Laparoscopic Management of Adrenal Lesions Larger Than 5 cm in Diameter

Introduction: Laparoscopic adrenalectomy remains a controversial procedure for large tumors. The incidence of adrenocortical carcinoma increases and technical difficulty of adrenalectomy increases as the size increases. We examined the outcome and complications of laparoscopic adrenalectomy for such lesions. Materials and Methods: Twenty-nine patients underwent laparoscopic adrenalectomy, of whom 19 had tumors larger than 5 cm in diameter, having a median tumor size of 7.0 cm. They were compared with patients whose adrenal tumors were smaller than 5 cm. Results: Patients with small tumors (< 5 cm) had a significantly shorter median operative time of 90 minutes as compared to 145 minutes in those with large tumors (> 5 cm). There was no significant difference in the median hemoglobin drop (1.05 g/dL versus 1.30 g/dL), time for starting oral intake (24 hours in both groups) or hospital stay (3.5 days versus 4.0 days) between patients with small and large tumors, respectively. There were no intra-operative complications except for 1 incidence of supraventricular tachycardia in a patient with a large pheochromocytoma. There were no major complications seen in any of the patients and no open conversions. Histopathology of large tumors revealed 16 benign tumors (8 pheochromocytomas, 4 adenomas, 2 ganglioneuromas, 1 pseudocyst, and 1 myelolipoma) and 3 malignancies, of which 1 was primary adrenocortical carcinoma and 2 were metastatic renal cell carcinoma. Conclusion: In experienced hands, laparoscopic adrenalectomy is safe and feasible for large functioning adrenal tumors. Large adrenal tumors suspicious of harboring malignancy with no peri-adrenal involvement can be tackled laparoscopically

Small incision basilic vein transposition technique: A good alternative to standard method

End-stage renal disease is a significant health problem. The primary use of the autogenous arteriovenous access is recommended by NKF-DOQI (National Kidney Foundation-Dialysis Outcomes Quality Initiative) guidelines. Though basilic vein transposition is well established in multiple failed fistulae's and obese patients, it requires large incision and morbidities like edema and infection. To avoid such compilations we, at our institution, adopted a small incision technique using two small 3-4 cm incisions. This method is inspired by videoendoscopic minimally invasive method used to dissect the basilic vein, thus avoiding extensive dissection and related morbidities

Does rejection have a role in lymphocele formation post renal transplantation? A single centre experience

Aim : To assess the relation of acute rejection with respect to lymphocele incidence and determine the effect of lymphocele with graft survival. Methods : The paper is a singlecenter retrospective data review of renal transplant recipients from 1980 to 2007. A total of 1700 patients received kidneys from live donation, and 9 patients received from cadaver donor. The standard transplant technique was performed in all. Lymphocele incidence, demography, relation to rejection episodes, type of immunosuppression, and management options were studied. Univariate analysis was performed to assess the role of rejection to lymphocele formation. Results : 47 (35 males and 12 females) patients had symptomatic lymphocele in the post-transplant period. 51% of the lymphocele patients had history of rejection as compared to overall rejection rate of 20% (P = 0.009). 4 (7.2%) had at least 1 rejection and 19 (40.4%) had more than one rejection episodes. All 47 patients required aspiration. Of the 14 patients who did not settle with a maximum of two aspirations underwent marsupilization (5 open and 9 laparoscopic). 1, 5, and 10 year graft survival of overall transplant recipient and post-transplant lymphocele patients was 86.54%, 82.41% and 76.36% vs. 86.44%, 81.2% and 68.14%, respectively. Conclusion : Acute rejection episodes were associated with statistically increased risk of lymphocele. There was no adverse outcome of graft with lymphocele formation after rejection episodes with respect to the overall graft survival

Donor gonadal vein reconstruction for extension of the transected renal vessels in living renal transplantation

Introduction: Donor gonadal vein is a readily available vascular reconstruction material for vascular reconstruction, for difficult situations, in living related renal transplantation. Vein extension with the gonadal vein has been described as a simple and safe method to elongate renal vein especially in right living donor kidneys. We applied the donor gonadal vein for lacerated accessory renal artery and renal vein reconstruction. Materials and Methods: The donor gonadal vein was used to reconstruct the lacerated accessory renal artery in one patient. The donor gonadal vein was isolated, used as an interposition graft to bridge the gap between transected accessory renal artery and external iliac artery of the recipient. In another patient, gonadal vein was used to reconstruct short right renal vein, which got damaged during retrieval. Results: This technique resulted in a tension-free anastomosis. There were no procedure related complications. The ischemia time remained within acceptable limits and grafts showed excellent outcomes. Conclusions: The use of gonadal vein for renal vascular reconstruction seems to be an acceptable option during living related renal transplantation, lest the need arise, with no increased graft morbidity

Laparoscopic radical nephrectomy versus open radical nephrectomy in T1-T3 renal tumors: An outcome analysis

Aims: To compare laparoscopic radical nephrectomy (LRN) with open radical nephrectomy (ORN) in T1-T3 renal lesions. Materials and Methods: The records of 65 patients who underwent LRN between January 2002 and December 2006 were entered prospectively in a database. The patients were compared with 56 patients who had undergone ORN between January 2000 and December 2005. The two groups were comparable in terms of age, body mass index (BMI) and tumor size. LRN was compared with ORN in terms of operative room time, blood loss, complications , analgesic requirement, hospital stay and start of oral intake. The oncologic efficacy was evaluated in stages T1 and T2 in terms of cancer-free and overall survival. Results: The laparoscopy group had a significantly shorter hospital stay (5.72, range 3-23 days vs. 9.18, range 4-23 days, p value: < 0.0001), analgesia requirement (175.65, range 50-550 mg vs. 236, range 0-1100 mg of tramadol, p value: < 0.03), hemoglobin decline (1.55, range 0.1 to 4.4 mg/dl vs. 2.25, range 0.2 - 7 mg/dL, p value: < 0.001) and hematocrit drop (4.83, range 0.3 - 12.9 vs. 7.06 range 2 -18, p value: < 0.0001). The majority of specimens showed renal cell carcinoma. In the laparoscopy group, 29 tumors were T1 stage, 18 were T2, while eight were T3. In the open surgery group, 25 tumors were T1, 19 were T2 and 12 were T3. The cancer-free survival rate at 24 months for ORN and LRN in T1 lesions was 91.7% and 93.15% respectively and the patient survival rate was 100% in both groups. The cancer-free survival rate at 24 months for ORN and LRN in T2 lesions was 88.9% and 94.1%, respectively and the patient survival was 100% and 94%, respectively. After LRN, there was one instance of port site metastasis, local recurrence and distant metastasis. All recurrences were distant after ORN. Conclusion: Laparoscopic radical nephrectomy has advantages in terms of shorter hospitalization and a lower analgesia requirement. It is feasible and produces effective cancer control in T1 lesions, comparable to that of its open counterpart in T2 and selected cases of T3 lesions

Laparoscopic versus open nephrectomy for xanthogranulomatous pyelonephritis: An outcome analysis

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