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Urology & Kidney Disease News

For physicians, patients and those researching information about the latest developments in urological disorders and treatment options, Cleveland Clinic’s Glickman Urological & Kidney Institute provides Urology & Kidney Disease News.

The Institute has been sharing its research and innovations through this printed publication for 13 years. Now, in addition to the print version, we’re making even more information available through the online edition of Urology & Kidney Disease News

Topics in the 2014 digital UKD News include robotic and image-guided surgery, urologic oncology, chronic kidney disease research, kidney and pancreas transplantation, and urological best practices.

For the full line-up of online articles, see the index below.


Best Practices

Shared Medical Appointments Offer Opportunity to Enhance Chronic Care

Jennifer Hyland, RN, MSN, CNP, and James Simon, MD

Key Points:

  • Evidence suggests that patients with chronic medical problems such as chronic kidney disease stand to benefit from shared medical appointments (SMAs).
  • Less resource utilization and fewer emergency room visits are potential byproducts of SMAs.
  • Providers gain efficiency in the clinic with an opportunity to offer education to more patients in the shared appointment setting, thereby improving productivity.

Providing safe, effective, quality care to an aging and growing population with chronic medical problems remains a challenge in the ever-changing world of healthcare. Almost half of Americans have a chronic medical problem and at least 25 percent have multiple chronic conditions.

One significant challenge is to overcome reduced patient access to their providers due to demanding provider schedules and heightened expectations of productivity. The provider is expected to do more for the chronically ill patient with fewer resources available. In an effort to conquer these challenges at Cleveland Clinic, the Department of Nephrology’s Chronic Kidney Disease (CKD) clinic has begun offering shared medical appointments (SMAs) for patients with CKD Stages 3, 4 and 5.

An SMA is a 90-minute group session, with a provider (physician or certified nurse practitioner) leading the visit. Typically, eight to 12 patients are present at the office visit. The office visits have the same components as a traditional medical visit, except that a group of the patients’ peers is present to lend social support as each patient’s unique medical needs are addressed.

The SMA provides several benefits to both the motivated and unmotivated patient. Multiple studies in the past several years reveal an increase in patient satisfaction among several different chronically ill populations, including those with asthma, diabetes, obesity, arthritis, migraines and congestive heart failure. The enhanced patient satisfaction was a result of expanded access to the provider, more interaction time and an increase in the amount of education provided. Additional benefits include increased social support and improved coordination of care.

Patients tended to utilize fewer healthcare resources after attending SMAs. They had fewer refill requests, a decline in number of emergency room visits and less need for same-day add-on appointments. The patients began or increased the number of healthy behaviors they performed, such as changing their diet, increasing their intake of fruits and vegetables, and increasing the frequency of blood glucose monitoring.

Education remains a large part of the SMA, with more time available to provide it. The ability to have a multidisciplinary team that may include an MD, CNP, RN, registered dietitian or social worker is another advantage. These patients have the opportunity to learn how to manage their own chronic illness and the skills needed to do so. Patients have expressed a greater sense of trust in their providers, allowing for a more effective working relationship for disease management.

Providers also benefit from SMAs through greater efficiency in the clinic. They have the ability to dispense more education and more time to otherwise interact with their patients. There are financial benefits to SMAs as well. Providers may see a 200 percent to 300 percent improvement in productivity at the same time as they see a reduction in office costs.

The CKD SMA is available to most patients with CKD Stages 3, 4 and 5. The group is not stage-specific, allowing for greater variability and greater opportunity for education through the stages of CKD. Education topics include blood pressure management, diet, delaying progression of CKD and treatment options for end-stage renal disease. Laboratory results are reviewed in a group session, allowing for patients to identify with others in the same disease category. Patients have the opportunity to interact with each other to help in formulating a better treatment plan for themselves.

As the need persists for an innovative, productive way to approach chronic medical disease, SMAs will continue to gain in popularity. Treating the appropriate patient in a group session should eventually prove to be a more individualized, comprehensive visit than imagined.

Analyses in Laparoscopic Nephrectomy and Prostatectomy: Mechanical Bowel Preparation

Toru Sugihara, MD, MPH, and Michael Kattan, PhD

Key Points:

  • Preoperative mechanical bowel preparation (MBP) is considered standard care for surgery involving the abdomen or pelvic area.
  • MBP is an uncomfortable experience for patients, and studies have shown that a majority of patients who received MBP reported a negative attitude toward their hospital stay and did not want to have MBP again.
  • We found no significant differences between non-MBP and MBP groups in terms of overall complications, operation time and postoperative length of stay.

Mechanical bowel preparation (MBP) is the mechanical removal of feces from the intestines. Preoperative MBP is considered standard care for surgery involving the abdomen or pelvic area. This procedure has been widely accepted among surgeons since its introduction by Sir William Halsted in the late 19th century. Dogmatically, it is believed that MBP is beneficial for reducing the volume of bowel contents and the total amount of bacteria in the colon.

Though the latest Cochrane review summarized that MBP is not an efficient procedure in open colon surgery, studies evaluating the benefit of MBP in laparoscopic surgery are still limited. Many laparoscopic surgeons opt for MBP preoperatively because they believe that MBP can decompress the bowel and make more room for surgery in the intra-abdominal space.

On the other hand, it is recognized that MBP may have multiple adverse side effects, including discomfort, insomnia, weakness, abdominal distension and an electrolyte disturbance, especially in dehydrated or elderly patients. Overall, these adverse events may serve to discourage preoperative MBP in some groups of patients.

To challenge the belief that MBP improves the efficiency of the laparoscopic surgery, we performed a retrospective multicenter study and compared laparoscopic surgeries with and without MBP in both prostatectomy and nephrectomy. In the study, we employed the Japanese Diagnosis Combination Procedure database, which is highly representative of that country, and detailed information on oncological staging and medications used for MBP.

The definition of MBP in the study was a preoperative medication including at least one of the following drugs, all of which were approved for preoperative MBP in Japan: polyethylene glycol electrolyte solution, magnesium citrate solution and sodium picosulfate. Because of the limitation of the database and a difference in clinical customs between Japan and the United States, evaluation of fast-track diet was not included in this study.

We found 154 non-MBP cases and 580 MBP cases in prostatectomy and 1,110 non-MBP cases and 1,630 MBP cases in nephrectomy. After making a background adjustment by using age, sex, oncological staging, preoperative pre-existing comorbidities and several institutional variables, we found no significant differences between non-MBP and MPB groups in terms of overall complications, operation time and postoperative length of stay. (Table 1)

This is the first study to analyze the effect of MBP in laparoscopic urological surgeries for a large number of patients. The data suggest that MBP would be safely omitted before these surgeries. Interestingly, in reviewing the background, we collaterally learned that MBP was more often used for patients with a higher comorbidity index and at the academic and high-volume hospitals. In addition, MBP was used in about 75 percent of prostatectomy cases and 60 percent of nephrectomy cases. This corroborates the prevalence of MBP in our specialty.

