Intrarenal and extrarenal autonomic nervous system redefined.

PURPOSE: The autonomic nervous supply to the kidneys is involved in the development of several diseases including hypertension. The neural distribution at the segmental vessels and intrarenal vasculature has not been well characterized. Thus, we evaluated the autonomic nerve distribution from the great vessels to the renal cortex in a cadaveric model. MATERIALS AND METHODS: We performed a detailed anatomical nerve dissection from the inferior mesenteric artery to the renal operculum in 2 human cadaveric torsos. Autonomic nerve fibers were verified by dissecting the greater splanchnic, sympathetic trunk and ganglia. We then systematically cross-sectioned the kidneys in 12, 1 mm slices across 3.6 cm, and stained the slices for histopathological analysis of neural tissue in relation to segmental arteries and other anatomical landmarks. Advanced reconstructive software was used to create a 3-dimensional computer image. RESULTS: Autonomic nerve fibers are located almost exclusively anteriorly on the main renal arteries and segmental arteries, and are absent from veins. Histopathology revealed that the intrarenal nerves continued to track exclusively with the arteries but were more circumferentially distributed. There is minimal nerve tissue around the veins. Many nerves were within a few millimeters of the renal collecting system. CONCLUSIONS: The autonomic nerves supplying the kidney maintain their distribution almost exclusively along the anterior surface of arteries as they pass from the aorta to the segmental arteries. Once inside the renal parenchyma, the nerves are circumferentially distributed around the renal arteries and are in close proximity to the renal collecting system.

Active surveillance of renal cortical neoplasms: a contemporary review.

INTRODUCTION: Over the past 2 decades, there has been a significant increase in the number of incidentally found small renal cortical neoplasms (RCNs). As more RCNs are being discovered in the elderly and infirmed patient populations, there has been a growing interest in the role of active surveillance (AS). Active surveillance is recommended for high surgical-risk patients and those with a reduced life expectancy. It is also an option for patients wishing to avoid surgery. We review the current literature on AS and highlight the natural history of disease, the important factors to evaluate during AS, and the contemporary role of biopsy. METHODS AND MATERIALS: The MEDLINE database was searched using PubMed. Search terms included active surveillance, renal mass, natural history, and renal mass histology. From 1966 to present, 17 AS series were identified, all of which have been included in this summary. A summary was performed by compiling all available data and performing a weighted mean where applicable. RESULTS: Initial tumor size does not correlate with growth rate or malignancy. The mean growth rate in large published series is low (0.28-0.34 cm/year). Tumors with high growth rates usually represent malignant lesions and typically undergo delayed intervention. Progression to metatatic disease is a low-probability event for tumors on AS (1.4%); however, this is still a risk that patients must be willing to accept. Larger tumors (cT1b and cT2) also demonstrate relatively low growth (0.57 cm/year); however, these tumors should be monitored carefully. Tumors followed for > 5 years demonstrate a low growth rate (0.15 cm/year), will not likely require intervention, and have a low chance of progression to metastatic disease. CONCLUSION: For highly selected patients with RCN, AS is a reasonable treatment option. Age, surgical risk, comorbidities, and patient opinion must all factor into the final decision when considering a patient for AS.

Complicaciones en cirugía laparoscópica renal en la edad pediátrica: análisis de nuestra experiencia y revisión de la literatura / Complications in laparoscopy renal surgery in pediatric age: Analysis of our experience and literature review

