Anatomic and Radiologic Study of Renal Avascular Plane (Brödel's Line) and Its Potential Relevance on Percutaneous and Surgical Approaches to the Kidney

Feasibility of Performing Supine Percutaneous Nephrolithotomy for Solitary Renal Pelvic Stones (1.5-3 cm) Under Spinal Anaesthesia: A Single-Centre Study

Introduction Percutaneous nephrolithotomy (PCNL) procedure has evolved over the years and one such evolution has been the introduction of supine PCNL by Valdivia in 1987. This approach offers the added advantage of safe access in patients with compromised cardiovascular and pulmonary function. General anesthesia is the preferred anesthetic technique for PCNL. However, in the last decade, there has been an increase in the usage of regional anesthesia for this procedure. We share our experience of supine PCNL for solitary renal pelvic stones under regional anesthesia. Aim and objective To assess the feasibility, safety, and efficacy of supine PCNL for solitary renal pelvic stones sized 1.5 to 3 cm under spinal anesthesia. Material and methods This was a retrospective record review of 35 patients (21 male) who underwent supine PCNL under regional anesthesia between January 2022 till December 2022 at our institute. All patients had a solitary renal pelvic calculus sized 1.5-3 cm. Intraoperative and postoperative data were analyzed. Results The mean age of patients was 38.5 ± 15 years. The postoperative pain visual analog scale (VAS) score was <5 in 31 (89%) and >5 in 4 (11%) patients. The mean hospital stay was 3.33 ± 0.88 days. Mean fall in hemoglobin level was 0.49 ± 0.43 mg/dL. Postoperatively, mild hematuria occurred in three patients (8.5%) and fever occurred in two (5.7%) patients. There was no injury to adjacent organs in this series. Blood transfusion was required only in one patient. Complete stone clearance was achieved in all patients. Conclusion In experienced hands, supine PCNL under regional anesthesia is a feasible, safe, and effective approach with minimal morbidity.

Common haemostatic techniques used in surgical practice

Intraoperative bleeding can be difficult to manage and is associated with worse patient outcomes. Good intraoperative haemostasis by the surgeon is a key factor in ensuring a bloodless field and reducing intraoperative blood loss. There is a myriad of mechanical, thermal and energy-based techniques available to use, each of which has their own benefits and drawbacks. The decision of which to use will depend on patient and procedural factors as well as the surgeon's preference. This article reviews techniques commonly used in surgical practice to maintain intraoperative haemostasis.

Forensic Implications of Anatomical Education and Surgical Training With Cadavers

Anatomical education and surgical training with cadavers are usually considered an appropriate method of teaching, above all for all surgeons at various levels. Indeed, in such a way they put into practice and exercise a procedure before performing it live, reducing the learning curve in a safe environment and the risks for the patients. Really, up to now it is not clear if the nonuse of the cadavers for anatomical education and surgical training can have also forensic implications. A substantial literature research was used for this review, based on PubMed and Web of Science database. From this review, it is clear that the cadaveric training could be considered mandatory, both for surgeons and for medical students, leading to a series of questions with forensic implications. Indeed, there are many evidences that a cadaver lab can improve the learning curve of a surgeon, above all in the first part of the curve, in which frequent and severe complications are possible. Consequently, a medical responsibility for residents and surgeons which perform a procedure without adequate training could be advised, but also for hospital, that has to guarantee a sufficient training for its surgeons and other specialists through cadaver labs. Surely, this type of training could help to improve the practical skills of surgeons working in small hospitals, where some procedures are rare. Cadaver studies can permit a better evaluation of safety and efficacy of new surgical devices by surgeons, avoiding using patients as ≪guinea pigs≫. Indeed, a legal responsibility for a surgeon and other specialists could exist in the use of a new device without an apparent regulatory oversight. For a good medical practice, the surgeons should communicate to the patient the unsure procedural risks, making sure the patients' full understanding about the novelty of the procedure and that they have used this technique on few, if any, patients before. Cadaver training could represent a shortcut in the standard training process, increasing both the surgeon learning curve and patient confidence. Forensic clinical anatomy can supervise and support all these aspects of the formation and of the use of cadaver training.

