Anil Gulia

Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis

Study Type – Therapy (case series)
Level of Evidence 4

Closure versus nonclosure of buccal mucosal graft harvest site: A prospective randomized study on post operative morbidity

Objective: To prospectively compare the postoperative morbidity of closure versus non closure of the buccal mucosal graft (BMG) harvest site. Methods: Patients who underwent BMG harvest for urethroplasty were randomized into 2 groups; in group 1 donor site was closed and in group 2 it was left open. Self made questionnaires were used to assess post-operative pain, limitation to mouth opening, loss of sensation at graft site. The time to resumption of liquid and solid diet were also noted. Results: Fifty patients were studied, 25 in each group from July 2003 to July 2005. BMG was harvested from single cheek in most of the patients. Mean post operative pain score was 4.20 and 3.08 at day 1 in group 1 and group 2, respectively (P < 0.05). Return to oral intake in terms of liquid and solid diet was comparable between the groups. Difficulty with mouth opening was maximal during the first week with no difference among the two groups. Two patients in group 1 and one in group 2 had persistent peri-oral numbness at 6 months. None of the patients in both the groups had changes in salivation or retention cysts. Conclusion: Pain appears to be worse in the immediate post operative period with suturing of the harvest site. There is no difference in long term morbidity whether the graft site is closed or left open. It may be best to leave buccal mucosa harvest sites unsutured.

Laparoscopic live donor nephrectomy: comparison of outcomes right versus left

OBJECTIVE To compare outcomes between right- and left-sided laparoscopic live donor nephrectomy (LDN). Left LDN (LLDN) remains the side of choice whenever possible because the left renal vein is longer; however, there are some donors in whom the right kidney is taken for donation due to anatomical or functional reasons. Right LDN (RLDN) is perceived to be difficult due to anatomical factors. Therefore, many surgeons have a bias for left kidney donation or will do right side donation as an open donor nephrectomy. At our institution, we routinely perform RLDN when indicated and herein compare the outcomes between right- and left-sided LDN. METHODS From January 2007 to January 2017, 1850 laparoscopic donor nephrectomies were conducted at the Max Super Speciality Hospital. Of these, 168 were right-sided donor nephrectomies and 1682 were left-sided donor nephrectomies. All the donor case records were retrospectively reviewed; the operative time, warm ischemia time, intraoperative events, blood loss, and postoperative parameters were recorded. The kidney recipient data were also recorded. RESULTS The donor demographic characteristics were comparable between 2 groups. Among other variables, operating time was significantly less in RLDN (120 minutes) versus the LLDN group (146 minutes). Intraoperative estimated blood loss (118 mL in RLDN; 126 mL in LLDN), warm ischemia time (4.8 minutes in RLDN; 5.2 minutes in LLDN) and hospital stay (4.2 days in RLDN; 4.3 days in LLDN) was comparable. Vascular complications occurred in four patients in the RLDN group and six cases in the LLDN group. Recipient outcomes were comparable. CONCLUSIONS With adequate experience, RLDN can be accomplished in a safe manner with comparable outcomes to LLDN.

Standard vs Modified Technique of Laparoscopic Donor Nephrectomy

Introduction Laparoscopic donor nephrectomy (LDN) has now become a standard procedure to retrieve the kidney. We present a modified technique of laparoscopic trans-peritoneal donor nephrectomy, which reduces total surgery time, chances of vascular spasm and post-operative lymphatic leak. Materials and Methods We started doing LDN in standard fashion from the year 1998. Donor was placed in kidney position. Standard port placement was done and colon was mobilised medially. Ureter-gonadal vein complex was identified and followed cranially till renal vein. Dissection of lymphatic vessels was carried out around the renal pedicle and renal fat was dissected free with baring of the kidney. Graft was retrieved through preplaced Pfannensteil incision. There were a number of cases with renal artery spasm and occasional acute tubular necrosis (ATN), lymphorrhoea and prolonged drainage from drain in situ. We modified this technique from 2010 with minimal dissection around renal vessels and mobilization of kidney along with renal fat. Lymphatic vessels were clipped and cut after clipping and cutting renal vessels. Removal of perinephric fat and lymphatics was done on the bench. (Video of the techniques to be demonstrated during oral presentation). Results We performed around 1200 LDN with standard technique vs. 800 cases with modified technique. Mean operative time in modified technique was 104 min vs. 136 min in standard technique. Mean duration of drain in situ was 4.2 days for standard technique vs. 2.3 days in modified technique. Renal artery spasm requiring papaverine instillation was in 112 cases of standard technique vs. nil in modified technique. Post operative ATN was seen in 24 cases of standard technique vs. 6 cases of modified technique. Minor renal trauma was seen in 86 cases of standard technique vs. in 12 cases of modified technique. Conclusions Our modified technique of LDN reduces chances of arterial spasm and subsequent ATN, total surgery time and incidence of post-operative lymphatic leak. Chances of renal injury (hematoma/tear) are also minimized.

