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Kędzierska-Kapuza K, Łopuszyńska I, Mizerska A, Matejak-Górska M, Safranow K, Durlik M. Robotic-Assisted Nephrectomy for Living Kidney Donation-Single Center Initial Experience (Case Series) and Review of the Literature. J Clin Med 2024; 13:3754. [PMID: 38999324 PMCID: PMC11242777 DOI: 10.3390/jcm13133754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/16/2024] [Accepted: 06/19/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Robotic-assisted nephrectomy for living kidney-donation (RANLD) has the potential of becoming the leading technique of harvesting kidney, if expertise is available. The aim of this work is to present our initial experience with robotic technique with additional hand-assistance. Materials and Methods: We initiated RANLD at our clinic using the DaVinci System in September 2022, since then harvesting six kidneys, four left and two right; in two cases, multiple arteries existed. The renal vessels were ligated using vascular staplers. All the operations included a hand-assist with the use of Gelport. The mean operation time was 119.2 min (SD 12 min). Results: There were no conversions or donors' post-operative complications. Time of discharge from the hospital was 4.5 days post-operatively. Total hospital length of stay was 7.8 days. All the harvested kidneys were transplanted, five of them with adequate function, three with initially delayed function, and one needed to be removed due to thrombotic complications. Post-operative was pain assessed on the VAS scale and overall pain was assessed according to the NRS scale. At the discharge day, donors' performance status was about 87.5% according to the Karnofsky scale. The donors resumed their normal life activity within 15.7 days and returned to work within 45.2 days. The serum mean creatinine level before the donation was 0.85 mg/dL (SD 0.1 mg/dL), and mean eGFR (MDRD) = 91.8 mL/min/1.73 m2 (SD 16.1 mL/min/1.73 m2). Conclusions: Further development of RANLD could lead to an increase in the number of living kidney donors, particularly in Poland where the number is currently lower than that of deceased donors. Prolonged operation time, longer warm ischemic time, and high equipment costs are significant drawbacks of RANLD.
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Affiliation(s)
- Karolina Kędzierska-Kapuza
- Department of Gastroenterological Surgery and Transplantology, National Medical Institute, Ministry of Interior Affairs and Administration, Wołoska St. 137, 02-507 Warsaw, Poland
| | - Inga Łopuszyńska
- Department of Gastroenterological Surgery and Transplantology, National Medical Institute, Ministry of Interior Affairs and Administration, Wołoska St. 137, 02-507 Warsaw, Poland
| | - Agnieszka Mizerska
- Department of Gastroenterological Surgery and Transplantology, National Medical Institute, Ministry of Interior Affairs and Administration, Wołoska St. 137, 02-507 Warsaw, Poland
| | - Marta Matejak-Górska
- Department of Gastroenterological Surgery and Transplantology, National Medical Institute, Ministry of Interior Affairs and Administration, Wołoska St. 137, 02-507 Warsaw, Poland
| | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University in Szczecin, Powstańców Wlkp. 72, 70-111 Szczecin, Poland
| | - Marek Durlik
- Department of Gastroenterological Surgery and Transplantology, National Medical Institute, Ministry of Interior Affairs and Administration, Wołoska St. 137, 02-507 Warsaw, Poland
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Khajeh E, Nikbakhsh R, Ramouz A, Majlesara A, Golriz M, Müller-Stich BP, Nickel F, Morath C, Zeier M, Mehrabi A. Robot-assisted versus laparoscopic living donor nephrectomy: superior outcomes after completion of the learning curve. J Robot Surg 2023; 17:2513-2526. [PMID: 37531044 PMCID: PMC10492879 DOI: 10.1007/s11701-023-01681-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/17/2023] [Indexed: 08/03/2023]
Abstract
The use of robots in donor nephrectomy has increased in recent years. However, whether robot-assisted methods have better outcomes than traditional laparoscopic methods and how surgical experience influences these outcomes remains unclear. This meta-analysis compares the outcomes of robot-assisted donor nephrectomy (RADN) with those of laparoscopic donor nephrectomy (LDN) and to investigate the effects of surgical experience on these outcomes. A systematic literature search was conducted in Medline (through PubMed) and Web of Science databases. Perioperative data were extracted for meta-analysis. To assess the impact of the learning curve, a subgroup analysis was performed to compare outcomes between inexperienced and experienced surgeons. Seventeen studies with 6970 donors were included. Blood loss was lower (mean difference [MD] = - 13.28, p < 0.01) and the warm ischemia time was shorter (MD = - 0.13, p < 0.05) in the LDN group than the RADN group. There were no significant differences in terms of conversion to open surgery, operation time, surgical complications, hospital stay, costs, and delayed graft function between the groups. Subgroup analysis revealed that operation time (MD = - 1.09, p < 0.01) and length of hospital stay (MD = - 1.54, p < 0.05) were shorter and the rate of conversion to open surgery (odds ratios [OR] = 0.14, p < 0.0001) and overall surgical complications (OR = 0.23, p < 0.05) were lower in experienced RADN surgeons than in experienced LDN surgeons. Surgical experience enhances the perioperative outcomes following RADN more than it does following LDN. This suggests that RADN could be the method of choice for living donor nephrectomy as soon as surgeons gain sufficient experience in robotic surgery.
