Technical modifications of hand-assisted retroperitoneoscopic living donor nephrectomy: a single-center experience

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.

Comparison of modified hand-assisted retroperitoneoscopic laparoscopic nephrectomy and open nephrectomy in patients with benign inflammatory non-functioning kidney diseases

Background

To assess the validity and feasibility of the modified hand-assisted retroperitoneoscopic laparoscopic nephrectomy (MHARLN) in patients with benign inflammatory non-functioning kidney diseases.

Methods

We retrospectively compared the data of 223 patients who underwent an MHARLN (n=142) or an open nephrectomy (ON) (n=81) with benign inflammatory non-functioning diseases between January 2014 and October 2019 at our hospital. Patients' demographic data, perioperative outcomes, preoperative and postoperative inflammatory data, and postoperative complications were reviewed.

Results

The basic demographic data of patients were similar between the 2 groups. The mean operative times for the MHARLN and the ON were 135 and 143 minutes (P=0.181), respectively. The first time at which postoperative ambulation occurred, the visual analog pain scale (VAS) score before discharge and the postoperative complication rate were similar in both groups. However, compared to the MHARLN, the ON was associated with a more severe inflammatory response on the first day after surgery (P=0.045), higher estimated blood loss (309.8 vs. 139.6 mL; P=0.036), more peritoneal ruptures (19.8% vs. 9.2%; P=0.024), higher intraoperative transfusion (14.82% vs. 4.93%; P=0.011), higher VAS scores 24 hours after surgery (5.9 vs. 5.2; P=0.002), additional analgesic use (35.8% vs. 21.8%; P=0.024), and longer hospital stays (5.3 vs. 4.6 days; P=0.048). Before a liquid diet was commenced in the MHARLN and ON groups, the mean time was 1.2 and 1.5 days, respectively (P=0.004).

Conclusions

When performed by a skilled laparoscopic surgeon, the use of the MHARLN in patients with benign inflammatory non-functioning kidney diseases is reliable and safe. The MHARLN may help to treat challenging cases and result in less trauma successfully.

Hand-assisted retroperitoneoscopic donor nephrectomy offers more liberal use of right kidneys: lessons learned from 565 cases - a retrospective single-center study

The introduction of laparoscopic donor nephrectomy caused a shift toward' left donor nephrectomy. Some centers report a significantly low rate of endoscopic right donor nephrectomy. Hand-assisted retroperitoneoscopic donor nephrectomy (HARP-DN) was introduced as a novel surgical technique, which aims to avoid intra-abdominal complications. It was also reported to provide technical advantages for right-sided DN. In this retrospective single-center study, we evaluated the impact of HARP-DN technique on utilization of right-sided DNs. After the implementation of HARP-DN on February 2009, a total of 565 DNs were performed until December 2015. The introduction of HARP-DN technique resulted in an immediate increase in the utilization of right kidneys from 6.1% to an average of 19.6% annually. The donors 'outcome was similar to the left-sided and right-sided DN groups, excluding the increased incidence of incisional hernias in left kidney donors. None of the donors developed intra-abdominal complications. In conclusion, the implementation of HARP technique significantly increased the use of right-sided DNs, which enables a more liberal use of donors in LDKT.

Hand-Assisted Laparoscopic Nephrectomy for Live Donor Kidney Transplantation

INTRODUCTION

The live donor nephrectomy is an unusual surgical procedure as it is performed on healthy individuals. It is important to make the procedure as safe as possible without compromising the health of the donor and graft function.

JUSTIFICATION

In Mexico during 2014, 2610 kidney transplantations performed, and 1862 grafts were from living donors.

OBJECTIVE

We describe our experience with hand-assisted laparoscopic nephrectomy on live donors for kidney transplantation.

MATERIALS AND METHODS

We present a descriptive and observational study in which all living donors who completed the study protocol for renal transplantation are included.

RESULTS

From September 2006 to July 2015, there were 238 hand-assisted laparoscopic nephrectomies with live donors; 227 (95.37%) were performed on the left side and 11 (4.63%) on the right side. Of donors, 54.1% were females. The average values for the variables analyzed were age 38.17 years, 25.94 BMI, creatinine 0.82-1.13 mg/dL pre- and postoperative month respectively, length of stay 4.95 (range 2-8), warm ischemia 5.07 (range 3-13) minutes, surgical time 168.85 minutes (range 90-306), and transsurgical bleeding 139 055 mL (range 25-650). One patient was reoperated for abdominal pain and bloating without evidence of pathology, attributing it to metabolic ileus. Two patients were converted to open surgery; 1 by technical problems with the laparoscopic equipment and the second by bleeding from the renal vein, both with good results.

DISCUSSION AND CONCLUSIONS

Laparoscopic nephrectomy is a safe method that allows kidney donors to have a speedy recovery without modifying the survivals of renal grafts.

A comparison of technique modifications in laparoscopic donor nephrectomy: a systematic review and meta-analysis

OBJECTIVE

To compare the effectiveness of different technique modifications in laparoscopic donor nephrectomy.

DESIGN

Systematic review and meta-analyses.

DATA SOURCES

Searches of PubMed, EMBASE, Web of Science and Central from January 1st 1997 until April 1st 2014.

STUDY DESIGN

All cohort studies and randomized clinical trials comparing fully laparoscopic donor nephrectomy with modifications of the standard technique including hand-assisted, retroperitoneoscopic and single port techniques, were included.

DATA-EXTRACTION AND ANALYSIS

The primary outcome measure was the number of complications. Secondary outcome measures included: conversion to open surgery, first warm ischemia time, estimated blood loss, graft function, operation time and length of hospital stay. Each technique modification was compared with standard laparoscopic donor nephrectomy. Data was pooled with a random effects meta-analysis using odds ratios, weighted mean differences and their corresponding 95% confidence intervals. To assess heterogeneity, the I2 statistic was used. First, randomized clinical trials and cohort studies were analyzed separately, when data was comparable, pooled analysis were performed.

RESULTS

31 studies comparing laparoscopic donor nephrectomy with other technique modifications were identified, including 5 randomized clinical trials and 26 cohort studies. Since data of randomized clinical trials and cohort studies were comparable, these data were pooled. There were significantly less complications in the retroperitoneoscopic group as compared to transperitoneal group (OR 0.52, 95%CI 0.33-0.83, I2 = 0%). Hand-assisted techniques showed shorter first warm ischemia and operation times.

CONCLUSIONS

Hand-assistance reduces the operation and first warm ischemia times and may improve safety for surgeons with less experience in laparoscopic donor nephrectomy. The retroperitoneoscopic approach was significantly associated with less complications. However, given the, in general, poor to intermediate quality and considerable heterogeneity in the included studies, further high-quality studies are required.

TRIAL REGISTRATION

The review protocol was registered in the PROSPERO database before the start of the review process (CRD number 42013006565).