Tranexamic acid in patients with complex stones undergoing percutaneous nephrolithotomy: a randomised, double-blinded, placebo-controlled trial

OBJECTIVES

To assess the efficacy and safety of single-dose tranexamic acid on the blood transfusion rate and outcomes of patients with complex kidney stones undergoing percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

In a randomised, double-blinded, placebo-controlled trial, 192 patients with complex kidney stone (Guy's Stone Scores III-IV) were prospectively enrolled and randomised (1:1 ratio) to receive either one dose of tranexamic acid (1 g) or a placebo at the time of anaesthetic induction for PCNL. The primary outcome measure was the occurrence rate of perioperative blood transfusion. The secondary outcome measures included blood loss, operative time, stone-free rate (SFR), and complications. ClinicalTrials.gov identifier: NCT02966236.

RESULTS

The overall risk of receiving a blood transfusion was reduced in the tranexamic acid group (2.2% vs 10.4%; relative risk, 0.21, 95% confidence interval [CI] 0.03-0.76, P = 0.033; number-needed-to-treat: 12). Patients randomised to the tranexamic acid group had a higher immediate and 3-month SFR compared with those in the placebo group (29% vs 14.7%, odds ratio [OR] 2.37, 95% CI 1.15-4.87, P = 0.019, and 46.2% vs 28.1%, OR 2.20, 95% CI 1.20-4.02, P = 0.011, respectively). Faster haemoglobin recovery occurred in patients in the tranexamic acid group (mean, 21.3 days; P = 0.001). No statistical differences were found in operative time and complications between groups.

CONCLUSIONS

Tranexamic acid administration is safe and reduces the need for blood transfusion by five-times in patients with complex kidney stones undergoing PCNL. Moreover, tranexamic acid may contribute to better stone clearance rate and faster haemoglobin recovery without increasing complications. A single dose of tranexamic acid at the time of anaesthetic induction could be considered standard clinical practice for patients with complex kidney stones undergoing PCNL.

Robotic Partial Nephrectomy: Update on Techniques

Surgical techniques for robot-assisted partial nephrectomy are driven by the aims of simplifying the most challenging surgical steps, maximizing functional and oncologic outcomes, and consistently pushing the envelope on possibilities. Over the past several years, we have seen an emergence in not only innovation in surgical technique, and robotic platforms, but integration of a variety of imaging techniques. We believe with developing robotic expertise, practicing urologists will continue to push the envelope in nephron preservation and complication-free recovery.

Integration of anatomical and radiological analysis suggests more segments in the human kidney

An increasing number of observations have called the general scheme of five renal segments into question: anatomists, radiologists, and surgeons have reported discrepancies between Graves's scheme and morphological observations. The aims of the present study are: (1) to assess the correspondence between a virtual and a real vascular cast of the kidney; (2) to analyze the arterial anatomy with reference to the renal segments. Fifteen kidneys were injected with acrylic resins to obtain vascular casts, which were also analyzed by computed tomography. A mean of 6.3 (range 4-8) avascular fissures was found, indicating a mean of 7.3 segments (range 5-9). In the superior and middle territories there was a single segment in 4 (26.7%) and 8 (53.3%) cases, respectively, and there were two segments in 11 (73.3%) and in 7 (46.7%) cases, respectively. In the inferior territory there was a single segment in two cases (13.3%), two segments in nine (60%), and three segments in four (26.7%). A mean segmental volume of 550.5 mm³ was calculated; the posterior (1,030.1 mm³ , 28.9%) and inferior (450.3 mm³ , 24.2%) segments were the largest. More third order branches were identified in the inferior segments than in the other segments (three branches of the inferior segmental artery in 26.6%). According to these data the inferior segment occupies the inferior pole, extending both anteriorly and posteriorly. In conclusion, the high correspondence between a virtual and a real vascular cast permits more segments to be identified than those described by Graves, and the volume of each segment can be calculated. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc.