Feasibility and safety of laparoscopic living donor nephrectomy in case of right kidney and multiple-renal artery kidney: a systematic review of the literature

Single versus multiple renal arteries in living donor kidney transplantation: A systematic review and patient-level meta-analysis

INTRODUCTION

Grafts with multiple renal arteries (MRAs) were historically considered a relative contraindication to transplantation due to the higher risk of vascular and urologic complications. This study aimed to evaluate graft and patient survival between single renal artery (SRA) and MRA living-donor kidney transplants.

METHODS

An electronic literature search was conducted on PubMed, EMBASE, and Scopus for prospective or retrospective studies comparing SRA versus MRA in living donor renal transplantation, with the provision of Kaplan-Meier curves for recipient overall survival (OS) or graft survival (GS). A graphical reconstructive algorithm was used to obtain OS and GS of individual patients, which was then pooled under random-effects individual patient data (IPD) meta-analysis using Cox-models to determine hazard ratios (HRs) and 95% confidence intervals (CIs). Meta-regression of baseline covariates versus HRs of OS and GS was performed for variables reported in 10 or more studies.

RESULTS

Fourteen studies were retrieved, of which 13 (8400 patients) reported OS and 9 (6912 patients) reported GS. There were no significant differences in OS (shared-frailty HR = .94, 95%CI = .85-1.03, p = .172) or GS (shared-frailty HR = .95, 95%CI = .83-1.08, p = .419) between SRA and MRA. This comparison remained non-significant even when restricted to open- or laparoscopic-only studies. Meta-regression yielded no significant associations of GS with donor age, recipient age, and percentage of double renal arteries within the MRA arm.

CONCLUSIONS

The similar rates of GS and OS between MRA and SRA grafts suggest that there is no need for discrimination between the two when evaluating donors for nephrectomy.

Massive Chylous Ascites After Living Donor Nephrectomy Successfully Treated With Lymphatic Embolization

Chylous ascites may result from a variety of pathological conditions, most of them from nontraumatic causes, such as congenital defects of the lymphatic system, infections, liver cirrhosis, and malignancy. Rarely, chylous ascites occurs as an iatrogenic complication after left-sided laparoscopic donor nephrectomy (LDN). Injury to the cisterna chyli and its main lymphatic tributaries around the para-aortic region intraoperatively can cause the lymphatic fluid to accumulate. There is currently no standardized treatment for chylous ascites as there have only been 54 cases documented to date. Most patients can be managed with conservative therapy. Recommended guidelines include high-protein and low-fat diet with medium-chain triglycerides. Paracentesis is often used as a diagnostic and therapeutic first-line measure with total parenteral nutrition (TPN), bowel rest, and somatostatin analogue as adjunct therapies. We present a case of massive chylous ascites refractory to conservative therapy. The patient had progressive abdominal distention and unintentional weight gain 2 weeks postoperatively warranting multiple paracenteses of >7 L of chylous fluid. Ultimately, the patient was successfully treated with lymphatic embolization using N-butyl cyanoacrylate glue.

Laterality in laparoscopic hand assisted donor nephrectomy - Does it matter anymore? Outcomes of a large retrospective series

This retrospective study was performed to analyse if laterality of the retrieved living donor kidney had any effect on donor and recipient outcomes after hand assisted laparoscopic donor nephrectomy (HALDN). 739 donors who underwent HALDN between January 2006 and January 2018 at a large tertiary transplant centre in the United Kingdom were included. Donor outcomes in individuals undergoing right versus left HALDN were compared with respect to conversion rates, morbidity, warm and cold ischaemia times and recipient failure rates, vascular and ureteric complications. 604 (81.7%) underwent left HALDN and 135 (18.3%) underwent right HALDN, mean age was 47.1 years and 46.8 years respectively with comparable gender distribution. The operative time was shorter for the left side (p = 0.003) and improved during the study for the left but not the right side. In recipients who received left kidneys there were more early technical failures observed (8 versus 1) though not statistically significant. Most centres prefer performing a left nephrectomy and recipient surgeons prefer a left kidney for transplantation primarily because of having a longer vein. This large study provides reassurance that right HALDN nephrectomy is a safe procedure with similar outcomes to left HALDN.

