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European Urology Dec 2015A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes. (Review)
Review
CONTEXT
A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes.
OBJECTIVE
To evaluate the literature regarding pertinent surgical anatomy of the kidney and related structures, nephrometry scoring systems, and current surgical strategies for partial nephrectomy (PN).
EVIDENCE ACQUISITION
A literature review was conducted.
EVIDENCE SYNTHESIS
Surgical renal anatomy fundamentally impacts PN surgery. The renal artery divides into anterior and posterior divisions, from which approximately five segmental terminal arteries originate. The renal veins are not terminal. Variations in the vascular and lymphatic channels are common; thus, concurrent lymphadenectomy is not routinely indicated during PN for cT1 renal masses in the setting of clinically negative lymph nodes. Renal-protocol contrast-enhanced computed tomography or magnetic resonance imaging is used for standard imaging. Anatomy-based nephrometry scoring systems allow standardized academic reporting of tumor characteristics and predict PN outcomes (complications, remnant function, possibly histology). Anatomy-based novel surgical approaches may reduce ischemic time during PN; these include early unclamping, segmental clamping, tumor-specific clamping (zero ischemia), and unclamped PN. Cancer cure after PN relies on complete resection, which can be achieved by thin margins. Post-PN renal function is impacted by kidney quality, remnant quantity, and ischemia type and duration.
CONCLUSIONS
Surgical renal anatomy underpins imaging, nephrometry scoring systems, and vascular control techniques that reduce global renal ischemia and may impact post-PN function. A contemporary ideal PN excises the tumor with a thin negative margin, delicately secures the tumor bed to maximize vascularized remnant parenchyma, and minimizes global ischemia to the renal remnant with minimal complications.
PATIENT SUMMARY
In this report we review renal surgical anatomy. Renal mass imaging allows detailed delineation of the anatomy and vasculature and permits nephrometry scoring, and thus precise, patient-specific surgical planning. Novel off-clamp techniques have been developed that may lead to improved outcomes.
Topics: Humans; Kidney; Nephrectomy
PubMed: 25911061
DOI: 10.1016/j.eururo.2015.04.010 -
American Journal of Physiology. Renal... May 2022
Topics: Angiotensins; Kidney; Nephrectomy
PubMed: 35343851
DOI: 10.1152/ajprenal.00063.2022 -
Saudi Journal of Kidney Diseases and... Sep 2022Kidney transplantation is the gold standard treatment option for patients with endstage kidney disease. As the number of waitlisted patients increases, the gap between... (Review)
Review
Kidney transplantation is the gold standard treatment option for patients with endstage kidney disease. As the number of waitlisted patients increases, the gap between supply and demand for suitable donor kidneys keeps widening. The adoption of novel strategies that expand the donor pool has attenuated this issue to a certain degree, and this has led to a progressive increase in the number of annual transplants performed. As transplanted kidneys have a finite lifespan, there is a reciprocal rise in the number of patients who return to dialysis once their allograft fails. The clinicians involved in the management of such patients are left with the problem of managing the nonfunctioning allograft. The decision to undertake transplant nephrectomy (TN) in these patients is not straightforward. Allograft nephrectomy is a procedure that is associated with significant morbidity and mortality. It will have implications for the outcomes of the subsequent transplant. In this review, we aimed to compressively discuss the indications, techniques, and outcomes of TN, which is an integral component of the management of a failing allograft.
Topics: Humans; Kidney Transplantation; Kidney; Nephrectomy; Transplantation, Homologous; Kidney Failure, Chronic
PubMed: 37955463
DOI: 10.4103/1319-2442.389431 -
International Journal of Surgery... Jun 2023The present study aimed to conduct a pooled analysis to compare the efficacy and safety of minimally invasive partial nephrectomy (MIPN) with open partial nephrectomy... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The present study aimed to conduct a pooled analysis to compare the efficacy and safety of minimally invasive partial nephrectomy (MIPN) with open partial nephrectomy (OPN) in patients with complex renal tumors (defined as PADUA or RENAL score ≥7).
METHODS
The present study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, Supplemental Digital Content 1, http://links.lww.com/JS9/A394 . We conducted a systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases until October 2022. MIPN and OPN-controlled trials for complex renal tumors were included. The primary outcomes were perioperative results, complications, renal function, and oncologic outcomes.
