Hand-assisted laparoscopic nephrectomy for inflammatory renal conditions

PURPOSE: Laparoscopic surgery for large renal lesion or kidneys with chronic inflammation has proved to be technically challenging. Hand-assisted laparoscopic surgery might be useful in these complex cases, as it provides surgeons the benefits of tactile feedback, digital retraction, and facilitated dissection of the renal hilar vessels. PATIENTS AND METHODS: Twenty-two patients undergoing hand-assisted laparoscopic (HAL) nephrectomy for benign conditions were compared with patients who underwent HAL radical nephrectomy during the same period. The demographic data, laterality, operative time, estimated blood loss, conversion rate, length of stay, histopathology findings, morbidity, and mortality were reviewed. RESULTS: The main indications for surgery were chronic inflammation and xanthogranulomatous pyelonephritis. Twenty patients had unilateral nephrectomy (10 each on the right and left), and two patients had bilateral nephrectomy. The mean operative times for unilateral and bilateral nephrectomy were 163 minutes (range 55-261 minutes) and 265 minutes (range, 238-291 minutes), respectively. Nine patients (45%) with inflammation had complications (15% major and 30% minor). The mean length of hospitalization for patients undergoing HAL nephrectomy was 7.2 days (range 2-35 days). The patients with inflammatory pathology had longer mean operative times, higher estimated blood loss, longer hospital stay, and higher morbidity than patients undergoing radical nephrectomy. CONCLUSION: Compared with standard laparoscopy, the hand-assisted approach has been reported to reduce operative times and increase safety. The advantages of minimally invasive surgery, such as reduced analgesia, shorter hospital stay, and faster return to normal activity, appear to be similar to those in patients undergoing a pure laparoscopic nephrectomy. Compared with radical nephrectomy for renal tumor, HAL simple nephrectomy can often be more challenging and associated with greater morbidity. For both the community urologist as well as an experienced laparoscopist, this approach is useful in handling these challenging cases.     

Bilateral renal calculi: assessment of staged v synchronous percutaneous nephrolithotomy

BACKGROUND AND PURPOSE: Percutaneous stone removal has replaced open renal surgery and has become the treatment of choice for large or complex renal calculi. However, patients with large bilateral stone burdens still present a challenge. Simultaneous bilateral percutaneous nephrolithotomy (PCNL) has been demonstrated to be a well-tolerated, safe, cost-effective, and expeditious treatment. We present what is, to our knowledge, the first large retrospective series comparing synchronous and asynchronous bilateral PCNL. PATIENTS AND METHODS: A chart review was performed on 26 patients undergoing 57 PCNLs for bilateral renal calculi over a 7-year period. Seven patients received synchronous PCNL (same anesthesia; Group 1), and 19 patients underwent asynchronous PNL (procedures separated by 1-3 months; Group 2). Complete surgical and hospital records were available on all patients. The average stone burden for Group 1 was 8.03 cm(2) on the left and 9.18 cm(2) on the right v 10.1 cm(2) on the left and 14.23 cm(2) on the right for Group 2 (P> 0.05). Variables of interest included anesthesia time, operative time, blood loss, transfusion rates, length of hospital stay, and complication rates. Each variable was evaluated per operation and per renal unit. Follow-up imaging with stone assessment was available on 20 patients. RESULTS: Group 1 required 1.14 access tracts per renal unit to attempt complete clearance of the targeted stones v 1.88 tracts per renal unit in Group 2 (P> 0.05). The average operative time per renal unit was significantly less in Group 1 (83 minutes) than in Group 2 (168.5 minutes) (P< 0.0001), as was blood loss (178.5 mL v 307.4 mL, respectively; P= 0.02). However, blood loss per operation was similar at 357 mL in Group 1 and 282 mL in Group 2. Comparable transfusion rates of 28.6% and 36.8%, respectively, were noted. Forty percent of the patients in Group 1 were completely stone free compared with 36% of the patients in Group 2; however, an additional 50% and 57%, respectively, had residual stone burden <4 mm (P> 0.05). Complications occurred in 2 of 7 operations (28%) in Group 1 and 8 of 42 operations (19%) in Group 2. The total length of hospital stay was nearly doubled for patients undergoing staged PCNL (P= 0.0005). CONCLUSIONS: These results demonstrate similar stone-free rates, blood loss per operation, and transfusion rates for simultaneous and staged bilateral PCNL. The reduced total operative time, hospital stay, and total blood loss, along with the requirement for only one anesthesia, makes synchronous bilateral PCNL an attractive option for select individuals. However, in patients with larger, less easily accessible stones, excessive bleeding may be encountered more frequently on the first side, thereby delaying management of the second side to a later date. Synchronous bilateral PCNL should be considered in patients in whom the first stage of stone removal is accomplished quickly and safely.     

