Laparoscopic assisted live donor nephrectomy--a comparison with the open approach

Lapdoctor: Multicentre Validation of a Scoring System for Preoperative Evaluation of Difficulty of Laparoscopic Donor Nephrectomy

We previously developed and validated LAPDOCTOR (LAParoscopic-Donor-nephreCTomy-scORe), a novel scoring system for the preoperative assessment of the difficulty of living donor nephrectomy (LDN). To prove its significance, we extended our investigation to a prospective, multicenter, national study. Difficulty was assessed by the operating surgeon using a scale from 1 to 3 (1-standard, 2-moderately difficult, 3-very difficult) based on eight parameters: availability of laparoscopic space, mobilization of the colon, kidney, gonadal, adrenal and renal vein, renal artery, and ureter. Donor CT-scans were blindly reviewed by a radiologist, and the LAPDOCTOR scores were compared with the difficulty levels assigned by the surgeon to investigate the match rates. One hundred eighty-five donors were enrolled, with a mean age of 54 years (range 24-77), BMI 25 kg/m2 (range 17-35), and male/female 59/126. LDN was blindly scored as standard in 45% of the cases, moderately-difficult in 52%, and very-difficult in 3%. The agreement between the LAPDOCTOR and expert donor surgeons' rate in categorizing LDN into risk groups had a QWK of 0.711 (95% CI 0.577-0.844) with p < 0.001. The LAPDOCTOR enables precise preoperative determination of the difficulty of LDN, particularly in very difficult cases, and assessment of surgical risk in living kidney donors.

Clinical Trial Notation

https://ClinicalTrials.gov, Identifier NCT05769686.

Thirty-Year Trends in Perioperative Mortality Risk for Living Kidney Donors

This study uses a national registry study to characterize temporal trends in perioperative mortality in donors and risk factors associated with this event.

Seasonal Patterns of Living Kidney Donation in the United States From 1995 to 2019

BACKGROUND

The number of living kidney donors in the United States has declined since 2005, with variations based on the donor-recipient relationship. The reasons for this decline are unclear, and strategies to mitigate declined donations remain elusive. We examined the change in donor number monthly (within-year) versus annually (between-years) to inform potentially modifiable factors for future interventions.

METHODS

In this registry-based cohort analysis of 141 759 living kidney donors between 1995 and 2019, we used linear mixed-effects models for donor number per month and year to analyze between-year and within-year variation in donation. We used Poisson regression to quantify the change in the number of donors per season before and after 2005, stratified by donor-recipient relationship and zip-code household income tertile.

RESULTS

We observed a consistent summer surge in donations during June, July, and August. This surge was statistically significant for related donors (incidence rate ratio [IRR] range: 1.12-1.33) and unrelated donors (IRR range: 1.06-1.16) across donor income tertiles.

CONCLUSION

Our findings indicate lower rates of living kidney donation in non-summer months across income tertiles. Interventions are needed to address barriers to donation in non-summer seasons and facilitate donations throughout the year. Since the Organ Donor Leave Law provides a solid foundation for supporting year-round donation, extending the law's provisions beyond federal employees may mitigate identified seasonal barriers.

Non-Maleficence toward Young Kidney Donors: A Call for Stronger Ethical Standards and Associated Factors in Multidisciplinary Nephrology Teams

BACKGROUND

The rising frequency of live kidney donations is accompanied by growing ethical concerns as to donor autonomy, the comprehensiveness of disclosure, and donors' understanding of long-term consequences.

AIM

To explore donors' satisfaction with the ethical competence of multi-professional nephrology teams regarding disclosure of donation consequences to live kidney donors.

METHODS

A cross-sectional study was performed among Israeli live kidney donors who had donated a kidney in two hospitals that belonged to the Ministry of Health's Transplantation Center one year after the donation, from December 2018 to December 2020. Data collection was conducted online and through face-to-face interviews with the donors in their native language (Hebrew or Arabic).

