Laparoscopic assisted live donor nephrectomy--a comparison with the open approach

Video-assisted minilaparotomy in urology

Minimally invasive surgery has gained wide acceptance as a method of reducing postoperative pain and curtailing the convalescence period. We have devised a modified surgical technique of video-assisted surgery through minilaparotomy (VAMS). This technique is a hybrid of conventional open and laparoscopic surgery that combines the benefits of both techniques by reducing postoperative pain and scarring, as in laparoscopy, but at the same time maintaining the safety of conventional open surgery. Video-assisted procedures have become standard as a result of our experience with 245 consecutive patients operated on between January 1993 and January 2001. The VAMS is a minimally invasive technique that is safe, feasible, standardized, and reproducible with a short learning curve. This technique can be an alternative to open and laparoscopic surgery in daily urologic practice.

Unexpected surgical difficulties leading to hemorrhage and gas embolus during laparoscopic donor nephrectomy: a case report

PURPOSE

To report the case of a laparoscopic donor nephrectomy in which the preoperative evaluation of the patient gave no indication of the surgical difficulties that were encountered intraoperatively, resulting in substantial bleeding, a suspected gas embolism, and emergency conversion of the procedure from laparoscopic to open donor nephrectomy.

CLINICAL FEATURES

A 59-yr-old man - height: 175 cm, weight: 85.5 kg, American Society of Anesthesiologists physical status I - presented as kidney donor for laparoscopic donor nephrectomy. He was healthy, on no medication, and had no previous abdominal surgery or diseases of the urinary tract. The preoperative computed tomography (CT) scan evaluation of his kidneys confirmed this by reporting a normal bilateral renal and renal vascular anatomy. In contradiction to the preoperative CT scan findings, the surgeon discovered abnormalities in the operative field. This included extensive scarring surrounding the left kidney, adenopathy near the right hilum, and a large branch lumbar vein entering the renal vein. The large branch lumbar vein was clipped but the clips dislodged, causing significant blood loss, and a suspected gas embolus. The procedure was converted to an emergency open donor nephrectomy. Postoperatively the patient made a full recovery.

CONCLUSION

Laparoscopic donor nephrectomies, though usually performed on healthy individuals, have their pitfalls, and complications during this procedure can be sudden and serious. As shown in this case, although CT scan results are regarded as reliable, they can be misleading. As an anesthetic precaution for possible gas emboli during laparoscopic procedures, nitrous oxide should be avoided and the patient be ventilated with 100% oxygen.

Laparoscopic hand-assisted living donor nephrectomy: the Calgary experience

Laparoscopic techniques, such as hand-assisted live donor nephrectomy (HALDN), have the potential to increase the number of living kidney donors. For these techniques to be acceptable, however, the standards for donor, recipient, and graft survival achieved by the open technique need to be matched. In this study we present the results of the first 20 HALDN procedures at our center. The 20 donors included nine men and 11 women of mean (+/-SD) donor age 41 (+/-10) years and mean donor weight 78 (+/-13) kg. Mean operative time was 174 (+/-32) minutes. Only one patient required an open conversion to procedure because of venous bleeding. All kidneys were successfully implanted; there were no episodes of primary nonfunction or delayed graft function. There were no surgical complications, either in the donor or the recipient. The range of postoperative stay was 3 to 5 days. One recipient died 62 days after transplant from influenza virus pneumonia. There were no other causes of graft loss. Our preliminary results suggest that HALDN is safe and is associated with short-term donor, recipient, and graft outcomes that are at least comparable to the standard open technique.

Subcostal versus transcostal mini donor nephrectomy: is rib resection responsible for pain related donor morbidity

PURPOSE

Conventional donor nephrectomy is associated with significant postoperative morbidity. Whether this morbidity is associated with rib resection or a long incision is not clear. We designed a prospective randomized study of subcostal and transcostal mini incision donor nephrectomy and compared the results.

MATERIALS AND METHODS

We performed 82 donor nephrectomies in the study period of December 2000 to July 2001. Open donor nephrectomies were randomized to subcostal (25) or transcostal (24) mini incision techniques. Results were compared and analyzed using the independent t test.

RESULTS

The subcostal and transcostal groups were comparable in terms of patient age, body mass index, nephrectomy side, number of renal vessels and incision length (9.32 vs 9.72 cm). Patients in the subcostal group had a lesser postoperative analgesic requirement (304 +/- 49.8 vs 487 +/- 74.1 mg, p = 0.0001), shorter hospital stay (2.36 +/- 0.7 vs 3.71 +/- 0.81 days, p = 0.0001) and early convalescence (26.56 +/- 4.06 vs 37.46 +/- 6.05 days) compared with the transcostal group. Warm ischemia time and recipient outcome were similar in the groups.

CONCLUSIONS

Rib sparing, subcostal mini incision donor nephrectomy has significantly less morbidity and a shorter hospital stay compared with the rib resection transcostal technique.

