Laparoscopic donor nephrectomy versus open donor nephrectomy: Outcomes from a single transplant center. / Nefrectomía laparoscópica del donante vivo en comparación con nefrectomía abierta del donante vivo.

OBJECTIVES: Laparoscopic donor nephrectomy (LDN) is currently replacing open donor nephrectomy (ODN) across the world. Its advantages in terms of patient recovery are well known. We sought to compare surgical outcomes, particularly renal function during the post-nephrectomy period, for renal grafts procured by LDN versus ODN in our center. METHODS: We retrospectively analyzed all cases of living donor nephrectomies performed from 2004 to 2014 at Hospital Universitario La Paz. We compared demographic data; medical background, operative times, post-operative complications, and renal function follow up at 6, 12 and 18-month controls. RESULTS: A total of 114 living donor nephrectomies were performed: 85 LDN and 29 ODN. Demographic characteristics and medical background were similar among both groups, except mean donor age; 41.4 vs 47.4 years (p = 0.009) in the LDN and ODN groups respectively. LDN was used predominantly for left kidneys (83 out of 85), and ODN for right kidneys (28 out of 29). Although not significantly, mean operative time was shorter for the LDN group (169.37 vs 181.46 minutes; p = 0.2). Mean warm ischemia time was shorter for the ODN group (2.92 vs 2.36 minutes; p = 0.28). Differences between post-operative complications were not statistically different between both groups (p = 0.19). There were no conversions from LDN to ODN, and no re-admissions were registered. Length of stay was slightly shorter in LDN but not different (4.29 vs 4.92 days; p = 0.43). Renal function follow-up, measured with serum creatinine levels showed no difference over time (p = 0.67). CONCLUSIONS: Data from our series demonstrate that outcomes and renal function follow up over time were similar among both groups. In expert hands, this altruistic procedure can be performed with a minimally invasive approach without an increased complication rate or compromising renal function in donors.

OBJETIVOS: La nefrectomía laparoscópica del donante vivo (NLDV) está reemplazando actualmente a la nefrectomía abierta (NADV) en todo el mundo. Sus ventajas en términos de recuperación del paciente son bien conocidas. Comparamos los resultados quirúrgicos, particularmente función renal durante el periodo postnefrectomía, para los injertos obtenidos en nuestro centro por NLDV o NADV. MÉTODOS: Analizamos retrospectivamente todos los casos de nefrectomía del donante vivo realizados entre 2004 y 2014 en el Hospital Universitario La Paz. Comparamos los datos demográficos, antecedentes médicos, tiempo operatorio, complicaciones postoperatorias y funcion renal a los 6, 12 y 18 meses de seguimiento. RESULTADOS: Se han realizado un total de 114 nefrectomías del donante vivo: 85 NLDV y 29 NADV. Las características demográficas y antecedentes médicos eran similares entre ambos grupos, excepto la edad media del donante: 41,4 vs 47,4 años (p = 0,009) en los grupos de NLDV y NADV, respectivamente. La NLDV se utilizó preferentemente para riñones izquierdos (83 de 85) y la NADV para los riñones derechos (28 de 29). Aunque no fue significativo, el tiempo medio de operación del grupo de NLDV fue menor que el de NADV (169,37 vs 181,46 minutos; p = 0,2). El tiempo medio de isquemia caliente era menor en el grupo de NADV (2,92 vs 2,36 minutos; p = 0,28). No hubo diferencias estadísticamente significativas en las complicaciones postoperatorias entre ambos grupos (p=0,19). No hubo conversión a cirugía abierta en ninguna NLDV y no se registró ningún reingreso. La estancia hospitalaria fue ligeramente menor en la NLDV pero la diferencia no fue estadísticamente significativa (4,29 vs 4,92 días; p = 0,43). La función renal en el seguimiento, medida con los niveles de creatinina sérica no mostró diferencias con el tiempo (p = 0,67). CONCLUSIONES: Los datos de nuestra serie demuestran que los resultados y función renal en el seguimiento eran similares entre ambos grupos. En manos expertas, este procedimiento altruista puede ser realizado con un abordaje mínimamente invasivo sin aumento de la tasa de complicaciones o compromiso de la función renal del donante.

A novel heterozygous mutation in the Birt-Hogg-Dubé Syndrome.

