Thomas McGregor

Renal Perfusion Pump vs. Cold Storage for Donation After Cardiac Death Kidneys: A Systematic Review.

PURPOSE Static cold storage is generally used to preserve kidney allografts from deceased donors. Hypothermic machine perfusion may improve the outcome after transplantation but few studies with limited power have addressed this issue. We reviewed evidence of the effectiveness of storing kidneys from deceased donors after cardiac death before transplantation using cold static storage solution or pulsatile hypothermic machine perfusion. MATERIALS AND METHODS We searched electronic databases in September 2011 for systematic reviews and/or meta-analyses, randomized, controlled trials and studies of other designs that compared delayed graft function and graft survival. Sources included The Cochrane Library, PubMed® and EMBASE®. Studies excluded from review included those that did not discriminate between donation after cardiac death and donation from a neurologically deceased donor. Primary outcomes were delayed graft function and 1-year graft survival. Statistical analysis was done using RevMan (http://ims.cochrane.org/revman). RESULTS Nine studies qualified for review. Pulsatile perfusion pumped kidneys from donation after cardiac death donors had decreased delayed graft function compared to kidneys placed in cold storage (OR 0.64, 95% CI 0.43-0.95, p = 0.03). There was a trend toward improved 1-year graft survival in the pulsatile perfusion group but statistical significance was not attained (OR 0.74, 95% CI 0.48-1.13, p = 0.17). CONCLUSIONS Pulsatile machine perfusion of donation after cardiac death kidneys appears to decrease the delayed graft function rate. We noted no benefit in 1-year graft survival. Due to the great heterogeneity among the trials as well as several confounding factors, the overall impact on allograft function and survival requires more study.

Totally tubeless outpatient percutaneous nephrolithotomy: initial case report.

We report the first case of totally tubeless outpatient percutaneous nephrolithotomy (PCNL). Our patient was discharged home safely less than 4 hours following uncomplicated PCNL with no nephrostomy tube, ureteral stent, or urethral catheter. Follow-up the next day in clinic confirmed that the procedure was successful, as the patient was clinically well and stone free. To our knowledge, this is the first case report of totally tubeless (no nephrostomy, no ureteral stent) PCNL performed on a truly outpatient basis.

Hypothermic machine perfusion improves Doppler ultrasonography resistive indices and long-term allograft function after renal transplantation: a single-centre analysis

To evaluate whether hypothermic machine perfusion (HMP) of transplanted kidneys can improve long‐term renal allograft function compared with static cold storage (CS).

Laparoscopic nephroureterectomy in a patient with a left ventricular assist device

Left ventricular assist device (LVAD) therapy is an established treatment option for select patients with advanced heart failure. Advances in technology and patient management have resulted in improved post-implant outcomes. Consequently, more patients with LVADs are presenting for evaluation and care of non-cardiac surgical disease. However, there is a paucity of literature regarding the optimal perioperative and surgical management of such patients. We present the case of a 71-year-old male with a HeartMate II (Thoratec Corporation, Pleasanton, CA) LVAD, who underwent a laparoscopic left nephroureterectomy for an upper urinary tract transitional cell carcinoma. His perioperative course was uneventful due to the multidisciplinary efforts of cardiac surgery, cardiac anesthesia, nephrology and urology. To our knowledge, this is the first reported case of a laparoscopic nephroureterectomy in a patient with a HeartMate II LVAD.

Five-year experience with donation after cardiac death kidney transplantation in a Canadian transplant program: Factors affecting outcomes.

BACKGROUND : Donation after cardiac death (DCD) has led to an increase of up to 40% in the number of kidney transplants in some programs. Unfortunately, the increase in warm ischemic time results in higher rates of delayed graft function (DGF). The purpose of our study was to examine our initial 5-year experience with DCD kidney transplantation and to determine the factors involved in early postoperative function and function at 1 year. METHODS : This retrospective study included a review of the recipient and donor charts of 63 DCD kidneys retrieved and transplanted by the London Multi-Organ Transplant Program between July 2006 and October 2011. Comparisons were carried out between our early (n=31, July 2006 to January 2009) and our recent experience (n=32, March 2009 to October 2011). DGF and creatinine clearance at 3, 7 and 365 days were examined with regression analyses. RESULTS : DGF was seen in 65% of transplanted kidneys. Mean creatinine clearance (CrCl) at 1 year was 66.7 mL/min. Low pre-transplant recipient daily urine output was the most statistically significant predictor of DGF in multivariate analysis (p < 0.001). In comparisons between our early and more recent results, improvements were noted in time from asystole to flush (16.0 vs. 12.0 minutes, p = 0.003), while cold ischemic time increased (464 vs. 725 minutes, p = 0.006). Experience contributed to a significant reduction in hospital length of stay (16 vs. 13 days, p = 0.035) and improved early renal function (CrCl at 3 days 7.8 vs. 11.9 mL/min, p = 0.027). The use of machine cold perfusion and higher recipient preoperative daily urine output predicted improved early renal function, while increasing donor age predicted poorer function at 1 year. DISCUSSION : Despite early DGF, our results justify the continued transplantation of kidneys from DCD donors.

