Robot-Assisted Harvesting of Kidneys for Transplantation and Global Complications for the Donor

A Quality Analysis of Donor Nephrectomy-Related Information on YouTube; Education or Misinformation?

INTRODUCTION

There currently remains an urgent need to increase living kidney donation to help mitigate the high demand for waitlisted kidney failure patients. Potential kidney donors can readily access social media, particularly YouTube, to gain basic knowledge about live donor nephrectomy surgical procedures. YouTube is an open-source platform where anyone can upload videos about any topic without peer review or quality control and is frequently used for disseminating health education. This study aims to assess the quality and accuracy of information regarding live donor nephrectomy on YouTube.

METHODS

A YouTube search was performed using the keywords "donor nephrectomy" and "kidney transplant." A total of 57 videos were assessed for eligibility criteria. Two validated tools for evaluating health information, the DISCERN and The Patient Education Materials Assessment Tool for Audiovisual Materials tools, were used to assess YouTube video information quality, understandability, and actionability.

RESULTS

A total of 53 of 57 screened videos were included in this study, with 4 videos being excluded for not being primarily in the English language. The mean (SD) DISCERN score was 23.3 (±8.3), and the mean (SD) The Patient Education Materials Assessment Tool for Audiovisual Materials Understandability and Actionability scores of 41.7% (±17.5) and 8.2% (±22.9%), respectively. Although videos were generally relevant in content to donor nephrectomy, videos lacked quality information and actionable items.

CONCLUSIONS

Information on living donor nephrectomies is prevalent on YouTube. Our assessment using quality measures of selected videos illustrates substantial misinformation on living donor nephrectomies. YouTube has the potential to be a source of reliable and accurate information on living donor nephrectomies and donations.

Right versus left fully robotic live donor nephrectomy and open kidney transplantation: Does the laterality of the donor kidney really matter?

Objective

Robotic-assisted live donor nephrectomy (LDN) is being gradually adopted across transplant centers. The left donor kidney is preferred over right due to anatomical factors and ease of procurement. We aimed to study donor and recipient outcomes after robotic procurement and subsequent open implantation of right and left kidneys.

Methods

All fully robotic LDNs and their corresponding open kidney transplants performed at our center between February 2016 and December 2021 were retrospectively analyzed.

Results

Out of 196 robotic LDN (49 [right] vs. 147 [left]), 10 (5.1%) donors had intra-operative events (6.1% [right] vs. 4.8% [left], p=0.71). None of the LDN required conversion to open surgery. The operative times were comparable for the two groups. Nausea (13.3%) was the most common post-operative complication. There was no mortality in either LDN group. Herein, we report our outcomes on 156 recipients (39 right and 117 left allografts) excluding robotic implants, exports, and pediatric recipients. There were no significant differences between right and left kidney recipients with respect to 1-year post-transplant patient survival (100.0% vs. 98.1%, p=0.45) or graft survival (93.9% vs. 97.1%, p=0.11), or delayed graft function (7.7% vs. 5.1%, p=0.55).

Conclusion

Non-hand-assisted robotic live donor nephrectomies can be safely performed with excellent outcomes. Right LDN was not associated with higher incidence of complications compared to left LDN. Open implantation of robotically procured right renal allografts was not associated with higher risk of recipient complications.

Robotic Versus Laparoscopic Donor Nephrectomy: A Retrospective Bicentric Comparison of Learning Curves and Surgical Outcomes From 2 High-volume European Centers

BACKGROUND

Although laparoscopic donor nephrectomy (LDN) represents the gold-standard technique for kidney living donation, robotic donor nephrectomy (RDN) settled as another appealing minimally invasive technique over the past decades. A comparison between LDN and RDN outcomes was performed.

METHODS

RDN and LDN outcomes were compared, focusing on operative time and perioperative risk factors affecting surgery duration. Learning curves for both techniques were compared through spline regression and cumulative sum models.

RESULTS

The study analyzed 512 procedures (154 RDN and 358 LDN procedures) performed between 2010 and 2021 in 2 different high-volume transplant centers. The RDN group presented a higher prevalence of arterial variations (36.2 versus 22.4%; P  = 0.001) compared with the LDN cohort. No open conversions occurred; operative time (210 versus 195 min; P  = 0.011) and warm ischemia time (WIT; 230 versus 180 s; P  < 0.001) were longer in RDN. Postoperative complication rate was similar (8.4% versus 11.5%; P  = 0.49); the RDN group showed shorter hospital stay (4 versus 5 d; P  < 0.001). Spline regression models depicted a faster learning curve in the RDN group ( P  = 0.0002). Accordingly, cumulative sum analysis highlighted a turning point after about 50 procedures among the RDN cohort and after about 100 procedures among the LDN group.Higher body mass index resulted as an independent risk factor for longer operative time for both techniques; multiple arteries significantly prolonged operative time in LDN, whereas RDN was longer in right kidney procurements; both procedures were equally shortened by growing surgical experience.

