-
Journal of Endourology Apr 2017Robotic partial nephrectomy (RPN) is gaining increasing prominence for nephron-sparing surgery in the treatment of patients with localized kidney tumors. RPN offers the... (Review)
Review
Robotic partial nephrectomy (RPN) is gaining increasing prominence for nephron-sparing surgery in the treatment of patients with localized kidney tumors. RPN offers the benefits of minimally invasive surgery with a shorter learning curve compared with its laparoscopic counterpart. While long-term data are awaited, RPN does provide short-term oncologic and functional outcomes comparable to open and laparoscopic partial nephrectomy. Furthermore, robotic surgery has facilitated technical innovation, including the elimination of warm ischemia, provided minimally invasive alternatives to patients with complex tumors, and importantly, has fuelled increased dissemination of partial nephrectomy surgery among community urologists.
Topics: Humans; Kidney Neoplasms; Laparoscopy; Minimally Invasive Surgical Procedures; Nephrectomy; Nephrons; Organ Sparing Treatments; Robotic Surgical Procedures; Treatment Outcome; Urologists; Warm Ischemia
PubMed: 28117608
DOI: 10.1089/end.2016.0639 -
BJU International Feb 2023To provide a narrative review of the major advances regarding ischaemia and functional recovery after partial nephrectomy (PN), along with the ongoing controversies. (Review)
Review
OBJECTIVE
To provide a narrative review of the major advances regarding ischaemia and functional recovery after partial nephrectomy (PN), along with the ongoing controversies.
METHODS
Key articles reflecting major advances regarding ischaemia and functional recovery after PN were identified. Special emphasis was placed on contributions that changed perspectives about surgical management. Priority was also placed on randomized trials of off-clamp vs on-clamp cohorts.
RESULTS
A decade ago, 'Every minute counts' was published, showing strong correlations between duration of ischaemia and development of acute kidney injury (AKI) and chronic kidney disease after clamped PN. This reinforced perspectives that ischaemia was the main modifiable factor that could be addressed to improve functional outcomes and helped spur efforts towards reduced or zero ischaemia PN. These approaches were associated with strong functional recovery and some peri-operative risk, although they were generally safe in experienced hands. Further research demonstrated that, when parenchymal volume changes were incorporated into the analyses, ischaemia lost statistical significance, and percent parenchymal volume saved proved to be the main determinant. Cold ischaemia was confirmed to be highly protective, and limited warm ischaemia also proved to be safe. The reconstructive phase of PN, with avoidance of parenchymal devascularization, appears to be most important for functional outcomes. Randomized trials of on-clamp vs off-clamp PN have shown minimal impact of ischaemia on functional recovery.
CONCLUSIONS
The past decade has witnessed great progress regarding functional recovery after PN, with many lessons learned. However, there are still unanswered questions, including: What is the threshold of warm ischaemia at which irreversible ischaemic injury begins to develop? Are some cohorts at increased risk for AKI or irreversible ischaemic injury? and Which patients should be prioritized for zero-ischaemia PN?
Topics: Humans; Kidney; Kidney Neoplasms; Nephrectomy; Warm Ischemia; Ischemia; Acute Kidney Injury; Glomerular Filtration Rate; Retrospective Studies
PubMed: 35835519
DOI: 10.1111/bju.15848 -
The Journal of Thoracic and... Apr 2024Single-dose del Nido solution was recently used in human donation after circulatory death (DCD) heart procurement. We compared the effect of del Nido cardioplegia on...
BACKGROUND
Single-dose del Nido solution was recently used in human donation after circulatory death (DCD) heart procurement. We compared the effect of del Nido cardioplegia on myocardial edema, inflammatory response, and injury in human DCD hearts and human donation after brain death (DBD) hearts with different warm ischemic times (WIT) and subsequent cold saline storage times (CST).
METHODS
A total of 24 human hearts, including 6 in the DBD group and 18 in the DCD group-were procured for the research study. The DCD group was divided into 3 subgroups based on WIT: 20, 40, and ≥60 minutes. All hearts received 1 L of del Nido cardioplegia before being placed in cold saline for 6 hours. Left ventricular biopsies were performed at 0, 2, 4, and 6 hours. Temporal changes in myocardial edema, inflammatory cytokines (TNF-α, IL-6, and IL-1β), and histopathology injury scores were compared between the DBD and DCD groups.