RESULTS

Overall, 91 live kidney donors aged 18-49 years were enrolled. Of those, 65.9% were males, and 54.9% were academic donors. Among the live kidney donors, 59.3% reported that the motivation behind the donation was a first-degree family member vs. 35.2% altruistic and 5.5% commercial. Only 13.2% reported that the provided disclosure adequately explained the possible consequences of living with a single kidney. Approximately 20% of the participants reported that the disclosure included information regarding their risk of developing ESRD, hypertension, and proteinuria. The donors reported a low mean of the index score that indicates a low follow-up by the physician after the donation (mean = 1.16, SD = 0.37). The mean GFR level was significantly lower in the post-donation period one year following a kidney donation (117.8 mL/min/1.73 m2) compared with the pre-donation period (84.0 mL/min/1.73 m2), p < 0.001.

CONCLUSION

Our findings display that donors' satisfaction with the ethical competence of multi-professional nephrology teams regarding the disclosure of donation consequences to live kidney donors is low. This study indicates that donors are at an increased risk of worsening kidney functions (creatinine and GFR), and BMI. Our findings underscore the imperative to advise donors that their condition may worsen over time and can result in complications; thus, they should be monitored during short and long-term follow-up periods. This study was not registered.

Minimally invasive surgery for pediatric renal tumors: A systematic review by the APSA Cancer Committee

Minimally invasive nephrectomy is performed routinely for adult renal tumors and for many benign pediatric conditions. Although open radical nephroureterectomy remains the standard of care for Wilms tumor and most pediatric renal malignancies, there are an increasing number of reports of minimally invasive surgery (MIS) for those operations as well. The APSA Cancer Committee performed a systematic review to better understand the risks and benefits of MIS in pediatric patients with renal tumors.

METHODS

The search focused on MIS for renal tumors in children and followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist. The initial database search identified 491 published articles, and after progressive review of abstracts and full-length articles, 19 were included in this review.

RESULTS

There were two direct comparison studies where open surgery and MIS were compared. The remaining studies reported only on minimally invasive nephrectomy. Across all studies, there were a total of 151 patients, 126 of which had Wilms tumor and 10 patients had RCC. 104 patients had MIS, with 47 patients having open surgery. In the two studies in which open surgery and MIS were directly compared, more lymph nodes were harvested during open surgery (median = 2 (MIS) vs 5 (open); mean = 2.47 (MIS) vs 3.8 (open)). Many noncomparison studies reported the harvest of 2 of fewer lymph nodes for Wilms tumor. Several MIS patients were also noted to have intraoperative spill or positive margins. Survival between groups was similar.

CONCLUSIONS

There is a lack of evidence to support MIS for pediatric renal tumors. This review demonstrates that lymph node harvest has been inadequate for MIS pediatric nephrectomy and there appears to be an increased risk for intraoperative spill. Survival data are similar between groups, but follow-up times were inconsistent and patient selection was clearly biased, with only small tumors being selected for MIS.

TYPE OF STUDY

Review article.

LEVEL OF EVIDENCE

III.

Safety and Efficacy of Right Retroperitoneal Laparoscopic Live Donor Nephrectomy: A Retrospective Single-Center Study

Background

The aim of this study was to investigate the efficacy and safety of right retroperitoneal laparoscopic live donor nephrectomy (LDN) in 81 cases of living-related renal transplant.

Material/Methods

We retrospectively reviewed all living-related donors who underwent right retroperitoneoscopic living donor nephrectomy between June 2010 and December 2017 at the First Hospital of Jilin University and their corresponding recipients. Demographic and clinical data were collected from the hospital’s electronic clinical data system. Data on preoperative renal retention parameters, operative time, and donor kidney warm ischemia time, the trimmed length of the renal artery and vein of donor kidney, and the time to extubation were recorded. Complications in both donors and recipients were recorded.

