Trends in Body-Mass Index After Donor Nephrectomy.

The link between obesity and diabetes, hypertension, and eventual kidney dysfunction is well recognized. To evaluate trends in the body-mass index (BMI) of donor nephrectomy patients, the BMI was evaluated in 532 donors over 11 years from 2002 to 2012. Measurements were made preoperatively, at 1 year, and at the present time. The follow-up range varied from 12 months to 11 years dependent on the date of donation. Of the 532 patients queried, 100 patients had long-term results. At 1 year, there was an overall decrease in BMI, however, at anytime after the first year, postoperative BMI trended upward, with more than half of the overweight patients (BMI 25-30), at the time of donation, dipping into the obese range (BMI >30). Given these results and recognizing the attendant risks-especially with the background of a single kidney-we have initiated further lifestyle and nutrition counseling at our center and are considering a more stringent preoperative weight control policy.

Long-Term Body Mass Index Trends After Living-Donor Nephrectomy.

OBJECTIVES: As the demand for kidney transplant allografts has increased, many centers are expanding the upper limit of acceptable body mass index for kidney donors. However, obesity is a risk factor for developing renal disease. Our goal was to quantify body mass index trends in donor nephrectomy patients and to institute nutrition counseling to promote sustainable weight loss to reduce the risk of metabolic syndrome-derived renal dysfunction. MATERIALS AND METHODS: Ninety patients who underwent donor nephrectomy between 2007 and 2012 consented to having height and weight data collected at multiple time points. After data collection, each patient underwent a standardized nutrition counseling session. One year later, body mass index was reassessed. RESULTS: Preoperatively, 52% of the patients were overweight or obese. The percentage of overweight and obese patients remained stable for 2 years after surgery. However, at 3, 4, and 5 years after surgery, these rates increased to 59%, 69%, and 91%. Each patient was counseled about obesity-related comorbidities and provided information about lifestyle modification. One year later, 94% of previously overweight patients and 82% of previously obese patients had a decrease in mean body mass index from 27.2 ± 4.0 kg/m2 to 25.1 ± 3.6 kg/m2. CONCLUSIONS: Living-donor nephrectomy patients are at risk of developing obesity, similar to the adult population. Nutrition counseling may be beneficial to help normalize body mass index in patients who have become overweight or obese to potentially prevent obesity-related comorbidities. All patients were evaluated by a nutrition specialist after surgery to review our donor nephrectomy nutrition brochure. Body mass index monitoring and primary care follow-up appear to be appropriate surveillance methods.

A comparison of running suture versus figure-8 sutures as the initial step in achieving hemostasis during laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: During laparoscopic partial nephrectomy, the importance of the initial suture placed under warm ischemic conditions cannot be underestimated. Inadequate hemostasis may lead to further surgical complications. Our goal was to determine which method of suture ligation (running vs figure-8 interrupted) provides better initial hemostasis when performing partial nephrectomy in an ex-vivo porcine model. MATERIALS AND METHODS: Deep partial nephrectomy defects were cut in the lateral aspect of six porcine kidneys. The renal artery was cannulated, and the kidneys were perfused from a water reservoir. The level (cm H(2)O) at which parenchymal leakage occurred was measured and recorded in three situations: No parenchymal suture; running suture along the base of the defect; and interrupted figure-8 sutures placed in parallel along the base of the defect. RESULTS: Six kidneys were studied. Using interrupted figure-8 sutures, the mean leak pressure was 56.7 cm H(2)O (over baseline). Using a running suture, the mean leak pressure was 147.5 cm H(2)O (over baseline). Mean values were compared using two-tailed t test and found to be statistically significant (P = 0.05). CONCLUSION: In an ex-vivo porcine kidney model, use of a running suture along the base of a renal tumor defect (simulating that which is seen during partial nephrectomy) appears to allow for better initial hemostatic control, as compared with interrupted figure-8 sutures placed in parallel.

Percutaneous biopsy of renal cell carcinoma underestimates nuclear grade.