Vitamin D receptor polymorphism and susceptibility to type 1 diabetes in chilean subjects: A case-parent study

Several reports have found a relation between polymorphisms of the vitamin D receptor gene (VDR) and the development of type 1 diabetes. We have examined the association of three VDR polymorphism with type 1 diabetes in 59 Chilean case-parents trios. Genotyping for Bsm1, Apa1 and Taq1 polymorphism were performed. Transmission/disequiibrium tests were used to assess gene-disease associations through the evaluation of allelic transmission to affected offspring. Non-significant increased transmissions of B allele (probability of transmission=52.5, p=0.69), A allele (probability of transmission=58.4, p=0.17) and T allele (probability of transmission=52.0, p=0.77) were estimated in Bsm1, Apa1 and Taq1 sites, respectively. Haplotype-based analyses showed non-significant preferential transmissions (global p=0.52). The present study does not support the hypothesis of a significant contribution of VDR alleles in the etiology of type 1 diabetes of Chilean cases.     

Obesity trends and determinant factors in Latin America

Obesity rates have increased markedly in Latin America, especially during the last 10-15 years, becoming a public health problem in most countries. Prevalence of obesity among preschool children remains low, while among schoolchildren it has increased considerably. Prevalence is high in the adult population, especially among women with less schooling. In developed populations, obesity occurs more frequently among the poor; the opposite occurs in less developed societies, where in households undergoing nutritional transition, underweight can coexist with obesity. The most important determinant factors involved in the increasing obesity prevalence are fetal and infant nutritional conditions (stunting), education and socioeconomic conditions, dietary changes (especially increased total energy intake), and physical inactivity. Because chronic diseases are the main causes of death in the Region and obesity is one of the main risk factors for these diseases, policies to improve economic and educational levels with the implementation of health promotion and prevention should be a priority in every country.     

Fibrin sealants in clinical practice

Fibrin sealants are used in a wide range of surgeries, primarily as hemostatic agents, but also to assist tissue sealing and wound healing. While all fibrin sealants contain fibrinogen and thrombin, they differ in their final composition. This affects the properties of the resulting fibrin clot and may influence their use in different surgical procedures. Sealants with high concentrations of fibrinogen tend to produce stronger clots, whereas those containing higher concentrations of thrombin form clots rapidly. This is essential when rapid hemostasis is required to stop blood loss (e.g. suturing of blood vessels). However, in situations that require careful adjustment of tissue (e.g. a skin flap) a slower clot formation is advantageous. Some sealants are supplemented with factor XIII and this may increase the tensile strength and stability of the clot and improve hemostasis. Antifibrinolytic agents (e.g. aprotinin and aminocaproic acid) increase the lifespan of the clot by inhibiting fibrinolysis. Fibrin sealants containing aprotinin may have an added advantage when used on surgical sites with naturally high concentrations of fibrinolytic agents. The physical properties of the fibrin sealants also vary. For example, the fibrinogen component is relatively viscous and requires a lot of force to inject it through a long catheter. Fibrin sealants with a fibrinogen component of low viscosity are easier to use than highly viscous solutions in surgical situations where the sealant is applied by a catheter. Until recently, the use of fibrin sealants in the USA has been limited to noncommercial products--'home-brews'. The fibrinogen concentration of these products can vary between preparations, with subsequent variation in the mechanical strength of the clot making handling difficult. The introduction of commercial sealants into the USA with consistent composition should reduce the varying performance of fibrin sealants, although autologous and point-of-use prepared sealants may still vary. Consistency of performance is expected to result in an increased use of fibrin sealants both in established and novel fields of surgery.     

