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Journal of Pediatric Urology Aug 2022Mucus production by the intestinal segment used in bladder augmentation results in long term concerns especially stones and UTI. Bladder augmentation with demucosalized...
INTRODUCTION
Mucus production by the intestinal segment used in bladder augmentation results in long term concerns especially stones and UTI. Bladder augmentation with demucosalized intestinal flap is a potential promising approach for mucus-free bladder augmentation, however the contraction of the flap remains a major concern. Mucosectomy has been shown to result in abrupt and immediate cessation of microcirculation in the ileum. However, assessment of microcirculation shortly after mucosectomy may miss a gradual recovery of micro-circulation over a longer period of time. Previous studies have not assessed the colon response to mucosectomy.
OBJECTIVE
Our aim was to assess the effect of mucosectomy on the microcirculation of the colon and ileum beyond the known warm ischemia time.
STUDY DESIGN
Ileum and colon segments were detubularised and mucosectomy was performed in (n = 8) anesthetised minipigs. Group A: sero-musculo-submucosal flaps were created with removal of the mucosa and preserving the submucosal layer Group B: sero-muscular flaps were created with the removal of submucosal-mucosal layer. The Microvascular Flow Index (MFI), the velocity of the circulating red blood cells (RBCV) was measured using Intravital Dark Field (IDF) side stream videomicroscopy (Cytoscan Braedius, The Netherlands) after mucosectomy, for up to 180 min.
RESULTS
Both the MFI and RBCV showed an abrupt reduction of microcirculation, on both surfaces of the remaining intestinal flap, in the ileum as well as in the colon. Slightly better values were seen in Group A of the colon, but even these values remain far below the preoperative (control) results. Some, tendency of recovery of the microcirculation was noted after 60-90 min, but this remained significantly lower than the preoperative control values at 180 min.
CONCLUSION
Both the ileal and the colonic flap remains in severe ischemia after mucosectomy beyond the warm ischemia time.
DISCUSSION
This study shows that surgical mucosectomy compromises vascular integrity of the intestinal flaps used for bladder augmentation. Partial recovery which occurs within the warm ischemia time is not significant enough to avoid fibrosis therefore flap shrinkage may be inevitable with this technique.
LIMITATION
The gastrointestinal structure of the porcine model is not the same exactly as the human gastrointestinal system. However, although not an exact match it is the closest, readily available animal model to the human gastrointestinal system.
Topics: Animals; Swine; Humans; Urinary Bladder; Swine, Miniature; Ileum; Urinary Bladder Diseases; Colon; Ischemia; Intestinal Mucosa
PubMed: 35545491
DOI: 10.1016/j.jpurol.2022.04.015 -
World Journal of Urology Apr 2023The lack of a reliable and reproducible technique to ensure a constantly low temperature of the graft during kidney transplantation (KT) may be a cause of renal... (Review)
Review
PURPOSE
The lack of a reliable and reproducible technique to ensure a constantly low temperature of the graft during kidney transplantation (KT) may be a cause of renal nonfunction. The aim of this review was to assess all the methods and devices available to ensure hypothermia during vascular anastomosis in KT.
METHODS
A literature search was conducted through May 2022 using PubMed/Medline, Cochrane Library, Embase and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The review protocol was registered on PROSPERO (CRD42022326550).
RESULTS
A total of 20 studies reporting on four hypothermia techniques met our inclusion criteria. Simple instillation of cold serum is not sufficient, the graft reaching up to 33 ℃ at the end of warm ischemia time (WIT). Plastic bags filled with ice slush have questionable efficiency. The use of a gauze jacket filled with ice-slush was reported in 12/20 studies. It ensures a graft temperature up to 20.3 ℃ at the end of WIT. Some concerns have been linked to potentially inhomogeneous parenchymal cooling and secondary ileus. Novel devices with continuous flow of ice-cold solution around the graft might overcome these limitations, showing a renal temperature below 20 ℃ at all times during KT.
CONCLUSION
The gauze filled with ice slush is the most common technique, but several aspects can be improved. Novel devices in the form of cold-ischemia jackets can ensure a lower and more stable temperature of the graft during KT, leading to higher efficiency and reproducibility.
Topics: Humans; Kidney Transplantation; Warm Ischemia; Hypothermia, Induced; Hypothermia; Ice; Reproducibility of Results
PubMed: 36826486
DOI: 10.1007/s00345-023-04328-9 -
Investigative and Clinical Urology Sep 2020This study aimed to determine the effectiveness and safety of partial nephrectomy (PN) without ischemia compared with PN with warm ischemia for reducing the... (Comparative Study)
Comparative Study Meta-Analysis
PURPOSE
This study aimed to determine the effectiveness and safety of partial nephrectomy (PN) without ischemia compared with PN with warm ischemia for reducing the deterioration in renal function in patients with cT1 renal tumors.
