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Nephrology Dialysis Transplantation

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  • 1. Nephrol Dial Transplant (1998) 13: 1221–1225 Nephrology Dialysis Original Article Transplantation Laparoscopic nephrectomy: comparison of dialysis and non-dialysis patients Paolo Fornara, Christian Doehn, Gianpiero Miglietti, Lutz Fricke1, Jurgen Steinhoff1, Klaus Sack1 ¨ and Dieter Jocham Department of Urology, and 1Department of Internal Medicine, Medical University of Lubeck, Lubeck, Germany ¨ ¨ Abstract Introduction Background. Laparoscopy is believed to result in pos- sible clinical benefits for the patient. We report our Laparoscopic nephrectomy was first performed in 1990 experience with renal laparoscopy in dialysis patients by Clayman and colleagues [1]. Since then, many and compare the results with those from non-dialysis urological centres have adopted this minimally invasive patients. technique. Most complications of laparoscopic neph- Methods. Between December 1994 and April 1997, 19 rectomy occur during the postoperative period [2,3]. dialysis patients underwent laparoscopic nephrectomy A potential problem is bleeding during laparoscopy or nephroureterectomy at our hospital. The group that requires adequate control and, if not controlled consisted of 11 female and eight male patients (mean during laparoscopy, immediate laparotomy. This age 45 years). In nine patients the indication for bleeding has been shown to occur in 0.93 cases per nephrectomy was chronic pyelonephritis. Nephro- 10 000 gynaecological laparoscopies [4,5]. ureterectomy for vesicoureteral reflux with recurrent Little is known about renal laparoscopy in dialysis episodes of pyelonephritis or analgesic nephropathy patients. These patients are thought to possibly have for exclusion of transitional cell carcinoma of the an affected blood clotting system with increased occur- upper urinary tract was considered in nine other rences of both bleeding and thrombosis when patients. Laparoscopic bilateral nephrectomy for drug- compared with non-dialysis patients. Bleeding, spon- resistant hypertension was performed in one patient. taneously or from tissue traumatization, is mainly In comparison, a consecutive group of non-dialysis associated with platelet dysfunction and reduced capil- patients who had undergone renal laparoscopy was lary resistance [6,7]. Thrombosis may be evident, reviewed. however, due to arteriosclerosis, hypercoagulation or Results. In the dialysis group, one patient had to be hypofibrinolysis [8,9]. converted to open nephrectomy due to bleeding. Six In this paper we report our experience with 19 dialysis patients required blood transfusions compared dialysis patients who underwent laparoscopic nephrec- with none in the non-dialysis group. There were four tomy for benign diseases at the Medical University of complications in the dialysis group and two in the Lubeck and compare the results with those from non- ¨ non-dialysis group. Both groups had comparable dialysis patients. results for operative times, analgesic consumption, postoperative start of oral intake and mobilization, and duration of hospitalization and convalescence. Subjects and methods Conclusions. Laparoscopic nephrectomy in dialysis patients has acceptable results. The higher transfusion Patients rate is probably due to a lower preoperative haemo- globin and is not aggravated by possible affects of the Between December 1994 and April 1997, 19 dialysis patients clotting system in patients with chronic uraemia. underwent laparoscopic nephrectomy or nephroureterectomy for various benign diseases at our institution (Table 1). The group comprised 11 female and eight male patients with a Key words: bleeding; complications; haemodialysis; mean age of 45 years (range, 24–70). The mean duration of laparoscopy; nephrectomy; nephroureterectomy; haemodialysis was 60 months (range, 6–180). Four patients uraemia had previously undergone renal transplantation but had lost allograft function due to chronic rejection. No patient received immunosuppressive medication at the time of Correspondence and offprint requests to: Paolo Fornara, M. D., laparoscopy. Deputy Director, Department of Urology, Medical University of Twelve patients had either laparoscopic nephrectomy (n= Lubeck, Ratzeburger Allee 160, D-23538 Lubeck, Germany. ¨ ¨ 9) or nephroureterectomy (n=3) for chronic pyelonephritis © 1998 European Renal Association–European Dialysis and Transplant Association
