Use of Hem-o-lok Clips for Vascular Control During Retroperitoneoscopic Nephrectomy in Children.

Aim: To evaluate safety and efficacy of 5-mm Hem-o-lok clips in children undergoing retroperitoneoscopic nephrectomy. Material and Methods: Twenty-four retroperitoneoscopic nephrectomies were performed between September 2004 and August 2007. The indications of nephrectomy were ureteropelvic junction obstruction, reflux nephropathy, ectopic ureteral opening with renal dysplasia, and stone disease with pyonephrosis and primary obstructed megaureter with renal dysplasia. Nine cases were on right side and others on left side. Multiple 5- or 10-mm Hem-o-lok clips were used to control renal artery and vein separately in each case. The specimen was mobilized and removed either by extension of a port site incision or by a separate incision at ipsilateral iliac fossa at the lateral border of the rectus muscle. Results: Hem-o-lok clips were deployed on renal pedicle separately in each case. Two clips were deployed on the body side and one on the specimen side. On the left side lumbar, gonadal and adrenal tributaries were also clipped by 5-mm Hem-o-lok clips. No clip dislodgement was observed in any patient. Mean operative time was 111 (80 ± 47) minutes, and mean blood loss was 25 (10 ± 45) mL. Mean hospital stay was 2.4 (1.9-3.1) days. Conclusion: Five- and 10-mm Hem-o-lok clips are safe and effective for renal pedicle control during retroperitoneoscopic nephrectomy in children.

The Learning Curve of Pure Retroperitoneoscopic Donor Nephrectomy.

BACKGROUND: Retroperitoneoscopic donor nephrectomy (RDN) is a well-established modality for the procurement of kidneys for renal transplantation. However the learning curve of pure RDN is not yet defined. Defining the learning curve will help in proper mentorship of the new donor surgeons besides providing safety to the donors. OBJECTIVE: To define the learning curve of pure RDN. METHODS: We analyzed the prospectively collected data of 102 voluntary kidney donors who underwent RDN by a single surgeon between August 2012 and April 2015 at our center. The donors were classified into group A (1-34), group B (35-68), and group C (69-102) according to the chronological order of their surgery. Left RDN was performed in 28 (82%), 25 (74%), and 28 (82%) donors of group A, B, and C, respectively. Right RDN was performed in 6 (18%), 9 (26%), and 6 (18%) donors of group A, B, and C, respectively. The clinical data were analyzed for each group. RESULTS: Statistically significant difference was observed for the mean operative time (p<0.01) and warm ischemia time (p<0.04). The operative time remained around 200 minutes after the initial 35 cases. CONCLUSION: The learning curve of pure RDN was 35 cases, although the mastery requires more number of cases to be performed.

Gall bladder Adenocarcinoma in a Young Girl.

A 16-year-old girl presented with abdominal discomfort, weakness, and jaundice. General examination revealed deep icterus with hard lymph nodes in left supraclavicular region. On gastrointestinal examination, we appreciated a hard intra-abdominal lump in the right hypochondrium. Biochemical evaluation showed features of obstructive jaundice. Imaging confirmed the presence of gall bladder lump with multiple intra-abdominal lymph nodes. Fine needle aspiration cytology of neck nodes demonstrated metastatic adenocarcinoma. Fine needle aspiration cytology of the gall bladder lump (done under sonographic guidance) confirmed poorly differentiated adenocarcinoma. To the best of our knowledge, malignancy of the gall bladder has not been reported in individuals less than 18 years in India, and only three cases have been reported worldwide in English literature.

Outcome of live and deceased donor renal transplantation in patients aged ≥55 years: A single-center experience.

Renal transplantation (RTx) has now become an accepted therapeutic modality of choice for elderly ESRD patients. This single-center study was undertaken to evaluate the outcome of RTx in ESRD patients ≥55 years. A total of 103 patients underwent RTx 79 living related living donors [LD], 24 deceased donors [DD]) at our center. Post-transplant immunosuppression consisted of calcineurin inhibitor-based regimen. The mean donor age was 58.3 years in the LD group and 59.5 years in the DD group. Male recipients constituted 92% in LD and 75% in DD group. In living donor renal transplantation, 1- and 5-year patient survival was 93% and 83.3% respectively and death-censored graft survival was 97.3% and 92.5% respectively. There were 12.6% biopsy proven acute rejection (BPAR) episodes and 12.6% patients were lost, mainly due to infections. In deceased donor renal transplantation, 1- and 5-year patient survival was 79.1% and 74.5% respectively and death-censored graft survival was 95.8% and 85.1% respectively. There were 12.5% BPAR episodes and 25% of patients were lost, mainly due to infections. RTx in ESRD (≥55 years) patients has acceptable patient and graft survival if found to have cardiac fitness and therefore should be encouraged.

