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PubMed2005

Incidence of adrenal involvement and assessing adrenal function in patients with renal cell carcinoma: is ipsilateral adrenalectomy indispensable during radical nephrectomy?

OBJECTIVE: To determine the value of ipsilateral adrenalectomy with radical nephrectomy, by investigating the clinical aspects of adrenal involvement and adrenocortical function in patients with renal cell carcinoma (RCC). PATIENTS AND METHODS: The demographic, clinical and pathological data of adrenal involvement were reviewed in 247 patients with RCC. To evaluate adrenocortical function, 14 patients (adrenalectomy in eight, adrenal-sparing in six) had a rapid adrenocorticotropic hormone (ACTH) stimulation test before and 2 weeks after surgery. RESULTS: There was adrenal involvement with RCC in seven of the 247 (2.8%) patients (a solitary adrenal metastatic tumour in four and direct extension into the adrenal gland in three). All adrenal involvement was detectable on abdominal computed tomography before surgery, and these patients had a large primary renal tumour of > pT2 and/or distant metastasis. Plasma cortisol levels declined significantly more in response to the rapid ACTH stimulation test in those treated by adrenalectomy than in those with spared adrenal glands at 2 weeks after surgery (P < 0.05), while there was no significant difference between the groups before surgery. CONCLUSIONS: These results suggest that unconditional ipsilateral adrenalectomy with radical nephrectomy for RCC should be avoidable, and thus preserve the reserve of adrenocortical function, as preoperative imaging, especially thin-slice multidetector helical computed tomography, can detect adrenal involvement with RCC in most cases. Unilateral adrenalectomy might cause an irreversible impairment of the reserve of adrenocortical function.

Adrenal Gland Neoplasms↗
PubMed2006

Mini-flank supra-11th rib incision for open partial or radical nephrectomy.

OBJECTIVE: To report our approach to partial (PN) or radical nephrectomy (RN) using a supra-11th mini-flank incision, as the widespread availability of advanced imaging has increased the detection of incidental, lower-stage renal tumours that are generally amenable to resection using smaller incisions. PATIENTS AND METHODS: The study included 167 consecutive patients undergoing PN/RN for renal tumours treated between February 2000 and March 2003 using the supra-11th rib mini-flank approach. Variables analysed were age, gender, nephrectomy type (PN vs RN), operative duration, estimated blood loss (EBL), hospital stay, tumour size and location, pathological stage and histology, perioperative transfusions, and complications. Patients undergoing PN were examined for ischaemia type (cold, warm, none) and duration of renal artery clamping. The interval after surgery to initiate solid diet and discontinue patient-controlled analgesia, and overall pain control, were analysed and compared between PN and RN. RESULTS: In all, 133 patients (80%) underwent PN and 34 (20%) RN, at a median age of 61.7 years. The median operative duration was 2.9 h, the EBL 400 mL, tumour size 3.2 cm and median hospital stay 5 days. At a median follow-up of 18.2 months, there were seven (4%) late complications: six patients had a flank bulge and one had a reducible hernia. Surgical margins were negative in 164 (98%) patients. CONCLUSIONS: The supra-11th rib mini-flank incision offers a practical alternative to traditional open or laparoscopic PN or RN. Using a small (8 cm) incision with no rib resection, this approach affords optimum exposure without compromising cancer control, with excellent cosmetic results and a lower risk of late complications at the wound site.

Adult↗
PubMed2006

Magnetic resonance renal angiography and venography: an analysis of 111 consecutive scans before donor nephrectomy.