Does the Side Matter? A Retrospective Cohort Study Comparing Left and Right Pure Laparoscopic Donor Nephrectomies

OBJECTIVES

Right laparoscopic donor nephrectomy (RLDN) is no longer regarded inferior to left LDN (LLDN). However, this knowledge is based on many studies suffering from inherent learning curves, center-specific imbalances, and different laparoscopic techniques.

METHODS

Pure LDNs at a high-volume referral center from 2011 to 2016 were retrospectively analyzed. Patient, graft characteristics, outcomes of LDNs, and corresponding open kidney transplantations were compared between LLDN and RLDN including a follow-up.

RESULTS

160 (78.4%) LLDNs and 44 (21.6%) RLDNs only differed regarding graft characteristics, as more right grafts had multiple veins (34.1 vs. 6.9%, p < 0.001) and worse scintigraphic function (44 vs. 51%, p < 0.001). RLDNs were shorter (201 vs. 220 min, p = 0.032) with longer warm ischemia time (165 vs. 140 s, p < 0.001), but left grafts were transplanted faster (160 vs. 171 min, p = 0.048). Recipients of right kidneys had more postoperative complications (grade 3: 25.6 vs. 11.3%, p = 0.020). At a follow-up of 45 (range 6-79) months, neither the kidney function, nor death-censored graft (5-year: LLDN 89 vs. 92%, p = 0.969) and patient survival (5-year: LLDN 95 vs. 98%, p = 0.747) differed.

CONCLUSIONS

Pure LLDN and RLDN can have different outcomes at high-volume centers, especially higher complications for recipients of right grafts. However, long-term function and graft survival are the same irrespective of the chosen side.

Comparing outcomes in right versus left kidney transplantation: A systematic review and meta-analysis

INTRODUCTION

Transplantation of right kidneys can pose technical challenges due to the short right renal vein. Whether this results in inferior outcomes remains controversial.

METHOD

Healthcare Database Advanced Search (HDAS) was used to identify relevant studies. Two authors independently reviewed each study. Statistical analyses were performed using random effects models and results expressed as HR or relative risk (RR) with 95% confidence intervals. Subgroup analyses were performed in kidneys from deceased donors (DD) and living donors (LD).

RESULTS

A total of 35 studies (257,429 participants) were identified. Both deceased and living donor right kidneys were at increased risk of delayed graft function (DGF; RR = 1.12[1.06-1.18] and RR = 1.33[1.21-1.46] respectively; both p < .0001). In absolute terms, for each 100 kidney pairs of DD kidneys transplanted there are 2.72 (1.67-3.78, p < .00001) excess episodes of DGF in right kidneys. Graft thromboses and graft loss due to technical failure was also significantly more likely in right kidneys, in both DD and LD settings. There was no evidence that laterality alters long term graft survival in LD or DD.

CONCLUSION

Right kidneys have inferior early outcomes, with higher rates of DGF, technical failure and graft thrombosis. However, these differences are small in absolute terms, and long-term graft survival is equivalent.

The impact of multiple donor renal arteries on perioperative complications and allograft survival in paediatric renal transplantation

BACKGROUND

The impact of using allografts with multiple renal arteries in paediatric kidney transplantation has not been clearly established. The aim of this study was to determine whether kidney grafts with multiple arteries pose any adverse effects upon perioperative surgical outcomes, and graft survival up to 12 months post-transplant.

OBJECTIVE

The objective of this study was to perform a comparative analysis of a minimum of 12-month graft survival and transplant renal function in paediatric renal transplant recipients receiving single versus multiple donor arteries, and to assess perioperative and early post-operative surgical outcomes.