MATERIALS AND METHODS
We conducted a systematic review that included patients over 18 years of age who underwent PN with or without warm ischemia for cT1 renal tumors. The primary outcome was impaired renal function. A search strategy was performed in MEDLINE, EMBASE, LILACS, CENTRAL, the article reference lists, and the unpublished literature to reach saturation of the information. We assessed the risk of bias with the methodological index for nonrandomized studies (MINORS) tool, and we performed a meta-analysis according to the type of variable.
RESULTS
We found a total of 5,682 articles, of which 14 met the inclusion criteria. Seven studies evaluated renal function, identifying a difference in means (MD) of 3.50 (95% confidence interval [CI], 1.16 to 5.83), favoring no ischemia. We did not find any significant differences regarding intraoperative bleeding or operative time (MD, 55 mL; 95% CI, -33.16 to 144.08; and MD, 1.87; 95% CI, -20.47 to 24.21; respectively).
CONCLUSIONS
In this study, PN without ischemia showed a decrease in deterioration of the estimated glomerular filtration rate compared with warm ischemia.
Topics: Humans; Kidney Neoplasms; Neoplasm Staging; Nephrectomy; Treatment Outcome; Warm Ischemia
PubMed: 32869563
DOI: 10.4111/icu.20190313 -
American Journal of Transplantation :... May 2022Donation after circulatory death (DCD) represents a promising opportunity to overcome the relative shortage of donors for heart transplantation. However, the necessary...
Donation after circulatory death (DCD) represents a promising opportunity to overcome the relative shortage of donors for heart transplantation. However, the necessary period of warm ischemia is a concern. This study aims to determine the critical warm ischemia time based on in vivo biochemical changes. Sixteen DCD non-cardiac donors, without cardiovascular disease, underwent serial endomyocardial biopsies immediately before withdrawal of life-sustaining therapy (WLST), at circulatory arrest (CA) and every 2 min thereafter. Samples were processed into representative pools to assess calcium homeostasis, mitochondrial function and cellular viability. Compared to baseline, no significant deterioration was observed in any studied parameter at the time of CA (median: 9 min; IQR: 7-13 min; range: 4-19 min). Ten min after CA, phosphorylation of cAMP-dependent protein kinase-A on Thr197 and SERCA2 decreased markedly; and parallelly, mitochondrial complex II and IV activities decreased, and caspase 3/7 activity raised significantly. These results did not differ when donors with higher WLST to CA times (≥9 min) were analyzed separately. In human cardiomyocytes, the period from WLST to CA and the first 10 min after CA were not associated with a significant compromise in cellular function or viability. These findings may help to incorporate DCD into heart transplant programs.
Topics: Death; Heart; Heart Arrest; Heart Transplantation; Humans; Perfusion; Tissue Donors; Tissue and Organ Procurement; Warm Ischemia
PubMed: 35114047
DOI: 10.1111/ajt.16987 -
Digestive Diseases and Sciences Apr 2021The benefit of ischemic postconditioning (IPostC) might be the throttled inflow following cold ischemia. The current study investigated advantage and mechanisms of...
BACKGROUND
The benefit of ischemic postconditioning (IPostC) might be the throttled inflow following cold ischemia. The current study investigated advantage and mechanisms of IPostC in healthy and fatty rat livers.
METHODS
Male SD rats received a high-fat diet to induce fatty livers. Isolated liver perfusion was performed after 24 h ischemia at 4 °C as well as in vivo experiments after 90 min warm ischemia. The so-called follow-up perfusions served to investigate the hypothesis that medium from IPostC experiments is less harmful. Lactate dehydrogenase (LDH), transaminases, different cytokines, and gene expressions, respectively, were measured.
RESULTS
Fatty livers showed histologically mild inflammation and moderate to severe fat storage. IPostC reduced LDH and TXB in healthy and fatty livers and increased bile flow. LDH, TNF-α, and IL-6 levels in serum decreased after warm ischemia + IPostC. The gene expressions of Tnf, IL-6, Ccl2, and Ripk3 were downregulated in vivo after IPostC.
CONCLUSIONS
IPostC showed protective effects after ischemia in situ and in vivo in healthy and fatty livers. Restricted cyclic inflow was an important mechanism and further suggested involvement of necroptosis. IPostC represents a promising and easy intervention to improve outcomes after transplantation.
