Renal Pedicle Research Articles

A hint for the obesity paradox and the link between obesity, perirenal adipose tissue and Renal Cell Carcinoma progression

Increasing evidence supports a role for local fat depots in cancer outcomes. Despite the robust positive association of obesity with renal cell carcinoma (RCCa) diagnosis, increased adiposity is inversely related to RCCa oncological outcomes. Here, we sought to ascertain whether imagiologically assessed local fat depots associate with RCCa progression and survival and account for this apparent paradox. A retrospective cohort of renal carcinoma patients elective for nephrectomy (n = 137) were included. Beyond baseline clinicopathological characteristics, computed tomography (CT)-scans at the level of renal hilum evaluated areas and densities of different adipose tissue depots (perirenal, subcutaneous, visceral) and skeletal muscle (erector spinae, psoas and quadratus lumborum muscles) were analyzed. Univariate and multivariable Cox proportional hazards models were estimated following empirical analysis using stepwise Cox regression. Age, visceral adipose tissue (VAT) area and body mass index (BMI) predicted tumour-sided perirenal fat area (R2 = 0.584), which presented upregulated UCP1 expression by 27-fold (P = 0.026) and smaller adipocyte areas, compared with subcutaneous depot. Multivariate analyses revealed that increased area of perirenal adipose tissue (PRAT) on the contralateral and tumour side associate with improved progression-free survival (HR = 0.3, 95CI = 0.1–0.8, P = 0.019) and overall survival (HR = 0.3, 95CI = 0.1–0.7, P = 0.009). PRAT measurements using CT, might become a possible tool, well correlated with other measures of obesity such as VAT and BMI, that will improve determination of obesity and contribute to assess the risk for disease progression and mortality in renal cancer patients. Present data supports the obesity paradox in RCCa, assumed that larger PRAT areas seem to protect from disease progression and death.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope. The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Natural history of renal artery aneurysms

ObjectiveThe existing renal artery aneurysm (RAA) literature is largely composed of reports of patients who underwent intervention. The objective of this study was to review the natural history of RAA. MethodsThis single-institution retrospective analysis studied all patients with RAA diagnosed by computed tomography imaging between 2015 and 2019, identified by our institutional radiology database. Imaging, demographic, and clinical data were obtained via the electronic medical record. He growth rate was calculated for all patients with radiological follow-up. ResultsThe cohort consists of 331 patients with 338 RAAs. Most patients were female (61.3%), with 11 (3.3%) of childbearing age. The mean age at diagnosis was 71.5 years (range, 24-99 years). Medical comorbidities included hypertension (73.7%), prior smoking (34.4%), and connective tissue disease (3.9%). Imaging indications included abdominal pain (33.5%), unrelated follow-up (29.6%), and follow-up of an RAA initially diagnosed before the study period (10.7%). Right RAA (61.9%) was more common than left (35.1%); 3% of patients had bilateral RAA. The mean diameter at diagnosis was 12.9 ± 5.9 mm. Size distribution included lesions measuring less than <15 mm (69.9%), 15 to 25 mm (27.1%), and more than 25 mm (3.0%). Anatomic locations included the distal RA (26.7%), renal hilum (42.4%), and mid-RA (13.1%). The majority were true aneurysms (98%); of these, 72.3% were fusiform and 27.7% were saccular. Additional characteristics included calcification (82.2%), thrombus (15.9%), and dissection (0.9%). Associated findings included aortic atherosclerosis (65.6%), additional visceral aneurysms (7.3%), and abdominal aortic aneurysm (5.7%). The mean clinical follow-up among 281 patients was 41.0 ± 24.0 months. The mean radiological follow-up among 137 patients was 26.0 ± 21.4 months. Of these, 43 patients (31.4%) experienced growth, with mean growth rate of 0.23 ± 4.7 mm/year; the remainder remained stable in size. Eight patients eventually underwent intervention (5 endovascular), with the most common indications including size criteria (4/8) and symptom development (3/8). No patient developed rupture. On multivariate analysis, obesity (P = .04) was significantly associated with growth. An initial diameter of more than 25 mm was significantly associated with subsequent intervention (P = .006), but was not significantly associated with growth. Four of five RAAs with an initial diameter 30 mm or greater did not undergo intervention. The mean clinical follow-up for these patients was 24 months; none developed rupture and two remained stable in size. ConclusionsThis large institutional cohort found that the majority of RAAs remained stable in size, with few patients meeting indications for repair based on societal guidelines. Current guidelines recommending intervention for asymptomatic aneurysms more than 30 mm seem to be appropriate given their slow progression.

