Wesley A. Mayer

Comparison of laparoendoscopic single site (LESS) and conventional laparoscopic donor nephrectomy at a single institution

Most transplant centres harvest living donor kidneys via a conventional laparoscopic surgical approach. Laparoendoscopic single‐site donor nephrectomy (LESS‐DN) is a relatively novel minimally invasive approach that allows the surgery to be performed via a single incision. This technique may be advantageous in decreasing surgical morbidity and improving cosmetic outcomes, thus plausibly reducing the barriers to kidney donation. The study demonstrates the safety and feasibility of LESS‐DN in a large consecutive series of kidney donors. Comparative analysis between LDN and LESS‐DN showed that there was a significant decrease in intra‐operative blood loss and allograft warm ischaemia time in the LESS‐DN group, but also a significant increase in operating time. Other peri‐operative outcomes were similar between the two approaches. Evaluation of the LESS‐DN cases alone revealed that, the operating times did not significantly change through the course of the series. Using this outcome as a surrogate for technical difficulty suggests a relatively shallow learning curve for LESS‐DN.

Clinical analysis of the PADUA and the RENAL scoring systems for renal neoplasms: A retrospective study of 245 patients undergoing laparoscopic partial nephrectomy

To investigate the clinical significance of preoperative aspects and dimensions used for anatomic (PADUA) and radius exophytic/endophytic nearness anterior/posterior location (RENAL) scoring systems for renal neoplasms in patients undergoing laparoscopic partial nephrectomy.

To Dust or Not To Dust: a Systematic Review of Ureteroscopic Laser Lithotripsy Techniques

Purpose of ReviewThis review discusses factors affecting outcomes during ureteroscopy (URS) with laser lithotripsy (LL), explores specific clinical challenges to the efficacy of URS LL, and reviews the available literature comparing the dusting and basketing approaches to URS LL.Recent FindingsData show high stone-free rates with URS LL in all locations of the urinary tract and with all stone types and sizes. Recent data comparing LL with dusting versus basketing suggest higher rates of residual fragments with dusting but less utilization of ureteral access sheaths and potentially shorter operative times. Differences in postoperative complications, re-intervention rates, and other outcome parameters are not yet clear. Interpretation of published data is problematic due to variability in laser settings, follow-up intervals, and definitions for what constitutes stone-free status.SummaryURS has overtaken shock wave lithotripsy in the last decade as the most commonly utilized surgical approach for treating urolithiasis. Two primary strategies have emerged as the most common techniques for performing LL: dusting and basketing. There is a relative paucity of data examining the difference in these techniques as it pertains to peri-operative outcomes and overall success. We attempt to synthesize this data into evidence-based and experience-based recommendations.

A 60-year-old Woman With an Incidentally Discovered Right Renal Mass

CASE REPORT 60-year-old woman presented to our clinic for evaluation of a right renal mass, incidentally Adiscovered on a computed tomography (CT) scan obtained during a workup for shortness of breath. Her medical history was significant for hypertension, hyperlipidemia, hypothyroidism, and asthma. She had undergone several abdominal surgeries, including laparoscopic gastric banding, splenectomy, hysterectomy, and bilateral salpingo-oophorectomy. She denied a history of tobacco, heavy alcohol, or illicit drug use. She had no family history of kidney disease or genitourinary malignancy. On a review of systems, she reported intermittent nausea, vomiting, and dyspepsia but denied fevers, night sweats, weight loss, gross hematuria, dysuria, or a change in bowel habits. Her vitals signs were within normal limits, and her body mass index was 32.4 kg/m. Her abdomen was soft, not distended, and without palpable masses, although several surgical scars were present. Routine laboratory tests, including complete blood count, electrolytes, creatinine, coagulation studies, and urinalysis, were performed. The complete blood count with differential demonstrated mild thrombocytosis (473 K/ mL) and leukocytosis (13 K/mL) but was otherwise normal. The results from the remainder of the laboratory studies were also within normal limits. A CT scan with intravenous contrast of the abdomen and pelvis obtained 1 month before her clinic evaluation revealed a 3.4 3.0-cm, enhancing mass located in the posterior mid-pole cortex of the right kidney (Fig. 1). No additional masses were seen in the remainder of the right kidney. The left kidney and both ureters appeared normal. No retroperitoneal lymphadenopathy or other intra-abdominal abnormalities were identified.

Intermediate-Term Outcomes of Dual Adult versus Single-Kidney Transplantation: Evolution of a Surgical Technique

Background. Acceptance of dual kidney transplantation (DKT) has proven difficult, due to surgical complexity and concerns regarding long-term outcomes. We herein present a standard technique for ipsilateral DKT and compare outcomes to single-kidney transplant (SKT) recipients. Methods. A retrospective single-center comparison of DKT and SKT performed between February 2007 and July 2013. Results. Of 516 deceased donor kidney transplants, 29 were DKT and 487 were SKT. Mean follow-up was 43 ± 67 months. DKT recipients were older and more likely than SKT recipients to receive an extended criteria graft (p < 0.001). For DKT versus SKT, the rates of delayed graft function (10.3 versus 9.2%) and acute rejection (20.7 versus 22.4%) were equivalent (p = ns). A higher than expected urologic complication rate in the DKT cohort (14 versus 2%, p < 0.01) was reduced through modification of the ureteral anastomosis. Graft survival was equivalent between DKT and SKT groups (p = ns) with actuarial 3-year DKT patient and graft survivals of 100% and 93%. At 3 years, the groups had similar renal function (p = ns). Conclusions. By utilizing extended criteria donor organs as DKT, the donor pool was enlarged while providing excellent patient and graft survival. The DKT urologic complication rate was reduced by modification of the ureteral anastomosis.

Percent of Tracer Clearance at 40 Minutes in MAG3 Renal Scans Is More Sensitive Than T1/2 for Symptomatic Ureteropelvic Junction Obstruction

OBJECTIVE To increase the diagnostic sensitivity of standard MAG3 diuretic renal scans for ureteropelvic junction obstruction (UPJO) by exploring the utility of an alternative measurement P40, the percentage of maximal tracer counts present at 40 minutes. MATERIALS AND METHODS Patients with strong clinical and anatomic evidence for UPJO may have a normal T1/2, making definitive diagnosis difficult. We reviewed the charts of 142 consecutive patients who underwent successful laparoscopic or robotic-assisted laparoscopic pyeloplasty for UPJO between 2005 and 2015. Both pre- and postoperative renal scan images were available for 37 symptomatic patients with primary unilateral UPJO and 2 kidneys. We defined P40 as the percentage of maximal tracer counts present at 40 minutes. We identified the upper limit of normal (97.5th percentile, +2SD) for P40 using the preoperative renal scans from the unaffected kidney. We compared the sensitivity of P40 to T1/2 to identify symptomatic UPJO. RESULTS In our cohort, 51% of symptomatic patients (n = 19) had a normal T1/2 (median 8.9 minutes; interquartile range: 7.5 minutes) and 49% (n = 18) had an abnormal T1/2 (median: 40 minutes; interquartile range: 0 minute). None of the patients had an abnormal P40 on their unaffected kidney. All patients with an abnormal T1/2 also had an abnormal P40. P40 increased the sensitivity of the renal scan from 49% (n = 18 of 37) to 73% (n = 27 of 37) when compared to T1/2. The majority of patients (95%) demonstrated an improvement in P40 after pyeloplasty. CONCLUSION P40 markedly increases the sensitivity of a renal scan for diagnosing symptomatic UPJO and may be another valuable marker in addition to T1/2 to document functional improvement in drainage after pyeloplasty.