Critical analysis of laparoscopic donor nephrectomy in the setting of complex renal vasculature: initial experience and intermediate outcomes.

OBJECTIVE: We report our experience with laparoscopic donor nephrectomy (LDN) in the setting of complex renal vasculature and critically analyze the technique and intermediate recipient outcomes. METHODS: Thirty-nine living renal donors with multiple renal arteries or veins, or anomalous venous anatomy, who underwent LDN between 2003 and 2007 at our institution were retrospectively reviewed. Demographic and perioperative data were collected on donors and recipients. RESULTS: Complex vasculature consisted of multiple renal arteries in 26 cases (67%), multiple renal veins in 10 cases (26%), retroaortic renal vein in 5 cases (13%), circumaortic renal vein in 4 cases (10%), and a persistent left-sided inferior vena cava (IVC) in 1 case (3%). Thirty-four (87%) patients had a single anomaly and five (13%) had multiple anomalies. Mean operative time was 196.3 minutes (range 135-311 minutes), mean blood loss was 99.4 mL (range 25-400 mL), and mean hospitalization period was 2.6 days (range 1-4 days). Donor creatinine preoperatively and at discharge was 0.8 mg/dL and 1.2 mg/dL, respectively. Mean warm ischemia time was 168.9 seconds (range 90-300 seconds). Mean recipient creatinine at the time of discharge was 1.45 mg/dL, and nadir creatinine at 1 and 2 years follow-up was 1.41 mg/dL and 1.30 mg/dL, respectively. There were three (7.7%) intraoperative complications and two (5%) cases of allograft failure over the 2-year period. CONCLUSIONS: LDN in patients with complex vascular anatomy is safe and efficacious and does not negatively impact the complication rate or recipient outcomes. This procedure may improve the availability of allografts.

Grade 4 cystocele repair using four-defect repair and porcine xenograft acellular matrix (Pelvicol): outcome measures using SEAPI.

OBJECTIVES: To determine the efficacy of grade 4 cystocele repair using the four-defect repair (FDR) or modified FDR with porcine xenograft matrix (FDR+Pelvicol). METHODS: During a 4-year period, 45 women underwent grade 4 cystocele repair. Of the 45 patients, 43 (95.5%) were available for follow-up. The mean age was 65 years. Patients presented with the following problems: grade 4 cystocele in 43 (100.0%), stress urinary incontinence in 24 (55.8%), urge urinary incontinence in 26 (60.4%), and obstructive voiding symptoms in 26 (60.4%). Patients were evaluated using the stress, emptying, anatomic, protection, and instability (SEAPI) test. We performed FDR in the first consecutive 24 (55.8%) and FDR+Pelvicol in the remaining 19 (44.2%) patients. Cystocele repair was accompanied by other transvaginal repair in 38 (88.3%) of the 43 patients. RESULTS: The mean follow-up time was 15 months. A comparison of the preoperative and postoperative SEAPI scores of 0, representing the absence of complaints, revealed a statistically significant improvement in all the SEAPI domains using McNemar's test. Cystocele recurred in 3 patients (6.9%), all in the Pelvicol subgroup. Two patients (4.7%) had postoperative urinary retention. De novo urge incontinence occurred in 2 patients (11.7%). No infection, erosion, fistula, or vaginal stenosis have been reported. CONCLUSIONS: Grade 4 cystocele repair using FDR or FDR+Pelvicol are two effective methods of cystocele repair. Although cystocele failures occurred exclusively in the Pelvicol+FDR subgroup, their small number and asymptomatic presentation did not result in statistical or clinical significance at this point. Both techniques are simple, efficacious, and well tolerated by patients. Follow-up is ongoing to evaluate the durability of the techniques.