomy. The location of previous abdominal surgery does not influence the rate of intraoperative or postoperative complications. The type of partial nephrectomy (robotic or laparoscopic) does not affect the frequency of complications.

CT imaging of acute and chronic pyelonephritis: a practical guide for emergency radiologists

Contrast-enhanced CT is not routinely indicated in uncomplicated urinary infections, but it may be necessary in patients with specific risk factors (i.e., diabetes, immunocompromised patients, history of stones, or prior renal surgery) or in patients not responding to antibiotics and in detecting complications of pyelonephritis. CT is the gold standard for imaging assessment of pyelonephritis severity. Imaging appearance of acute pyelonephritis, including focal (i.e., wedge-shaped zones of decreased attenuation or hypodense mass) and diffuse (i.e., global enlargement, poor parenchymal enhancement, lack of excretion of contrast, fat stranding) forms, needs to be differentiated from renal infarction, renal lymphoma, and interstitial nephritis. Chronic pyelonephritis-which appears as focal polar scars with underlying calyceal distortion, global atrophy, and hypertrophy of residual tissue-may mimic at imaging lobar infarcts. This pictorial essay reviews the CT imaging appearance of acute and chronic pyelonephritis, their uncommon subtypes, and their complications, with key features for early diagnosis. Their knowledge is crucial for emergency and abdominal radiologists to avoid misdiagnosis with malignancy and to guide the clinician towards the appropriate medical or surgical treatment.

Selecting the surgical approach in complex reoperative partial nephrectomies: Does robotics have a role?

658 Background: Minimally invasive surgery (MIS) has shown equal oncologic efficacy as the open approach for treating small renal masses but results in improved perioperative parameters. Surgical principles also dictate that the open technique should be considered when facing difficult surgeries though this is experience and not evidenced based. The goal of our study is to explore differences in outcomes amongst open or robotic approaches in complex reoperative partial nephrectomies. Methods: 194 patients who had prior renal surgery from 2008 to 2019 were identified, the majority of which presented with multiple tumors due to known or suspected hereditary kidney cancer syndrome. Patients were stratified into the following cohorts based on surgical history: open after open surgery, open after MIS, robotic after open surgery, and robotic after MIS. Perioperative outcomes were compared amongst cohorts. Results: Significant differences were noted in estimated blood loss (EBL), number of tumors resected, and postoperative complications as assessed by Clavien score. Univariate regression analysis of EBL showed that the number of tumors resected (p <.0001, coefficient: 111 ml), number of prior renal procedures (p=.012, coefficient: 419 ml), hilar clamping (p = .015, coefficient: 840 ml), and intended surgical approach (p = .001; coefficient: 905 ml) were significant. On multivariate analysis, number of tumors resected (p<.0001, coefficient: 97 ml) was the only significant factor. Univariate analysis on post-operative complications showed that number of prior surgeries (p = 0.03, OR: 1.5) and final intended approach (p < .0001, OR: 4.6) were significant. On multivariate analysis, the final intended surgical approach (p = .001, OR: 4.3) was shown to be significant. Conclusions: These data show that the surgical approach of prior procedures is not a significant factor that affects perioperative outcomes, but the use of robotic surgery was associated with decreased post-operative complications in reoperative renal surgery . While open surgery will likely continue to be the standard of care for complex reoperative procedures, these data suggest that robotic surgery is safe and well tolerated in select cases.

Tubeless Pediatric Percutaneous Nephrolithotomy: Assessment of Feasibility and Safety.

Introduction:Tubeless pediatric percutaneous nephrolithotomy (TL-PCNL) is evolving and adult criteria are being safely applied to children. We examine the feasibility, safety, and outcomes of pediatric TL.Materials and Methods:A retrospective review of pediatric (≤18 years) PCNL patients at our institute was done. Patients eligible for TL but underwent tube (T) PCNL due to surgeon choice or protocol were compared with TL. Only children with 100% stone clearance were included, and those receiving nephrostomy for intraoperative complications were excluded from the study. Demographic, baseline, and stone characteristics were matched. Safety, outcome, and complications were assessed. Group T was classified into large bore (22F-LB) and small bore (16F-SB) based on nephrostomy size. Statistical analysis was done.Results:A total of 46 children were eligible - TL in 17 (37%) and T in 29 (63%). Among T, SB was performed in 6/29 (20.7%) and LB in 23/29 (79.3%). TL had fewer complications. Urinary leak developed in 2 (6.9%) patients in T. Eight (27.6%) patients in T and 3 (17.7%) patients in TL had supracostal access with complications similar to infracostal access. SB had significantly lesser and analgesic requirement than LB. SB and TL had similar LOH and analgesic requirement. Adult expanded criteria such as supracostal access, 2 punctures, prior renal surgery, and larger tract size were feasible.Conclusions:TL is safe, feasible, and less morbid alternative to T in uncomplicated pediatric nephrolithiasis. TL is feasible with supracostal access, 2 punctures, adult tract size (24F), and anomalous kidneys. SB nephrostomy is reasonable when tube is indicated.