CONCLUSIONS

RDN grants a faster learning curve and improves multiple vessel handling. Incidence of postoperative complications was low for both techniques.

[Robot-assisted Living Donor Nephrectomy - Technical Aspects and Initial Evidence]

Minimally invasive donor nephrectomy has become the standard procedure in most transplant centres over the past two decades and has contributed to a reduction in postoperative morbidity for the donor. Robot-assisted technology is an alternative to conventional (hand-assisted) laparoscopic technology and will find increasing use in the future. In this review article, we address technical aspects of robotic-assisted donor nephrectomy, in accordance with our own experience and will provide an overview of the currently available literature. Robot-assisted living kidney donation is a safe procedure with a very low postoperative complication rate. The procedure offers advantages over the open surgical technique with respect to the reduction in the postoperative need for analgesia and the duration of hospital stay, with longer operating times and warm ischemia times, but without a measurable effect on transplant function. The postoperative outcome parameters are comparable to those of the laparoscopic technique, indicating a further acceleration of postoperative convalescence. The advantages of robot-assisted technology, due to the better exposure options, are most relevant in patients with a high BMI and multiple renal arteries, as well as in right-sided nephrectomies in which a longer transplant artery can be obtained. Robot-assisted living kidney donation will play a major role in the future of transplant surgery and is a serious alternative to conventional laparoscopic technology.

Robot-Assisted Laparoscopic Living Donor Nephrectomy: The University of Florence Technique

Objective: To provide a step-by-step overview of the University of Florence technique for robotic living donor nephrectomy (LDN), focusing on its technical nuances and perioperative outcomes.

Methods: A dedicated robotic LDN program at our Institution was codified in 2012. Data from patients undergoing robotic LDN from 2012 to 2019 were prospectively collected. All robotic LDNs were performed by a highly experienced surgeon, using the da Vinci Si robotic platform in a three-arm configuration. In this report we provide a detailed overview of our surgical technique for robotic LDN. The main objective of the study was to evaluate the technical feasibility and safety of the technique, including perioperative surgical complications rate and mid-term functional outcomes.

Results: Overall, 36 patients undergoing robotic LDNs were included in the study. Of these, 28 (78%) were left LDNs. Median (IQR) donor pre-operative eGFR was 88 (75.6–90) ml/min/1.73 m². In all cases, robotic LDN was completed without need of conversion. The median (IQR) overall operative time was 230 (195–258) min, while the median console time was 133 (IQR 117-166) min. The median (IQR) warm ischemia time was 175 (140–255) s. No intraoperative adverse events or 90-d major surgical complications were recorded. At a median (IQR) follow-up of 24 months (IQR 11-46), median (IQR) eGFR patients undergoing in living donor nephrectomy was 57.4 (47.9; 63.9) ml/min/1.73 m².

Conclusions: In our experience, robotic LDN is technically feasible and safe. The use of robotic surgery for LDN may provide distinct advantages for surgeons while ensuring optimal donors' perioperative and functional outcomes.

Robotic liver resection: Hurdles and beyond

Laparoscopy is currently considered the standard of care for certain procedures such as left-lateral sectionectomies and wedge resections of anterior segments. The role of robotic liver surgery is still under debate, especially with regards to oncological outcomes. The purpose of this review is to describe how the field of robotic liver surgery has expanded, and to identify current limitations and future perspectives of the technology. Available evidences suggest that oncologic results after robotic liver resection are comparable to open and laparoscopic approaches for hepatocellular carcinoma and colorectal liver metastases, with identifiable advantages for cirrhotic patients and patients undergoing repeat resections. Excellent outcomes and optimal patient safety can be only achieved with specific hepato-biliary and general minimally invasive training to overcome the learning curve.

Donor and Recipient Outcomes following Robotic-Assisted Laparoscopic Living Donor Nephrectomy: A Systematic Review

Aims

We aimed to summarize available lines of evidence about intraoperative and postoperative donor outcomes following robotic-assisted laparoscopic donor nephrectomy (RALDN) as well as outcomes of graft and recipients.

