Review of the article "First experience of superselective embolization of renal arteries supplying the tumor with subsequent laparoscopic kidney resection"

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First experience of superselective embolization of renal arteries supplying the tumor with subsequent laparoscopic kidney resection

Background. Patients with signs of tumor lesions in a single kidney or in the only one functioning kidney, with bilateral renal tumors are at high risk of functional failure or insufficiency of the kidney after surgery. Joint discussions with specialists in X-ray endovascular surgeries resulted in the development of a treatment algorithm for patients with localized kidney cancer who require organ-sparing surgery without ischemic kidney resection.Objective: to evaluation of the immediate results of two-stage surgical treatment of localized kidney cancer in patients with signs of tumor lesions in a single kidney or in the only one functioning kidney, with bilateral renal tumors, including superselective embolization of the artery supplying the tumor at the first stage, and laparoscopic kidney resection without renal ischemia parenchyma at the second stage.Materials and methods. This study included 5 patients with localized kidney cancer, who underwent two-stage treatment at Moscow Regional Oncology Dispensary between 24.03.2021 and 19.04.2021. The first stage included superselective embolization of the artery supplying the tumor; the second stage implied laparoscopic kidney resection 6-7 days following the first stage.Results. The median age of the patients was 62 years (range: 42-73 years). Four patients (80%) had unilateral kidney lesions, while 1 patient (20 %) had bilateral (synchronous) kidney cancer. The mean RENAL score was 8 (range: 6-10); patients were distributed as follows: score 4-6 in 40 %, score 7-9 in 40 %, and score >10 in 20 % of patients. At the first stage, patients underwent endovascular embolization of the branches of the renal artery. Patients had superselective embolization of either middle (n = 3; 60 %), upper (n = 1; 20 %), or lower (n = 1; 20 %) segmental arteries supplying the tumor. In one of them (20 %), we identified 3 large arterial branches; in another one (20 %), we identified 2 large arterial branches.At the second stage, we performed laparoscopic kidney resection. None of the patients required renal artery clamping, because there was an excellent visualization of the demarcation zone and no significant blood loss. The resection area was sutured in 1 case (20 %). In 2 individuals (40 %), a hemostatic sponge was installed in the removed tumor bed. In the remaining 2 cases (40 %), hemostasis was ensured by coagulation. The median blood loss was 100 mL (range: 50-200 mL). The postoperative period was uneventful in all patients. None of the patients developed symptoms of acute renal failure.Conclusion. Thus, superselective embolization of arteries supplying a kidney tumor has undeniable advantages in organ-sparing surgeries for patients with localized kidney cancer and some additional kidney problems, when organ preservation is crucial for patient's life.

SOME FEATURES OF THE KIDNEY SCAR FORMATION AFTER SURGERY IN THE EXPERIMENT

Objective. To study the features of scar formation and structural changes in the remaining renal parenchyma in rats after the kidney resection in various terms. Methods. A layeredclosure of midline laparotomy and the caudal part of the left kidney removal was performed in rats under general inhalation ether anesthesia in a clean operating room. The morphology of the remaining kidney part after resection was studied using light microscope in different terms. Results. Athrombusfrom blood leaking outof the cut vessels is formed on the damaged surface of the kidney immediately after the resection. This clot with the parenchyma is gradually replaced by the connective tissue along the edge of the defect with the subsequently formation of a thin connective or fibrous tissue scar. However, in many cases, the number of which in rats can reach 40%, the processes of kidney damage continue for a long time after surgery, and leading to total or subtotal nephrosclerosis. The detected cystic change in tubular structures, apparently, occurred firstly due to their intersection during the resection, clamping by a blood clot and / or compression by edema distal to the observation site. Then, the forming extensive scar again clamped the adjacent tubular structures with subsequent cystic degeneration and sclerosis. In this case, detritus formed from non-viable renal tissues is eliminated by macrophages, which can form multinucleated cells with fused cytoplasm. Conclusion. Structural changes in the nephrosclerosis progression after kidney resection consist in the gradual replacement of the all renal cortical and medullar parenchyma by the connective tissue. This is not associated with the autoimmune process, but is more likely due to both impaired urine outflow after intercut of the tubular structures at resection and/or compression by edema, inflammatory infiltrate, forming or organizing scar, and vascular disorders associated with these causes. The inflammation accompanying necrosis and sclerosis of the renal structures can become granulomatous. What this paper adds For the first time, it has been shown that the progressively enlarging scar can be formed after the kidney resection, resulting in total nephrosclerosis. Such changes develop both due to the intersection of the tubular structures during the resection and their compression by edema, inflammatory infiltrate, forming or organizing a scar, and vascular disorders due to the above-mentioned causes.

