Effect of Warm Ischemia on Graft Outcome in Laparoscopic Donor Nephrectomy

PURPOSE

To assess the impact of warm ischemia time (WIT) on delayed graft function (DGF), graft loss, and graft function in laparoscopic donor nephrectomy (LDN).

PATIENTS AND METHODS

We prospectively studied 100 kidney recipients from LDN donors from 2001 to 2003. For comparison of graft outcome with different extents of WIT, recipients were divided into three groups: group A received kidneys having 4 to 6 minutes, group B kidneys having >6 to 10 minutes, and group C kidneys having >10 minutes of WIT. The median follow-up was 415 days (range 11-791) days.

RESULTS

The mean kidney WIT was 8.7 minutes (range 4-17 minutes). Graft outcome (DGF, graft loss, and median serum creatinine) was not significantly different in the three groups.

CONCLUSIONS

Different extents of WIT in LDN, within the range of our study, were not associated with an adverse outcome in kidney transplantation.

Living unrelated versus living related kidney transplantation: 20 years' experience with 2155 cases

PURPOSE

To compare the long-term results of kidney transplantation from living unrelated donors (LURDs) with that from living related donors (LRDs).

MATERIALS AND METHODS

From 1984 to 2004, we performed 2155 kidney transplantations of which 374 were from LRDs and 1760 from LURDs. We reviewed and compared the long-term data from these cases.

RESULTS

The LURD group included 64.2% men with an overall mean age of 33.46 +/- 14.61 (range 3 to 76) years. Laparoscopic donor nephrectomy was performed in 329 cases (18.7%) with mean follow-up of 45.68 +/- 46.80 months. The LRD group included 66.5% of male recipients with overall mean age of 28.97 +/- 9.58 (range 9 to 65) years. Laparoscopic donor nephrectomy was performed in 12 cases (3.2%) of LRDs with mean follow-up of 81.15 +/- 67.03 months. One-, 3-, 5-, 10-, and 15-year graft survivals among LRDs were 91.6%, 81.7%, 76.4%, 64.4%, and 48.4%; and for LURDs, 91.5%, 86.7%, 81.4%, 68.2%, and 53.2%, respectively (P = .07). Patient survivals for 1, 3, 5, 10, and 15 years in LRDs were 94.6%, 91.9%, 83%, 79.5%, and 73.9%, and in LURDs were 93.6%, 91.7%, 89.3%, 84%, and 76.4%, respectively (P = .14).

CONCLUSION

The results of living unrelated kidney transplantation upon long-term follow-up with a large number of cases were as good as living related kidney transplantation. The organ shortage can be alleviated by using living unrelated kidney transplantation. To our knowledge this is the largest experience with long-term follow-up reported from one center to date.

Laparoscopic Pyelopyelostomy for Retrocaval Ureter Without Excision of the Retrocaval Segment: First Report of 6 Cases

PURPOSE

We report our series of 6 cases of retrocaval ureter that were successfully treated with a laparoscopic approach.

MATERIALS AND METHODS

Three men and 3 women with a mean age of 31 years (range 16 to 50) were referred to our department with a diagnosis of retrocaval ureter. One patient had a 12 mm renal pelvic calculus. A transperitoneal laparoscopic approach was used in all cases. The retrocaval segment along with some of the more proximal and distal segments of the ureter was readily mobilized. The distal part of the dilated renal pelvis was transected and the divided distal segment was repositioned to lie anterior to the inferior vena cava. The renal pelvic stone in 1 patient was readily removed at this point. Re-anastomosis was then performed over a Double-J stent placed intraoperatively using 2 rows of running 4-zero polyglactin sutures with intracorporeal knot tying. The stent was removed 4 weeks later. Excretory urography was performed 3 months after the laparoscopic procedure.

RESULTS

Mean operative duration was 180 minutes (range 150 to 210). Patients were discharged home at a mean of 4 days (range 3 to 5). Followup excretory urogram 3 months after laparoscopic repair revealed a widely patent anastomosis with considerable improvement in hydronephrosis in all patients.

CONCLUSIONS

To our knowledge this is the largest series of laparoscopic repair of retrocaval ureter reported to date. Laparoscopic pyelopyelostomy for retrocaval ureter without excision of the retrocaval segment is associated with an excellent outcome, minimal postoperative morbidity, short hospital stay and highly satisfactory cosmetic results.

