Search

Objective: To test the hypothesis that longer warm ischaemia time (WIT) might have a marginal impact on renal functional outcomes and might, in fact, reduce haemorrhagic risk intra‐operatively. Patients and Methods: Data from 1140 patients treated with elective partial nephrectomy (PN) for a cT1‐2 cN0 cM0 renal mass were prospectively collected. WIT was defined as the duration of clamping of the main renal artery with no refrigeration and was tested as a continuous variable. The primary outcome of the study was evaluation of the effect of WIT on renal function (estimated glomerular filtration rate [eGFR]) postoperatively, at 6 months and in the long term (measured between 1 and 5 years after surgery). The secondary outcome of the study was haemorrhagic risk, defined as estimated blood loss (EBL) or peri‐operative transfusions. Multivariable linear, logistic and Cox regression analyses, accounting for age, Charlson comorbidity index, clinical size, preoperative eGFR and year of surgery, were used and the potential nonlinear relationship between WIT and the study outcomes was modelled using restricted cubic splines. Results: A total of 863 patients (76%) underwent PN with WIT and 277 (24%) without. The baseline median eGFR was 87.3 (68.8–99.2) mL/min/1.73m2 for the on‐clamp population and 80.6 (63.2–95.2) mL/min/1.73m2 for the off‐clamp population. The median duration of WIT was 17 (13–21) min. At multivariable analyses predicting renal function, longer WIT was associated with decreased postoperative eGFR (estimate: −0.21, 95% confidence interval [CI] −0.31; −0.11 [P < 0.001]). Conversely, no association between WIT and eGFR was recorded at 6‐month or long‐term follow‐up (all P > 0.8). At multivariable analyses predicting haemorrhagic risk, clampless resection with no ischaemia time and PN with short WIT was associated with an increased EBL (estimate: −21.56, 95% CI −28.33; −14.79 [P < 0.001]) and peri‐operative transfusion rate (estimate: −0.009, 95% CI −0.01; −0.003 [P = 0.002]). No association between WIT and positive surgical margin status was recorded (all P = 0.1). Conclusion: Patients and clinicians should be aware that performing PN with very limited or even with zero WIT might increase bleeding and the need for peri‐operative transfusion while not improving long‐term renal function outcomes. [ABSTRACT FROM AUTHOR]

This article discusses the use of a novel technique called transincisional quadratus lumborum block (QLB) in robotic and laparoscopic renal and adrenal surgery. The QLB is a regional anesthetic block that allows for effective pain management during surgery. The technique involves delivering local anesthetic through the lumbar interfacial triangle to the thoracolumbar fascia, which provides visceral analgesia. The article describes the steps of the procedure and highlights the potential advantages of this technique, including improved efficiency and reduced operating time. However, the article also acknowledges the limitations of the study and the need for further research to compare transincisional QLB with other approaches. [Extracted from the article]

Background: Ultrasound‐guided quadratus lumborum block (QLB) is considered a novel nerve block for postoperative pain control. However, its efficacy after urological surgery remains unclear. Objectives: The purpose of the current meta‐analysis was to evaluate the effects of the QLB block versus control (placebo or no injection) on postoperative pain and other adverse outcomes after urological surgery, providing extensive evidence of whether quadratus lumborum block is suitable for pain management after urological surgery. Study design: Systematic review with meta‐analysis of randomized clinical trials. Methods: We searched PubMed, Cochrane Library, Embase, Web of Science, and ClinicalTrials.gov to collect studies investigating the effects of QLB on analgesia after urological surgery. The primary outcomes included visual analog scale (VAS) at rest and during movement, 24‐h postoperative morphine consumption, and the incidence of postoperative nausea and vomiting (PONV). Results: Overall, 13 randomized controlled trials (RCTs) were reviewed, including 751 patients who underwent urological surgery. The QLB group exhibited a lower VAS score postoperatively at rest or on movement at 0, 6, 12, and 24 h, with less 24‐h postoperative morphine consumption and lower incidence of PONV. Limitations: Although the result is stable, heterogeneity exists in the current research. Conclusions: QLB exhibited a favorable effect of postoperative analgesia with reduced postoperative complications at rest or during movement after urological surgery. However, it is still a novel technology at a primary stage, which needs further research to develop. [ABSTRACT FROM AUTHOR]