OBJETIVE: Our aim is to present a novel mutation of the Birt-Hogg-Dubé Syndrome. METHODS: We present a case report of a 70-year-old male with three solid nodulary lesions of 4, 2.6, and 3 cm each in the right kidney, and two lesions of 1.5 and 1.3 cm in the left kidney. RESULTS: Needle biopsy was performed. The pathological analysis of right kidney lesions revealed a renal tumor suggestive of chromophobe renal cell carcinoma and medullar tumor with zones that suggested oncocytosis. Genetic test results were positive for a novel heterozygous mutation c.1198G>A; p.V400I in exon 11 of the FLCN gene. CONCLUSION: In patients presenting with bilateral multifocal renal tumors of oncocytic hybrid histology, Birt- Hogg-Dubé syndrome should be the first diagnosis in mind. The mutation found in this patient has not been previously described in the literature in the context of BHD.

Human native Cav1 channels in chromaffin cells: contribution to exocytosis and firing of spontaneous action potentials.

The present study was performed to evaluate the Cav1 channel subtypes expressed in human chromaffin cells and the role that these channels play in exocytosis and cell excitability. Here we show that human chromaffin cells obtained from organ donors express Cav1.2 and Cav1.3 subtypes using molecular and pharmacological techniques. Immunocytochemical data demonstrated the presence of Cav1.2 and Cav1.3 subtypes, but not Cav1.1 or Cav1.4. Electrophysiological experiments were conducted to investigate the contribution of Cav1 channels to the exocytotic process and cell excitability. Cav1 channels contribute to the exocytosis of secretory vesicles, evidenced by the block of 3µM nifedipine (36.5±2%) of membrane capacitance increment elicited by 200ms depolarizing pulses. These channels show a minor contribution to the initiation of spontaneous action potential firing, as shown by the 2.5 pA of current at the threshold potential (-34mV), which elicits 10.4mV of potential increment. In addition, we found that only 8% of human chromaffin cells exhibit spontaneous action potentials. These data offer novel information regarding human chromaffin cells and the role of human native Cav1 channels in exocytosis and cell excitability.

Approach to kidney stones associated with ureteropelvic junction obstruction during laparoscopic pyeloplasty.

INTRODUCTION: We have performed laparoscopic pyeloplasty (LP) in our department since 2004. Our goal is to describe, step by step, the approach of kidney stones during transperitoneal laparoscopic pyeloplasty and the outcomes after the procedure. MATERIAL AND METHODS: Twelve patients with kidney stones treated by transperitoneal laparoscopic pyeloplasty were found. The hospital records with clinical features, supplementary tests, and imaging studies were reviewed for demographic, procedural, and efficacy data. RESULTS: Kidney stones were found in 12 of 62 patients (19%) who had undergone transperitoneal laparoscopic pyeloplasty. Eight cases were treated using a flexible cystoscope and a nitinol N-Circle basket; in the remaining four cases the stones were extracted using laparoscopic grasping instruments. We want to emphasize a case of horseshoe kidney associated with ureteropelvic junction (UPJ) obstruction and a kidney stone in which the procedure was performed successfully. CONCLUSIONS: Laparoscopic pyeloplasty has now emerged as a standard approach to UPJ obstruction. Associated renal abnormalities or kidney stones add complexity to the procedure, however, as shown in our results, centers with experience in the laparoscopic approach of reconstructive urology make this technique feasible.

Pharmacological characterization of native α7 nicotinic ACh receptors and their contribution to depolarization-elicited exocytosis in human chromaffin cells.

BACKGROUND AND PURPOSE: Expression of α7 nicotinic acetylcholine receptors (nAChRs) and their role in exocytosis have not yet been examined in human chromaffin cells. EXPERIMENTAL APPROACH: To characterize these receptors and investigate their function, patch-clamp experiments were performed in human chromaffin cells from organ donors. KEY RESULTS: The nicotinic current provoked by 300µM ACh in voltage-clamped cells was blocked by the nicotinic receptor antagonists α-bungarotoxin (α-Bgtx; 1µM; 6 ± 1.7%) or methyllycaconitine (MLA; 10nM; 7 ± 1.6%), respectively, in an irreversible and reversible manner, without affecting exocytosis. Choline (10mM) pulses induced a biphasic current with an initial quickly activated (5.5 ± 0.4ms rise time) and inactivated component (8.5 ± 0.4ms time constant) (termed α7), which was blocked by α-Bgtx or MLA, followed by a slower component (non-α7). α7 nAChR currents were dissected by blocking the non-α7 nAChR current component of the ACh and choline response with the α6* nAChR blocker α-conotoxin (α-Ctx) MII[S4A, E11A, L15A]. PNU-282987, an α7 nAChR-specific agonist, elicited rapidly activated and rapidly inactivated currents. α7 nAChR-positive allosteric modulators, such as 5-hydroxyindole (1mM) and PNU-120596 (10µM), potentiated responses that were blocked by α-Bgtx or MLA. Exocytosis was evoked by depolarization-elicited α7 nAChR currents, using choline in the presence of α-Ctx MII[MS4A, E11A, L15A] or PNU-282987 as agonists. CONCLUSIONS AND IMPLICATIONS: Our electrophysiological recordings of pure α7 nAChR currents elicited by rapid application of agonists demonstrated that functional α7 nAChRs are expressed and contribute to depolarization-elicited exocytosis in human chromaffin cells.