Results

We included 81 donors who underwent successful right-sided retroperitoneoscopic LDN, with 31 males and 50 females and a mean age of 47.1 years (range 21–63 years). There was no intraoperative conversion to open donor nephrectomy. The mean operative time was 120.68±29.8 min. The mean warm ischemic time was 49.26±3.86 s. The estimate blood loss was 54.32 mL (range 50–400 mL). The median length of hospital stay was 7 days (range 4–13 days). There was neither intraoperative complication such as hemorrhage or lymph fistula nor kidney graft injury. There was no graft renal vein thrombosis and ureteral stricture or other complications. No graft rejection occurred.

Conclusions

Right retroperitoneal laparoscopic live donor nephrectomy is safe and effective for renal transplant in living-related renal transplant by laparoscopic excision and extraction of the right kidney with vena cava flap.

Preoperative assessment system for hand-assisted laparoscopic donor nephrectomy by discriminant analysis

We developed a preoperative assessment system to predict surgical workload in hand-assisted laparoscopic donor nephrectomy (HALDNx) using the normal-based linear discriminant rule (NLDR). A total of 128 cases of left HALDNx performed by a single operator were used as training data. Surgical workload was measured by operative time. The optimized model had 9 explanatory variables: age, total protein, total cholesterol, number of renal arteries (numberRA), 4 variables of perinephric fat (PNF), and thickness of subcutaneous fat. This model was validated using cross-validation and the .632 estimator to estimate discrimination rates with future test data. PNF and numberRA were the predominant factors affecting workload followed by the computed tomography value of PNF, body weight, and male sex. The estimated accuracy of the prediction system was 94.6%. The complication rate was 9.38% and did not correlate with surgical workload. We also made our program available online for constructing assessment functions from other cohort data. In conclusion, the surgical workload of HALDNx could be predicted with PNF and numberRA as the dominant risk factors.

Right Living Donor Nephrectomies: Retroperitoneoscopic vs Laparoscopic Transperitoneal Approach

Retroperitoneoscopic right living donor nephrectomy (RLDN) provides direct access to the renal hilum without the need to mobilize the colon. However, factors such as lack of anatomic landmarks to guide orientation, smaller working space, and steep learning curve provided a debate against this approach. In this retrospective study, we reviewed our single-center experience of retroperitoneoscopic RLDN.

MATERIALS AND METHODS

Between January 2015 and January 2017, 10 patients underwent retroperitoneoscopic RLDN by a single surgeon at the National University Hospital, Singapore. Baseline demographics, intraoperative parameters, and both donor and recipient outcomes were retrieved from the database.

RESULTS

Mean (SD) age was 52.7 (13.8) years, mean (SD) body mass index was 25.2 (2.9) kg/m², mean (SD) operating time was 196.8 (38.0) minutes, mean (SD) warm ischemic time was 5.1 (2.1) minutes, and mean (SD) blood loss was 43 (25.0) mL. Mean (SD) renal vein length was 10 (2.5) mm, and mean (SD) renal artery length was 6 (1.8 mm). One patient had to be converted to laparoscopic transperitoneal nephrectomy. No donors developed complications. Mean (SD) hospital stay was 3.5 (1.1) days. All transplanted right kidneys had immediate graft function with no complications. Mean (SD) serum creatinine (at 1 year) was 103.6 (20.3) μmol/L. There is no graft loss among the recipient after 1 year.

CONCLUSIONS

Right donor nephrectomy can be performed safely using retroperitoneoscopic approach. Retroperitoneoscopy offers advantages, especially in a patient who previously had transabdominal surgery or high body mass index. However, transperitoneal approach may be preferable in anomalous situations because it provides instinctive orientation from anatomic landmarks and a greater working space.