Topics: Animals; Diet, High-Fat; Fatty Liver; Ischemic Postconditioning; Male; Rats; Rats, Sprague-Dawley; Reperfusion Injury
PubMed: 32451758
DOI: 10.1007/s10620-020-06328-w -
Surgical Approaches and Outcomes in Living Donor Nephrectomy: A Systematic Review and Meta-analysis.European Urology Focus Nov 2022The use of living kidney donors is increasing and there are several surgical approaches for donor nephrectomy but it remains unknown which procedure is optimal for the... (Meta-Analysis)
Meta-Analysis Review
CONTEXT
The use of living kidney donors is increasing and there are several surgical approaches for donor nephrectomy but it remains unknown which procedure is optimal for the patient and the graft.
OBJECTIVE
To review different surgical techniques for living donor nephrectomy and compare complication rates, warm ischemia time, and delayed graft function.
EVIDENCE ACQUISITION
A systematic review of prospective studies involving surgical complications following living donor nephrectomy was conducted in the MEDLINE/PubMed and EMBASE databases according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Baseline data, perioperative and postoperative parameters, and postoperative complications are reported. Overall complication rates between surgical techniques were compared via analysis of variance with post hoc analysis. We included 35 studies involving 6398 patients and representing six different surgical procedures for living donor nephrectomy.
EVIDENCE SYNTHESIS
Hand-assisted laparoscopic donor nephrectomy had a significantly higher overall complication rate compared to open, laparoscopic, retroperitoneoscopic, and laparoendoscopic single-site techniques (p < 0.005). The complication rates were low and no mortality was observed. The main limitation was varying reporting of complications, with only one-third of the studies using the Clavien-Dindo classification.
CONCLUSIONS
No specific surgical approach seems superior in terms of complications, which were generally low. Different factors such as warm ischemia time, blood loss, and surgeon expertise define which surgical approach should be chosen.
PATIENT SUMMARY
We looked at the different surgical methods for removing the kidney from a living kidney donor. Overall, the different surgical techniques were similar in terms of complications and no donors died in the studies we reviewed. The choice of procedure depends on multiple factors such as the expertise of the surgeon and the surgical center.
Topics: Humans; Kidney; Prospective Studies
PubMed: 35469780
DOI: 10.1016/j.euf.2022.03.021 -
Transplantation Jun 2021Donation after circulatory death (DCD) grafts are commonly used in liver transplantation. Attributable to the additional ischemic event during the donor warm ischemia... (Review)
Review
Donation after circulatory death (DCD) grafts are commonly used in liver transplantation. Attributable to the additional ischemic event during the donor warm ischemia time (DWIT), DCD grafts carry an increased risk for severe ischemia/reperfusion injury and postoperative complications, such as ischemic cholangiopathy. The actual ischemia during DWIT depends on the course of vital parameters after withdrawal of life support and varies widely between donors. The ischemic period (functional DWIT) starts when either Spo2 or blood pressure drop below a certain point and lasts until the start of cold perfusion during organ retrieval. Over the years, multiple definitions and thresholds of functional DWIT duration have been used. The International Liver Transplantation Society organized a Consensus Conference on DCD, Liver Preservation, and Machine Perfusion on January 31, 2020 in Venice, Italy. The aim of this conference was to reach consensus about various aspects of DCD liver transplantation in context of currently available evidence. Here we present the recommendations with regards to the definitions used for DWIT and functional DWIT, the importance of vital parameters after withdrawal of life support, and acceptable thresholds of duration of functional DWIT to proceed with liver transplantation.
Topics: Hepatectomy; Humans; Liver Transplantation; Organ Preservation; Perfusion; Time Factors; Tissue Donors; Tissue Survival; Tissue and Organ Harvesting; Warm Ischemia
PubMed: 34048418
DOI: 10.1097/TP.0000000000003819 -
Translational Cancer Research May 2022As the development of various imaging techniques, the incidental detection of renal masses is increasing. Laparoscopic partial nephrectomy (LPN) is the current standard...
BACKGROUND
As the development of various imaging techniques, the incidental detection of renal masses is increasing. Laparoscopic partial nephrectomy (LPN) is the current standard of treatment for renal carcinoma. Though the retroperitoneal laparoscopic partial nephrectomy (RLPN) become the prior choice, the edge of lateroconal fascia blocks the sight and make operation more challenging.
METHODS
Between October 2018 and December 2020, the clinical data of 28 cases diagnosed with renal cell carcinoma (RCC) in our hospital was collected and analyzed retrospectively. All patients underwent RLPN and for management of curtain effect, we performed lateroconal fascia suspension (LFS) procedure in all cases with prepared Hem-o-lock clip which bound with 2-0 suture.
RESULTS
RLPN for renal tumor was successfully performed in all cases with no conversions to open surgery and other interruptions. In all cases, the free edge of lateroconal fascia and peritoneum partially blocked the sight of surgeon. We managed the curtain effect successfully and got a satisfying field of view for subsequent surgical procedure. The median operation time was 142 [interquartile range (IQR), 110-164] min, median estimated blood loss was 93 (IQR, 50-100) mL. Median warm ischemia time was 29 (IQR, 22-30) min.