It is beyond dispute that MBP is an uncomfortable experience for patients. In addition, studies have shown that a majority of patients who received MBP reported a negative attitude toward their hospital stay and did not want to have MBP again. We hope that the evidence our study offers will help physicians foster an improvement in quality of care of patients and reduce patients’ pain during hospitalization.

Table 1. Comparisons of outcomes between laparoscopic surgeries with and without mechanical bowel preparation
  Prostatectomy Nephrectomy
  MBP Non-MBP p value MBP Non-MBP p value
n 580 154   1,630 1,100  
Complications 6.9% 6.5% 0.961 11.8% 11.4% 0.257
Operation time
(min)
250 222 0.194 278 268 0.674
Postoperative stay
(days)
10 11 0.383 10 10 0.586
MBP = mechanical bowel preparation
p values were calculated after multivariable adjustments.

Center for Robotics and Image-Guided Surgery

Robot-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Left Clinical Stage I Testicular Cancer

Jihad Kaouk, MD; Maria Carmen Mir, MD, PhD; Riccardo Autorino, MD, PhD; and Andrew  Stephenson, MD

Key Points:

  • A specific, efficient port configuration for left robotic retroperitoneal lymph node dissection (RPLND) appears to guarantee maximal range of motion for the robotic instruments, ultimately facilitating a meticulous and safe dissection.
  • As a result, robot-assisted unilateral left RPLND can be safely performed in minimally invasive fashion and according to accepted oncological principles.

Laparoscopic retroperitoneal lymph node dissection (RPLND) requires substantial technical experience and has failed to gain widespread acceptance. Robot-assisted laparoscopic RPLND seems to be the next logical step due to the improved quality of vision and range of motion. Only a few, very small case series on this robotic procedure have been reported to date. Here, we describe the features of a specific port placement and discuss the nuances of the surgical technique of robotic RPLND for left-side Stage I nonseminomatous germ cell tumor (NSGCT).

Case details
A 37-year-old male presented with a left intermediate risk (95 percent embryonal carcinoma and 5 percent yolk sac tumor, negative lymphovascular invasion) NSGCT. The patient’s body mass index was 31 kg/m2. Tumor markers were within normal limits at preoperative RPLND workup, whereas abdominopelvic CT showed a small (5-8 mm) interaortocaval lymph node. The patient was advised of the natural history of the disease as well as the treatment options, including observation, RPLND or chemotherapy. He elected to undergo a robot-assisted laparoscopic RPLND. This was a preventive RPLND for Stage I NSGCT, and the dissection of the interaortocaval lymph nodes was an extra procedure due to suspected lesion.

Operative details
The patient was positioned in 60-degree right-flank position with the left side up and the bed flexed. A 10-degree Trendelenburg was applied to the whole bed. Pneumoperitoneum was established using a Veress needle. A 12 mm camera port was placed about 10 cm cephalad to the umbilicus, halfway between the midline and the left pararectal line at the level of the tip of twelfth rib. Three 8 mm robotic trocars were placed on the same line, parallel to the midline. Space between them was about 10 cm (Figure 1). Two 12 mm assistant ports were located over the midline, one on the right umbilical edge and the other halfway between the two lower robotic trocars. The periumbilical assistant port was used for suction and instrument introduction. The lower assistant port was used to introduce a fan retractor in order to obtain an atraumatic retraction of the bowel medially. The robot was docked perpendicularly to the operative table (Figure 2).

The operation started with mobilizing medially the left colon by incising along the avascular line of Toldt. The left ureter and spermatic cord were identified, and both were isolated with vessel loops. A left modified bilateral template dissection with removal of the para-aortic nodes from the left renal hilum to the crossing of the left ureter over the common iliac vessels was performed. The interaortocaval lymph nodes were removed above the inferior mesenteric artery. As no future paternity was desired, no attempt was made to preserve the postganglionic sympathetic fibers. The para-aortic lymph nodes and left common iliac lymph nodes were dissected laterally off the anterior surface of the psoas muscle. The lymph nodes anterior and lateral to the aorta and left common iliac arteries were dissected off the vessels using a split-and-roll technique up to the root of the left renal artery. The lumbar arteries were clipped proximally and distally with Hem-o-lok® clips before division. At the cephalad extent of the dissection, Hem-o-lok clips were placed across the lymphatic tissue at the inferior border of the left renal artery. The left gonadal vein was divided at its insertion in the left renal vein after the Weck clips were placed proximally and distally. The lymph nodes were then dissected off the anterior surface of the spine and anterior psoas, with application of Hem-o-lok clips to control the lumbar veins.

Next, the lymph nodes were dissected off the inferior edge of the left renal vein to its insertion into the inferior vena cava. The interaortocaval lymph nodes were dissected medially off the interior vena cava and aorta using a split-and-roll technique up to the root of the right renal artery and inferiorly to the inferior mesenteric artery. The lumbar arteries and veins were clipped proximally and distally with Hem-o-lok clips before division. At the cephalad extent of the dissection, Hem-o-lok clips were placed across the lymphatic tissue at the inferior border of the right renal artery (Figure 3). The left spermatic cord was dissected to the internal inguinal ring. The lymph nodes and spermatic cord were placed in an Endo Catch™ bag for removal at the end of the procedure through one of the assistant ports.

Operative time was 200 minutes, and there were no perioperative complications. No drain was placed, and the Foley catheter was removed on postoperative day one. The postoperative course was uneventful, and the patient was discharged to home after 48 hours. Pathology revealed a count of 20 lymph nodes, all negative.
In conclusion, an efficient port configuration for left robotic RPLND seems to guarantee maximal range of motion for the robotic instruments, ultimately facilitating a meticulous and safe dissection. As a result, a robot-assisted unilateral left RPLND can be safely performed in minimally invasive fashion and according to accepted oncological principles.

Figure 1. Port placement (R: robotic ports, C: camera port, U: umbilicus, A: assistant ports). Camera port and assistant ports were all 12 mm diameter ports.

Figure 2. Operating room robotic docking and assistant’s positioning.

Figure 3. Vision of the left retroperitoneal space after dissection, interaortocaval dissection completed. A: left renal vein, B: aorta, C: inferior mesenteric artery, D: inferior vena cava. The limits of dissection were left ureter on the lateral side, mid aorta, renal hilum, and IMA-inguinal canal in the distal portion.

Robot-Assisted Laparoscopic Transabdominal Vasovasostomy

Jihad  Kaouk, MD; Dinesh Samarasekera, MD; Christopher Starks, MD; and Edmund Sabanegh Jr., MD

Key Point:

  • Robot-assisted microsurgical intra-abdominal techniques such as vasovasostomies are feasible. Advantages include elimination of surgeon tremor, excellent visualization, and precise dissection and suturing.

Microsurgical vasectomy reversal can be technically challenging. Recently, robot-assisted vasovasostomy has been performed by surgeons via a scrotal incision and may offer some advantage, including elimination of surgeon tremor and decreased surgeon fatigue. Here, we present a unique case of a transabdominal robot-assisted laparoscopic vasovasostomy.