A case of chyluria with nephrotic-range proteinuria caused by lymphatic malformation, leading to a diagnosis of Klippel-Trenaunay syndrome.

Klippel-Trenaunay syndrome (KTS) is a rare syndrome, which is clinically diagnosed by the presence of unilateral limb hypertrophy with vascular malformation including cutaneous capillaries, veins and lymphatic vessels. Most cases typically exhibit cutaneous manifestations such as port-wine stains and limb hypertrophy from infancy, but cases with mild manifestations may remain undiagnosed. We here report a case of KTS who was diagnosed by chance chyluria. A 15-year-old girl who exhibited hematochyluria with nephrotic-range proteinuria was referred to our hospital. She had been diagnosed as idiopathic scoliosis accompanied by left lower limb hypertrophy in the past. She noticed her milky urine for the first time two months before. Immediately thereafter, she noticed edema of her left leg. Hematochyluria with nephrotic-range proteinuria was found by our initial urine examination. Magnetic resonance imaging suggested venous or lymphatic malformation along the left common iliac vein at the retroperitoneal side. Lymphoscintigraphy showed congestion of radioisotope around backside of the pancreas to the left renal hilus, suggesting an existence of lymphostasis. Based on the findings, we diagnosed the patient as KTS. After admission, hematochyluria and proteinuria were decreased and became insignificant by three days with bed rest. Her left leg edema was reduced. After taking a guidance to avoid intensive exercise, she was discharged in two weeks. Because the present case exhibited mild manifestations, diagnosis was made by urine abnormalities for the first time. The case suggests that we should be aware of the presence of undiagnosed patients of KTS due to relatively mild manifestations.

Randomized Clinical Trial Comparing On-clamp Versus Off-clamp Laparoscopic Partial Nephrectomy for Small Renal Masses (CLOCK II Laparoscopic Study): A Intention-to-treat Analysis of Perioperative Outcomes

BackgroundRecent randomized trials (RCTs) in the field of robotic partial nephrectomy (PN) showed no significant differences in perioperative outcomes between the off- and on-clamp approaches. ObjectiveTo compare the perioperative outcomes of on- versus off-clamp pure laparoscopic PN (LPN). Design, setting, and participantsA multi-institutional analysis of the on- versus off-clamp approach during LPN in the setting of an RCT (CLOCK II trial; ClinicalTrials.gov NCT02287987) was performed. InterventionOff- versus on-clamp LPN. Outcome measurements and statistical analysisBaseline patient and tumor variables, and peri- and postoperative data were collected. Randomized allocation with a 1:1 ratio was assigned. Surgical strategy for managing the renal pedicle was dictated by the study protocol. In the off-clamp arm, the renal artery had to remain unclamped for the duration of the whole procedure. Reporting the intention-to-treat analysis is the purpose of the study. Results and limitationsThe study recruited 249 patients. Of them, 123 and 126 were randomized and allocated into the on- and off-clamp treatment groups, respectively. Treatment groups were comparable at baseline after randomization with respect to patients’ demographics, comorbidities, renal function, and tumor size and complexity. A univariable analysis found no differences in the perioperative outcomes between the groups, including median (interquartile range) estimated blood loss (150 [100–200] vs 150 [100–250] ml, p = 0.2), grade ≥2 complication rate as classified according to the Clavien-Dindo system (5.7% vs 4.8%, p = 0.6), and positive surgical margin rate (8.2% vs 3.5% for the on- vs off-clamp group, p = 0.1). No differences were found in terms of the 1st (81.3 [66.7–94.3] vs 85.3 [71.0–97.7] ml/min, p = 0.2) and 5th postoperative days estimated glomerular filtration rate (83.3 [70.5–93.7] vs 83.4 [68.6–139.3] ml/min, p = 0.2). A multivariable analysis found each +1 increase in RENAL score corresponded to an increase in the protection from the occurrence of complications (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.54–0.97, p = 0.034), while each +1 cm increase in tumor size corresponded to an increase in the risk of blood transfusion (OR 1.39, 95% CI 1.14–1.70, p = 0.001). ConclusionsIn the setting of an RCT, no differences were found in the perioperative and early functional outcomes between on- and off-clamp LPN. Patient summaryIn this study, we investigated, by means of a randomized trial, whether avoiding the clamping of renal artery during laparoscopic resection of renal mass is able to translate into benefits. We found no differences in terms of safety, efficacy, and renal function from the standard approach, which includes arterial clamping.

