Evaluation of cadaveric renal vein lengths and their extension loss with three types of ligature and section

BACKGROUND AND PURPOSE

The right kidney has been less frequently used in live donor nephrectomy, because of the shorter length of the right renal vein (RRV) that is associated with technical difficulties and higher rates of venous thrombosis. In live open donor or deceased donor transplant nephrectomy, an additional cuff of the inferior vena cava is usually removed, but this is a more difficult and risky maneuver in laparoscopic nephrectomy. For this reason, laparoscopic right nephrectomy (LRN) for renal transplantation (RT) is not frequently performed in most medical institutions. We evaluate the difference between RRV and left renal vein (LRV) lengths in cadavers, as harvested for RT by three clamping methods. Our objective was to obtain information that could clarify when LRN for RT should be encouraged or avoided with regard to conventional surgery.

MATERIALS AND METHODS

Ninety adult fresh unfrozen cadavers were randomly divided into three groups of 30, according to the clamping device used: Satinsky, stapler, and Hem-o-lok clip. The abdominal viscera were removed through a median xyphopubic incision, and the veins were measured on the bench. Two lateral limits were used: The renal hilum and the tangential line of the renal poles. As for medial limits, the inferior vena cava or the laparoscopic clipping device on the RRV were used on the right side, while on the LRV, the medial border of the emergence of the adrenal vein was considered. After section of the renal vein, a slight traction of the extremity was applied for the measurement. All measurements were obtained three times using a metallic millimetric ruler, and the arithmetic mean was considered. The chi-square, one-way analysis of variance, and paired t tests were used for statistical analysis. Statistical significance was accepted at P <or= 0.05.

RESULTS

The groups of cadavers were homogeneous in demographic characteristics. Regardless of the clamping method and considering the useful length of the LRV, the RRV was statistically smaller. The evaluation of the vein length did not depend on the lateral limit considered. Independent of the clamping method, on both sides, the lengths after the vein section were larger than before the section, a fact attributed to traction. Use of a stapler and a single Hem-o-lok presented the same waste of vein length on the right side. On average, the RRV was 13.7% shorter than the LRV.

CONCLUSIONS

With the wide acceptance of laparoscopic live donor nephrectomy, the length difference between the veins of both kidneys is an important issue, and the right kidney is therefore used less than the left, compared with conventional surgery. This article represents the first step to quantify the anatomic length of renal veins in different situations. Certainly, more imagenologic or surgical studies should be carried out before decisions can be made for better selection of patients for LRN.

Diagnostic accuracy of color Doppler sonographic study of the ureteric jets in evaluation of hydronephrosis

OBJECTIVE

Hydronephrosis (HN) and obstruction are closely associated, but upper urinary tract dilatation can occur without significant obstruction. Despite some pitfalls, conventional ultrasonography and diuretic renography (DR) are the main means of evaluation of HN in children. Recent reports have demonstrated color Doppler ultrasonography (CDUS) to reliably identify ureteric jets in the bladder. The aim of this study was to evaluate this method as a diagnostic tool to distinguish obstructive from non-obstructive dilatations of the upper tract.

METHODS

We evaluated 51 patients (37 boys and 14 girls), aged 3 months to 14 years (median 4 years), who presented with unilateral grade III and IV hydronephrosis with suspicion of pyeloureteral junction obstruction. All patients underwent DR and evaluation of ureteric jets by transverse CDSG of the bladder within a maximum of 2 weeks. Obstruction was considered in the DR when the hydronephrotic unit showed a differential renal function of less than 40%, or when symptomatic intermittent renal colic was present in older children. The number of ureteric jets was counted over a 5-min period and the frequency calculated for each ureteral orifice. Relative jet frequency (RJF) was defined as frequency of the hydronephrotic side divided by total ureteric jet frequency. Receiver-operating characteristic (ROC) plots were constructed to determine the best cut-off for RJF, in order to identify renal units with obstructive hydronephrosis.

RESULTS

Twenty-three (45.1%) hydronephrotic units were considered obstructed. The mean RJF differed between obstructive (0.09+/-0.15) and non-obstructive hydronephrosis (0.42+/-0.11) (p<0.001). ROC analysis revealed that RJF <0.25 was the best threshold, and correctly discriminated obstruction in 91.2% of the children with a sensitivity of 87% (95% CI 78.6-98.2%) and specificity of 96.4% (95% CI 87.8-99%). The positive likelihood ratio was 24.3 and the area under the ROC curve was 0.92 (95% CI 0.86-0.98).

CONCLUSIONS

RJF <25% was found to be a good indicator of obstruction in children with unilateral hydronephrosis. CDUS evaluation of ureteric jets is an easy and non-invasive method that can be used as an initial diagnostic tool, and in follow-up cases, to differentiate obstructed from non-obstructed hydronephrosis in the pediatric population.

Laparoscopic nephrectomy for wilms tumor after chemotherapy: initial experience

PURPOSE

We describe 2 cases of laparoscopic nephrectomy for unilateral Wilms tumor in children who underwent preoperative chemotherapy.