  • 2. 1222 P. Fornara et al. Table 1. Demographic data carefully. The Verres needle was inserted periumbilically and carbon dioxide insufflated to an initial intra-abdominal pres- Dialysis Non-dialysis sure of 12–15 mmHg. patients patients For simple nephrectomy 3–5 trocars were placed after transillumination of the inside abdominal wall using the Number of patients 19 20 endocamera. The operating table was rotated to the non- Sex (female/male) 11/8 12/8 affected side. The peritoneum was incised along the line of Mean age, years (range) 45 (24–70) 38 (20–73) Toldt and the colon mobilized and retracted medially. The Period 12/94–4/97 9/95–3/96 ureter was identified above its cross over the iliac vessels and Laparoscopic procedures ligated using clips. Following the proximal ureter, the renal Unilateral nephrectomy 9 12 hilum was exposed and the renal vessels ligated. The renal Bilateral nephrectomy 1 1 artery was divided between clips and in most cases the vein Unilateral nephroureterectomy 9 7 was secured using a vascular stapler. Dissection of the remaining fat and connective tissue was completed for full mobilisation of the kidney. with or without vesicoureteral reflux. Six patients with known For nephroureterectomy the patient was placed in a semi- analgesic abuse underwent laparoscopic nephroureterectomy flank position and 4–6 trocars were used. The kidney was for exclusion of transitional cell carcinoma of the upper mobilized completely followed by downward dissection along urinary tract prior to a planned renal transplantation. One the ureter. The ureter was clipped at the vesicoureteral patient with drug-resistant hypertension was selected for junction. A cuff on the bladder was not removed. laparoscopic bilateral nephrectomy. The technique of laparoscopic bilateral nephrectomy was In comparison, a consecutive group of non-dialysis patients as described previously [10]. was reviewed (Table 1). These patients underwent laparos- In all cases the kidney and ureter were placed in an organ copy at our institution between September 1995 and March entrapment sack and removed through an extended skin 1996. There were 12 patients who had a laparoscopic nephrec- incision. A morcellation of the kidney was not performed. tomy for non-functioning and chronically infected kidneys. Finally, the intra-abdominal pressure was reduced to Seven patients had a laparoscopic nephroureterectomy for 5 mmHg and the abdomen examined for bleeding. Trocars vesicoureteral reflux. One renal transplant patient had a were removed one after the other under direct vision. The laparoscopic bilateral nephrectomy for drug-resistant fascia of incisions larger than 5 mm were closed with inter- hypertension. rupted absorbable sutures. The skin was approximated with non-absorbable sutures or clips. A full blood count, clotting parameters, creatinine and Preoperative investigations electrolytes were taken 4–6 h after the operation and on a daily basis thereafter. In dialysis patients, intravenous or Most patients were admitted the day before the operation oral fluid replacement was restricted according to individual for routine preoperative investigations. Patients had been urine output. Haemodialysis was performed on the day of instructed to discontinue drugs affecting platelet function the operation when indicated (for example in cases of elevated (for example acetylsalicylic acid) during the week before the potassium in serum or fluid overload ), or routinely the day operation. None of the patients had a known dysfunction of after. Indications for blood transfusions were either haemo- the clotting system. Routine coagulation tests such as partial globin below 6.5 g/l or clinical symptoms such as angina thromboplastin time, prothrombin time, thrombin time and or dyspnea. fibrinogen were within the normal range prior to laparoscopy. Patients with vesicoureteral reflux had a reflux cystogram and a cystoscopy before the operation. Patients with known Results analgesic abuse had a cystoscopy to exclude transitional cell carcinoma of the bladder. Haemodialysis was performed on the day before laparos- Dialysis group copy in all patients. A 10 mg suppository of bisacodyl was The mean operative time was 96 min (range, given on the evening before the operation and oral intake was stopped at least 10 h before laparoscopy. According to 40–170 min, Table 2). Mean estimated blood loss results from previous urine cultures, adequate antibiotic during laparoscopy was 180 ml. Owing to bleeding, medication was given before laparoscopy. one conversion to open