Reninoma: case report and literature review.

Reninoma is a tumor of the renal juxtaglomerular cell apparatus that causes hypertension and hypokalemia via hypersecretion of renin. We describe a case of reninoma and provide a review of the literature, with a discussion emphasizing the diagnostic evaluation for such patients. The subject had persistent elevation of both plasma renin activity (PRA) and aldosterone. Imaging studies revealed the presence of a lesion in the renal cortex, which was further identified as a renin-producing lesion via selective venous catheterization following administration of an angiotensin-converting enzyme inhibitor (ACE-I). Following partial nephrectomy, the PRA and plasma aldosterone levels declined rapidly and the blood pressure and potassium supplementation requirements normalized. This case demonstrates the utility of both appropriate imaging studies and selective venous catheterization following provocative administration of an ACE-I for diagnosis.

Laparoscopic calicovesicostomy: a novel surgical procedure.

Laparoscopic calicovesicostomy in the horseshoe kidney with ureteropelvic junction obstruction associated with ipsilateral ureteral duplication and a large-capacity bladder is described. The intraoperative and postoperative clinical parameters were satisfactory in this preliminary report. Additional studies are necessary to evaluate this novel surgical procedure.

Ectopic adrenal tissue as radiographic lymphadenopathy in renal cell carcinoma.

In the presence of solid, contrast-enhancing renal mass, concomitant contrast-enhancing retroperitoneal mass is usually viewed as regional lymph node metastasis unless proven otherwise. The present report of ectopic adrenal tissue demonstrates that the presence of retroperitoneal contrast-enhancing mass may be a benign finding in patients with renal malignancy. Pathology remains the definitive method for diagnosis in such situation.

Laparoscopic Mitrofanoff appendicovesicostomy.

A novel technique of performing fully laparoscopic Mitrofanoff appendicovesicostomy in the management of neurogenic bladder is described. All steps, including appendix harvesting and extravesical appendiceal-vesical anastomosis with flap-valve mechanism creation, were completed laparoscopically and provided satisfactory preliminary clinical results. Additional studies are necessary for the evaluation of this novel technique.

A novel open surgical approach to transvesical distal ureterectomy in nephroureterectomy.

A single-incision transvesical approach to open distal ureterectomy is described herein. The surgical technique has been applied successfully to 6 consecutive patients undergoing laparoscopic nephrectomy with open distal ureterectomy for upper tract transitional cell carcinoma. The technique presented allows easy and effective excision of the ipsilateral distal ureter, ureteral orifice, and bladder cuff as well as closure of the single cystotomy. Further studies with long-term follow-up data are necessary to confirm the satisfactory preliminary clinical experience presented in this report.

Anterior extraperitoneal approach to laparoscopic pyeloplasty in horseshoe kidney: a novel technique.

We describe a novel technique of laparoscopic pyeloplasty in the horseshoe kidney with ureteropelvic junction obstruction using an anterior extraperitoneal approach. The surgical technique is associated with satisfactory clinical outcomes. Additional studies are necessary to evaluate its potential as an alternative to the existing approaches to laparoscopic pyeloplasty.

Bipolar needle electrocautery for laparoscopic partial nephrectomy without renal vascular occlusion in a porcine model.

OBJECTIVES: To report a novel method of accomplishing laparoscopic lower pole partial nephrectomy in an acute porcine model using a bipolar needle electrode without the need for renal arterial occlusion. METHODS: Six animals (12 renal units) underwent laparoscopic polar nephrectomy using the bipolar needle electrode. After complete laparoscopic mobilization of the lower pole of the kidney, the bipolar needle electrode was repeatedly inserted full-thickness into the renal parenchyma and applied transversely, creating regional ischemia to the entire lower pole without renal vascular occlusion. The specimen was then amputated using laparoscopic scissors. RESULTS: For the 12 laparoscopic partial nephrectomies, the mean operative time was 39 +/- 30 minutes, and the mean blood loss was 90 +/- 112 mL. Of the 12 cases, 10 (83%) were performed successfully with the bipolar needle electrocautery as the only source of hemostasis and without the need for ancillary hemostatic measures. Two of the procedures (17%) required temporary arterial control for hemostasis. For the successful procedures, the mean operative time was 29 +/- 4 minutes, and the mean blood loss was 48 +/- 11 mL. Histologic analysis of the specimens demonstrated coagulative necrosis between 2 and 4 mm from the line of the surgical incision. CONCLUSIONS: Bipolar needle electrocautery is a promising device that can be used to facilitate laparoscopic partial nephrectomy with minimal blood loss and without the need for renal arterial occlusion and warm ischemia. Additional studies are required to optimize the delivery parameters of this device.