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Affiliation(s)
- Elias Khajeh
- Head of the Division for Abdominal Transplantation, Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Rajan Nikbakhsh
- Head of the Division for Abdominal Transplantation, Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ali Ramouz
- Head of the Division for Abdominal Transplantation, Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ali Majlesara
- Head of the Division for Abdominal Transplantation, Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Mohammad Golriz
- Head of the Division for Abdominal Transplantation, Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Beat P Müller-Stich
- Head of the Division for Abdominal Transplantation, Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Felix Nickel
- Head of the Division for Abdominal Transplantation, Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Head of the Division for Abdominal Transplantation, Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
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Thai MS, Chau QT, Hoang KC, Ngo XT, Tran TT, Nguyen TH, Thai KL, Vu DH, Dinh LQV, Pham DM, Tiong HY, Nguyen TT. Introducing robot-assisted laparoscopic donor nephrectomy after experience in retroperitoneal endoscopic approach: a matched propensity score analysis. ANZ J Surg 2021; 92:531-537. [PMID: 34927326 DOI: 10.1111/ans.17424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/11/2021] [Accepted: 12/06/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess the safety and efficacy of introducing robotic-assisted laparoscopic donor nephrectomy (RALDN) to the standard retroperitoneal endoscopic donor nephrectomy (REDN). METHODS Data were collected prospectively from 124 consecutive living kidney donors (93 for REDN subgroup and 31 for RALDN subgroup) from February 2018 to December 2020. Donor baseline demographics, perioperative outcomes and recipient outcomes were recorded, and these parameters were compared between the two subgroups before and after propensity-score matching. RESULTS Mean age was 51.1 ± 9.1 years; 42.7% were males; mean body mass index was 22.7 ± 2.4; and there were 109 (88%) left kidneys. The following data of REDN and RALDN was, respectively, recorded: operative time (213 ± 43 versus 216 ± 39 min, p = 0.721), warm ischemic time (4.7 ± 1.2 versus 4.9 ± 1.4 min, p = 0.399), postoperative complications (5.4% versus 6.5%, p = 1), haemoglobin (g/L) drop (9.4 ± 7.2 versus 9.7 ± 6.6, p = 0.836), blood creatinine at 6 month (1.15 ± 0.23 versus 1.13 ± 0.24 mg/dL, p = 0.734) and at 1 year (1.09 ± 0.22 versus 1.17 ± 0.28 mg/dL, p = 0.591). In post-propensity score matched analyses, there was no significant differences between the two groups including intraoperative and postoperative complications. CONCLUSIONS RALDN could be safely introduced into a living donor program experienced in laparoscopic donor nephrectomy. The outcomes of our study comparing these minimally invasive techniques are mostly similar in terms of intraoperative and postoperative outcomes for kidney donors.
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Affiliation(s)
- Minh Sam Thai
- Urology Department, Cho Ray Hospital, Ho Chi Minh City, Viet Nam.,Urology Department, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Quy Thuan Chau
- Urology Department, Cho Ray Hospital, Ho Chi Minh City, Viet Nam
| | - Khac Chuan Hoang
- Urology Department, Cho Ray Hospital, Ho Chi Minh City, Viet Nam
| | - Xuan Thai Ngo
- Urology Department, Cho Ray Hospital, Ho Chi Minh City, Viet Nam.,Urology Department, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Trong Tri Tran
- Urology Department, Cho Ray Hospital, Ho Chi Minh City, Viet Nam
| | | | - Kinh Luan Thai
- Urology Department, Cho Ray Hospital, Ho Chi Minh City, Viet Nam.,Urology Department, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Duc Huy Vu
- Urology Department, Cho Ray Hospital, Ho Chi Minh City, Viet Nam
| | - Le Quy Van Dinh
- Urology Department, Cho Ray Hospital, Ho Chi Minh City, Viet Nam.,Urology Department, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Duc Minh Pham
- Urology Department, Cho Ray Hospital, Ho Chi Minh City, Viet Nam.,Urology Department, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Ho Yee Tiong
- Urology Department, National University Hospital, Singapore
| | - Tuan Thanh Nguyen
- Urology Department, Cho Ray Hospital, Ho Chi Minh City, Viet Nam.,Urology Department, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
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Prudhomme T, Roumiguié M, Benoit T, Lesourd M, Beauval JB, Doumerc N, Sallusto F, Soulié M, Kamar N, Gamé X. Laparoscopy for living donor left nephrectomy: Comparison of three-dimensional and two-dimensional vision. Clin Transplant 2019; 33:e13745. [PMID: 31665808 DOI: 10.1111/ctr.13745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/29/2019] [Accepted: 10/21/2019] [Indexed: 12/01/2022]