STUDY DESIGN

A retrospective divisional chart review of 379 transplants performed (2000-2018), of which 90 (23.7%) contained multiple donor arteries. The number of arteries of the graft, donor type, vascular reconstruction technique, occurrence of urological and vascular complications, estimated GFR and graft survival up to 12 months post-transplantation, graft loss and mortality were analysed. Comparisons in baseline characteristics and outcome measures were made between both groups.

RESULTS

No significant differences were found in age (p = 0.42), BMI (p = 0.39), estimated intraoperative blood loss (p = 0.14), overall (p = 0.63) or warm ischaemic time (p = 0.37). 51.3% patients with multiple donor arteries underwent an ex vivo reconstruction. There were no differences in the site of arterial anastomosis (aorta, external iliac, internal iliac), or anastomotic type (end-side; end-end). Whilst there was a significantly higher post-operative lymphocoele rate in the multiple vessel cohort (p = 0.024), there was no increase in post-transplant urine leaks, rejection episodes, graft loss (1.1% multiple vs 2.1% single), perioperative complications (p = 0.68), or estimated GFR at 1 month (p = 0.9) or at 1 year (p = 0.67).

DISCUSSION

We demonstrated in this study that there was no significant difference in postoperative complications up to 3 months, eGFR and renal function up to 1 year, and graft survival up to 4 years post transplantation irrespective of allograft type or reconstruction technique. There was however, a higher rate of lymphocoeles in the multiple artery cohort. The results seen here broadly mirror trends seen in adult studies, however, there is little data available from paediatric series.

CONCLUSION

Our study demonstrates that multiple renal artery allografts - previously been considered to carry a high complication risk - can be safely used for paediatric renal transplantation with equivalent perioperative complications and graft outcomes to single artery allografts.

Midline Rotation of the Right Renal Hilum During Hand-Assisted Laparoscopic Living Donor Nephrectomy

BACKGROUND/OBJECTIVES

Laparoscopic living donor nephrectomy (LLDN) of the right kidney is currently considered as part of standard of care; however, dealing with the renal hilum when performing ligation/division of its renal vessels is still a main concern. Here, we describe a simple-to-perform technique, i.e., flipping the fully mobilized right kidney to the midline so that the renal artery becomes anteriorly, which offers better visualization and easier dissection of the renal vessels (achieving maximized lengths) when performing hand-assisted LLDN of the right kidney.

METHODS

Living donors who underwent hand-assisted LLDN of the right kidney, along with their respective renal transplant recipients, were included in this report. Donor characteristics included renal artery and vein lengths; recipient characteristics included creatinine at months 12 - 36. Graft vein and arterial anastomosis data were also reported.

RESULTS

Nineteen living donors and 19 recipients, with median donor and recipient ages being 39 (24 - 60) and 53 (3 - 81) years, respectively, were included. None of the 38 patients had intra- or postoperative complications. Donor renal vein was anastomosed to the right external iliac vein (n = 16), right common iliac vein (n = 2), and inferior vena cava (n = 1). Gonadal vein (n = 1) and deceased donor iliac vein (n = 2) were used to increase the right renal vein length in 3 cases. Four donor kidneys had 2 arteries reconstructed side by side. None of the recipients developed any vascular or urological complications.

CONCLUSIONS

The laparoscopic technique described is safe and allows better visualization of the right hilum, mainly the renal artery, and helps in stapling the renal vein and renal artery.

Is a Retroaortic Vein a Risk Factor in Laparoscopic Living Donor Nephrectomy?

INTRODUCTION

In living donor transplantation choosing the right donor and donor side for laparoscopic donor nephrectomy is a challenging task in clinical practice. Knowledge about anomalies in renal blood supply are crucial to evaluate the feasibility of the operative procedure. Few data so far exist whether the existence of a retroaortic left renal vein has an impact on living kidney transplantation outcome for donor and recipient.