MATERIALS AND METHODS

Two children with unilateral nonmetastatic Wilms tumor included in the International Society of Pediatric Oncology 2001 protocol were preoperatively treated with vincristine/actinomycin D and subsequently underwent laparoscopic nephrectomy and lymph node sampling. A 5 and 10 mm trocar transperitoneal approach was used in each case. The tumor was extracted without morcellation through a 4 cm Pffannensteil incision.

RESULTS

The 2 tumors were completely removed as well as lymph node samples. Intraoperative bleeding was minimal (50 ml). The postoperative period was free of complications and patients were discharged home after 3 days.

CONCLUSIONS

Laparoscopic nephrectomy for Wilms tumor is feasible in children after chemotherapy. It is a safe procedure and it allows the complete surgical approach required to treat this tumor. Longer followup is necessary to evaluate long-term results and more cases are necessary to compare the results of laparoscopic techniques with those of open surgical procedures.

Laparoscopic management of intersexual states

Laparoscopy has gained acceptance as the ideal method of surgical treatment of the internal [figure: see text] genital organs in patients with intersex disorders. The intersexual states for which laparoscopy is needed are female and male pseudohermaphroditism, true hermaphroditism, and Turner's syndrome. In these patients, the indications for laparoscopy are the removal of normal gonads and ductal structures that are contrary to the assigned gender and the removal of dysgenetic gonads that are nonfunctional and that present potential for malignancy. In addition to being a minimally invasive surgery, one of the main advantages of this method is the lack of scars, a fact much appreciated by patients and their parents. Generally, gonadectomy is a straightforward operation because the gonads present with an accessible pedicle. Laparoscopic orchidopexy has been standardized and can be performed in patients in whom the testis must be relocated to the scrotum. The removal of ductal structures is also easily performed in most cases, whereas hysterectomy with resection of the vagina may present some difficulties owing to the location of these structures. In patients with a long vaginal component of the urogenital sinus, the distal segment must be removed by a retrograde perineal access, usually performed simultaneously with genitoplasty. Endocrinologists must be aware of the application of this method of treatment in intersex patients, and urologists proficient in laparoscopic techniques must extend their field of work in this area.

Pheochromocytoma treated by laparoscopic surgery

OBJECTIVE

To evaluate the results of the laparoscopic technique in the treatment of adrenal pheochromocytoma.

METHOD

Ten patients, 7 men and 3 women, between 10 and 67 years of age (mean 48) with pheochromocytoma underwent transperitoneal laparoscopic adrenalectomy and were evaluated retrospectively, based on clinical, laboratory, and pathological diagnosis. In all cases there was a solid unilateral adrenal tumor, 5 on the left side and 5 on the right side, whose greater diameter varied from 7 to 80 mm (mean 32). Nine of the 10 patients were chronically hypertensive or had already had hypertensive crises. One patient was normotensive, but presented metabolic alterations suggestive of adrenergic hyperfunction.

RESULTS

No deaths occurred in this series. There were two (20%) conversions to open surgery, one due to venous bleeding and one due to the difficulty of dissection behind the vena cava in a patient presenting a partially retro-caval tumor. Surgical time in the 8 non-converted cases ranged from 70 to 215 minutes (mean 136). One patient (10%) received blood transfusion, and another (10%) presented two complications - acute renal failure and a subcutaneous infection. Both had been converted to open surgery. None of the non-converted cases was transfused or presented complications. Hospital discharge occurred between the 2nd and 11th post-operative day (mean 3). The pathological exam of the surgical specimens confirmed the diagnoses of pheochromocytoma in all 10 cases, one of them associated with an aldosterone-producing cortical tumor.

CONCLUSIONS

Laparoscopic adrenalectomy for selected patients presenting pheochromocytoma is feasible and provides good results.

[Vesicoureteral reflux in children]

The association between vesicoureteral reflux and urinary tract infection represents a significant threat to the kidney, in the form of pyelonephritic scarring. The physiopathologic events that allow the upward migration of bacteria and their inoculation in the renal tissue, causing irreversible damage if not adequately treated, are reasonably understood. Reflux nephropathy is a major cause of childhood hypertension and renal insufficiency. Early diagnosis of reflux, and identification of the pyelonephritic aggression are important for successful therapy. Long-term chemoprophylaxis,to prevent urinary tract infection and renal scarring is the adequate form of treating low-grade vesicoureteric reflux, since spontaneous cure is expected in most of these cases. Although the same approach can be employed in high-grade reflux, surgery is a favorable alternative, with high rates of primary success,reducing the need of long-term medication and the exposure of the kidney to recurring pyelonephritic aggression. The retrograde flow of urine from the bladder to the upper urinary tract is an abnormal situation in the human being, known as vesicoureteral reflux (VUR). It results either from an intrinsic anatomical deficiency of the vesicoureteral junction or from an increased bladder pressure, due to mechanical or dysfunctional vesicourethral obstruction. The recognition of the association between VUR, urinary tract infection (UTI) and renal scars has led to an increased study of this disease in the last two decades.