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.

Effect of intentional cryo-injury to the renal collecting system.

PURPOSE: We determined the short-term and long-term sequelae of intentional cryoablation of the renal pelvicaliceal system and evaluated whether continuous irrigation of the renal pelvicaliceal system with warm saline protects it against cryo-injury. MATERIALS AND METHODS: In 12 swine open bilateral renal cryoablation using an argon gas based system was performed to create a cryolesion in the lower pole that was intentionally extended into the collecting system. A single cryoprobe was used to create a 3 cm ice ball in group 1 (6 animals) and 2, 3 mm cryoprobes were used to create a 4.5 cm ice ball in group 2 (6). In all 12 right kidneys pelvicaliceal warming (range 38C to 42C) was performed using continuous retrograde saline irrigation through an indwelling 5Fr ureteral catheter. In all 12 left kidneys cryoablation was performed without pelvicaliceal warming. Real-time confirmation of caliceal involvement by the cryolesion was obtained by retrograde ureteropyelogram. Immediately after cryo-injury 6 left and 6 right kidneys were harvested for histology and the animals with a solitary kidney were followed for 1 to 3 months. RESULTS: Nadir cryoprobe tip temperature was -136C with a mean cryolesion time of 10.5 minutes. Cryolesion size was comparable in the right vs left kidneys in groups 1 and 2 (2.9 vs 3.0 and 4.7 vs 4.6 cm, respectively). Similarly cryoablation time was comparable between the right and left kidneys in groups 1 and 2 (11.3 vs 10.8 and 11.9 vs 12.2 minutes, respectively). Two animals died of aspiration pneumonia (1) and wound dehiscence (1). In all 10 surviving animals no instance of urinary extravasation was noted. At 1-month followup regrowth of normal urothelium occurred with some scarring of the lamina propria or underlying smooth muscle. Adjacent renal parenchyma was replaced by fibrous scar. At 3 months the cryo-injured collecting system was completely healed with a fibrous scar. There were no appreciable histological differences between the kidneys with or without warm pelvicaliceal irrigation. CONCLUSIONS: Our data suggest that absent physical puncture injury of the collecting system with the cryoprobe tip the cryodamaged renal collecting system heals by secondary intention in a watertight manner. These data have clinical relevance for facilitating cryoablation of a small, localized, central renal tumor in proximity to the pelvicaliceal system.

Laparoscopic radical nephrectomy incorporating intraoperative ultrasonography for renal cell carcinoma with renal vein tumor thrombus.

The purpose of this study was to describe the technique of laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography in the management of renal cell carcinoma with level 1 renal vein tumor thrombus. With the patient in a modified flank position, a transperitoneal four-port approach was used to laparoscopically resect an 8.5-cm right renal mass with tumor thrombus extending to, but not into, the inferior vena cava. Early arterial control with gentle traction on the right renal vein provided a short proximal renal venous segment devoid of tumor on laparoscopic inspection. Intraoperative laparoscopic ultrasonography allowed confident identification of the proximal extent of the tumor thrombus. After hilar control, complete resection and intact removal of the renal specimen was performed using standard non-hand-assisted laparoscopic techniques. The actual surgical time was 180 minutes. Surgical resection was successfully performed laparoscopically. No postoperative complications or hospital readmission occurred. Pathologic examination confirmed T3b renal cell carcinoma with negative surgical margins. Laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography is feasible in the management of renal cell carcinoma with a large-sized level 1 renal vein thrombus. Additional studies are necessary to evaluate its role in urologic oncologic surgery.

Laparoscopic adult donor nephrectomy for pediatric renal transplantation.

To evaluate retrospectively our laparoscopic adult donor nephrectomy experience for pediatric transplantation. Since February 1995, 7 adult donors have undergone laparoscopic donor nephrectomy for pediatric renal transplantation (recipients younger than 18 years and weighing less than 30 kg). The outcomes of these donors and pediatric recipients were evaluated. The 7 laparoscopic renal donors had a median operative time of 306 minutes, median allograft warm ischemia time of 275 seconds, median blood loss of 200 mL, median hospital stay of 3 days, and 14.2% overall complication rate. No graft loss or patient mortality occurred. The pediatric recipients of the laparoscopic live-donor allografts had a median creatinine clearance level of 52.1, 52.1, 44, and 41.1 mL/min at 3, 6, 12, and 18 months, respectively. The overall complication rate was 14.2%. The 1 and 2-year graft survival rates were 100%. No mortality occurred in the pediatric recipients. Laparoscopic donor nephrectomy is well tolerated by the adult donors and appears to provide acceptable recipient and allograft outcomes in the pediatric population.