Regulation of the autophagy plays an important role in acute kidney injury induced acute lung injury

Aim This study aimed to investigate the regulatory role of autophagy in acute kidney injury (AKI) induced acute lung injury (ALI). Methods The male Sprague–Dawley rats were divided into four groups: normal saline-treated sham rats (sham group), normal saline-treated ischemia-reperfusion injury rats (IRI group), 3-methyladenine-treated IRI rats (3-MA group), and rapamycin-treated IRI rats (RA group). The rats in the IRI rat model received the nephrectomy of the right kidney and was subjected to 60 mins of left renal pedicle occlusion, followed by 12, 24, 48, and 72 h of reperfusion. The levels of Scr, BUN, wet-to-dry ratio of lung, inflammatory cytokines, and oxidative stress were determined. The damage to tissues was detected by histological examinations. The western blot and immunohistochemistry methods were conducted to determine the expression of indicated proteins. Results Renal IRI could induce the pulmonary injury after AKI, which caused significant increases in the function index of pulmonary and renal, the levels of inflammatory cytokines, and biomarkers of oxidative stress. In comparison to the IRI group, the RA group showed significantly decreased P62 and Caspase-3 expression and increased LC-II/LC3-I, Beclin-1, Bcl-2, and unc-51-like autophagy activating kinase 1 expression. Meanwhile, by suppressing the inflammation and oxidative stress, as well as inhibiting the pathological lesions in kidney and lung tissues, the autophagy could effectively ameliorate IRI-induced AKI and ALI. Conclusions Autophagy plays an important role in AKI-induced ALI, which could be used as a new target for AKI therapy and reduce the mortality caused by the complication.

Calcitriol attenuates vascular remodeling in association with alteration of ppET-1/ETBR/eNOS and ETAR expression in acute and chronic phases of kidney ischemia-reperfusion injury in mice.

Kidney ischemia-reperfusion injury (IRI) causes acute kidney injury with increasing risk of maladaptive repair through endothelin-1 (ET-1)/endothelin type A receptor (ETAR) signaling. Calcitriol shows renoprotection in kidney fibrosis, however, its effects on vasoactive substances expression and vascular remodeling following kidney IRI remain unclear. This research aimed to investigate Calcitriol's effects on preproendothelin-1 (ppET-1), ETAR, endothelial nitric oxide synthase (eNOS) mRNA expression and vascular remodeling in acute and chronic phases of kidney IRI in mice. Twenty-five male Swiss mice were randomly divided into five groups (n=5): SO (sham-operated), IR3 (3 day kidney IRI), IR12 (12 day kidney IRI), IRD3 (3 day kidney IRI+Calcitriol 0.5 µg/kg body weight (BW)/day), and IRD12 (12 day kidney IRI+Calcitriol 0.5 µg/kg BW/day). Ischemia-reperfusion injury groups underwent bilateral renal pedicles clamping for 30 min, then reperfusion. Kidneys were harvested for Sirius Red staining to observe interstitial fibrosis and vascular remodeling, polymerase chain reaction to quantify ppET-1, endothelin type B receptor (ETBR), eNOS mRNA expression, and Western blotting to quantify ETAR protein expression. Calcitriol treatment in both phases of kidney IRI showed lower serum creatinine and ETAR protein expression, while higher eNOS and ETBR mRNA expression than IRI-only groups. Furthermore, ppET-1 mRNA expression was higher in IRD3 than IR3, but lower in IRD12 than IR12. Calcitriol also prevented vascular remodeling as indicated by lower wall thickness and higher lumen/wall area ratio than IRI-only groups.

An external validation of the nocera nomogram: Predicting non-organ confined stage of ≥pT3 in cT1 clear cell renal cell carcinoma.