Effects of fibrin glue on injured rabbit ureter

BACKGROUND AND OBJECTIVE: Fibrin glue is used as a hemostatic agent, has potential as a tissue adhesive, and may promote tissue healing. The histologic effects of fibrin glue on the ureter have not yet been fully investigated. We studied the effect of fibrin glue on the thickness of various layers of injured and uninjured ureters and its effect on vessel density in the rabbit model. MATERIALS AND METHODS: Rabbits were divided into two groups. The ureters were exposed using a midline abdominal incision. In the study group, one of the ureters was crushed, and fibrin glue was instilled around both ureters. In the control group, one of the ureters was crushed, but no fibrin glue was instilled. The animals were sacrificed at 6 weeks and the ureters examined histologically. Using NIH Image Analysis solftware, the thickness of the urothelium, muscular, and adventitial layers and the cross-sectional area of the ureters were measured. The vessel density of the ureters was also assessed. RESULTS: Whereas the thickness of the epithelium was increased in the crushed ureters treated with fibrin glue (20.7 microm v 15.3 microm), the thickness was reduced in the uncrushed ureters treated with fibrin glue compared with controls (16.3 microm v 19.8 microm). There was no statistically significant difference in the thickness of the muscular or adventitial layers in the study and control groups. There was a reduction in the cross-sectional area of the uncrushed ureters treated with fibrin glue compared with controls (7,095 microm2 v 9,409 microm2). In addition, the vessel density in the crushed ureters was reduced in ureters treated with fibrin glue compared with controls (0.00067/microm2 v 0.00108/micro2). In the uncrushed ureters, the difference was not statistically significant. CONCLUSIONS: Fibrin glue has potential as an adhesive agent in the ureter and may promote healing. It may affect epithelial layer thickness and vessel density of the ureter, but these effects were variable. Fibrin glue does not appear to have significant effects on the ureteral muscular and adventitial layers or on the overall cross-sectional area of all three layers. These results indicate that fibrin glue does not appear to have a detrimental effect on the ureter.     

Fibrin glue applications in urology

Fibrin glue is used as a hemostatic and adhesive agent. Until recently, safety issues had delayed approval of the commercial preparation in the United States. Fibrin glue has found several urologic applications, especially as an adhesive agent. It has excellent potential in laparoscopic surgery, where conventional tissue approximation techniques are cumbersome and time-consuming. Fibrin glue has also been used as a delivery vehicle for autologous cell transplantation and may play a major role in tissue engineering techniques in the future.     

Osteonecrosis in patients with Hodgkin disease following combination chemotherapy

Three cases of osteonecrosis in patients receiving prednisone as part of multidrug chemotherapy for lymphoma are presented. These patients are discussed in the context of previously reported series. The etiology of steroid-induced osteonecrosis and its radiologic manifestations are reviewed with regard to the need for biopsy to confirm the diagnosis. In light of this complication, the need for prednisone in lymphoma chemotherapy is considered.     

Endopyelotomy in the Age of Laparoscopic and Robotic-Assisted Pyeloplasty

Ureteropelvic junction obstructixon (UPJO) management has undergone significant changes in the past few years. The aim of this review is to establish the role of endopyelotomy in the age of laparoscopic and robot-assisted laparoscopic pyeloplasty (RALP). Open pyeloplasty (OP) has been the gold standard of care for UPJO for the past six decades. Due to lower long-term efficacy, endopyelotomy has failed to replace OP. However, laparoscopic pyeloplasty (LP) has been able to reproduce the high success rates of OP, while also achieving minimal morbidity. Unfortunately, the steep learning curve and technical difficulties have hindered its use. Recently, robot-assisted systems have enabled LP to overcome its disadvantages, and this may render endopyelotomy obsolete. Although LP and RALP are emerging as the gold standard of treatment for UPJO, endopyelotomy could carve out a niche area as a salvage procedure. Endopyelotomy will continue to have a role in the management of UPJO, albeit a smaller one.