Laparoscopic approach for an intra-abdominal kidney allograft nephrectomy after pediatric transplantation: a case report

We report a case of minimally invasive nephrectomy of a kidney transplanted into the abdominal cavity in a child. A 15-year-old girl underwent transplantation with a cadaveric donor kidney due to congenital pyelonephritis, vesicoureteral reflux, and secondary bladder atrophy. The transplant was complicated by hyperacute rejection, cytomegalovirus infection, and anastomotic stenosis of the Bricker neobladder. After recurrent urinary tract infections, the patient was reintroduced to hemodialysis in 2010. After pneumo-peritoneum, we placed 2 10-mm trocars in the hypochondrium and left side and 2 5-mm in the left iliac fossa and right upper quadrant. The transplanted kidney was skeletonized, the artery and vein were cut to the end-to-side anastomoses to the juxta-renal aorta and cava using an automatic 35-mm, stapler, and the ureter was dissected and closed with clips. Via a Pfannestiel minilaparotomy we extracted the allograft. The patient was discharged on the third postoperative day. After 4 months of follow-up, she is alive an on dialysis. Laparoscopic nephrectomy of a kidney transplanted into the abdominal cavity is feasible and safe in centers with skilled minimally invasive techniques.     

经阴道纯NOTES肾切除术2例报告并文献复习

目的：评价经阴道纯自然腔道内镜手术（NOTES）肾切除术的临床可行性和有效性。方法：对1例右肾无功能和1例左。肾结石并左肾萎缩、左肾无功能的女性患者行经阴道纯NOTES肾切除术。患者取全麻,截石位。切开阴道后穹窿,置入Triport及操作器械。所有操作均经此Triport完成,按照普通腹腔镜肾切除方法游离并切除患肾,装入自制标本袋,自阴道后穹窿切口取出。留置盆腔引流管,缝合阴道后穹窿切口。结果：手术均顺利完成,术中未出现肠管、实质性器官和大血管损伤等并发症。手术时间分别为330min、300min,术中失血量分别为300ml、250ml。例1、2分别于术后第2、1天下床活动,第3、2天肛门通气并进饮食。2例均于术后第6天痊愈出院,患者体表均无切口或穿刺孔。结论：经阴道纯NOTES肾切除术临床应用可行,美容优势明显,可在临床选用。但仍需进一步研发、完善相关器械。     

Laparoscopic donor nephrectomy in a patient with previous upper pole partial nephrectomy

A 56-year-old woman underwent laparoscopic partial nephrectomy for symptomatic angiomyolipoma. She then donated her remaining ipsilateral kidney for renal transplantation. The allograft had good, immediate function in the recipient. This is the first reported case of a patient undergoing renal donor nephrectomy after partial nephrectomy for angiomyolipoma.     

Kidney Transplantation After Multiple Urinary Tract Conversion with an Ileal Conduit: A Case Report

BackgroundKidney transplantation (KTx) after urinary tract conversion surgery is extremely difficult due to several complications. In our case, KTx was performed after multiple operative procedures, including diversion urethrostomy.Case ReportThe patient was a 46-year-old woman with a right atrophic kidney, an ectopic opening of the left ureter, and urethral dysplasia since birth. The patient underwent a right nephrectomy, left ureteral sigmoidostomy, Stamey surgery, augmentation ileocystoplasty, and left ureteroileostomy. Thereafter, she underwent nephrostomy, ileal conduit diversion, open sigmoid colectomy, and total cystectomy because of persistent urinary incontinence, sigmoid colon cancer, and recurrent cystitis. Her renal function gradually deteriorated, and hemodialysis was initiated. Before the KTx, she underwent laparoscopic left nephrectomy, an intraperitoneal adhesion debridement, and left ileal conduit resection. We dissected the left ileal conduit in the abdominal cavity and penetrated the anorectal side of the free ileal conduit into the wall of the right side of the abdomen. Thereafter, a kidney from a living donor was transplanted into the right iliac fossa through the existing right ileal conduit when the patient was 46 years old. The allograft function was stable without rejection for 2 years.ConclusionsWe report the case of a patient who underwent multiple urethral modifications followed by ileal conduit transfer and living donor KTx, which progressed without major postoperative complications.     

