Ureteral Complications in the Renal Transplant Recipient after Laparoscopic Living Donor Nephrectomy

Ureterovesical Leak Following Renal Transplant and Effects of Acute Rejection and Antirejection Therapy: A Nested Case-Control Analysis and Outcome of 1102 Consecutive Renal Transplant Recipients

OBJECTIVES

Studies on nontechnical risk factors for ureterovesical leak after renal transplant are scarce. This study aimed to report the possible pre- and postoperative risk factors and the role of acute rejection and antirejection therapies for urine leak after transplant and its effect on graft and patient survival.

MATERIALS AND METHODS

We conducted a retrospective analysis of 13 patients (1.17%) with urine leak (case group) and 52 patients without leak (control group) (case-to-control ratio of 1:4) from 1102 living related (first degree) renal transplant recipients seen between January 2012 and December 2021. We analyzed demographic and clinical details and biochemical and outcome parameters using a nested case-control design.

RESULTS

Cases were olderthan controls (P = .018), were more ABO incompatible (P = .009), and had more 6/6 HLA mismatch transplants (P = .047). Donors of cases were older than donors of controls (P = .049). The rate of postoperative hypoalbuminemia was greaterin the case group (P = .050). Rates of acute rejection (P = .012) and plasmapheresis (P = .003) were greaterin the case group than in the control group. On multivariate logistic regression analysis, recipient age, 6/6 HLA mismatch, and plasmapheresis were found to independently associated with urine leak. None ofthe patient required surgical repair, as all responded to conservative therapy. Urine leak did not affect graft outcomes (P = .324), but overall survival was less in cases than in controls.

CONCLUSIONS

Nontechnical risk factors that cause posttransplant ureteric leak include older donor and recipient age and ABO incompatible and 6/6 HLA mismatch transplants. Acute rejection and plasmapheresis predispose leak, and an indwelling double J stent can allow adequate healing of the anastomosis. High index of suspicion and prompt management are imperative to preserve graft and patient outcome.

Robotic ureter reconstruction using the native ureter to treat long-segment ureteral stricture of the transplant kidney utilizing Indocyanine green: The first Korean experience

PURPOSE

Ureteral strictures are a common complication after kidney transplantation. Open reconstruction is preferred for long-segment ureteral strictures that cannot be resolved endoscopically; however, it is known to have the potential to fail. We report 2 successful cases of robotic reconstruction surgery of a transplant ureter using the native ureter with the aid of intraoperative Indocyanine green (ICG).

MATERIALS AND METHODS

Patients were placed in semi-lateral position. Using Da Vinci Xi, the transplant ureter was dissected, and the stricture site was identified. End-to-side anastomosis of the native ureter to the transplant ureter was performed. ICG was utilized to identify the course of the transplant ureter and confirm the vascularity of the native ureter.

RESULTS

Case 1: A 55-year-old female underwent renal transplantation at another hospital. She had recurrent febrile urinary tract infections (UTIs) and a ureteral stricture requiring percutaneous nephrostomy (PCN). The PCN and ureteral stent were removed successfully after surgery. The patient had only 1 febrile UTI episode after surgery. Case 2: A 56-year-old female underwent renal transplantation at another hospital. She had acute pyelonephritis 1-month post-transplantation, and a long-segment ureteral stricture was identified. She developed a UTI with anastomosis site leakage in the early postoperative period, which resolved with conservative treatment. The PCN and ureteral stent were removed 6 weeks after surgery.

CONCLUSIONS

Robotic surgery for managing long-segment ureteral stricture after kidney transplantation is safe and feasible. The use of ICG during surgery to identify the ureter course and its viability can improve the success.

Creating a Single Inflow Orifice From Living Donor Kidney Allografts With Multiple Renal Arteries

Background: Multiple renal arteries (MRA) are often encountered during living-donor kidney transplantation (LDKT), requiring surgeons to pursue complex renovascular reconstructions prior to graft implantation. With improvements in reconstruction and anastomosis techniques, allografts with MRA can be successfully transplanted with similar outcomes to allografts with a single renal artery. Here, we describe in detail various surgical techniques for reconstruction of MRA grafts with the intent of creating a single arterial inflow.

Methods: We retrospectively reviewed the medical records of all LDKT recipients with laparoscopically procured MRA kidneys between March 2008 and July 2021. Recipient and donor characteristics, operative data, type of reconstruction, and recipient outcomes were analyzed. The primary outcomes were the incidence of developing delayed graft function (DGF) and/or a vascular or urological complication within 12 months post-transplant.