Case details
A 34-year-old male underwent a transabdominal vasectomy at the time of a diagnostic laparoscopy for evaluation of inguinal hernias. He presented post-vasectomy with chronic bilateral orchalgia, which was unresponsive to analgesia. The patient had been evaluated by the chronic pain service and had no resolution of his symptoms. He was diagnosed with post-vasectomy pain syndrome and referred for a vasectomy reversal. He had three children with his current partner, and the couple was now interested in additional children. His body mass index was 27.67 kg/m2, and his past surgical history included the diagnostic laparoscopy/vasectomy and a laparoscopic cholecystectomy. A urinalysis was negative. All options were presented to the patient, and the decision was made to proceed with a robot-assisted laparoscopic vasovasostomy.

The patient was placed in the lithotomy position, in steep Trendelenberg. Port placement was similar to that of a radical prostatectomy, in a W configuration. The robot was docked between the patient’s legs in a standard fashion. The surgical clips on each vas were removed, and the vasovasostomy was performed with a 9-0 monofilament suture using a modified two-layer technique that involved quadrant full-thickness luminal stitches and additional interrupted seromuscular stitches after patency had been documented (Figure 1).

Operative time was 300 minutes, and estimated blood loss was less than 50 cc. There were no intraoperative complications. The patient was discharged to home the same day. Semen analysis six months post-procedure revealed normal volume and concentration, but 99 percent immotility. Anti-sperm antibody testing was positive, and the patient is being treated with steroid therapy. Additionally, he has had complete resolution of his post-vasectomy pain syndrome.

Transabdominal vasovasostomy is technically feasible. This represents a unique case, as most vasectomies are not done in a transabdominal fashion. However, this demonstrates the ability to perform complex reconstructive procedures robotically. Advantages include elimination of surgeon tremor, excellent visualization, and precise dissection and suturing with robotic micro instruments in the peritoneal cavity.

Figure 1: Vasovasostomy performed with 9-0 monofilament suture.

Minimally Invasive Heminephrectomy: A Specific Definition

Jihad Kaouk, MD

Key Points:

  • A heminephrectomy performed for a tumor in a nonduplicated system may be defined by excision of the upper or lower pole of the kidney, removing at least 30 percent of the parenchymal mass, cutting to hilar fat and transecting the collecting system.
  • This definition might allow precise clinical and research communication about heminephrectomy and may aid in the prediction of outcomes after partial nephrectomy.

Some renal tumors have a size or location that requires the resection of a significant portion of the renal parenchyma during a partial nephrectomy. Resection of approximately half the kidney in these complex cases is sometimes referred to as a heminephrectomy. The term is most commonly used when more than 30 percent of the renal mass is removed. A definition relying only on the amount of tissue excised, however, does not properly classify those procedures during which a large interpolar mass or an extensive exophytic mass is resected. Based on the following analysis, we propose a specific definition of heminephrectomy: excision of the upper or lower pole of the kidney, removing at least 30 percent of the parenchymal mass, cutting to hilar fat and transecting the collecting system.

Analysis details
Our Institutional Review Board-approved database was queried for those patients who underwent robotic or laparoscopic partial nephrectomy between 2002 and 2011 with resection of at least 30 percent of the renal parenchymal mass, exposure of hilar fat in the resection bed and opening of the renal collecting system. For purposes of determining the percentage of the kidney resected, total parenchymal mass was defined as the volume of the tumor plus the volume of the affected kidney. The percentage of renal parenchymal mass removed was estimated by the surgeon based on intraoperative findings and preoperative CT scan. These patients who underwent a robotic or laparoscopic heminephrectomy were compared with the remainder of patients who had a robotic or laparoscopic partial nephrectomy. Patients who had a “true” heminephrectomy for obstruction in a duplicated collecting system were excluded to reduce confusion. Patients with resection of half of a horseshoe kidney were also excluded.

Sixty-one out of 643 patients who underwent a minimally invasive partial nephrectomy for tumor during the study period met our definition of heminephrectomy. Of the heminephrectomies, 16 (26 percent) were performed laparoscopically and 45 (74 percent) were performed robotically, while 200 (34 percent) of the nonheminephrectomy partial nephrectomies were performed laparoscopically and 382 (66 percent) were performed robotically.

Table 1 summarizes the patient characteristics and comparative outcomes. The tumors in the heminephrectomy group were larger (5.1 cm vs. 2.8 cm, p < 0.001) and had a higher RENAL score (8.5 vs. 6.5, p < 0.001). Estimated blood loss (EBL) was greater (373 mL vs. 267 mL, p = 0.04), operative time was longer (214 minutes vs. 185 minutes, p < 0.001), warm ischemia time was longer (25 minutes vs. 20 minutes, p = 0.002), the rate of intraoperative complications was greater (5 [8 percent] vs. 15 [3 percent], p = 0.02), and the rate of conversion to radical nephrectomy was greater (4 [7 percent] vs. 1 [0.2 percent], p < 0.001) in the heminephrectomy group. Length of stay in the hospital was slightly longer in the heminephrectomy group (4.1 days vs. 3.5 days, p = 0.02). The decrease in glomerular filtration rate (GFR) from preoperative to most recent value was greater (mean −14.6 mL/min/1.73m2 vs. −7.6 mL/min/1.73m2, p = 0.03) in the heminephrectomy group. On multivariable analysis adjusted for age, preoperative GFR, RENAL score and warm ischemia time, heminephrectomy was a significant predictor of lower postoperative GFR (p < 0.001) and of greater decrease in GFR from preoperative to most recent GFR (p < 0.001).
Patients undergoing robotic vs. laparoscopic heminephrectomy were significantly more likely to have more comorbidities (Charlson index 3.4 vs. 1.4, p < 0.001), larger tumor size (5.6 cm vs. 3.7 cm, p = 0.002) and higher RENAL score (8.9 vs. 7.4, p < 0.001). Despite these factors — all of which make heminephrectomy significantly more difficult — the operative times, warm ischemia times and estimated blood loss were similar between the robotic and the laparoscopic heminephrectomy groups (Table 2).

Chronic kidney disease (CKD) upstaging occurred after heminephrectomy in 30 patients (49 percent) and never exceeded a one-stage increase. New-onset renal insufficiency (CKD Stage 3 or higher) developed in 12 patients (20 percent). No patient progressed to dialysis dependence.

In conclusion, this analysis shows that a heminephrectomy performed for tumor in a nonduplicated system may be defined by excision of the upper or lower pole of the kidney, removing at least 30 percent of the parenchymal mass, cutting to hilar fat and transecting the collecting system. This definition might allow precise clinical and research communication about heminephrectomy patients and may aid in the prediction of outcomes after partial nephrectomy. Robotic heminephrectomy is a safe and effective method to remove large renal polar masses.

