Trifecta and Pentafecta Outcomes in Laparoscopic and Robotic Nephron-Sparing Surgery for Highly Complex Renal Tumors: A Propensity Score-Matched Cohort Analysis.

Purpose: To compare the trifecta and pentafecta outcomes of laparoscopic partial nephrectomy (LPN) and robotic partial nephrectomy (RPN) in highly complex renal tumors (RENAL nephrometry score ≥10) using a matched cohort analysis. Methods: Patients undergoing LPN or RPN for renal tumors with RENAL score ≥10 between January 2014 and December 2019 were matched using 1:2 propensity score match analysis based on age, body mass index, gender, laterality of tumor, RENAL score, and American Society of Anesthesiologists (ASA) score. The two groups were compared for trifecta and pentafecta outcomes. Results: Thirty patients undergoing LPN (Group A) were matched with 60 patients undergoing RPN (Group B). The mean age (standard deviation) was 53.7 (12.9) years. The median (interquartile range) RENAL score was 10 (10-11). In comparison, the mean warm ischemia time in Group A was significantly longer than that in Group B (26.2 vs 23.0 minutes, p = 0.013). The overall complication rate was 36.7% in Group A as compared with 20% in Group B (p = 0.440). The trifecta outcomes could be achieved in 11 patients (36.7%) in Group A compared with 40 patients (66.7%) in Group B (p = 0.012). Moreover, 10 patients (33.3%) in Group A and 28 patients (46.7%) in Group B achieved pentafecta outcomes (p = 0.227). Conclusions: In a matched cohort of patients undergoing nephron-sparing surgery for highly complex renal tumors (RENAL score ≥10), the robotic approach offers a superior advantage in the achievement of trifecta outcomes as compared with the laparoscopic approach. However, both LPN and RPN can achieve similar pentafecta outcomes.

Renal autotransplant for major ureteric loss: Results from median 11 years of follow-up.

OBJECTIVE: Renal autotransplant (RA) is an underutilized procedure to treat major ureteric loss. Studies on long-term outcomes and follow-up after RA are scarce. This study aimed to report the long-term outcomes and follow-up after RA. MATERIAL AND METHODS: We identified 9 patients, from 2007 to 2019, who underwent RA after major ureteric loss (where direct restoration of continuity was not possible). We collected data regarding the etiology of ureteric loss, preoperative differential renal function, method of nephrectomy (laparoscopic or open), method of anastomosing the residual ureter/pelvis to the bladder, postoperative complications, duration of hospital stay, and renal function and drainage postoperatively and until the last follow-up. Changes in renal function and/or any obstruction to urinary drainage of the ipsilateral kidney postoperatively or during follow-up were measured. The Wilcoxon matched-pairs signed-rank test was used to compare the mean creatinine values preoperatively, postoperatively, and at last follow-up (p<0.05 was considered statistically significant). RESULTS: All the patients had uneventful intraoperative and postoperative periods. The mean hospital stay was 6.4 (5-8) days. The median follow-up was 132 (46-156) months. The mean preoperative serum creatinine level was 1.0 (0.7-1.7) mg/dL. The mean creatinine value postoperatively and at last follow-up had no significant difference with preoperative value (p=0.96 and 0.75, respectively). The postoperative diethylene triamine pentaacetic acid scan demonstrated good perfusion and drainage. There was no deterioration of renal function or drainage during the follow-up. CONCLUSION: RA is an excellent modality to treat major ureteric loss. It preserves renal function and avoids the problems related to bowel interposition and the need for long-term follow-up.

Management of donor kidneys with double renal arteries with significant luminal discrepancy: A retrospective cohort study.