Laparoscopic kidney resection in a child with unilateral Wilms tumor

The modern Wilms tumor treatment protocols used all over the world can cure up to 90 % of children. Such successes make it possible to actively introduce risk-adapted therapy methods aimed at de-escalating the chemotherapy regimen and radiation therapy impact to the tumor. The most conservative was the stage of surgical treatment, implying the organ-depleting nature of the surgery. Nevertheless, over the past decade, a lot of experience has been accumulated with both nephron-sparing and minimally invasive interventions in patients with both bilateral and unilateral Wilms tumor.We presented the experience of laparoscopic kidney resection with intraoperative ultrasound control in a child with unilateral Wilms tumor, receiving treatment at the N.N. Petrov National Medical Research Center of Oncology.

Evaluation of the corrective effect of therapeutic plasmapheresis on the state of renal function in patients after surgical treatment of localized kidney cancer

Purpose of the study. To assess the state of renal function in the application of therapeutic plasmapheresis in order to correct the disorders accompanying the development of preclinical stage of AKI in patients after partial nephrectomy under conditions of warm ischemia.Patients and methods. We examined 119 patients (average aged 57.6±7.8 years) from 2018 to 2019, who underwent open or laparoscopic kidney resection for cancer according to elective indications and with the usage of standard WIT technique within 15-21 minutes. Patients with a high risk of developing a clinical stage of AKI (n=21) were divided into 2 groups: in group I (n=10), patients continued to receive standard nephroprotective therapy, in group II (n=11), 24 hours after surgery, therapeutic plasmapheresis was performed according to the TPE (Therapeutic plasma exchange) protocol. During 7 days after the surgery patients in both groups were monitored daily for the rate of hourly diuresis, serum creatinine, and creatinine GFR. The presence of significant differences in the groups was evaluated using the STATISTICA 12.6 software package and the differences between the samples were considered significant at p<0.05.Results. The development of the clinical stage of AKI in group I was detected in 80.0 % of cases, in group II in 9.0 % of patients (p=0.0019). The rate of diuresis in group II was significantly higher: by more than 2 times by day 3, by 90.0 % on day 4, by 81.4 % on day 5, by 36.8 % on day 6, and by 25.4 % on day 7 (p<0.05). The average increase in creatinine in group I was significantly higher: more than 5 times on day 5 and more than 4 times on day 6 and 7 of the study (p<0.05). GFR in group II was significantly higher on day 3 (65.3 %), day 5 (54 %), day 6 (39.2 %) and day 7 (50 %) (p<0.05).Conclusion. Therapeutic plasmapheresis is highly effective in the correction of renal function disorders after kidney resection under WIT conditions and demonstrates an advantage in reducing the risk of developing a clinical stage of AKI in comparison with preventive measures that include standard nephroprotective infusion therapy.

IS THERE A FUTURE FOR SINGLE PORT LAPAROSCOPIC SURGERY?

Aim. To identify a perspectives for using a single incision laparoscopic technologies in surgery.Materials and methods: Today we have a several questions relating to a single incision laparoscopic surgery such as the possible spectrum of their application, safety and economic efficiency. The main is: does this technologies have a perspectives in future.In paper was performed a retro and prospective analysis of the data of modern literature and authors own experience in surgical treatment using a single incision laparoscopic technologies.Results: The study included 74 patients who underwent: cholecystectomy – 64 (86,5%), nephrectomy – 4 (5,4%), ovarian cyst removal – 4 (5,4%), kidney resection – 2 (2,7 %), using various kind of ports: “X-Cone Karl Storz” (28), “Covidien” (18), “PPP” (7), and 21 cases of multi-trocar access.Conclusions: Our opinion that the perspectives for the development of single incision laparoscopy, is the further development of endoscopic devices, including robotic ones, and we believe that it will be a real future and endoscopic surgeons should be ready for this.

Experience of performing laparoscopic organ-preserving operations in treatment of kidney tumors