Table 1. Heminephrectomy vs. nonheminephrectomy minimally invasive partial nephrectomy
Variable Heminephrectomy
n = 61)
Nonhemi Partial Nephrectomy
(n = 582)
p value
Technique, n (%)     0.2
Laparoscopic
Robotic
16 (26)
45 (74)
200 (34)
382 (66)
 
Age, years 59 ± 12 58 ± 12 0.7
Male, n (%) 35 (57) 339 (58) 0.9
BMI, kg/m2 30.2 ± 6.2 30.4 ± 7.3 0.9
Left sided, n (%) 23 (38) 279 (48) 0.3
Size on CT scan, cm 5.1 ± 2.1 2.8 ± 1.5 < 0.001
Solitary kidney, n (%) 2 (3) 21 (4) 0.8
Preoperative creatinine, mg/dL 1.02 ± 0.31 0.97 ± 0.32 0.3
Preoperative GFR, mL/min/1.73 m2 78 ± 22 84 ± 29 0.13
RENAL score <8.5 ± 1.6/td> 6.5 ± 1.9 < 0.001
EBL, mL 373 ± 411 267 ± 365 0.04
Operative time, min 214 ± 66 185 ± 51 < 0.001
Warm ischemia time, min 25 ± 11 20 ± 11 0.002
Intraoperative complications, n (%) 5 (8) 15 (3) 0.02
Conversion to radical nephrectomy, n (%) 4 (7) 1 (0.2) < 0.001
Malignant histology, n (%) 50 (82) 431 (74) 0.6
T stage, n (%)
T1a
T1b
T2a
T3a
20 (33)
21 (34)
5 (8)
4 (7)
369 (63)
46 (8)
1 (0.2)
21 (4)
< 0.001
Hospital stay, days 4.1 ± 2.4 3.5 ± 1.7 0.02
Postoperative complications, n (%) 20 (33) 135 (23) 0.1
Follow-up, months 20 ± 17 23 ± 24 0.2
Last creatinine, mg/dL 1.31 ± 0.85 1.09 ± 0.50 0.002
Last GFR, mL/min/1.73 m2 64 ± 21 76 ± 24 < 0.001
Change in GFR, % −14.6 ± 15.8 −7.6 ± 24.0 0.03
Data are presented as mean ± standard deviation for continuous variables, and as frequency (%) for categorical variables. BMI = body mass index; EBL = estimated blood loss; GFR = glomerular filtration rate.
Table 2: Laparoscopic vs. robotic heminephrectomy: patient characteristics and operative outcomes
Variable Laparoscopic
(n=16)
Robotic
(n=45)
p value
Age, years 61 ± 12 58 ± 12 0.4
Male, n (%) 13 (81) 22 (49) 0.02
BMI, kg/m2 29.0 ± 5.3 30.6 ± 6.5 0.4
CCI 1.38 ± 1.26 3.42 ± 2.18 < 0.001
Left-sided, n (%) 5 (31) 18 (40) 0.5
Size on CT, cm 3.7 ± 1.1 5.6 ± 2.2 0.002
Solitary kidney, n (%) 1 (6) 1 (2) 0.4
Preoperative creatinine 1.15 ± 0.33 0.97 ± 0.29 0.05
Preoperative GFR, mL/min/1.73 m2 71 ± 20 81 ± 22 0.12
RENAL score 7.4 ± 1 .9 8.9 ± 1.3 < 0.001
EBL, mL 438 ± 409 353 ± 413 0.5
Operative time, min 250 ± 61 207.63 ± 65.36 0.0956
Warm ischemia time, min 28 ± 12 24 ± 10 0.2
Intraoperative complication, n (%) 2 (13) 5 (11) 0.9
Conversion to radical nephrectomy, n (%) 2 (13) 2 (4) 0.3
Malignant histology, n (%) 12 (75) 38 (84) 0.01
T stage, n (%)
T1a
T1b
T2a
T3a
9 (56)
3 (19)
0 (0)
0 (0)
11 (24)
18 (40)
5 (11)
4 (9)
0.001
Hospital stay, days 5.6 ± 3.2 3.5 ± 1.7 0.002
Postoperative complications, n (%) 8 (50) 12 (27) 0.09
Follow-up, months 32 ± 21 15 ± 12 < 0.001
Last creatinine, mg/dl 1.76 ± 1.47 1.15 ± 0.38 0.01
Last GFR, mL/min/1.73 m2 54 ± 24 67 ± 19 0.03
Change in GFR, % -17.0 ± 20.0 -13.7 ± 14.1 0.5
BMI = body mass index; CCI = Charleston comorbidity index; GFR = glomerular filtration rate; EBL = estimated blood loss.
Robotic Partial Nephrectomy in Patients with History of Previous Abdominal Surgery

Jihad Kaouk, MD

Key Point:

  • Performing robot-assisted laparoscopic partial nephrectomy (RALPN) in the setting of previous abdominal surgery can be challenging. However, with sound surgical techniques in gaining access, placing ports and performing meticulous adhesiolysis, the procedure can be safely completed and can provide surgical outcomes comparable to those of patients with negative surgical history.

A history of previous surgery formerly was considered one of the relative contraindications for laparoscopic surgery because of higher risk for port trocar injuries, perioperative complications and prolonged operative time due to adhesiolysis. With increased laparoscopic experience, refinement of surgical techniques and improved instrumentation, laparoscopic surgery has been extended to patients with previous abdominal surgery. Here, we focus on our single-center experience with robot-assisted laparoscopic partial nephrectomy (RALPN) in patients with a history of previous abdominal surgery.

The study population was retrieved from our ongoing Institutional Review Board-approved, prospectively maintained database. The medical records of patients who underwent RALPN from June 2006 to February 2013 were reviewed. Patients were divided into two groups: those who had history of previous abdominal surgery and those with no previous abdominal surgery. The two study groups were compared in terms of baseline patient characteristics and tumor characteristics, as well as in terms of operative outcomes and intraoperative and postoperative complications.

In the setting of previous abdominal surgery, few modifications to our standard RALPN technique are adopted. The access point of the Veress needle is placed as far as possible from the incision site, usually 4 cm to 5 cm away from a previous surgery incision site. An alternative access point is 4 cm to 5 cm cranial and medial to the anterior superior iliac spine if it is a scar-free area. A positive drop test is performed and low initial insufflation pressure is confirmed before proceeding with pneumoperitoneum. In case of doubt, an open Hassan technique is employed for placement of ports. The abdominal cavity is insufflated to 15 mm Hg. A 12 mm camera port is introduced and the cavity is examined for visceral injuries or adhesions.

Adhesions are taken down sharply using laparoscopic scissors if encountered in the site of placement of other ports. If the adhesions are located medially, lateral ports are placed and adhesions can be taken down sharply. A 3-port or 4-port configuration can be used, as per surgeon’s preference. The rest of the procedure is completed by following the standard steps, including bowel mobilization, identification of the ureter and gonadal vessels, exposure of the psoas muscle, identification and dissection of the hilum, defatting of the kidney, tumor identification, intraoperative ultrasound, scoring of tumor margins, hilar clamping (when necessary), tumor excision, and renorrhaphy.

