Successful introduction of laparoendoscopic single-site donor nephrectomy after experience with laparoscopic single-site plus-one trocar donor nephrectomy

Graft retrieval incisions in minimally invasive donor nephrectomy: Systematic review and network meta-analysis

BACKGROUND

Various incisions are employed for graft extraction during minimally invasive donor nephrectomy, but an overarching synthesis of associated short-term donor outcomes is lacking.

METHODS

An electronic literature search was conducted on PubMed, EMBASE and Scopus for studies comparing ≥2 graft extraction incisions in laparoscopic or robotic donor nephrectomy with ≥10 patients per arm. Eligible study designs included randomized trials, case-control, and cohort studies. Primary outcomes were donor length of stay (LOS); in-hospital analgesic requirement; and postoperative complications. Secondary outcomes were warm ischemia time (WIT), total operation time (TOT), and estimated blood loss (EBL). Random-effects Frequentist network meta-analyses were conducted for all outcomes.

RESULTS

Twenty-nine studies (4702 patients) were shortlisted. Six incisions were analyzed: iliac, Pfannenstiel, midline hand-assisted laparoscopic (HAL), midline umbilical, flank and transvaginal natural orifice transluminal endoscopic surgery (NOTES). The flank incision had significantly longer LOS than all other incisions. LOS was significantly longer in Pfannenstiel than iliac incision (mean difference [MD] = 0.29, 95%CI = 0.002-0.58 days). Midline HAL had significantly shorter TOT than most other incisions. Midline umbilical incisions had significantly higher WIT than midline HAL and Pfannenstiel incisions. Midline HAL had shorter WIT than transvaginal NOTES (MD = 0.80, 95%CI = 0.05-1.56 min). No major differences were seen in analgesia requirement, postoperative complications and EBL.

CONCLUSION

Six different incisions for graft retrieval are broadly comparable across most short-term outcomes although long-term outcomes remain to be elucidated. Iliac and Pfannenstiel incisions yielded similar outcomes besides marginally lower LOS for the former. Midline incision for HAL may be associated with shorter TOT, and transvaginal NOTES is an effective technique for selected female donors.

TRIAL REGISTRATION

PROSPERO CRD42023445407.

A comparison of laparoendoscopic single-site surgery versus conventional procedures for laparoscopic donor nephrectomy: a Japanese multi-institutional retrospective study

PURPOSE

Laparoendoscopic single-site donor nephrectomy (LESSDN) is a feasible and effective procedure because of its non-invasiveness and better cosmetic outcomes. However, there have been few multi-institutional studies conducted by multiple surgeons on LESSDN. We retrospectively compared the clinical data and outcomes between LESSDN and conventional laparoscopic donor nephrectomy (LDN) at multiple institutes in Japan.

MATERIALS AND METHODS

From 2009 to 2015, the clinical data of 223 donors who underwent LESSDN and 151 donors who underwent LDN were collected from 10 institutes. All LESSDNs were performed transperitoneally, whereas LDNs were performed transperitoneally (P-LDN) in 75 patients and retroperitoneally (R-LDN) in 76 patients.

RESULTS

In the LESSDN group, the single-incision site was pararectal in 155 (69.5%) patients and umbilical in 65 (29.1%) patients. Multiple surgeons (one to eight per institute) performed the LESSDN. No significant differences were observed between the three groups regarding estimated blood loss and warm ischemic time. The operative time was significantly shorter in the LESSDN group than in the R-LDN group (p = 0.018). No significant differences were observed regarding the rates of blood transfusion, open conversion, visceral injuries, and postoperative complications. Furthermore, no significant differences were observed regarding the dose of analgesic and the rate of delayed graft function. One patient required open conversion due to injury to the renal artery. Selection of LESS procedure was not an independent risk factor for the median serum creatinine level of above 1.27 mg/dL in recipients at 1 year after kidney transplantation.