Objectives: To explore the comparative effectiveness of partial nephrectomy (PN), radical nephrectomy (RN), ablative therapies (ablation) and active surveillance (AS) for small renal masses (SRMs; tumour diameter ≤4.0 cm) in the domains of survival, renal function and quality of life (QoL) using the prospectively maintained Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) Registry. Patients and Methods: Estimated glomerular filtration rate (eGFR) was calculated from creatinine values to determine renal function. QoL was measured using the Short Form 12 (SF‐12) questionnaire. The Kaplan–Meier method and Cox proportional hazards regression were used for survival analysis. The mixed‐effects model was used for renal function and QoL analysis. Results: Of 638 patients, 231 (36.2%) chose PN, 41 (6.4%) RN, 27 (4.2%) ablation and 339 (53.1%) AS. Cancer‐specific survival at 7 years was 98.8% in PN patients and 100% in all other groups. Overall survival (OS) at 7 years was 87.9%, 90.2%, 83.5% and 66.1% in PN, RN, ablation and AS patients, respectively. The OS rate was significantly worse in the AS group than other groups and likely attributable to older age and increased comorbidities. The eGFR was lowest in RN patients but comparable in all other groups. QoL was lowest in AS patients due to lower physical health scores, but mental health scores were similar in all groups. Conclusions: With excellent oncological outcomes in all groups, nephron‐sparing approaches, like PN and ablation, are preferred over RN when intervention is indicated for SRMs. AS is a reasonable option for select patients, given the comparable oncological and mental health outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVE To critically evaluate the effectiveness of placing nonspecific deep corticomedullary sutures in the setting of major vascular and collecting system injury during laparoscopic partial nephrectomy (LPN). We also aimed to evaluate the incidence of ischaemic injury to the remaining renal remnant because of these sutures, as many laparoscopic centres have adopted this practice. MATERIALS AND METHODS We performed open PN on eight porcine kidneys. Both the artery and vein were clamped. The ureter was transected and tied around an angiocatheter for evaluating collecting system integrity both before and after corticomedullary suturing. The renal artery was cannulated for angiography before and after the corticomedullary suturing. The rate of bleeding was also assessed before and after corticomedullary suturing. RESULTS There was marked arterial bleeding and large collecting system injury induced in all kidneys. Two of the eight renal units continued to have significant arterial bleeding after the deep corticomedullary sutures were placed. All of the eight units had at least a small urinary leak after suturing, with three having medium-to-large leaks. In four of the renal units, there were major segmental vessels occluded by the sutures, as detected by angiography. CONCLUSIONS The practice of placing nonspecific deep corticomedullary sutures, during PN, may not adequately control major vascular and collecting system injury. In addition, segmental vessels supplying remnant renal tissue are often affected; thereby further compromising function because of devascularization. The search for the best technique for LPN continues. [ABSTRACT FROM AUTHOR]

OBJECTIVE To describe our experience of excising the inferior vena cava (IVC) without a graft; en bloc resection of a renal cell carcinoma (RCC) with the renal vein and vena cava tumour thrombus and a segment of the entire abdominal IVC is technically feasible, but traditionally, after resection, attempts are made to restore continuity with the use of synthetic or homologous venous grafts. PATIENTS AND METHODS Between May 1997 and September 2004, 60 patients (mean age 62 years) underwent surgical resection of a renal tumour with a thrombus extending into the IVC. To resect the entire evident tumour, excision of the affected portion of the IVC was required in three patients (5%); the IVC was not reconstructed. RESULTS The three patients were aged 38, 39 and 74 years; the mean operative duration was 5.88 h, the mean (range) estimated blood loss was 833 (500–1000) mL, the mean number of blood units transfused was 3.3 (0–7) units, and the mean follow-up was 24 months. The course after surgery was uneventful; specifically, none of the patients had a venous thrombosis or a pulmonary embolus. CONCLUSIONS RCC has a propensity to invade the renal vein and IVC. Occasionally the thrombus invades the wall of the IVC and complete removal requires excision of a circumferential portion of the IVC; this can be done safely without a graft. [ABSTRACT FROM AUTHOR]

Examines the role of three-dimensional imaging in surgical planning for kidney surgery. Recommendation of three-phase helical computed tomography techniques; Ability of magnetic resonance imaging to reveal most renal tumors, renal vasculature and the collecting system; Imaging for renal transplant donor nephrectomy.