Impact of center volume and the adoption of laparoscopic donor nephrectomy on outcomes in pediatric kidney transplantation

Reports for pediatric kidney transplant recipients suggested better outcomes for ODN compared to LDN. Contemporary outcomes stratified by donor type and center volume have not been evaluated in a national dataset. UNOS data (2000-2014) were analyzed for pediatric living donor kidney transplant recipients. The primary outcome was GF; secondary outcomes were DGF, rejection, and patient survival. Live donor nephrectomies for pediatric recipients decreased 30% and transitioned from ODN to LDN. GF rates did not differ for ODN vs LDN (P = .24). GF was lowest at high volume centers (P < .01). Donor operative approach did not contribute to GF. LDN was associated with less rejection than ODN (OR 0.66, CI 0.5-0.87, P < .01). Analysis of the 0- to 5-yr recipient group showed no effect of ODN vs LDN on GF or rejection. For the contemporary era, there was no association between DGF and LDN in the 0- to 5-yr group (OR 1.12, CI 0.67-1.89, P = .67). Outcomes of kidney transplants in pediatric recipients following LDN have improved since its introduction and LDN should be the approach for live donor nephrectomy regardless of recipient age. The association between case volume and improved outcomes highlights future challenges in organ transplantation.

Mini-incision versus hand-assisted laparoscopic donor nephrectomy in living-donor kidney transplantation: A retrospective cohort study

BACKGROUND

Increasing use of Living Donor Kidney Transplantation (LDKT) would decrease the discrepancy between patients awaiting transplantation and organ availability. Minimally invasive surgical approaches attempt to improve outcomes and foster living donation. This report compares outcomes of open minimal incision nephrectomy (Mini N) and a hand assisted laparoscopic nephrectomy (HALN).

METHODS

This is a retrospective analysis of a prospectively maintained clinical database of LDKT using HALN or Mini N at a single institution between July 2007 and December 2015. Donor and recipient demographics, relevant pre-, intra- and post-operative factors, outcomes such as patient and graft survival rates, and complications were evaluated.

RESULTS

Four hundred and fifty-four adult LDKT (243 Mini N, 211 HALN) were performed during the study period. Recipient and donor demographics were comparable except for higher BMI (p = 0.027) in HALN donors. One-, 3- and 5-year patient and graft survival rates were comparable. Six HALN donors experienced infectious wound complications or superficial skin dehiscence; none did in the Mini N group (p = 0.009). Eight HALN donors and one Mini N donor required an incisional hernia repair (p = 0.014). Recipients had similar warm ischemia times (33 v. 35 min, p = 0.491), but recipient surgeons of HALN nephrectomies subjectively noted higher anastomotic difficulty (10.4% v. 4.5%, p = 0.0183). Other parameters were similar between groups.

CONCLUSION

Both Mini N and HALN provide similar long term recipient and donor outcomes. Offering techniques such as Mini N and HALN for living donor kidney procurement facilitates the opportunity to provide living donors safer and better tolerated nephrectomy procedures.

Ureteral Complications in Kidney Transplantation: Analysis and Management of 853 Consecutive Laparoscopic Living-Donor Nephrectomies in a Single Center

BACKGROUND

We report the incidence and nature of ureteral and surgical complications in our series of 853 consecutive living-donor renal transplants after laparoscopic living-donor nephrectomy. The aim of this study was to analyze the therapeutic approaches to ureteral complications in kidney transplantations and their relationship with recipient outcome.

METHODS

The medical records of patients who underwent kidney transplantation from 2000 to 2014 were reviewed retrospectively. After the donor nephrectomies were performed with the use of laparoscopic, hand-assisted laparoscopic, and vesico-ureteral anastomosis, the recipient's ureteral complications were classified according to the mechanism and site of urinary tract involvement: anastomosis stricture, anastomosis leakage, vesico-ureteral reflux, and urolithiasis.