OBJECTIVES: To assess the accuracy of renal biopsy for predicting the final nuclear grade and histologic subtype. Small renal masses can be safely observed in select patients who are poor surgical candidates. Renal biopsy may help identify patients who are candidates for observation. METHODS: A total of 81 patients (29 female, 52 male) underwent percutaneous biopsy of their renal mass with ultrasound or computed tomography guidance. Percutaneous 18-gauge biopsy cores were obtained, and all patients subsequently underwent radical nephrectomy or partial nephrectomy. Preoperative biopsy results were compared with postoperative specimens. RESULTS: The mean tumor size was 5.3 cm (range, 1-17). Overall, biopsy correctly identified 71 of 81 (88%) histologic subtypes. The preoperative biopsy correctly identified 62 of 64 (97%) clear cell renal carcinomas, 9 of 10 (90%) papillary carcinomas, 0 of 3 (0%) chromophobe carcinomas, and 1 of 2 (50%) oncocytomas. The final pathologies for 2 nondiagnostic biopsies were clear cell renal carcinoma and inflammatory pseudotumor. For 67 tumors, the pathologists assigned a nuclear grade for both the biopsy and the final specimen. The biopsy correctly identified 29 of 67 (43%) final nuclear grades. The biopsy underestimated the nuclear grade in 37 of 67 (55%) cases. In 7 of 67 (10%) cases, the biopsy nuclear grade increased by 2 when compared with the final grade. The biopsy rarely overestimated the nuclear grade; 1 case (1%) that was assigned a grade 2 on biopsy was assigned a grade 1 after nephrectomy. CONCLUSIONS: Core biopsies for renal masses underestimate nuclear grade in most cases; however, histologic subtype is more reliably assessed, particularly for clear cell renal tumors.

Enlargement of accessory spleen after splenectomy can mimic a solitary adrenal tumor.

We report on a 72-year-old woman who had previously undergone splenectomy and subsequently presented with an incidental 5-cm adrenal mass. Laparoscopic adrenalectomy was performed, and the mass was identified to be an accessory spleen. Remaining accessory splenic tissue may undergo compensatory hypertrophy after splenectomy. When a biochemically inactive, well-marginated ovoid adrenal mass is identified in a postsplenectomy patient, consideration should be given to the presence of accessory spleen. In such cases, radionuclide imaging with technetium sulfur colloid may provide information that would confirm the presence of accessory normal tissue and would therefore support observation rather than surgical resection.

Urolithiasis in adults with congenital megaureter.

The primary presentation of congenital megaureter in adults is rare. Development of urolithiasis may lead to this unusual underlying diagnosis. Urinary tract stones can form either within the dilated ureteral segment or in a part of the upper urinary tract proximal to the abnormal ureteral segment. We report two cases of nephrolithiasis that occurred in adults found to have segmental megaureter. The first case is that of a 58-year-old man who presented with left lower quadrant pain. Computed tomography scan revealed a 2-cm stone in the distal left ureter within an area of isolated segmental distal ureteral dilation. The second case is a 48-year-old man who developed recurrent renal urolithiasis associated with isolated distal megaureter.Although a rare condition in adults, congenital megaureter may present when kidney stones develop as a result of the ureteral abnormality. Typically, stones will develop within the dilated segment of ureter. Atypically, stones may develop away from the site of the underlying abnormality. Congenital megaureter is a diagnosis that urologists and radiologists need to consider in the setting of isolated distal ureteral dilation, as the diagnosis of adult megaureter may require more involved surgical measures to prevent recurrence of adverse symptoms.

Adrenal metastasis with inferior vena cava tumor thrombus through adrenal vein.

A 69-year-old woman was evaluated for anemia. Abdominal ultrasonography showed a large right renal mass. Magnetic resonance imaging revealed a 12-cm renal mass and a separate 7.5-cm ipsilateral adrenal mass, with a tumor thrombus extending through the adrenal vein and into the inferior vena cava. Right radical nephrectomy/adrenalectomy with caval tumor thrombectomy was performed, and both lesions were diagnosed as renal cell carcinoma. We report on an unusual case of a large renal cell carcinoma with metastasis to the adrenal gland and vena caval extension by way of the adrenal venous system, without renal vein thrombus.

Delayed hematuria secondary to bleeding papilla--potential complication of laparoscopic partial nephrectomy.

The complications of partial nephrectomy include hemorrhage, urinary leak, infection, formation of urinary fistula, and the development of renal insufficiency. We report a unique case of a patient who was found to have necrotic-appearing, bleeding, renal papillae after undergoing laparoscopic partial nephrectomy. A 66-year-old man was diagnosed with a left-sided, solid, enhancing, 2.5-cm, exophytic renal mass. Laparoscopic partial nephrectomy was performed, and the warm ischemia time was 31 minutes. He recovered uneventfully from surgery, but he started having episodes of gross hematuria approximately 5 months later. Computed tomography scan showed changes consistent with previous partial nephrectomy but no other abnormality. Ureterorenoscopy allowed us to identify several necrotic-appearing papillae in the same kidney that had undergone laparoscopic partial nephrectomy. A papilla in the lower pole was actively bleeding, and it was successfully obliterated using neodymium:yttrium-aluminum-garnet laser technology. Papillary necrosis can be a rare complication of laparoscopic or open partial nephrectomy. Additional study and close follow-up of patients who undergo partial nephrectomy is warranted.