Does Pre-Transplantation Antireflux Surgery Eliminate Post-Renal Transplantation Pyelonephritis in Children?

PURPOSE

Antireflux surgery for VUR before renal transplantation decreases the risk of post-kidney transplant UTI in pediatric patients with primary vesicoureteral reflux. We studied the risk of post-kidney transplant UTI in patients with or without surgical correction of VUR before transplantation compared to patients without VUR.

MATERIALS AND METHODS

We compared 12 patients who had VUR corrected before transplantation (group 1) to 17 patients with VUR who did not undergo antireflux surgery before transplantation (group 2) and 36 patients undergoing renal transplantation without VUR (group 3). A total of 10 patients in group 1 (83.3%) and 10 in group 2 (58.8%) had high grade VUR.

RESULTS

Eight patients in group 1 (66.7%), 6 in group 2 (35.3%) and 33 in group 3 (91.7%) remained free of febrile UTI during followup (p = 0.00). Among patients with high grade VUR 6 in group 1 and 1 in group 2 remained UTI-free (p = 0.02). A total of 33 patients in the control group (91.7%) remained free of febrile UTI, an incidence that was significantly lower compared to group 1 (p = 0.03) and group 2 (p = 0.00). Of the patients with high grade VUR 3 in group 1 (30%) and 4 in group 2 (40%) experienced recurrent febrile UTIs (p = 0.64).

CONCLUSIONS

Even after surgical correction of VUR before transplantation the frequency of febrile UTI remained higher than that in kidney transplant recipients without VUR. In cases of high grade VUR reimplantation before renal transplantation decreased the rate of febrile UTI but it was still higher than the level of risk in the control group.

Pedicular Vascular Control in Laparoscopic Living Donor Nephrectomy: The Use of Clips Instead of Stapler in 341 Donors

PURPOSE

To demonstrate a less expensive approach for laparoscopic donor nephrectomy.

MATERIALS AND METHODS

Left donor nephrectomy was done transperitoneally in flank position. Renal vein and artery were exposed and prepared for nephrectomy. Nondisposable trocars and instruments were used. The adrenal vein was clipped and its arteries were bipolar coagulated. Both renal artery and vein were clip-ligated using three medium large nonautomatic metallic clips and divided, instead of using rather expensive vascular endostapler. Kidney was hand-extracted from suprapubic incision (no Endobag was used).

RESULTS

Donor nephrectomy was performed in 341 donors. Mean warm ischemia time was 8.17 minutes. Mean operative time was 260.3 minutes. Conversion and reoperation was required in 2.1% and 3.8% of donors, respectively. Ureteral complications were observed in 2.1% of recipients. No vascular accident occurred from pedicular vessels. One-year graft survival in recipients was 92.6%. By this approach, at least $600 was saved in each nephrectomy.

CONCLUSION

Laparoscopic donor nephrectomy can be performed with a less expensive setup without adverse effects on graft outcome. Vascular control using nonautomatic clips instead of more costly vascular endostapler and also hand extraction of the kidney is safe, practical, and economical.

Kidney retransplantation in comparison with first kidney transplantation

INTRODUCTION

The aim of this study was to depict the outcome of second and third kidney allografts in comparison with first kidney allografts.

METHODS

Among 2150 kidney transplantations are 103 second and 5 third transplantations. Demographic characteristics and survivals of retransplanted patients were compared with a randomly selected group of first kidney recipients, consisting of two cases matched with each retransplanted patient for age, gender, and date of transplantation.

RESULTS

Retransplanted patients consisted of 78 men and 30 women of mean age 32.63 +/- 11.92 years. They had received kidneys from 91 living-unrelated and 17 living-related donors. Median followup was 27 months. One-, 2-, 3-, and 5-year graft survivals were 81.4%, 78.9%, 78.9%, and 73.7% among retransplants, versus 92.9%, 91.5%, 89.8%, and 85.3% in the control group, respectively (P = .0037). Patient survival was 96%, 94.6%, 92.4%, and 87.8% in the retransplant group versus 93.1%, 92.4%, 90.9%, 87.4% in the control group, respectively (P = .63). Also, graft survivals were slightly lower in female compared to male retransplant patients (P = .09). No significant difference in survival rates was seen in different age groups.