Comparison of Outcomes in Noncomplicated and in Higher-Risk Donors after Standard versus Hand-Assisted Laparoscopic Nephrectomy

Hand-assisted techniques facilitated dissemination of the laparoscopic approach in live kidney donors and addressed concerns regarding potential procedural complications. We report our experience with both standard and hand-assisted laparoscopic nephrectomy in routine, complicated, and higher-risk donors. From July 1999 to September 2002, 47 donors underwent standard laparoscopic donor nephrectomy (SLDN; n = 29) or hand-assisted laparoscopic donor nephrectomy (HALDN; n = 18). Donors were “complicated” if they were >60 years of age, obese, refused blood-product transfusion, had multiple renal arteries or veins, or had right nephrectomies. “Higher-risk” donors had two or more risk factors. Results for SLDN and HALDN were compared for the overall groups and for the “complicated” and “higher-risk” groups. No donor required blood transfusion or reoperation. Warm-ischemia times were shorter in left nephrectomies (191 ± 72 seconds vs. 337 ± 95 seconds, P = 0.005), and blood loss was greater in patients with a body mass index ≥30 kg/m2 (296 ± 232 mL vs. 170 ± 139 mL, P = 0.03). Higher-risk donors had an increased operative blood loss and longer hospital stay than low-risk donors. Mean donor creatinine at discharge was 1.19 ± 0.2 mg/dL. Comparison of SLDN versus HALDN revealed shorter operating times for the latter, which approached statistical significance. Warm-ischemia time, operative blood loss, length of hospitalization, and donor and recipient discharge creatinines were similar for both groups. Laparoscopic donor nephrectomy can be applied to selected higher-risk donors with outcomes comparable to uncomplicated donors. Hand-assisted techniques facilitate the procedure during the learning curve, with advantages similar to standard laparoscopic techniques.

Management of renal allografts with multiple renal arteries resulting from laparoscopic living donor nephrectomy

Laparoscopic living donor nephrectomy (LLDN) has become an accepted procedure in many transplant centers. The placement of laparoscopic vascular staples can result in multiple short, small-caliber renal arteries that the recipient surgeon must deal with to restore perfusion to all parts of the kidney. The incidence of multiple renal arteries resulting from LLDN, surgical management of multiple renal arteries, and the short- and long-term graft functions were studied in 73 consecutive kidney recipients at a single center. Various techniques used for reconstruction are described, including the use of recipient internal iliac artery for the extension and reconstruction of small-caliber, short renal vessels. Single-artery allografts were compared with those with multiple arteries, with length of renal artery, warm ischemia time, hospital length of stay, operating time, creatinine levels, and 1 yr survival rates not found to be significantly different. The presence of multiple renal arteries should not exclude the possibility of using the left kidney for LLDN.

Ipsilateral orchialgia after laparoscopic donor nephrectomy

BACKGROUND AND PURPOSE

Complications related to laparoscopic donor nephrectomy (LDN) have been similar to those associated with open renal donor nephrectomy (ODN). However, during clinical follow-up, we noted a group of male patients who developed acute ipsilateral orchialgia after LDN. In an effort to assess the incidence of this problem, determine the etiology, and adapt preventive measures, we reviewed our experience.

PATIENTS AND METHODS

A retrospective chart review was performed on 381 consecutive LDNs performed between February 1995 and November 2001 to assess for postoperative orchialgia. There were 157 male patients (41.2%) in our series. Our technique involves ligation of the gonadal vessels, periureteral tissue, and ureter over the iliac artery using either surgical clips or a linear laparoscopic GIA stapler.

RESULTS

Left-sided nephrectomy was performed in 145 (92.3%) male patients, of whom 14 (9.6%) complained of ipsilateral orchialgia. Statistical analysis (t-test) of the orchialgia and non-orchialgia groups with respect to operative time, estimated blood loss, warm ischemia time, and ureteral length revealed no statistical differences (P>0.1). Onset of testicular pain occurred on average at postoperative day 5 (range days 1-14). The mean follow-up was 24.4 +/- 14.8 months (range 6-52 months). Ten patients were evaluated with transcrotal duplex ultrasonography. One patient with decreased flow and was managed conservatively, while one patient without detectable testicular flow underwent surgical exploration. One patient underwent spermatocelectomy and had improvement but not resolution of pain. The remaining patients were treated conservatively with nonsteroidal anti-inflammatory medication and empiric antibiotics. Seven patients (50%) had complete spontaneous resolution of orchialgia on average 6.3+/-7.2 months after LDN.

CONCLUSION

Laparoscopic donor nephrectomy has proven to be an effective and safe surgical procedure. However, further evaluation has demonstrated a complication not previously reported, namely ipsilateral orchialgia. The etiology remains unclear but may be injury to the sensory nerves of the testicle during dissection of the periureteral tissue or transection of the spermatic cord. Further anatomic and physiological studies are needed to elucidate the pathophysiology of this problem.

Laparoscopic radical nephrectomy: oncologic efficacy

Laparoscopic radical nephrectomy has evolved tremendously over the past decade to the point where it should be considered the standard of care for localized renal tumors not amenable to nephron-sparing surgery. The benefits of decreased postoperative pain, shortened hospital stay, quicker convalescence, and improved cosmesis have been proved in numerous studies. Long-term oncologic results of LRN have demonstrated equivalent outcomes to ORN.

Multidetector CT angiography for preoperative evaluation of living laparoscopic kidney donors

OBJECTIVE

The purpose of this study was to determine the accuracy of multidetector CT (MDCT) angiography as the primary imaging technique in the evaluation of living kidney donors.

