Renal Beds Research Articles

Renal infarction by cannabis consumption

Renal infarction is a rare cause for an acute renal failure. At the time being, there is no sufficient correlation to the consumption of cannabis described. A 40-year-old male patient presented to our emergency room because of pain in the right renal bed. The duplex ultrasound showed no ectasia, but the computed tomography confirmed a renal infraction on the right side. The further diagnostics gave no indication of a classical pathogenesis, but there was a constant consumption of cannabis documented. We decided for a conservative treatment with analgesia, diagnostic laboratory controls and anticoagulants because of the prolonged process. The complaints decreased. The correlation between thrombo-embolic events and the consumption of cannabis has to be more explored because of its recent legalization in Germany. It should be considered as a cardiovascular risk factor. Until today there are no recommendations for the anticoagulants.

Recruitment of neutrophils in glomeruli in early mouse sepsis is associated with E-selectin expression and activation of endothelial NF-κB and MAPK pathways.

Sepsis is a dysregulated systemic inflammatory response to an infection, which can lead to multiple organ dysfunction syndrome that includes the kidney. Leukocyte recruitment is an important process of the host immune defense in response to sepsis. Endothelial cells (EC) actively regulate leukocyte recruitment by expressing adhesion molecules following the activation of dedicated intracellular signal transduction pathways. Previous studies reported that the expression of adhesion molecules was associated with the activation of endothelial NF-κB p65 and MAPK c-Jun pathways in vitro in response to conditions that mimic processes that occur in inflammation. This study aimed to investigate the spatiotemporal patterns of leukocyte recruitment, expression of adhesion molecules, and endothelial nuclear p65 and c-Jun localization in renal microvascular beds of septic mice. Here, we used a cecal ligation and puncture (CLP) sepsis mouse model and RT-qPCR and immunohistochemical staining. We showed that neutrophils, macrophages, and T lymphocytes were all present in the kidney, yet only neutrophils accumulated in a spatiotemporally discernible pattern, mainly in glomeruli at 4 hours after CLP-sepsis initiation. E-selectin, not VCAM-1, was expressed in glomeruli at the same time point. In a subset of mice at 72 hours after CLP-sepsis started, VCAM-1 expression was prominent in glomerular EC, which was not related to changes in mmu-microRNA(miR)-126a-3p levels, a short noncoding microRNA previously shown to inhibit the translation of VCAM-1 mRNA into protein. Nuclear localization of p65 and c-Jun occurred in EC of all microvascular segments at 4 and 7 hours after CLP-sepsis initiation. In summary, sepsis-induced recruitment of neutrophils, E-selectin expression, and NF-κB p65 and MAPK c-Jun pathway activation coincided in glomeruli at the early stage of the disease. In the other microvascular beds, sepsis led to NF-κB p65 and MAPK c-Jun pathway activation with limited expression of E-selectin and no association with VCAM-1 expression or leukocyte recruitment.

The effect of 11th rib excision on perioperative outcomes in patients undergoing partial nephrectomy for upper pole renal tumors

IntroductionWe aimed to evaluate the effect of eleven11th rib resection.on the perioperative period TRIFECTA criteria in patients who underwent retroperitoneal partial nephrectomy (PN) with the diagnosis of upper pole kidney tumors.Materials and methodsWe conducted a retrospective analysis of the data of the patients who underwent Open PN for upper pole renal masses between 2018 and 2023. The patients were divided into two groups: PN with rib resection and PN without rib resection. The demographic characteristics, tumor sizes, PADUA scores, warm–cold renal ischemia times, mass excision and tumor bed suturing times, histopathological tumor type and surgical margin positivity of the patients were examined. Both groups were evaluated comparatively based on this data.ResultsThe renal nephrometry scores of the two groups were similar. The total renal ischemia time was significantly shorter in the patients who underwent a rib resection than in those who did not (p < 0.001). Both the tumor excision and tumor bed suturing times were significantly shorter in the group that underwent a rib resection than in the group that did not (p < 0.001). The Clavien–Dindo complication grades were statistically similar between the two groups.ConclusionComplex in nature and high–risk renal masses located in the upper pole of the kidney, partial nephrectomy performed with an 11th rib resection can be considered a reliable surgical option with a shorter ischemia time, supporting the preservation of long-term renal function.

Pre-gerotal fat patch-A novel alternative to haemostatic agents during partial nephrectomy.