surgery was necessary. This patient had an operative revision 2 days after laparos- copy and required a total of 10 units of blood. Statistics and follow-up In the dialysis group, mean preoperative haemo- Statistical analysis for comparison of parameters for both globin was 116 g/l and dropped to 100 g/l 6 h after the groups was carried out using the Mann–Whitney U test. operation and 91 g/l the day after ( Table 3, all haemo- Follow-up data were obtained from patient charts, telephone globin values after blood transfusion). Five patients interviews and patient visits to our outpatient department. received 2 units of blood on the first or second day after the operation ( Table 3). Three patients had a Operative techniques postoperative haemoglobin below 6.5 g/l and two patients complained about angina and dyspnea despite Following the induction of general anaesthesia, a nasogastric a haemoglobin of 7.1 and 7.9 g/l, respectively. tube and bladder catheter were inserted in all patients. For A total of four postoperative complications occurred unilateral nephrectomy the patients were placed in a supine (21%). Two patients demonstrated postoperative eleva- or semiflank position. The arteriovenous fistula was padded tion of body temperature. In these cases antibiotic
  • 3. Laparoscopic nephrectomy 1223 Table 2. Comparison of operative parameters in dialysis and non-dialysis patients Dialysis patients Non-dialysis P-value (n=19) patients (Mann–Whitney (n=20) U test) Mean operative time, minutes (range) 96 (40–170) 110 (40–120) n.s. Number of complications (%) 4 (21) 2 (10) n.d. Mean time before starting oral intake, hours (range) 11 (7–27) 12 (6–32) n.s. Mean morphine equivalent, mg (range) 16 (0–88) 14 (0–40) n.s. Mean hospital stay, days (range) 7.3 (2–45) 4.9 (2–14) n.s. Mean time before resuming normal activities, days (range) 30 (9–144) 23 (8–44) n.s. Mean follow-up, months (range) 12 (3–31) 18 (16–22) n.d. n.d.: not done; Mann–Whitney U test: statistical significance with P<0.05; n.s.: not significant. Table 3. Comparison of blood loss from renal laparoscopy in dialysis and non-dialysis patients Dialysis patients Non-dialysis P-value (n=19) patients (Mann–Whitney (n=20) U test) Mean perioperative blood loss, ml (range) 180 (50–750) 190 (100–350) n.s. Number of patients receiving blood transfusions 6 0 <0.0001 Mean number of blood transfusions (range) 3.3 (2–10) 0 <0.0001 Mean preoperative haemoglobin, g/l (range) 116 (88–147) 131 (97–160) 0.002 Mean postoperative haemoglobin at 6 h, g/l (range) 100 (69–145) 111 (73–146) n.s. Mean postoperative haemoglobin at 24 h, g/l (range) 91 (66–134) 112 (86–140) <0.0001 Mean postoperative haemoglobin at 48 h, g/l (range) 88 (64–115) 119 (84–155) <0.0001 n.d.: not done; Mann–Whitney U test: statistical significance with P<0.05; n.s.: not significant. treatment was continued until the normalization of hospital stay and convalescence, and follow-up period, body temperature. Two patients had a thrombotic as well as statistical analysis, are given in Table 2. occlusion of the arteriovenous fistula that was treated conservatively (massage) in one patient and required surgical thrombectomy in the other. Discussion Oral intake and mobilization after successful laparo- scopy were started within 32 h after the operation. The Since the first laparoscopic nephrectomy in 1990 by mean hospital stay in this group was 7.3 days (range, Clayman and colleagues this procedure has become 2–45). The mean hospital stay was 5.2 days (range, routine at many urological centres [1]. Most patients 2–12) when excluding the patient who had a conver- undergo laparoscopic nephrectomy for benign disease. sion, an operative revision 2 days later and a total However, at some centres patients with renal cell hospital stay of 45 days. carcinoma or transitional cell carcinoma are also At a mean follow-up of 12 months (range, 3–31) all selected for laparoscopic nephrectomy [2]. Laparo- patients were alive and none demonstrated late scopic techniques can also be used efficaciously in complications. the renal transplant population and in paediatric patients [11,12]. Based on our experience with laparoscopic nephrec- Non-dialysis group tomy in non-dialysis patients, we performed laparo- The mean operative time was 110 min (range, scopic nephrectomy or nephroureterectomy in 19 40–210 min, Table 2). Mean estimated blood loss was dialysis patients. The results were compared with those 190 ml (range, 100–350) and no patient received a for a group of 20 consecutive non-dialysis patients