Introducción: El desarrollo de la cirugía mínimamente invasiva en la edad pediátrica ha sido más lento que en la edad adulta ya que sus ventajas no son tan claras. El aprendizaje y las complicaciones presentadas durante este periodo, así como el tipo de material utilizado han sido los factores que han contribuido a este hecho. Objetivo: Mostrar nuestra experiencia y las complicaciones presentadas en la cirugía laparoscópica de exéresis renal, añadiendo una revisión bibliográfica de las publicadas en esta edad hasta la fecha. Material y Métodos: Estudio retrospectivo de nuestros casos clínicos en que practicamos cirugía renal laparoscópica extirpativa. Encontramos 56casos desde Enero de 2003, en que se implantó, hasta Septiembre del 2008. Hubo 36 niños (64%) y 20 niñas (36%). La edad media de intervención fue de 3,6 años. Analizamos el diagnóstico principal, la situación que condujo a la intervención así como el tipo de cirugía efectuada, vía de abordaje, tiempo utilizado, tiempo de ingreso, complicaciones y tratamiento aplicado. Los resultados se analizaron mediante el programa estadístico SPSS® (SPSSCorp, Chicago, Illinois). La revisión bibliográfica se efectuó en las bases de datos MEDLINE, EMBASE y COCHRANE. Los trabajos seleccionados fueron revisados por dos investigadores. Series que contuvieran adultos fueron excluidas. Resultados: Se han efectuado 42 nefrectomías (75%), 13 heminefrectomías (23%) y 1 quistectomía (2%). En 5 casos (9%) utilizamos la retroperitoneoscopia y en 51 (91%) la vía transperitoneal. El tiempo medio quirúrgico fue de 118+/-0,75 min, para las nefrectomías, de 192+/-1,07 min., para lasnefrectomías parciales, 111+/-0,64 min para las nefroureterectomías y de 240 minutos para la quistectomía. La estancia media ha sido de 3,18 (2-6) días para las nefrectomías, 5,91 (3-11) días para las nefrectomías parciales, 3 días (2-4) para las nefroureterectomías y 6 días para la quistectomía. Hemos tenido 8 complicaciones (14%): 2 reconversiones por sangrado y dificultad técnica y 6 postoperatorias (3 fueron menores, fiebre durante el postoperatorio y 3 mayores (2 Urinomas y un pseudoaneurisma, requiriendo 2 intervenciones y una colocación de catéter doble J). La evolución ha sido buena en todos los casos. En la revisión bibliográfica se seleccionaron 47 artículos con un nivel de evidencia IIIB (Oxford Centre for Evidence-based Medicine). El número de nefrectomías encontrado ha sido de 347 pacientes. Las causa más frecuente de reconversión fueron los problemas vasculares y las complicaciones variaron de ninguna hasta el 37%.Conclusiones: La cirugía laparoscópica ha demostrado ser una técnica segura y fiable en el tratamiento de la patología renal benigna de la edad pediátrica con buenos resultados. Actualmente sus indicaciones se están ampliando a procesos de reconstrucción, donde muestran unos resultados prometedores, y a procesos oncológicos seleccionados (AU)

Introduction: The development of the minimally invasive surgery in pediatric age has been slower than in the adult age since their advantages are not so clear. The learning curve and the complications presented during this period, as well as the type of material used has been the factors that have contributed to this fact. Objective: We collected our experience and the complications presented in renal laparoscopic exegesis surgery, adding a review of the published literature to date. Materials and Methods: Retrospective study of our clinical cases in that we practiced laparoscopic renal exegesis surgery. We collected 56 cases from January 2003, when it was implanted, to September 2008. We had 36 boys (64%) and 20 girls (36%). The mean age was 3.6 years. We analyzed principal diagnosis, the situation that conducted to the surgery and the type of surgery performed, time of surgery, hospital stay and complications with their solution. The results were analyzed by the statistical program SPSS® (SPSS Corp, Chicago, Illinois). The literature review was practiced in MEDLINE, EMBASE and COCHRANE database. The selected works were reviewed by two investigators. Series containing adults were excluded. Results: We perfomed 42 nephrectomies (75%), 13 heminephrectomies (23%) and 1 quistectomy (2%). 5 cases (9%) were done by retroperitoneoscopy and 51 cases (91%) transperitoneally. The mean operative time was 118+/-0,75 min, for nephrectomies; 192+/-1,07 min, for partial nephrectomies,111+/-0,64 for nephroureterectomies and 240 min for quistectomía. The mean hospital stay was 3.18 min (2-6) days for nephrectomies; 5.91 (3-11)days for partial nephrectomies, 3 days (2-4) for nephroureterectomies and 6 days for the quistectomy. We had 8 complications (14%): 2 conversions for bledding and technical difficulty and 6 postoperative complications (3 were minor complications, postoperative fever and 3 mayor (2 Urinomas and one pseudoaneurism, requiring 2 interventions and one catheter double J placement). The evolution has been satisfactory in all cases. In the bibliographic review 47 articles with a level of evidence IIIB were selected (Oxford Centers for Evidence-based Medicine). The main reasons to conversion to open surgery were vascular problems and the complication rate change from anyone to 37%.Conclusions: Laparoscopic surgery has proved to be a secure and feasible technique in the treatment of benign renal pathology in pediatric age with satisfactory results. Actually the indications are expanding to reconstructive procedures, with promising results, and selected oncologic procedures (AU)