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Robles-Torres JI, García-Chairez LR, Castellani D, Enrriquez-Ávila JV, Monzón-Falconi JF, Esqueda-Mendoza A, Flores-Tapia JP, Wroclawski ML, Duarte-Santos HO, Ragoori D, Gadzhiev N, Mahajan A, Kumar S, Farooq M, Ganpule A, Tanidir Y, Maheshwari PN, Gite VA, Sinha MM, Somani BK, Gutiérrez-González A, Gauhar V. Perioperative outcomes and risk factors for major complications associated with nephrectomy for Xanthogranulomatous pyelonephritis: a multicenter study. World J Urol 2023; 41:2905-2914. [PMID: 37171477 DOI: 10.1007/s00345-023-04415-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/28/2023] [Indexed: 05/13/2023] Open
Abstract
PURPOSE To determine the risk factors associated with major complications in patients with histologically confirmed Xanthogranulomatous pyelonephritis (XGP) who underwent nephrectomy. METHODS A multicenter retrospective study was performed including patients who underwent nephrectomy between 2018 and 2022 with histopathological diagnosis of XGP. Clinical and laboratory parameters at the initial presentation were evaluated. Data on extension of XGP was recorded as per the Malek clinical-radiological classification. Characteristics of nephrectomy and perioperative outcomes were obtained. The primary outcome was major complications, defined as a CD ≥ grade 3 and the need for intensive care unit (ICU) admission. Secondary outcomes included the comparison of complications evaluating the nephrectomy approach (transperitoneal, retroperitoneal, and laparoscopic). A sub-analysis stratifying patients who needed ICU admission and Malek classification was performed. RESULTS A total of 403 patients from 10 centers were included. Major complications were reported in 98 cases (24.3%), and organ injuries were reported in 58 patients (14.4%), being vascular injuries the most frequent (6.2%). Mortality was reported in 5 cases (1.2%). A quick Sepsis-related Organ Failure Assessment (qSOFA) score ≥ 2, increased creatinine, paranephric extension of disease (Malek stage 3), a positive urine culture, and retroperitoneal approach were independent factors associated with major complications. CONCLUSION Counseling patients on factors associated with higher surgical complications is quintessential when managing this disease. Clinical-radiological staging, such as the Malek classification may predict the risk of major complications in patients with XGP who will undergo nephrectomy. A transperitoneal open approach may be the next best option when laparoscopic approach is not feasible.
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Affiliation(s)
| | | | - Daniele Castellani
- Urology Unit Azienda Ospedaliero-Universitaria Delle Marche, Ancona, Italy
| | | | | | | | | | - Marcelo Langer Wroclawski
- Faculdade de Medicina Do ABC, Santo André, São Paulo, SP, Brazil
- BP - a Beneficência Postuguesa de São Paulo, São Paulo, SP, Brazil
| | | | - Deepak Ragoori
- Asian Institute of Nephrology and Urology, Hyderabad, Telangana, India
| | - Nariman Gadzhiev
- Saint Petersburg State University Hospital, St. Petersburg, Russia
| | - Abhay Mahajan
- Mahatma Gandhi Mission's Medical College and Hospital, Aurangabad, India
| | - Santosh Kumar
- Department Urology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mudasir Farooq
- Department Urology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Arvind Ganpule
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Yiloren Tanidir
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey
| | | | | | - Mriganka Mani Sinha
- University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Bhaskar K Somani
- University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
| | | | - Vineet Gauhar
- Ng Teng Fong General Hospital (NTFGH)/NUHS, Singapore, Singapore
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Harley F, Wei G, O'Callaghan M, Wong LM, Hennessey D, Kinnear N. Xanthogranulomatous pyelonephritis: a systematic review of treatment and mortality in more than 1000 cases. BJU Int 2023; 131:395-407. [PMID: 35993745 DOI: 10.1111/bju.15878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To systematically review the current demographics, treatment and mortality rate associated with xanthogranulomatous pyelonephritis (XGP) and to test the hypothesis that the weighted pooled peri-operative mortality rate will be <10%. METHODS Searches were performed of the Cochrane, Embase and Medline databases and the grey literature for studies published during the period 1 January 2000 to 30 August 2021. Eligible studies reported cohorts of ≥10 predominantly adult patients with XGP and described either average patient age or mortality rate. RESULTS In total, 40 eligible studies were identified, representing 1139 patients with XGP. There were 18 deaths, with a weighted pooled peri-operative mortality rate of 1436 per 100 000 patients. The mean age was 49 years, 70% of patients were female and 28% had diabetes mellitus. The left kidney was more commonly affected (60%). Four patients had bilateral XGP, and all of whom survived. Renal or ureteric stones were present in 69% of patients, including 48% with staghorn calculi. Urine culture was positive in 59% of cases. Fistulae were present in 8%. Correct preoperative diagnosis occurred in only 45% of patients. Standard treatment continues to comprise a short cause of antibiotics and open radical (total) nephrectomy. Preoperative decompression occurred in 56% of patients. When considered at all, laparoscopic nephrectomy was performed in 34% of patients. Partial nephrectomy was conducted in 2% of patients. CONCLUSIONS Xanthogranulomatous pyelonephritis has a lower mortality rate than historically reported. A typical patient is a woman in her fifth or sixth decade of life with urolithiasis. While open radical nephrectomy remains the most common treatment method, laparoscopic, and to a lesser degree partial nephrectomy, are feasible in well selected patients.