RESULTS
A total of 2405 patients were included in 13 studies. MIPN outperformed OPN in terms of hospital stay [weighted mean difference (WMD) -1.84 days, 95% CI -2.35 to -1.33; P <0.00001], blood loss (WMD -52.42 ml, 95% CI -71.43 to -33.41; P <0.00001), transfusion rates [odds ratio (OR) 0.34, 95% CI 0.17-0.67; P =0.002], major complications (OR 0.59, 95% CI 0.40-0.86; P =0.007) and overall complications (OR 0.43, 95% CI 0.31-0.59; P <0.0001), while operative time, warm ischemia time, conversion to radical nephrectomy rates, estimated glomerular decline, positive surgical margins, local recurrence, overall survival, recurrence-free survival, and cancer-specific survival were not significantly different.
CONCLUSIONS
The present study demonstrated that MIPN was associated with a shorter length of hospital stay, less blood loss, and fewer complications in treating complex renal tumors. MIPN may be considered a better treatment for patients with complex tumors when technically feasible.
Topics: Humans; Postoperative Complications; Treatment Outcome; Kidney Neoplasms; Robotic Surgical Procedures; Nephrectomy
PubMed: 37094827
DOI: 10.1097/JS9.0000000000000397 -
The Netherlands Journal of Medicine May 2010Living donor nephrectomy has been developed and promoted as a method to address the shortfall in kidneys available for transplantation. The classical method to procure a... (Review)
Review
Living donor nephrectomy has been developed and promoted as a method to address the shortfall in kidneys available for transplantation. The classical method to procure a kidney from a living donor is the open donor nephrectomy performed through a flank lumbotomy incision. However, this classical method has negative short- and long-term side effects for the donor. These disincentives are a drawback for possible donors to donate a kidney. Therefore, transplant surgeons were stimulated to develop new and less invasive techniques. In this review several new open and laparoscopic techniques are described. Compared with open donor nephrectomy, laparoscopic donor nephrectomy has shown superior results in terms of postoperative pain, cosmetics, convalescence, and return to normal daily activities. No significant differences exist between the two approaches in terms of complication rates, cost-effectiveness and graft function. Nowadays, laparoscopic donor nephrectomy has become the preferred method for procuring kidney grafts of living donors in many centres.
Topics: Humans; Kidney; Kidney Transplantation; Laparoscopy; Living Donors; Nephrectomy; Tissue and Organ Procurement
PubMed: 20508268
DOI: No ID Found -
Revista Da Associacao Medica Brasileira... Dec 2018The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to...
OBJECTIVE
The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors.
CONCLUSIONS
The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.
Topics: Evidence-Based Medicine; Humans; Kidney Transplantation; Living Donors; Nephrectomy
PubMed: 30569978
DOI: 10.1590/1806-9282.64.12.1061 -
International Journal of Surgery... Dec 2016Although most partial nephrectomies are performed as primary procedures in the elective or semi-imperative setting on kidneys with relatively normal anatomy, this is not... (Review)
Review
Although most partial nephrectomies are performed as primary procedures in the elective or semi-imperative setting on kidneys with relatively normal anatomy, this is not always the case. The indications for partial nephrectomy continue to expand and it is becoming particularly relevant in patients with single functioning kidneys, poor kidney function, anatomical anomalies and hereditary syndromes predisposing to multiple kidney cancers, such as Von Hippel-Lindau syndrome. These, along with previous abdominal surgery, pose surgical challenges. In this article we offer advice as to how to tackle these unusual situations. An ability to master the whole range of indications will allow the modern upper renal tract surgeon to offer partial nephrectomy to a wider range of patients.
Topics: Abdomen; Carcinoma, Renal Cell; Humans; Kidney; Kidney Neoplasms; Nephrectomy; Syndrome; von Hippel-Lindau Disease
PubMed: 27262880
DOI: 10.1016/j.ijsu.2016.05.070 -
BMJ Open Sep 2017The provision of complex surgery is increasingly centralised to high-volume (HV) specialist hospitals. Evidence to support nephrectomy centralisation however has been... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
The provision of complex surgery is increasingly centralised to high-volume (HV) specialist hospitals. Evidence to support nephrectomy centralisation however has been inconsistent. We conducted a systematic review and meta-analysis to determine the association between hospital case volumes and perioperative outcomes in radical nephrectomy, partial nephrectomy and nephrectomy with venous thrombectomy.
METHODS
Medline, Embase and the Cochrane Library were searched for relevant studies published between 1990 and 2016. Pooled effect estimates for nephrectomy mortality and complications were calculated for each nephrectomy type using the DerSimonian and Laird random-effects model. Sensitivity analyses were performed to examine the effects of heterogeneity on the pooled effect estimates by excluding studies with the heaviest weighting, lowest methodological score and most likely to introduce bias from misclassification of standardised hospital volume.