Ten kidney paired donation transplantation on World Kidney Day 2013: raising awareness and time to take action to increase donor pool.

BACKGROUND: Kidney paired donation (KPD) is feasible for any center that performs living related donor renal transplantation (LRDRTx). Lack of awareness, counseling and participation are important hurdles in KPD patients with incompatible donors. MATERIALS AND METHODS: This is an institutional review board approved study of 10 ESRD patients who consented to participate in the KPD transplantation at our center. All the surgeries were carried out on the same day at the same center on the occasion of World Kidney Day (WKD) (14 March 2013). All recipients had anatomic, functional and immunological similar donors. RESULTS: KPD were performed to avoid blood group incompatibility (n = 8) or to avoid a positive crossmatch (n = 2). None of the patients experienced delayed graft function and surgical complications. At 3 month follow-up, median serum creatinine was 1 (range 0.6 to 1.25) mg/dL and two patients developed allograft biopsy-proven acute rejection and responded to antirejection therapy. Due to impact of our awareness activity, 20 more KPD patients are medically fit for transplantation and waiting for permission from the authorization committee before transplantation. CONCLUSION: This is a report of 10 simultaneous KPD transplantations in a single day in a single centre on WKD raising awareness of KPD. KPD is viable, legal and rapidly growing modality for facilitating LRDRTx for patients who are incompatible with their healthy, willing LRD.

Outcome of renal transplantation from deceased donors after cardiac death: a single-center experience from a developing country.

BACKGROUND: Limited information is available in the literature about the use of organs from donation after cardiac death (DCD) renal transplantation (RTx) from a developing country. MATERIAL AND METHODS: We report RTx outcome between DCD donors ≥70 years (Group 1; n = 14; mean age, 75.7 ± 5.81) and DCD donors <70 years (Group 2; n = l9; mean age, 51.7 ± 10.1) between January 1999 and January 2012. The mean age of recipients was 39.5 ± 14.7 years, 24 of whom were males. The mean donor age was 61.9 ± 14.6 years, 21 of whom were males. All recipients received single-dose thymoglobulin induction followed by immunosuppression with a steroid, a calcineurin inhibitor, and mycophenolate mofetil or azathioprine. Statistical analysis used chi-square test and unpaired Student t test. Kaplan-Meier curves were used for survival analysis. RESULTS: Over a mean follow-up of 3.21 ± 3.46 years, one-, five-, and ten-year, patient survival rates were 77%, 67.4%, and 67.4%, respectively, and death-censored graft survival rates were 85.7% for one, five, and ten years. Delayed graft function (DGF) was observed in 36.4% (n = 12) with 12.1% (n = 4) biopsy-proven acute rejection (BPAR). Patient survival (P = .27), graft survival (P = .20), DGF (P = .51), and BPAR (P = .74) were similar in 2 groups. A total of 27.2% (n = 9) of patients died, mainly due to infections (n = 5). CONCLUSION: Given the widespread organ shortage, outcomes of controlled DCD renal transplantation has a potential to expand the donor pool and shorten the waiting list for RTx, encouraging the use of this approach even in low-income countries.

Incidentally detected lymphatic filariasis in a renal allograft recipient.

Post-transplntation lymphocele is a well known complication, and lymphatic filariasis (LF) has occasionally been found to present as post-transplantation lymphocele. However, incidentally detected LF during transplantation surgery has not been reported. We present an incidentally detected LF presenting as enlarged lymph node in the right iliac fossa of a recipient during transplantation of donor kidney. He was subsequently treated after transplantation and had stable graft function without any complications after 8 months of follow-up.

Laparoscopic excision of a congenital seminal vesicle cyst associated with ipsilateral renal agenesis.

Seminal vesicle cyst (SVC) with ipsilateral renal agenesis is a rare congenital anomaly. Surgical treatment is indicated for symptomatic patients. The open surgical approach, traditionally considered the definitive form of treatment, has been associated with a high rate of morbidity. A laparoscopic approach for the management of SVCs has recently been described. We performed a laparoscopic excision of a SVC with special precaution taken to avoid injury to the neurovascular bundle in a symptomatic 27-year-old patient. The patient was discharged home on the second postoperative day and at the 1-year follow-up he had remained symptom-free with normal erectile and ejaculatory function.

Living donor paired-kidney exchange transplantation: A single institution experience.