This study aimed to determine if using a pre-gerotal fat patch at open partial nephrectomy (PN) as a haemostatic bolster is a viable alternative to using synthetic haemostatic agents. Human Research Ethics Committee approval was obtained for audit of a prospectively kept database from July 2012 to July 2021, which followed outcomes of patients who received a low-tension pre-gerotal fat patch renorrhaphy at open PN. Patient demographics, intraoperative measures, histological outcomes and post-operative complications were analysed. Using a retroperitoneal approach, the peritoneum was mobilised and a vascularised pedicle of pre-gerotal fat was rotated in the direction of the kidney. Routine definition of the hilum, clamping of the hilar vessels and dissection of mass followed. After watertight closure and haemostasis, the harvested pre-gerotal fat patch was placed over the defect and secured using low-tension renorrhaphy. Two-layer closure of the abdominal wall with placement of a drain was routine. A total of 55 patients underwent open PN. Mean age was 60.4 (35-77) years. There were 38 men and 17 women, and 32 right and 23 left PNs. Mean mass size was 31.9 mm (10-95 mm) and collecting system was breached in 36.5% of cases. One patient (1.9%) suffered a Clavien-Dindo IIIb complication requiring return to theatre and transfusion due to a bleed from an intercostal artery. There were no renal bed bleeds, urine leaks or urine fistulas detected. Mean intraoperative blood loss was 355 mL (50-1500 mL) and mean post-operative creatinine increased by 10.7 μmol/L (51-172 μmol/L). Mean follow up was 40.2 (4-109) months. Utilisation of an anatomical pre-gerotal fat patch to provide pressure at the renorrhaphy site during open PN is an effective technique to assist with surgical haemostasis. This simple technique avoids the costs of haemostatic agents, whilst adding minimal operating time to procedures.

Prolonged life-threatening anaphylaxis to Floseal during partial nephrectomy: A case report

Abstract Floseal Hemostatic Matrix is a topical hemostatic agent used across specialties and commonly applied to the renal bed during partial nephrectomy. Here we present the first adult case of Floseal allergy in the literature and the second case of a topical gelatin hemostatic agent. A 62-year-old man underwent partial nephrectomy for a Bosniak type IV cyst. After unclamping the kidney, the patient declined precipitously, later determined due to an anaphylactic reaction to the Floseal placed on the renal bed. The patient had a prolonged anaphylactic reaction that required ionotropic support for over 24 h, possibly due to continued exposure. His tryptase level was elevated, and allergy testing revealed an allergy to the gelatin matrix component of the Floseal. Floseal anaphylaxis should be considered during episodes of cardiovascular collapse after drug administration. However, consideration should be given to removing it to prevent continued exposure and weighed against the risk of prolonged surgery in an anaphylactic patient.

A novel functional role for the classic CNS neurotransmitters, GABA, glycine, and glutamate, in the kidney: potent and opposing regulators of the renal vasculature.

The presence of a renal GABA/glutamate system has previously been described; however, its functional significance in the kidney remains undefined. We hypothesized, given its extensive presence in the kidney, that activation of this GABA/glutamate system would elicit a vasoactive response from the renal microvessels. The functional data here demonstrate, for the first time, that activation of endogenous GABA and glutamate receptors in the kidney significantly alters microvessel diameter with important implications for influencing renal blood flow. Renal blood flow is regulated in both the renal cortical and medullary microcirculatory beds via diverse signaling pathways. GABA- and glutamate-mediated effects on renal capillaries are strikingly similar to those central to the regulation of central nervous system capillaries, that is, exposing renal tissue to physiological concentrations of GABA, glutamate, and glycine led to alterations in the way that contractile cells, pericytes, and smooth muscle cells, regulate microvessel diameter in the kidney. Since dysregulated renal blood flow is linked to chronic renal disease, alterations in the renal GABA/glutamate system, possibly through prescription drugs, could significantly impact long-term kidney function.NEW & NOTEWORTHY Functional data here offer novel insight into the vasoactive activity of the renal GABA/glutamate system. These data show that activation of endogenous GABA and glutamate receptors in the kidney significantly alters microvessel diameter. Furthermore, the results show that these antiepileptic drugs are as potentially challenging to the kidney as nonsteroidal anti-inflammatory drugs.