Purpose: to conduct a comparative assessment of the effectiveness and safety of laparoscopic kidney resections for benign and malignant neoplasms with and without vascular isolation of the organ. Materials and methods: the research presents a comparative analysis of the direct results of treatment of 182 patients who underwent laparoscopic kidney resection. Among them there were 94 men (51,7 %) and 88 women (48,3 %). The average age was 61,6 ± 6,2 years. Two main methods were used: kidney resection with vascular isolation and without vascular ischemia. Surgical treatment was performed for malignant neoplasms in 152 cases (86,5 %) and for benign neoplasms in 24 cases (13,6 %). We used the methods of laparoscopic resection of the kidney with total vascular ischemia in 44 cases (24,2 %) and without vascular ischemia in 138 patients (75,8 %). Results: the average duration of surgery was 80 ± 18,5 minutes. The average duration of the operation with the use of vascular ischemia was 122,1 ± 17,5 minutes, without ischemia — 81,7 ± 10,6 minutes. The volume of intraoperative blood loss averaged 174,4 ± 20,1 ml, while this indicator when using the ischemic-free technique was 154,2 ± 15,7 ml, which is 32,9 % less (p> 0,05) than in cases with the use of vascular isolation (230,1 ± 20,8 ml). When using the technique of vascular isolation, the serum creatinine has increased for 16,2 ± 1,7 μmol / L (16,7 %), without vascular isolation 6,5 ± 1,5 μmol / L (6,7 %). Conclusion: laparoscopic kidney resections without vascular isolation are characterized by a lower volume of intraoperative blood loss, a shorter operation time and are not accompanied by an increase in the number of postoperative complications.

Hypertensive nephropathy as an outcome of unilateral nephrectomy in kidney cancer

Aim. To study the adaptive mechanisms of structural and functional changes in a single kidney after nephrectomy for kidney cancer. Materials and Methods. A total of 179 operations of two types were performed: nephrectomy and kidney resection in patients with cancerous lesions. Postoperative ultrasound was performed size control and dopplerography of the vessels of the contralateral single kidney, monitoring-control of blood pressure. Results. In case of kidney resection, the adaptive mechanisms controlling the volume of functioning tissue are preserved. The load on the organ remains minimal and physiological, and is not redistributed, blood pressure remains close to baseline. Nephrectomy does not lead to functional changes in a single kidney, but to adaptive and pathophysiological structural damage as a result of increased plasma pressure, organ reboot, its vicarious hypertrophy, which is accompanied by venous edema of interstitium as a pressure factor on the tissue, increased tone of arterioles, the development of secondary organ ischemia, circulatory hypoxia and increased blood pressure. All this fits into the clinical picture of hypertensive nephropathy. Conclusions. The potential risk of hypertension and hypertensive nephropathy in patients undergoing nephrectomy, compared with patients after organ-saving surgery, is significantly higher. One of the most important manifestations of hypertension in the elderly is a violation of the structure and function of target organs, which include: the brain, heart, blood vessels, kidney. Nephrectomy forms a pathological vicious circle, contributing to the development and further progression of renal and cardiovascular failure.

Electrocoagulation with greased lidocaine gel 2% as hemostatic maneuver after minimally invasive partial nephrectomy: Experimental and preliminary clinical results

Methods: Experimental phase: Performed a partial nephrectomy off clamp in pig model followed by cauterization of lidocaine gel 2% with different power (control, 30W, 50W and 100W) in the kidney resection bed to evaluate efficacy and deep injury extension. Clinical phase: 20 patients submitted to laparoscopic or partial nephrectomy for low risk RENAL score were utilized greased lidocaine gel 2% with 50W in cautery scalpel to hemostasis of renal parenchima to validate efficacy and safety. Results: Experimental study shows that this technique is effective and promote better hemostasis with 50W and 100W, with deep injury of less than 3 mm. Clinical study confirm efficacy, good control of hemorrage, few complications and no transfusion. Minimal changes in hematocrit, haemoglobin and creatinine were observed. Conclusion: In this preliminary experience the use of this new alternative to hemostasis for low risk partial nephrectomy was satisfactory and with good intra and postoperative results. The best advantages were safety in terms of the depth thermal injury, low cost and absence of artifacts over the resection area observed at CT scan postoperatively.

Laparoscopic removal of a kidney tumor after superselective embolization of the kidney vessels

The study objective is to evaluate the effectiveness of using superselective embolization of the renal arterial bed prior to organ-preserving laparoscopic kidney tumor resection.Materials and methods. At the Center for Urology, Kidney Transplantation and Nephrology of the National Research Oncology Center (Nur-Sultan, Kazakhstan) between 2015 and 2019 laparoscopic kidney tumor resection was performed in 45 patients; in 9 patients with stage T1 kidney tumors, superselective embolization was also performed. Mean age of the patients was 54 years, mean tumor diameter was 2.8 cm. Localization near the kidney pole and presence of an artery isolatedly supplying the tumor were the main indications for superselective embolization of the feeding artery prior to kidney resection.Results. Mean blood loss was 280 ml. Complications characteristic of post-embolization period (pain, fever, arterial hypertension), as well as loss of function of the organ, were absent 3, 6 and 12 months after the procedure per laboratory and radiological examinations.Conclusion. Superselective embolization of the tumor feeding artery is an effective method allowing to minimize warm ischemia of the renal parenchyma and perform kidney resection with minimal blood loss.The authors declare no conflict of interest.All patients gave written informed consent to participate in the study and to the publication of their data.