Prospective Comparison Between Open and Robot Assisted Kidney Transplant: Our Initial Results

Introduction Herein, we compare our first 30 consecutive robot assisted kidney transplant (RAKT) with 30 open kidney transplants (OKT) done during the same period. Materials and Methods All eligible patients were explained about both procedures. Patients were divided into the two groups based on their preference. Right sided grafts and grafts with more than two arteries were excluded. After bench preparation, graft was placed in gauze jacket and placed inside peritoneal cavity using Gel-port or Pfannenstiel incision. Da Vinci surgical system was docked; graft vein and artery were consecutively anastomosed with external iliac vein and artery using end-to-side fashion with Gor-tex® 6-0 suture. Modified Lich-Gregoir ureteroneocystostomy was done. Data was prospectively maintained and analyzed. The comparison was done using Levens’s test for equality of variances and student’s t-test for equality of means. Results All patients were live related, either first degree or second-degree relatives. The two groups were comparable in terms of age, sex, duration on hemodialysis (HD) and warm ischemia time (WIT). Recipients in RAKT group were having higher body mass index (BMI). Re-warm ischemia time was longer and fall of creatinine was slower in RAKT as compared OKT, but were not statistically significant. There was statistically significant less requirement of perioperative analgesic dose in RAKT group. One patient in RAKT expired on 25th day due to massive brain haemorrhage. She was a case of juvenile diabetes with diabetic nephropathy and was on HD for 36 months prior to presenting for transplant. Two patients with morbid obesity (BMI – 42 and 47) developed hospital acquired respiratory infection and required ventilator support and colistin. Both recovered completely and their creatinine at 1-year follow up is 1.6 and 2.2 mg/dL respectively. Rest all patients did very well Figure. No caption available. Conclusions This is our initial experience of RAKT, which is comparable to our vast experience in OKT. After 10 cases, our anastomosis time and re-warm ischemia time has steadily improved and is presently in well-selected cases, the results are similar. RAKT a very good modality especially in morbidly obese patients, where wound related complications are minimum.

OBESE KIDNEY DONOR - LAPAROSCOPIC DONOR NEPHRECTOMY IS THE RIGHT WAY TO GO: 2140

Introduction: Obese donors are usually not accepted in the live donor kidney transplant programme due to higher morbidity associated with the open donor nephrectomy. However, Laparoscopic donor nephrectomy has emerged as a viable option as it is associated with minimum morbidity. In the present report, we discuss the feasibility and morbidity of Laparoscopic donor nephrectomy in obese patients. Methods: From July 2006 to July 2009, 50 obese patients underwent transperitoneal laparoscopic donor nephrectomy with retrieval of the kidney graft through a Pfannensteil incision. Patients had a mean body weight of 118 Kg (range 95-126 Kg) with a mean body mass index (BMI) of 34 (Range 30-38). Routine prophylaxis against deep venous thrombosis was used. Operative time, estimated blood loss, intraoperative and postoperative complications and postoperative hospital stay were recorded. Results: Mean operative time was 156 min (range 124-182 min). Mean estimated blood loss was 160 ml (110 – 300 ml). No patient required a blood transfusion. No patient required conversion to open surgery. There were no major perioperative complications. Two patients had minor wound complications that resolved with conservative treatment. 4 patients developed basal atelectasis and were managed conservatively. One patient had ileus for 3 days and subsided with conservative treatment. two patients developed wound seroma. Mean postoperative hospital stay was 3.6 days (range 2-7 days). Conclusions: Laparoscopic donor nephrectomy is safe in selected obese donors and does not result in a high rate of perioperative complications. Hence, obese donors should not be denied an opportunity to donate kidney and should be given the benefit of minimum morbidity by the Laparoscopic approach.