SUBJECTS AND METHODS

Seventy-four consecutive living kidney donors (30 men, 44 women; mean age, 41.7 years) who underwent MDCT were evaluated. CT examination was performed with 120 mL of IV contrast material at an injection rate of 3 mL/sec and a pitch of 6. In every case, arterial and venous phase volumetric data sets were acquired at 25 and 55 sec, respectively. Scans were reconstructed at 1-mm intervals for three-dimensional (3D) imaging using a volume-rendering technique. Axial CT images and 3D CT angiography were evaluated prospectively by one reviewer and retrospectively by two reviewers who had no knowledge of surgical results. Surgical correlation for the location of primary and accessory renal arteries, early branching of the renal arteries, and renal vein anomalies was made.

RESULTS

Seventy-two subjects underwent left nephrectomy, and two subjects underwent right nephrectomy because supernumerary left renal arteries were detected on preoperative CT angiography. Eighteen supernumerary renal arteries (two arteries to 16 kidneys and three arteries to one kidney) to 74 kidneys underwent nephrectomy. CT and surgical findings agreed in 93% of subjects (the average of three reviewers; range, 89-97%). Two small accessory renal arteries were missed by all three reviewers. Those arteries were diminutive and were thought to be insignificant by the surgeons. Early branching of the renal arteries was shown in 14 arteries, and CT and surgical findings agreed in 96% (the average of three reviewers; range, 93-97%). Renal vein anomalies were present in eight subjects, and CT and surgical findings agreed in 99% of the cases (range, 96-100%).

CONCLUSION

MDCT angiography is highly accurate for detecting vascular anomalies and providing anatomic information for laparoscopic living donor nephrectomy.

Pain experienced by laparoscopic donor nephrectomy patients in an academic medical setting

CONTEXT

Since 1996, 414 laparoscopic live donor nephrectomy procedures have been completed at our institution. Although this procedure has gained acceptance within the past 5 years, little is known about its nursing implications.

OBJECTIVE

The purpose of this performance improvement project was to identify pain management practices, satisfaction levels, and clinical outcomes among patients undergoing laparoscopic live donor nephrectomy.

PATIENTS

Data were collected for a convenience sample of 70 patients for 18 months.

INTERVENTION

Several pain management methods were used, including patient-controlled analgesia and intramuscular and oral medications.

RESULTS

Pain ratings ranged from 3.2 to 3.8 for the first 36 hours postoperatively. The mean pain level did not differ significantly between pain regimes. At discharge, patients perceived a mean overall pain level of 5.0 but anticipated a pain level of 6.1. A significant negative correlation between satisfaction and pain rating also was noted.

CONCLUSIONS

Opportunities exist to standardize current regimens of pain medications and address pain level and treatment 24 hours postoperatively.

One hundred consecutive living kidney donors: modern issues and outcomes

In order to define current issues and outcomes of living kidney donation, 100 consecutive living donors operated on between July 1996 and March 2001 were evaluated. The 64 women and 36 men ranged in age from 19 to 72 yr (mean 42.5 yr), and 65 were related to the recipient while 35 were unrelated donors. Hospital admission the morning of surgery and use of a minimal open approach to the donor kidney were standard, as were post-operative epidural pain control and plans for short hospital stay. The 100 donors were hospitalized for 2 (25), 3 (48), 4 (18), 5 (8), or 6 (1) days, with an average length of stay of 3.12 d (range 2-6 d). The mean charge for kidney donor hospitalization was 14,470 dollars (range 9671-22,808 dollars). There were no major intra or immediate post-operative complications. Six rehospitalizations occurred for post-donation nausea, vomiting, dehydration (n = 2); spinal headache; pneumonia and wound haematoma; and late wound reexploration (one hernia and one nerve entrapment). All donors returned to pre-operative functional status within 6 d to 6 wk of donation. All kidneys functioned immediately in the 100 recipients (50 women, 50 men) who averaged 46.6 yr of age (range 17-69 yr); recipient length of stay averaged 3.81 d (range 2-15 d). All donors survived in excellent health; recipient graft and patient survival, respectively, are 87 and 90% through the entire 5-yr period. Excellent long-term outcomes for living kidney donors may be accomplished using minimal open surgical technique, post-operative epidural pain control and plans for a brief hospitalization. Expansion of living donor resources in renal transplant programs may grow as unrelated kidney donation and non-directed donation as well as minimally invasive (open and laparoscopic) techniques evolve.

[Laparoscopic transperitoneal donor nephrectomy. Technique and results]

Living donor kidney transplantation is one possibility to meet the growing demand for organs in patients with chronic renal failure. In 1995 the first laparoscopic living donor nephrectomy (LDN) was performed in the United States. More than 100 transplant centers worldwide perform LDN. The expectations of a larger number of willing organ donors were fulfilled due to the less traumatic operation. Meanwhile, several techniques exist to retrieve a kidney laparoscopically, including the trans- or retroperitoneal, strictly laparoscopic, or hand-assisted approach. From February 1999 to September 2002, 63 strictly laparoscopic, transperitoneal LDNs were performed at the Department of Urology of the Charité University Hospital, Berlin. Warm ischemic time was 148 s (105-360) and operating time was 203 min (110-305). Intraoperative complications were due to insufficient closure of the vessels in four patients. Mean postoperative hospital stay was 5.7 days (3-9). One year after LDN, renal function as well as creatinine levels of the recipient showed no difference compared to the organs harvested via the approach at our department prior to implementation of LDN. Strictly laparoscopic transperitoneal donor nephrectomy is a safe method for kidney retrieval and ensures excellent graft function.