OBJECTIVE: To determine the accuracy of magnetic resonance imaging (MRI) renal angiography in predicting vascular anatomy before donor nephrectomy, to determine the significance of missed vessels and to ascertain whether vessels are missed because of technical limitations or errors in interpretation. PATIENTS AND METHODS: In all, 111 consecutive living donations were assessed; the anatomy on MRI before donation was compared with that at nephrectomy. The significance of additional arteries and veins was recorded at the time of donation, with extra vessels either anastomosed or sacrificed. Finally, the scans in which extra vessels had not been identified were re-examined to establish whether these could be identified retrospectively. RESULTS: In all, 93 kidneys had a single renal artery and 18 had two. All lower pole arteries were anastomosed and all upper pole arteries were sacrificed. Nine arteries were identified before surgery (five were to the lower pole), and nine were missed (four to the lower pole). There were 13 kidneys with more than one vein. Four of these were seen on MRI. However, an extra vein was anastomosed in only one case. On review of the imaging, three arteries were missed because of human error and six due to technical limitations. Of the nine missed veins, only three were easily identified retrospectively. Overall, using MRI as a preoperative investigation for the 111 consecutive cases, the surgeon encountered a previously unidentified accessory artery in nine (8%), and this required anastomosis in four (4%). CONCLUSION: MR angiography has the advantage over computed tomography (CT) of having virtually no side-effects, and if the small possibility is accepted of missing extra vessels because of technical limitation or interpretation, it is a good investigation. However, in light of the failure to visualize all arteries transplanted, we have started to use multi-slice (16-channel) CT to see if its improved spatial resolution alters the results.

Adult↗
PubMed2006

Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4-7 cm.

OBJECTIVE: To compare the outcomes of patients who had a elective partial nephrectomy (PN) or radical nephrectomy (RN) for clear cell renal cell carcinoma (RCC) of 4-7 cm. PATIENTS AND METHODS: From March 1998 to July 2004, 45 and 151 patients underwent PN and RN, respectively, for clear cell RCC. A multivariate Cox model was constructed for disease-free survival with adjustment for markers of disease severity, and a propensity-score approach used as a confirmatory analysis. RESULTS: In the PN and RN cohorts the treatment failed in one and 20 patients, respectively; the median follow-up was 21 months. The hazard ratio (95% confidence interval) for PN after adjusting for disease severity was 0.36 (0.05-2.82; P = 0.3). Using planned PN as a predictor (intent-to-treat analysis) the hazard ratio was 1.06 (0.32-3.53; P = 0.9). In the propensity-score model, planned PN was associated with a hazard ratio of 1.75 (0.50-6.14; P = 0.4). The serum creatinine level 3 months after surgery was significantly lower in patients who had PN, with a difference between the means of 0.36 (0.23-0.48; P < 0.001). CONCLUSIONS: Renal function was preserved after PN for 4-7 cm clear cell RCC tumours. When comparing the outcomes of PN and RN it is important to consider the intended operation as an independent variable. There was no clear evidence that PN was associated with worse cancer control, although a continued follow-up of this and other cohorts is warranted.

Carcinoma, Renal Cell↗
PubMed2006

Laparoscopic vs open living donor nephrectomy: a contemporary series from one centre.

OBJECTIVE: To report our experience of laparoscopic living donor nephrectomy (LDN) vs open donor nephrectomy (ODN), as LDN offers potential advantages to the donor and has become a routine procedure for live kidney procurement worldwide. PATIENTS AND METHODS: Between February 2000 and August 2005 we performed 183 donor-recipient operations at our institution (ODN, 83; LDN, 100). We prospectively collected information on all donors and recipients for the same period to audit our experience with the first 100 LDNs. Patients made their operative choice after discussions that included unit experience and published information. We present our findings with the emphasis on donor operative details and early recipient graft outcome. RESULTS: Donor and recipient age, gender, body mass index, human leukocyte antigen mismatches, and vascular anastomotic times did not differ significantly between the groups. There were two conversions to an open operation in the LND group; neither affected recipient-graft outcome. The mean (sd) operative duration was 178 (38) min for the LDN and 159 (34) min for the ODN (P < 0.05). The mean (sd) hospital stay was 4.7 (1.2) days in the LND group and 6.8 (1.5) days in the ODN group (P < 0.05). There was one case of delayed graft function in both groups. Serum creatinine levels at 1, 6 and 12 months after transplantation did not differ significantly between the groups. CONCLUSIONS: Our contemporaneous series shows the safe introduction of a laparoscopic living-donor programme without compromising donor patient safety or allograft outcome.