Laparoscopic transperitoneal radical prostatectomy in renal transplant recipients: a review of the literature.

OBJECTIVES: To report our experience with laparoscopic radical prostatectomy (LRP) for the treatment of localized prostate carcinoma in two renal transplant recipients and a review of the literature. PATIENTS AND METHODS: We retrospectively identified all patients who had undergone LRP for clinically localized prostate cancer between 2002 and 2008 at our institution (n = 1150). Of these patients, two were renal transplant recipients (one with donor renal transplant cadaver and the other with prior transplantectomy). We reviewed all available clinicopathological data and the scientific literature. RESULTS: The two patients underwent successful LRP with no major complications. The mean (range) operative time was 200 (180-220) min with a mean estimated blood loss of 300 (200-400) mL. There were no changes in renal graft function as measured by serum creatinine level. At pathology, the surgical margins were negative and disease was organ-confined in each case. The two patients tolerated the procedure well and had a mean (range) hospital stay of 3.5 (3-4) days. CONCLUSIONS: The data from our two patients suggest that LRP, as an accepted minimally invasive treatment for a middle-aged man with organ-confined prostate cancer, is a technically feasible and safe treatment of localized prostate cancer in renal transplant recipients.

[Laparoscopic radical nephrectomy in big surgical specimens]. / Nefrectomía radical laparoscópica en piezas quirúrgicas de gran tamaño.

INTRODUCTION: The retroperitoneal surgery is the clearer indication for the laparoscopic approach. Still there are indications for open surgery because of the complexity of the patient and the surgeon experience. OBJECTIVES: The main objective is to report our experience of laparoscopic radical nephrectomies in patient with tumors greater than 7 cm. or surgical specimens with more than 700 g of weight. We analyze their characteristics, complications rate, surgical time, postoperative outcome and hospital stay. MATERIALS AND METHODS: Since July 2004 to July 2008 we have performed 104 laparoscopic radical nephrectomies. We have selected 41 patients with characteristics of big surgical specimens. RESULTS: The average surgical time has been of 184,3 min. Only 1 case has been converted into open surgery and only 1 intraoperative death because of cardiologic arrhythmia. The average hospital stay has been of 3,51 days. The complications rate and postoperative outcome are similar to the whole series. DISCUSSION: Laparoscopic nephrectomy is technically less complex than radical prostatectomy. However, their possible complication implies a much bigger severity. The more complex cases must be approach laparoscopically only after a wide experience. Actually, in our department we usually indicate an open approach when surgical specimen crossover the abdominal middle line and in those cases where the tumoral thrombus affect the main renal vein and/or the vena cava.

Laparoscopic repair of the vesicovaginal fistula (laparoscopic O'Connor repair).

INTRODUCTION: The most frequent cause of vesicovaginal fistula in developed countries is hysterectomy, while in the third world it is related to time in labour. Any surgical iatrogenic trauma implies encountering added difficulties of various kinds when repairing the condition. MATERIAL AND METHOD: We report the first case of vesicovaginal fistula to be resolved laparoscopically in our department. The patient is a woman 50 years of age who had undergone an abdominal hysterectomy 8 months previously, and who presented a syndrome compatible with vesicovaginal fistula. She was referred to our division after an unsuccessful attempt at vaginal repair. We will now describe the laparoscopic vesicovaginal fistula repair procedure. RESULTS: The surgical procedure lasted approximately 3 hours and 30 minutes. The patient began oral intake 48 hours after surgery, normal intestinal transit was restored by the 5th day, a cystography was performed on the 7th day, and the patient was discharged on the 8th day. The patient remains asymptomatic after more than a year and a half. CONCLUSIONS: Laparoscopic resolution of vesicovaginal fistula is perfectly feasible and safe. If we consistently reproduce the principles applied in the open surgery, it offers the same success rate with the lowest possible morbidity.

Impact of a clinical pathway in patient care following surgery on laparoscopic radical prostatectomy.