BackgroundOnly one previously published study by Nocera et al. addressed the risk of upstaging to ≥pT3 in cT1 clear cell renal cell carcinoma (ccRCC) by using characteristics of the R.E.N.A.L and PADUA score (age, tumor size, rim location, exophytic rate, polar involvement) developing an accurate nomogram. However, this nomogram has never been externally validated yet.Material and methodsThe study cohort consisted of 288 patients with cT1a-b ccRCC, diagnosed between 2008-2021 at the University Hospital Frankfurt, Germany. Analyses addressed clinical, tumor and radiographic characteristics. The external validation of the nomogram relied on accuracy calculations derived from the area under the curve of the receiver operator characteristic analysis.ResultsOverall, 11.8% (n=34) patients harbored ≥pT3 ccRCC. Median radiographic tumor size (3.6 vs. 5.3cm), R.E.N.A.L. (8 vs. 9 points) and PADUA score (9 vs. 11 points), as well as proportions of renal sinus involvement (82.4% vs. 51.6%), renal hilus involvement (44.1 vs. 13.0%), and medial rim location significantly differed between the pT1-2 and ≥pT3 group (all p ≤ 0.01). In subgroup analyses of small renal mass ccRCC patients (<4cm, cT1a), only 3.8% (n=6) patients had ≥pT3 pathology. Upstaged patients were significantly older and more frequently had endophytic tumor than pT1-2 counterparts (p<0.05). The external validation of the Nocera nomogram showed a good accuracy of 76.6%. Using the suggested cut-off of 21%, 26.5% of patients exhibited ≥pT3 ccRCC. Conversely, within patients below cut-off, 5.9% patients exhibited ≥pT3 ccRCC.ConclusionWe reported the first external validation of the nomogram addressing the risk of ≥pT3 in cT1 ccRCC patients, demonstrating a good accuracy, with a low false-negative rate. Therefore, the nomogram can accurately be used for patients’ counselling and treatment decision making.

Clinicopathological features and diagnosis of pericytic tumors of the kidney

Objective: To investigate the clinicopathologic features,diagnosis and prognosis of pericytic tumor of the kidney. Methods: Three cases of pericytic tumor of the kidney (two cases were diagnosed as glomangiomyomas and one case as pericytic tumor,unclassified) were collected from the affiliated Hospital of Qingdao University between January 2014 to May 2021; the clinical and morphologic features, immunohistochemical and molecular characteristics were analyzed and the relevant literature was reviewed. Results: The three patients included one male and two females, with ages ranging from 21 to 70 years. In two patients the tumors were detected incidentally at physical examination and one patient presented with low back discomfort. Imaging showed a rounded nodular soft tissue density shadow in renal parenchyma, and enhancement scan showed uneven delayed enhancement. Grossly, two tumors were located in the renal hilum and one in the renal parenchyma; all were nodular. The tumors were measured in size from 1.6 cm to 5.1 cm (mean 4.1 cm) and showed gray or gray-red cut surface. Histologic examination showed the tumor cells were arranged in solid sheets or small nodules, closely related to vascular wall. Tumor cells were mostly epithelial-like with abundant cytoplasm, light eosinophilia, obscure boundary and round nuclei with visible nucleoli. Vague bundles and fascicular arrangements of smooth muscle component were noted in some areas, with transition of both components. There was no necrosis. By immunohistochemistry, the tumor cells strongly and diffusely expressed vimentin, SMA and collagen Ⅳ, two cases expressed CD34, all three cases expressed PDGFRB to varying extent, and the Ki-67 index was 2%-3%. PCR tests showed absent K-RAS, BRAF V600E gene mutation in all three cases. PDGFRB mutations in exons 3 and 18, respectively were found in two of the three cases by high-throughput sequencing, and no NOTCH 1/2/3 gene fusions were found in any of them. Follow-up information (range: 6-92 months) showed no evidence of local recurrence or distant metastasis in all three patients. Conclusions: Pericytic tumor of the kidney is a rare mesenchymal tumor originating in the kidney with differentiation to smooth muscle, most commonly glomus tumor. The mild pleomorphism, close relationship with vascular wall and spindled smooth muscle components suggest the diagnosis of the tumor. Expression of both epithelial and muscle-associated markers aids the diagnosis. PDGFRB gene mutations may have an important role in the development of this tumor. Most patients have a good prognosis, and a few cases have malignant biological behavior.