MP69-17 NECESSITY OF PROPHYLACTIC DRAINAGE TUBE IN RETROPERITONEAL LAPAROSCOPIC NEPHROURETERECTOMY WITH OPEN DISTAL URETERECTOMY: A MATCHED-PAIR ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP69-17 NECESSITY OF PROPHYLACTIC DRAINAGE TUBE IN RETROPERITONEAL LAPAROSCOPIC NEPHROURETERECTOMY WITH OPEN DISTAL URETERECTOMY: A MATCHED-PAIR ANALYSIS Hiroki Hagimoto, Mutsushi Kawakita, and Toshinari Yamasaki Hiroki HagimotoHiroki Hagimoto More articles by this author , Mutsushi KawakitaMutsushi Kawakita More articles by this author , and Toshinari YamasakiToshinari Yamasaki More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003332.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To assess the necessity of prophylactic drain placement in retroperitoneal laparoscopic nephroureterectomy with open distal ureterectomy for upper tract urothelial cancer. METHODS: Between July 2011 and March 2021, 200 patients with localized clinical Tis-T3 upper urinary tract urothelial carcinoma underwent laparoscopic nephroureterectomy with open distal ureterectomy. After removing the specimen, drainage tubes were placed on the renal beds and/or in the retrovesical spaces. Drain tubes were omitted for most patients after 2017. We compared the postoperative outcomes between the patients with drain placement (D+ group) and without drain placement (D- group) by propensity score matching. RESULTS: A total of 164 patients (90 in the D+ group and 74 in the D- group) were enrolled, and matched pairs of 108 patients were analyzed. There was no significant difference in the incidence of complications according to Clavien–Dindo grade in the two groups after the propensity score matching. There was no significant difference in the incidence of postoperative lymphocele (n=5 vs. 9, p=0.395) and symptomatic lymphocele (n=1 vs. 1, p=1) between the two groups. The length of hospital stay was significantly shorter in the D- group (11 vs. 8 days, p<0.0001). CONCLUSIONS: Omitting the drainage tube after laparoscopic radical nephroureterectomy does not increase postoperative complications or lymphocele and shortens the post-hospital stay. Source of Funding: No funding © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e971 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hiroki Hagimoto More articles by this author Mutsushi Kawakita More articles by this author Toshinari Yamasaki More articles by this author Expand All Advertisement PDF downloadLoading ...

Necessity of prophylactic drainage tube in retroperitoneal laparoscopic nephroureterectomy with open distal ureterectomy: Amatched-pair analysis.

To assess the necessity of prophylactic drain placement in retroperitoneal laparoscopic nephroureterectomy with open distal ureterectomy for upper tract urothelial cancer. Between July 2011 and March 2021, 200 patients with localized clinical Tis-T3 upper urinary tract urothelial carcinoma underwent laparoscopic nephroureterectomy with open distal ureterectomy. After removing the specimen, drainage tubes were placed on the renal beds and/or in the retrovesical spaces. Drain tubes were omitted for most patients after 2017. We compared the postoperative outcomes between the patients with drain placement (D+ group) and without drain placement (D- group) using propensity score matching. A total of 164 patients (90 in the D+ group and 74 in the D- group) were enrolled, and matched pairs of 108 patients were analyzed. There was no significant difference in the incidence of complications according to Clavien-Dindo grade in the two groups after the propensity score matching. There was no significant difference in the incidence of postoperative lymphocele (n=5 vs. 9, p=0.395) and symptomatic lymphocele (n=1 vs. 1, p=1) between the two groups. The length of hospital stay was significantly shorter in the D- group (11 vs. 8 days, p < 0.0001). We found that omitting the drainage tube after laparoscopic radical nephroureterectomy did not increase postoperative complications or lymphocele and shortened the post-hospital stay.

A peptide fraction from hardened common beans (Phaseolus vulgaris) induces endothelium-dependent antihypertensive and renal effects in rats