Transureterocalicostomy: an alternative internal diversion technique

We report a case of an infiltrating retroperitoneal tumor that completely enveloped and obstructed the mid third of the left ureter. After resection of the tumor, including a 10 cm. long segment of ureter, the upper left ureter was successfully diverted to the upper calix of the right ectopic kidney (transureterocalicostomy). To our knowledge our report represents the first case of such surgery.

Malakoplakia of the urinary tract

The authors report 4 cases of urinary tract malakoplakia. This rare disease of unknown etiopathogenesis can present with a benign character in the bladder, but when the upper urinary tract is affected, loss of renal function can occur. Treatment aims to control the primary infection, as well as enhance intracellular bactericidal activity, which seems to be compromised in these cases. Cytoreductive surgery may be indicated when this treatment fails.

Retroperitoneal fibrosis: an alternative therapy

A case of retroperitoneal fibrosis satisfactorily treated with indwelling double J catheters is presented. This method, although reserved for special cases, is an adequate alternative treatment as it allows efficient long-term drainage of kidneys without aggressive surgical dissection of ureters.

Prolapsed ureterocele

Although rare, the prolapsed ureterocele constitutes a urologic emergency that can rapidly evolve to severe conditions due to congestion and necrosis, and to obstruction of the urinary tract. A simple external resection resolves the emergency, allowing a postoperative investigation of the whole urinary tract to be performed, in order to adequately prepare urinary reconstruction.

Steroid therapy in idiopathic retroperitoneal fibrosis: report of two successful cases

We report 2 patients in whom regression of ureteral obstruction due to recurrent idiopathic retroperitoneal fibrosis was obtained with steroids. Steroids are a valid alternative to surgery in the initial treatment of biopsy-proven benign (idiopathic) retroperitoneal fibrosis.

Vesical haemangioma. Report of two cases

Two cases of vesical haemangioma and a review of the literature are presented. In one of the cases association with cutaneous "Blue Rubber Bleb Nevus" has been found. Vesical haemangioma is a benign tumour, probably of congenital origin, that occurs in young patients. The first symptom is generally haematuria, and diagnosis is confirmed by cystoscopy. The treatment of choice is partial cystectomy, and the most common histologic form is cavernous haemangioma.

Keratinizing squamous metaplasia of the upper urinary tract

We report a case of squamous keratinizing metaplasia of the upper urinary tract. This benign pathology is very rare and difficult do differentiate from other space occupying lesions of the upper urinary tract. Its aetiopathogenesis is still not well understood, but whenever early diagnosis is made, conservative treatment can be employed.

Ureteral endometriosis

The authors present two cases of ureteral endometriosis. Urinary tract endometriosis has been frequently described affecting mainly the bladder. In the ureter, it is a rare pathology, of difficult identification. Treatment aims at ureteral disobstruction together with eradication of endometrial foci. This is accomplished by surgical, radiotherapeutic and chemotherapeutic means.

Renovascular hypertension in children

Due to better methods of diagnosis, an increasing number of children with renovascular hypertension are being discovered. The disease itself has variable clinical manifestations, and an adequate laboratorial workup, including arteriography and renin assays, is mandatory in suspected cases. Treatment depends on the prognostic values of the renin assays and surgery cures 80% of the patients, either by nephrectomy or by revascularization techniques. Among these, renal autotransplantation gives better exposure of the operative field, and therefore better results. In most cases, systemic infection seems to be the main cause of the inflammatory reaction within the arterial wall that causes obstruction.

Pelvic neurilemmoma

A rare case of benign pelvic neurilemmoma with bladder infiltration and ureteral obstruction is presented. This neurally originated tumor may occur anywhere in the body, but involvement of the urinary tract is rare. Management depends upon location and other clinical findings, and in this case, since complete removal was impossible, urinary derivation was employed as a palliative treatment.

Cavernospongiosum shunt in management of priapism: is it a reliable method?

The efficiency of cavernospongiosum shunt in the management of priapism was evaluated in 10 patients. Technical details such as the "Z" perineal incision and the opening followed by closure of the contralateral corpus cavernosum, at the time of corpora evacuation, can improve the local exposure and permits a more complete drainage of the corpus cavernosum, but did not improve our results when they were compared with other techniques for treatment of priapism. Penile flaccidity and preservation of sexual potency occurred in 6 (60%) and 5 (50%) patients, respectively, and no surgical complications were observed. Immediate penile flaccidity and regaining of physiologic erection were, however, not complete even in the successfully treated patients. The cavernospongiosum shunt does not seem to represent the definitive form of treating priapism. New knowledge about mechanisms involved in priapism has to be obtained, in order to improve the approach and the prognosis of this disabling condition.

Traumatic rupture of the corpora cavernosa

Treatment of penile fracture, due to the low number of cases, still lacks adequate documentation. The authors present two cases of such pathology, which were treated conservatively, and presented penile deformities in the late follow up. Both conservative and surgical management are discussed; since surgery in these cases has low mortality and clinical treatment can be followed by various sequelae, the authors favour the former, stressing that it is mandatory in cases with urinary obstruction, progressive infiltration of cutaneous laceration.