Abstract
The main objective of this preliminary study was to evaluate the feasibility and safety of 3-D laparoscopic living donor left nephrectomy (LDLN). The secondary objective was to compare intraoperative and postoperative outcomes between 3-D and 2-D laparoscopic LDLN. All patients who underwent a laparoscopic LDLN from January 2015 to April 2018 in a university center were included. All surgeries were performed by three experienced surgeons. Seventy three patients were included the following: 16 underwent a 3-D laparoscopic LDLN (3-D group), and 57 underwent a 2-D laparoscopic LDLN (2-D group). Operative time and warm ischemia time (WIT) were significantly lower in the 3-D group (operative time: 80.9 ± 10.2 vs 114.1 ± 32.3 minutes in the 3-D and 2-D groups, P = .0002) (WIT: 1.7 ± 0.6 vs 2.3 ± 0.9 minutes in the 3-D and 2-D groups, P = .02). No conversion to open surgery occurred in both groups. Length of hospital stay was significantly shorter in the 3-D group. No major postoperative complications (Clavien ≥ III) occurred. One-year postoperative GFR was similar to 3-D and 2-D groups. Our preliminary study demonstrates that 3-D laparoscopic LDLN is a feasible and safe surgical procedure. Intraoperative and postoperative outcomes were similar in both 2-D and 3-D vision systems, but 3-D vision systems allow reduction in WIT and operative time.
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Affiliation(s)
- Thomas Prudhomme
- Department of Urology, Kidney Transplantation and Andrology, Toulouse University Hospital, Toulouse, France
| | - Mathieu Roumiguié
- Department of Urology, Kidney Transplantation and Andrology, Toulouse University Hospital, Toulouse, France
| | - Thibaut Benoit
- Department of Urology, Kidney Transplantation and Andrology, Toulouse University Hospital, Toulouse, France
| | - Marine Lesourd
- Department of Urology, Kidney Transplantation and Andrology, Toulouse University Hospital, Toulouse, France
| | | | - Nicolas Doumerc
- Department of Urology, Kidney Transplantation and Andrology, Toulouse University Hospital, Toulouse, France
| | - Federico Sallusto
- Department of Urology, Kidney Transplantation and Andrology, Toulouse University Hospital, Toulouse, France
| | - Michel Soulié
- Department of Urology, Kidney Transplantation and Andrology, Toulouse University Hospital, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse University Hospital, Toulouse, France
| | - Xavier Gamé
- Department of Urology, Kidney Transplantation and Andrology, Toulouse University Hospital, Toulouse, France
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5
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Akin EB, Aydogdu I, Barlas IS. Introducing Robot-Assisted Laparoscopic Donor Nephrectomy after Experience in Hand-Assisted Retroperitoneoscopic Approach. Transplant Proc 2019; 51:2221-2224. [PMID: 31405735 DOI: 10.1016/j.transproceed.2019.02.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 02/17/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Robot-assisted laparoscopic donor nephrectomy (RALDN) can help to improve donor safety by enabling enhanced precision, flexibility, control, and vision. We are presenting our initial series during the introduction of RALDN by comparing our adopted surgical technique, hand-assisted retroperitoneoscopic donor nephrectomy (HARPDN), performed at the same time interval. METHODS We performed 12 RALDN and 27 HARPDN with Pfannenstiel incision between March 2018 and July 2018. We evaluated the demographics, operation duration, warm/cold ischemia time, estimated blood loss, length of hospital stay, postoperative complications, and donor and recipient serum creatinine levels retrospectively. RESULTS Demographics including sex, mean of age, and body mass index of the 2 groups were similar. Five cases were right sided nephrectomy in the HARPDN group. We performed only left sided donor nephrectomy in the RALDN group. The duration of operation and warm ischemia time was significantly longer in the robot-assisted group (P < .001). Postoperative major complications were not detected in any of the donors. The function of the transplanted kidneys in both groups was good on the fifth day and 1 month postoperatively. CONCLUSION We introduced the robot-assisted approach for donor candidates who are not suitable candidates for HARPDN in our center. The operation time and warm ischemia time was longer in the RALDN group, but it did not have any impact on outcome. The robot-assisted donor nephrectomy technique can be introduced safely in centers experienced in the hand-assisted approach.