Impact of renal artery multiplicity on outcomes of renal donors and recipients in laparoscopic donor nephrectomy.

OBJECTIVES: To review our laparoscopic donor nephrectomy experience to determine the impact of multiple renal arteries on renal donor and recipient outcomes. Multiple renal arteries can present a challenge during live laparoscopic donor nephrectomy. METHODS: During a 6-year period, 353 patients underwent laparoscopic donor nephrectomy and an equal number of patients underwent living-related renal transplantation. A retrospective chart review was performed to evaluate the renal donors and recipients associated with the laparoscopic procedure. RESULTS: Laparoscopic donor nephrectomies were associated with one renal artery in 277 cases (78.5%), two renal arteries in 71 cases (20.1%), and three renal arteries in 5 cases (1.4%). A left-sided procedure was most commonly performed in all three groups. The operative and renal allograft warm ischemia times increased with the number of renal arteries, but the differences were not statistically significant. The renal artery anatomy did not have a significant association with intraoperative blood loss, postoperative hospital stay, or complication rate in the donor group. Regarding the transplant recipients, renal artery multiplicity had no significant association with the complication rate, 1-year graft survival, or creatinine clearance levels at 1, 2, or 3 days or at 3, 6, or 12 months postoperatively. CONCLUSIONS: With meticulous procurement and reconstructive transplantation techniques, the presence of multiple renal arteries in laparoscopic donor nephrectomy does not have a significant impact on the outcomes of the renal donors or recipients.

Renovascular complications of laparoscopic donor nephrectomy.

OBJECTIVES: To review the operative renovascular injuries related to our laparoscopic donor nephrectomy experience, since management of intraoperative renovascular complications during laparoscopic nephrectomy can present a serious challenge. METHODS: During a 6-year period, 353 patients underwent laparoscopic donor nephrectomy. A retrospective chart review was performed to identify and evaluate the renovascular complications associated with the procedure. RESULTS: Eight cases (2.3%) of renovascular complications were identified. Vascular injury involved the renal artery in 6 cases and the renal vein in 2 cases. The etiologies included endovascular GIA stapling failure (n = 2), surgical clip dislodgment (n = 2), and vessel laceration during dissection or stapling (n = 4). Open conversion was necessary in 6 cases (75%). No patient mortality or allograft loss occurred. CONCLUSIONS: Laparoscopic donor nephrectomy is associated with a low incidence of renovascular complications. Laparoscopic or open surgical management may be required when problems arise to optimize donor safety and allograft survival.

Laparoscopic donor nephrectomy in the elderly patient.

OBJECTIVES: To evaluate retrospectively the outcome of laparoscopic donor nephrectomy in patients aged 65 years or older, because data regarding tolerance profile and renal allograft outcome of laparoscopic donor nephrectomy in the elderly patient are lacking. METHODS: Since February 1995, 6 patients aged 65 years or older underwent laparoscopic donor nephrectomy for living-related renal transplantation. Patient demographic, intraoperative, and postoperative parameters, as well as renal allograft outcome, were evaluated. RESULTS: The median donor age was 69.5 years (range 65 to 74), and the median American Society of Anesthesiologists score was 2 (range 2 to 3). The median operative time was 240 minutes (range 183 to 298), with a median blood loss of 300 mL (range 150 to 400). No intraoperative complications or open conversions occurred. Postoperatively, the median time to resumption of oral intake was 1 day (range 1 to 3), and the median hospital stay was 3 days (range 2 to 4). The median narcotic analgesic requirement was 17 mg (range 11 to 27) morphine sulfate equivalent, and the median convalescence was 2 weeks (range 1 to 4). The 1-year renal allograft survival was 100% (n = 6). CONCLUSIONS: Laparoscopic donor nephrectomy is well tolerated by the elderly patient and provides satisfactory patient and renal allograft outcome. Although our sample size was small, it appears that laparoscopy is an acceptable modality for renal donation in the elderly population.

Laparoscopic ileovesicostomy.