Calycosin attenuates renal ischemia/reperfusion injury by suppressing NF-κB mediated inflammation via PPARγ/EGR1 pathway.

Renal ischemia reperfusion injury (IRI) is a leading and common cause of acute kidney injury (AKI), and inflammation is a critical factor in ischemic AKI progression. Calycosin (CAL), a major active component of Radix astragali, has been reported to have anti-inflammatory effect in multiple organs. However, whether CAL can alleviate renal IRI and its mechanism remain uncertain. In the present study, a renal IRI model is established by bilateral renal pedicles occlusion for 35 min in male C57BL/6 mice, and the effect of CAL on renal IRI is measured by serum creatinine and pathohistological assay. Hypoxia/reoxygenation (H/R) stimulated human renal tubular epithelial cells HK-2 were applied to explore the regulatory mechanisms of CAL. Luciferase reporter assay and molecular docking were applied to identify the CAL’s target protein and pathway. In the mice with renal IRI, CAL dose dependently alleviated the renal injury and decreased nuclear factor kappa B (NF-κB) mediated inflammatory response. Bioinformatics analysis and experiments showed that early growth response 1 (EGR1) increased in mice with renal IRI and promoted NF-κB mediated inflammatory processes, and CAL dose-dependably reduced EGR1. Through JASPAR database and luciferase reporter assay, peroxisome proliferator-activated receptor γ (PPARγ) was predicted to be a transcription factor of EGR1 and repressed the expression of EGR1 in renal tubular epithelial cells. CAL could increase PPARγ in a dose dependent manner in mice with renal IRI and molecular docking predicted CAL could bind stably to PPARγ. In HK-2 cells after H/R, CAL increased PPARγ, decreased EGR1, and inhibited NF-κB mediated inflammatory response. However, PPARγ knockdown by siRNA transfection abrogated the anti-inflammation therapeutic effect of CAL. CAL produced a protective effect on renal IRI by attenuating NF-κB mediated inflammatory response via PPARγ/EGR1 pathway.

Extra-Kidney Mass

A 64-year-old man with hypertension (156/76 mm Hg) without associated tachycardia was admitted to our hospital for a 1-week history of left-sided loin pain. Routine blood work indicated that hemoglobin was 10.3 g/dL and the ratio of neutrophil-to-lymphocyte (NLR) was 4.9. Complete metabolic panel and serum catecholamines were normal. Computed tomography (CT) revealed a round soft tissue mass measuring 55 × 45 × 35 mm located beside the left renal hilum and 10 mm away from the celiac trunk. 2 renal hilum lymph nodes were visible.

Retroperitoneal laparoscopic renal biopsy: an 8year experience at a single centre.

To present our experience and outcome of consecutive laparoscopic renal biopsy (LRB) in a series of Chinese patients over an 8year period. Between January 1, 2013, and December 31, 2020, 104 patients (M/F 71/33, age 43.6 ± 16.0years) were enrolled. All patients underwent LRB for various indications, e.g., dialysis dependence (33.7%), serum levels of creatinine ≥ 442μmol/L (20.2%), morbid obesity (18.3%), uncontrolled severe hypertension (14.4%), aberrant renal anatomy (5.8%), solitary kidney (2.9%), deaf-mutes (2.9%), failed percutaneous biopsy (1.0%) and patient choice (1.0%). The kidney was approached via the laparoscopic retroperitoneal route using a three-port technique. Then, 16-gauge true-cut needle biopsy was performed and haemostasis was achieved by compression. Topical collagen mesh was used if necessary. Renal tissue was obtained in all cases. The operative time and amount of blood loss were significantly (P < 0.05) lower in 2017-2020 than 2013-2016 [42.6 ± 1.5min and 9.6 ± 0.7mL, respectively (n = 61) vs. 51.2 ± 1.3min and 14.4 ± 0.9mL, respectively (n = 43)], while the hospital stay was not significantly different between the two periods. The rate of tissue adequacy and median number of glomeruli were significantly higher in 2017-2020 than 2013-2016 [100% and 52 (IQR 24-94), respectively vs. 93% and 35 (IQR 6-98), respectively). Two postoperative complications occurred in the first 4years: disseminated intravascular coagulation (DIC) during the operation and injury at the hilum of the kidney (n = 1 each). The renal pathological diagnoses were also complex: 70.2% of the cases were independent pathological types, including IgA nephropathy (IgAN) (13.5%), Henoch-Schönlein purpura nephritis (HSPN) (2.9%), focal segmental glomerulosclerosis (FSGS) (9.6%), membranous glomerulonephritis (MN) (1.9%), lupus nephritis (LN) (3.8%), crescentic glomerulonephritis (CreGN) (7.7%), diabetic nephropathy (DN) (10.6%), tubulointerstitial nephritis (TIN) (11.5%) and malignant hypertensive nephropathy (MHTN) (8.7%). However, the rates of combinations of two and three pathological types were 25.0% and 4.8%, respectively. Retroperitoneal LRB is a safe, reliable, minimally invasive alternative for patients in whom PRB in not feasible. As a helpful supplement to PRB, it may be necessary to use this technique more often in the future.