后腹腔镜下肾切除应用威克外科结扎锁处理肾动静脉可靠性分析

目的:探讨后腹腔镜下肾切除应用威克外科结扎锁处理肾脏动静脉的可靠性.方法:124例后腹腔镜肾切除,采用腰部3个Trocar(2个10 mm,1个5 mm),由腹膜外人路.根据肾动脉搏动找到并分离出肾动脉,游离肾动脉至适当长度,用13 mm威克外科结扎锁(Hem-o-lok,Week Closure Systems)处理肾动脉,肾动脉近心端以2枚夹闭,远心端以1枚夹闭.切断肾动脉,同法处理肾静脉.结果:124例均顺利完成手术,动静脉处理过程顺利、安全,所有病例均用威克外科结扎锁处理完成,无结扎锁滑脱现象,术中及术后未出现继发性出血,术中出血10～100 ml,平均45 ml,均未输血,术后平均住院日6.5天.结论:后腹腔镜肾切除应用威克外科结扎锁处理肾脏动静脉安全、可靠、经济、操作方便.     

Transvaginal natural orifice transluminal endoscopic surgery-assisted minilaparoscopic nephrectomy: a step towards scarless surgery

The feasibility of a transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy has already been demonstrated using standard laparoscopic ports through the abdominal wall. We evaluated the feasibility of a transvaginal NOTES-assisted minilaparoscopic nephrectomy (mLN).The patient is positioned in a semilumbotomy position with legs separated to allow for vaginal access. A 3.5-mm port is placed at the umbilicus for a 30° laparoscope; two 3.5-mm ports are placed in the flank in the same location as for a standard transperitoneal nephrectomy; and a 12-mm port is placed through the vagina, perforating the vaginal wall. Kidney dissection is performed following the steps of a traditional nephrectomy. The renal pedicle is dissected and secured with Hem-o-Lok clips through the vaginal access port. The specimen is then extracted through an extended incision in the posterior wall of the vagina.We treated five patients. The average operative time was 120 min, blood loss was 160 ml, and no complications were recorded.Our initial experience suggests that transvaginal NOTES-assisted mLN is feasible and appears to be safe. It is simpler than a pure NOTES procedure and ensures excellent cosmetic results.     

伴有肾静脉瘤栓的左肾癌全腹腔镜根治术

目的：探讨左肾癌并肾静脉瘤栓患者行经后腹腔途径全腹腔镜左肾痛根治术的可行性。方法：3例左肾癌伴左。肾静脉瘤栓患者均在全麻下行经后腹腔全腹腔镜左肾癌根治术：术中放置4个穿刺套管针,游离腹主动脉和肾动脉后,用Hem—o-lok结扎切断肾动脉,于肾静脉近下腔静脉处用Hem-o-lok结扎切断肾静脉,完整切除。肾脏及瘤栓。结果：3例手术均获得成功,术后恢复良好,5灭出院。病理检查分别诊断为肾透明细胞癌2例,嫌色细胞癌1例。术后随访1～3个月,未见肿瘤复发和转移。结论：对选择性左肾癌并肾静脉瘤栓患者行经后腹腔全腹腔镜左。肾癌根治术完全可行。     

Hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with inferior vena caval thrombus

PURPOSE: To our knowledge we present the initial clinical report of hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with tumor thrombus extending into the inferior vena cava. MATERIALS AND METHODS: A 76-year-old man was referred to our medical center with a 12.5 x 10 cm. stage T3b right renal tumor extending into the inferior vena cava. The caval thrombus was limited and completely below the level of the hepatic veins. After preoperative renal embolization via the hand assisted transperitoneal approach the right kidney was completely dissected with the renal hilum. Proximal and distal control of the inferior vena cava was obtained with vessel loops and a single lumbar vein was divided between clips. An endoscopic Satinsky vascular clamp was placed on the inferior vena cava just beyond its juncture with the right renal vein, thereby, encompassing the caval thrombus. The inferior vena cava was opened above the Satinsky clamp and a cuff of the inferior vena cava was removed contiguous with the renal vein. The inferior vena cava was repaired with continuous 4-zero vascular polypropylene suture and the Satinsky clamp was then removed. A literature search failed to reveal any similar reports of laparoscopic radical nephrectomy for stage T3b renal cell cancer. RESULTS: Surgery was completed without complication with an estimated 500 cc blood loss. Pathological testing confirmed stage T3b grade 3 renal adenocarcinoma with negative inferior vena caval and soft tissue margins. CONCLUSIONS: The introduction of vascular laparoscopic instrumentation and the hand assisted approach enabled us to extend the indications for laparoscopic radical nephrectomy to patients with minimal inferior venal caval involvement.     