RESULTS

Among the 853 cases of kidney transplantation, ureteral complications occurred in 66 patients (7.73%). The most common complication was urinary tract infection caused by vesico-ureteral reflux (n = 24, 2.81%), which was managed with by means of sub-ureteral polydimethylsiloxane injection. The second most common complication was the anastomosis site stricture (n = 23, 2.69%), which was treated by means of ureteral re-implantation or percutaneous nephrostomy. Anastomosis site leakage occurred in 11 patients (1.28%) and was managed by percutaneous nephrostomy with double-J stenting and drainage or ureteral re-implantation. Urolithiasis occurred in 8 patients (0.93%).

CONCLUSIONS

There was an 8% rate of recipient ureteral complications at our institution. Of the 66 patients, 46 (5.4%) required surgical repair. The remaining 20 patients with ureteral complications were treated with conservative care or minimally invasive procedures. The keys to successful management of these problems are early diagnosis and prompt reconstruction whenever possible. Most ureteral complications are easily managed with a successful outcome with early intervention.

Should hand-assisted retroperitoneoscopic nephrectomy replace the standard laparoscopic technique for living donor nephrectomy? A meta-analysis

OBJECTIVE

We performed this meta-analysis to compare hand-assisted retroperitoneoscopic (HARP) and traditional laparoscopic (TLS) techniques for living donor nephrectomy.

METHODS

We searched PubMed, Cochrane Central, EMBASE, and Web of science for prospective studies, comparing HARP and TLS techniques. Data were extracted from eligible studies and pooled as risk ratios (RR) or standardized mean difference (SMD), using RevMan software (version 5.3 for windows). We performed a sensitivity analysis to test the robustness of our evidence and a subgroup analysis to stratify intraoperative complications on Clavien-Dindo score.

RESULTS

Seven studies (498 patients) were included in the final analysis. HARP was superior to TLS in terms of shortening the operative duration (SMD = -0.84, 95% CI [-1.18 to -0.50]) and warm ischemia time (SMD = -0.93, 95% CI [-1.13 to -0.72]). There was no significant difference between HARP and TLS in terms of blood loss (SMD = 0.13, 95% CI [-0.50 to 0.76]), hospital stay (SMD = -0.27, 95% CI [-0.70 to 0.15]) or graft survival (RR = 0.97, 95% CI [0.92 to 1.02]). The overall risk ratio of intraoperative complications did not differ significantly between the two groups (RR = 0.62, 95% CI [0.31 to 1.21]).

CONCLUSION

Our meta-analysis shows that HARP was associated with a shorter surgery duration and less warm ischemia time than TLS. However, no significant differences were found between the two groups in terms of graft survival or intraoperative complication rates. We recommend HARP over TLS for living donor nephrectomy; however, future studies with larger sample sizes are recommended to compare both techniques in terms of operative safety and quality of life outcomes.

Comparative Study of the Effect of Intravenous Paracetamol and Tramadol in Relieving of Postoperative Pain after General Anesthesia in Nephrectomy Patients

Aim:

The aim of this study was to compare the effect of intravenous paracetamol and tramadol in relieving of postoperative pain after general anesthesia for nephrectomy in prospective donor patients for kidney transplantation.

Materials and Methods:

A randomized study was conducted on 100 adult patients scheduled for nephrectomy aged from 35 to 55 years of both sexes and divided into two groups and were administered intravenous paracetamol and tramadol for postoperative pain relief and assessed with visual analog scale score and variations in vital parameters to assess extent of pain relief.

Results:

After statistical interpretation of collected data, the observations were extrapolated. There was a statistically significant difference in the pain intensity scores obtained between the paracetamol and tramadol groups.

Conclusion:

On the basis of the present study, it is concluded that tramadol due to its lesser onset of action time was superior to paracetamol in providing acute postoperative pain relief.

Pain Experienced by Laparoscopic Donor Nephrectomy Patients in an Academic Medical Setting

Context

Since 1996, 414 laparoscopic live donor nephrectomy procedures have been completed at our institution. Although this procedure has gained acceptance within the past 5 years, little is known about its nursing implications.