Results: Seventy-three LDKT recipients of MRA donor allografts were evaluated. Two renal arteries (RA) were encountered in 62 allografts (84.9%) and three RA in 11 allografts (15.1%). Renal artery reconstruction was performed in 95.8% (70/73) of patients. Eighteen different reconstruction techniques of MRA were utilized, the most common being side-to-side anastomosis in allografts with two RA (N = 44) and side-to-side-to-side anastomosis in allografts with three RA (N = 4). Interposition grafting was performed in seven cases (9.6%). A single ostium was created in 69 cases (94.5%), and the median warm ischemia time was 27 (range 20–42) minutes. None of the patients developed DGF or post-operative vascular or urological complications. Median creatinine at 3, 6, and 12 months post-transplant remained stable at 1.1 mg/dl. With a median follow-up of 30.4 months post-transplant, only one graft failure has been observed–death-censored graft survival was 98.6%.

Conclusion: Complex reconstruction techniques to create a single renal artery ostium for graft implantation anastomosis in allografts with MRA show acceptable warm ischemic times, with no increased risk of post-operative vascular or urological complications.

Long-term outcomes of left versus right laparoscopic living donor nephrectomy with multiple renal arteries

OBJECTIVES

The objective of this study is to compare the long-term graft outcomes of left versus right donor nephrectomy with multiple renal arteries, and therefore creating a reference for the expansion of the potential living kidney donor pool.

METHODS

Laparoscopic live donor nephrectomy cases between May 2010 and October 2020 were included in this retrospective cross-sectional study. The data relating to donor and recipient demographics, surgical and anatomical characteristics, recipient and graft status were retrieved and compared using nonparametric statistical methods and multivariate regression. Analyses were fit for survival factors.

RESULTS

A total of 1009 recipients were included in this retrospective cross-sectional study with their donors. 16.7% of the donors had been discovered to have more than one renal artery supplying the donated kidney. The acute rejection rate was 12.8%. Death-censored graft survival at post-operative year 5 for single renal artery transplants was 89.6%, 89.5% for left-sided multiple renal arteries, and 88.2% for right-sided ones.

CONCLUSIONS

Both right donor nephrectomy and left donor nephrectomy are safe procedures with no significant negatively impacted rates for neither survival nor complications of the recipients in the long-term, compared to single renal artery ones.

Description and Outcomes of Three Different End-to-Side Microsurgical Techniques for the Anastomosis of Accessory Renal Artery With the Dominant Renal Artery in Kidney Transplantation

BACKGROUND

In this study, we compared the outcomes of three different surgical microscope-assisted end-to-side anastomosis techniques between the dominant and accessory renal arteries during living donor kidney transplant.

METHODS

The demographics, serum creatinine levels, warm and cold ischemia times, rate of complications, and incidence of delayed graft function of 135 kidney recipients were analyzed according to the type of arterial anastomosis. Group A (n = 98) had one dominant renal artery (DRA) with one end-to-side anastomosis to the external iliac artery (EIA) using a surgical microscope. Group B (n = 17) had one DRA plus one accessory renal artery (ARA) with two separate end-to-side anastomoses to the EIA using a surgical microscope. Group C (n = 20) had one DRA with end-to-side anastomosis to the EIA and one ARA with an ex vivo on-bench end-to-side anastomosis to the DRA using a surgical microscope.

RESULTS

Compared with groups A and B, the cold ischemia time and the rate of delayed graft function were significantly higher in group C (P ≤ .001). At 6 months after transplant, group B demonstrated a higher creatinine value (2.40 ± 3.41 mg/dL) than group A and group B (P = .032). Also, the decrease in creatinine at postoperative month 6 was limited in group B as compared with groups A and C.

CONCLUSIONS

An end-to-side anastomosis between ARA (group B) and DRA (group A) of the kidney graft using a surgical microscope on the bench ex vivo results in superior outcomes. Single arterial anastomosis techniques are associated with a better function in a 6-month follow-up than two separate arterial anastomoses.