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Affiliation(s)
- Frances Harley
- Department of Urology, Western Health, Melbourne, Vic., Australia
| | - Gavin Wei
- Department of Urology, Austin Health, Melbourne, Vic., Australia
| | - Michael O'Callaghan
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Urology Unit, Flinders Medical Centre, Adelaide, SA, Australia
- Flinders University, Adelaide, SA, Australia
| | - Lih-Ming Wong
- St. Vincent's Hospital Melbourne, Melbourne, Vic., Australia
| | - Derek Hennessey
- Department of Urology, Mercy University Hospital, Cork, Ireland
| | - Ned Kinnear
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- St. Vincent's Hospital Melbourne, Melbourne, Vic., Australia
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Tsao SH, Wang CH, Juang HH, Lin YH, Yang PS, Chang PL, Chen CL, Hou CP. Surgery for Xanthogranulomatous Pyelonephritis: A Comparison of Midline Transperitoneal and Flank Retroperitoneal Laparotomy Approaches to Nephrectomy. J Clin Med 2022; 11:jcm11154476. [PMID: 35956092 PMCID: PMC9369389 DOI: 10.3390/jcm11154476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/29/2022] [Accepted: 07/29/2022] [Indexed: 02/01/2023] Open
Abstract
Xanthogranulomatous pyelonephritis (XGP) is a rare inflammatory disease often associated with high morbidity and mortality. Whether the midline transperitoneal or the flank retroperitoneal approach is superior remains unknown. We searched through pathology databases and reviewed 86 patients with an XGP diagnosis from 2000 to 2021 at our institution. After the patients who did not meet the inclusion criteria were excluded, 35 patients who had undergone nephrectomy through the midline transperitoneal or the flank retroperitoneal laparotomy approach were recruited. Nine (25.71%) of the thirty-five patients underwent nephrectomy through a midline approach, whereas twenty-six (74.29%) received a flank approach. Patients in the midline approach group had a longer surgical time (p = 0.03) than those in the flank approach group. In addition, patients in the flank approach group took less time after surgery to resume oral intake than those in the midline approach group (p = 0.01). No significant differences in the rates of intraoperative and postoperative complications such as peritonitis or intraabdominal infection were observed between the groups. For the patients with XGP who are good candidates for surgery, nephrectomy is a relatively safe surgical treatment method. Both surgical methods produced favorable surgical outcomes, and the patients who received these methods had similar complication rates.
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Affiliation(s)
- Shu-Han Tsao
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (S.-H.T.); (H.-H.J.); (Y.-H.L.); (P.-S.Y.); (P.-L.C.); (C.-L.C.)
| | - Chien-Ho Wang
- Deartment of Emergency Medicine, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan;
| | - Horng-Heng Juang
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (S.-H.T.); (H.-H.J.); (Y.-H.L.); (P.-S.Y.); (P.-L.C.); (C.-L.C.)
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Anatomy, School of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 333, Taiwan
| | - Yu-Hsiang Lin
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (S.-H.T.); (H.-H.J.); (Y.-H.L.); (P.-S.Y.); (P.-L.C.); (C.-L.C.)
| | - Pei-Shan Yang
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (S.-H.T.); (H.-H.J.); (Y.-H.L.); (P.-S.Y.); (P.-L.C.); (C.-L.C.)
| | - Phei-Lang Chang
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (S.-H.T.); (H.-H.J.); (Y.-H.L.); (P.-S.Y.); (P.-L.C.); (C.-L.C.)
| | - Chien-Lun Chen
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (S.-H.T.); (H.-H.J.); (Y.-H.L.); (P.-S.Y.); (P.-L.C.); (C.-L.C.)
| | - Chen-Pang Hou
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (S.-H.T.); (H.-H.J.); (Y.-H.L.); (P.-S.Y.); (P.-L.C.); (C.-L.C.)
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Healthcare Management, Yuanpei University of Medical Technology, Hsinchu 300, Taiwan
- Correspondence:
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Xanthogranulomatous pyelonephritis: a review and meta-analysis with a focus on management. Int Urol Nephrol 2022; 54:2445-2456. [PMID: 35809205 DOI: 10.1007/s11255-022-03253-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/03/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Xanthogranulomatous pyelonephritis (XGP) is a rare form of pyelonephritis more commonly seen in females and diabetics. Frequently associated with renal tract calculi, it is often difficult to diagnose, as it can clinically and radiologically mimic other disorders. Most cases are treated with antibiotics and nephrectomy. The aim of our review is to summarise and analyse the current evidence focusing on management. METHODS A literature search was conducted to identify papers relating to xanthogranulomatous pyelonephritis in adults. Studies containing ten or more patients with XGP were included for descriptive analysis, and a meta-analyses of cohort studies conducted comparing open and minimally invasive nephrectomy undertaken. Other papers were included for narrative review. RESULTS 52 studies were identified, 20 were included for narrative review and 32 retrospective observational studies containing 868 patients were included for descriptive analysis. 99.8% of patients underwent nephrectomy, about one-third laparoscopically. The most commonly cultured organisms were Escherichia coli and Proteus mirabilis. 60% of patients, where reported, underwent preoperative drainage. Seven studies containing 211 patients were included for meta-analysis which found that postoperative complications, length of stay and transfusion requirements were all significantly reduced in those who underwent minimally invasive surgery. CONCLUSION The mainstay management of XGP is antibiotic therapy and nephrectomy. Some studies highlight a role for preoperative upper urinary tract drainage, but evidence supporting this is limited. We present the first meta-analyses examining operative approach for patients undergoing nephrectomy for XGP. Though limited by the data available, our meta-analysis indicates minimally invasive nephrectomy for XGP provides better postoperative outcomes.