Bilateral renal cell carcinoma associated with polycystic kidney disease: case report and literature review

A 56-year-old Japanese man consulted a urologist because of urethral bleeding. He had been undergoing hemodialysis for the past 15 years due to polycystic kidney disease. Computed tomography revealed an irregular cyst wall in the left kidney. Since a neoplasm could not be ruled out, we removed the left kidney, by laparoscopic radical nephrectomy after obtaining the patient's consent. Histopathologic diagnosis was renal cell carcinoma. Fourteen months after the operation, urethral bleeding recurred. Further examination of the bladder and the urethra revealed no significant abnormalities. The patient insisted on right nephrectomy. Therefore, laparoscopic radical nephrectomy was performed. Histopathologic diagnosis was also renal cell carcinoma. Renal cell carcinoma in patients with end-stage renal disease is fairly common and is associated with acquired cystic kidney disease. However, renal cell carcinoma associated with polycystic kidney disease is extremely rare.     

后腹腔镜结核性无功能肾切除术（附9例报告）

目的：探讨后腹腔镜下切除结核性无功能肾脏的可行性与临床疗效。方法：2005年9月～2007年12月,采用后腹腔镜技术切除结核性无功能肾脏9例,首先解剖出肾脏动、静脉用尼龙夹结扎后切断,而后用Ligasure血管闭合系统于肾周筋膜外分离切除肾脏,保留同侧肾上腺,输尿管尽量向下游离。取同侧下腹小切口,行输尿管全长切除,标本自下腹切口取出。有2例结核性膀胱挛缩患者同时行乙状结肠膀胱扩大术。结果：9例患者腹腔镜手术完全成功,未发生周围脏器及大血管的损伤等严重并发症,无中转开放手术。手术时间120～150min,平均132min,失血量70～140ml,平均110ml。随访3～15个月,7例患者肾脏功能正常,2例膀胱挛缩行膀胱扩大患者肾功能较术前有好转,尿频尿急等膀胱刺激症状消失,膀胱容量240～300ml。结论：改良的后腹腔镜下肾脏切除术可以安全的切除结核性无功能肾,对于腔镜经验丰富的操作者可以作为临床治疗结核性无功能肾脏的新选择。     

Natural orifice translumenal endoscopic surgery (NOTES) renal cryoablation in a porcine model

OBJECTIVE

To present our laboratory experience with natural orifice translumenal endoscopic surgery (NOTES) renal cryoablation.

MATERIALS AND METHODS

In two female farm pigs, we performed four procedures of NOTES renal cryoablation. In each pig, NOTES was performed through a transgastric approach and a transvaginal approach for each kidney, respectively. The pig was placed in the flank position and pneumoperitoneum obtained using a transabdominal Veress needle. In the first pig, we started with the left kidney with a transgastric approach: a dual‐channel video gastroscope (Olympus, Tokyo, Japan) was used, the stomach wall was punctured using a needle‐knife, a guidewire was passed into the abdominal cavity and the access dilated using a controlled radial expansion balloon. The bowel was mobilized medially and the Gerota’s fascia overlying the upper pole was dissected. Under direct endoscopic vision, a cryoablation probe was introduced percutaneously into the anterior upper pole of the kidney. The pig was then flipped to the right flank position and a transvaginal approach was used: the gastroscope was introduced through the posterior fornix of the vagina. For the second pig, we performed initially a transgastric right‐side cryoablation then a transvaginal left‐side cryoablation as described for the first pig.

RESULTS

All four procedures were performed successfully, with no intraoperative complications. No additional laparoscopic ports or open conversions were necessary. The vision of the kidney and the ice‐ball was adequate for all cases. The mean operative duration was 83 min. Stomach closure was tested watertight, and there were no abdominal or pelvic injuries found at autopsy.

CONCLUSIONS

NOTES can provide adequate minimal surgical dissection for safe and effective percutaneous renal cryoablation under direct videoscopic monitoring at kidney locations otherwise not accessible percutaneously. Both transgastric and transvaginal approaches can be used effectively for renal cryoablation providing a minimally invasive scar‐less surgery.     