Laparoscopic Live Donor Nephrectomy: Experience of High-Volume Center with 2,477 Cases

OBJECTIVE

Donors' health and safety are mandatory in the living-donor kidney transplantation procedure. Laparoscopic live donor nephrectomy (LLDN) provides an increase in donor numbers with its benefits and becomes a standard of care. We aimed to explain the results, complication rates, tips, and tricks of the largest number of LLDN case series ever performed in the literature.

MATERIALS AND METHODS

Between August 2012 and December 2019, 2,477 live donor case files were analyzed retrospectively. Age, gender, hospitalization times, body mass index, warm ischemia times, operation times, numbers of arteries, side of the kidneys, and complications were noted.

RESULTS

1,421 (57.4%) of 2,477 donors were female (p = 0.007). Operation times and warm ischemia times were found longer in right-sided LLDN and donors with multiple renal arteries (p = 0.046, <0.001, and <0.001, respectively). Obesity (BMI >30 kg/m2) did not affect warm ischemia times while prolonging the operation times (p = 0.013). Hospitalization times and numbers of complications were higher in obese donors.

CONCLUSIONS

LLDN seems to be a reliable solution with fewer complications and higher satisfaction rates. We hope to illuminate the way with tips and trick points for beginner transplant surgeons based on the experience obtained from 2,477 LLDN cases.

Timely surgical intervention for ureteric complications ensures adequate graft function in renal transplantation: a 10-year review

BACKGROUND

Ureteric complications can cause significant morbidity in renal and simultaneous pancreas-kidney (SPK) transplantation. This 10-year review identified transplant patients with ureteric complications necessitating surgical intervention in an Australian tertiary centre.

METHODS

The hospital records were scrutinized in detail to identify all patients who underwent renal or SPK transplantation from 1 June 2009 to 31 May 2019 with subsequent surgical management of ureteric complications. A case series of patients with ureteric complications was generated and findings were analysed.

RESULTS

A total of 893 renal and SPK transplants were performed over the 10-year period. Ten of these (1.12%; seven renal and three SPK) had ureteric complications. All were managed surgically. Five of the 10 had ureteric leaks (0.56%); three had ureteric strictures (0.34%), one had ureteric obstruction from extraluminal compression (0.11%) and one had both leak and stricture (0.11%). All 10 patients underwent ureteric reimplantation. Two patients required more than one operation for their ureteric complication. No graft loss or surgical mortality occurred. All 10 patients currently have functioning kidney transplants and none require maintenance dialysis.

CONCLUSION

We report a low rate (1.12%) of ureteric complications in our renal and SPK transplants. Our standard practice of definitive correction by ureteric reimplantation is proving successful. The authors confirm that appropriate surgery is a viable and durable option in renal transplant patients with excellent graft outcomes.

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.

Is peritoneal dialysis prior to kidney transplantation a risk factor for ureteral stenosis after adult to adult live kidney transplantation

Objectives

Major urinary complications such as urinary leaks, stenosis or urinary tract infections after kidney transplantation can lead to graft or patient loss. The effect of peritoneal dialysis on post-kidney transplantation complications have been discussed but its effect on ureteral stenosis is unknown. In this study, it was aimed to analyze factors effecting major ureteral complications after living donor kidney transplantation and impact of peritoneal dialysis and double J-stents (JJ stents).

Material and Methods

This study included 116 adult to adult living donor kidney transplant patients. Factors effecting major urologic complications after living donor kidney transplantation were analyzed. The donors were primary relatives of the recipients.

Results

Major urologic complications after living donor kidney transplantation was 8/116 (6.9%). Urinary leak was present in 2 (1.7%) patients. Ureteral stenosis was encountered in 6 (5.2%) patients. Double J stents were used in 84 (72.4%) of the cases. The effect of JJ ureteral stent was not statistically significant for urinary leak, ureteral stenosis (p= 0.074, p= 0.470, respectively). A total of 29 (25%) patients had peritoneal dialysis before kidney transplantation. Preoperative peritoneal dialyses and bacteriuria after kidney transplantation were independent risk factors for ureteral stenosis in multivariate analysis (p= 0.013, and p= 0.010 respectively).

Conclusion

In the guidance of the results of the present study, peritoneal dialysis prior to kidney transplantation and bacteriuria are independent risk factors for ureteral stenosis after living donor kidney transplantation. JJ stents have no effect on urologic complications after living donor kidney transplantation.