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Chiron P, Savoie PH, Boissier R, Long JA. [Rare emergencies in urology]. Prog Urol 2021; 31:987-1000. [PMID: 34419373 DOI: 10.1016/j.purol.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 07/22/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The aim of this article was to cite rare but sometimes serious emergencies that may be encountered by any urologist during their practice, and to outline the main principles of their management. MATERIAL AND METHOD A systematic review of the literature using PubMed, Embase and Google Scholar was carried out between January 2000 and June 2021. The articles obtained were selected according to their age and type. The original articles, meta-analyses, recommendations and the most recent journal articles published in French and English have been retained. A total of 312 articles were identified and 58 selected from their abstracts. The articles were then analysed exhaustively by the authors, and 24 references were finally selected. RESULTS Several rare emergencies of an infectious nature (xanthogranulomatous pyelonephritis, emphysematous cystitis and pyelonephritis, malacoplasia, hydatiduria), ischemic nature (Fournier's gangrene, penile calciphylaxis), or hemorrhagic nature (hemospermia, hemorrhages of the upper urinary tract or adrenal gland spontaneous hematoma), or at the origin of painful manifestations (spermatic colic, venous thrombosis of the penis), can pose diagnostic and therapeutic difficulties, in the absence of consensus concerning their management. CONCLUSION These pathologies, rare but sometimes serious, must be recognized in order to not delay the treatment and to be able to reduce their morbidity and mortality. Combined with the constant improvement of our diagnostic and therapeutic arsenal, a better knowledge of these rare emergencies will help to preserve the functional and vital prognosis of patients.
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Affiliation(s)
- P Chiron
- Service d'urologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France.
| | - P-H Savoie
- Service d'urologie, hôpital d'instruction des armées Sainte-Anne, 2, boulevard Sainte-Anne, 83000 Toulon, France
| | - R Boissier
- Service de chirurgie urologique et de transplantation rénale, Aix-Marseille université, centre hospitalier universitaire de la Conception, AP-HM, 147, boulevard Baille, 13005 Marseille, France
| | - J-A Long
- Service d'urologie et de la transplantation rénale, centre hospitalier universitaire de Grenoble Alpes, avenue des Maquis du Grésivaudan, 38700 La Tronche, France
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Artiles-Medina A, Laso-García I, Lorca-Álvaro J, Mata-Alcaraz M, Duque-Ruiz G, Hevia-Palacios M, Arias-Funez F, Burgos-Revilla FJ. Xanthogranulomatous pyelonephritis: a focus on microbiological and antibiotic resistance profiles. BMC Urol 2021; 21:56. [PMID: 33827527 PMCID: PMC8026091 DOI: 10.1186/s12894-021-00800-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/17/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Xanthogranulomatous pyelonephritis (XGP) is an inflammatory condition of the kidney and its treatment most often involves a combination of antibiotics and nephrectomy. This study aimed to define the clinical features and management of XGP, focusing on microbiological aspects and antibiotic therapy. METHODS We performed a retrospective study of 27 cases of XGP diagnosed between January 2001 and January 2020 to analyse their clinical and management characteristics. In addition, a literature review was conducted of XGP case series covering the period from 2000-2020. We searched PubMed for case series through April 2020 without language restrictions. Studies reporting case series of XGP (more than ten cases) were included if they were relevant to this study. RESULTS Twenty-seven patients were diagnosed with XGP, and 26 of them were histologically proven to have XGP. A total of 81.5% of the patients were female and the mean age was 59.6 years (SD 19.2). The most frequent symptoms were flank pain (70.4%) and fever (59.3%), while 77.8% of patients had renal stones. Proteus mirabilis was detected in the urine culture in 18.5% of patients, followed by detection of Escherichia coli in 14.8% of patients. The computed tomography (CT) findings included perirenal (29.6%) or pararenal (29.6%) involvement in the majority of patients. Twenty-six patients underwent nephrectomy. Piperacillin/tazobactam and ceftriaxone were the most commonly prescribed antibiotics for treatment. The reported piperacillin/tazobactam and ceftriaxone resistance rates were 14.3% and 16.6%, respectively. Twenty-six case series were included in the literature review, reporting 693 cases in total. CONCLUSION We found well-established characteristics of XGP patients among series in terms of previous history, clinical, laboratory and imaging findings, and operative and postoperative outcomes. It is important to know the clinical presentation and potential severity of XGP, as well as the most frequently involved microorganisms and their antibiotic resistance profiles, to select the most appropriate antibiotic therapy.
