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.

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.

Clipless management of the renal vein during hand-assist laparoscopic donor nephrectomy.

BACKGROUND: Laparoscopic live donor nephrectomy has become the preferred method of donor nephrectomy at many transplant centers. The laparoscopic stapling device is commonly used for division of the renal vessels. Malfunction of the stapling device can occur, and is often due to interference from previously placed clips. We report our experience with a clipless technique in which no vascular clips are placed on tributaries of the renal vein at or near the renal hilum in order to avoid laparoscopic stapling device misfires. METHODS: From December 20, 2002 to April 12, 2005, 50 patients underwent hand-assisted laparoscopic left donor nephrectomy (LDN) at our institution. Clipless management of the renal vein tributaries was used in all patients, and these vessels were divided using either a laparoscopic stapling device or the LigaSureTM device (Valleylab, Boulder, CO). The medical and operative records of the donors and recipients were reviewed to evaluate patient outcomes. RESULTS: The mean follow-up time was 14 months. Of the 50 LDN procedures, there were no laparoscopic stapling device malfunctions and no vascular complications. All renal allografts were functioning at the time of follow-up. CONCLUSION: Laparoscopic stapling device failure due to deployment across previously placed surgical clips during laparoscopic live donor nephrectomy can be prevented by not placing clips on the tributaries of the renal vein. In our series, there were no vascular complications and no device misfires. We believe this clipless technique improves the safety of laparoscopic donor nephrectomy.

Treatment of primary hyperoxaluria type 1 with sequential liver and kidney transplants from the same living donor.

Alanine-glyoxalate aminotransferase deficiency occurs in patients with primary hyperoxaluria type 1. Increased hepatic oxalate production leads to high urine concentrations of glycolate and oxalate. Calcium oxalate nephrolithiasis and nephrocalcinosis occur, and renal function progressively declines until patients develop end-stage renal disease. Renal transplantation alone is inadequate therapy because the primary enzyme deficiency remains. We report what we believe to be the second-youngest recipient to undergo successful sequential liver and kidney transplantation from a single living-related donor for treatment of primary hyperoxaluria type 1. We also discuss the changes in this patient's serum oxalate levels after transplantation.

Exacerbation of occult femoral hernia during laparoscopic prostatectomy.

Laparoscopic prostatectomy has been accepted as an appropriate treatment for prostate cancer because of the shorter hospital stay and quicker recovery. We present a rare complication of groin hernia with incarceration and necrosis of small bowel following laparoscopic prostatectomy. Occult hernias and small fascia defects may not always be apparent pre-operatively, but extension of pneumoperitoneal insufflation to extraperitoneal compartments should alert the surgeon to the possible presence of such a defect.