blood transfusion ( Table 3). Mean preoperative hae- who underwent renal laparoscopy between October moglobin was 131 g/l and reached a postoperative 1995 and March 1996. Various clinical parameters such minimum of 111 g/l ( Table 3). as operative time, perioperative blood loss, consump- Two postoperative complications occurred (10%). tion of analgesics and complications other than throm- One patient developed a chest infection and required bosis of the fistula or blood transfusion rate were antibiotic treatment for 8 days. The patient made an comparable for both groups. These results are in uneventful recovery and the hospital stay lasted 14 accordance with those from large a series of laparo- days. Another patient had a urinary tract infection scopic nephrectomy in non-dialysis patients. Eraky that was brought under control with oral ciprofloxac- et al. [13] reported on 106 patients who underwent a ine. Data for consumption of analgesics, duration of laparoscopic nephrectomy. In nine patients a conver-
  • 4. 1224 P. Fornara et al. sion to open surgery was necessary, in three cases this acid may have elevated the risk for thrombosis of the was due to bleeding. Four major and 28 minor com- fistula. On the other hand, the arm was placed in a plications were noted. The perioperative blood loss hanging position above the body during laparoscopy. and the transfusion rate were not reported. In a However, as in all patients, the arm was carefully multicentre review reported by Gill et al. [2] laparo- padded and no perioperative episodes of hypotension scopic nephrectomy was carried out in 153 patients were present. In case of shunt thrombosis treatment with benign disease and in 32 patients with renal options include balloon dilatation, thrombolysis and malignancy. The complication rate was 16% and the mechanical thrombectomy. In a series of 44 dialysis conversion rate 5%. Perioperative blood loss and the patients who underwent various open surgical proced- number of blood transfusions were only reported for ures, three patients (6.8%) had shunt thrombosis [19]. patients who had complications. The estimated blood These results are comparable to ours and we believe loss ranged between 100 and 1500 ml in patients with that shunt thrombosis is not a specific problem of benign disease and between 75 and 2000 ml in those laparoscopic nephrectomy in dialysis patients. with malignancy. The number of blood transfusions In summary, our results show that laparoscopic required ranged between 0 and 6. nephrectomy in dialysis patients is associated with an In our study, only dialysis patients required blood increased number of blood transfusions when com- transfusions. When compared with non-dialysis pared with non-dialysis patients. This is probably due patients, however, dialysis patients had a significantly to a lower preoperative haemoglobin in the dialysis lower preoperative haemoglobin. Bleeding may result group. When perioperative haemostasis can be from an injury of the intra-abdominal vessels or organs, achieved, the known affects of the clotting system in from the introduction of the Verres needle or trocars, patients with chronic uraemia do not seem to play a or during operative dissection. In our series, no major major role. Other operative and postoperative para- haemorrhage was observed during the laparoscopic meters are comparable with those from non-dialysis procedures. The mean perioperative blood loss of patients. Dialysis patients often have an increased risk 180 ml was similar for both the dialysis and non- for anaesthesia due to concomitant diseases. Despite dialysis group. Other reports also showed moderate this, laparoscopic nephrectomy is not associated with blood loss or bleeding complications in dialysis increased operative or postoperative morbidity in these patients. In 100 dialysis patients who underwent an patients. Finally, a shorter postoperative course can open bilateral nephrectomy prior to a planned renal be assumed for patients undergoing a laparoscopic transplantation, the mean estimated blood loss for nephrectomy when compared with open surgical non-polycystic nephrectomy was 215 ml using the flank techniques. approach and 358 ml for the midline approach [14]. This resulted in a mean intra-operative transfusion volume of 195 and 321 ml, respectively. Another series investigated an open bilateral nephrectomy in 305 References dialysis patients [15]. Renal bed bleeding occurred in 1. Clayman RV, Kavoussi LR, Soper NJ, Dierks SM, Meretyk S, six patients requiring a operative revision, and severe Darcy MD, Roemer FD, Pingleton ED, Thompson PG, Long gastrointestinal bleeding requiring blood transfusions SR. Laparoscopic nephrectomy: initial case report. J Urol 1991; was observed in seven patients. The overall blood loss 146: 278–282 and the transfusion rate were not given. 