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Affiliation(s)
- A Artiles-Medina
- Department of Urology, Hospital Universitario Ramón Y Cajal. Instituto Ramón Y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.
| | - I Laso-García
- Department of Urology, Hospital Universitario Ramón Y Cajal. Instituto Ramón Y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - J Lorca-Álvaro
- Department of Urology, Hospital Universitario Ramón Y Cajal. Instituto Ramón Y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - M Mata-Alcaraz
- Department of Urology, Hospital Universitario Ramón Y Cajal. Instituto Ramón Y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - G Duque-Ruiz
- Department of Urology, Hospital Universitario Ramón Y Cajal. Instituto Ramón Y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - M Hevia-Palacios
- Department of Urology, Hospital Universitario Ramón Y Cajal. Instituto Ramón Y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - F Arias-Funez
- Department of Urology, Hospital Universitario Ramón Y Cajal. Instituto Ramón Y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - F J Burgos-Revilla
- Department of Urology, Hospital Universitario Ramón Y Cajal. Instituto Ramón Y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
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Barboza MP, Nottingham CU, Calaway AC, Wei T, Flack CK, Cary C, Boris RS. Xanthogranulomatous pyelonephritis: a comparison of open and minimally-invasive surgical approaches. J Robot Surg 2020; 15:611-617. [PMID: 33000399 DOI: 10.1007/s11701-020-01153-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/25/2020] [Indexed: 11/28/2022]
Abstract
To compare perioperative outcomes between patients undergoing minimally-invasive (MIS) and open surgical approaches for the treatment of Xanthogranulomatous Pyelonephritis (XGP). Between 2007 and 2017 we retrospectively identified 40 patients undergoing nephrectomy at our institution for pathologically confirmed XGP. Patients whose operations were ultimately completed with open technique were analyzed with the open cohort, whereas patients whose operations were completed in entirety using any laparoscopic approach were analyzed with the MIS group. Twenty-three patients were analyzed in the open cohort, compared to seventeen in the MIS group. Three patients in the open cohort were converted intraoperatively from MIS to open approach. Compared to the open group, the MIS group less often had an abscess on preoperative CT (11.8% vs 54.5%; p = 0.006). The MIS group also had lower intraoperative blood loss (100 vs 400 mL; p < 0.001), lower rate of blood transfusion (0% vs 45.5%; p = 0.002), lower postoperative intensive care admission (0% vs 34.8%; p = 0.013), and shorter hospital stay (4 vs 7 days; p = 0.013). However, there was no significant difference in high-grade complications between these groups (5.9% vs 34.8%; p = 0.054). Preoperative CT scan may be an important factor when considering operative approach for treatment of XGP. Patients who are able to undergo MIS approach have less blood loss, shorter hospitalization, and are less likely to require intensive care admission, which may be related to the disease process, the surgical technique, or both.
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Affiliation(s)
- Marcelo Panizzutti Barboza
- Department of Urology, Indiana University School of Medicine, 535 Barnhill Drive, RT 150, Indianapolis, IN, 46202, USA
| | - Charles U Nottingham
- Department of Surgery, Division of Urology, Washington University School of Medicine, 1044 N Mason Road, Suite 230, Creve Coeur, MO, 63141, USA.
| | - Adam C Calaway
- Case Western Reserve School of Medicine, Urology Institute, 11000 Euclid Ave, Lakeside Building, 4th Floor, Cleveland, OH, 44106, USA
| | - Ting Wei
- Department of Urology, Indiana University School of Medicine, 535 Barnhill Drive, RT 150, Indianapolis, IN, 46202, USA
| | - Chandra K Flack
- Department of Urology, Indiana University School of Medicine, 535 Barnhill Drive, RT 150, Indianapolis, IN, 46202, USA
| | - Clint Cary
- Department of Urology, Indiana University School of Medicine, 535 Barnhill Drive, RT 150, Indianapolis, IN, 46202, USA
| | - Ronald S Boris
- Department of Urology, Indiana University School of Medicine, 535 Barnhill Drive, RT 150, Indianapolis, IN, 46202, USA
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8
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Asali M, Tsivian A. Laparoscopic nephrectomy in xanthogranulomatous pyelonephritis. Cent European J Urol 2019; 72:319-323. [PMID: 31720037 PMCID: PMC6830490 DOI: 10.5173/ceju.2019.1891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 07/17/2019] [Accepted: 07/27/2019] [Indexed: 12/31/2022] Open
Abstract
Introduction The aim of this article was to report our experience with laparoscopic and retroperitoneoscopic nephrectomy in patients with xanthogranulomatous (XPG) pyelonephritis. Material and methods Between November 2002 and September 2010, 27 patients, with a mean age of 61.1 years (range 43–85), underwent laparoscopic nephrectomy for a unilateral nonfunctioning kidney, because of xanthogranulomatous pyelonephritis. Patient's data was collected retrospectively and included patient age, gender, intraoperative conversion rate, operative time, estimated blood loss, length of hospital stay, perioperative transfusion rate, renal function pre- and postoperatively and postoperative complications. Results Laparoscopic nephrectomy was successful in 26 patients. It was transperitoneal in 15 patients, retroperitoneal in 11 patients and in one patient the operation was initiated as retroperitoneal and converted to transperitoneal. One conversion to open surgery was needed. The mean operative time was 193.6 minutes (range 123–340). The mean estimated blood loss was 223.5 ml (range 30–1000). The mean hospital stay was 4.8 days (range 3–12). The transfusion rate was 29.6%. Serum creatinine was 1.3 mg/dl the day before and the day after the operation. Major complications occurred in patients (11.1%). Conclusions Laparoscopic nephrectomy should be considered as an initial approach for XGP. The indications for laparoscopic nephrectomy should be extended to these patients.