INTRODUCTION: Paired-kidney exchange (PKE) is used in western countries to increase donor pool. In India, there are not many centers involved in PKE program. We present 10 years of this experience and outcome of the recipients. MATERIALS AND METHODS: Between year 2000 and 2009, 34 transplants with PKE were performed. All donors were live related, and permission from Authorization committee(s) from one or more states was obtained prior to transplantation. Both donor and recipient surgeries were carried out simultaneously in all cases at a single institution. Last 10 donors were offered laparoscopic donor nephrectomy and all other previous donors were operated by open surgery. RESULTS: Five donor-recipient pairs were from the state of Rajasthan, one from Madhya Pradesh, and all others from Gujarat. ABO incompatibility between donor and recipient was present in 12 pairs and positive lymphocyte cross-match in 5 pairs. CONCLUSION: Paired-kidney-exchange transplantation expands donor pool and total number of transplantation.

Retroperitoneoscopic nephrectomy for crossed-fused ectopic kidney.

A 25-year-old female presented with a history of recurrent urinary tract infection and end stage renal failure. Voiding cystourethrography revealed bilateral Grade IV vesicoureteral reflux with left to right crossed ectopia. A computed tomography scan showed fusion of both kidneys with the left kidney situated at the lower and anterior part of the right orthotopic moiety. A retroperitoneoscopic nephrectomy with a right side ureterectomy was carried out.

Retroperitoneoscopic right-sided donor nephrectomy with pre- and postcaval renal arteries.

A 56-year-old male donor was evaluated for a kidney donation. Computed tomography angiography revealed 2 right renal arteries, 1 coursing in front and 1 behind the inferior vena cava. The renal scan showed a lower glomerular filtration rate on the right side. We present a technique of retroperitoneoscopic right-sided donor nephrectomy.

Laparoscopic ureteroneocystostomy and psoas hitch for post-hysterectomy ureterovaginal fistula.

PURPOSE: We assessed the results of laparoscopic ureteroneocystostomy with a psoas hitch for iatrogenic lower ureteral injuries leading to a ureterovaginal fistula. MATERIALS AND METHODS: Between July 2003 and November 2007, 18 patients with iatrogenic lower ureteral injuries during hysterectomy leading to ureterovaginal fistula underwent laparoscopic ureteroneocystostomy with a psoas hitch. Of the patients 17 underwent abdominal or vaginal hysterectomy, while in 1 with a ruptured gravid uterus emergency hysterectomy was done for uncontrolled bleeding. Mean patient age was 35.5 years (range 23 to 45) and mean time to surgery since the injury was 2.2 months (range 1.5 to 3.5). Transperitoneal 3 or 4 port laparoscopic ureteroneocystostomy with a psoas hitch was performed. RESULTS: Of the procedures 17 were completed successfully. Intraoperative cardiac arrhythmia occurred in 1 patient due to pneumoperitoneum and hypercarbia, requiring open conversion. Mean operative time was 2.5 hours (range 1.9 to 2.8) hours, mean blood loss was 90 ml (range 45 to 150) and total hospital stay was 5.3 days (range 2.9 to 8). The nephrostomy tube was blocked on the table in all patients and it was removed on day 7. At an average followup of 26.4 months (range 3 to 52) postoperative excretory urography did not reveal obstruction in any patient. One patient had vesicoureteral reflux on voiding cystogram. CONCLUSIONS: Laparoscopic ureteroneocystostomy with a psoas hitch for ureterovaginal fistula secondary to hysterectomy is safe and effective, and associated with a low incidence of postoperative reflux and obstruction.

Case report: laparoscopic pyeloplasty for ureteropelvic junction obstruction of lower moiety in duplex system.

BACKGROUND AND PURPOSE: Ureteropelvic junction (UPJ) obstruction can be associated with renal anomalies. We report a case of laparoscopic dismembered pyeloplasty in a lower moiety of a complete duplex system. CASE REPORT: A 40-year-old woman presented with right flank pain. Intravenous urography revealed a typical UPJ obstruction on the right side, and a diuretic renal scan showed 35% uptake of the tracer and a glomerular filtration rate of 57 mL/min with delayed excretion (T1/2 28 minutes). Transperitoneal laparoscopic dismembered pyeloplasty was performed. The operative time was 140 minutes with a blood loss of 30 mL. Diclofenac sodium (total requirement 150 mg) was used for analgesia. A diuretic renal scan at 3 months showed 41% uptake and a glomerular filtration rate of 66 mL/min, with prompt drainage without obstruction of the right kidney (T(1/2) 18 minutes). At 6 months' follow-up, the patient was symptom free. CONCLUSION: To our knowledge, our report is the third where laparoscopic pyeloplasty for a duplex system was carried out. Prior placement of Double-J stent made identification of the ureter draining the lower moiety during laparoscopic surgery much easier. The principles of open surgery could be duplicated.