Resolving erythrocytosis and hypertension after open surgical extirpation of giant renal cyst measuring 30 cm: case report

The case of giant renal cyst measuring 30 cm, accompanied by abdominal swelling and erythrocytosis, is presented. A 45-year-old male presented with large abdominal mass, atrophic left kidney, hypertension, and erythrocytosis. The patient underwent multiple preoperative phlebotomies, open extirpation of the cyst, and nephrectomy. After the surgery, erythrocytosis ceased completely, blood pressure became normal without any medications whereas function of the remaining kidney was stable. The giant renal cysts measuring more than 15 cm are extremely rare. However, they can cause erythrocytosis and hypertension very frequently, especially in the case of cysts originating from the proximal tubule. To our knowledge, this is the largest renal cyst published in the literature that caused the above-mentioned complications.     

Thyroid cancer metastasizing to the kidney. Report of a case

The authors report a case of renal metastasis from a thyroid adenocarcinoma in a 56-year-old man, occurring 3 years after isthmolobectomy for papillary thyroid carcinoma. He predominant clinical symptoms were low back pain, haematuria and deterioration of the general state. Ultrasonography showed a hypoechoic left renal mass, 56 mm in diameter, with a thickened wall. Renal CT showed a homogeneous low-density formation with a thickened wall in the left kidney. Iodine 131 whole body scan showed increased uptake in the left kidney. The patient wes treated surgically via a subcostal incision. The surgical procedure consisted of radical nephrectomy. Macroscopic examination of the lesion showed a cystic mass. Histological examination of the mass revealed a renal metastasis from moderately differentiated thyroid adenocarcinoma.     

A case of renal cell carcinoma in a horseshoe kidney

A-50-year-old patient visited our hospital to have further examination for left renal mass. Drip infusion pyelography revealed a cluster of calculi in the upper pole of the left kidney. Computed tomography and magnetic resonance imaging revealed a heterogeneous mass on the left side of a horseshoe kidney. Left nephrectomy was performed through an abdominal transperitoneal approach. An operation for dividing isthmus was simultaneously done using a microwave tissue coagulator. Histopathological findings showed grade 1 > 2, pT1aN0M0, clear cell subtype, renal cell carcinoma. Convalescence was uneventful and the patient was free of tumor at one year postoperatively.     

侧卧位"Φ"字切除法在经皮肾镜等离子肾囊肿去顶术中的应用

目的探讨侧卧位"Φ"字切除法在经皮肾镜等离子肾囊肿去顶术中的效果。 方法回顾性分析2017年2月至2021年5月在厦门大学附属东南医院泌尿外科手术治疗的31例背侧肾囊肿患者资料。手术取侧卧位，彩超引导穿刺针刺入囊肿腔内，置导丝，退针，置入22 F剥皮鞘及经皮肾镜，探查囊腔是否与肾盂相通并辨识囊壁与肾实质的交界线，置入等离子电极，分别向12及6点钟方向切割囊壁至交界或囊壁增厚处；自6点钟沿交界线附近向左弧形挑拨切割至12点方向，同法切割右侧囊壁，总体切割路径呈"Φ"字型。不进一步游离囊壁，以穿刺点左侧囊壁为钳夹部位，边旋转边将左半边囊壁牵拉出体外，同法处理右侧。检查有无出血，必要时电凝止血。留置引流管退鞘。术后复查囊肿腔较术前缩小50%以上为有效。 结果1例术中修正诊断为肾盏憩室，余30例患者手术均按计划完成，手术时间15~52 min，无并发症。随访3~12个月，未见明显复发。 结论经皮肾镜等离子肾囊肿去顶术治疗背侧单纯性肾囊肿的过程中采用侧卧位改良"Φ"字切除法安全、有效，便于麻醉管理，可完整取出手术标本。     

A laparoscopic approach to allograft nephrectomy and bilateral native nephrectomy: a case report

INTRODUCTION: Laparoscopic surgery is rapidly emerging as the standard of care for a variety of urological conditions, even among patients who have undergone prior renal transplantation. We describe the technique of bilateral native nephrectomy and allograft nephrectomy by laparoscopy. CASE REPORT: A 32-year-old man with end-stage renal disease who had undergone a cadaveric renal transplant presented with chronic graft dysfunction. He had received a living donor kidney transplant with a postoperative course complicated by persistent proteinuria and refractory hypertension. Our nephrology service indicated the need for bilateral native nephrectomy and allograft nephrectomy for better blood pressure control following a second transplant. Bilateral native nephrectomy was performed following the previous reported techniques for pure laparoscopic nephrectomy. Allograft nephrectomy started by dissection of the iliac vessels to identify the vascular anastomosis. The hilum of the transplanted kidney was accessed. The renal vessels were clipped and transected. The ureter was identified and clipped. All three kidneys were removed from the abdominal cavity through a 3-cm skin incision. RESULTS: The left nephrectomy took 25 minutes and the right nephrectomy, 40 minutes. The estimated blood loss was 300 mL and the total operative time was 210 minutes. The patient had an uneventful postoperative course and was discharged on the third postoperative day. CONCLUSIONS: We demonstrate the feasibility of laparoscopic allograft nephrectomy and bilateral native nephrectomy in a transplant recipient.     