Concomitant surgery with laparoscopic live donor nephrectomy

Routine live donor evaluations reveal unexpected silent pathologies. Herein, we describe our experience treating such pathologies at the time of laparoscopic donor nephrectomy. We have not encountered any previous reports of such an approach. We prospectively collected data on 321 donors. Concomitant surgeries at the time of procurement included two laparoscopic adrenalectomies, one colposuspension, one laparoscopic cholecystectomy, and one liver biopsy. Mean operative time was 321 min (range 230-380), with a mean blood loss of 280 mL (range 150-500). No blood transfusions were required. The left kidney was procured in four cases. The right kidney was obtained on one occasion. Mean hospital stay was 3 days (median 3, range 2-4). No short- or long-term complications have been identified. Mean follow-up time was 2.63 years (median 2.76, range 2.23-2.99). Four of the five kidney recipients were first-time transplants who had not yet started dialysis. Simultaneous surgical interventions at the time of laparoscopic live kidney donation are safe and can be undertaken in selected cases. This practice is beneficial to both the donor and the recipient, and is likely to become more commonplace with changing practice patterns involving donor evaluation and management.

Three-dimensional navigator for retroperitoneal laparoscopic nephrectomy using multidetector row computerized tomography

PURPOSE

We evaluated the efficacy of a 3-dimensional (D) navigator for retroperitoneal laparoscopic nephrectomy.

MATERIALS AND METHODS

A total of 21 patients with malignant localized renal (16) or ureteral (5) neoplasms underwent multi-detector row computerized tomography. The 3-D navigator was created using volume rendering technique. These findings were compared with videos obtained during laparoscopy.

RESULTS

The 3-D navigator depicted all renal arteries (100% sensitivity) and 24 of the 25 renal veins (96% sensitivity). Hilar anatomy, including the tumor, major vessels and adrenal gland, and their relationships were visualized as in laparoscopic views.

CONCLUSIONS

The 3-D navigator has a potentially important role in retroperitoneal laparoscopic nephrectomy. It is able to guide surgeons and aid in avoiding operative risks and possible complications.

Comprehensive MR imaging in the preoperative evaluation of living donor candidates for laparoscopic nephrectomy: initial experience

PURPOSE

To evaluate the accuracy of magnetic resonance (MR) imaging in the preoperative evaluation of potential living renal donors who are candidates for laparoscopic nephrectomy.

MATERIALS AND METHODS

Twenty-eight donor candidates who underwent subsequent laparoscopic nephrectomy were examined by using a torso phased-array coil at 1.5 T. Gadolinium-enhanced MR angiograms, MR venograms, and MR urograms were obtained in all patients by using an interpolated three-dimensional T1-weighted spoiled gradient-echo sequence (3.4-6.8/1.2-2.3 [repetition time msec/echo time msec], 25 degrees -40 degrees flip angle). Interpretation of the MR images was used to assess the arterial, venous, and ureteral anatomy, as well as parenchymal masses and scarring, and findings were compared with the surgical findings in all patients. Statistical evaluation was performed, with the surgical findings as the reference standard.

RESULTS

At MR imaging, 31 of 32 renal arteries and one of three early-branching arteries were identified correctly. The correct venous anatomy was identified in 23 of 28 patients, including a single left renal vein anterior to the aorta (n = 16), retroaortic left renal vein (n = 2), circumaortic left renal vein (n = 2), and single right renal vein (n = 3). A single collecting system in all harvested kidneys was identified correctly with MR urography. Overall, MR imaging correctly depicted vascular, ureteral, and parenchymal anatomy in 21 of 28 patients. Twenty-seven of 28 patients underwent successful laparoscopic donor nephrectomy on the basis of the MR findings. One procedure was converted to open nephrectomy on the basis of complex venous anatomy not prospectively identified on the MR images. The sensitivity and positive predictive value of MR imaging in correctly determining the combined vascular, ureteral, and parenchymal anatomy in the harvested kidney were 75% (21 of 28) and 95% (21 of 22), respectively.

CONCLUSION

Comprehensive gadolinium-enhanced MR imaging can depict the vascular anatomy, collecting system, and renal parenchyma preoperatively in patients who are candidates for laparoscopic living-donor nephrectomy.

Right-sided laparoscopic live-donor nephrectomy: is reluctance still justified?

BACKGROUND

Laparoscopic donor nephrectomy (LDN) of the right kidney is performed with great reluctance because of the shorter renal vein and possible increased incidence of venous thrombosis.

METHODS

In this retrospective, clinical study, right LDN and left LDN were compared. Between December 1997 and May 2001, 101 LDN were performed. Seventy-three (72%) right LDN were compared with 28 (28%) left LDN for clinical characteristics, operative data, and graft function.

RESULTS

There were no significant differences between the two groups regarding conversion rate, complications, hospital stay, thrombosis, graft function, and graft survival. Operating time was significantly shorter in the right LDN group (218 vs. 280 min).

CONCLUSION

In this study, right LDN was not associated with a higher number of complications, conversions, or incidence of venous thrombosis compared with the left LDN. Thus, reluctance toward right LDN is not justified, and therefore, right LDN should not be avoided.