Video rounding system: a pilot study in patient care.

BACKGROUND AND PURPOSE: Integration of information technology (IT) with health care improvement is ever increasing. National initiatives, such as Transforming Care at the Bedside, and physician-nurse collaboration committees use IT to enhance patient care. We sought to determine the impact of "video rounding" on the post-operative care of endourologic inpatients. PATIENTS AND METHODS: Laptop computers with built-in Webcam and video conferencing software were used for real-time video and audio connections between patient and nurse at the bedside and urologist at a remote location. This video rounding system (VRS) was used in addition to standard rounds. Ten patients were randomly selected and consented to participate with one of two surgeons. Post-VRS surveys with six questions each were completed by patient, physician, and nurse using a 5-point Likert scale. RESULTS: Ten physician, 10 patient, and 14 nursing surveys were filled for 10 patients who completed VRS. Of these patients, 90% strongly agreed/agreed that they could easily communicate with their physician using VRS. All patients strongly agreed that VRS should be a regular part of patient care and that they would be comfortable using VRS if their physician was unable to be in direct contact with them. All physicians and nurses strongly agreed/agreed that VRS was easy to use, enhanced patient care, would be a comfortable alternative if direct physician contact was not possible, and that it should be a regular part of institutional care. For all participants, video and audio quality were rated excellent/very good by 91.2% and 70.6%, respectively. CONCLUSION: VRS has shown promising usefulness in enhancing patient care and improving communication between nurse, physician, and patient. VRS is not intended to replace daily face-to-face physician rounding. Additional features of this system are currently being evaluated, including four-way simultaneous video rounding as well as sending intraoperative photos and video clips for real-time patient/nurse education.

Laparoscopic nephrectomy outcomes of elderly patients in the 21st century.

BACKGROUND AND PURPOSE: As life expectancy continues to increase, we will be faced with the need to counsel older patients on the risks and benefits of undergoing surgery. It is clear that laparoscopic renal surgery has significant benefits over open renal surgery. However, contemporary data on whether these benefits carry over to the elderly is less robust. The objective of this study is to compare the perioperative outcomes of laparoscopic nephrectomy in patients age 70 and over to those under age 70. Outcomes from the study can be used to assist in preoperative counseling for older patients. PATIENTS AND METHODS: Between February 2000 and December 2005, 405 consecutive patients underwent laparoscopic nephrectomy for benign or malignant conditions. To decrease selection bias, kidney donors, bilateral nephrectomies, partial nephrectomies, as well as patients under the age of 17 were excluded. Laparoscopic nephrectomies included simple nephrectomies, radical nephrectomies, and nephroureterectomies. A total of 158 patients were included in the analysis. Patient demographics and perioperative data were recorded prospectively. The preoperative American Society of Anesthesiologists (ASA) score was used to reflect patient co-morbidity. Subset analysis between pure laparoscopic nephrectomy (LN) and hand-assisted laparoscopic nephrectomy (HALN) was also performed. RESULTS: Average hospital stay for patients 70 years and older was 3.6 days versus 2.6 days for their younger counterparts (p = 0.02). All other demographic and perioperative parameters were comparable between groups, including incidence of intraoperative or postoperative complications, blood transfusions, and conversions to open surgery. In a subset analysis of patients undergoing HALN, despite having similar co-morbid conditions (ASA score 2.57 vs. 2.56, p = 0.9), the elderly group had a significantly increased length of stay compared to patients younger than 70 years (3.0 vs. 4.2 days, p < 0.05). However, in the group undergoing LN, there was no statistically significant difference in hospital stay (3.1 vs. 2.4 days, p = 0.22), despite the older group having higher co-morbid conditions (ASA score 2.55 vs. 2.10, p < 0.01). CONCLUSION: Other than an increased hospital stay by one day, patients 70 years and older undergoing laparoscopic nephrectomy can expect comparable perioperative outcomes to those achieved in younger patients. Such differences in the length of hospital stay may be mitigated by pure laparoscopic nephrectomy as opposed to hand-assisted laparoscopic nephrectomy in patients 70 years or older. These data may be useful in preoperative decision-making and counseling in this growing subset of patients.

Simultaneous bilateral retrograde intrarenal surgery for stone disease in patients with significant comorbidities.

