Is Right-sided Laparoendoscopic Single-site Donor Nephrectomy Feasible?

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.

Single-port laparoscopic retroperitoneal surgery using a modified single-port device in urology

OBJECTIVES

To investigate the use of a flexible instrument platform in performing single-port laparoscopic retroperitoneal urologic surgeries and to verify the safety and feasibility of these surgeries.

METHODS

The homemade instrument platform consisted of two control loops and a powder-free surgical glove to form multichannels. 56 patients underwent this kind of single-port surgery for different urologic diseases, including radical nephrectomy in 31 patients, nephroureterectomy in 7 patients, partial nephrectomy in 8 patients, living donor nephrectomy in 4 patients, adrenalectomy in 3 patients, renal cyst surgery in 2 patients and ureterolithotomy in 1 patient.

RESULTS

All surgeries were completed successfully with no switch to conventional laparoscopic or open surgery. The mean hospital stay was 13.13 days (range 6-36). All patients were satisfied without major complications.

CONCLUSIONS

Retroperitoneal laparoendoscopic single-site surgery using our cost-effective homemade instrument platform appears to be a feasible and safe surgical strategy to perform retroperitoneal laparoscopic urologic surgery.

Laparoendoscopic single-site surgery in kidney surgery: clinical experience and future perspectives

Laparoscopic surgery of the upper urinary tract has reduced the morbidity related to large abdominal incisions and has resulted in significant advantages over open surgery. Nevertheless, the pursuit for even more minimally invasive alternatives to laparoscopy has led to the concept of scarless surgery and the approach of laparoendoscopic single-site surgery (LESS). LESS is currently a feasible approach for the majority of kidney surgical procedures, and there is intense debate regarding its efficiency and advantages. In the present review of the literature, the current status of upper urinary LESS and its advantages and disadvantages, as well the technological and technical evolution, are presented.

Safe initiation of a laparoendoscopic single site living donor nephrectomy program in a small-volume transplant center

OBJECTIVE

To describe keys to successful programmatic implementation of laparoendoscopic single-site (LESS)-living donor nephrectomy (LDN) in a small-volume center. Laparoscopic LDN has become the standard of care. Technically challenging LESS-LDN has been limited to high-volume centers. However, approximately half of all U.S. transplant centers perform ≤15 LDNs/year, including our center.

METHODS

A hand-assisted laparoscopy (HAL) device was used as the LESS platform at a periumbilical midline incision. We used an adhesive drape to cover the platform to prevent gas leakage. A 30° telescope and 3-4 instruments were inserted through its gel-cap. After careful dissection, the kidney was bagged into a recovery device with an external handle before its vessels were ligated with staples and was then removed immediately through the LESS wound.

RESULTS

LESS-LDN was successful in all of 10 living donors without any multisite laparoscopic or open conversion and without any instruments inserted through extra wounds. No patient had perioperative complications or received transfusions. Median operative time was 271 minutes with a warm ischemia time (WIT) of 3.5 minutes. Hospital stay averaged 2 days with visual analog pain score 4 of 10 at discharge and 2 of 10 at 2 weeks. All recipients recuperated well with immediate graft function.

CONCLUSION

Our LESS-LDN technique offers improved cosmesis, favorable perioperative outcomes, and versatile options for conversion, if necessary, making it a viable approach for small-volume centers.

Laparoendoscopic single-site radical nephrectomy for large renal masses

PURPOSE

To report our operative experience and short-term outcomes for the laparoendoscopic single-site (LESS) management of large renal tumors and tumors of advanced stage.

PATIENTS AND METHODS

Ten consecutive patients underwent LESS-radical nephrectomy (RN) for large (≥ 7 cm) and/or locally advanced tumors (>T(2)). Intraoperative, postoperative, and short-term follow-up data were analyzed.

RESULTS

Median surgical time was 146 minutes (range 73-164 min), and median estimated blood loss was 100 mL (range 25-400 mL). No procedure needed conversion to open RN or hand-assisted laparoscopic RN. The median hospital stay was 47 hours (range 42 hours-12 days). One (10%) patient had a minor complication (postoperative fever treated with antibiotics) and one (10%) patient had a major complication (small bowel obstruction necessitating reoperation). Of the 10 tumors, 2 were pathologic stage T(1b), 4 were pathologic stage T(2), and 4 were stage T(3a). At a median follow-up of 12.3 months (range 1-16 mos), six (60%) patients were alive without evidence of recurrence, and 4 (40%) patients were alive with disease. Of those four patients, all four had known metastatic disease before surgery.

CONCLUSION

LESS-RN for large or advanced stage renal masses is a technically challenging operation. In experienced hands, however, it is a safe and feasible therapeutic option for the management of these tumors.

Laparoendoscopic single-site donor nephrectomy

A donor would prefer a minimally invasive procedure because of lesser morbidity, this may be the reason that laparoscopic donor nephrectomy (LDN) rates have exponentially increased. The rationale dictates that a virtually scarless surgery would be most beneficial to this patient subgroup. In this article, we review the approach, instrumentation, dissection and retrieval issues and the results of laparoendoscopic single-site donor nephrectomy (LESS-DN). The existing literature on LESS-DN was reviewed in Pubmed. The various access sites described for LESS-DN include the umbilicus and Pfannenstiel incision. The steps of LESS-DN duplicate those of standard LDN. There is a paucity of studies comparing LESS-DN with LDN, particularly randomized studies. The most challenging step of LESS-DN is graft retrieval. Authors have described a variety of methods for graft retrieval which include manual methods, and those using retrieval bags. In the majority of the studies, the graft retrieval time is longer in comparison to standard LDN. However, the graft outcome in recipients is comparable. In this article, we also allude to the complications mentioned in various series. LESS-DN is currently an evolving procedure. The procedure requires a high level of skills in laparoscopic surgery. The choice of access site, access site ports and the type of instruments to be used is a matter of surgeon preference. Although the warm ischemia time in most of the series is longer in LESS-DN, this has not translated into poor recipient outcomes. Further work needs to be done to make the retrieval quick.

Current literature from comparative studies with standard LDN suggests that the results in terms of graft outcome are comparable.