Ureteral Complications in Kidney Transplantation: Analysis and Management of 853 Consecutive Laparoscopic Living-Donor Nephrectomies in a Single Center

BACKGROUND

We report the incidence and nature of ureteral and surgical complications in our series of 853 consecutive living-donor renal transplants after laparoscopic living-donor nephrectomy. The aim of this study was to analyze the therapeutic approaches to ureteral complications in kidney transplantations and their relationship with recipient outcome.

METHODS

The medical records of patients who underwent kidney transplantation from 2000 to 2014 were reviewed retrospectively. After the donor nephrectomies were performed with the use of laparoscopic, hand-assisted laparoscopic, and vesico-ureteral anastomosis, the recipient's ureteral complications were classified according to the mechanism and site of urinary tract involvement: anastomosis stricture, anastomosis leakage, vesico-ureteral reflux, and urolithiasis.

RESULTS

Among the 853 cases of kidney transplantation, ureteral complications occurred in 66 patients (7.73%). The most common complication was urinary tract infection caused by vesico-ureteral reflux (n = 24, 2.81%), which was managed with by means of sub-ureteral polydimethylsiloxane injection. The second most common complication was the anastomosis site stricture (n = 23, 2.69%), which was treated by means of ureteral re-implantation or percutaneous nephrostomy. Anastomosis site leakage occurred in 11 patients (1.28%) and was managed by percutaneous nephrostomy with double-J stenting and drainage or ureteral re-implantation. Urolithiasis occurred in 8 patients (0.93%).

CONCLUSIONS

There was an 8% rate of recipient ureteral complications at our institution. Of the 66 patients, 46 (5.4%) required surgical repair. The remaining 20 patients with ureteral complications were treated with conservative care or minimally invasive procedures. The keys to successful management of these problems are early diagnosis and prompt reconstruction whenever possible. Most ureteral complications are easily managed with a successful outcome with early intervention.

Diagnosis and management of ureteral complications following renal transplantation

When compared with maintenance dialysis, renal transplantation affords patients with end-stage renal disease better long-term survival and a better quality of life. Approximately 9% of patients will develop a major urologic complication following kidney transplantation. Ureteral complications are most common and include obstruction (intrinsic and extrinsic), urine leak and vesicoureteral reflux. Ureterovesical anastomotic strictures result from technical error or ureteral ischemia. Balloon dilation or endoureterotomy may be considered for short, low-grade strictures, but open reconstruction is associated with higher success rates. Urine leak usually occurs in the early postoperative period. Nearly 60% of patients can be successfully managed with a pelvic drain and urinary decompression (nephrostomy tube, ureteral stent, and indwelling bladder catheter). Proximal, large-volume, or leaks that persist despite urinary diversion, require open repair. Vesicoureteral reflux is common following transplantation. Patients with recurrent pyelonephritis despite antimicrobial prophylaxis require surgical treatment. Deflux injection may be considered in recipients with low-grade disease. Grade IV and V reflux are best managed with open reconstruction.

Optimizing scintigraphic evaluation of split renal function in living kidney donors using the geometric mean method: a preliminary retrospective study

BACKGROUND

Accurate assessment of pre-transplant split renal function in candidates for living kidney donation is indispensable for side-selection and a sufficient long-term residual renal function.

OBJECTIVE

To analyse the need of depth correction in the assessment of split renal function in potential living kidney donors.

METHODS

In 13 consecutive patients screened for living kidney donation split renal function was measured with four different methods including conventional posterior MAG-3-scintigraphy, the geometric mean method in MAG-3-scintigraphy, MAG-3-scintigraphy with CT-based depth correction and CT-volumetry. Correlation and agreement of methods were analyzed using Spearman's rho correlation coefficient and the Bland-Altman method.

RESULTS

Despite good correlation and agreement between the different radioisotopic methods there were clinically relevant differences in split renal function in 2/13 patients (15 %) between conventional posterior MAG-3 scan and the geometric mean method. The best correlation was found between the two scintigraphic methods with depth correction. Comparing radioisotopic methods with CT-volumetry, significant differences were found in up to 6/13 patients (46 %).

CONCLUSIONS

Our results clearly indicate that in the case of living kidney donation further assessment concerning the accuracy and reliability of measuring split renal function is necessary. As there are no differences in duration of examination, costs and radiation exposure between techniques with and without depth correction, but clinically relevant differences in up to 46 % of patients, kidney depth should be incorporated in daily clinical practice of living kidney donor evaluation. The geometric mean method could significantly improve future patient assessment in cases of living kidney donation.