RESULTS
Some 226 372 patients from 16 publications were included in our review and meta-analysis. Considerable between-study heterogeneity was noted and only a few reported volume-outcome relationships specifically in partial nephrectomy or nephrectomy with venous thrombectomy.HV hospitals were correlated with a 26% and 52% reduction in mortality for radical nephrectomy (OR 0.74, 95% CI 0.61 to 0.90, p<0.01) and nephrectomy with venous thrombectomy (OR 0.48, 95% CI 0.29 to 0.81, p<0.01), respectively. In addition, radical nephrectomy in HV hospitals was associated with an 18% reduction in complications (OR 0.82, 95% CI 0.73 to 0.92, p<0.01). No significant volume-outcome relationship in mortality (OR 0.84, 95% CI 0.31 to 2.26, p=0.73) or complications (OR 0.85, 95% CI 0.55 to 1.30, p=0.44) was observed for partial nephrectomy.
CONCLUSIONS
Our findings suggest that patients undergoing radical nephrectomy have improved outcomes when treated by HV hospitals. Evidence of this in partial nephrectomy and nephrectomy with venous thrombectomy is however not yet clear and could be secondary to the low number of studies included and the small patient number in our analyses. Further investigation is warranted to establish the full potential of nephrectomy centralisation particularly as existing evidence is of low quality with significant heterogeneity.
Topics: Hospitals, High-Volume; Hospitals, Low-Volume; Humans; Kidney Diseases; Kidney Neoplasms; Nephrectomy; Postoperative Complications
PubMed: 28877947
DOI: 10.1136/bmjopen-2017-016833 -
PloS One 2014To critically review the currently available evidence of studies comparing robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN). (Comparative Study)
Comparative Study Meta-Analysis Review
OBJECTIVES
To critically review the currently available evidence of studies comparing robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN).
MATERIALS AND METHODS
A comprehensive review of the literature from Pubmed, Web of Science and Scopus was performed in October 2013. All relevant studies comparing RPN with OPN were included for further screening. A cumulative meta-analysis of all comparative studies was performed and publication bias was assessed by a funnel plot.
RESULTS
Eight studies were included for the analysis, including a total of 3418 patients (757 patients in the robotic group and 2661 patients in the open group). Although RPN procedures had a longer operative time (weighted mean difference [WMD]: 40.89; 95% confidence interval [CI], 14.39-67.40; p = 0.002), patients in this group benefited from a lower perioperative complication rate (19.3% for RPN and 29.5% for OPN; odds ratio [OR]: 0.53; 95%CI, 0.42-0.67; p<0.00001), shorter hospital stay (WMD: -2.78; 95%CI, -3.36 to -1.92; p<0.00001), less estimated blood loss(WMD: -106.83; 95%CI, -176.4 to -37.27; p = 0.003). Transfusions, conversion to radical nephrectomy, ischemia time and estimated GFR change, margin status, and overall cost were comparable between the two techniques. The main limitation of the present meta-analysis is the non-randomization of all included studies.
CONCLUSIONS
RPN appears to be an efficient alternative to OPN with the advantages of a lower rate of perioperative complications, shorter length of hospital stay and less blood loss. Nevertheless, high quality prospective randomized studies with longer follow-up period are needed to confirm these findings.
Topics: Blood Loss, Surgical; Cost-Benefit Analysis; Humans; Length of Stay; Nephrectomy; Operative Time; Robotics; Treatment Outcome
PubMed: 24740259
DOI: 10.1371/journal.pone.0094878 -
International Journal of Surgery... Dec 2016Advancement in surgical management of urolithiasis has revolved around improvements in technology. Urologists have been at the forefront on embracing new technology and... (Review)
Review
Advancement in surgical management of urolithiasis has revolved around improvements in technology. Urologists have been at the forefront on embracing new technology and passing on the benefits to the patients. Da Vinci robotic system has contributed significantly in improving the outcomes of minimally invasive procedures especially those requiring complex resections and reconstruction. Endourological and percutaneous techniques have established superiority in management of urolithiasis and majority of the patients are ideal candidates for such procedures. However, in certain stone disease indications like simultaneous pyeloplasty-pyelolithotomy, robotic assisted procedure has established superiority, at least in the developed world. Other indications like complex pyelolithotomy and stone extraction with simultaneous partial nephrectomy are being continuously documented. Large, multi-institutional studies to evaluate the effective advantages of the robotic approach against well-established methodologies in the treatment of stone disease are required. However the wider availability of robotic system in areas where stone disease is endemic continues to be the biggest challenge.
Topics: Humans; Kidney; Nephrectomy; Robotic Surgical Procedures; Urolithiasis
PubMed: 27856354
DOI: 10.1016/j.ijsu.2016.11.031