Hand-assisted and conventional laparoscopic live donor nephrectomy: a comparison of two contemporary techniques

BACKGROUND AND PURPOSE

Laparoscopic nephrectomy may make kidney donation more attractive. Modifications such as hand assistance may improve surgical outcomes. We compared our initial experience with hand-assisted laparoscopic nephrectomy with that of the conventional laparoscopic technique.

PATIENTS AND METHODS

Two series of similar patients underwent conventional laparoscopic donor nephrectomy (LDN; N = 15) or hand-assisted laparoscopic donor nephrectomy (HLDN; N = 29). Operative time, warm ischemia time, estimated blood loss, complications, analgesic use, postoperative recovery, and serum creatinine concentration were compared.

RESULTS

Open conversion was required in one HLDN patient because of intra-abdominal adhesions, and this patient was excluded from further analysis. The operative time, time to kidney extraction, and warm ischemia time were significantly shorter in the HLDN group, averaging 204.8 v 275.7 minutes, 173.4 v 239.3 minutes, and 2 minutes 21 seconds v 3 minutes 45 seconds, respectively. The intraoperative complication rates were 3.6% and 13.3%, respectively (P = 0.07). The postoperative complication rates were 6.8% and 6.7%. All grafts were functioning at the end of the study period, and there were no differences in rejection episodes, need for dialysis, complications, or nadir creatinine concentration according to the method of harvest.

CONCLUSIONS

Hand-assisted laparoscopic donor nephrectomy provides shorter operative and warm ischemia times without a significant increase in donor morbidity.

Laparoscopic v open donor nephrectomy: a cost-utility analysis of the initial experience at a tertiary-care center

BACKGROUND AND PURPOSE

Laparoscopic donor nephrectomy (LapDN) offers donors more rapid postoperative recovery and recipients equivalent graft function when compared with open donor nephrectomy (OpenDN). Nonetheless, costs are less favorable for LapDN than for OpenDN. We compared LapDN and OpenDN with cost-utility analysis.

METHODS

A decision analysis modeling approach was performed: utilities derived using time trade-off and quality-adjusted life year (QALY) techniques; probabilities derived from a systematic review of the literature. All costs were included from a societal perspective using actual cost data from OpenDN and LapDN patients performed contemporaneously between July 1, 2000 and December 31, 2000. Costs of lost employment were estimated using mean provincial annual earnings. Incremental cost-effectiveness ratio (ICER) was calculated with "best-case" and "worst-case" scenarios for confidence intervals; sensitivity analyses were used to assess robustness.

RESULTS

LapDN costs are higher ($10,317.40 vs. $9,853.70), while quality of life (QOL) is superior (0.7683 vs. 0.7062). The ICER from a societal perspective was C$7,471.11/QALY. If all donor nephrectomies nationally were performed laparoscopically, there would be an additional annual cost of C$665,240 with a societal gain of 24.84 QALYs.

CONCLUSIONS

LapDN offers improved QOL at marginally higher cost. A societal ICER of $7,471.11/QALY compares favorably to many accepted health-care interventions. By potentially increasing organ donor rates, LapDN may be cost saving by decreasing the number of patients on dialysis.

Hand-assisted laparoscopic donor hepatectomy for living related transplantation in the porcine model

Use of a minimally invasive approach for donor nephrectomy has proven to be safe and feasible and has increased the pool of donors for living related renal transplantation. A porcine study to assess the safety and feasibility of performing laparoscopic donor hepatectomy was performed, with potential application to human liver donors for living related liver transplantation. Of the 10 50-kg pigs used, 2 underwent an open left lateral segmentectomy to define the pig anatomy. Two subsequent pigs underwent a laparoscopic liver resection to refine the technique. Subsequently, under sterile conditions, six pigs underwent laparoscopic liver resection with use of a hand-assisted technique for long-term study. Diameters and lengths of hepatic vessels and ducts were measured. Operative blood loss, operative time, and warm ischemia duration were noted. Biopsies of the resected specimens were done to look for ischemia. There was one operative death in the group with chronic liver failure, due to stapler misfire and hemorrhage from the left hepatic vein. The only instance of morbidity was a wound infection. The resected liver had minimal warm ischemia time and microscopic changes, which led us to believe that the organ was suitable for transplantation. We believe that this long-term study establishes the feasibility of this procedure.

Hand-assisted retroperitoneoscopic living-donor nephrectomy: initial 10 cases

BACKGROUND

Most living-donor nephrectomies are performed either by transperitoneal laparoscopy, with or without hand assistance, or by retroperitoneal open surgery, with or without video assistance. We therefore started to combine the benefits of these techniques: hand assistance to increase safety and control of the laparoscopic technique, and the retroperitoneal approach to minimize the risk of complications associated with the transabdominal approach. Herein, we report on our first 10 donors nephrectomized with hand-assisted retroperitoneoscopy.

RESULTS

Only left nephrectomies were performed. One donor had two renal arteries and two donors had retroaortic renal veins. There were no intra- or postoperative complications. Mean operating time was 155 min (110-230 min).

CONCLUSIONS

Hand-assisted retroperitoneoscopy in living-donor nephrectomy is a promising new method that could reduce the risks of traditional transperitoneal laparoscopy and should be further evaluated.

