Laparoscopic nephrectomy for autosomal dominant polycystic kidneys in patients with end-stage renal disease on maintenance hemodialysis: 10-year single surgeon experience from an Indian center.

CONTEXT: Pure laparoscopic nephrectomy in patients with ADPKD (autosomal dominant polycystic kidney disease) and ESRD (end-stage renal disease) on MHD (maintenance hemodialysis) is challenging with high incidence of complications. Limited experiences from India has been reported in these scenarios. AIMS: To present a 10-year single surgeon experience from India in laparoscopic nephrectomy in autosomal dominant polycystic kidneys (ADPKD) and end-stage renal disease (ESRD) on maintenance hemodialysis (MHD). SETTINGS AND DESIGN: Retrospective. MATERIALS AND METHODS: Retrospective analysis of records of similar subset of patients who were offered laparoscopic nephrectomy between 2003 and 2012. Preoperative, operative and postoperative parameters were recorded. Few technical modifications were adopted over the years. Patients were sub-classified into two groups (Group I: 2003-2006, Group II: 2007-2012) based on surgical technique. STATISTICAL ANALYSIS USED: SAS software 9.1 version. RESULTS: 75 patients (84 renal units, Group I: 31, Group II: 53) were included in this analysis. Unilateral procedure was performed in 66 and bilateral staged or simultaneous procedure in 9. Despite larger kidneys in Group II (mean longitudinal renal length 25.7 ± 3.4 vs 17.5 ± 2.7 centimeters, P <0.001), improved operative and postoperative profile were noted in Group II in several parameters-mean total operative time (205 ± 11.5 vs 310 ± 15.3 min, P = 0.00), time for specimen retrieval (30.5 ± 3.5 vs 45 ± 4.1 min, P = 0.02), postprocedure drop in hemoglobin (1.1 ± 0.1 vs 2.27 ± 0.03 grams/deciliter, P = 0.00). Conversion rates, intraoperative and postoperative events were also considerably less in Group II. CONCLUSIONS: Despite existence of comorbidities and technical difficulties, laparoscopic nephrectomy in patients with ADPKD with ESRD and on MHD is a feasible option. Technical modifications with increasing surgeon's experience allows successful conductance of this approach in more complex cases with better outcome.

Laparoscopic extirpation of giant adrenal ganglioneuroma.

Laparoscopic adrenalectomy is the standard of care for management of adrenal neoplasms. However, large sized adrenal lesions are considered as relative contraindication for laparoscopic extirpation. We report laparoscopic excision of giant ganglioneuroma of adrenal gland in a 33-year-old female patient. Patient was presented with left loin pain of 2 months duration. Computed tomography (CT) scan was suggestive of non-enhancing left suprarenal mass measuring 17 × 10 cm. Preoperative endocrine evaluation ruled out functional adrenal tumor. Patient underwent transperitoneal excision of suprarenal mass. The lesion could be completely extirpated laparoscopically. Duration of surgery was 250 minutes. Estimated blood loss was 230 milliliters. Specimen was extracted through pfannenstiel incision. No significant intraoperative or postoperative happenings were recorded. Microscopic features were suggestive of ganglioneuroma of adrenal gland.

Transperitoneal laparoscopic dismembered pyeloplasty in unusual circumstances--is the outcome comparable to that achieved in familiar pathologies?

OBJECTIVE: To compare the operative outcome, morbidity profile, and functional outcome after transperitoneal laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction in unusual circumstances (intrinsic pathology in anomalous kidneys or unusual extrinsic pathologies; group 1) to the outcome after this procedure in familiar pathologies (normally located kidneys with intrinsic dysfunctional segment or extrinsic compression due to a crossing vessel; group 2). METHODS: The patients were evaluated in detail. All patients underwent transperitoneal laparoscopic dismembered pyeloplasty. The operative and postoperative parameters were recorded. Patients were followed up after the procedure on a 3-month protocol. Imaging was repeated at 1 year. No intervention during the follow-up period (ie, nephrostomy, ureteral stenting, or redo pyeloplasty) and improvement in the hydronephrosis grade and diuretic renogram parameters was interpreted as procedural success. The operative, postoperative, and follow-up parameters in the 2 groups were compared. RESULTS: Group 1 included 17 patients with intrinsic pathologic features and renal anomalies with ureteropelvic junction obstruction due to unusual extrinsic pathology. All procedures were successfully completed with the laparoscopic approach. A significant difference was noted in the mean operative duration (group 1, 196.9 ± 10.3 minutes; group 2, 125.44 minutes, P = .00). The other operative and postoperative parameters were comparable. No significant operative or postoperative events were noted. A total of 14 patients (group 1) completed the 1-year follow-up protocol. The success rate was 92.9% (13 of 14) in group 1 and 97.9% (44 of 45) in group 2 (P = .42). CONCLUSION: The procedural duration for laparoscopic dismembered pyeloplasty in unusual circumstances is longer than in familiar pathologies. However, the morbidity profile and functional outcome in these 2 scenarios were comparable.

Upper ureteric obstruction secondary to entrapment between twin segments of inferior vena cava--an unusual occurrence.

A retrocaval ureter is a rare congenital cause of upper ureteric obstruction that results from entrapment of the upper ureter by the inferior vena cava (IVC) as it courses posterior to the cava. We report an interesting scenario of upper ureteric obstruction secondary to entrapment between twin segments of IVC.

Laparoscopic reconstruction of iatrogenic-induced lower ureteric strictures: Does timing of repair influence the outcome?

CONTEXT: Influence of timing of repair on outcome following laparoscopic reconstruction of lower ureteric strictures AIMS: To assess the influence of timing of repair on outcome following laparoscopic reconstruction of lower ureteric strictures in our adult patient population. SETTINGS AND DESIGN: Single surgeon operative experience in two institutes. Retrospective analysis. MATERIALS AND METHODS: All patients were worked up in detail. All patients underwent cystoscopy and retrograde pyelography prior to laparoscopic approach. Patients were categorised into two groups: early repair (within seven days of inciting event) and delayed repair (after two weeks). Operative parameters and postoperative events were recorded. Postprocedure all patients were evaluated three monthly. Follow-up imaging was ordered at six months postoperatively. Improvement in renal function, resolution of hydronephrosis and unhindered drainage of contrast through the reconstructed unit on follow-up imaging was interpreted as a satisfactory outcome. STATISTICAL ANALYSIS USED: Mean, standard deviation, equal variance t test, Mann Whitney Z test, Aspin-Welch unequal variance t test. RESULTS: Thirty-six patients (37 units, 36 unilateral and 1 simultaneous bilateral) underwent laparoscopic ureteral reconstruction of lower ureteric stricture following iatrogenic injury - 21 early repair (Group I) and 15 delayed repair (Group II). All patients were hemodynamically stable at presentation. Early repair was more technically demanding with increased operation duration. There was no difference in blood loss, operative complications, postoperative parameters, or longterm outcome. CONCLUSIONS: In hemodynamically stable patients, laparoscopic repair of iatrogenically induced lower ureteric strictures can be conveniently undertaken without undue delay from the inciting event. Compared to delayed repairs, the procedure is technically more demanding but morbidity incurred and outcome is at par.