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Affiliation(s)
- Murad Asali
- Department of Urology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alexander Tsivian
- Department of Urology, E. Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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9
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Peña PA, Torres-Castellanos L, Patiño G, Prada S, Villarraga LG, Fernández N. Minimally invasive nephrectomy for inflammatory renal disease. Asian J Urol 2019; 7:345-350. [PMID: 32995279 PMCID: PMC7499324 DOI: 10.1016/j.ajur.2019.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/02/2019] [Accepted: 04/23/2019] [Indexed: 11/17/2022] Open
Abstract
Objective Once chronic inflammatory renal disease (IRD) develops, it creates a severe peri-fibrotic process, which makes it a relative contraindication for minimally invasive surgery (MIS). Our objective is to show that laparoscopic nephrectomy (LN) is a surgical option in IRD with fewer complications and better outcomes. Methods Retrospective review of patients who underwent a modified-surgical laparoscopic transperitoneal nephrectomy was performed. Data search included all operated patients between May 2013 and May 2018 that had a pathology result with any renal inflammatory condition (xanthogranulomatous pyelonephritis, chronic nephritis, and renal tuberculosis). We describe intra-operative variables such as operative time, blood loss, conversion rate, postoperative complications and length of hospital stay. Results There were 51 patients who underwent laparoscopic nephrectomy with a confirmatory pathology report for IRD. We identified four (8%) major complications; three of them required transfusion and one conversion to open surgery. The mean operative time was 233±108 min. Mean estimated blood loss was 206±242 mL excluding the conversion cases and 281±423 mL including them. The mean length of hospital stay was 3.0±2.0 days. Conclusion Laparoscopic nephrectomy for IRD can safely be done. It is a reproducible technique with low risks and complication rates. Our experience supports that releasing the kidney first and leaving the hilum for the end is a safe approach when vascular structures are embedded into a single block of inflammatory and scar tissue.
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Affiliation(s)
- Paula Andrea Peña
- Pontificia Universidad Javeriana, School of Medicine, Bogotá D.C., Colombia
| | - Lynda Torres-Castellanos
- Department of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, School of Medicine, Bogotá D.C., Colombia
| | - Germán Patiño
- Division of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá D.C., Colombia
| | - Stefanía Prada
- Department of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, School of Medicine, Bogotá D.C., Colombia
| | - Luis Gabriel Villarraga
- Department of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, School of Medicine, Bogotá D.C., Colombia
| | - Nicolás Fernández
- Division of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, School of Medicine, Bogotá D.C., Colombia.,Department of Urology, Fundación Santa Fe de Bogotá, Colombia.,Division of Urology, Hospital for SickKids, University of Toronto, Toronto, Canada
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10
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Campanario-Pérez R, Sáiz-Marenco R, Amores-Bermúdez J, Arroyo-Maestre JM, Quintero-Gómez V, Ruíz-Rosety E, Fuentes-Curtido M, De Paz-Suárez M, Juárez-Soto Á. Laparoscopic Nephrectomy for the Management of Xanthogranulomatous Pyelonephritis: Still a Challenging Procedure. J Endourol 2018; 32:859-864. [PMID: 30024301 DOI: 10.1089/end.2018.0467] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The aim of the study was to assess the feasibility of laparoscopic nephrectomy (LN) in the treatment of patients with xanthogranulomatous pyelonephritis (XGP). METHODS Retrospective review of medical records of 17 patients (mean age 60.0 ± 13.3 years) who underwent LN by a single surgeon from 2010 to 2018. Sociodemographic and clinical data including diagnosis, presenting clinical features, surgical management, and postoperative course were analyzed. RESULTS LN was successfully performed in 15 (88.2%) patients. Two (12.5%) patients with disseminated disease were electively converted to open nephrectomy (ON) due to failure to progress. Two (11.8%) patients experienced intraoperative complications (grades 3b and 4b). Among patients in whom LN was successfully performed (n = 15), the mean operative time was 198.0 ± 107.1 min and was shorter when no intraoperative complications occurred (169.0 ± 48.1 min). Three (20%) of these patients required transfusions and nine (60.0%) required postoperative pelvic drainage (PD). Six (40%) patients experienced postoperative complications: one grade 1, four grade 2, and one grade 5. Mean hospital stay was 4.4 ± 4.3 days, and 3.4 ± 2.2 for those experiencing manageable or no complications. Among patients without postoperative complications (n = 6), mean hospital stay was shorter when no PD was placed (1.6 vs 2.6 days). CONCLUSION LN is a feasible surgical option in patients with XGP although given the nature of XGP, it is associated with complications-nearly all manageable-which makes it a challenging surgical procedure. Advanced laparoscopic skills and experiences are needed. Dissemination of the disease is associated with the occurrence of more severe complications and conversion to ON. PD placement seems associated with shorter hospital stay.