Of 587 patients who underwent RALPN during the study period, five were excluded due to incomplete documentation. Overall, 348 patients (59.2 percent of total) had a history of previous abdominal surgery (Table 1). The two study groups were comparable in terms of age, body mass index, American Society of Anesthesiologists (ASA) score, Charlson comorbidity index, tumor size and laterality. Renal nephrometry score was higher in patients with previous surgery as compared with those with negative surgical history (7.3 vs. 7, p = 0.04). There was no difference in operative time, warm ischemia time and estimated blood loss. Surgical access was accomplished using a Veress needle in all but three patients. There were no complications related to gaining pneumoperitoneum, placement of robotic ports or takedown of peritoneal adhesions.
In conclusion, although performing RALPN in the setting of previous abdominal surgery can be challenging, with sound surgical techniques in gaining access, placing ports and performing meticulous adhesiolysis, the procedure can be safely completed and can provide surgical outcomes comparable to those of patients with negative surgical history.

Table 1. RALPN in patients with previous abdominal surgery: comparative outcomes
  No previous surgery
(n = 234)
Previous surgery
(n = 348)
p value
Baseline variables  
Mean age, years 57.9 58.7 0.6
Female, n (%) 54 (23) 186 (53) < 0.0001
BMI, kg/m2 30.6 30.5 0.8
Median (IQR) ASA 3 (2-3) 3 (2-3) 0.3
Mean Charlson
Comorbidity Index
2.2 2.4 0.4
Mean tumor size, cm 3.3 3.1 0.5
Mean RENAL score 7 7.3 0.3
Right side laterality, n (%) 133 (56) 168 (48) 0.7
Perioperative outcomes  
Mean OR time, min 184 182 0.7
Mean ischemia time, min 20.4 19.1 0.8
Mean EBL, mL 239 241 0.9
Mean hospital stay, days 3.4 3.4 0.7
Overall intraoperative
complications, n
3 3 0.72
Overall conversions, n 2 4 0.63
Overall postoperative complications, n 33 32 0.15
Difference between groups is evaluated using Wilcoxon rank sum test for continuous and chi square test for categorical variables. BMI = body mass index; IQR = interquartile range; OR = operating room; EBL = estimated blood loss.

Center for Urologic Oncology

Heat Therapy to Ablate Tumors

Ryan K, Berglund, MD

Key Point:

  • Various techniques are in use to deliver heat energy as a treatment option for localized genitourinary tumors. Application of heat is a promising alternative to surgery or radiation therapy for ablating tumors while minimizing morbidity.

Traditionally, localized tumors of the genitourinary tract have been treated through either surgical extirpation or radiation therapy. While these often are effective treatments for these tumors, there are a number of potential side effects to such modalities. Techniques that ablate tumors with curative intent while limiting the morbidity of the treatment are under development.

One ablative approach in use is the application of heat to a tumor. When tissues are heated to > 55 degrees Celsius, coagulation necrosis occurs, and the tumor and a margin of normal adjacent tissue are destroyed. At temperatures > 60 degrees Celsius, coagulation necrosis is immediate. There are several ways to deliver heat to a tissue. Heat can be delivered via direct contact with a heated probe. One example of this approach is the use of laser energy either via a beam (e.g., GreenLight™ laser) or direct contact (e.g., holmium laser). These heat sources are used to photovaporize (GreenLight laser) or incise (holmium laser) an enlarged prostate from benign prostatic hyperplasia (BPH). Another approach is the use of radiofrequency energy to create a current that releases resistive energy as it passes through tissues. Examples of this approach are transurethral needle ablation (TUNA) of the prostate for BPH and radiofrequency ablation (RFA) of kidney tumors using a percutaneously placed probe guided by computed tomography.

High intensity focused ultrasound (HIFU) is a technique in which acoustic energy is produced from running a current through a piezoelectric crystal or transducer. This energy is the same as that used for diagnostic imaging with ultrasound. Once a tumor is identified for treatment, acoustic energy waves are focused on the tissue to be ablated. Heat energy is generated via the kinetic energy of the waves passing through the tissues and the cavitation created by the rapid expansion and collapse of microbubbles in the tissues being treated. One important advantage to this technique is that the delivery of the energy to the targeted tissues is “trackless,” since the tissues through which the waves pass are unaffected by the waves as they are delivered to the focal point. Trackless delivery allows for preservation of some of the surrounding tissues. Patients also can be retreated. Inability to retreat is a major disadvantage of radiation therapy. Currently, HIFU is considered investigational in the United States, although it is available in many places including Canada, Europe and Asia.
With improved heat delivery techniques and the ability to couple treatments to ever more accurate forms of imaging, the use of heat to ablate genitourinary tumors continues to expand. Novel methods of energy delivery may include minimally invasive or even noninvasive techniques. Currently at Cleveland Clinic, we are investigating such applications in clinical trials. Going forward, treatment of localized genitourinary tumors may no longer require undergoing traditional surgery or radiation therapy, but may instead involve the precision delivery of heat energy to the targeted tissue.

Low Fistula Rate during Hydrodissection for Cryotherapy

David Levy, MD

Key Points:

  • Rectal fistula is a devastating potential complication of prostate cryotherapy, and different approaches have been utilized in an effort to minimize its incidence.
  • Since 2010, we have utilized normal saline hydrodissection of the anterior rectal wall in more than 132 primary and 68 salvage cryoablation cases without a single case of rectal fistula.
  • We believe that hydrodissection has had a significant impact on the incidence of this procedure-related complication.

Prior to 2000, experience with prostate cryotherapy was associated with significant procedure-related morbidity. Issues stemmed from poor control of the liquid nitrogen cooling agent, as well as the lack of an effective urethral-warming device and inability to monitor target tissue temperatures.

The development of third-generation cryosurgical technology in 2000 incorporated the following: delivery of pressurized argon and helium gases through small, direct-access transperineal probes; utilization of an FDA-approved urethral-warming catheter; modified computer software to provide the surgeon with intraoperative treatment planning; and computer-assisted cryoprobe placement. These modifications resulted in dramatic decreases in procedure-related rectal fistula and urinary incontinence.

In a recent report from the national Cryo On-Line Database (COLD) Registry (AUA 2012), the incidence of rectal fistula and urinary incontinence was 0.2 percent and 3.4 percent, respectively, in a study cohort of 1,280 patients with five-year follow-up. Despite these encouraging data, some providers remain hesitant to embrace this technology and apply it to patients for primary therapy or in the setting of localized radiation failure.
Rectal fistula is a devastating potential complication of prostate cryotherapy, and different approaches have been utilized in an effort to minimize its incidence. Posterior displacement of the ultrasound probe to physically separate the anterior rectal wall from the prostate and the ice ball is one such maneuver, but this may compromise visualization of the anterior aspect of the gland.

Since 2010, we at Cleveland Clinic have utilized normal saline hydrodissection of the anterior rectal wall in more than 132 primary and 68 salvage cryoablation cases without a single case of rectal fistula. We believe that hydrodissection has had a significant impact on the incidence of this procedure-related complication.

Procedure details
Hydrodissection of the rectum is performed with a 6-inch 18-gauge spinal needle inserted into Denonvilliers’ fascia. Normal saline is injected into the avascular plane between the prostate and rectal wall, which results in posterior migration of the anterior rectal wall (Figures 1.a. and 1.b.). A measurable space is created between the posterior aspect of the prostate and anterior rectal wall that can exceed 1.5 cm. Despite the assumption that the rectum is fused to the prostate after radiation, we find this feasible to achieve even in radiation-failure patients (Figure 2).

This maneuver is performed after placement of the first two cryoprobes, which help stabilize the gland and minimize movement. Following injection of the saline, the Denonvilliers’ thermocouple is placed, followed by the external sphincter thermocouple, and the procedure continues per routine. We have recorded Denonvilliers’ fascia temperatures as low as –33 degrees Celsius without any rectal dysfunction or injury. One of us has abandoned the use of the Denonvilliers’ thermocouple and simply irrigates fluid actively during the latter stages of the freeze cycles to visually ensure that the rectum is significantly separated from the ice ball, even when it extends well outside the prostate.

It is imperative to avoid injection of air during this maneuver as well as violation of the perirectal vasculature. The presence of air or bleeding can compromise ultrasound visualization, which is necessary for the completion of the cryoablation procedure.

Hydrodissection of the anterior rectal wall enhances the safety of prostate cryoablation, further decreasing the likelihood of procedure-related complications even in the more difficult post-radiation salvage-cryoablation setting. We continue to study our cryoablation population to further enhance the safety of this minimally invasive outpatient prostate cancer therapy.

 

Figure 1.a. Introduction of spinal needle and injection of normal saline into the avascular plane.

Figure 1.b. Saline injection creates a measurable space between the posterior aspect of the prostate and the anterior rectal wall.

Figure 2. A perioperative ultrasound image shows successful hydrodissection of the anterior rectal wall.

Novel Molecular Biomarker for Prostate Cancer Screening and Early Detection

Mark Stovsky, MD

Key Points:

  • While recent U.S. Preventive Services Task Force recommendations against prostate cancer screening have been internalized by some physicians, most urologists and many primary care physicians will choose to follow the current American Urological Association guidelines.
  • Even if all screening and early detection programs ended today, patients and their urologists would still be challenged through shared decision-making to determine the best course of action.
  • At Cleveland Clinic, urologists are playing leading roles in the use and development of promising next-generation prostate cancer biomarkers.

Patients and physicians face a challenging dilemma when addressing the controversial issues of prostate cancer screening and early detection. While screening and early detection strategies make intuitive sense, recently published data on the diagnostic and prognostic inaccuracy of the standard serum prostate specific antigen (PSA) test confound the discussion. While recent U.S. Preventive Services Task Force recommendations against prostate cancer screening have been internalized by some physicians, most urologists and many primary care physicians will choose to follow the current American Urological Association guidelines, which indicate that screening and early detection strategies may be appropriate in high-risk patients (e.g., primary family history and African-American groups) and in men between the ages of 55 and 69 with an appropriate risk/benefit informed consent discussion. Moreover, as long as competing guidelines exist, patients will continue to undergo screening and early detection either with their primary care physicians or in community-based health programs. To be sure, patients and their urologists have been placed between a rock and a diagnostic hard place.

In perhaps the most common clinical scenario, a generation of patients has been evaluated with regular serum PSA tests and digital rectal examinations. Many of these patients have undergone prolonged periods of clinical surveillance for abnormal serum PSA or PSA analogue results (e.g., free PSA, complexed PSA, PSA velocity, PSA density, age-specific PSA). Further, a large subset of these patients also has undergone at least one transrectal ultrasound guided prostate biopsy (TRUS biopsy) procedure showing either benign prostate tissue or a noncancer deviation from normal, such as prostate intraepithelial neoplasia or atypical small acinar proliferation.

Even if all screening and early detection programs ended today, these patients and their urologists would still be challenged through shared decision-making to determine the best course of action. In this clinical context, the management options are clearly defined. They include clinical observation, repeat prostate biopsy using either standard or extended/saturation techniques, or the use of novel proteomic or genomic molecular biomarkers, to attempt to improve on the diagnostic precision, predictive value and prognostic accuracy of standard serum PSA testing.

In current practice, the prostate cancer antigen 3 (PCA3) biomarker can be used to help guide decision-making for initial and repeat TRUS biopsy in high-risk patients. PCA3 is an RNA transcription product of DNA that is overexpressed in the urine in a high percentage of prostate cancers. Peer-reviewed studies outlining the diagnostic performance of PCA3 indicate that PCA3 has greater sensitivity and specificity than standard total PSA, PCA3 outperforms total PSA for initial and repeat biopsy decision-making, and PCA3 provides independent diagnostic information as compared with PSA testing.

At Cleveland Clinic, urologists are playing leading roles in the use and development of promising next-generation prostate cancer biomarkers. One new test under investigation, PSA/solvent interaction analysis (PSA/SIA), shows promise in improving the diagnostic accuracy of screening and early detection strategies by differentiating PSA structural changes induced by cancer as compared with benign glands. In the initial multicenter validation trial published previously in Urology, PSA/SIA in urine displayed an area under the curve (AUC) of 0.90, sensitivity of 100 percent, specificity of 80.3 percent, positive predictive value of 80.6 percent and negative predictive value of 100 percent. A follow-up multi-institutional study of the PSA/SIA assay in serum showed similar performance with an AUC of 0.83, sensitivity range of 90 to 100 percent and specificity range of 48 to 60 percent for the complexed PSA fraction at various test cutoff values, as well as enhanced ability to separate structural cancer and noncancer isoforms.

Future studies will aim to gauge the performance of PSA/SIA in other clinical settings, including the evaluation of patients after definitive treatment with radiation or cryotherapy.

Sustainable Growth Rate Update: We ALL Need to Understand Where We Stand

James Ulchaker, MD

Key Point:

  • H.R. 2810 would replace the current sustainable growth rate formulation under the Medicare Part B physician payment system with an alternative that would make payments based on how a provider performs on certain quality of care measures.

The sustainable growth rate (SGR) is an important legislative issue that affects ALL physicians. Our various colleagues may suffer differently from the potential future changes to the SGR, but we will all be impacted. Here, we will discuss the SGR and its varying potential effects on both academic/hospital-based urologists and those in independent practice.

The U.S. House Energy and Commerce Health Subcommittee approved and sent H.R. 2810 to the full committee for a markup of the bill this past summer. In general, the bill would replace the current SGR formulation under the Medicare Part B physician payment system with an alternative. Beginning in 2019, this new system would make payments based on how a provider performs on certain quality of care measures. For example, providers would see a 1 percent increase in payments for scores above a designated midrange level and a 1 percent decrease for scores below the midrange. Physician payments would increase by a fixed 0.5 percent during the five-year phase-in to allow a stabilization period for providers to transition to new payment models.

The bill also offers incentives to encourage care coordination and promote medical homes, repeals the Independent Payment Advisory Board, and seeks medical liability reform. Other elements of the bill include an emphasis on quality improvements led by physicians, and options for participating in quality improvement efforts that allow flexibility for various specialties and practices and other potential exceptions

Specific provisions to pay for the changes were not included in the legislation, and a resolution of the cost issue will likely have to wait until the House Ways and Means Committee marks up the bill, which was jointly referred to this committee. Whether the bill will be taken up in the House as separate legislation or as part of a larger budget package has yet to be determined. So, the $138 billion question remains: How are we going to pay for this?

Some payment concepts being contemplated on Capitol Hill may include payment reductions that would affect academic/hospital-based physicians. The reduction of the facility fee reimbursed to hospitals would result in a decrease in departmental revenue. Independent practitioners could take a potential financial hit if modifications to the in-office ancillary exception are enacted, and their bottom line could be affected by a reduction in their overall revenue stream. Increased federal regulations that may be accompanied by a fee, penalty or payment reduction also are being openly discussed.

Thus, we need to stay vigilant about the changes that will occur with this bill in the coming months. Committee markups, additions, amendments and modifications must be monitored closely. As the Chair of the American Urological Association’s Legislative Affairs Committee, I will continue to work for a fair solution to this and other difficult problems that affect our profession.

Center for Chronic Kidney Disease

Consequences of Metabolic Syndrome in Kidney Disease

Sankar D. Navaneethan, MD

Key Points:

  • To test the hypothesis that the presence of metabolic syndrome is associated with an increased incidence of end-stage renal disease (ESRD) and death among those with Stage 3 and 4 chronic kidney disease (CKD), we followed these patients in our healthcare system and examined the associations between metabolic syndrome, ESRD and death.
  • Our findings show that metabolic syndrome is associated with ESRD but not mortality in a diverse population with CKD. The associations between the individual components of metabolic syndrome and outcomes varied, demonstrating a need for further investigation into the mechanisms.

Metabolic syndrome, or insulin-resistance syndrome, is defined as the presence of hyperglycemia, hypertriglyceridemia, low HDL cholesterol levels, abdominal obesity and hypertension. It affects 23 percent of the U.S. population. Eleven percent of the U.S. population has some form of chronic kidney disease (CKD), and 6 percent has both CKD and metabolic syndrome. These numbers are increasing secondary to the diabetic epidemic and the growing prevalence of obesity. Patients with metabolic syndrome have higher cardiovascular and all-cause mortality rates. Furthermore, CKD is an independent risk factor for cardiovascular and all-cause mortality, and 50 percent of these patients die of cardiac disease.

We hypothesized that the presence of metabolic syndrome is associated with an increased incidence of end-stage renal disease (ESRD) and death among those with Stage 3 and 4 CKD, and these associations might be modified by age, gender, race and stage of kidney disease. To test these hypotheses, we examined the associations between metabolic syndrome, ESRD and death among those with Stage 3 and 4 CKD followed in our healthcare system.

Study data
Of 43,546 patients in our Cleveland Clinic CKD registry (as of Sept. 15, 2009), 25,868 patients (59 percent) had relevant data relating to the different components of metabolic syndrome and were included in this analysis. About 60 percent of the study population (n = 15,605) had metabolic syndrome. Among these patients, during a median follow-up of 2.4 years (mean 2.3 years), 3,345 participants died before ESRD, and 481 reached ESRD. Overall (pre- and post-ESRD), 3,504 patients died. The Kaplan-Meier and competing risk analyses showed no significant difference in overall mortality between those with and without metabolic syndrome. However, there were significantly higher rates of ESRD among those with metabolic syndrome than those without metabolic syndrome in both Kaplan-Meier and competing risk analyses (log rank p < 0.001), and the results were similar in both analyses.

In the Cox proportional hazards model, after adjusting for demographic factors, comorbidities, laboratory parameters and kidney function, the presence of metabolic syndrome was not associated with pre-ESRD death. However, the presence of metabolic syndrome was associated with a 33 percent increased hazard for ESRD. An analysis of covariate-adjusted overall mortality (pre- and post-ESRD) provided similar results to that which included only pre-ESRD death, with a hazard ratio (HR) for patients having metabolic syndrome of 1.06 (95 percent confidence interval [CI] 0.98-1.13). Among the individual components of metabolic syndrome, elevated serum triglycerides (HR 1.07, 95 percent CI 1.00-1.15), impaired glucose metabolism (HR 1.67, 95 percent CI 1.36-2.0) and hypertension (HR 1.83, 95 percent CI 1.04-3.25) were associated with an increased risk for ESRD. Diabetes (HR 1.18, 95 percent CI 1.10-1.27) and low HDL cholesterol (HR 1.10, 95 percent CI 1.02-1.18) were associated with an increased hazard for death, but obesity was associated with a lower hazard for death.

These findings have significant clinical importance, as there is a rapid increase in the individual components of metabolic syndrome, metabolic syndrome itself and CKD in the U.S. population and around the globe. Metabolic syndrome is widely prevalent in those with nondialysis-dependent CKD, and this has public health implications. Metabolic syndrome is associated with ESRD but not mortality in a diverse population with CKD. The associations between the individual components of metabolic syndrome and outcomes varied, demonstrating a need for further investigation into the mechanisms. Long-term studies are needed to examine the relationship between metabolic syndrome and mortality in CKD patients. Additionally, whether interventions such as lifestyle modifications can improve the risk associated with metabolic syndrome on kidney disease progression in these patients warrants further study. At Cleveland Clinic we are conducting additional studies (both observational and interventional) to address these unanswered questions.

Center for Kidney/Pancreas Transplantation

Initiating a Laparoendoscopic Single-Site Live Donor Nephrectomy Program

Initiating a Laparoendoscopic Single-Site Live Donor Nephrectomy Program

Shih-Chieh Jeff Chueh, MD, PhD, and Bashir R. Sankari, MD

Key Points:

  • Laparoendoscopic single-site live donor nephrectomy (LESS-LDN) using a GelPort® device as the access platform enhances feasibility and safety, and offers various exit strategies for an easy conversion in case of difficulty.
  • This technique is especially attractive for surgeons who have performed standard or hand-assisted laparoscopic LDN and would like to advance to the next level of LESS-LDN.

Laparoscopic live donor nephrectomy (LDN) is the current surgery of choice for living kidney donors. Laparoendoscopic single-site LDN (LESS-LDN) is very demanding on surgeons, due to its technical challenges and need for precision.

Here, we share our experience of LESS-LDN and show our procedure. We also provide guidance on how to handle any difficulties that emerge, and how to convert stepwise, if needed, to conventional laparoscopic LDN or open surgery for safe execution of this yardstick surgery.

A GelPort device was installed as the LESS platform at a 5 cm periumbilical midline incision. A large adhesive drape was applied over the abdomen, covering the whole GelPort (Figure 1). Through the gel-cap of the GelPort, 3~ 4 ports were spaced apart to achieve triangulation and to avoid clashing of the instruments during LESS-LDN (Figure 1). Standard dissection of the kidney for donation was performed by ensuring that the kidney was well-perfused and the renal vein was nicely distended (Figure 2).