CONCLUSION

It seems that kidney retransplantation can yield desirable outcomes, albeit relatively lower graft survivals.

Concomitant nephrectomy of massively enlarged kidneys and renal transplantation in autosomal dominant polycystic kidney disease

OBJECTIVES

We compared perioperative and intraoperative data of patients with end-stage renal disease (ESRD) due to autosomal dominant polycystic kidney disease (ADPKD) who received a renal allograft without native nephrectomy with ADPKD patients who underwent concomitant native nephrectomy of massively enlarged kidneys and renal transplantation to determine whether the latter approach is reasonable and safe.

PATIENTS AND METHODS

From January 1987 to December 2003, 13 patients with ESRD due to ADPKD were stratified as 6 patients who underwent bilateral and 7 patients who underwent unilateral native nephrectomy in conjunction with renal transplantation (group A), versus 20 patients with ESRD due to ADPKD underwent renal transplantation without native nephrectomy (group B). Operative time, need for intraoperative transfusion, time to oral intake, duration of hospital stay, serum creatinine level on the day of discharge, readmission rate, and postoperative complications were compared for both groups.

RESULTS

Mean intraoperative duration was significantly longer for patients in group A, but there was no statistically significant difference in the findings between both groups.

CONCLUSIONS

Concomitant native nephrectomy of massively enlarged kidneys at the time of renal transplantation is reasonable and safe for patients with ESRD due to ADPKD.

Laparoscopic Management of Ureteropelvic Junction Obstruction by Division of Anterior Crossing Vein and Cephalad Relocation of Anterior Crossing Artery

PURPOSE

We report our experience with laparoscopic management of ureteropelvic junction (UPJ) obstruction by division of the anterior crossing vein and cephalad relocation of the anterior crossing artery.

PATIENTS AND METHODS

We used this laparoscopic approach in four male and six female patients with UPJ obstruction associated with anterior crossing vessels. The mean age of the patients was 31.9 years (range 14-59 years). The obstruction was present on the right side in four and on the left side in six patients. Using a transperitoneal approach, the crossing vein was divided, while the crossing artery was preserved, relocated cephalad, and fixed to the peripelvic tissues with metal clips or sutures. Because a grossly normal appearance of the UPJ and upper ureter together with proper pyeloureteral peristalsis and complete renal pelvic emptying were observed intraoperatively, dismembered pyeloplasty was not performed in any of these patients. Diuretic renography and intravenous urography were performed 3, 6, and 12 months postoperatively.

RESULTS

The mean operative duration was 140 minutes (range 100-170 minutes). The mean hospital stay was 2.9 days (range 2-5 days), and the mean follow-up was 9.1 months (range 3-22 months). Diuretic renography revealed absence of obstruction in all patients, and intravenous urography showed considerable improvement of the hydronephrosis.

CONCLUSION

Select cases of UPJ obstruction associated with anterior crossing vessels seem to be amenable to laparoscopic management by division of the crossing vein and cephalad relocation of the crossing artery. Laparoscopy as a minimally invasive approach may offer a better opportunity to evaluate the role of anterior crossing vessels in UPJ obstruction.

Renal Allograft Accumulation of Technetium-99m Sulfur Colloid as a Predictor of Graft Rejection

Differentiation between rejection (the most common cause) and many other possibilities for detrimental effects on graft function represents a difficult issue to diagnose the cause of renal allograft dysfunction. This study was designed to determine whether technetium-99m sulfur colloid (TSC) accumulation predicted graft rejection. We prospectively studied 54 episodes of allograft dysfunction in 53 kidney transplant recipients who underwent TSC scintiscanning and graft biopsy. Visual analysis of TSC uptake compared uptake, in the allograft with that in the marrow of the fifth lumbar vertebra (L5). A 3+ result meant that allograft uptake was greater than L5 marrow uptake; 2+, the same; 1+, less and finally 0, no allograft uptake. Transplant accumulation of 2+ or more was considered consistent with rejection (P = .01). Allograft biopsies interpreted based on the Banff Working Classification showed rejection in 45 of 54 renal biopsies with 42 the biopsy-proven rejection episodes showing at least 2+ graft uptake. Furthermore, this nuclear medicine technique had a sensitivity of 93.3%, a specificity of 44.4%, a positive predictive value of 89.3%, a negative value of 57.1% and an efficiency of 83.3% for the diagnosis of renal allograft rejection.