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Ma L, Yu Y, Ge G, Li G. Laparoscopic nephrectomy outside gerota fascia and En bloc ligation of the renal hilum for management of inflammatory renal diseases. Int Braz J Urol 2018; 44:280-287. [PMID: 29144627 PMCID: PMC6050554 DOI: 10.1590/s1677-5538.ibju.2017.0363] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 08/13/2017] [Indexed: 05/29/2023] Open
Abstract
Objectives This study aims to improve laparoscopic nephrectomy techniques for inflammatory renal diseases (IRD) and to reduce complications. Materials and Methods Thirty-three patients underwent laparoscopic nephrectomy for IRD, with a method of outside Gerota fascia dissection and en-bloc ligation and division of the renal pedicle. Operative time, blood loss, complications, analgesia requirement, post-operative recovery of intestinal function and hospital stay were recorded. The degrees of perinephric adhesion were classified based on the observation during operation and post-operative dissection of the specimen, and the association of different types of adhesion with the difficulty of the procedures was examined. Results Among 33 cases, three were converted to hand-assisted laparoscopy, and one was converted to open surgery. Mean operative time was 99.6±29.2min, and blood loss was 75.2±83.5 mL. Postoperative recovery time of intestinal function was 1.6±0.7 days and average hospital stay was 4.8±1.4 days. By classification and comparison of the perinephric adhesions, whether inflammation extending beyond Gerota fascia or involving renal hilum was found to be not only an important factor influencing the operative time and blood loss, but also the main reason for conversion to hand-assisted laparoscopy or open surgery. Conclusions In laparoscopic nephrectomy, outside Gerota fascia dissection of the kidney and en-bloc ligation of the renal pedicle using EndoGIA could reduce the difficulty of procedure and operative time, with satisfactory safety and reliability. Inflammation and adhesion extending beyond Gerota fascia or involving renal hilum is an important predictor of the difficulty related to laparoscopic nephrectomy for IRD.
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Affiliation(s)
- Liang Ma
- Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yanlan Yu
- Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Guangju Ge
- Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Gonghui Li
- Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
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12
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Zambrano IA, Van Batavia J, Bonzo J, Pawel BR, Long CJ. Xanthogranulomatous Pyelonephritis Manifesting as a Nephrocutaneous Fistula in a 5-Year-Old Female. Urology 2017; 105:24-28. [PMID: 28131924 DOI: 10.1016/j.urology.2017.01.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/14/2017] [Accepted: 01/18/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Ibardo A Zambrano
- Department of Surgery, Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Jason Van Batavia
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jeremy Bonzo
- Department of Surgery, Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Bruce R Pawel
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher J Long
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA
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13
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The role of laparoscopic nephrectomy in pediatric xanthogranulomatous pyelonephritis: a case report. Case Rep Urol 2013; 2013:598950. [PMID: 23533930 PMCID: PMC3600230 DOI: 10.1155/2013/598950] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 01/31/2013] [Indexed: 12/04/2022] Open
Abstract
Xanthogranulomatous pyelonephritis (XGP) is a rare chronic renal infection characterized by the destruction of renal parenchyma. Traditional treatment involves open radical nephrectomy, which is challenging due to the inflammatory process associated with XGP. More recently, laparoscopic nephrectomy has been employed successfully in adult XGP. We present a case of a six-year-old female child with XGP who was successfully treated by laparoscopic nephrectomy with minor complications. Our case demonstrates the safety and feasibility of laparoscopic nephrectomy for childhood XGP, indicating that it should be considered a management option in such cases.
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Shah KJ, Ganpule AP, Kurien A, Muthu V, Sabnis RB, Desai MR. Laparoscopic versus open nephrectomy for xanthogranulomatous pyelonephritis: An outcome analysis. Indian J Urol 2012; 27:470-4. [PMID: 22279311 PMCID: PMC3263213 DOI: 10.4103/0970-1591.91434] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Context: Current literature suggests that laparoscopic nephrectomy (LN) in patients with xanthogranulomatous pyelonephritis (XGP) is associated with high conversion and complication rate. Aims: To report contemporary outcome of patients with XGP, managed with either open nephrectomy (ON) or LN. Settings and Design: In this retrospective study, medical records of 37 patients with histopathologically confirmed XGP from January 2001 to October 2009 were reviewed. Materials and Methods: The clinical presentation, preoperative course, intraoperative findings, postoperative recovery and complications in ON and LN were analyzed. Statistical Analysis: Student's t test was used to perform statistical comparison between the LN and ON groups. Values are expressed as mean ± standard deviation. Results: In 37 patients, 20 underwent ON and 17 underwent LN. One patient in the LN group required conversion. He had ectopic pelvic kidney, and the vascular pedicle could not be identified because of dense adhesions. There were no intraoperative complications. The mean blood loss was 257.5 ± 156.67 ml and 141.18 ± 92.26 ml in ON and LN groups, respectively. Mean hospital stay was 15.45 ± 7.35 days and 9.71 ± 4.55 days in ON and LN groups, respectively. Postoperative complications were classified according to Clavien grading for surgical complications. Grade 2 complications were seen in 40% and 29.4% of patients in ON and LN groups, respectively. One patient in LN required secondary suturing of specimen retrieval site. Conclusions: LN in patients with XGP is often challenging and requires considerable experience in laparoscopy. In properly selected patients, all benefits of minimally invasive surgery can be availed with LN.