Beans reached the research spotlight as a source of bioactive compounds capable of modulating different functions. Recently, we reported antioxidant and oxidonitrergic effect of a low molecular weight peptide fraction (<3 kDa) from hardened bean (Phaseolus vulgaris) in vitro and ex vivo, which necessitate further in vivo assessments. This work aimed to evaluate the hypotensive effect and the involved physiological mechanisms of the hardened common bean peptide (Phaseolus vulgaris) in normotensive (Wistar) and hypertensive (SHR) animals. Bean flour was combined with a solution containing acetonitrile, water and formic acid (25: 24: 1). Protein extract (PV3) was fractioned (3 kDa membrane). We assessed PV3 effects on renal function and hemodynamics of wistar (WT–normotensive) and spontaneously hypertensive rats (SHR) and measured systemic arterial pressure and flow in aortic and renal beds. The potential endothelial and oxidonitrergic involvements were tested in isolated renal artery rings. As results, we found that PV3: I) decreased food consumption in SHR, increased water intake and urinary volume in WT, increased glomerular filtration rate in WT and SHR, caused natriuresis in SHR; II) caused NO- and endothelium-dependent vasorelaxation in renal artery rings; III) reduced arterial pressure and resistance in aortic and renal vascular beds; IV) caused antihypertensive effects in a dose-dependent manner. Current findings support PV3 as a source of bioactive peptides and raise the potential of composing nutraceutical formulations to treat renal and cardiovascular diseases.

Conformal Pencil Beam Scanning Proton Therapy for Delivery of Flank Radiation in Children with Renal Tumors

<h3>Purpose/Objective(s)</h3> Post-operative flank radiotherapy (RT) is standard for many children with renal tumors for treatment of microscopic disease in the retroperitoneal (RP) renal bed/ para-aortic lymph nodes (PALN). Standard APPA X-ray (XRT) fields include normal tissues (NT) within abdomen not at risk for malignant contamination, and do not conform to RP region. We report results of planned interim analysis from a study evaluating use of conformal pencil beam scanned proton therapy (PBS) for RT of RP. <h3>Materials/Methods</h3> Patients (pts) were enrolled on Phase II trial with IRB approval; eligibility included Wilms tumor or clear cell sarcoma of kidney (CCSK) requiring flank-only RT according to Children's Oncology Group guidelines. Primary endpoint: toxicity (CTCv4.0). Secondary endpoints: patient reported outcomes (PRO), NT dosimetry, local recurrence (LR), and overall survival (OS). After 4D simulation, pre-operative images were fused. Superior/ inferior/ lateral GTV were determined by pre-op disease extent, with 1cm tool used to contour RP space; GTV was expanded 1cm to create CTV; PALN included when involved. Standard RT (10.8 Gy/6 fx) was condensed to 10 Gy/5 fx. Normal tissue constraints (NTC) included kidney (CK) (V80<10Gy), cord (max 12Gy), heart (max 11Gy, V50<10Gy), liver (V70<20Gy). <h3>Results</h3> From 1/2018-12/2021, 11 pts enrolled with planned interim analysis after 10th: 8 boys/3 girls, 6 black/ 5 white, median age 3y (range 1-9 y), 2 with clinical Beckwith-Wiedemann syndrome, 7 requiring daily anesthesia. Nine had unilateral (UL) tumors (5 left-sided, 8 Wilms tumor (7 favorable histology, 2 diffuse anaplasia (DA)), 1 CCSK); 2 had bilateral Wilms with UL DA. Overall stage was I (1), II (2), III (4), IV (2), V (2) and local I (2), II (2), III (7). All had chemotherapy, 8 pre-operatively. Total dose was 10 Gy/ 5 fx for 9 pts given in one week; 2 required additional 9 Gy for unresected PALN (1) and positive margin (1). PBS was delivered to CTV using two energy-degraded beams from 230 MeV cyclotron (posterior and posterior oblique) with daily IGRT. Of 10 pts analyzed, none experienced LR (median follow-up 26 m (range 12-48 m). One fx to 1 pt was given with x-rays due to proton downtime; no other missed fx. No pt experienced G2+ toxicity; 2 had hypertension at diagnosis which has resolved. Most common PRO were constipation (n=3), nausea (n=2), vomiting (n=1). NTC and >=98% CTV receiving >=98% of planned dose were met for all pts. Median dose to 50% of liver was 0.7 Gy (R 0.09-10), CK 1.35 Gy (R 0.3-2.8 Gy), bowel 5.1 Gy (R 1.2-11.4 Gy), compared to expected 10 Gy, 2 Gy, and 10 Gy with XRT to flank. <h3>Conclusion</h3> Based on planned interim analysis, the use of conformal PBS proton fields to treat the RP space for children requiring RT for Wilms tumor appears feasible and safe, allowing reduction in exposure of NT compared to XRT flank fields. Change in regimen from 6 to 5 fx has been well-tolerated. These findings support continuation of the planned trial.