The value of a core clinical rotation in urology for medical students

INTRODUCTION In 2013, our institution underwent a change to the undergraduate medical curriculum whereby a clinical urology rotation became mandatory. In this paper, we evaluated the perceived utility and value of this change in the core curriculum. METHODS Third year medical students, required to complete a mandatory 1-week clinical urology rotation, were asked to complete a survey before and after their rotation. Fourth year medical students, not required to complete this rotation, were also asked to complete a questionnaire. Chi-squared and Fishers exact test were used for data analysis. RESULTS In total, 108 third year students rotated through urology during the study period. Of these, 66 (61%) completed the pre-rotation survey and 54 (50%) completed the post-rotation survey. In total, there were 110 fourth year students. Of these, 44 (40%) completed the questionnaire. After completing their mandatory rotations, students felt more comfortable managing and investigating common urological problems, such as hematuria and renal colic. Students felt they had a better understanding of how to insert a Foley catheter and felt comfortable independently inserting a Foley catheter. Importantly, students felt they knew when to consult urology and were also more likely to consider a career in urology. Compared to fourth year students, third year students felt urology was an important component to a family medicine practice and felt they had a better understanding of when to consult urology. CONCLUSION The introduction of a mandatory urology rotation for undergraduate medical students leads to a perceived improvement in fundamental urological knowledge and skill set of rotating students. This mandatory rotation provides a valuable experience that validates its inclusion.

Telementoring and Telesurgery: Future or Fiction?

Over the last two decades, minimally invasive surgery (MIS) has emerged as an attractive alternative to traditional open surgical procedures. MIS has been shown to provide excellent surgical outcomes with the added benefit of decreased procedure-related morbidity. Minimal bleeding, reduced blood transfusion rates, shorter hospitalization, and shorter recovery times are all proven advantages for laparoscopic procedures. [1-3] However, many MIS procedures are more technically challenging than the traditional open counterpart, and the learning curve to proficiency is markedly steeper than standard open procedures. Several factors including establishing adequate access, two dimensional vision, decreased depth perception, restricted instrument maneuverability, decreased dexterity and dampened tactile feedback are all unique limitations that make laparoscopic surgery challenging for surgeons trained in traditional open approaches. To the laparoscopically naive surgeon, this translates into a loss of confidence in performing a procedure in which they were previously skilled. Appropriate training and education are therefore essential for a surgeon to develop the necessary skills required in order to comfortably perform a surgery adequately and safely. Unfortunately, resources are limited. Time, monetary and geographical constraints often limit the ubiquitous dissemination of new surgical knowledge, skills and techniques. The inability to provide adequate training opportunities and support for surgeons in the community continues to be the limiting factors determining the success and widespread availability of laparoscopic surgeries. Thankfully, with the ever-increasing push to incorporate technological advances into the medical field, we are now able to overcome these barriers. In this chapter we outline how the recent progress in technology and telecommunication has led to the advent of telemedicine – an ingenious solution to our current problem, which will allow for the widespread availability of MIS and improve patient care.

Right Versus Left Laparoscopic Donor Nephrectomy: Initial 3 year Experience from a Single Centre Transplant Program

Laparoscopic living donor nephrectomy is the standard of care at high volume transplant centers. Despite this there is still reticence to harvest the right kidney laparoscopically because of concerns regarding the shorter renal vein, higher complexity of dissection and potentially higher complication rates and worse renal allograft outcomes. The aim of this single-center study of 72 consecutive laparoscopic donor nephrectomies was to compare left versus right-sided laparoscopic donors in terms of surgical difficulty, complication rates and outcomes. There were 56 left-sided and 16 right-sided donors. There was no significant difference in surgical outcomes or complication rates. Similarly, the recipient surgery complication rates and allograft outcomes were no different between kidneys procured laparoscopically from the left or the right. This single center study shows comparable donor operative parameters and recipient post-operative outcomes in left and right laparoscopic donor nephrectomies. Procuring the right kidney laparoscopically is safe and does not have a negative impact on donor recovery or long term graft function in the recipient.

Laparoscopic nephrectomy, ex vivo partial nephrectomy, and autotransplantation for the treatment of complex renal masses.

In the contemporary era of minimally invasive surgery, very few T1/T2 renal lesions are not amenable to nephron-sparing surgery. However, centrally located lesions continue to pose a clinical dilemma. We sought to describe our local experience with three cases of laparoscopic nephrectomy, ex vivo partial nephrectomy, and autotransplantation. Laparoscopic donor nephrectomy was performed followed by immediate renal cooling and perfusion with isotonic solution. Back-table partial nephrectomy, renorrhaphy, and autotransplantation were then performed. Mean warm ischemia (WIT) and cold ischemic times (CIT) were 2 and 39 minutes, respectively. Average blood loss was 267 mL. All patients preserved their renal function postoperatively. Final pathology confirmed pT1, clear cell renal cell carcinoma with negative margins in all. All are disease free at up to 39 months follow-up with stable renal function. In conclusion, the described approach remains a viable option for the treatment of complex renal masses preserving oncological control and renal function.

Kidney paired donation and the unique challenges of kidney shipment in Canada

SUMMARY Kidney paired donation (KPD) programs are an effort to bridge the disparity between kidney supply and demand. These programs combine several incompatible donor-recipient pairs in a national paired exchange database, thereby increasing the number of compatible matches. But KPD programs face unique challenges, particularly the large distances that often separate donors and recipients. Here we discuss key factors to consider when transitioning from a donor travelling model to a kidney shipment model in the Canadian context.