Experience with laparoscopic nephrectomy]

Laparoscopic procedures are promising techniques which allow less invasive surgery not only for intra-abdominal organs but also for retroperitoneal organs. Laparoscopic nephrectomy was first described by Clayman et al. We removed the left kidney of a 36-year-old male patient using laparoscopic procedures according to Clayman's technique. The kidney had developed hydronephrosis due to congenital ureteropelvic junction stenosis. In the peritoneal cavity the freed kidney was pushed into a Lapsac, minced using scissors and forceps, and removed without elongation of the wound. During the operation, pneumoperitoneum with CO2 gas induced increases in PaCO2, central venous pressure, pulmonary artery wedge pressure and cardiac output, all of which the patient tolerated well. The patient was discharged from the hospital on the 9th postoperative day. Laparoscopic nephrectomy is a useful alternative to the conventional open surgery in selected cases, when surgical techniques and instruments are improved appropriately.     

Retroperitoneoscopic right-sided donor nephrectomy with pre- and postcaval renal arteries

A 56-year-old male donor was evaluated for a kidney donation. Computed tomography angiography revealed 2 right renal arteries, 1 coursing in front and 1 behind the inferior vena cava. The renal scan showed a lower glomerular filtration rate on the right side. We present a technique of retroperitoneoscopic right-sided donor nephrectomy.     

External oblique muscle-cutaneous flap use of the in the reconstruction of large chest wall defects after mastectomy

The use of an external oblique muscle-cutaneous flap in the reconstruction of large chest wall defects after mastectomy is described. The flap is drown as a V-Y advancement-rotation flap, laterally based, on the ipsilateral abdominal wall. The flap extends from the posterior axillary line to the linea alba, vascular supply is provided by the musculo-cutaneous perforating arteries of the intercostal vessels. Mobilization starts medially including the anterior rectus sheath, décollement continues between the external and the internal oblique muscles as far as the posterior axillary line. The abdominal wall, after flap mobilization, is reinforced by the plication of the internal oblique sheath. The flap was used in 13 patients with major anterior chest-wall defects after mastectomy. In one patient a marginal skin necrosis of about 2 cm was observed. The flap described differs from other external oblique flaps already described in several technical innovations that allow to obtain better functional and esthetic results.     

Application of “cinch/tie” technique to robotic-assisted nephropexy for posterior abdominal wall fixation

Nephropexy remains standard for symptomatic nephroptosis, and several minimally-invasive techniques have been described. Triangulation sutures placed between the abdominal wall and the renal capsule are often difficult to tie tightly due to the confined working space. We propose a technique modification to fixate the kidney utilizing the da Vinci Surgical System robot and Lapra-Ty absorbable suture clips. Four female patients with symptomatic nephroptosis diagnosed via kidney hypermobility demonstrated on intravenous urography (IVU) underwent robotic-assisted laparoscopic nephropexy (RALNP) from February 2008 to April 2010. After complete mobilization and stripping of perirenal fat, several 0 Vicryl sutures were placed in a “figure of eight” fashion and tied loosely. Subsequently we utilized a Lapra-Ty to tighten the stitch serially and fixate the kidney. The mean age was 46 years (43–52); one patient underwent simultaneous pyeloplasty and one underwent partial nephrectomy in the ipsilateral kidney. There were no intraoperative complications and two postoperative complications, both Clavien grade I. All patients were asymptomatic postoperatively at a mean follow-up of 9.2 months (1–28), and had no evidence of kidney hypermobility on upright IVU or diuretic renal scintigraphy (RS) scan at 6 weeks postoperatively. RALNP is a viable option in the treatment of symptomatic nephroptosis. Secure placement of several “pexing” sutures helps to ensure appropriate security of these itinerant kidneys. Our technique modification corrects kidney hypermobility while improving symptoms related to nephroptosis.