Methods

A systematic review of PubMed/Medline, ISI Web of Knowledge, and Scopus databases was performed in May 2018. The following search terms were combined: nephrectomy, robotic, and living donor. We included full papers that met the following criteria: original research; English language; human studies; enrolling patients undergoing RALDN.

Results

Eighteen studies involving 910 patients were included in the final analysis. Mean overall operative and warm ischemia times ranged from 139 to 306 minutes and from 1.5 to 5.8 minutes, respectively. Mean estimated blood loss varied from 30 to 146 mL and the incidence of intraoperative complications ranged from 0% to 6.7%. Conversion rate varied from 0% to 5%. The mean hospital length of stay varied from 1 to 5.8 days and incidence of early postoperative complications varied from 0% to 15.7%. No donor mortality was observed. The incidence of delayed graft function was reported in 7 cases. The one- and 10-year graft loss rates were 1% and 22%, respectively.

Conclusions

Based on preliminary data, RALDN appears as a safe and effective procedure.

Living Kidney Donation Is Recipient Age Sensitive and Has a High Rate of Donor Organ Disqualifications

BACKGROUND

Living donor kidney transplantation (LDKT) is the best therapy for patients with chronic renal failure. Its advantages, compared with cadaveric transplantation, include the possibility of avoiding dialysis, the likelihood of best outcome, and donor pool expansion. Careful assessment of potential donors is important to minimize the risks and ensure success. However, the proportion of donors disqualified has been poorly investigated. The aim of this work is to describe our experience and present the main reasons for missed donation.

METHODS

This was a single-center, retrospective study of all potential donors and recipients evaluated for LDKT between January 2008 and December 2017.

RESULTS

During the period of study, 81 donor-recipient pairs were evaluated. Of these, 45.7% were disqualified and 37 LDKTs were carried out. LDKT was the first choice in 68% of cases and preemptive in 20%; 60% of transplants were among family members. Sex distribution revealed a prevalence of females in the donor group (69%) and males in the recipient group (70%). The mean living donor age was 53 ± 9.5 years; the mean recipient age was lower in recipients listed in the living transplant program than those listed for cadaver transplantation (45.8 ± 13.4 vs 54.2 ± 11.08; P < .0001). Reasons for denial included hypertension (18.9%), deceased donor transplant performed during the study period (16.2%), urologic pathology (13.5%), incompatibility (13.5%), withdrawal of consent by donor or recipient (13.5%), psychological unsuitability (8.1%), donor cancer (5.4%), and reduced renal clearance (2.7%).

CONCLUSION

LDKT is considered an option especially for younger recipients. Of the potential kidney living donors, 45.7% were disqualified during the evaluation, with medical reasons being the primary cause.

High BMI and male sex as risk factor for increased short-term renal impairment in living kidney donors - Retrospective analysis of 289 consecutive cases

BACKGROUND

Kidney transplantation represents the treatment of choice for end-stage renal disease (ESRD). However, nephrectomy bears certain short- as well as long-term risks for the healthy, voluntary donor. As obesity is increasing and is a known risk factor for surgical complications, we wanted to assess the impact of BMI on perioperative complication rates and renal function.

MATERIALS AND METHODS

We retrospectively assessed patients undergoing living donor kidney nephrectomy at our institution. We identified 289 donors that underwent unilateral nephrectomy between January 2006 and December 2015. Donors were categorized according to their BMI (BMI <25 kg/m², BMI ≥25/<30 kg/m², BMI ≥30 kg/m²). Where indicated, analysis of variance (ANOVA) was used to compare groups, a stepwise linear regression model was used to assess impact of BMI on the change of eGFR.

RESULTS

126 donors (43.6%) had a BMI <25 while 120 (41.5%) had a BMI ≥25/<30 and 43 (14.9%) were obese with a BMI ≥30. BMI had no statistically significant influence on the percentage of laparoscopic approach (86.5% vs. 83.3% vs. 88.4%, p = 0.6564), on conversion rates (0% vs. 2.0% vs. 2.6%, p = 0.2879) or postoperative complication rates defined as Clavien Dindo ≥ II (8.7% vs. 13.3% vs. 14.0%, respectively; p = 0.4474). Notably, there were no Grade III or higher complications in any group. There was no difference in pre-operative kidney function, postoperative surgical site infection or systemic infection. BMI and male sex had a statistically significant influence on short-term decline of eGFR.

CONCLUSION

Obese donors do not suffer from an increased risk of intraoperative or perioperative complication rates. However, male sex and high BMI are associated with a more pronounced short-term decline in renal function. The impact of BMI on long-term consequences for kidney donors needs to be defined in larger prospective cohorts.