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Affiliation(s)
- Kartik J Shah
- Department of Urology, Muljibhai Patel Urology Hospital, Nadiad, Gujarat, India
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15
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Laparoscopic Nephrectomy in Xanthogranulomatous Pyelonephritis: 7-Year Single-surgeon Outcome. Urology 2011; 78:797-801. [DOI: 10.1016/j.urology.2011.05.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 05/05/2011] [Accepted: 05/15/2011] [Indexed: 11/19/2022]
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16
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Valero G, Ortiz F. Peritonitis de causa no intestinal: una rara complicación de nefrectomía laparoscópica. Actas Urol Esp 2010. [DOI: 10.1016/j.acuro.2010.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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17
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Varkarakis I, Chatzidarellis EP, Deliveliotis C. High-Risk Laparoscopic Urologic Surgery. J Endourol 2010; 24:1219-28. [DOI: 10.1089/end.2009.0484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ioannis Varkarakis
- 2nd Department of Urology, Sismanoglion Hospital, Athens Medical School, Athens, Greece
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18
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Xanthogranulomatous pyelonephritis presentation in the ED: a case report. Am J Emerg Med 2009; 27:1175.e1-3. [PMID: 19931791 DOI: 10.1016/j.ajem.2009.01.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 01/24/2009] [Indexed: 11/21/2022] Open
Abstract
Xanthogranulomatous pyelonephritis (XGP) is a slowly progressive, chronic kidney infection. It presents with nonspecific symptoms and is definitively diagnosed by surgical examination. Xanthogranulomatous pyelonephritis must be differentiated in the emergency department (ED) from acutely progressive conditions, such as emphysematous pyelonephritis, which require immediate intervention. Xanthogranulomatous pyelonephritis requires nephrectomy; however, emergent kidney removal is not crucial. The low prevalence and nonspecific presentation of XGP increase the importance of recognizing common risk factors and comorbidities, such as type 2 diabetes, hyperlipidemia, and untreated urinary tract infections. Computed tomography (CT) scan is crucial in XGP assessment and should be obtained quickly upon presentation.
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Guzzo TJ, Bivalacqua TJ, Pierorazio PM, Varkarakis J, Schaeffer EM, Allaf ME. Xanthogranulomatous pyelonephritis: presentation and management in the era of laparoscopy. BJU Int 2009; 104:1265-8. [PMID: 19389010 DOI: 10.1111/j.1464-410x.2009.08547.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report a contemporary series of patients with xanthogranulomatous pyelonephritis (XGP, an inflammatory condition of the kidney that has traditionally been treated with open nephrectomy, ON), managed with either ON or laparoscopic nephrectomy (LN), as early reports suggest that the benefits of LN do not extend to patients with XGP. PATIENTS AND METHODS The medical and procedural records of patients with pathologically confirmed XGP between December 1993 to February 2004 were reviewed retrospectively. During this period, 26 patients (mean age 43.5 years, range 17-85) had surgical management of XGP; information on the mode of presentation, surgical management, hospital course and complications were analysed. RESULTS Twelve (46%) and 14 (54%) patients had ON and LN, respectively. The LN group had significantly lower blood loss (P = 0.002), transfusion rates (P = 0.02), time to resumption of oral intake (P = 0.002) and length of hospital stay (P = 0.002) than the ON group. One (7%) LN was converted to ON due to failure to progress. The overall complication rates between the ON and LN groups were not significantly different (P = 0.95). CONCLUSIONS LN in the setting of XGP is often difficult and requires advanced laparoscopic skills. In highly selected patients this approach can be offered, with acceptable morbidity, allowing for lower blood loss and shorter convalesce times.
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Affiliation(s)
- Thomas J Guzzo
- Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.