MP78-19 DO RENIN-ANGIONTENSIN BLOCKERS AFFECT RENAL FUNCTION AND ADVERSE OUTCOMES IN PATIENTS UNDERGOING PARTIAL NEPHRECTOMY?

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging II1 Apr 2016MP78-19 DO RENIN-ANGIONTENSIN BLOCKERS AFFECT RENAL FUNCTION AND ADVERSE OUTCOMES IN PATIENTS UNDERGOING PARTIAL NEPHRECTOMY? Yaw A. Nyame, Helen Liang, Hans Arora, Bradley Gill, Peter Caputo, Daniel Ramirez, Khaled Fareed, Robert Stein, Georges-Pascal Haber, Andrew J. Stephenson, Amr Fergany, and Jihad Kaouk Yaw A. NyameYaw A. Nyame More articles by this author , Helen LiangHelen Liang More articles by this author , Hans AroraHans Arora More articles by this author , Bradley GillBradley Gill More articles by this author , Peter CaputoPeter Caputo More articles by this author , Daniel RamirezDaniel Ramirez More articles by this author , Khaled FareedKhaled Fareed More articles by this author , Robert SteinRobert Stein More articles by this author , Georges-Pascal HaberGeorges-Pascal Haber More articles by this author , Andrew J. StephensonAndrew J. Stephenson More articles by this author , Amr FerganyAmr Fergany More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1975AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The cardiothoracic literature recently suggested that cessation of renin-angiotensin system (RAS) blockers may increase the risk of adverse perioperative outcomes. Some surgeons hold RAS blockers and other medications affecting renal function in the immediate post-operative period following renal surgery. This study assessed the effects of RAS blocker resumption on renal function and adverse outcomes after robotic-assisted laparoscopic partial nephrectomy (RALPN). METHODS A retrospective analysis of patients who underwent RALPN at a large academic medical center from 2006- 2014 was performed. Relevant covariates perioperative glomerular filtration rate (GFR) and postoperative adverse events were collected via review of the electronic medical record. Patients were classified as having either immediate (postoperative day 1) or delayed (at or after discharge) resumption of RAS blockade. Patients with prior renal surgery, planned staged renal surgeries, or a history of solitary kidney were excluded. Comparative statistics were performed with Wilcoxon rank-sum and ?2 tests. Data are presented as median (interquartile range). RESULTS A cohort of 901 patients with median follow-up of 10.4(1.4-30.8) months was identified. Median age of patients on RAS blockers was 63.0 (56.0-70.0) compared to 57.0 (49.0-66.0) years in those without (p < 0.001), and 40.7% of patients were women. In total, 338 patients were on RAS blockade at the time of surgery with 219/338 (64.8 %) on angiotensin converting enzyme inhibitors and 119/338 (35.2%) on angiotensin receptor blockers. Of these patients, 137 (41.9 %) resumed RAS blockade immediately. Among patients on RAS blockade, immediate resumption did not significantly impact postoperative day 3 GFR [70.1(54.4-87.4) vs 69.9 (56.1-84.0) p = 0.81]. Similarly immediate versus delayed RAS blockade resumption did not significantly change stage 4-5 CKD rates (GFR < 30 ml/min) at last recorded follow-up (3.3% vs. 4.3%, p = 0.45). There was no significant difference in postoperative cardiovascular events (arrhythmia or infarction), with or without immediate RAS blocker resumption (6.6% vs. 4.7%, p = 0.47). However, with malignancy on final pathology, immediate RAS blockade resumption was associated with significantly decreased mortality (0.10%; p = 0.02). CONCLUSIONS RAS blockers appear safe to continue immediately postoperatively in patients undergoing RALPN. Despite increased age, immediate resumption of RAS blockers was associated with improved survival in patients with cancer on final pathology. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1033-e1034 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Yaw A. Nyame More articles by this author Helen Liang More articles by this author Hans Arora More articles by this author Bradley Gill More articles by this author Peter Caputo More articles by this author Daniel Ramirez More articles by this author Khaled Fareed More articles by this author Robert Stein More articles by this author Georges-Pascal Haber More articles by this author Andrew J. Stephenson More articles by this author Amr Fergany More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outlining the limits of partial nephrectomy.