MATERIALS AND METHODS

We retrospectively analyzed 221 patients who underwent laparoscopic living donor nephrectomy between 2011 and 2017 for existence of a retroaortic left renal vein. Clinical characteristics and operative outcomes for donors and recipients were analyzed.

RESULTS

221 patients underwent donor nephrectomy between 2011 and 2017; 11 patients (4.98%) showed the feature of a retroaortic left renal vein, and in 8 patients (72.7%) out of those 11 the left kidney was chosen for transplantation. Mean preoperative serum creatinine was 0.77 (0.49-0.98) mg/dL and 1.28 (0.97-1.64) mg/dL at discharge. In recipients mean serum creatinine preoperatively, after 1 week, 1 month,1 year, 2 and 3 years of follow-up was 10.36 (6.09-20.77) mg/dL, 1.71 (0.67-2.72), 1.33 (0.70-1.89), 1.31 (0.95-2.13), 1.31 (0.98-2.13) and 1.33 (1.03-1.84), respectively. Neither donors nor recipients suffered from any operative complications.

CONCLUSIONS

Laparoscopic living donor nephrectomy of a left kidney with retroaortic renal vein is safe for the donor, without limitation in the outcome for the recipient.

Hand-assisted laparoscopic donor nephrectomy in kidneys with multiple renal arteries versus a single renal artery: An analysis of vascular complications from 1,350 cases

OBJECTIVE

Laparoscopic donor nephrectomy (LDN) has been shown to be a safe approach with better morbidity results. Impact of multiple renal arteries (MRAs) and anatomical variations has been reviewed by many authors. In our study, the relationship between the donors with MRAs and risk of perioperative vascular complications related to donor nephrectomy was investigated.

MATERIAL AND METHODS

Patients who underwent hand-assisted LDNs between January 2007 and February 2018 were reviewed retrospectively. Patient age, sex, body mass index (BMI), waist circumference, side of donor nephrectomies, donors with MRAs, intraoperative vascular complications, conversion rates, hospitalization durations, and operative times were extracted. Risk factors for perioperative vascular complications were defined.

RESULTS

There were MRAs in 288 kidney donors (21.3%). The number of patients who underwent a right donor nephrectomy was 113 (8.4%). BMI, waist circumference, and postoperative hospital stay were not significantly different between donors with one artery and those with MRAs (p>0.05). The renovascular complication rate and overall conversion rate to open surgery were significantly higher in donors with MRAs (p<0.05).

CONCLUSION

Perioperative safety of the kidney donors is of crucial importance. Surgeons performing LDNs must be aware of the potential risks. Our analysis suggests that procurement of kidneys from donors with MRAs is a risk factor for renovascular complications.

Use of Iliac Allograft from Cadaveric Donor as a Rescue Technique in Living Donor Kidney Transplant: Two Case Reports

BACKGROUND

A short right renal vein (RRV) remains a challenge for renal transplant surgery, especially in the living donor. Different techniques exist to obtain an RRV with a suitable length in cadaveric donor; however, in living donors the options are limited.

MATERIAL AND METHODS

We present 2 living kidney transplants in which we obtained a very short RRV, making the implantation very difficult. We describe our technique to overcome this problem by using cadaveric iliac vessels retrieved from previous cadaveric donations and preserved at 4°C in histidine-tryptophan-ketoglutarate (HTK) solution, without intraoperative or postoperative complications. We complied with the Helsinki Congress and the Istanbul Declaration regarding the donor source.

RESULTS

In both cases, kidney grafts had optimal primary function, with good creatinine clearance after transplant and good patency of vascular anastomosis by Doppler ultrasounds.

CONCLUSIONS

We believe the use of cadaveric vessel grafts in living donor kidney transplant is a valuable resource as a rescue tool in emergency situations like the ones being presented in this article in order to avoid discarding a kidney graft with damage or short vessels. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.