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20
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Duarte RJ, Mitre AI, Chambô JL, Arap MA, Srougi M. Laparoscopic nephrectomy outside gerota fascia for management of inflammatory kidney. J Endourol 2008; 22:681-6. [PMID: 18324896 DOI: 10.1089/end.2007.0291] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE A nonfunctioning inflammatory kidney is a challenging surgical condition for urologists. Some investigators recommend open surgery because of the surgical difficulties caused by the inflammatory process, whereas others try to apply the advantages of a "simple" non-hand-assisted laparoscopic approach. We report our experience with simple laparoscopic nephrectomy for inflammatory kidney management. PATIENTS AND METHODS From July 2002 through December 2006, 50 pure laparoscopic nephrectomies were performed for inflammatory kidney (43 because of pyelonephritis, 5 for xanthogranulomatous pyelonephritis (XGP), and 2 for pyonephrosis). Histopathologic analysis was the criterion used for inflammatory kidney diagnosis. Pain or recurrent urinary tract infection associated with a nonfunctioning excluded kidney was the eligibility criterion for the procedure. Preoperatively, all patients underwent complete image and functional renal assessment. Morcellation was used to remove surgical specimens. Conversion index, surgical difficulties, operative time, and postoperative complications were evaluated. RESULTS Conversion was performed in 14 of 50 (28%) patients, including two with XGP and one with pyonephrosis. Adhesions, vascular (two inferior vena cava) lesions, and intestinal lesions (two colon) were the main causes of conversion. Acute pancreatitis developed in one patient, and one patient had a wound infection. Reoperations were unnecessary, and no deaths occurred. CONCLUSION Pure laparoscopic nephrectomy was successful in 72% of patients with inflammatory kidneys. The laparoscopic dissection was useful even in those cases converted to open surgery. This is a high-risk procedure, however, and both surgeon and patient must be aware of that before the decision is made for this approach.
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Affiliation(s)
- Ricardo J Duarte
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.
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21
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Joshi AA, Parashar K, Chandran H. Laparoscopic nephrectomy for xanthogranulomatous pyelonephritis in childhood: the way forward. J Pediatr Urol 2008; 4:203-5. [PMID: 18631926 DOI: 10.1016/j.jpurol.2007.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2007] [Accepted: 11/09/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Xanthogranulomatous pyelonephritis (XGP) is a severe, chronic renal parenchymal infection. Nephrectomy is curative. Open nephrectomy is a well-known operative challenge. We describe successful laparoscopic nephrectomy in three patients with XGP. MATERIALS AND METHODS Case notes and radiology of three patients who underwent laparoscopic nephrectomy for XGP were reviewed. The preoperative presentation, operative details, postoperative recovery and complications were recorded. RESULTS The ages of the three children were 9, 5 and 1.3 years. Retroperitoneoscopy was performed via 3 x 5-mm ports. Creation of retroperitoneal space was easier than anticipated despite the perinephric inflammation. Excellent visualization of renal pedicle was obtained. The renal vessels were divided using the ultrasonic dissector (Sonosurg, Olympus). The kidney was then mobilized and dissected off adjacent structures. It was extracted via a small extension to one of the incisions on each occasion. None of them needed conversion. Average operating time was 3h and 30 min. Histology of XGP was confirmed in all. CONCLUSIONS Laparoscopic nephrectomy has replaced open nephrectomy for most conditions. Preoperatively, it was thought that laparoscopy might be unsuitable because of the involvement of perinephric tissues commonly seen in this condition; however, excellent visualization was achieved enhancing the ease of dissection. Dealing with the pedicle before handling the kidney also proved beneficial, allowing better visualization and safe dissection. Postoperative pain and morbidity were greatly reduced. The cosmetic result was excellent. We recommend the laparoscopic approach for nephrectomy in XGP when expertise is available.
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Affiliation(s)
- A A Joshi
- Birmingham Children's Hospital, Birmingham, UK.
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22
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Role of laparoscopic stone surgery. Urology 2008; 71:578-80. [PMID: 18387386 DOI: 10.1016/j.urology.2007.10.052] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Revised: 08/31/2007] [Accepted: 10/25/2007] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To define the role of laparoscopic stone surgery in current urologic practice. METHODS All cases of laparoscopic surgery for renal calculus disease performed at a single institution during a 2-year period were reviewed. A total of 449 stone-removing procedures were performed by one of us (D.G.A.) during this interval, of which 5 were laparoscopic (1.1%). Of the five laparoscopic procedures, three were pyelolithotomy/pyeloplasty, one was laparoscopic-assisted percutaneous nephrostolithotomy, and one was caliceal diverticular stone removal. RESULTS All 5 patients were rendered stone free, and no patient had perioperative complications. CONCLUSIONS A laparoscopic approach is rarely needed in patients requiring stone removal. However, it can be a safe and effective approach in the management of select patients with complex stone disease.
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23
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Cho HK, Kim DS, Ryu DS, Oh TH, Jeon YS. Retroperitoneal Laparoscopic Nephrectomy for Inflammatory Renal Diseases. Korean J Urol 2008. [DOI: 10.4111/kju.2008.49.2.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Hyun Kee Cho
- Department of Urology, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Doo Sang Kim
- Department of Urology, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Dong Soo Ryu
- Department of Urology, College of Medicine, Sungkyunkwan University College of Medicine, Masan, Korea
| | - Tae Hee Oh
- Department of Urology, College of Medicine, Sungkyunkwan University College of Medicine, Masan, Korea
| | - Youn Soo Jeon
- Department of Urology, College of Medicine, Soonchunhyang University, Cheonan, Korea
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