Mechanisms of Post-critical Illness Cardiovascular Disease.

Prolonged critical care stays commonly follow trauma, severe burn injury, sepsis, ARDS, and complications of major surgery. Although patients leave critical care following homeostatic recovery, significant additional diseases affect these patients during and beyond the convalescent phase. New cardiovascular and renal disease is commonly seen and roughly one third of all deaths in the year following discharge from critical care may come from this cluster of diseases. During prolonged critical care stays, the immunometabolic, inflammatory and neurohumoral response to severe illness in conjunction with resuscitative treatments primes the immune system and parenchymal tissues to develop a long-lived pro-inflammatory and immunosenescent state. This state is perpetuated by persistent Toll-like receptor signaling, free radical mediated isolevuglandin protein adduct formation and presentation by antigen presenting cells, abnormal circulating HDL and LDL isoforms, redox and metabolite mediated epigenetic reprogramming of the innate immune arm (trained immunity), and the development of immunosenescence through T-cell exhaustion/anergy through epigenetic modification of the T-cell genome. Under this state, tissue remodeling in the vascular, cardiac, and renal parenchymal beds occurs through the activation of pro-fibrotic cellular signaling pathways, causing vascular dysfunction and atherosclerosis, adverse cardiac remodeling and dysfunction, and proteinuria and accelerated chronic kidney disease.

Bartter Syndrome in A Nigerian Child with Recurrent Vomiting

Bartter syndrome is a rare renal tubular disease characterized by hypokalemic metabolic alkalosis and renal salt wasting. There is paucity of report of this condition from Africa. We report a case of a four–year–old Nigerian boy who presented with growth failure, recurrent episodes of vomiting, features of severe dehydration and normal blood pressure warranting in–hospital care on several occasions over a period of 16 months. This patient had hypokalemia, hypochloremia, hyponatraemia and hypercalciuria. He also had abdominal x-ray findings of a triangular-shaped calcific density in the right renal bed suggestive of right medullary nephrocalcinosis. Diagnosis of Bartter syndrome was confirmed by elevated plasma renin of 8.1ng/ml/hr (normal 0.5 – 5.9). The patient was managed with intravenous normal saline, potassium chloride infusion, calcium gluconate, and then oral potassium, calcium and magnesium supplements. Follow up at the clinic revealed significant weight gain and stable clinical state. A high index of suspicion is needed for early diagnosis of this rare syndrome, particularly in children presenting with persistent vomiting, failure to thrive and dyselectrolytemia. This, invariably, will improve survival and health-related quality of life of such children, hence the need for this report.

MO350: Transfer Times for Renal Patients to a Tertiary Centre

BACKGROUND AND AIMSThe renal unit at Sunderland Royal Hospital (SRH) provides tertiary services to an area of North East England covering South Tyneside, Sunderland and County Durham. An AKI service was commenced in September 2020 at University Hospital North Durham (UHND), which is part of the County Durham and Darlington NHS Foundation Trust (CDDFT) with aims to improve recognition and treatment, support early discharge planning, and prevent severe injury for patients with AKI and renal conditions. The service comprises two specialist nurses and a team of consultant renal physicians providing in-reach at UHND across Monday–Friday 52 weeks/year, with over 700 patients seen within the first 12 months of operation.With the introduction of this service, we carried out a review of transfer times for patients requiring transfer from UHND to SRH for inpatient renal management. Delays in patient transfer between hospitals can result in deferred treatment and poor patient outcomes, hence the importance of analysing the benchmarking the first year's performance to inform future service development both regionally and nationally. With the use of this data, we hope to share our model with other teams and trusts with the goal of enhancing and streamlining the referral methods to renal services.METHODWe examined transfer data for 36 patients from CDDFT to the renal unit at SRH over a 12-month period from August 2020 to July 2021. This information looked at transfers from the time of consultant acceptance to the time of arrival on the ward and was compiled in conjunction with the AKI specialist nurses at CDDFT. Using the computer system and phone records, we were able to accurately document time of acceptance to time of arrival. Data was split into categories to enable further comparison; pre-June 2021 (when haematology patients were excluded from the inpatient ward at SRH due to protective isolation during COVID-19) increasing the availability of acute renal beds and June 2021 onwards. Additionally, we analysed patients with acute kidney injury versus those that were known to us with chronic kidney disease, and times by week days and where emergency cover is usual.RESULTSThe data showed a median time between acceptance and arrival for patients accepted pre-June 2021 of 8 h 7 min compared with 6 h 18 min from June 2021 onwards. Median time between acceptance and arrival of acute patients was 8 h 7 min compared with 6 h 35 min for chronic kidney disease patients. Acceptance and arrival times varied also depending on time of transfer; 6 h 29 min during working hours on a weekday, 9 h 23 min out-of-hours on a weekday and 8 h 48 min on a weekend. The overall median transfer time from acceptance to arrival across all categories was 7 h 38 min.CONCLUSIONCurrently, no standard national target exists for the transfer of patients to tertiary renal services, however there are ongoing discussions surrounding this and how it could be implemented. There are difficulties in compiling data to effect change in referral methods, in part due to the inter-trust movement of patients and challenges in coding; however, our initial findings support the positive impact of the AKI service at CDDFT and highlight the scope for further service development across the region. For example, in commissioning at software to streamline, process audit data using a web-based portal, accessible to all parties and extending nurse presence across 7 days due to the delayed times for weekend and evening transfers. Additionally, we were encouraged that our prevalent patients, usually dialysis recipients, experienced the shortest wait.FIGURE 1:Median Time Between Acceptance and Arrival Based on Time of Patient Transfer.