2. Gill IS, Kavoussi LR, Clayman RV, Ehrlich R, Evans R, Fuchs G, Gersham A, Hulbert JC, McDougall EM, Rosenthal Despite the fact that low preoperative haemoglobin T, Schuessler WW, Shepard T. Complications of laparoscopic in dialysis patients can be assumed to be a risk factor nephrectomy in 185 patients: a multi-institutional review. J Urol for a transfusion requirement, attempts must be made 1995; 154: 479–483 to reduce perioperative blood loss. Preparation of the 3. Capelouto CC, Kavoussi LR. Complications of laparoscopic surgery. Urology 1993; 42: 2–12 patient should include the early withdrawal of drugs 4. Thiel R, Adams JB, Schulam PG, Moore RG, Kavoussi LR. which affect platelet function such as acetylsalicylic Venous dissection injuries during laparoscopic surgery. J Urol acid or non-steroidal anti-inflammatory drugs [16 ]. 1996; 155: 1874–1876 During laparoscopy the renal artery is generally ligated 5. Bergqvist D, Bergqvist A. Vascular injuries during gynecologic between clips whereas the renal veins are secured using surgery. Acta Obstet Gynecol Scand 1987; 66: 19–23 6. Castillo R, Lozano T, Escolar G, Revert L, Lopez J, Ordinas a vascular stapler. It has been shown in animal studies A. Defective platelet adhesion on vessel subendothelium in that clips are as safe as sutures and superior to staples uremic patients. Blood 1986; 68: 337–342 when occluding the renal artery and applying supra- 7. Sagripanti A, Casalino F, Baicchi U, Barsotti G, Morelli E, physiologic pressures [17]. These observations, how- Giovannetti S. Effectiveness of a polypeptide fraction from ever, are difficult to transfer to dialysis patients factor VIII on the bleeding tendency of uremic patients. Schweiz Med Wochenschr 1991; 121(suppl 43): 127 undergoing laparoscopy. In some cases the use of 8. Varizi ND, Gonzales ED, Wang J, Said S. Blood coagulation, heparin-free dialysis might be helpful in reducing the fibrinolytic, and inhibitory proteins in end-stage renal disease: risk of bleeding [18]. effect of hemodialysis. Am J Kidney Dis 1994; 23: 828–835 In our series, two dialysis patients had postoperative 9. Canavese S, Stratta P, Pacitti A, Mangiarotti G, Racca M, Oneglio R, Vercellone A. Impaired fibrinolysis in uremia: partial thrombosis of the arteriovenous fistula. Both patients and variable correction by four different dialysis regimes. Clin had never before had problems with their fistula. On Nephrol 1982; 17: 82–89 one hand, preoperative withdrawal of acetylsalicylic 10. Fornara P, Doehn C, Fricke L, Durek C, Thyssen G, Jocham
  • 5. Laparoscopic nephrectomy 1225 D. Laparoscopic bilateral nephrectomy: results in 11 renal bilateral nephrectomy; analysis of 305 cases. Urology 1978; transplant patients. J Urol 1997; 157: 445–449 12: 55–58 11. Ehrlich RM, Gershman A, Fuchs G. Laparoscopic surgery in 16. Antiplatelet Trialists’ Collaboration. Collaborative overview of children. J Urol 1994; 151: 735–739 randomised trials of antiplatelet therapy. II. Maintenance of 12. Fornara P, Doehn C, Fricke L, Hoyer J, Jocham D. Laparoscopy vascular graft or arterial patency by antiplatelet therapy. Br in renal transplant patients. Urology 1997; 49: 521–527 Med J 1994; 308: 159–168 13. Eraky I, El-Kappany HA, Ghonheim MA. Laparoscopic neph- 17. Kerbl K, Chandhoke PS, Clayman RV, McDougall E, Stone AM, Figenshau RS. Ligation of the renal pedicle during laparo- rectomy: Mansoura experience with 106 cases. Br J Urol 1995; scopic nephrectomy: a comparison of staples, clips, and sutures. 75: 271–275 J Laparoendosc Surg 1993; 3: 9–12 14. Viner NA, Rawl JC, Braren V, Rhamy RK. Bilateral nephrec- 18. Schwab SJ, Onorato JJ, Sharar LR, Dennis PA. Hemodialysis tomy: an analysis of 100 consecutive patients. J Urol 1975; without anticoagulant. One-year prospective trial in hospitalized 113: 291–294 patients at risk for bleeding. Am J Med 1987; 83: 405–410 15. Yarimizu SN, Susan LP, Straffon RA, Stewart BH, Magnusson 19. Schreiber S, Korzets A, Powsner E, Wolloch Y. Surgery in MD, Nakamoto SS. Mortality and morbidity in pretransplant chronic dialysis patients. Isr J Med Sci 1995; 31: 479–483 Received for publication: 20.8.97 Accepted for publication: 11.1.98

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