Impact of Ramadan Fasting on Renal Allograft Function

Fasting during the holy month of Ramadan is a religious duty for all healthy adult Muslims. They are only allowed to eat and drink between sunset and dawn. This study was designed to find the effect of Ramadan fasting on allograft function. We prospectively studied 19 kidney transplant recipients who voluntarily chose to fast during Ramadan versus 20 matched recipients, who had not fasted for 3 consecutive years. Data were recorded before, during, and after the fasting month. The mean posttransplant periods in the fasting and control groups were 52.6 +/- 30.3 and 56.6 +/- 30.0 months, respectively. A statistical analysis showed no significant changes in serum creatinine concentrations before and after Ramadan 1.07 +/- 0.24 versus 1.08 +/- 0.22 mg/dL (P > .05) and 1.00 +/- 0.24 versus 1.03 +/- 0.28 mg/dL (P > .05) in fasting and control groups, respectively. The results did not show any adverse effects of fasting in recipients with stable renal function. In conclusion, our study suggests that fasting during the month of Ramadan is safe and has no significant harmful effects on kidney transplant recipients with normal renal function.

Preliminary Report of a Nationwide Case-Control Study for Identifying Risk Factors of Tuberculosis Following Renal Transplantation

BACKGROUND

Tuberculosis (TB) is an important infection encountered posttransplantation, especially among patients in developing countries, where there are high incidences of morbidity and mortality.

MATERIALS AND METHODS

One hundred and twenty subjects (1%) from 15 major kidney transplantation centers in Iran from 1984 to 2003 were compared with 440 controls who were matched for operative time, treatment center, and surgical team.

RESULTS

Mean ages of research subjects and controls were 38.6 and 36.6 years (P = .04), respectively. The mean duration of pretransplantation hemodialysis was 29 months (range, 2 to 192 months) in research subjects and 20 months (range, 1 to 180 months) in controls (P = .003). Positive past history of tuberculosis was detected in 4 (3.3%) research subjects and in 7 (1.5%) controls (P = .2). Fifty-two research subjects (43.3%) and 241 controls (54.8%) had pretransplantation purified protein derivative of tuberculin less than 5 mm (P = .02). Mean dosages of initial and maintenance immunosuppressive drugs in research subjects and in controls were not significantly different. Sixty research subjects (50%) and 152 controls (34.5%) had rejection prior to diagnosis of TB (P = .03).

CONCLUSION

To our knowledge, this is the first study that demonstrates an increased risk of posttransplant TB by prolonged duration of pretransplant hemodialysis and number of posttransplant rejection episodes. Further study is needed to clarify these findings specifically with respect to various immunosuppressive regimens.

Laparoscopic Ureteral Resection and Anastomosis for Management of Low-Grade Transitional-Cell Carcinoma

Laparoscopic segmental ureterectomy and ureteroureterostomy was carried out in a patient with a low-grade ureteral tumor. To our knowledge, this approach is the first application of laparoscopic segmental ureterectomy for proximal ureteral tumor.

A comparison between laparoscopic and open pyeloplasty in patients with ureteropelvic junction obstruction

INTRODUCTION

Our aim was to compare clinical and radiological outcomes, complications, and hospital stay in laparoscopic and open pyeloplasty.

MATERIALS AND METHODS

From February 2002 to February 2003, 69 patients with ureteropelvic junction obstruction (UPJO) were assigned into two groups. Thirty-seven patients underwent transperitoneal laparoscopic pyeloplasty and 32 underwent open surgical pyeloplasty. Clinical symptoms were assessed before and after surgery, subjectively. Radiological assessment was also done three months postoperatively.

RESULTS

Mean operative time was 3.2 hours and 2.2 hours in laparoscopic and open pyeloplasty groups, respectively. Intraoperative bleeding was trivial in both groups and no complication or conversion to open surgery occurred. Postoperative complication rates were 24% and 6% in laparoscopic and open pyeloplasty groups, respectively. Mean hospital stay was similar (6.2 days) in the two groups. Mean follow-up was 16.5 months versus 11.4 months. Clinical and radiological success rates were 89% and 83.8% for laparoscopy group versus 96.5% and 87% for open pyeloplasty group. Due to recurrence of stricture, repeated surgery was performed in 4 patients of laparoscopy and 1 of open pyeloplasty groups.