RESULTS
DCD hearts showed more profound changes in myocardial edema, inflammation, and injury than DBD hearts at baseline and subsequent CST. The DCD heart with WIT of 20 and 40 minutes with CST of 4 and 2 hours, respectively, appeared to have limited myocardial edema, inflammation, and injury. DCD hearts with WIT ≥60 minutes showed severe myocardial edema, inflammation, and injury at baseline and subsequent CST.
CONCLUSIONS
Single-dose cold del Nido cardioplegia and subsequent cold normal saline storage can preserve both DCD and DBD hearts. DCD hearts have been shown to be able to tolerate a WIT of 20 minutes and subsequent CST of 4 hours without experiencing significant myocardial edema, inflammation, and injury.
Topics: Humans; Warm Ischemia; Heart Transplantation; Heart; Edema; Inflammation; Tissue Donors
PubMed: 37743010
DOI: 10.1016/j.jtcvs.2023.09.034 -
Transplantation Proceedings 2021One of the cornerstone research models used in our laboratories is the induction of ischemic injury through cold ischemia followed by warm ischemia to donor kidneys to...
One of the cornerstone research models used in our laboratories is the induction of ischemic injury through cold ischemia followed by warm ischemia to donor kidneys to mimic the clinical realities of transplantation. The experimental design of the present study included bilateral nephrectomies on the day of syngeneic kidney transplant, with serum creatinine measured 24 hours postoperatively to measure acute function. Cold ischemia time in these experiments was always 30 minutes, and warm ischemia time was not standardized but always recorded. It became apparent that some transplanted kidneys that should have displayed injury were producing close to normal serum creatinine levels on postoperative day 1. In reviewing our data, we found a potential correlation between warm ischemia time and serum creatinine, in particular a significant proportion of low serum creatinine results (0.48 ± 0.26 mg/dL vs 1.99 ± 1.11 mg/dL; P < .05) was associated with warm ischemia times that were significantly shorter than our historical average (29.2 ± 2.7 min vs 35.7 ± 2.2 min; P < .05). The kidneys with lower serum creatinine also displayed lower apoptosis and brush border injury scores and fewer tubular casts. Therefore, we concluded that establishing a minimum warm ischemia time was just as important as standardized cold ischemia time to ensure consistent injury in this model.
Topics: Animals; Cold Ischemia; Creatinine; Disease Models, Animal; Ischemia; Kidney; Kidney Transplantation; Male; Mice; Warm Ischemia
PubMed: 33168203
DOI: 10.1016/j.transproceed.2020.08.010 -
Journal of Endourology May 2018Nephron-sparing surgery, especially through a minimally invasive approach, is increasingly being performed for incidentally detected renal masses with excellent...
Nephron-sparing surgery, especially through a minimally invasive approach, is increasingly being performed for incidentally detected renal masses with excellent outcomes. Tumors in central location remain a surgical challenge during nephron-sparing surgery. In this chapter, we discuss the minimally invasive management of these tumors, which include complex hilar tumors and endophytic central tumors, with a focus on surgical technique. The key to management of these tumors is to maintain good preoperative hydration, achieving adequate exposure of tumor, and the use of intraoperative ultrasound to plan the resection plane. Individual vessels may be ligated as they enter close to the tumor. Careful renorrhaphy is essential, especially in hilar tumors, which have major blood vessels at the base of the tumor. Selective use of near infrared fluorescence imaging, on-demand ischemia, early unclamping, enucleoresection techniques, and intracorporeal hypothermia may help minimize, or reduce the effect of warm ischemia.
Topics: Hemostasis; Humans; Ischemia; Kidney Neoplasms; Minimally Invasive Surgical Procedures; Nephrectomy; Nephrons; Organ Sparing Treatments; Patient Positioning; Postoperative Period; Preoperative Period; Robotic Surgical Procedures; Ultrasonography; Video Recording; Warm Ischemia
PubMed: 29774822
DOI: 10.1089/end.2018.0046 -
Surgery Today Jul 2015Hydrogen sulfide (H2S) ameliorates hepatic ischemia and reperfusion injury (IRI), but the precise mechanism remains elusive. We investigated whether sodium hydrogen...
