[How to operate kidney puncture in percutaneous nephrolithotomy?]. / Comment ponctionner un rein pour réaliser une néphrolithotomie percutanée?

Obtaining a precise percutaneous calyceal puncture gave way to the development of percutaneous nephrolithotomy, one of the first micro-invasive techniques described in urology. Both radiologist and urologist can perform puncture, sometimes in a collaborative effort. However, being followed by a true surgical procedure, it should be done in the O.R; perfect knowledge of the procedure is mandatory for every urologist. Standard guidance uses a fluoroscopic C-arm device, only able to guide the needle precisely towards the apex of the chosen calyx. Moving the C-arm with cephalad tilting will provide 3-D imaging. Ultrasound guidance is an alternative, but might be difficult with non dilated upper tract. CT guidance and retrograde puncture are rarely used. The access is to be adapted according to the patient (adult or child), type of stone (single or multiple access), or kidney position (eutopic or ectopic). Direct ad stable puncture entering the apex of the chosen calyx is a pre-requisite for easy and efficient subsequent nephrolithotomy.

The role of pleural fluid-serum gradient of tumor necrosis factor-alpha concentration in discrimination between complicated and uncomplicated parapneumonic effusion.

In a previous preliminary study an excess of tumor necrosis factor-alpha (TNF) was found in pleural fluid of patients with complicated parapneumonic effusion (CPPE), and its levels in pleural fluid of these patients were shown to be significantly higher than those in patients with uncomplicated parapneumonic effusion (UCPPE). This larger population study was undertaken to investigate, for the first time, the role of pleural fluid-serum gradient of TNF (TNFgradient) in discrimination between UCPPE and CPPE. Using a commercially available high sensitivity ELISA kit, levels of TNF were measured in serum and pleural fluid of 51 patients with UCPPE and 30 patients with nonempyemic CPPE. The mean +/- SEM values of serum TNF (TNFserum), pleural fluid TNF (TNFpf), and TNFgradient in the UCPPE group were 6.65 +/- 0.48 pg/mL, 10.85 +/- 0.74 pg/mL, and 4.2 +/- 0.38 pg/mL respectively, and in the CPPE group they were 7.59 +/- 0.87 pg/mL, 54.02 +/- 5.43 pg/mL, and 46.43 +/- 5.34 pg/mL, respectively. While no significant difference was found between the two groups regarding levels of TNFserum (p = 0.31), a highly significant difference between these two groups was found regarding levels of TNFpf and TNFgradient (p < 0.0001 for both variables). A significant correlation was found between levels of TNFserum and levels of TNFpf in the UCPPE group (r = 0.89, p < 0.0001), but not in the CPPE group (r = 0.18, p < 0.33). TNFgradient at an optimal cut-off level of 9.0 pg/mL was found to be a good marker for discrimination between UCPPE and CPPE (sensitivity, 96.7%, specificity, 98%, accuracy, 97.5%, and p < 0.0001). In conclusion, levels of TNFpf but not TNFserum are significantly higher in CPPEs than those in UCPPEs where TNFgradient at an optimal cut-off level of 9.0 pg/mL is a good marker for discrimination between UCPPE and CPPE.

Laparoscopic radical nephrectomy for T1 renal cancer: the gold standard? A comparison of laparoscopic vs open nephrectomy.

OBJECTIVE: To evaluate the complication rate and clinical follow-up of patients treated for T1 renal cancer by open or laparoscopic nephrectomy at the same institution, as this approach appears to be attractive for treating small renal cancers. PATIENTS AND METHODS: Between 1995 and 2002, 39 patients underwent retroperitoneal laparoscopic and 26 transperitoneal open radical nephrectomy for T1 renal cancer (TNM 1997). Variables before during and after surgery, e.g. cancer recurrence, were compared between the groups. RESULTS: There were no differences between the laparoscopic and open groups in age, sex ratio, weight, height, fitness score, operative duration (134 vs 133 min), minor or major complications, tumour diameter, Fuhrman grade or length of follow-up. Patients who underwent laparoscopic surgery had less blood loss (133 vs 357 mL, P < 0.001), less need for transfusion (none vs 150 mL, P = 0.04), a lower consumption of analgesia drugs, and shorter hospitalization (5.5 vs 8.8 days, P < 0.001). With a mean follow-up of 20.4 months there was no recurrence or tumour progression. CONCLUSION: Laparoscopic radical nephrectomy for patients with T1 renal cancer is a safe, reliable procedure that decreases hospitalization time and bleeding, and ensures the same cancer control as open nephrectomy.