Native ureteropyelostomy in the treatment of obstructive uropathy in adult renal transplant. Experience and technical alternatives

OBJECTIVE

To analyze and evaluate our experience in surgical treatment with the open approach of the complex ureteral stenosis after adult kidney transplantation in a tertiary level hospital in the last seven years. We have reviewed the different surgical options used.

PATIENTS AND METHODS

A total of 589 consecutive adult renal transplants were performed from January 2005 to December 2012. Of these, 1.1% showed some degree of symptomatic obstructive uropathy which after initial urinary diversion required open surgical approach using the ipsilateral or contralateral native urinary tract. Characteristics of the patient, clinical examinations performed and surgical technique performed as well as their results are presented.

RESULTS

During the period under review, in 5 men and 2 women who had ureteral stenoses after renal transplant, 7 reparative surgeries were performed by open ureteropyelostomy, using ipsilateral native ureter in 6 cases and contralateral ureter in the remaining case. In one case, uretero-calicial anastomosis was performed due to severe pyelic shrinkage. There were no significant complications. Native kidney nephrectomy was not required for further complications. All the patients operated on had optimum plasma creatinine levels with resolution of previous dilatation.

CONCLUSIONS

The initial percutaneous nephrostomy followed by open surgical repair using native ureter represents a definitive, valid and optimal alternative in terms of safety and preservation of renal function.

Long-term outcomes of living donor kidney transplants in pediatric recipients following laparoscopic vs. open donor nephrectomy

We compared long-term outcomes of LDKT in pediatric recipients following either laparoscopic (LDN) or ODN. In our retrospective single-center study, we compared 38 pediatric LDKT recipients of a laparoscopically procured kidney with a historic ODN group comprising 17 pediatric recipients. In our center, the first pure laparoscopic non-hand-assisted LDN for a pediatric LDKT recipient was performed in June 2001. Demographic data of donors and recipients were comparable between groups. Mean follow-up was 64 months in the LDN group and 137 months in the ODN group. Patient survival was comparable between groups. Graft survival at one and five yr was 97% (LDN) vs. 94% (ODN) and 91% (LDN) vs. 88% (ODN; p = n.s.), respectively. Serum creatinine at one and five yr was 1.16 ± 0.47 mg/dL (LDN) vs. 1.02 ± 0.38 mg/dL (ODN) and 1.38 ± 0.5 mg/dL (LDN) vs. 1.20 ± 0.41 mg/dL (ODN), respectively. The type and frequency of surgical complications did not differ between groups. DGF and acute rejection rates were similar between groups. In the ODN group, a higher proportion of right donor kidneys was used. In the ODN group, all kidneys had singular arteries, whereas in the LDN group five kidneys had multiple arteries. Arterial multiplicity was associated with a higher incidence of DGF. In our experience, LDN does not compromise long-term graft outcomes in pediatric LDKT recipients. Arterial multiplicity of the donor kidney may be a risk factor for impaired early graft function in the pediatric population.

Impact of surgeon experience on complication rates and functional outcomes of 484 deceased donor renal transplants: a single-centre retrospective study

OBJECTIVE

To determine how postoperative and functional outcomes after deceased donor renal transplantation (DDRT) are related to surgeon experience.

PATIENTS AND METHODS

The outcomes of 484 adult DDRT performed by 13 urological surgeons were retrospectively reviewed. After completion of a staged renal transplant training programme under supervision of an attending urological transplant surgeon, the 13 surgeons were either assigned to the inexperienced group (n = 8) or the experienced group (n = 5). Surgeons in the experienced group had performed more than 30 unsupervised DDRT in a standard fashion with routine ureteric stenting. Between 1988 and 2005, inexperienced surgeons performed 152 DDRT, whereas experienced surgeons performed 332 DDRT.

RESULTS

Patient and graft survival at 2 hyears were 98% and 94.7%, respectively. Early graft loss in five recipients was unrelated to surgeon experience. Delayed graft function occurred in 29% of cases and median 1-year serum-creatinine was 1.48 mg/dL, with no difference between surgeon groups. Postoperative bleeding and lymphocele formation were the most frequent surgical complications, with an equal distribution between groups. Ureteric complications had a significantly higher incidence among inexperienced surgeons (6.6% versus 2.7%; P = 0.04).