BACKGROUND AND PURPOSE
Hydrogen sulfide (H2S) ameliorates hepatic ischemia and reperfusion injury (IRI), but the precise mechanism remains elusive. We investigated whether sodium hydrogen sulfide (NaHS), a soluble derivative of H2S, would ameliorate hepatic IRI, and if so, via what mechanism.
METHODS
Mice were subjected to partial warm ischemia for 75 min followed by reperfusion. Either NaHS or saline was administered intravenously 10 min before reperfusion. The liver and serum were collected 3, 6, and 24 h after reperfusion.
RESULTS
In the NaHS(-) group, severe IRI was apparent by the ALT leakage, tissue injury score, apoptosis, lipid peroxidation, and inflammation (higher plasma TNF-α, IL-6, IL-1β, IFN-γ, IL-23, IL-17, and CD40L), whereas IRI was significantly ameliorated in the NaHS(+) group. These effects could be explained by the augmented nuclear translocation of Nrf2, and the resulting up-regulation of HO-1 and thioredoxin-1. Phosphorylation of the PDK-1/Akt/mTOR/p70S6k axis, which is known to mediate pro-survival and anti-apoptotic signals, was significantly augmented in the NaHS(+) group, with a higher rate of PCNA-positive cells thereafter.
CONCLUSION
NaHS ameliorated hepatic IRI by direct and indirect anti-oxidant activities by augmenting pro-survival, anti-apoptotic, and anti-inflammatory signals via mechanisms involving Nrf-2, and by accelerating hepatic regeneration via mechanisms involving Akt-p70S6k.
Topics: Animals; Apoptosis; Biomarkers; Blotting, Western; Cytokines; Immunohistochemistry; Liver; Male; Mice; Mice, Inbred C57BL; Oxidative Stress; Protective Agents; Reperfusion; Reperfusion Injury; Sulfides; Warm Ischemia
PubMed: 25362520
DOI: 10.1007/s00595-014-1064-4 -
PloS One 2021Organs from donors after controlled circulatory death (DCD III) exhibit a higher risk for graft dysfunction due to an initial period of warm ischemia. This procurement...
Lower beta cell yield from donor pancreases after controlled circulatory death prevented by shortening acirculatory warm ischemia time and by using IGL-1 cold preservation solution.
Organs from donors after controlled circulatory death (DCD III) exhibit a higher risk for graft dysfunction due to an initial period of warm ischemia. This procurement condition can also affect the yield of beta cells in islet isolates from donor pancreases, and hence their use for transplantation. The present study uses data collected and generated by our Beta Cell Bank to compare the number of beta cells in isolates from DCD III (n = 141) with that from donors after brain death (DBD, n = 609), before and after culture, and examines the influence of donor and procurement variables. Beta cell number per DCD III-organ was significantly lower (58 x 106 versus 84 x 106 beta cells per DBD-organ; p < 0.001) but their purity (24% insulin positive cells) and insulin content (17 μg / 106 beta cells in DCD III-organs versus 19 μg / 106 beta cells in DBD-organs) were similar. Beta cell number correlated negatively with duration of acirculatory warm ischemia time above 10 min; for shorter acirculatory warm ischemia time, DCD III-organs did not exhibit a lower beta cell yield (74 x 106 beta cells). Use of Institut Georges Lopez-1 cold preservation solution instead of University of Wisconsin solution or histidine-tryptophan-ketoglutarate also protected against the loss in beta cell yield from DCD III-organs (86 x 106 for IGL-1 versus 54 x 106 and 65 x 106 beta cells respectively, p = 0.042). Multivariate analysis indicates that both limitation of acirculatory warm ischemia time and use of IGL-1 prevent the reduced beta cell yield in islet cell isolates from DCD III-organs.
Topics: Adenosine; Adult; Allopurinol; Brain Death; Female; Glutarates; Glutathione; Graft Survival; Histidine; Humans; Insulin; Insulin-Secreting Cells; Liver Transplantation; Male; Middle Aged; Organ Preservation Solutions; Raffinose; Tissue Donors; Tissue and Organ Procurement; Tryptophan; Warm Ischemia
PubMed: 33939760
DOI: 10.1371/journal.pone.0251055 -
Transplantation Proceedings Dec 2023The limitation of ischemia times, which damages the organs and impacts transplant outcomes, is a drawback of controlled donation after circulatory death. (Observational Study)
Observational Study
BACKGROUND
The limitation of ischemia times, which damages the organs and impacts transplant outcomes, is a drawback of controlled donation after circulatory death.