Multiple renal arteries do not pose an impediment to the routine use of laparoscopic donor nephrectomy

Since the first description by Ratner and collegues in 1996, laparoscopic live-donor nephrectomy is gaining wide acceptance in an attempt to minimize the donor morbidity, length of hospital stay and length of time to return to work. It is unknown whether multiple renal arteries pose additional problems with laparoscopic donor nephrectomy. In November 1998, our institution initiated laparoscopic donor nephrectomy program. In the ensuing 19 months, we performed 25 living donor renal transplants, 24 of them using laparoscopic donor nephrectomy. The left kidney was procured in all cases. Eight donor candidates (33%) had two or more renal arteries (two arteries in five patients and three patients).

RESULTS

In six cases (25%), findings at surgery differed from the CT angography results (in four cases, CT angiogram reported fewer arteries than were found at surgery and in two cases it reported more). We found no significant differences in both donor outcomes and recipient, based on the presence or absence of multiple renal arteries. Among donor outcomes, we found equivalent results for donor warm ischemia time total donor operating time, and donor length of stay. For recipient outcomes, we found no significant differences between groups for the incidence of acute tubular necrosis (ATN), graft survival and most recent serum creatinine. In one case, we constructed two arteries into a single conduit on the backtable prior to transplantation. However, in most cases with multiple arteries, we implanted the arteries separately into the recipient external iliac artery. Based on this experience, we do not find the presence of multiple renal arteries to be a barrier to the successful use of kidney grafts procured by laparoscopic donor nephrectomy.

Laparoscopy-assisted live donor nephrectomy: a modified cost-effective approach for developing countries

BACKGROUND AND PURPOSE

Because of the prohibitive cost of laparoscopic disposable instruments such as the PneumoSleeve, Endocatch, and vascular staples, laparoscopic live-donor nephrectomy has not gained wide acceptance in many developing countries. To circumvent this problem, we have developed a cost-saving approach, which is described herein and compared with the open method.

PATIENTS AND METHODS

Forty-nine patients underwent laparoscopic live-donor nephrectomy at our institute, of which two were performed by the hand-assisted technique, five by the technique described by Fabrizio et al and forty-two by our modified cost-saving laparoscopy-assisted technique (LD). The latter patients were compared with 50 patients who had a standard open donor nephrectomy (OD) through a rib-resecting (12th rib) flank incision. Our technique is similar to the procedure described by Fabrizio et al except for a 6- to 8-cm incision placed in the subcostal region to retrieve the kidney after the renal vessels are cut and ligated as in the open procedure. The costs of the various techniques at our institute were compared.

RESULTS

The LD and OD groups were similar in terms of age, weight, side of nephrectomy, and number of renal vessels. The operative time was longer in the LD group than in the OD group (180.7 +/- 18 minutes v 101.5 +/- 10.4 minutes), whereas the mean intraoperative blood loss was less (85.5 +/- 21.35 v 220 +/- 22.5 mL; P < 0.001). Warm ischemia time and recipient outcomes were comparable in the two groups. Patients in the LD group had lower postoperative narcotic (tramadol hydrochloride) requirement (155.3 +/- 53.3 mg v 251.8 +/- 63.1 mg; P < 0.001) and earlier discharge from the hospital (3.14 v 5.7 days; P < 0.001). The mean expense incurred was US$175 v US$160 in the LD and OD groups, respectively. The cost of the hand-assisted and standard laparoscopic techniques was significantly higher than that of our modified technique.

CONCLUSIONS

Our modified technique of laparoscopy-assisted live-donor nephrectomy avoids the use of costly disposables yet offers the advantages of lesser morbidity and small incision of LD. It is cost effective and is an alternative to open nephrectomy in the developing world.

Living kidney donation: a comparison of laparoscopic and conventional open operations

Laparoscopic donor nephrectomy has the potential to lessen the burden placed on live kidney donors. This study describes the first British comparison of donor morbidity and recovery following conventional open donor nephrectomy (ODN) and laparoscopic donor nephrectomy (LDN). An initial series of LDN (n=20) was compared to a historical control group of ODN (n=34). Laparoscopic operations were performed via a transperitoneal approach, the kidney being removed through a 6--12 cm Pfannensteil incision. Open operations were performed using a retroperitoneal flank approach with resection of the 12th rib. Postoperatively, donors were managed with a patient controlled analgesia system. LDN was associated with shorter mean (SD) inpatient stay (6 (2) v 4 (1) days; p=0.0001) and lower parenteral narcotic requirements (morphine 179 (108) v 67 (54) mg; p=0.0001). Laparoscopic donors started driving their cars sooner (2 (1.5) v 6 (4) weeks; p=0.0001) and returned to work more quickly (5 (3) v 12 (6) weeks; p=0.0001) than open nephrectomy donors. There were no differences in recipient serum creatinine levels at three months post-transplant but two recipients of transplant kidneys retrieved laparoscopically (10%) developed ureteric obstruction, whereas this complication did not occur after ODN (p=0.13). LDN is associated with less postoperative pain and a substantial improvement in donor recovery times. It is not yet clear whether or not the outcome of the recipient kidney transplants are the same after ODN and LDN and much more experience is required before the place of this new technique can be defined.