CONCLUSION

The results showed the technical feasibility of LESSDN compared with the standard LDNs in a multi-institutional and multi-surgeon setting. A few observed non-negligible complications and the significantly higher levels of serum creatinine in patients who underwent LESSDN indicate that this procedure should be employed cautiously when performed by surgeons without ample experience in performing LESS procedures.

Host-related Risk Factors for Adherent Perinephric Fat in Healthy Individuals Undergoing Laparoscopic Living-donor Nephrectomy

PURPOSE

The purpose of this study is to assess the risk factors and characteristics of adherent perinephric fat (APF) in healthy individuals.

PATIENTS AND METHODS

Men who underwent laparoscopic donor nephrectomy were included. Video review was used to divide patients on the basis of APF severity. Relationship between APF scores and clinical and radiographic features was evaluated.

RESULTS

Of the 92 patients, 43 (46.7%) and 8 (8.7%) were categorized as APF and severe APF, respectively. The median total operative time was significantly associated with APF severity. Sex, body mass index, and perinephric fat area, stranding, and thickness were significantly associated with severe APF. In the multivariate analysis, perinephric fat areas and stranding were independent risk factors for severe APF (HR, 1.189 and 14.450, respectively). In the 44 analyzed cytokines, levels of sIL-6R in the perinephric adipose tissue-conditioned medium were significantly higher for APF group than that for non-APF group (P=0.049).

CONCLUSIONS

Host-related risk factors for APF could predict surgical difficulty in patients undergoing partial nephrectomy.

Laparoendoscopic single-site donor nephrectomy (LESS-DN) versus standard laparoscopic donor nephrectomy

BACKGROUND

Advances in minimally invasive surgery for live kidney donors have led to the development of laparoendoscopic single site donor nephrectomy (LESS-DN). At present, laparoscopic donor nephrectomy is the technique of choice for donor nephrectomy globally. Compared with open surgical approaches, laparoscopic donor nephrectomy is associated with decreased morbidity, faster recovery times and return to normal activity, and shorter hospital stays. LESS-DN differs from standard laparoscopic donor nephrectomy; LESS-DN requires a single incision through which the procedure is performed and donor kidney is removed. Previous studies have hypothesised that LESS-DN may provide additional benefits for kidney donors and stimulate increased donor rates.

OBJECTIVES

This review looked at the benefits and harms of LESS-DN compared with standard laparoscopic nephrectomy for live kidney donors.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant's Specialised Register to 28 January 2016 through contact with the Information Specialist using search terms relevant to this review.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared LESS-DN with laparoscopic donor nephrectomy in adults.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed studies for eligibility and conducted risk of bias evaluation. Summary estimates of effect were obtained using a random-effects model and results were expressed as risk ratios (RR) or risk difference (RD) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes.

MAIN RESULTS

We included three studies (179 participants) comparing LESS-DN with laparoscopic donor nephrectomy. There were no significant differences between LESS-DN and laparoscopic donor nephrectomy for mean operative time (2 studies, 79 participants: MD 6.36 min, 95% CI -11.85 to 24.57), intra-operative blood loss (2 studies, 79 participants: MD -8.31 mL, 95% CI -23.70 to 7.09), or complication rates (3 studies, 179 participants: RD 0.05, 95% CI -0.04 to 0.14). Pain scores at discharge were significantly less in the LESS-DN group (2 studies, 79 participants: MD -1.19, 95% CI -2.17 to -0.21). For all other outcomes (length of hospital stay; length of time to return to normal activities; blood transfusions; conversion to another form of surgery; warm ischaemia time; total analgesic requirement; graft loss) there were no significant differences observed.Although risk of bias was assessed as low overall, one study was assessed at high risk of attrition bias.

AUTHORS' CONCLUSIONS

Given the small number and size of included studies it is uncertain whether LESS-DN is better than laparoscopic donor nephrectomy. Well designed and adequately powered RCTs are needed to better define the role of LESS-DN as a minimally invasive option for kidney donor surgery.