BACKGROUND AND PURPOSE: Advances in endoscopic equipment have allowed urologists to access stones in virtually any location in the upper tracts. Where clinically appropriate, this approach may represent the preferred treatment option, regardless of stone size. We report the first description of simultaneous bilateral retrograde intrarenal surgery (SB-RIRS) in patients with both significant upper-tract stone burdens and comorbidities such as morbid obesity or heart disease. PATIENTS AND METHODS: Between September 2003 and April 2004, three men and one woman with an average of 62 years underwent a total of seven sessions of SB-RIRS. All four patients were referred from other urologists after failing prior treatments, including shockwave lithotripsy (five sessions) and RIRS (two sessions). The average stone burden was 8.8 cm. The procedures were performed by two surgeons operating simultaneously using two sets of video/holmium laser equipment. Flexible (7.5F) ureteroscopes were used to fragment and basket stone debris without the use of ureteral access sheaths. RESULTS: Three patients underwent a scheduled second-stage procedure to ensure adequate stone clearance. The average total and SB-RIRS-specific operative times were 256 and 131 minutes for the initial procedure and 235 and 95 minutes for the second-stage procedure, respectively. No major complications were noted. CONCLUSION: Simultaneous bilateral RIRS is an appropriate treatment option for stone patients with significant comorbidities.

Multi-institutional validation study of neural networks to predict duration of stay after laparoscopic radical/simple or partial nephrectomy.

PURPOSE: We developed models to predict post-laparoscopic radical or simple nephrectomy (LapNx) and post-laparoscopic partial nephrectomy (LapPNx) hospital duration of stay (DOS). MATERIALS AND METHODS: We performed a retrospective review (design group) of all 726 patients (July 1997 to April 2004) who underwent LapNx or LapPNx at the Cleveland Clinic Foundation (CCF). Preoperative findings were recorded. Neural network algorithms were designed to predict the DOS before surgery. The models were then tested on a separate 252 patients from 6 different institutions, namely Tulane University Medical School, University of Arkansas for Medical Sciences, Cedars-Sinai Medical Center, University of Iowa, Mayo Clinic at Scottsdale and CCF. RESULTS: In the CCF design groups, the LapNx model accuracy was 73% to 74% and the LapPNx model 73% to 83%. Overall accuracy in the test groups at all 6 institutions was 72% (area under ROC 0.6 to 0.7) for the LapNx model and 52% to 81% (ROC 0.5 to 0.7) for the LapPNx model. CONCLUSIONS: The LapNx model provides 72% accuracy in predicting the DOS at all 6 institutions. The LapPNx model provided fair accuracy only at CCF and Tulane University Medical School. These models may streamline the delivery of care and continued testing will allow for further refinement.

Bladder reconstitution with bone marrow derived stem cells seeded on small intestinal submucosa improves morphological and molecular composition.

PURPOSE: Tissue engineering has been used for bladder augmentations with small intestinal submucosa (SIS). Although favorable short-term outcomes have been reported, long-term followup has been poor. We investigate whether tissue engineering with stem cells improves the morphological and genetic composition. MATERIALS AND METHODS: A total of 33 Lewis rats (Harlan Laboratories, Indianapolis, Indiana) were used to investigate bladder augmentations with 4-layer SIS in certain groups, including the control group (sham operation), partial cystectomy with oversewn defect group (OG), augmentation with unseeded SIS group (USG) and augmentation with stem cell seeded SIS group (SSG). Bladders from 4 rats per group were harvested 1 and 3 months after surgery. Morphological analyses were performed using Masson's trichrome and immunohistochemical staining with cytokeratin AE1/AE3, smooth muscle alpha-actin and S100. Gene expression was evaluated using quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) for collagen I (CI), collagen III (CIII), cytokeratins 8 and 19, and smooth muscle myosin heavy chain (MHC). RESULTS: At 1 month trichrome staining revealed collagen admixed with indiscrete cells and morphology similar to that in controls in USG and SSG, respectively. Discrete smooth muscles fascicles and S100 staining were found in all groups except USG. Organized urothelium with increased basal cell layer staining was present in controls and SSG only. At 3 months increased collagen formation was present in OG and USG. Immunostaining showed hyperplasia of the urothelium with increased staining of the basal cell layer, discrete muscle fascicles and positive nerve staining in all groups. Using quantitative RT-PCR expression levels in SSG were more improved than in USG, especially for CI, CIII and MHC. This was further evident at 3 months when CI and CIII were over expressed in OG and USG but not in the control group or SSG. Furthermore, RT-PCR showed that cytokeratins 8 and 19, and MHC had greater expression levels in SSG than in USG. CONCLUSIONS: Bladder reconstitution occurs more rapidly using stem cell seeded SIS. Although in USG and SSG all 3 cellular constituents appear to develop by 3 months, only SSG had gene expression levels similar to those in controls. The results suggest an explanation for the fibrosis noted in unseeded SIS bladder augmentations and the possible solution using stem cells.