CONCLUSION

We conclude that DDRT as performed by inexperienced urological renal transplant surgeons has both acceptable short- and long-term outcomes.

Ureteropyelostomy using the native ureter for the management of ureteric obstruction or symptomatic reflux following renal transplantation

OBJECTIVE

To evaluate the outcome of ureteropyelostomy using the native ureter for the management of ureteric obstruction or symptomatic reflux after renal transplantation.

MATERIALS AND METHODS

This is a single-center retrospective review of consecutive patients who underwent ureteropyelostomy after renal transplantation between the years 2000 and 2009. Ureteropyelostomy was performed using the ipsilateral native ureter. The native kidney was not removed. Patients' baseline characteristics, preceding interventions, and postprocedural outcomes were analyzed.

RESULTS

Ten patients underwent ureteropyelostomy after renal transplantation. All had initial Lich Gregoir ureterovesical anastomosis. Reasons for the reconstructive surgery were transplant ureteric stenosis in 8 patients or vesicoureteric reflux causing recurrent graft pyelonephritis in 2 patients. Median follow-up was 53 months (range 24-76). Postoperative complications included 3 patients who had transient anastomotic obstruction after removal of the double pigtail stent. They were managed with short-term ureteric restenting or nephrostomy tube insertion. In addition, 2 patients required delayed ipsilateral native nephrectomy because of infection. At last follow-up, all grafts remained unobstructed and free of infections.

CONCLUSION

Ureteropyelostomy using the native ureter for the management of transplant ureteric obstruction or symptomatic reflux is safe and provides good long-term preservation of graft function in selected patients.

Retrograde balloon dilation >10 weeks after renal transplantation for transplant ureter stenosis - our experience and review of the literature

Objective

Despite many efforts to prevent ureteric stenosis in a transplanted kidney, this complication occurs in 3–5% of renal transplant recipients. Balloon dilatation (BD) is a possible minimally invasive approach for treatment, but reports to date refer only to the antegrade approach; we analysed our experience with retrograde BD (RBD) and reviewed previous reports.

Patients and methods

From October 2008 to February 2011, eight patients after renal transplantation (RTX) underwent RBD for transplant ureteric stenosis at our hospital. We retrospectively analysed the outcome and reviewed previous reports.

Results

The eight recipients (five men and three women; median age 55 years, range 38–69) were treated with one or two RBDs for transplant ureteric stenosis. There were no complications. The median (range) time after RTX was 4.5 (2.5–11) months. Long-term success was only achieved in one recipient, while five patients were re-operated on (three with a new implant, two by replacement of transplanted ureter with ileum) after a median (range) of 2.8 (0.7–7.0) months after unsuccessful RBD(s). For two recipients the success remained unclear (one graft loss due to other reasons, one result pending). When the first RBD was unsuccessful there was no improvement with a second.

Conclusion

RBD is technically feasible, but our findings and the review of previous reports on antegrade ureteric dilatation suggest that the success rate is low when the ureter is dilated at ⩾10 weeks after RTX. From our results we cannot recommend RBD for transplant ureteric stenosis at ⩾10 weeks after RTX, while previous reports show favourable results of antegrade BD in the initial 3 months after RTX.

Long-term outcome of grafts with multiple arteries in live-donor renal allotransplantation: Analysis of 2100 consecutive patients

Purpose

To analyse the long-term outcome in relation to multiple graft arteries (MGA) in live-donor renal transplantation, and assess its effect on graft and patient survival.

Patients and methods

Between March 1976 and November 2009, a total of 2100 live-donor renal transplants were carried out at our centre. Patients were stratified according to the number of graft arteries into two groups, i.e. MGA (two or more arteries; 237 patients) and single-graft artery (SGA; 1863 patients). Variables assessed included patient demographics, site of vascular anastomosis, ischaemia time, onset of diuresis, delayed graft function, acute tubular necrosis (ATN), acute rejection, vascular and urological complications. Moreover, long-term patient and graft survival were compared among both groups. Patients were followed up for a mean (SD) of 112 (63) months.