Adult↗
PubMed1974

Specific supersensitivity of smooth muscle to angiotensin II after nephrectomy.

1 The dose-response curves for angiotensin, 5-hydroxytryptamine and carbachol were obtained on rat uterus and colon excised 24 h after a bilateral nephrectomy or a sham operation.2 There was a shift to the left in the dose-response curves to angiotensin of organs from nephrectomized animals. Dose-response curves to 5-hydroxytryptamine and carbachol were not affected by nephrectomy.3 The interaction of the two competitive antagonists (1-Asn, 5-Ileu, 8-Ala)-angiotensin II and (1-Asn, 5-Ileu, 8-Ileu)-angiotensin II with angiotensin II receptors was tested in control and nephrectomized organs. There was a decrease of the K(I) values in colon muscle after nephrectomy.4 In conclusion, nephrectomy produces a specific supersensitivity to angiotensin that seems to be due to a change in the structure of angiotensin receptors, at least in colon smooth muscle. This increase in sensitivity may be the result of the elimination of a tropic factor that acts on angiotensin receptor sites.

Angiotensin II↗
PubMed1991

Increased endothelin excretion in rats with renal failure induced by partial nephrectomy.

1. Six weeks following partial nephrectomy in rats, significant increases in serum urea nitrogen and serum creatinine concentration and a significant decrease in creatinine clearance were observed. 2. Measurement of systolic blood pressure by tail plethysmography indicated that animals that had undergone partial nephrectomy were hypertensive. 3. Compared to sham-operated animals, there were 4 fold increases in both urinary protein excretion and urinary endothelin excretion. 4. There was a significant correlation between urinary protein and urinary endothelin excretion (r = 0.77). There was also a correlation (r = 0.65) between urinary endothelin excretion and systolic blood pressure. 5. Plasma endothelin concentrations were not different in sham-operated and partially nephrectomized rats. 6. The data indicate that there is an increased renal endothelin production in rats with chronic renal failure.

Animals↗
PubMedDate not supplied

Unilateral nephrectomy in a juvenile llama.

OBJECTIVE: The purpose of this study was to describe the clinical presentation, diagnostic evaluation, and surgical management of a llama with an ectopic ureter. ANIMALS OR SAMPLE POPULATION: Nine-month-old female llama. RESULTS: The diagnostic evaluation included the use of computed tomography and an excretory ureterogram to confirm and identify the location of the ectopic ureter. Surgical management involved a unilateral nephrectomy. CONCLUSIONS AND CLINICAL RELEVANCE: Computed tomography is a valuable asset to diagnose the presence and terminal location of an ectopic ureter in llamas, and nephrectomy appears to be a viable procedure to resolve the subsequent urinary incontinence.

Animals↗
PubMed2005

Laparoscopic live donor nephrectomy: a risk factor for delayed function and rejection in pediatric kidney recipients? A UNOS analysis.

The impact of laparoscopic (vs. open) donor nephrectomy on early graft function and survival in pediatric kidney recipients (< or =18 years) is unknown. We studied 995 pediatric live donor txs reported to UNOS from January 2000 to June 2002, in two recipient age groups: 0-5 years (n = 212, 44% laparoscopic donors [LapD]) and 6-18 years (n = 783, 50% LapD). Delayed graft function (DGF) rates were higher for LapD versus open donor (OpD) txs (0-5 years, 12.8% vs. 2.5% [p = 0.004]; 6-18 years, 5.9% vs. 2.8% [p = 0.03]). Acute rejection incidence for LapD versus OpD txs was higher at 6 months for recipients 0-5 years (18.6% vs. 5.9%, p = 0.01) and 6-18 years (22.5% vs. 15.6%, p = 0.03), and 1 year for recipients 0-5 years (24.3% vs. 7.9%, p = 0.004). In multivariate analyses, significant independent risk factors for rejection at 6 months and 1 year were recipient age 6-18 years, pretx dialysis, LapD nephrectomy and DGF. Graft survival was similar for LapD versus OpD txs. In this retrospective UNOS database analysis, LapD procurement was associated with increased DGF and an independent risk factor for rejection during the first year, particularly for recipients 0-5-years old. Future investigations must confirm these findings and identify strategies to optimize procurement and pediatric recipient outcome.