Amongst nephron-sparing modalities, partial nephrectomy (PN) is the standard of care in the treatment of renal cell carcinoma (RCC). Despite the increasing utilization of PN, particularly propagated by robot-assisted, minimally invasive approaches for small renal masses (SRMs), the limits of PN appear to be also evolving. In this review, we sought to address the tumour stage beyond which PN may be oncologically perilous. While the evidence supports PN in the treatment of tumours < pT2a, PN may have a role in advanced or metastatic RCC. Other scenarios wherein PN has limited utility are also explored, including anatomical or surgical factors that dictate the difficulty of the case, such as prior renal surgery. Lastly, we discuss the emerging role of molecular biomarkers, specifically epigenetics, to aid in the risk stratification of SRMs and to select tumours optimally suited for PN.

Complete supine percutaneous nephrolithotomy (csPCNL) in patients with and without a history of stone surgery: safety and effectiveness of csPCNL

To determine the effects of previous stone surgery on the results of complete supine percutaneous nephrolithotomy (csPCNL), we reviewed 81 patients undergoing csPCNL at our center between March 2008 and March 2009. The principal aim in our study was whether prior renal surgery affects the outcome of PCNL. The results of the study were analyzed using SPSS 11 software. Our patients were divided to in two groups. Group 1 consisted of patients with a previous history of renal stone surgery and group 2 consisted of patients without history of renal surgery. Mean operative time in group 1 was 98.75±56.31min, and in group 2 99.71±45.9min (p=0.93). Bleeding requiring transfusion occurred in four (14.2%) patients in group 1, and in eight (15.09%) patients in group 2 (p=0.826). Fever was detected in no patients in group 1, and in four (7.5%) patients in group 2 (p=0.136). Postoperative hematoma was seen in one (3.5%) patient in group 1 and in no patient in group 2 (p=0.166). Other major complications including extravasations, sepsis, pleural effusion, pelvis perforation, and visceral organ trauma were not seen in any groups. This is the first experience of csPCNL in patients with and without a previous history of renal surgery. We found that there was no difference in results between the two groups that underwent complete supine PCNL. So csPCNL in patients with a history of stone surgery can be safe and effective. csPCNL offers the potential advantages of less patient handling, easier access to the urethra, easier possibility of changing spinal or regional anesthesia to general anesthesia if needed, better airway control and less hazard, especially for patients with compromised cardiopulmonary function, morbid obesity, or those who require a prolonged procedure and easier access to upper calyx. Its popularity is still minimal in the field of urology as a whole, because of fear of colon injury and a lack of training in this position in educational centers.

Flank bruits due to giant renal arteriovenous malformation.

A 58-year-old woman was referred to the nephrology department because of a continuous bruit over the right flank heard by her primary care physician. Blood pressure was 120/80 mmHg. Complete blood count and urinary analysis were within normal limits. She had no history of prior renal surgery or trauma. A large cyst-like lesion at the right kidney with turbulent blood flow was found on colour Doppler ultrasound. Volume-rendered computed tomography (CT) angiography (Figure 1A) demonstrated giant cirsoid aneurysmal dilations of the right renal artery with early opacification of right renal vein (arrow) and inferior vena cava (arrowhead), indicating congenital renal arteriovenous malformations (AVMs). Therefore, right renal artery angiography (Figure 1B) confirmed the diagnosis of right giant renal AVMs by demonstrating cirsoid arterial communication with early visualization of the right renal vein (arrow) and inferior vena cava (arrowhead). At the same time, endovascular embolization of right AVMs was performed successfully with preservation of renal parenchymal vascular supply. The patient’s post-operative course was uneventful, and she was well 6 months later. Fig. 1 Volume-rendered computed tomography angiography (A) showing giant cirsoid aneurysmal dilations of right renal artery with early opacification of right renal vein (arrow) and inferior vena cava (arrowhead), indicating of congenital renal arteriovenous ... Renal AVMs are an uncommon disease of abnormal communications between intrarenal arterial and venous systems. These malformations can be congenital or acquired due to trauma, surgery and tumours. Acquired AVMs are often termed renal arteriovenous fistula. Congenital AVMs are a rare disease and account for 25% of renal AVMs [1]. Most congenital AVMs are asymptomatic. Symptomatic AVMs usually present with microscopic or gross haematuria, abdominal pain and flank bruit [2]. Renal Doppler sonography is a non-invasive tool that can help in distinguishing vascular lesions from cystic lesions based on a turbulent blood flow [3]. Renal CT angiography showed a typical appearance of cirsoid arterial communication with early visualization of inferior vena cava, indicating congenital arteriovenous malformations. Renal arteriography is still the gold standard modality which can help in a clearly visualization of abnormal vessels with early draining veins and the nidus of the AVM. Transcatheter embolization of renal AVMs can successfully obliterate the nidus of AVMs and preservation of renal normal parenchyma with reduced morbidity in comparison with surgical resection of renal AVMs [4]. Conflict of interest statement. None declared.

Complications after percutaneous radiofrequency ablation of renal tumors

ObjectivesTo evaluate our experience with percutaneous radiofrequency ablation (pRFA) to determine common characteristics of patients with complications, to elucidate possible relative contraindications to therapy. MethodsMedical records of all patients undergoing pRFA were reviewed for demographic data, medical and surgical history, indication, tumor characteristics, and treatment information (complications and management). The group of patients with complications was analyzed for common characteristics. ResultsFrom January 2000 to September 2003, 24 patients (mean age 61 years, 5:1 male/female) with 32 renal tumors were treated with pRFA. Indications for pRFA included prior renal surgery and/or chronic renal insufficiency, significant medical disease, patient choice, von Hippel-Lindau disease, and treatment of a metastasis. Average pretreatment tumor size was 2.4 cm (range 0.5–8.6 cm). Of the 5 patients experiencing complications from pRFA treatment, 2 developed perinephric hematomas, 1 had a persistent urinoma and proximal ureteral stricture, and 2 had colonic injuries. Among patients with complications, 3 of 5 had undergone prior partial nephrectomy on the pRFA-treated kidney. Two of four patients treated for multiple tumors and 57% of patients (4 of 7) with anteriorly located tumors experienced complications. ConclusionsEarly experience with pRFA for renal tumor seems promising, but patient selection criteria are evolving. On the basis of our limited experience, we recommend caution when using renal pRFA in patients with prior partial nephrectomy, multiple tumors treated in the same setting, and tumors located anteriorly or centrally. Further clinical experience will help establish guidelines for the use of this powerful technology in the management of renal tumors.

Failed percutaneous balloon dilation for renal access: Incidence and risk factors

Objectives To present our experience using balloon dilation and discuss secondary techniques to establish a percutaneous tract when balloon dilation fails. Balloon dilation is a safe and effective method to achieve percutaneous renal access, but it is not uniformly successful. Also, the failure rate and risk factors have not been well documented. Methods We retrospectively reviewed our last 99 consecutive percutaneous renal procedures using a balloon system as our initial dilation modality. In all cases, the urologist achieved needle access. We determined the balloon failure rate, relationship to prior renal surgery and other patient-related factors, and success rate using secondary techniques of tract dilation. Results The balloon did not adequately dilate a tract in 17 (17% failure rate) of 99 cases. The risk factors for failure included a history of prior ipsilateral renal surgery (25% failure rate versus 8% without surgery) and subcostal compared with supracostal puncture (18% versus 9% failure rate). The failure rate was not increased when stratified by laterality, stone composition, stone size and location, or history of ipsilateral renal infection. Amplatz dilators were used in 16 refractory cases and were successful in 15. Metal Alken dilators were successfully used in 2 patients. Conclusions The balloon dilation system is commonly used as the primary modality to establish percutaneous renal access. Although safe and effective (83%), the success rate drops dramatically in patients with prior ipsilateral renal surgery. Knowledge and skill with alternative dilation systems, such as Amplatz or metal Alken dilators, are necessary to successfully gain entry into all renal collecting systems.