Results

Grafts with MGA were associated with a prolonged ischaemia time (P = 0.001) and ATN (P = 0.005). Vascular thrombosis (arterial and venous) had a higher incidence in MGA (2.5%) than SGA (0.6%) (P = 0.01). Both groups were not significantly different for the onset of diuresis, acute rejection and urological complications (P = 0.16, 0.23 and 0.85, respectively). Graft and patient survival were comparable in both groups. The mean (SD) 1-, 5-, 10- and 20-year graft survival rates (%) for MGA were 96.1 (1.26), 86.6 (2.39), 61.3 (4.42) and 33.8 (7.23), and 97.5 (0.36), 86.8 (0.84), 66.0 (1.35) and 37.3 (2.76) for SGA (P = 0.54).

Conclusions

Although there was a higher incidence of prolonged ischaemia time, ATN and vascular thrombosis in live-donor renal transplants with MGA, it did not adversely affect patient or graft survival. The early, intermediate- and long-term follow-up showed an outcome comparable to that in patients with SGA.

Ureteral complications in the era of laparoscopic living donor nephrectomy: do we need to preserve the gonadal vein with the specimen?

BACKGROUND AND PURPOSE

The aim of this study was to analyze the ureteral complication rate in recipients transplanted with laparoscopically retrieved kidneys in our institution's 8-year experience when the gonal vein was not preserved with the specimen during the donor procedure.

PATIENTS AND METHODS

We reviewed the records of 800 consecutive laparoscopic donor nephrectomy patients. Donor sex, age, body mass index, warm ischemia time, hospital length of stay, donor and recipient serum creatinine levels, and incidence and type of complications including the incidence of ureteral complications were recorded.

RESULTS

Mean patient age was 39 +/- 10 years. Mean body mass index was 27 +/- 5. A total of 482 cases were treated purely laparoscopically. Of them, 318 were performed hand assisted. Seven hundred and ninety-three procedures were done on the left side and seven were done on the right side. The overall rate of intraoperative complications was 2.9%. The overall open conversion rate was 1.4%. The overall rate of postoperative complications was 3.9%. The postoperative day-7 serum creatinine values of the donors were 1.4 +/- 0.3 mg/dL. Mean creatinine in all patients at 1 week after transplantation was 1.5 +/- 0.2 mg/dL. We had one case of ureteral stricture in the recipients of laparoscopically procured kidneys without gonadal vein preservation technique among 800 patients.

CONCLUSION

Gonadal vein preservation with the entire specimen during laparoscopic donor nephrectomy procedure is not a necessary step to protect periureteral blood supply to prevent ureteral strictures.

Novel Technique for Hand Assisted Laparoscopic Right Donor Nephrectomy

PURPOSE

Most surgeons divide the renal vein with a laparoscopic stapler during laparoscopic donor nephrectomy. The right renal vein is usually shorter than the left one and using the stapler on the right side can result in a higher incidence of vascular complications for right kidney recipients. We present our experience with a new technique for hand assisted laparoscopic right donor nephrectomy.

MATERIALS AND METHODS

We designed a new vascular clamp to be completely inserted into the peritoneal cavity through the hand port incision in hand assisted laparoscopy. The renal vein with a cuff of the inferior vena cava was then excised. The defect in the inferior vena cava was sutured intracorporeally.

RESULTS

A total of 80 kidney donors underwent hand assisted laparoscopic right donor nephrectomy using the new technique. Mean +/- SD operative time was 184 +/- 36 minutes. Operative time was decreased in the last 30 patients to 152 +/- 22 minutes. Intracorporeal suture time on the inferior vena cava was 16 +/- 3 minutes. No intraoperative complications were noted and there was no partial or total graft loss. Mean blood loss was 50 +/- 35 cc. Mean warm ischemia time was 4 +/- 2 minutes. Hospital discharge was on postoperative day 1 or 2 in 81% of patients. Graft function was normal in 78 recipients with a day 5 postoperative serum creatinine of 1.6 +/- 0.9 mg/dl. Two recipients showed delayed graft function and were treated medically.

CONCLUSIONS

This technique for hand assisted laparoscopic right donor nephrectomy has proved to be safe and reproducible. We recommend practicing laparoscopic inferior vena cava suturing in the animal laboratory before performing it in humans.

Open versus laparoscopic live donor nephrectomy: a focus on the safety of donors and the need for a donor registry

PURPOSE

A review of the existing literature showed that the subject of live donor nephrectomy is a seat of underreporting and underestimation of complications. We provide a systematic comparison between laparoscopic and open live donor nephrectomy with special emphasis on the safety of donors and grafts.

MATERIALS AND METHODS

The PubMed literature database was searched from inception to October 2006. A comparison was made between laparoscopic and open live donor nephrectomy regarding donor safety and graft efficacy.