Adolescent↗
PubMed1985

The effect of nephrectomy and ureter ligation on plasma neurotensin-like immunoreactivity levels in the conscious rat.

The effect of nephrectomy and ureter ligation on the concentration of endogenous plasma neurotensin-like immunoreactivity (p-NTLI) was studied in conscious rats by means of antiserum 17-8201 which detects NT (1-13) only, and antiserum 0-7709 which detects NT(1-13) and NT(1-8). The unstimulated p-NTLI concentration did not change significantly during a 25-h observation period following nephrectomy in comparison with sham operation. However, stimulation of the release of NTLI by intraduodenal administration of oleic acid (0.2 ml) resulted in significantly higher p-NTLI levels in the nephrectomized rats than in the sham operated rats. Ureter ligation did not significantly affect basal or stimulated p-NTLI. The data indicate that the kidneys play an important part in the elimination of p-NTLI released after fat ingestion.

Animals↗
PubMed1981

Kinetics of the disappearance of endogenous plasma renin following nephrectomy in pregnant and non-pregnant rats.

1. Plasma renin concentration was higher in pregnant rats than in non-pregnant female controls (43 +/- 5 vs. 12 +/- 1 ng/ml. per hr); 24 hr post partum, it was 8 +/- 2 ng/ml. per hr. 2. Twenty-four hours after bilateral nephrectomy, plasma renin concentrations in pregnant and non-pregnant rats were not significantly different from zero; the uterine venous minus arterial value in nephrectomized pregnant rts was not significantly different from zero either, and was not increased by haemorrhage. These observations suggest that neither the pregnant uterus nor any other extrarenal site of renin storage contributes to the elevated plasma renin concentration. 3. The disappearance of plasma renin following bilateral nephrectomy was resolved into fast and slow components. The half-time of the slow component, which is considered to reflect the metabolic clearance of renin was significantly higher in pregnant rats than in controls. It is concluded that the plasma renin concentration is elevated, at least in part, because of a decreased metabolic clearance of renin during pregnancy.

Animals↗
PubMed2006

Follow-up of early unilateral nephrectomy for hypertension.

Early unilateral nephrectomy was carried out in four young children with unilateral renovascular disease, a poorly functioning kidney and hypertension. At follow-up 5-16 years later all showed normal growth, blood pressure and renal function, and only one child had low-grade albuminuria. Unilateral nephrectomy seems to be a safe and effective alternative to long-term hypotensive treatment.

Blood Pressure↗
PubMed1968

Results of nephrectomy in hypertension associated with unilateral renal disease.

Nephrectomy has been carried out in 34 patients with hypertension associated with unilateral parenchymal renal disease (28 with unilateral pyelonephritis, 3 tuberculosis, 2 hypoplasia, and 1 adenocarcinoma). In 13 of the patients the blood pressure was corrected, in four it was improved, and in 17 it was unaffected. The intravenous pyelogram (by the infusion technique with nephrotomography if necessary) and renogram give adequate information in most patients with unilateral parenchymal renal disease but may need to be supplemented by aortography, or retrograde pyelography, or divided renal function studies in a few special circumstances. When the function of the damaged kidney is less than 25% of the total (which is well maintained), and the contralateral kidney is intact, nephrectomy is recommended provided the hypertension is significant; success is more likely in younger patients with a short history of hypertension.

Adenocarcinoma↗
PubMed1993

Laparoscopic nephrectomy.