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Affiliation(s)
- Emin Baris Akin
- Istanbul Bilim University, School of Medicine, Sisli Florence Nightingale Hospital, Kidney Transplantation Unit, Istanbul, Turkey
| | - Ibrahim Aydogdu
- Bezmialem Vakif University, School of Medicine, Department of Pediatric Surgery, Kidney Transplantation Unit, Istanbul, Turkey.
| | - Ilhami Soykan Barlas
- Istanbul Bilim University, School of Medicine, Sisli Florence Nightingale Hospital, Kidney Transplantation Unit, Istanbul, Turkey
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6
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The Evolution of Kidney Transplantation Surgery Into the Robotic Era and Its Prospects for Obese Recipients. Transplantation 2019; 102:1650-1665. [PMID: 29916987 DOI: 10.1097/tp.0000000000002328] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Robotic-assisted kidney transplantation (RAKT) represents the most recent innovation in the evolution of kidney transplantation surgery. Vascular techniques enabling kidney transplantation have existed since the early 20th century and contributed to the first successful open kidney transplant procedure in 1954. Technical advances have since facilitated minimally invasive laparoscopic and robotic techniques in live-donor surgery, and subsequently for the recipient procedure. This review follows the development of surgical techniques for kidney transplantation, with a special focus on the advent of robotic-assisted transplantation because of its potential to facilitate transplantation of those deemed previously too obese to transplant by standard means. The different techniques, indications, advantages, disadvantages, and future directions of this approach will be explored in detail. Robot-assisted kidney transplantation may become the preferred means of transplanting morbidly obese recipients, although its availability to such recipients remains extremely limited and strategies targeting weight loss pretransplantation should never be abandoned in favor of a "RAKT-first" approach.
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7
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Timsit MO, Kleinclauss F, Mamzer Bruneel M, Thuret R. Le donneur vivant de rein. Prog Urol 2016; 26:940-963. [DOI: 10.1016/j.purol.2016.09.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 08/29/2016] [Accepted: 09/01/2016] [Indexed: 01/10/2023]
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9
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Barman N, Palese M. Robotic-Assisted Laparoscopic Donor Nephrectomy of Patient With Nutcracker Phenomenon. EXP CLIN TRANSPLANT 2016; 16:212-215. [PMID: 27210521 DOI: 10.6002/ect.2015.0335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the case of a 30-year-old male patient undergoing a robotic-assisted laparoscopic left donor nephrectomy, where compression of the left renal vein between the superior mesenteric artery and aorta was noted on magnetic resonance angiography before the operation. The patient was diagnosed with nutcracker phenomenon and was noted to be asymptomatic at that time. This is the first reported case to date of a patient with nutcracker phenomenon who underwent a robotic-assisted laparoscopic donor nephrectomy. This article also reviews the current literature on nutcracker phenomenon and nutcracker syndrome.
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Affiliation(s)
- Naman Barman
- From the Icahn School of Medicine at Mount Sinai, NY, USA
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10
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Janki S, Klop KWJ, Hagen SM, Terkivatan T, Betjes MGH, Tran TCK, Ijzermans JNM. Robotic surgery rapidly and successfully implemented in a high volume laparoscopic center on living kidney donation. Int J Med Robot 2016; 13. [PMID: 26987773 DOI: 10.1002/rcs.1743] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 01/13/2016] [Accepted: 02/08/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND It is important to minimize risks associated with live donor nephrectomy. In this study we evaluated the results of left-sided robot-assisted donor nephrectomies in comparison with standard techniques. METHODS Data on perioperative results, kidney function, and recipient and graft survival were collected. All left-sided laparoscopic and hand-assisted procedures were selected as control groups. RESULTS Fifty-nine robot-assisted procedures were performed by two surgeons. Operative time was significantly longer in the robot-assisted group compared with both control groups. However, it decreased significantly during procedures 40-59 compared with procedures 20-39 (P = 0.014) to median 172.5 (114.0-242.0) min. One conversion to the open approach occurred in the robot group due to a bleeding of the renal artery stump. No difference was found between all techniques at 3 months post-donation. CONCLUSION Left-sided robot-assisted donor nephrectomy is feasible with over time a significant decrease in operative time with good outcomes for donor and recipient. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- S Janki
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - K W J Klop
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S M Hagen
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - T Terkivatan
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M G H Betjes
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - T C K Tran
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J N M Ijzermans
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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Bhattu AS, Ganpule A, Sabnis RB, Murali V, Mishra S, Desai M. Robot-Assisted Laparoscopic Donor Nephrectomy vs Standard Laparoscopic Donor Nephrectomy: A Prospective Randomized Comparative Study. J Endourol 2015; 29:1334-40. [DOI: 10.1089/end.2015.0213] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Amit Satish Bhattu
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Arvind Ganpule
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Ravindra B. Sabnis
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Vinodh Murali
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Shashikant Mishra
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Mahesh Desai
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
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