A Fast and Safe Living Donor “Finger-Assisted” Nephrectomy Technique: Results of 359 Cases

Surgical Approaches and Outcomes in Living Donor Nephrectomy: A Systematic Review and Meta-analysis

CONTEXT

The use of living kidney donors is increasing and there are several surgical approaches for donor nephrectomy but it remains unknown which procedure is optimal for the patient and the graft.

OBJECTIVE

To review different surgical techniques for living donor nephrectomy and compare complication rates, warm ischemia time, and delayed graft function.

EVIDENCE ACQUISITION

A systematic review of prospective studies involving surgical complications following living donor nephrectomy was conducted in the MEDLINE/PubMed and EMBASE databases according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Baseline data, perioperative and postoperative parameters, and postoperative complications are reported. Overall complication rates between surgical techniques were compared via analysis of variance with post hoc analysis. We included 35 studies involving 6398 patients and representing six different surgical procedures for living donor nephrectomy.

EVIDENCE SYNTHESIS

Hand-assisted laparoscopic donor nephrectomy had a significantly higher overall complication rate compared to open, laparoscopic, retroperitoneoscopic, and laparoendoscopic single-site techniques (p < 0.005). The complication rates were low and no mortality was observed. The main limitation was varying reporting of complications, with only one-third of the studies using the Clavien-Dindo classification.

CONCLUSIONS

No specific surgical approach seems superior in terms of complications, which were generally low. Different factors such as warm ischemia time, blood loss, and surgeon expertise define which surgical approach should be chosen.

PATIENT SUMMARY

We looked at the different surgical methods for removing the kidney from a living kidney donor. Overall, the different surgical techniques were similar in terms of complications and no donors died in the studies we reviewed. The choice of procedure depends on multiple factors such as the expertise of the surgeon and the surgical center.

Living Kidney Donation: Practical Considerations on Setting Up a Program

Living kidney donation represents the best treatment for end stage renal disease patients, with the potentiality to pre-emptively address kidney failure and significantly expand the organ pool. Unfortunately, there is still limited knowledge about this underutilized resource. The present review aims to describe the general principles for the establishment, organization, and oversight of a successful living kidney transplantation program, highlighting recommendation for good practice and the work up of donor selection, in view of potential short- and long-terms risks, as well as the additional value of kidney paired exchange programs. The need for donor registries is also discussed, as well as the importance of lifelong follow up.

Living-donor nephrectomy at Singapore General Hospital: Evolution of surgical techniques over the last two decades

Background:

Laparoscopic living-donor nephrectomy is the current epitome of living kidney donation surgery. We review our experience in living-donor nephrectomies over the last 19 years, transitioning from open surgery to hand-assisted laparoscopy to full laparoscopic techniques.

Methods:

We retrospectively identified all living-donor nephrectomies performed at our institution from 1976 to 2018. The donors were categorised according to surgical techniques: open (ODN), hand-assisted laparoscopy (HALDN) and full laparoscopy (LDN). We reviewed changes in donor demographics over the years. Surgical outcomes between groups were compared from 2000 to 2018. We also compared the outcomes of LDN between different time periods to evaluate our learning curve.

Results:

A total of 214 living-donor nephrectomies were performed between 2000 and 2018. The majority were left sided (93%) and had single renal artery anatomy (90%). There were 22 ODN, 20 HALDN and 163 LDN cases. The mean operating time was 84±43, 151±32 and 179±37 minutes for ODN, HALDN and LDN, respectively ( p<0.001). There were no statistically significant differences in mean warm ischaemia times ( p=0.921) and length of hospital stay ( p=0.114) between groups. The overall 30-day surgical morbidity rate was 9.3%, with a major complications rate of 0.9%. The mean warm ischaemia time for LDN was significantly different ( p<0.001) between time periods: 281±260, 184±94 and 140±42 seconds for the periods between 2005–2009, 2010–2014 and 2015–2018, respectively.

Conclusion:

This study confirms the safety of living-donor nephrectomies performed at our institution, a centre with a modest volume of kidney transplants.

