Evaluation of the complications in laparoscopic retroperitoneal radical nephrectomy; An experience of high volume centre.

OBJECTIVES: To provide a standardised report of complications after retroperitoneal laparoscopic radical nephrectomy (rLRN) in a high-volume centre using Clavien-Dindo classification. MATERIALS AND METHODS: We analysed records maintained in a prospective database of 330 consecutive patients that underwent rLRN between March 1995 and September 2016. All complications were graded according to the modified Clavien-Dindo classification. Three generations of surgeons were defined and the learning curve in rLRN was evaluated by comparing the first 100 cases (Group A) performed by firstgeneration surgeons with the last 100 cases (Group B) by thirdgeneration surgeons. RESULTS: The mean age of our cohort was 66 ± 11.9 years. The overall complication rate was 19.7%. The majority of complications (12.7%) were Clavien 1 (5.1%) and Clavien 2 (7.6%) and did not require any interventions; blood transfusion was the most frequently encountered intervention (4.8%). Half of which were because of major intraoperative bleeding. Mortality rate was 0.9%. We found a trend towards lower complication rate in group B (19%) compared to group A (23%); this was mainly because of the reduction in the incidence of Clavien 1 and 2 complications. The pathological stage varied significantly in the two groups while the rate of negative surgical margins was comparable. CONCLUSIONS: rLRN is a safe procedure with an acceptable rate of complications. The learning curve was shorter for the thirdgeneration surgeons (group B); although these surgeons operated on a significantly higher number of patients with more advanced diseases. The Clavien-Dindo classification is suitable for assessing rLRN complications. Adopting this standardised system can help in the evaluation and comparison of surgical quality of LRN series.

The effect of anaesthetic management on neutrophil gelatinase associated lipocalin (NGAL) levels after robotic surgical oncology.

PURPOSE: The main objective of this study was to compare the effect of two anaesthetic techniques (general vs combined) on plasma levels of NGAL (Neutrophil Gelatinase Associated Lipocalin) after robotic urogenital oncosurgery. The secondary objective was to correlate NGAL levels with the incidence of acute kidney injury (AKI). METHODS: This was a longitudinal prospective study. Forty patients were included and randomized in 2 groups: group C (N=16 cases; combined general-epidural anesthesia) and group G (N=24 cases; control group with general anesthesia). Demographic data, Charlson Comorbidity Index, Apache II, SOFA and ASA scores were similar in both groups. Serum creatinine was determined preoperatively and every 24 hrs for 4 postoperative days to identify AKI according to RIFLE and AKIN criteria. Serum NGAL was determined at 6 and 12 hrs after induction of anesthesia. RESULTS: Serum creatinine increased at 24 hrs postoperatively in both groups as compared to baseline, but significant changes were registered only in the G group (p(control) = 0.004). Serum NGAL increased significantly in both groups as compared with baseline levels (pcase=0.0034 vs p(control)=0.0001). The incidence of AKI was 12.50% (95% CI 0.4-34) in the C group and 37.50% (95% CI 17-58) in the G group (p=0.0909), respectively. CONCLUSION: Impaired renal function and AKI occurred in robot-assisted laparoscopic urogenital oncosurgery under both general and combined anaesthesia. The incidence of AKI was lower in patients undergoing combined anesthesia compared to general anaesthesia after robotic urogenital oncosurgery but the difference did not reach statistical significance. However, plasma levels of NGAL were significantly increased at 6 and 12 hrs in the general anaesthesia group as compared with combined anaesthesia. NGAL may be a better marker in detecting postoperative acute kidney injury. Further studies are needed.

Management of renal extraskeletal mesenchymal chondrosarcoma.

BACKGROUND: Primary mesenchymal chondrosarcoma of the kidney is an extremely rare malignant tumor. To our best knowledge, only 9 such cases have been reported so far. CASE PRESENTATION: In the current paper, we present the case of a 67 year-old patient with recurrent left lumbar pain, increased fatigability and intermittent macroscopic hematuria. He underwent a surgical resection of the left kidney and left hemicolon.The pathological diagnosis was primary extraskeletal renal mesenchymal chondrosarcoma. Overall survival was 9 months, with pulmonary metastasis and local recurrence at 6 months. The management of the patient is described, from the initial differential diagnosis, after the first clinical examination to the surgical resection, with a special emphasis on the surgical procedures that were carried out. CONCLUSION: Extraskeletal chondrosarcoma of primary origin in the kidney are extremely rare tumors with a highly malignant potential and very poor prognosis. Because the role of chemotherapy or radiation therapy has not been evaluated properly yet, we underline the importance of surgery in the management of such cases as the main and best approach to achieve clinical remission and long-term survival, provided the patient is referred to a surgical consult in time.