Different Acute Kidney Injury Patterns after Renal Ischemia Reperfusion Injury and Extracorporeal Membrane Oxygenation in Mice.

The use of extracorporeal membrane oxygenation (ECMO) is associated with acute kidney injury (AKI) in thoracic organ transplantation. However, multiple other factors contribute to AKI development after these procedures such as renal ischemia-reperfusion injury (IRI) due to hypo-perfusion of the kidney during surgery. In this study, we aimed to explore the kidney injury patterns in mouse models of ECMO and renal IRI. Kidneys of C57BL/6 mice were examined after moderate (35 min) and severe (45 min) unilateral transient renal pedicle clamping and 2 h of veno-venous ECMO. Renal injury markers, neutrophil infiltration, tubular transport function, pro-inflammatory cytokines, and renal heme oxygenase-1 (HO-1) expression were determined by immunofluorescence and qPCR. Both procedures caused AKI, but with different injury patterns. Severe neutrophil infiltration of the kidney was evident after renal IRI, but not following ECMO. Tubular transport function was severely impaired after renal IRI, but preserved in the ECMO group. Both procedures caused upregulation of pro-inflammatory cytokines in the renal tissue, but with different time kinetics. After ECMO, but not IRI, HO-1 was strongly induced in tubular cells indicating contact with hemolysis-derived proteins. After IRI, HO-1 was expressed on infiltrating myeloid cells in the tubulo-interstitial space. In conclusion, renal IRI and ECMO both caused AKI, but kidney damage after renal IRI was more pronounced including severe neutrophil infiltration and tubular transport impairment. Enhanced HO-1 expression in tubular cells after ECMO encourages limitation of hemolysis as a therapeutic approach to reduce ECMO-associated AKI.

Feasibility and comparison of laparoscopic laser speckle contrast imaging to near-infrared display of indocyanine green in intraoperative tissue blood flow/tissue perfusion in preclinical porcine models.

To determine if laser speckle contrast imaging (LSCI) mitigates variations and subjectivity in the use and interpretation of indocyanine green (ICG) fluorescence in the current visualization paradigm of real-time intraoperative tissue blood flow/perfusion in clinically relevant scenarios. De novo laparoscopic imaging form-factor detecting real-time blood flow using LSCI and blood volume by near-infrared fluorescence (NIRF) of ICG was compared to ICG NIRF alone, for dye-less real-time visualization of tissue blood flow/perfusion. Experienced surgeons examined LSCI and ICG in segmentally devascularized intestine, partial gastrectomy, and the renal hilum across six porcine models. Precision and accuracy of identifying demarcating lines of ischemia/perfusion in tissues were determined in blinded subjects with varying levels of surgical experience. Unlike ICG, LSCI perfusion detection was real time (latency < 150ms: p < 0.01), repeatable and on-demand without fluorophore injection. Operating surgeons (n = 6) precisely and accurately identified concordant demarcating lines in white light, LSCI, and ICG modes immediately. Blinded subjects (n = 21) demonstrated similar spatial-temporal precision and accuracy with all three modes ≤ 2min after ICG injection, and discordance in ICG mode at ≥ 5min in devascularized small intestine (p < 0.0001) and in partial gastrectomy (p < 0.0001). Combining LSCI for near real-time blood flow detection with ICG fluorescence for blood volume detection significantly improves precision and accuracy of perfusion detection in tissue locations over time, in real time, and repeatably on-demand than ICG alone.