Before hilar vessels were ligated separately with Endo TA™ staplers, a laparoscopic retrieving bag was inserted through the gel-cap to bag the kidney for tenting up the vessels, so that a longer pedicle could be harvested. The kidney was removed through the LESS incision immediately after hilar transection.
Using this technique, LESS-LDN was successful in all living donors without any multisite laparoscopic or open conversion, and without any instrument through extra wounds — although we would have done so if at any point we felt that this would have provided additional patient safety or facilitated the operation.

No patient experienced perioperative complications or received transfusions. Median operative time was 271 minutes with a warm ischemia time of 3.5 minutes. Hospital stay averaged two days, with an average visual analog pain score of 4 of 10 at discharge and 2 of 10 at two weeks. All recipients recuperated well, with immediate graft function.

In case of difficulties, an extra one to two trocars can be inserted outside the LESS platform to form triangulation with the umbilicus. This immediately converts the surgery into a standard pure or hand-assisted laparoscopic LDN. If the condition requires open conversion, upward extension of the midline incision to the subxyphoid area and tilting the operating table will convert the procedure to an open surgery.
Using the GelPort as the access platform, LESS-LDN provides feasibility and safety. It can be easily converted to conventional laparoscopic LDN or open surgery, if necessary, to maintain the extremely high safety standard of LDN. This is especially attractive for less experienced surgeons.

Figure 1. External view of the ports and instruments during a laparoendoscopic single-site living donor nephrectomy.

Figure 2. Laparoscopic view during a laparoendoscopic single-site living donor nephrectomy. Note the pink left kidney (to the right of the black instrument), and the well-distended left renal vein (between the two instruments).

Lifestyle Modification as an Opportunity to Improve the Health of Living Kidney Donors

Emilio Poggio, MD

Key Points:

  • With an increasingly sedentary lifestyle and high rates of obesity exceeding 30 percent in most age and gender groups, the age-adjusted prevalence of metabolic syndrome stands at 34 percent.
  • Likewise, metabolic syndrome is common among living kidney donors.
  • Because this condition is potentially treatable with lifestyle interventions, and because the post-donation health of living kidney donors is of paramount importance, diagnosing and treating this condition in this relatively healthy population is essential.
  • This study found that advising, promoting and supporting lifestyle practices that promote weight loss during the kidney donor evaluation process should be actively advocated.

Metabolic syndrome includes the constellation of various metabolic abnormalities that have been associated with cardiovascular disease, stroke and all-cause mortality in the general population. With an increasingly sedentary lifestyle and high rates of obesity exceeding 30 percent in most age and gender groups, the age-adjusted prevalence of metabolic syndrome stands at 34 percent. Likewise, metabolic syndrome is common among living kidney donors. Because this condition is potentially treatable with lifestyle interventions, and because the post-donation health of living donors is of paramount importance, diagnosing and treating this condition in this relatively healthy population is essential.

The relationship between metabolic syndrome, kidney function and underlying renal histology in otherwise healthy adults is unclear. Therefore, we studied the prevalence of metabolic syndrome in living kidney donors and its association with kidney function, renal mass and histology at the time of donation. We further studied whether pre-donation metabolic syndrome associates with impaired post-donation renal function. Particularly, we wanted to study the impact of post-donation body weight changes on metabolic syndrome and its components.

Study results
Our results showed that metabolic syndrome was present in 12.2 percent of kidney donors. Donors with metabolic syndrome were more likely to have chronic histological changes (such as mild glomerulosclerosis and interstitial fibrosis) on implant biopsies performed during the kidney transplantation than were donors with no metabolic syndrome (29.0 percent vs. 9.3 percent, p < 0.001). This finding was associated with impaired kidney function recovery following kidney donation. Notably, at last follow-up, reversal of metabolic syndrome was observed in 57.1 percent of donors with pre-donation metabolic syndrome, while only 10.8 percent of donors developed de novo metabolic syndrome (p < 0.001). In addition, we noted that changes in body mass index (BMI) after donation led to changes in each of the components of metabolic syndrome. Weight loss, as measured by a decrease in BMI, showed a small but positive correlation, with improvements in blood pressure, triglycerides, HDL cholesterol and fasting blood glucose levels.

Cumulatively, it appears from our results that weight loss is the main driver for the improvement of the metabolic syndrome components. Therefore, advising, promoting and supporting lifestyle practices, including dietary and activity changes that promote weight loss during the donor evaluation process (before and after donation), should be actively advocated. This is being continuously advised for all living donors at our center. Although our study did not evaluate cardiovascular outcomes, based on available data, metabolic syndrome can be used as a simple and practical tool to identify and counsel patients who might be at high risk for cardiovascular disease in the future.

Indianapolis Renal Transplant Affiliate Continues Gains

As Cleveland Clinic’s affiliate kidney transplant program at St. Vincent Indianapolis Hospital marked its fifth anniversary in 2013, its continued growth and progress were clearly evident.

In February, surgeons at the Indiana hospital performed a simultaneous kidney-pancreas transplant. It was Cleveland Clinic’s first abdominal multi-organ transplant to be done outside of the main Cleveland campus. The patient was hospitalized for five days and has recovered well, reports Alvin Wee, MD, the St. Vincent Renal and Pancreas Transplant Program’s director and an associate staff member of Cleveland Clinic’s Glickman Urological & Kidney Institute.

Since the affiliate program’s launch in 2008, the St. Vincent Indianapolis Transplant Center has performed more than 200 kidney transplants. According to the latest data analyzed and publicly released by the Scientific Registry of Transplant Recipients (SRTR), for kidney transplants performed between Jan. 1, 2009 and Dec. 31, 2011, one-year graft survival was 95.5 percent and one-year patient survival was 98 percent. Those patient and graft survival rates indicated the center was performing as expected compared with similar transplant programs nationwide.

Average waiting time for a kidney transplant at the St. Vincent Indianapolis center was 12.6 months, according to SRTR’s analysis. That was considerably shorter than waiting periods at other transplant centers in the region and nationwide.

SRTR will release updated performance measures in March 2014 that include the St Vincent Indianapolis program’s three-year survival rates. Analysis by Cleveland Clinic’s Department of Quantitative Health Sciences shows those three-year results are better than the national benchmark, Dr. Wee said.

St. Vincent Indianapolis Hospital has a dedicated 11-bed unit for kidney transplant patients, as well as an outpatient transplant clinic. The renal transplant program evaluates patients from throughout the United States, and receives more than 400 referrals annually.

The program’s attending surgeon is Islam Ghoneim, MD, PhD, an associate staff member of the Glickman Urological & Kidney Institute.

For more information, contact Dr. Wee at 317.338.6701.

We also invite you to view our most recent editions of Research Notesa newsletter intended to provide an overview of important efforts in our institute that leverage our clinical, translational, health services research and basic science expertise toward the improvement of patients’ lives.

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