Bladder metastasis with additional metastases in multiple other organs 4 years after radical nephrectomy for clear cell renal cell carcinoma: a case report and review of the literature\xa0

BackgroundRenal cell carcinoma rarely metastasizes to the bladder, and its biological behavior is not yet fully understood.Case presentationIn our case (54-year-old Japanese woman), computed tomography evaluation suggested the presence of a bladder metastasis, associated with additional metastases in the lungs, mediastinal lymph nodes, ribs, and renal bed, 4 years after radical nephrectomy for renal cell carcinoma. The histological findings of the metastatic bladder tumor were consistent with those of clear cell carcinoma. The mediastinal lymph node, rib, and renal bed metastases responded to treatment with an immune checkpoint inhibitor administered for 12 months after surgery for the bladder and lung metastases. In patients with bladder metastasis, absence of metastases in other organs and an interval of more than 1 year after nephrectomy are known to be favorable prognostic factors. Interestingly, in our case, the bladder metastasis was detected more than 1 year after nephrectomy, which was a favorable factor, but there were also metastases in other organs, which was an unfavorable factor. Therefore, we reviewed the literature, including that pertaining to targeted therapy and immune checkpoint inhibitor therapy published in the last two decades, to analyze the clinical significance of the presence of additional metastasis in other organs in renal cell carcinoma (clear cell type, which is the predominant subtype) patients with bladder metastasis.ConclusionsPatients with bladder metastasis after nephrectomy for renal cell carcinoma also having metastases in other organs may respond to targeted therapy and immune checkpoint inhibitor therapy. This may suggest that the interval to relapse in the bladder after nephrectomy may be a more important prognostic factor than the presence of synchronous metastases in other organs.

A Review of the First 100 Cases of Laparoscopic Nephrectomy: A Single-Center Experience.

ObjectiveSince 1990, when the first laparoscopic nephrectomy was performed, there has been a dramatic increase in interest in laparoscopic procedures in urological surgeries.The aim of the study was to present our experience with the first 100 cases of laparoscopic nephrectomy at our institute, identify the difficulties encountered, and discuss how to approach the solutions.Materials and methodsThe data of all patients who underwent laparoscopic nephrectomy between May 2017 and April 2019 (n=100) were reviewed retrospectively.ResultsA total of 100 patients (49 men and 51 women), with a mean age of 34.1 ± 15.1 years, underwent laparoscopic nephrectomy. The mean operative time was 108 min (IQR, 45-240). The operative time was significantly reduced with the surgeons' experience. Of 100 cases, only four were converted to open surgery because of bleeding from the renal bed area, strong adhesions from previous surgeries, or morbid obesity. Of 100 patients, 30 were allowed intake on the same operative day while 70 were allowed on the first postoperative day. Intravenous and oral analgesics were discontinued on the second postoperative day in 81 patients.ConclusionThe learning curve in our series of cases is comparable to a very similar studywith reduced operative time, reduced blood loss, and fewer complications when compared to open nephrectomy. In addition, setups with minimal previous laparoscopic units can initiate laparoscopic procedures with minimal risk to the patient.

Sarcomatoid Chromophobe Renal Cell Carcinoma

Dear Editor, We read with great interest and attention the recent paper by De La Parra and co-authors on the sarcomatoid transformation of chromophobe renal cell carcinoma.[1] In the review of the literature, these authors incorporate 10 cases of this uncommon condition including two own cases (their Table 1). However, the article of Akhtar et al.[2] and the work of our group[3] on this kind of tumor are missing. The first case of sarcomatoid chromophobe renal cell carcinoma was published by Akhtar et al. in 1996.[2] The patient, a 64-year-old woman, was admitted because of a six-month history of right upper quadrant pain and a mass in the right flank. Ultrasound and CT scan of the abdomen showed a large mass invading the anterior portion of the kidney. A chest radiograph revealed a questionable metastatic lesion in the right lung. A radical nephrectomy was performed. The nephrectomy specimen weighed 1050 g. The kidney was extensively replaced by a multinodular, firm, well delimited, 7x5x4 cm mass. Pathologic diagnosis was sarcomatoid chromophobe renal cell carcinoma showing presence of equal proportions of carcinoma and sarcomatoid component. The carcinoma component was positive for colloidal iron acid stain, cytokeratins (CKs) 8,18,19, and epithelial membrane antigen (EMA). One year later, she was readmitted. Ultrasound examination of the abdomen revealed enlargement of para-aortic and mesenteric lymph nodes and massive recurrence of the tumor in the right renal bed. Besides, a metastatic nodule in the right lung and a supraclavicular mass were also present. She was given palliative radiotherapy to the renal bed and then discharged. She did not return for her follow-up visit and was considered dead. In 1997, we described one case of this aforementioned neoplasm.[3] A 61-year-old man presented with a sixmonth history of hematuria. A CT scan revealed an 11 cm hypodense mass with a central scar in the lower pole of the right kidney, suggesting the diagnosis of renal oncocytoma. The patient underwent a right radical nephrectomy. The right nephrectomy specimen weighed 667 g and measured 17x11x7.5 cm. The kidney presented an 11.2 cm light brown mass in the lower pole with hemorrhagic and necrotic foci that infiltrated the renal capsule and the perinephric adipose tissue (pT3aN0M0, stage III UICC). The microscopic study revealed a neoplasm composed of sheets of voluminous polygonal epithelial cells, with a narrow zone of condensation along the cell boundaries and translucent finely reticulated cytoplasm. The nuclei were central and vesicular with some areas where small nucleoli could be identified. 40% of the tumor displayed spindle-shaped and pleomorphic cells with large nuclei and prominent nucleoli and a significant number of mitotic figures (5/10 HPF; where 1HPF = 0.1924 mm2 ). Epithelial cells showed an intense diffuse reaction of the cytoplasm with Hale´s

Laparoscopic Nephrectomy in Benign Renal Diseases- A Tertiary Hospital Experience

ABSTRACT:&#x0D; &#x0D; Objectives: The purpose of our study is to share experience of performing simple laparoscopic nephrectomy in benign cases.&#x0D; Study Design: Descriptive study.&#x0D; &#x0D; Place &amp;&#x0D; Duration of&#x0D; Study: Department of Urology, Jinnah Postgraduate Medical Center (JPMC) Karachi, between Jan 2015 to Dec 2019 with minimal one and half year follow-up.&#x0D; &#x0D; Methodology: Our inclusion criteria were benign symptomatic nonfunctioning kidneys requiring nephrectomy. Laparoscopic nephrectomy was performed under general anesthesia with oblique position with three or four port technique was used. The demographic data, operative and post- operative details were carefully noticed and recorded in SPSS software version 20.&#x0D; &#x0D; Results: Total 40 patients were included in the study. Twenty four were females and 16 were males. Age ranges from 20 to 62 years with mean age of 44.64 + 11.04 years. Left sided were 24 patients (60%) while the right sided in 16(40%). Flank pain was the most common presenting complaint seen in 92.50% patients. Renal stone disease representing the most common indication for nephrectomy (40%) followed by ureteric stone (22.5%), chronic pyelonephritis (17.5%) and PUJO (15%). Our mean operative time was 200.29+47.98. Six patients (15%) were converted to open surgery because of intraoperative complications in 10% of patients including hilar vascular injury and gut injury and failure to progression in two (5%). Among the post- operative complications, early included low grade fever (10%) and wound infection (7.5%) while late included port site hernia (5%) and abscess at renal bed (2.5%). Chronic pyelonephritis was the most common histopathological report representing 45% of total cases. Our success rate was 85%.&#x0D; &#x0D; Conclusion: The role of laparoscopic nephrectomy in benign non-functioning kidneys is a better alternate to open nephrectomy in terms of pain, post-operative recovery and cosmetic results. The operative time and conversion rate can minimize after passing through adequate learning time and experience

Clinical Update on Vasopressors and Titration Strategies.

Clinical Update on Vasopressors and Titration Strategies.

Concurrent use of nivolumab and radiotherapy for patients with metastatic non‑small cell lung cancer and renal cell carcinoma with oligometastatic disease progression on nivolumab

Checkpoint inhibitors (CPIs), such as nivolumab, have transformed the treatment paradigm for patients with metastatic non-small cell lung cancer (mNSCLC) and metastatic renal cell carcinoma (mRCC). The combination of CPIs and radiotherapy (RT) constitutes a multimodal treatment approach that may work synergistically and facilitate augmented systemic responses. The aim of the present retrospective study was to assess the efficacy and safety of continuation of nivolumab treatment with the addition of RT in patients with mNSCLC and mRCC who develop oligometastatic disease progression on single-agent nivolumab. All patients with mNSCLC and mRCC who received nivolumab at the Department of Oncology, Prince Sultan Military Medical City (Riyadh, Saudi Arabia) between November 2016 and April 2018 were identified. The records of patients who developed oligometastatic disease progression during nivolumab treatment and were subsequently treated with RT, with nivolumab continued beyond disease progression, were retrospectively reviewed. Details of RT, clinical outcomes and toxicity data were collected. Of the 96 patients who received nivolumab, 22 received multiple courses of RT. A total of 39 sites were irradiated: Bone (n=15), lung (n=9), brain (n=8), adrenal gland (n=2), renal bed (n=2), skin (n=1), ethmoid sinus (n=1) and scalp (n=1). Partial response and complete response were noted at 25 (64%) and 3 (8%) sites, respectively. Stable disease was noted at 6 sites (15%) and disease progression was noted at 5 sites (13%). The median time on nivolumab from the date of the first fraction of RT was 4.5 months (range, 1.5-29 months) for patients with mNSCLC and 5 months (range, 1-38.5 months) for patients with mRCC. No patients developed grade 3-4 toxicities. Grade 2 pneumonitis was noted in 3 patients receiving lung RT. The addition of RT appeared to initiate a response and prolong the duration of nivolumab treatment. Therefore, the combination of nivolumab and RT was found to be well tolerated, with response rates exceeding those in published studies of nivolumab monotherapy.

Anatomical variations of the renal vasculature and outcome of live donor nephrectomies: experience of a single surgeon

IntroductionRenal artery [RA] variations occur in 18 % to 21%. Variations determine the side selection in kidney donors and the outcome of Kidney Transplantation. This series reports the renal vascular anatomy [RVAS] variations and associated complications encountered during live donor nephrectomies [LDN].Methods Consecutive LDN done by a single surgeon is included, the patient's demography, LDN side, RVAS variations and complications are recorded. The kidney with worse function and the least number of RA is selected for LDN. The RVAS is assessed by Computed Tomography Angiography and intra-operatively. Single RA and vein with the hilar division are considered normal anatomy. Results 159 were included with 103 [64.8%] males. The mean age was 38.2 years [23-63]. 106 [66.7%] were left LDN. 136 [85.5%] had single RA of these 34 [21.4%] had early-branching [EB]. 23 [14.5%] had multiple RA [2 in 21 and 3 in 2]. Therefore variations occurred in 35.8 %. In a subgroup analysis of 123 renal veins, only 6 [6.8%] with single RA but 9 [25.7%] out of 35 with multiple arteries or EB arteries had multiple veins. This difference was statistically significant [p-0.004]. 11 [6.9%] had complications [3 renal bed haematoma]. 2 of 3 haematoma patients had EB of RA [5.9% vs. 0.8%] and underwent right LDN [3.8% vs. 0.9% / p&gt;0.05].Conclusions RA variations occur in 35.8 %. Multiple arteries and EB is significantly associated with multiple veins. The complication rates in patients with EB appear to be high. However, this was not statistically significant probably due to low numbers.