Laparoscopic living donor hepatectomy for liver transplantation in children

BACKGROUND

Because cadaveric organ donors are in short supply, living donors are increasingly being used in transplantations. We have developed a safe and reproducible method for laparoscopic liver resection.

METHODS

Left hepatic lobectomy (resection of segments 2 and 3) was done by laparoscopy in one woman aged 27 years and one man aged 31 years. The grafts were prepared under laparoscopy, without any vascular clamping, and were externalised through a suprapubic Pfannenstiel incision. Both grafts were transplanted conventionally to the patients' respective sons, who were both aged 1 year and had biliary atresia.

FINDINGS

Donor operations lasted 7 h for the woman and 6 h for the man, and warm ischaemia times were 4 and 10 min, respectively. Blood loss was 150 and 450 mL, respectively, and no transfusions were required. Neither patient had complications during or after surgery; and hospital stay was 7 and 5 days, respectively. Both recipients are alive and have excellent graft function.

INTERPRETATION

We have shown the feasibility of laparoscopic living donor hepatectomy from parent to child. If the safety and feasibility of this procedure can be shown in larger series, laparoscopic donor left lobectomy could become a new option for paediatric living donor liver transplantation.

The general public's concerns about clinical risk in live kidney donation

Difficulty in attracting live kidney donors may be related to fears regarding both the surgical procedure for kidney harvesting and future failure of the remaining kidney. We conducted a cross-sectional study of households in Maryland to identify public disincentives to living related kidney donation. In multivariate analyses, we assessed the independent effects of several factors on willingness to donate a kidney to a sibling. We also assessed thresholds for factors above which persons would not donate a kidney. Of 385 participants, 66% were extremely willing to donate to a sibling. After adjustment, those who considered the length of a hospital stay, out-of-pocket expenses, size and appearance of a scar, the time it takes to get to the transplant center, and the donor risk of developing kidney failure very important had 50-60% less odds of being extremely willing to donate. Median acceptable levels for risk of complications, hospital stay, compensated and uncompensated time from work, time requiring pain medications, and out-of-pocket expenses were greater than levels from clinical evidence regarding both laparoscopic and open nephrectomy. Unrealistic concerns among the general public regarding live donation may serve as potential disincentives to donation. Efforts to educate the public regarding live donation might help assuage fears and attract those who may not otherwise donate.

Laparoscopic live donor nephrectomy. A review of the first 5 years

Laparoscopic live donor nephrectomy is technically feasible. The operation has evolved over the last 5 years and is greatly improved compared with the procedure originally described. Advantages to the donor when compared with the standard open operation are decreased postoperative pain, shorter hospitalization, a quicker recuperation, an earlier return to driving, and an earlier return to employment. These improvements have resulted in fewer lost wages and a lower financial burden for donors. Live donor nephrectomy also provides improved cosmetic results. It successfully removes many of the disincentives to live kidney donation and has resulted in an increased willingness of individuals to donate their kidneys. The operative risk seems to be equivalent to that of the open donor operation performed through a flank approach. Although there is no financial advantage of the laparoscopic operation in terms of hospital costs, the increase seen in live donor transplantation may result in long-term cost savings overall. Kidneys procured laparoscopically function well in recipents in the short and long term. There is no increased risk for rejection or technical complications, and the recipent's length of hospitalization is unaffected. The laparoscopic donor operation does not have any apparent deleterious effect on the recipient. The procedure is being adopted rapidly by transplant centers around the world and has been performed at more than 100 centers on five continents. The authors believe that laparoscopic live donor nephrectomy will become the standard of care in the not too distant future.

Evaluation of prospective living renal donors for laparoscopic nephrectomy with multisection CT: the marriage of minimally invasive imaging with minimally invasive surgery

Laparoscopic technique for excision of a kidney from a living donor has advantages over conventional open surgery, but operative visibility and surgical exposure are limited. Preoperative multisection computed tomography (CT) can provide necessary anatomic information in a minimally invasive procedure. A three-phase examination is suggested: (a) imaging from the top of the kidneys to the pubic symphysis with a section width of 2.5 mm and no contrast medium, (b) scanning of the kidneys and upper pelvis during the arterial phase of enhancement with a section width of 1.0 mm, and (c) scanning of the kidneys and upper retroperitoneum during the nephrographic phase of enhancement with a section width of 1.0 mm. Emphasis in this article is placed on analysis of the venous anatomy because most radiologists are unfamiliar with the anatomic variations. Conventional radiography of the abdomen and pelvis is performed after CT to evaluate the collecting system and ureters and to provide a lower total radiation dose than if CT were used. Of several postprocessing techniques that may be used, the authors prefer maximum intensity projection for arterial evaluation and multiplanar reformatting for venous evaluation.

Laparoscopic live donor nephrectomy: rationale, techniques, and implications

Laparoscopic live donor nephrectomy (LDN) was conceived as a means for decreasing donor nephrectomy morbidity and reducing disincentives for kidney donation. Since LDN was first reported in 1995, explosive growth has led to its performance at more than 100 centers worldwide. Despite initial skepticism in some segments of the transplant community, the results of LDN have improved progressively so that it is emerging as a new standard of care for live kidney donation. We review the development and refinement of LDN and its current rationale and applications.