Looped silk tie: surgical technique for management of the renal vein during laparoscopic live-donor nephrectomy.

Laparoscopic live-donor nephrectomy has revolutionized the field of kidney transplantation and has been adopted in many tertiary centers as the method of choice in procuring kidneys. While standard techniques for laparoscopic live-donor nephrectomy have been well described in the literature, there continues to be ample discussion about renal-vein ligation. Endo-GIA and other commonly used vascular stapling devices can be costly and prone to mechanical failures and may not be applicable in certain anatomic situations. Vascular clips, although simple to use for arteries, are difficult to apply to large renal veins. To address these issues, we describe a simple, cost-effective method of control that can be used for both right and left renal veins, using a loop constructed from a 0 silk tie.

Simultaneous bilateral retrograde intrarenal surgery for bilateral complex upper tract stone disease.

Recent advances in retrograde endoscopy have greatly expanded the role of minimally invasive surgery in addressing upper tract stone disease. In an attempt to decrease patient morbidity further, we present our initial experience with simultaneous bilateral retrograde intrarenal surgery in a patient with complex bilateral upper tract stones.

Newly designed laparoscopic retractable dissector and suture passer.

We introduce a novel laparoscopic instrument that performs as a dissector and retractable suture passer in preparation for intracorporeal knot tying. The newly designed instrument was developed at our institution to duplicate techniques of vessel ligation in open surgery.

Laparoscopic skills training using a webcam trainer.

PURPOSE: Many sophisticated and expensive trainers have been developed to assist surgeons in learning basic laparoscopic skills. We developed an inexpensive trainer and evaluated its effectiveness. MATERIALS AND METHODS: The webcam laparoscopic training device is composed of a webcam, cardboard box, desk lamp and home computer. This homemade trainer was evaluated against 2 commercially available systems, namely the video Pelvitrainer (Karl Storz Endoscopy, Culver City, California) and the dual mirror Simuview (Simulab Corp., Seattle, Washington). The Pelvitrainer consists of a fiberglass box, single lens optic laparoscope, fiberoptic light source, endoscopic camera and video monitor, while the Simuview trainer uses 2 offset, facing mirrors and an uncovered plastic box. A total of 42 participants without prior laparoscopic training were enrolled in the study and asked to execute 2 tasks, that is peg transfer and pattern cutting. Participants were randomly assigned to 6 groups with each group representing a different permutation of trainers to be used. The time required for participants to complete each task was recorded and differences in performance were calculated. Paired t tests, the Wilcoxon signed rank test and ANOVA were performed to analyze the statistical difference in performance times for all conditions. RESULTS: Statistical analyses of the 2 tasks showed no significant difference for the video and webcam trainers. However, the mirror trainer gave significantly higher outcome values for tasks 1 and 2 compared to the video (p = 0.01 and <0.01) and webcam (p = 0.04 and <0.01, respectively) methods. ANOVA indicated no overall difference for tasks 1 and 2 across the orderings (p = 0.36 and 0.99, respectively). However, by attempt 3 the time required to complete the skill tests decreased significantly for all 3 trainers (each p <0.01). CONCLUSIONS: Our homemade webcam system is comparable in function to the more elaborate video trainer but superior to the dual mirror trainer. For novice laparoscopists we believe that the webcam system is an inexpensive and effective laparoscopic training device. Furthermore, the webcam system also allows instant recording and review of techniques.

Spontaneous, unremitting gross hematuria occurring one week after laparoscopic donor nephrectomy.

Complications associated with the ureteral stump after nephrectomies rarely occur, especially after donor nephrectomies. The potential for the slippage of clips is a well-known event associated with vascular ligations. We report on the first case of clip slippage from the ureter and describe diagnosis and management of the most extreme of morbid presentations.

Spontaneous, unriitting gross hematuria occurring one week after laparoscopic donor nephrectomy

Complications associated with the ureteral stump after nephrectomies rarely occur, especially after donor nephrectomies. The potential for the slippage of clips is a well-known event associated with vascular ligations. We report on the first case of clip slippage from the ureter and describe diagnosis and managient of the most extrie of morbid presentations.