Laparoscopic renal-adrenal surgery in patients on oral anticoagulant therapy

PURPOSE: Patients requiring chronic anticoagulation are theoretically at increased risk for hemorrhage or thromboembolism perioperatively. Experience with laparoscopic renal/adrenal surgery in patients on chronic warfarin is limited. We assessed hemorrhagic/thromboembolic complications in this group of patients. MATERIALS AND METHODS: The records of 787 patients undergoing laparoscopic renal/adrenal surgery were retrospectively reviewed. A total of 25 patients on chronic oral anticoagulation with warfarin were identified. The indications for warfarin therapy as well as perioperative management were reviewed. Clinical parameters, including operative time, estimated blood loss, hemorrhagic/thromboembolic complications and transfusions, were documented and compared with those in patients not receiving chronic anticoagulation. RESULTS: Atrial fibrillation (56% of cases) and a prosthetic mitral valve (28%) were the most frequent indications for chronic anticoagulation. Bridging anticoagulation with unfractionated heparin was the most frequent management method (68% of cases). Patients with anticoagulation were older (p <0.001) and hospitalized longer (<0.001) than those without anticoagulation. Operative time, estimated blood loss and the conversion rate were not significantly different between the groups. However patients on chronic warfarin significantly more often required transfusion (24% vs 5.2%, p <0.005) and had more postoperative bleeding episodes (8% vs 0.9%, p <0.05) than patients not on chronic anticoagulation. No thromboembolic events occurred in the anticoagulated group, while 3 occurred in the nonanticoagulated group (p = 1). CONCLUSIONS: Laparoscopic renal/adrenal surgery in patients requiring chronic anticoagulation therapy can be performed safely. The risk of intraoperative bleeding is not increased, although the incidence of postoperative bleeding as well as transfusions is higher.     

Small cell carcinoma of epididymis: multimodal therapy

Extrapulmonary small cell carcinoma is an infrequent tumor that can occur in various organs. Although a few sporadic reports about extrapulmonary small cell carcinoma have been published, much remains to be uncovered about the clinical features, optimal treatment, and natural history. We present a case of small cell carcinoma of the epididymis with retroperitoneal recurrence, an exceedingly rare tumor with behavior and treatment not well characterized. Multimodal therapy with chemotherapy and retroperitoneal lymph node dissection was necessary to manage this aggressive disease.     

Necessity of ureteral catheter during laparoscopic partial nephrectomy

PURPOSE: Laparoscopic partial nephrectomy (LPN) is a relatively recently introduced method of treating renal tumors and, as such, surgical technique is evolving. In open series urinary fistula formation represents a common postoperative complication. In the laparoscopic approach investigators have advocated the placement of a ureteral catheter with retrograde dye injection to visualize caliceal entry to aid in closure. In this study we assessed the necessity of ureteral catheter placement during LPN in decreasing urinary leakage. MATERIALS AND METHODS: From February 1998 until November 2002 laparoscopic partial nephrectomy was performed in 103 patients with renal tumors. The patients were assessed retrospectively and divided into 2 groups according to placement (group 1) or no placement (group 2) of an external ureteral catheter. Group 1 included 54 patients (mean age +/- SD 57.4 +/- 13.4 years) and group 2 included 49 patients (mean age +/- SD 57.5 +/- 10.9). Intraoperative and postoperative parameters including blood loss, operative time, ischemia time, mass size, complications and hospital stay were reviewed and compared between the 2 groups. RESULTS: There were no differences between the 2 groups in mean estimated blood loss (group 1, 394.7 cc vs group 2, 291.5 cc, p = 0.07), postoperative serum creatinine (group 1, 0.95 mg/dl vs group 2, 0.89 mg/dl, p = 0.12), requirement for pain medication (group 1, 8.9 mg vs group 2, 4.9 mg morphine equivalents, p = 0.12), hospital stay (group 1, 3.1 vs group 2, 2.9, p = 0.29) and warm ischemia time (group 1, 28 minutes vs group 2, 26.5 minutes, p = 0.18). Mean total operative time was significantly longer for group 1 compared to group 2 (191.1 vs 149.4 minutes, respectively, p = 0.001). Postoperative urinary leakage requiring prolonged drainage occurred in 1 patient in group 1 and 1 in group 2. In both cases caliceal entry was identified and sutured. CONCLUSIONS: With experience caliceal entry can be identified without the need for a ureteral catheter in patients undergoing LPN for a tumor less than 4.5 cm. Urinary fistula may occur despite caliceal entry and repair. A ureteral catheter may not decrease urinary fistula in patients undergoing LPN.     

Interstitial photon radiation

Most minimally invasive ablative techniques utilize thermal energies for tissue destruction. However, the heat-sink phenomenon may limit the efficacy of radiofrequency ablation and cryotherapy of tissue near blood vessels. One alternative non-temperature-dependent ablative technique is photon radiation. This radiation is dependent on energy and intensity, and its effects are influenced only by the density of the surrounding tissue. Photon radiation therapy may offer a unique alternative for ablating tissue surrounding vascular structures.     

Demographics of 353 laparoscopic renal donor and recipient pairs at the Johns Hopkins Medical Institutions

BACKGROUND AND PURPOSE: The demographics of laparoscopic donor nephrectomy (LDN) have not been characterized in detail. The aim of this study was to review our LDN experience with respect to donor and recipient demographic characteristics and trends. PATIENTS AND METHODS: Over a 6-year period, 353 patients underwent LDN. A retrospective chart review was performed to identify the donor and recipient demographic characteristics and trends associated with the procedure. RESULTS: Among the donors, the mean age was 41 years, with a predominance of females (59.2%), whites (76.2%), and blood relations (72%). Siblings were the most common related-donor-to-recipient relationship, and spouses were the most common unrelated relationships. Among the recipients, the mean age was 43 years, with a predominance of males (58.4%), whites (73.7%), and dialysis-dependent patients (55%). Diabetes mellitus and hypertension were the most common causes of end-stage renal failure. With the introduction of laparoscopy, there was a nearly twofold increase in the total number of live renal donations, and there was a significant expansion in the unrelated-donor pool. CONCLUSIONS: Laparoscopic harvest of donated kidneys is associated with new trends that may help alleviate the current organ shortage.     

Histologic evolution of high-intensity focused ultrasound in rabbit muscle

RATIONALE AND OBJECTIVES: The purpose of this study was to examine the histologic evolution over time of rabbit skeletal muscle thermally ablated with high-intensity focused ultrasound. The objectives included determining the extent and focality of damage created by this noninvasive, transcutaneous ablative technology. METHODS: Transcutaneous, thermal ablation with an external focused ultrasound transducer was applied to the paraspinous muscles of 19 rabbits. At varying times, up to 100 days after therapy, single sonications were examined histologically. RESULTS: Initially, only subtle staining changes were identified within lesions. In the chronic phase (day 51-100), the muscle was replaced or infiltrated by variable amounts of scar and fat similar to degenerative muscle disorders. Histologic changes were limited to the tissue within the intensity focus of the transducer and were not seen in intervening tissues. DISCUSSION: The current study took a systematic approach to study the long term, in vivo histologic effects of single HIFU lesions in a nonregenerative tissue. This experience in muscle tissue will provide a basis for understanding ultrasound effects for clinical applications such as treatment of uterine fibroids, cardiac tissue, and sarcomas.