Hand-assisted Laparoscopic Nephrectomy: Evaluation of the Learning Curve

Relationship between surgical difficulty and postoperative complications of hand-assisted laparoscopic living donor nephrectomy and establishment of prediction model

BACKGROUND

Few studies have systematically explored the factors influencing the difficulty of hand-assisted laparoscopic living donor nephrectomy. To investigate the relationship between the difficulty of hand-assisted laparoscopic living donor nephrectomy and postoperative complications of the donor as well as the recipient, and then build a model for predicting the difficulty of surgery.

METHODS

In this study, 60 patients who underwent hand-assisted laparoscopic living donor nephrectomy by the same surgeon from September 2022 to March 2024 were included as the modeling group. 20 patients operated on by another surgeon served as the external validation group. The subjective score (1-3 points) of surgical difficulty was used as the quantitative index of surgical difficulty. Pearson and Spearman correlation tests were used to explore the correlation between preoperative data and surgical difficulty scores of kidney donors, and finally built a prediction model through multiple linear regression analysis.

RESULTS

With the increase in the difficulty of operation, both donors and recipients' complications were increased. Linear regression analysis showed that only the number of renal arteries, visceral fat thickness and MAP score were independent risk factors for the difficulty of hand-assisted laparoscopic living donor nephrectomy. The prediction equation is as follows: Difficulty score = 0.584*Number of renal arteries + 0.731*MAP score + 0.110*visceral fat thickness.

CONCLUSIONS

Donors with higher surgical difficulty are more likely to have serious complications after surgery as well as the recipient. We also established a reliable prediction model for the difficulty of hand-assisted laparoscopic donor nephrectomy.

Robotic donor nephrectomy: optimizing outcomes beyond the limitations of laparoscopy

BACKGROUND

Robotic donor nephrectomy (RDN) has emerged as a safe alternate to laparoscopic donor nephrectomy (LDN), offering improved visualization, instrument dexterity and ergonomics. There is still concern about how to safely transition from LDN to RDN.

METHODS

We performed a retrospective review of 150 consecutive living donor operations (75 LDN and 75 RDN) at our center, comparing the first 75 RDN's with the last 75 LDN's performed prior to the initiation of the robotic transplant program. Operative times and complications were used as surrogates of efficiency and safety, respectively, to estimate the learning curve with RDN.

RESULTS

RDN was associated with a longer total operative time (RDN 182 vs LDN 144 min; P < 0.0001) but a significantly shorter post-operative length of stay (RDN 1.8 vs LDN 2.1 days; P = 0.0213). Donor complications and recipient outcomes were the same between both groups. Learning curve of RDN was estimated to be about 30 cases.

CONCLUSIONS

RDN is a safe alternate to LDN with acceptable donor morbidity and no negative impact on recipient outcomes even during the early part of the RDN learning curve. Surgeon preferences for the robotic approach compared to traditional laparoscopy will require further scrutiny to improve ergonomics and operative efficiency.

Utilizing the same incision for staged renal transplant in patients with polycystic kidney disease requiring hand-assisted laparoscopic nephrectomy

BACKGROUNDS

Many autosomal dominant polycystic kidney disease (ADPKD) patients undergo nephrectomy and subsequent renal transplantation. We report our outcomes after hand-assisted laparoscopic nephrectomy (HALN) where a Rutherford-Morrison incision is used as a hand-port site and kidney extraction site, as well the future incision site for staged transplantation.

METHODS

A retrospective review was performed on all adult nephrectomies for ADPKD by the Transplant Surgery department at Westmead Hospital between June 2011 and June 2021. Outcomes were compared between HALN, laparoscopic nephrectomy (LN) and open nephrectomy (ON) including operation time, hospital length of stay (LOS), post-operative complications, subsequent transplantation and post-transplantation wound complications.

RESULTS

Twenty-two HALN, 8 LN and 5 ON were performed during the study period. Median kidney weights for HALN, LN and ON were significantly different (1575, 403, 3420 g respectively, P = 0.001). There was a significant difference in LOS between the HALN and ON (5.8 versus 9.8 days, P = 0.04), but not between HALN and LN (5.8 versus 5.1, P = 0.06). There was no significant difference for operation time (P = 0.34) and major complication rates (P = 0.58). There were 8 HALN, 5 LN and 2 ON who have had subsequent renal transplantation with one wound complication, an incisional hernia in the HALN group.

CONCLUSION

Our HALN is associated with a shorter LOS and similar complication rate to ON and can be efficiently performed for significantly larger kidneys than LN without a significant difference in operation time or LOS. The same Rutherford-Morrison incision site can be used for transplantation.