Laparoscopic Versus Finger-Assisted Open Donor Nephrectomy Technique: A Possible Safe Alternative

OBJECTIVES

Despite the present use ofthe laparoscopic technique for living-donor kidney nephrectomy, a search for alternative techniques continues.The aim of this study was to compare finger-assisted open donor nephrectomy versus laparoscopic donor nephrectomy.

MATERIALS AND METHODS

This study included retrospective data of 95 consecutive donors in a transplant center who were under going donor nephrectomy RESULTS: Donor demographics and clinical characteristics were generally similar between treatment groups. There were fewer female donors in the finger-assisted open donor nephrectomy treatment group (70.5% vs 29.5%; P = .003), but median body mass index was similar between groups (28 vs 26 kg/m²; P = .032). Patients who received laparoscopic donor nephrectomy had longer operative duration (3.5 vs 1.2 h; P < .001), longer combined length of incision (6 vs 5 cm; P = .001), andshorter median hospital length of stay (3 vs 4 days; P < .001). A left nephrectomy was preferred in both groups. Minor postoperative complications occurred less often in the finger-assisted open donor nephrectomy group (14.7% vs 31.6%; P = .0094). Donors who received laparoscopic nephrectomy had lower glomerular filtration rate at 1 year after donation (60 vs 89 mL/min/1.73 m²; P < .001) than donors who received finger-assisted nephrectomy. However, recipients of donors of both procedures had similar glomerular filtration rate at 1 year after transplant (65 vs 69 mL/min/1.73 m²; P = .5).

CONCLUSIONS

Our study demonstrated that finger-assisted open donor nephrectomy is a successful and safe alternative versus laparoscopic donor nephrectomy, providing favorable results for patients in terms of complications and outcomes.

Perioperative Events and Complications in Minimally Invasive Live Donor Nephrectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive live donor nephrectomy has become a fully implemented and accepted procedure. Donors have to be well educated about all risks and details during the informed consent process. For this to be successful, more information regarding short-term outcome is necessary.

METHODS

A literature search was performed; all studies discussing short-term complications after minimally invasive live donor nephrectomy were included. Outcomes evaluated were intraoperative and postoperative complications, conversions, operative and warm ischemia times, blood loss, length of hospital stay, pain score, convalescence, quality of life, and costs.

RESULTS

One hundred ninety articles were included in the systematic review, 41 in the meta-analysis. Conversion rate was 1.1%. Intraoperative complication rate was 2.3%, mainly bleeding (1.5%). Postoperative complications occurred in 7.3% of donors, including infectious complications (2.6%), of which mainly wound infection (1.6%) and bleeding (1.0%). Reported mortality rate was 0.01%. All minimally invasive techniques were comparable with regard to complication or conversion rate.

CONCLUSIONS

The used techniques for minimally invasive live donor nephrectomy are safe and associated with low complication rates and minimal risk of mortality. These data may be helpful to develop a standardized, donor-tailored informed consent procedure for live donor nephrectomy.

[Surgical aspects of living donor nephrectomy]

CONTEXT

Living donor renal transplant surgery has evolved from the classical nephrectomy by lumbotomy to less invasive surgery, the laparoscopic and robotic nephrectomy currently being the most important. It is important to know the available evidence on whether nephrectomy in patients with multiple arteries, right kidney and in obese patients can be performed safely when there is a correct indication.

OBJECTIVE

To perform a review of the different surgical techniques in living donor nephrectomy, adapted to the current surgical evidence and other aspects related to the indication.

EVIDENCE ACQUISITION

A systematic review was made in PubMed (1997-2011). This included previous reviews randomized controlled clinical studies, cohort studies, and meta-analyses of this surgical aspects of living donor nephrectomy.

CONCLUSIONS

Currently, there is sufficient evidence to consider living donor laparoscopic nephrectomy as the technique of choice, although the role of hand-assisted retroperitoneoscopic technique is still not totally clear. Open surgery techniques using mini-incision are an acceptable alternative for the sites that have not yet implemented laparoscopic surgery. Right kidney nephrectomy, of those cases that present multiple pedicles and in obese donors, is justified in selected cases.