PURPOSE: We present our initial experience with laparoscopic ileovesicostomy for managing neurogenic bladder. MATERIALS AND METHODS: A 5 port transperitoneal approach was used for laparoscopic ileovesicostomy. After bladder preparation a 17 cm. ileal segment was harvested and used as the urinary conduit. Ileovesical anastomosis was formed using intracorporeal suturing and knot tying techniques. RESULTS: Operative time was 4 hours. Blood loss was less than 100 ml. Physical activity and oral intake resumed on postoperative day 1 and the patient was discharged home on postoperative day 3. The postoperative narcotic requirement was 4 mg. morphine sulfate equivalent. There were no intraoperative or postoperative complications. CONCLUSIONS: Laparoscopic ileovesicostomy in this initial experience was associated with acceptable operative time and minimal postoperative morbidity. It may serve as an excellent minimally invasive alternative to conventional open ileovesicostomy.

Novel technique for combined repair of postirradiation vesicovaginal fistula and augmentation ileocystoplasty.

Concomitant vesicovaginal fistula and significant bladder contracture after radiation is an uncommon but complex urologic problem. We describe a surgical technique to address both issues and present our preliminary clinical data.

Bilateral laparoscopic adrenalectomy: retroperitoneal and transperitoneal approaches.

OBJECTIVES: To report our experience with bilateral laparoscopic adrenalectomy using either the retroperitoneal or the transperitoneal approach. METHODS: Between June 1998 and October 2000, 6 consecutive patients with bilateral adrenal disease (Cushing syndrome in 4, pheochromocytoma in 1, and solitary adrenal metastases in 1) underwent bilateral laparoscopic adrenalectomy by way of the retroperitoneal or transperitoneal approach. Bilateral adrenalectomy was performed either synchronously (4 patients) or in a staged manner (2 patients). RESULTS: All laparoscopic procedures were performed successfully. For the bilateral synchronous cases (n = 4) and metachronous cases (n = 4), the median surgical time was 278 and 195 minutes, blood loss was 175 and 125 mL, resumption of oral intake and ambulation required less than 1 day for both groups, and postoperative narcotic requirement comprised 14 and 10 mg morphine sulfate equivalent, respectively. For the synchronous and metachronous cases, the hospital stay was 1.5 and less than 1 day and convalescence was 3 and 2.5 weeks, respectively. An intraoperative surgical complication (adrenal vein bleeding) occurred in 1 case, but did not require open conversion. No postoperative complications or rehospitalization occurred. The retroperitoneal approach was used in 3 of the 4 bilateral synchronous and 3 of the 4 bilateral metachronous cases. In both synchronous and metachronous cases, the actual surgical time, blood loss, time to oral intake and ambulation, postoperative analgesia use, hospital stay, and convalescence of the transperitoneal approach were well within the range of those of the retroperitoneal approach. CONCLUSIONS: Retroperitoneal and transperitoneal bilateral laparoscopic adrenalectomy is feasible, safe, and results in minimal postoperative morbidity.

Nephron-sparing nephrectomy for giant renal angiomyolipoma associated with lymphangioleiomyomatosis.

Renal angiomyolipomas are benign tumors known to occur sporadically and in association with genetic syndromes, including tuberous sclerosis and lymphangioleiomyomatosis. Surgical removal or radiographic embolization of angiomyolipomas larger than 4 cm is usually indicated because of an increased risk of spontaneous hemorrhage. We describe successful nephron-sparing surgery for a giant angiomyolipoma and discuss relevant management issues in a patient with lymphangioleiomyomatosis who had previously undergone bilateral pulmonary transplantation.

The effect of dopamine on renal function in solitary partial nephrectomy surgery.

PURPOSE: Dopamine continues to be used for preventing and treating acute renal failure. We determined the effects of dopamine on postoperative renal function in patients with a solitary kidney undergoing partial nephrectomy. MATERIALS AND METHODS: We performed a prospective randomized controlled study at a tertiary care referral center involving 24 patients with a solitary kidney undergoing partial nephrectomy secondary to malignancy. Patients were randomized to receive dopamine (11) [corrected] or no dopamine (13) [corrected]. Intraoperatively those assigned to the dopamine group received a 3 microg./kg. per minute dopamine infusion. Patients in each group received an adequate amount of fluid to maintain good urine production, systemic blood pressure and central venous pressure. Serum electrolytes, blood urea nitrogen, creatinine, serum and urine osmolality, and urine output were measured at baseline, intraoperatively and through postoperative day 4. Preoperatively and postoperatively renal blood flow and the glomerular filtration rate were measured. RESULTS: In the 2 groups blood urea nitrogen and serum creatinine increased postoperatively. Although the degree of this increase showed a trend to be lower in the dopamine group, the difference did not reach statistical significance. There was no difference in renal blood flow or the glomerular filtration rate in the treatment groups. CONCLUSIONS: Administering dopamine to patients with a solitary kidney undergoing partial nephrectomy provided no renoprotective effect.