METHODS
The aim of the study was to analyze the influence of preservation and ischemia times on overall survival and both censured graft survival and overall graft survival. This was an observational and retrospective study of patients undergoing liver transplantation with grafts from controlled donation after circulatory death between November 2013 and November 2022.
RESULTS
Sixty-five patients were included in the study. Twenty percent (12 patients) developed early graft dysfunction according to Olthoff's classification, and 7 patients (11.6%) scored ≥7 points according to the Model for Early Allograft Function Scoring scale. Five patients (7.6%) met the criteria for primary graft failure. The retransplantation rate was 9.2% (6 cases). Fifty patients (76.9%) remained alive, and 15 patients (23.1%) died. When analyzing overall survival based on the main preservation and ischemia times, we observed that the best results occurred in the group with a functional warm ischemia time <12 minutes, with a survival rate at 1, 3, and 5 years of 95.8%, 87.1%, and 87.1%, respectively (P = .043). Regarding the analysis of censured graft survival based on the main preservation and ischemia times, we found that the worst results occurred in the group with a cold ischemia time ≥6 hours, with a survival rate of around 48% at 3 and 5 years (P = .047).
CONCLUSIONS
High-risk patients have lower overall and graft survival in the short and long term in grafts from controlled donation after circulatory death.
Topics: Humans; Retrospective Studies; Transplant Recipients; Ischemia; Tissue Donors; Warm Ischemia; Graft Survival; Death; Tissue and Organ Procurement
PubMed: 37813786
DOI: 10.1016/j.transproceed.2023.08.033 -
Journal of Vascular Surgery Jan 2019
Topics: Humans; Lower Extremity; Warm Ischemia
PubMed: 30126784
DOI: 10.1016/j.jvs.2018.04.067 -
World Journal of Gastroenterology Nov 2018To describe the prevalence of posttransplant metabolic syndrome (PTMS) after donation after cardiac death (DCD) liver transplantation (LT) and the pre- and postoperative...
AIM
To describe the prevalence of posttransplant metabolic syndrome (PTMS) after donation after cardiac death (DCD) liver transplantation (LT) and the pre- and postoperative risk factors.
METHODS
One hundred and forty-seven subjects who underwent DCD LT from January 2012 to February 2016 were enrolled in this study. The demographics and the clinical characteristics of pre- and post-transplantation were collected for both recipients and donors. PTMS was defined according to the 2004 Adult Treatment Panel-III criteria. All subjects were followed monthly for the initial 6 mo after discharge, and then, every 3 mo for 2 years. The subjects were followed every 6 mo or as required after 2 years post-LT.
RESULTS
The prevalence of PTMS after DCD donor orthotopic LT was 20/147 (13.6%). Recipient's body mass index ( = 0.024), warm ischemia time (WIT) ( = 0.045), and posttransplant hyperuricemia ( = 0.001) were significantly associated with PTMS. The change in serum uric acid levels in PTMS patients was significantly higher than that in non-PTMS patients ( < 0.001). After the 1 mo, the level of serum uric acid of PTMS patients rose continually over a period, while it was unaltered in non-PTMS patients. After transplantation, the level of serum uric acid in PTMS patients was not associated with renal function.
CONCLUSION
PTMS could occur at early stage after DCD LT with growing morbidity with the passage of time. WIT and post-LT hyperuricemia are associated with the prevalence of PTMS. An increased serum uric acid level is highly associated with PTMS and could act as a serum marker in this disease.
Topics: Adult; Biomarkers; Donor Selection; End Stage Liver Disease; Female; Follow-Up Studies; Humans; Hyperuricemia; Liver Transplantation; Male; Metabolic Syndrome; Middle Aged; Postoperative Complications; Preoperative Period; Prevalence; Retrospective Studies; Risk Factors; Time Factors; Tissue Donors; Treatment Outcome; Uric Acid; Warm Ischemia
PubMed: 30487701
DOI: 10.3748/wjg.v24.i43.4920