CONCLUSIONS
LFS is useful for management of curtain effect. It is a simple, economical and less invasive technique and we can get better efficiency with little consumption.
PubMed: 35706802
DOI: 10.21037/tcr-21-2467 -
Parenchymal volume analysis to assess longitudinal functional decline following partial nephrectomy.BJU International Oct 2023To identify factors associated with longitudinal ipsilateral functional decline after partial nephrectomy (PN).
OBJECTIVE
To identify factors associated with longitudinal ipsilateral functional decline after partial nephrectomy (PN).
PATIENTS AND METHODS
Of 1140 patients managed with PN (2012-2014), 349 (31%) had imaging/serum creatinine levels pre-PN, 1-12 months post-PN (new baseline), and >3 years later necessary for inclusion. Parenchymal-volume analysis was used to determine split renal function. Patients were grouped as having significant renal comorbidity (Cohort : diabetes mellitus with insulin-dependence or end-organ damage, refractory hypertension, or severe pre-existing chronic kidney disease) vs not having significant renal comorbidity (Cohort ) preoperatively. Multivariable regression was used to identify predictors of annual ipsilateral parenchymal atrophy and functional decline relative to new baseline values post-PN, after the kidney had healed.
RESULTS
The median follow-up was 6.3 years with 87/226/36 patients having cold/warm/zero ischaemia. The median cold/warm ischaemia times were 32/22 min. Overall, the median tumour size was 3.0 cm. The preoperative glomerular filtration rate (GFR) and new baseline GFR (NBGFR) were 81 and 71 mL/min/1.73 m , respectively. After establishment of the NBGFR, the median loss of global and ipsilateral function was 0.7 and 0.4 mL/min/1.73 m /year, respectively, consistent with the natural ageing process. Overall, the median ipsilateral parenchymal atrophy was 1.2 cm /year and accounted for a median of 53% of the annual functional decline. Significant renal comorbidity, age, and warm ischaemia were independently associated with ipsilateral parenchymal atrophy (all P < 0.01). Significant renal comorbidity and ipsilateral parenchymal atrophy were independently associated with annual ipsilateral functional decline (both P < 0.01). Annual median ipsilateral parenchymal atrophy and functional decline were both significantly increased for Cohort compared to Cohort (2.8 vs 0.9 cm , P < 0.01 and 0.90 vs 0.30 mL/min/1.73 m /year, P < 0.01, respectively).
CONCLUSIONS
Longitudinal renal function following PN generally follows the normal ageing process. Significant renal comorbidities, age, warm ischaemia, and ipsilateral parenchymal atrophy were the most important predictors of ipsilateral functional decline following establishment of NBGFR.
Topics: Humans; Kidney Neoplasms; Nephrectomy; Kidney; Warm Ischemia; Glomerular Filtration Rate; Atrophy; Retrospective Studies
PubMed: 37409822
DOI: 10.1111/bju.16110 -
Urologia Internationalis 2021Donors' health and safety are mandatory in the living-donor kidney transplantation procedure. Laparoscopic live donor nephrectomy (LLDN) provides an increase in donor...
OBJECTIVE
Donors' health and safety are mandatory in the living-donor kidney transplantation procedure. Laparoscopic live donor nephrectomy (LLDN) provides an increase in donor numbers with its benefits and becomes a standard of care. We aimed to explain the results, complication rates, tips, and tricks of the largest number of LLDN case series ever performed in the literature.
MATERIALS AND METHODS
Between August 2012 and December 2019, 2,477 live donor case files were analyzed retrospectively. Age, gender, hospitalization times, body mass index, warm ischemia times, operation times, numbers of arteries, side of the kidneys, and complications were noted.
RESULTS
1,421 (57.4%) of 2,477 donors were female (p = 0.007). Operation times and warm ischemia times were found longer in right-sided LLDN and donors with multiple renal arteries (p = 0.046, <0.001, and <0.001, respectively). Obesity (BMI >30 kg/m2) did not affect warm ischemia times while prolonging the operation times (p = 0.013). Hospitalization times and numbers of complications were higher in obese donors.
CONCLUSIONS
LLDN seems to be a reliable solution with fewer complications and higher satisfaction rates. We hope to illuminate the way with tips and trick points for beginner transplant surgeons based on the experience obtained from 2,477 LLDN cases.
Topics: Adult; Female; Hospitals, High-Volume; Humans; Laparoscopy; Living Donors; Male; Middle Aged; Nephrectomy; Postoperative Complications; Retrospective Studies; Tissue and Organ Harvesting
PubMed: 33207353
DOI: 10.1159/000511377