Since the first clinical operation in June 1990 laparoscopic nephrectomy for benign renal disease has become widely accepted. Although the laparoscopic operation takes much longer than open surgery, there are considerable reductions in the length of postoperative hospital stay and the time taken to return to normal activities and to full recovery. Major complications were relatively common in early operations, but with more experience morbidity has been reduced. Laparoscopic nephrectomy for malignant renal disease is still controversial, largely because of the fear of release of malignant tissue into the abdominal cavity during the morcellation and retrieval of the diseased kidney. To prevent this, the kidney is removed intact through a 5-7 cm incision. Long term follow up is needed, however, before we will know whether the laparoscopic procedure is effective in preventing recurrence of cancer. New developments have improved various technical aspects of the operation, but stringent assessment of new techniques is necessary so that the medical community can decide which procedures should become routine practice.

Humans↗
PubMed1972

Changes of blood pressure, renin, and angiotensin after bilateral nephrectomy in patients with chronic renal failure.

Circulating levels of renin, angiotensin I, and angiotensin II were increased in six patients with chronic renal failure and hypertension uncontrolled by dialysis and hypotensive drugs. Lower and often normal levels were found in 10 patients whose blood pressure was controlled by dialysis treatment. For a variety of reasons all patients were subjected to bilateral nephrectomy. The logarithm of the decrease in plasma concentrations of renin and angiotensin II was significantly related to the fall of blood pressure after operation. Plasma renin concentration correlated significantly with blood angiotensin I concentration and with plasma angiotensin II in samples taken before and after nephrectomy. Renin, angiotensin I, and angiotensin II were measurable in samples of blood taken 48 hours or more after the operation.

Adolescent↗
PubMed2006

Assessment of the Cardiff nephrectomy cut-up protocol with total blocking of the renal sinus: effect on tumour staging and practical issues.

AIM: To evaluate the effects on detection of vascular invasion and workload of a new standard dissection protocol for examining nephrectomy specimens for renal cell carcinoma. METHODS: Using 192 consecutive renal cell carcinoma nephrectomy specimens, the incidence of vascular invasion and number of tissue blocks per tumour were compared before and after introduction of the new protocol. RESULTS: The Cardiff protocol increased the percentage of tumours staged as T3b (renal sinus or hilar vein invasion) from 37.7% to 55.7% cases (p<0.001), with an increase from 9.1% to 21.7% of those staged as T3b due to renal sinus vein invasion alone (p<0.01). A small, but significant, permanent increase in workload was observed from an average of 11.7 to 13.4 blocks per case (p<0.001). CONCLUSIONS: This protocol is suitable for use in routine practice to evaluate pathological prognostic determinants important for clinical management, while causing only a small increase in workload.

Carcinoma, Renal Cell↗
PubMed1994

Intracapillary glomerular metastases in a nephrectomy specimen removed for ipsilateral renal cell carcinoma.

A case of intraglomerular metastases observed in a nephrectomy specimen removed for primary renal cell carcinoma is reported. The intraglomerular metastases arose by dissemination of malignant cells into the systemic circulation via invasion of the renal veins. Intraglomerular metastases are therefore an indicator of malignant dissemination which in turn should be associated with a poor prognosis. It is recommended that in nephrectomies undertaken for primary renal cell carcinoma at least one random block of renal cortex should be examined to confirm or exclude intraglomerular metastases.

Carcinoma, Renal Cell↗
PubMed2003

Evaluation of a protocol for examining nephrectomy specimens with renal cell carcinoma.

AIMS: To evaluate the practicality of use and the effectiveness of a standard protocol for examining nephrectomy specimens for renal cell carcinoma (RCC), with emphasis on the identification of vascular invasion. METHODS: A standard protocol, devised to identify the major prognostic determinants, was used to examine 79 consecutive tumours submitted to four histopathology departments. The incidence of vascular invasion found was compared with the incidence in a historical series of tumours. RESULTS: The protocol proved easy to follow, and appeared to increase the incidence of observed vascular invasion (40 of 69 cases compared with 69 of 176 cases in the historical series; p = 0.059, Fishers exact test, one sided) CONCLUSIONS: If pathological prognostic determinants are to be used for clinical management, then it is important that they are identified and recorded consistently. The protocol described provides a method of examining nephrectomy specimens that can be used in routine practice and would probably reliably identify recognised prognostic variables.

Carcinoma, Renal Cell↗