Renal replacement lipomatosis with granulomatous inflammation – A case report and review of literature

Renal replacement lipomatosis can be defined as the proliferation of fibrofatty tissue which subsequently replace the renal parenchyma. It is usually benign unilateral and occurs as a result of severe atrophy or destruction of the renal parenchyma, due to a calculus with secondary proliferation of renal sinus, renal hilus, and perirenal fatty tissue to a variable extent.A 55yr old female presented to surgeon with history ofpain and swelling in right flank. On CECT abdomen there was seen non functional right kidney with staghorn calculi along with perirenal abscess. Patient was treated with nephrectomy and drainage of collection. Intraoperatively Perirenal Abscess extending to psoas and iliopsoas region along with dense adhesion between kidney and liver was found. The multiple sections studied from the lesion showed extensive fibrofatty tissue with few tubule like structures lined by cuboidal epithelium and containing dense eosinophilic secretions. There is seen mixed inflammatory infiltrates with granulomas. Histological features confirmed that Renal replacement lipomatosis with granulomatous inflammation.The clinical importance of RRL is that it stimulates fat-containing tumors in the kidney or its vicinity such as lipomas, angiomyolipomas and liposarcomas can be misdiagnosed preoperatively. Hence this case report has been presented to create awareness of this condition among the pathologist and practicing urosurgeons.

UNILATERAL LEFT MALROTATED KIDNEY WITH VASCULAR AND HILAR VARIATIONS: A CADAVARIC CASE REPORT

During our dissection classes for abdomen, some abnormal appearance in a male cadaver in the Department of Anatomy, Rajendra Institute of Medical science, Ranchi was observed 1. The anomaly in the position of the kidney in the abdomen i.e., left kidney of the cadaver was lying below the normal level so much that the right kidney appeared to be higher than it with hilum facing ventromedially. (Usually, Right kidney lies somewhat lower than the left because of the relationship with the liver, and also the hilum is medial facing). (Figure.1) 2. Also, kidney is usually drained by one renal artery and one renal vein. But in this case the left kidney was drained by two renal arteries and both of them originated from the abdominal aorta itself. (Figure.2) The accessory renal artery was originating from the level above the origin of primary renal artery, and entering the hilum hence the arrangements of left renal hilum vary with respect to the normal arrangement. 3. Hilum relations that usually holds anterior to posterior, is renal vein exits renal artery enters and the renal pelvis exits, but in this case the left kidney hilum relations were also altered from anterior to posterior I.e., left renal artery enters, left renal vein exits, accessory renal artery enters and renal pelvis exits the hilum.

Renal Artery Aneurysm Mimicking Nephrolithiasis: A Case Report and Review of Literature

While originally described in the 18th century, the incidental detection of renal artery aneurysms (RAAs) has increased significantly with the advent and increased usage of modern cross-sectional imaging. Although the incidence remains low, RAAs are clinically important, especially if measuring greater than 2 cm in diameter. Therefore, ultrasonographers and radiologists alike should be aware of its features on multiple imaging modalities as well as imaging pitfalls. Renal duplex sonography is widely used for the evaluation of renal arteries stenosis, fibromuscular dysplasia, renal veins patency, and for the status of renal transplants. RAA is another, albeit rare, indication for renal arteries duplex examination. Furthermore, RAAs may be an incidental finding on abdominal or renal ultrasound. Therefore, familiarity with the sonographic presentation of a RAA is important. Diagnosing RAAs with duplex ultrasound may become exceptionally difficult when the aneurysm has peripheral calcification, even more so when the aneurysm is situated by the renal hilum. Those calcified arterial walls may produce strong acoustic shadowing, mimicking a renal calculus.

Clinical study of centrality index in predicting the postoperative pathological nuclear grade of clear cell renal cell carcinoma.