CONCLUSION

Laparoscopic pyeloplasty is a less invasive method with less pain, cosmetic advantages, no long incision, and outcome comparable with open surgery. Hospital stay is also not longer than that in open surgeries. Hence, laparoscopic pyeloplasty can be a substitute for skilled surgeons.

Transcutaneous ultrasound guided nephrolithotomy: the first report from Iran

PURPOSE

To evaluate the safety and efficacy of transcutaneous ultrasound guided nephrolithotomy.

MATERIALS AND METHODS

From December 1999 to December 2000, 12 patients with renal stone were selected for PCNL. Six patients had failed ESWL and the remainder had multiple and large stones in pelvis and lower calyx. Ultrasonography was used in 11 patients during the entrance to the system and dilatation of the tract. Entrance to the system was impossible in one case for which open surgery with dorsal lumbotomy was performed.

RESULTS

The stone was removed by just one session of PCNL in 8 and the residual stone was less than 1 cm in the 3 other cases. Repeated PCNL from the same tract was performed in one case and ESWL was carried out in the other 2 cases. After three months, all of the 11 patients were stone free.

CONCLUSION

It seems that ultrasonography could replace fluoroscopy in patients with dilated collective urinary system and a single large stone in calyx or pelvis.

Laparoscopic adrenalectomy: a report of the first experience in Iran

PURPOSE

To report the first experience in laparoscopic adrenalectomy and to study its efficacy and safety in the treatment of different adrenal diseases.

MATERIALS AND METHODS

From March 1997 to July 2001, 11 patients underwent laparoscopic adrenalectomy through transperitoneal approach, five of whom were males and 6 were females. Their mean age was 35.5 (range 28 to 52) years. Lesion was located on the left side in 6 patients and on the right side in 5. All necessary evaluations were done preoperatively including CT scan, MRI, MIBG scan, and endocrine tests such as ACTH, cortisol, mineralocorticoid, 17-hydroxyprogesterone, and urinary VMA. Three (5, 10, and 12 mm) trocars were used in left laparoscopic adrenalectomy and three or four (12, 10, 5, and 5 mm) trocars were applied in right laparoscopic adrenalectomy. All the patients were followed up for three months with physical examination and paraclinical tests.

RESULTS

Mean operative time (including anesthesia and surgery) was 205+/-65.95 (range 130 to 310) minutes. No significant difference was seen between the operative time in the left side and the right side adrenalectomy (p=0.5). Mean hospitalization was 5.54+/-3.4 (range 3 to 15) days. Mean size of mass was 5.45+/-1.7 (range 2 to 8) cm. Blood transfusion was performed in 2 patients and open surgery was conducted for one because of extensive adhesions. No mortality was reported. During a 3-month follow-up, hormonal tests and blood pressure were normal for all the patients, with no medical treatment being required.

CONCLUSION

Our study demonstrated that transperitoneal laparoscopic adrenalectomy is an effective and safe approach in the treatment of adrenal masses with the least morbidity.

PCNL in the management of lower pole caliceal calculi

INTRODUCTION

Several therapeutic methods are used in the management of lower pole caliceal calculi. This survey has been conducted to evaluate the safety and efficacy of percutaneous nephrolithotomy in the management of lower pole calculi.

MATERIALS AND METHODS

Fifty-five patients, 43 males and 12 females with a mean age of 41.5 (range 11 to 75) years, who had suffered from lower pole caliceal calculi and treated by standard percutaneous nephrolithotomy (PCNL) between 1997 and 2001, were enrolled in this study. The stones were classified as follows: small (less than 25 mm), intermediate (25 to 34 mm) and large (more than 35 mm). Mean follow-up was 6.2 months (range 2 weeks to 34 months).

RESULTS

The stones were completely extracted by one session PCNL in 43 patients (79%). Repeat PCNL was needed in one patient and another method was used for stone extraction in another patient. Regarding the size of stone, 88%, 79%, and 74% of small, intermediate, and large stones were completely extracted, respectively. No major complication was noted.

CONCLUSION

PCNL has high success rate in patients with stones larger than 2 cm and its morbidity would be low, provided that it is performed by skilled surgeons.