PURPOSE: The aim of this study was to evaluate the impact of clinical pathway (CP) implementation in laparoscopic radical prostatectomy (LRP) has had on patient care and clinical evolution after discharge. MATERIALS AND METHODS: Eighty-six patients were included in 2 groups: first group was composed of patients operated since the new technique (LRP) was used until the CP was implemented (26 patients operated in 2002) and, second group, with 60 patients, followed the CP during 2004 and 2005. RESULTS: The operative time was reduced from 377.7 to 172.3 minutes after the CP implementation. The duration of bladder catheterization decreased by more than 10 days (from 26.17 to 15.85 days) and that of thromboprophylaxis was reduced from 6.44 to 3.38 days. No difference was found in the rate of complications in the first month after surgery, nor was there any difference in the rate of occurrence of erectile dysfunction, incontinence, and biochemical recurrence during the first year after surgery. CONCLUSION: After the implementation of the CP, there have been better results in patient care, such as reduction in the duration of catheterization and thromboprophylaxis. In comparison with other studies, we observed a clear reduction in length of stay and operative time. However, there is still room for improvement in reducing the duration of catheterization.

[Laparoscopic nephroureterectomy: new position for the management of distal ureter]. / Nefroureterectomía laparoscópica: nueva posición para el manejo ureteral.

OBJECTIVES: The main challenge of laparoscopic nephroureterectomy is the management of distal ureter, which also will have an important repercussion in the oncological outcome of many cases. We present our experience in such aspect, considering that we performed the last five laparoscopic nephroureterectomies in forced Trendelemburg position, resulting in a more comfortable and safe management of the distal ureter. METHODS: Between August and December 2006 we performed five purely laparoscopic nephroureterectomies with bladder cuff positioning the patient in forced Trendelemburg, a position similar to that of laparoscopic radical cystectomy or prostatectomy. RESULTS: Mean surgical time was 182 minutes (170-210). Mean blood loss was 100 cc and no patient required transfusion. Mean hospital stay was four days. CONCLUSIONS: We believe this position is a good alternative for the management of the distal ureter during the laparoscopic approach. The technique is very similar to open surgery, which continues being the gold standard today.

[Bladder neurofibroma: case report and bibliographic review]. / Neurofibroma de la vejiga: caso clínico y revisión de la literatura.

OBJECTIVE: The prevalence of the disease is 1/3000 newborns; it is more frequent in men than in women with a 3:1 ratio in all races. Genitourinary tract neurofibromas usually arise from the pelvic and bladder nerves, and the prostatic plexus. Bladder is the most frequently affected organ of the urinary tract; bladder neurofibromatosis may present as a diffuse infiltrative process or an isolated neurofibroma. Bladder neurofibromas arise from nervous ganglia of the bladder wall and stain positive for protein S-100 and type IV collagen with immunohistochemical techniques. METHODS: We performed a bibliographic review about urinary tract neurofibromas, and specifically of bladder neurofibroma. We report the case of a 45-year-old female consulting for voiding symptoms and recurrent urinary tract infections. Imaging tests showed a mass in the left lateral wall of the bladder and diffuse thickening of the bladder wall. The thickening of the bladder wall is the most characteristic finding in imaging tests, which may also be present in other diseases such as inflammatory pseudotumor and leiomyoma, so that final diagnosis should be achieved by pathologic study. RESULTS: The case is relevant for the absence of previous diagnosis of neurofibromatosis, being bladder involvement its clinical debut. This is why it was difficult to suspect the final diagnosis: the absence of other characteristic clinical manifestations of the disease. Transurethral resection of the tumor was performed and pathologic and immunohistochemical studies offered the final diagnosis. The patient was followed in the urology clinic and also sent to the internal medicine department to rule out other organs involvement of the disease. CONCLUSIONS: Neurofibromatosis is a rare systemic disease, and urinary tract involvement is rarer. Bladder is the most frequently involved organ in the urinary tract, generally as a diffuse infiltration or more rarely a solitary tumor. The final diagnosis is pathological and immunohistochemical. Treatment is usually conservative. The patient should be worked up to rule out other manifestations of the disease, and followed to evaluate the development of new lesions.

[Ureteroenteric strictures: endourological treatment]. / Estenosis ureterointestinales: tratamiento endourológico.

OBJECTIVES: To review the outcomes of the ureteroenteric strictures treated by endourological techniques in our department, and to compare our long-term results with other reported series with similar follow-up and number of patients. METHODS: We retrospectively reviewed 27 ureteroenteric strictures treated from March 1994 to June 2003, with a mean follow-up of 30.2 months (1 day-53 months). 13 cases underwent ballon dilation + permanent double J catheter (3 of them antegrade) 8 patients underwent endoscopical incision + double J catheter (5 of them with Acucise). RESULTS: 12/21 (57,14%) renal units improved and/or remained stable. We emphasize the absence of peroperative complications except 1 case that had a very poor oncological prognosis and died of septicemia 1 day after balloon dilation. CONCLUSIONS: Endourological treatment of ureteroenteric strictures has demonstrated to provide good fuctional results on the short and mid-term in patients that open surgery, although being the treatment of choice, would be too aggressive due to their disease, age, morbid conditions,....