Outcomes of nephrectomy for renal cell carcinoma: An ecologic retrospective study in a middle-income country

OBJECTIVE

The aim of this study was to describe and compare the outcomes and indirect costs of oncological radical (RN) and partial nephrectomies (PN) in hospitals from the São Paulo public health system, Brazil.

MATERIALS AND METHODS

An ecologic retrospective study was performed from 2008 to 2019, using the TabNet Platform of the Brazilian Unified Health System Department of Informatics. Hospitals were classified according to volume of surgeries (low and high-volume, and also into four quartiles according to volume of surgeries), and with or without medical residency program in urology. The results were compared between groups.

RESULTS

In the period analyzed were performed 2.606 RN in 16 hospitals. Data available for PN ranged only from 2013-2019 and included 1.223 surgeries comprising 15 hospitals. Overall mortality rates were 0.41% for PN and 2.87% for RN. The length of hospital stay was significantly higher in low-volume hospitals for both RN and PN (8.97 vs. 5.62 days, p = 0.001, and 7.75 vs. 4.37 days, p = 0.001, respectively), and also for the RN in hospitals without residency program in Urology (9.37 vs. 6.54 days, p = 0.03). When the volume of surgeries was divided into four quartiles, the length of hospital stay and ICU hospitalization days were significantly higher in the first quartile hospitals for RN (p = 0.016) and PN (p = 0.009), respectively. The mortality rates and indirect costs were not different considering PN and RN in the different types of hospitals.

CONCLUSIONS

The length of hospital stay was significantly lower for both PN and RN in high-volume hospitals, and also for RN in hospitals with residency program in Urology.

Outcomes and surgical complications following living-donor renal transplantation using kidneys retrieved with trans-peritoneal or retro-peritoneal hand-assisted laparoscopic nephrectomy

The best minimally invasive procedure for living-donor kidney retrieval remains debated. Our objective was to assess trans-peritoneal (TP) and retro-peritoneal (RP) hand-assisted laparoscopic donor nephrectomy (HALDN). In this single-center retrospective study, we analyzed results from 317 living-donor renal transplants (RT) performed between 2008 and 2016. Donor and recipient outcomes were compared between TP-HALDN (n = 235) and RP-HALDN (n = 82). Conversion to open nephrectomy (0.4% vs 0%; P = 1.000), intra-operative complications (1.7% vs 1.2%; P = 1.000), and 1-year overall post-operative complications (11.9% vs 17.1%; P = .258) rates were similar in TP-HALDN and RP-HALDN. Overall surgical site infections were higher in RP-HALDN (6.1% vs 1.7%; P = .053), whereas incisional hernias were only recorded following TP-HALDN (3.4% vs 0%; P = .118). The duration of the procedure was 11-minute shorter for TP-HALDN than RP-HALDN (P < .001) but extraction time was equivalent (2, IQR 1.5-2.5 minutes; P = 1.000). RT following TP-HALDN and RP-HALDN showed comparable one-year death-censored allograft survival (97% vs 98.8%; P = .685), primary non-function (0.4% vs 0%; P = .290), delayed graft function (1.3% vs 4.9%; P = .077), and urological complications (2.6% vs 4.9%; P = .290) rates. In our series, donor and recipient outcomes were not substantially affected by the approach used for donor nephrectomy. TP-HALDN and RP-HALDN were both safe and effective.

A meta-analysis comparing hand-assisted laparoscopic right hemicolectomy and open right hemicolectomy for right-sided colon cancer

Background

Mini-invasive colorectal cancer surgery was adopted widely in recent years. This meta-analysis aimed to compare hand-assisted laparoscopic surgery (HALS) with open right hemicolectomy (OS) for malignant disease.

Methods

PRISMA guidelines with random effects model were adopted using Review Manager Version 5.3 for pooled estimates.

Results

Seven studies that involved 506 patients were included. Compared to OS, HALS improved results in terms of blood loss (MD = 53.67, 95% CI 10.67 to 96.67, p = 0.01), time to first flatus (MD = 21.11, 95% CI 14.99 to 27.23, p < 0.00001), postoperative pain score, and overall hospital stay (MD = 3.47, 95% CI 2.12 to 4.82, p < 0.00001). There was no difference as concerns post-operative mortality, morbidity (OR = 1.55, 95% CI 0.89 to 2.7, p = 0.12), wound infection (OR = 1.69, 95% CI 0.60 to 4.76, p = 0.32), operative time (MD = − 16.10, 95% CI [− 36.57 to 4.36], p = 0.12), harvested lymph nodes (MD = 0.59, 95% CI − 0.18 to 1.36, p = 0.13), and recurrence (OR = 0.97, 95% CI 0.30 to 3.15, p = 0.96).

Conclusions

HALS is an efficient alternative to OS in right colectomy which combines the advantages of OS with the mini-invasive surgery.