Evaluarea abordului transperitoneal în nefrectomia pentru rinichi pionefrotic

Introducere Nefrectomiile pentru pionefroză sunt adesea intervenţii chirurgicale lungi şi dificile, cu un număr crescut de complicaţii intraoperatorii potenţiale, necesitând o experienţă chirurgicală deosebită. Procesul inflamator ce cuprinde rinichiul şi grăsimea perirenală, cu perinefrită scleroasă sau sclerolipomatoasă, poate îngloba de asemenea şi vasele pediculului renal, care este adesea retractat. În aceste cazuri, disecţia rinichiului şi ligatura pediculului sunt foarte dificile, cu riscul lezării structurilor învecinate (vena cavă, duoden, colon, ficat, splină, etc), mai ales în cazul abordului chirurgical lombar. Conform experienţei noastre chirurgicale, abordul transperitoneal oferă un acces mult mai bun la rinichi, cu ligaturare a pediculului renal mult mai rapidă şi mai sigură, cu mai puţine complicaţii intraoperatorii. Material şi metodă. Am analizat retrospectiv 51 de nefrectomii transperitoneale succesive pentru pionefroză, efectuate între 1.01.2000. şi 31.12.2005. S-au notat complicaţiile intraoperatorii şi postoperatorii, precum şi durata spitalizării. Tehnica chirurgicală a început cu toracofrenolaparotomia extrapleurală, continuată pe partea dreaptă cu disecţia unghiului hepatic al colonului, mobilizarea duodenului, iar pe partea stângă cu disecţia unghiului splenic al colonului, cu mobilizarea acestuia; mai apoi, se trece la disecţia şi la ligaturarea pediculului renal, cu îndepărtarea în bloc a rinichiului şi a grăsimii perirenale. Rezultate. Vârsta medie a pacienţilor a fost de 58 de ani, iar raportul bărbaţi/femei de 0,8. Nefrectomia dreaptă a fost efectuată în 41 de cazuri (80,4%), iar durata medie a intervenţiei a fost de 70 de minute. Complicaţiile intraoperatorii au fost reprezentate de: deschiderea accidentală a pleurei (3 cazuri), lezarea accidentală a splinei (1 caz) şi de deschiderea accidentală a rinichiului pionefrotic în cursul disecţiei (3 cazuri); nu s-au notat cazuri de lezare accidentală a venei cave. Principalele complicaţii postoperatorii au fost: suprainfecţia plăgii (4 cazuri), febră peste 38oC (4 cazuri). Durata medie a spitalizării postoperatorii a fost de 7,1 zile, fără a se consemna nici un deces. Concluzii. După părerea noastră, abordul transperitoneal este prima opţiune în chirurgia deschisă a rinichiului pionefrotic, fiind superior abordului lombar din următoarele motive: 1. intervenţia chirirgicală este mai scurtă şi mai uşoară, fiind create condiţii intraoperatorii ideale, în cazuri, de obicei, dificile; 2. deschiderea intraoperatorie accidentală a rinichiului pionefrotic este foarte rară şi, în general, uşor de tratat, prin lavaj intraperitoneal cu ser fiziologic şi drenaj postoperator; 3. incidenţa leziunilor structurilor anatomice adiacente este mult mai scăzută comparativ cu abordul lombar; 4. chiar dacă cicatricea postoperatorie este mai mare, durata refacerii şi reintegrării sociale şi profesionale este comparabilă cu cele din abordul lombar

Acute Acalculous Cholecystitis Associated with Abscesses—An Unknown Dual Pathology

(1) Introduction and Aims: Little is known about the relationship between renal pathology and gallbladder pathology, although the two organs (the gallbladder and the right kidney) are in close proximity to one another. If a renal abscess disseminates, the gallbladder would be one of the secondary organs involved. As the bile provides a favorable environment for the development of pathogenic germs, it allows for the development of acute cholecystitis, even if calculi are absent, thus resulting in the development of acute acalculous cholecystitis. The aim of our study was to analyze the association between acute acalculous cholecystitis (AAC) and renal abscesses. (2) Methods: A department-wide retrospective cohort observational study including 67 patients with renal abscesses, with a mean age of 34.5+/−16.21 years and with five males and 62 females, was conducted. All of the patients were examined by an abdominal ultrasound. The lab tests included CBC with differential liver enzymes and serum bilirubin (in order to assess alterations in the liver function which can be associated with AAC) and serum creatinine (in order to assess the renal function). Blood culture and urine culture tests were also performed. (3) Results: Of the 67 patients with renal abscesses, eight (11.94%) were associated with acute cholecystitis: four cases (5.97%) of acalculous cholecystitis and four cases (5.97%) of calculous cholecystitis, two of which presented biliary sludge (acute micro-calculous cholecystitis). All four cases of acute acalculous cholecystitis presented with sepsis, and there was one case of septic shock at onset. We did not observe an impairment in renal function in the patients presenting with acute acalculous cholecystitis, and hepatic impairment was inconstant and moderate. All of the cases had a favorable outcome after a prompt initiation of intensive antibiotic therapy; both the renal abscess and the acute acalculous cholecystitis receded without further complications. (4) Conclusions: The association of acute acalculous cholecystitis with renal abscesses could be related to the possibility of germ dissemination from the infectious focus. In the case of a renal abscess, careful clinical, lab, and imaging exams of the gallbladder are recommended in order to ensure early therapeutic intervention in the event of an association with acute acalculous cholecystitis

Management of single large nonstaghorn renal stones in the CROES PCNL global study

Purpose: We compared stone characteristics and outcomes in patients with a single large nonstaghorn renal calculus treated with percutaneous nephrolithotomy in the Clinical Research Office of Endourological Society global study. Materials and Methods: Two statistical analyses were done, including one comparing renal stone size (20 to 30, 31 to 40 and 41 to 60 mm) and the other comparing renal stone site (pelvis, or upper, mid or lower calyx). Surgical outcomes, including operative time, hospital stay, stone-free rate and postoperative fever, were compared between groups. Fitness for surgery was assessed using the American Society of Anesthesiologists scoring system. Severity of postoperative complications was graded with the modified Clavien classification. Results: Of 1,448 stones 1,202 (83%) were 20 to 30 mm, 202 (14%) were 31 to 40 mm and 44 (3%) were 41 to 60 mm. Of the large stones 73% were located in the renal pelvis. A statistically significantly lower stone-free rate, and higher postoperative fever and blood transfusion rates were seen with increased calculous size. With increased American Society of Anesthesiologists score the proportion of large stones in the calyces increased. At a score of III the proportion of large stones in the calyces was more than twice that of stones in the renal pelvis (13.5% vs 5.7%). Generally more patients with large calyceal than large pelvic stones had postoperative complications across the range of Clavien scores from I to IIIB. Conclusions: Calyceal site was associated with decreased fitness for surgery and an increased risk of postoperative complications compared to renal site. An increase in stone size results in a lower stone-free rate, and higher rates of postoperative fever and blood transfusio