This study aimed to investigate whether the centrality index score (Cindex) can be used to predict the histological nuclear grade of clear cell renal cell carcinoma (ccRCC) and guide the clinical treatment of this disease. This study included 194 patients with ccRCC who underwent renal surgery at our center between 2016 and 2020 and had complete computed tomography or computed tomography angiography (CT/CTA) data and C index. The relationship between the pathological grade of renal masses and the C index was evaluated. In univariate analysis, the gender, body mass index (BMI), tumor size, or height from the center of the renal hilum to the maximum diameter of the tumor along the 90° vertical axis (in cm) is y. The horizontal distance from the reference point of the central axis of the renal hilum to the tumor center is x. The distance from the center of the kidney to the center of the tumor is c and the C index was significantly correlated with postoperative tumor grade (p < 0.05). Multivariate analysis showed that tumor size and C index were independent prognostic factors for the preoperative prediction of the pathological grade factor of ccRCC. The receiver operating characteristic curves of the multi-parameter regression model [0.9471, 95% confidence interval (95% CI) 0.9138-0.9803], C index (0.9324, 95% CI 0.8899-0.9748), and tumor size (0.9307, 95% CI 0.8951-0.9663) were compared. Tumor size and C index were independent prognostic factors for high-grade pathology, and large tumors and small C index were associated with high-grade pathology. Therefore, the C index can help urologists make treatment decisions.

Robot-assisted anatrophic nephrolithotomy for complete staghorn stone.

To assess the efficacy and safety of robot-assisted anatrophic nephrolithotomy (RANL) as a choice of minimally invasive treatment for patients with complete staghorn stone.In a single-tertiary referral center retrospective study, 10 consecutive patients underwent RANL for complete staghorn stone. After dissection to the renal hilum and clamping of the renal vessels, an incision was made along the Brodel line and exposed the collecting system to extract the stone. Then, the collecting system and parenchyma were closed in layers. The outcomes included reduction of the stone burden, short- and long-term postoperative kidney function, and pain score.The average age of patients was 54.6 years and body mass index was 27.58 kg/m2. Mean warm ischemia time was 28.40 minutes, mean robotic console time was 137 minutes, and mean estimated blood loss was 83 mL. The mean length of stay was 5.4 days and there were no severe perioperative complications. Eight of 10 patients had >90% reduction in stone burden and 5 (50%) patients were completely stone-free. There was no significant decrease in postoperative estimated glomerular filtration rate compared with preoperative values after 1 month and 1 year.Our experience with RANL demonstrated efficacy and safety in the minimally invasive treatment of complete staghorn stone in short- and long-term follow-up periods.

Upper pole first laparoscopic left donor nephrectomy: single surgeon experience from four centers in Jordan and Bahrain.

1.1.Background: The first laparoscopic donor nephrectomy was reported by Ratner in 1995. Subsequently, the procedure has been adopted by most transplant centers by replicating the open technique using either a total laparoscopic or hand-assisted technique.In 2011, Tunc reported the first direct upper pole kidney access in laparoscopic radical nephrectomy, with a reverse technique that started the dissection from the upper pole towards the renal hilum. We elected to apply a modification of this new technique to laparoscopic donor surgery to assess efficacy and safety.Methods: Retrospective analysis of sequential cohorts of 36 cases performed in 4 hospitals by the same surgeon over a period of 12 months compared to the previous 28 cases done by the same surgeon using a conventional laparoscopic technique. 1.2.Results: Mean operating time was lower with the upper pole first technique (62 ± 11 minutes vs. 87 ± 13 min) whereas warm ischemia times were similar between two groups (5 min vs 4.7 min). Mean recipient post-operative serum creatinine levels (0.92 vs 1.04 mg/dl) were likewise similar.. Mean blood loss was minimal in both groups2.Results: Mean operating time was lower with the upper pole first technique (62 ± 11 minutes vs. 87 ± 13 min) whereas warm ischemia times were similar between two groups (5 min vs 4.7 min). Mean recipient post-operative serum creatinine levels (0.92 vs 1.04 mg/dl) were likewise similar.Mean blood loss was minimal in both groups(&lt;50 cc) with no transfusion requirement, and no conversion to open surgery in either group. 1.3.Conclusion: upper pole first laparoscopic donor nephrectomy is safe and a slightly faster method compared to the conventional total laparoscopic technique with similar outcomes. (1) Eye Specialty General Hospital, Amman, Jordan (2) Salmaniya Medical Complex, Manama, Bahrain (3) Al-Khaldi Medical Center (4) Istiklal Hospital (5) Albashir Medical Center (6) Specialty Hospital, Amman, Jordan