Technique of right laparoscopic donor nephrectomy: a single center experience

The majority of laparoscopic donor nephrectomies (LDNs) are limited to the left side due to technical and allograft concerns in using the right. We review our experience with right LDNs. Since June 1997, 15 right LDNs were performed and the records retrospectively reviewed for demographics, operative time, transfusions, complications, and length of stay. Recipient records were also reviewed for delayed graft function, complications, and serum creatinine levels. Overall donor, recipient and graft survivals at 6 months are 100%. Mean operative time was 317 +/- 11.0 min, length of stay was 4.2 +/- 0.2 d, and mean serum creatinine levels at discharge, 1, 3, and 6 months were 1.74 +/- 0.19, 1.59 +/- 0.13, 1.72 +/- 0.13, and 1.68 +/- 0.13 mg/dL, respectively. No transfusions were required. There were no operative or hospital complications. Two recipients (13.3%) experienced delayed graft function, defined as requiring hemodialysis post-transplantation. With hand-assisted laparoscopy, the right laparoscopic donor nephrectomy is safe and allows excellent allograft function.

Hand-assisted laparoscopic radical nephrectomy: the experience of the inexperienced

PURPOSE

We retrospectively examined the experience of novice laparoscopic surgeons performing hand-assisted laparoscopic radical nephrectomy. The purpose was to determine if urologists with minimal laparoscopic training could perform hand-assisted laparoscopic nephrectomies in a safe and efficient manner.

MATERIALS AND METHODS

The first six hand-assisted laparoscopic radical nephrectomies performed by four different urology residents at the Chicago Lakeside VA hospital were reviewed. The residents included three chief urology residents and one postgraduate year 3 urology resident. None of the residents had taken any laparoscopic course, and all had limited exposure to the hand-assisted technique. In all cases, the residents performed the entire operation. The patients were evaluated for operative time, tumor size, body mass index, and ASA score.

RESULTS

All six procedures were completed without conversion to the open technique. The average operating time was 215.8 minutes, and the time from incision to organ removal averaged 140.8 minutes. The average estimated blood loss was 166 mL. Complications included an intraoperative diaphragmatic injury (recognized and repaired laparoscopically) and one postoperative ileus.

CONCLUSION

Hand-assisted laparoscopic radical nephrectomy can be performed safely and efficiently by urologists with minimal laparoscopic experience.

Hand-assisted laparoscopic donor nephrectomy

BACKGROUND

The hand-assisted approach to laparoscopic donor nephrectomy (LDN) might minimize the learning curve and shorten both the operation and the warm ischemia time. Our initial results from hand-assisted LDN are presented and compared with data from the literature.

METHODS

From January to September 2000, ten hand-assisted LDNs of the right kidney were performed.

RESULTS

The median operation time was 140 min (range, 120-400 min), and the warm ischemia time was 2.5 min (range, 1-4 min). There were no conversions. Postoperative morbidity included one urinary tract infection. All but one patient returned to a normal diet within 48 h. Opiates were needed a maximum of 48 h. One recipient experienced initial loss of graft function as a result of unknown causes.

CONCLUSIONS

Even at the beginning of the learning curve, operation time and warm ischemia time are significantly reduced by the hand-assisted approach, as compared with conventional LDN.

Should the indications for laparascopic live donor nephrectomy of the right kidney be the same as for the open procedure? Anomalous left renal vasculature is not a contraindiction to laparoscopic left donor nephrectomy

BACKGROUND

The left kidney is preferred for live donation. In open live donor nephrectomy, the right kidney is selected if the left kidney has multiple renal arteries or anomalous venous drainage. With laparoscopic live donor nephrectomy (LLDN), there is reluctance to procure the right kidney because of the more difficult exposure and further shortening of the right renal vein (RRV) after a stapled transection. An experience with LLDN is reviewed to determine whether the right kidney should be procured laparoscopically.

METHODS

From February 1995 to November 1999, 227 patients underwent live donor renal transplants with allografts procured by LLDN. The results of these transplants were analyzed.

RESULTS

Of the 227 kidneys transplanted, 17 (7.5%) were right kidneys. In the early experience, three (37.5%) of the eight right renal allografts developed venous thrombosis, two of which had duplicated RRV. Based on these initially unacceptable results, donor evaluation and LLDN techniques were modified. Spiral computerized tomography (CT) replaced conventional angiography to define better the venous anatomy. LLDN was modified in one of three ways: (1) changing the stapler port placement such that the RRV was transected in a plane parallel to the inferior vena cava, (2) relocation of the incision for open division of RRV, or (3) lengthening of the donor RRV with a panel graft constructed of recipient greater saphenous vein. Finally, the recipient operation enjoined complete mobilization of the left iliac vein with transposition lateral to the iliac artery. With these modifications, there were no vascular complications with the subsequent nine right renal allografts (P<0.05). Of the left kidneys transplanted, 31 had multiple renal arteries, 14 had retroaortic or circumaortic veins, 4 had both multiple arteries and venous anomalies, and 1 had a duplicated IVC draining the left renal vein. There were no vascular complications with left renal allografts that had multiple arteries or venous anomalies.

CONCLUSIONS

LLDN of the left kidney is technically easier. Left kidneys with multiple arteries or anomalous venous drainage are not problematic. The right kidney can be procured with LLDN; however, a rational approach to preoperative angiographic imaging, donor operation, and recipient operation is crucial.