INTRODUCTION: Side-to-side pantaloon anastomosis for renal grafts with double renal arteries (RA) with significant luminal discrepancy between graft arteries has not been reported. We hypothesized that the pantaloon technique is feasible and safe in these cases. MATERIALS AND METHODS: A retrospective review of all consecutive, open, live-related renal transplants with double RA with significant luminal discrepancy performed at our center from January 2014 to September 2018 was undertaken. Significant luminal discrepancy was defined as smaller RA constituting 30% ± 5% of total RA diameter on preoperative computed tomography angiogram. Three groups were defined: Group A - pantaloon anastomosis, Group B - end-to-side anastomosis of smaller to main RA, and Group C - separate implantation of each artery. The primary objective was to study feasibility and safety of pantaloon anastomosis measured by recipient serum creatinine levels, Doppler ultrasound, and vascular complications (vascular thrombosis and anastomotic bleed). Secondary objectives included measurement of cold ischemia time, warm ischemia time in recipient (WIR), and nonvascular recipient complications. RESULTS: Fifty-eight recipients had donors with double RA with significant luminal discrepancy. Group A - included 40, Group B - 5, and Group C - 13 patients. Recipient creatinine at day-7, - 30, and - 90 were similar among the groups. The 30-day perioperative complication rate was also similar. Group A and B had significantly lower WIR and higher cold ischemia time compared to Group C. CONCLUSION: Pantaloon anastomosis is feasible in renal grafts with double RA with significant luminal discrepancy and offers advantage of lower WIR compared to separate implantation technique.

Giant splenic artery aneurysm: A rare but potentially catastrophic surgical challenge.

INTRODUCTION: Splenic artery aneurysms are rare but clinically important entities because of their potential for life threatening rupture. They seldom exceed 3cms in size and only a few cases of giant splenic artery aneurysms (more than 10cm size) have been reported until now. PRESENTATION OF CASE: A 58yr old female presented with painless pulsatile progressively enlarging lump in left upper abdomen. Contrast enhanced computed tomography revealed a 10.6×10.38cm aneurysm arising from distal splenic artery along with a normal pancreas. Surgical treatment in form of complete excision of the aneurysm along with spleen and distal pancreas was performed. Gross examination showed an unruptured 12.7×11.8cm true aneurysm of distal splenic artery. Postoperative course was uneventful. DISCUSSION: Splenic artery aneurysms are discovered incidentally and the life time risk of rupture is 28% for giant aneurysms. Even with availability of less invasive procedures such as laproscopy or endovascular treatment, open surgery is mostly preferred. CONCLUSION: Giant splenic artery aneurysms, although rare, should be considered in patients presenting with left upper abdomen pulsatile masses. Clinical suspicion followed by emergent management is necessary to prevent potentially life threatening complications.

Duplication of vas deferens-A rare anomaly with review of literature.

INTRODUCTION: Isolated duplication of vas deferens is a rare anomaly with only eleven cases reported in medical literature. Unawareness regarding this rare anomaly can lead to inadvertent injury to the vas during inguinal hernia surgery or failure of vasectomy procedure. PRESENTATION OF CASE: A 27-year-old gentleman was diagnosed with isolated duplication of vas during left sided open inguinal hernia surgery. He had no other genito-urinary anomaly. Patient had an uneventful recovery from surgery. CONCLUSION: It is a rare anomaly and unawareness regarding this condition can lead to catastrophic consequences during inguinal hernia and vasectomy surgeries.

Recurrent laryngeal nerve and voice preservation: routine identification and appropriate assessment - two important steps in thyroid surgery.

INTRODUCTION: The aims of this study were to assess and compare vocal cord functions before and after thyroid surgery after intra-operative identification of recurrent laryngeal nerve. PATIENTS AND METHODS: Recurrent laryngeal nerve (RLN) is seen intra-operatively in all cases undergoing thyroid surgeries. Vocal cord functions including any voice change were evaluated by indirect laryngoscopy (I/L) and direct laryngoscopy (D/L) before and after surgery. RESULTS: Prospective study on 100 patients over 18 months with a total of 146 nerves at risk (NAR). Majority were women (n = 86) with mean age of 37.48 years (range, 13-60 years). RLN was seen in all patients and 19 patients complained of some change in quality of their voice after surgery. Evaluation by I/L and D/L at 6 weeks showed recurrent laryngeal nerve palsy (RLNP) in nine (47.36%) and five (26%) of these 19 patients respectively. Analysed according to total NAR, the incidence of voice change and temporary RLN palsy (I/L and D/L) at 6 weeks was still less at 13.01%, 6.16% and 3.42%, respectively. Voice change improved in all cases at 3 months with no RLNP palsy by I/L or D/L. All these 19 patients had undergone difficult or extensive surgery for malignancy, large gland, extratyhroidal spread or fibrosis. CONCLUSIONS: Despite identification and preservation of RLN, patients can develop postoperative voice change and RLNP although all voice change cannot be attributed to damaged RLN. Proper assessment of vocal cord functions by I/L and D/L laryngoscopy is required to rule out injuries to these nerves. Risk of damage is higher in patients undergoing more difficult surgery.