RESULTS

The review included 69 studies. There were 7 randomized controlled trials, 5 prospective nonrandomized studies, 22 retrospective controlled studies, 26 large (greater than 100 donors), retrospective, noncontrolled studies, 8 case reports and 1 experimental study. Most investigators concluded that, compared to open live donor nephrectomy, laparoscopic live donor nephrectomy provides equal graft function, an equal rejection rate, equal urological complications, and equal patient and graft survival. Analgesic requirements, pain data, hospital stay and time to return to work are significantly in favor of the laparoscopic procedure. On the other hand, laparoscopic live donor nephrectomy has the disadvantages of increased operative time, increased warm ischemia time and increased major complications requiring reoperation. In terms of donor safety at least 8 perioperative deaths were recorded after laparoscopic live donor nephrectomy. These perioperative deaths were not documented in recent review articles. Ten perioperative deaths were reported with open live donor nephrectomy by 1991. No perioperative mortalities have been recorded following open live donor nephrectomy since 1991. Regarding graft safety, at least 15 graft losses directly related to the surgical technique of laparoscopic live donor nephrectomy were found but none was emphasized in recent review articles. The incidence of graft loss due to technical reasons in the early reports of open live donor nephrectomy was not properly documented in the literature.

CONCLUSIONS

We are in need of a live organ donor registry to determine the combined experience of complications and long-term outcomes, rather than short-term reports from single institutions. Like all other new techniques, laparoscopic live donor nephrectomy should be developed and improved at a few centers of excellence to avoid the loss of a donor or a graft.

Laparoscopic Live Donor Right Nephrectomy: A New Technique to Maximize the Length of the Renal Vein Using a Modified Endo GIA Stapler

OBJECTIVES

To report the utilization of a modified Endo GIA vascular stapler to obtain the full length of the renal vein during transperitoneal laparoscopic live donor right nephrectomy.

METHODS

We used a modified Endo GIA stapler, in which the triple staggered rows of staples were removed from the kidney donor side to obtain the full length of the right renal vein. This technique has currently been used in nine consecutive transperitoneal laparoscopic right donor nephrectomies.

RESULTS

With this technique, the entire right renal vein length was harvested in all cases, without vascular complications. Mean renal warm ischemia time from clamping of the renal vessels to cold perfusion was 135s, and mean receptor postoperative glomerular filtration rate after 30 d was 67.3 ml/min. There were no graft losses.

CONCLUSIONS

A novel technique for laparoscopic live donor right nephrectomy is described. It allows harvesting the full length of the right renal vein in a safe and feasible way without compromising warm ischemia time.

Laparoscopic Donor Nephrectomy: Single-Center Experience in Egypt With 400 Consecutive Cases

INTRODUCTION

In this study, we present our experience with laparoscopic donor nephrectomy and evaluate the outcomes of donors and recipients.

PATIENTS AND METHODS

Between March 2003 and August 2006, 400 laparoscopic donor nephrectomies were performed in our institution. Donors were evaluated for renal vasculature using computed tomography angiography. We used the left kidney in 329 donors and the right kidney in 71. Donor surgeries were done transperitoneally using three trocars on the left side and four trocars on the right side. Kidneys were extracted manually through a 7-cm Pfanenstiel incision.

RESULTS

All cases were completed laparoscopically. Mean operative time was 117 +/- 34 minutes. Mean blood loss was 56 +/- 28 mL. None of the donors required a blood transfusion. Mean warm ischemia time was 2.6 +/- 0.4 minutes. The mean renal artery length was 3.1 +/- 0.4 cm; the mean renal vein length was 2.4 +/- 1.2 cm. Mean hospital stay was 2.1 days. No donor required readmission. Kidneys were transplanted successfully and the mean recipient creatinine on discharge was 1.2 +/- 0.6 mg/dL. One patient had a renal artery thrombosis on postoperative day 2. Another patient with double renal arteries had thrombosis of the smaller artery just after surgery. Acute tubular necrosis was seen in 17 patients, four of whom required dialysis. Kidney function recovered thereafter in all acute tubular necrosis cases.

CONCLUSION

Laparoscopic surgery is a minimally invasive approach for living donor nephrectomy with good functional outcomes. The donor benefits from lesser morbidity without compromising the anatomic or physiological outcome of the nephrectomized kidney.