Objective

The purpose of this performance improvement project was to identify pain management practices, satisfaction levels, and clinical outcomes among patients undergoing laparoscopic live donor nephrectomy.

Patients

Data were collected for a convenience sample of 70 patients for 18 months.

Intervention

Several pain management methods were used, including patient-controlled analgesia and intramuscular and oral medications.

Results

Pain ratings ranged from 3.2 to 3.8 for the first 36 hours postoperatively. The mean pain level did not differ significantly between pain regimes. At discharge, patients perceived a mean overall pain level of 5.0 but anticipated a pain level of 6.1. A significant negative correlation between satisfaction and pain rating also was noted.

Conclusions

Opportunities exist to standardize current regimens of pain medications and address pain level and treatment 24 hours postoperatively.

Intravenous Acetaminophen for Postoperative Pain Management in Patients Undergoing Living Laparoscopic Living-Donor Nephrectomy

Background: Postoperative pain is a common complication of laparoscopic living-donor nephrectomies (LLDNs). Objective: To determine whether intravenous (IV) acetaminophen administration post-LLDN influenced length of stay (LOS) when used for pain management. Methods: This single-center, retrospective study compared patients undergoing LLDN who had received IV acetaminophen for pain control versus those who did not between June 1, 2011, and November 30, 2015. Patient LOS, 30-day readmissions, frequency of pain assessments, patient-reported pain scores, and opioid administration were assessed. Results: A total of 90 patients were included in the analysis (IV acetaminophen, n = 48; non-IV acetaminophen, n = 42). Patients who did not receive IV acetaminophen were more often older (48.8 ± 12.1 vs 39.3 ± 12.1 years; P = 0.012) and female (71.4% vs 47.9%; P < 0.001). The average LOS was similar between the 2 groups (median = 3.0; interquartile range = [3, 4] vs 3.5 [3, 4]; P = 0.737). The 30-day readmissions were higher in the IV acetaminophen group (16.7%) compared with the group not receiving IV acetaminophen (2.4%; P = 0.033). After the first postoperative day, the frequencies of pain assessments performed were similar among the 2 groups. There was no difference in average pain scores between the groups at any time after LLDN. Conclusions: Patients receiving IV acetaminophen were found to have no improvements in hospital LOS, average pain score, or opioid requirements compared with patients not receiving IV acetaminophen. Patients who received IV acetaminophen were also found to have a higher 30-day readmission rate.

Identifying Donor Concerns to Increase Live Organ Donation

Increasing organ donation from live donors is a means to increase the pool of kidneys available for transplantation. To increase the number of live kidney donors, the major concerns of donors must be determined and addressed. This article describes the health and socioeconomic concerns of 61 live kidney donors from the Johns Hopkins Institutions between February 1, 1995 and December 1, 1997. Seventy-five percent of donors reported they had concerns, the most common ones being the effect of donation on their future health, how many work days they would miss, the ability to return to the same activities, and the pain they would experience. Other reported concerns consisted of fear of dying, the risks to a future pregnancy with one kidney, the fear that a son or daughter may need a kidney in the future, and the impact of donation on the family health insurance premium. Interventional strategies including the use of the laparoscopic donor nephrectomy procedure are offered to address these concerns.

3.0Tesla magnetic resonance angiography (MRA) for comprehensive renal evaluation of living renal donors: pilot study with computerized tomography angiography (CTA) comparison

PURPOSE

Most living related donor (LRD) kidneys are harvested laparoscopically. Renal vascular anatomy helps determine donor suitability for laparoscopic nephrectomy. Computed tomography angiography (CTA) is the current gold standard for preoperative imaging; magnetic resonance angiography (MRA) offers advantages including lack of ionizing radiation and lower incidence of contrast reactions. We evaluated 3.0T MRA for assessing renal anatomy of LRDs.

MATERIALS AND METHODS

Thirty consecutive LRDs underwent CTA followed by 3.0T MRA. Data points included number and branching of vessels, incidental findings, and urothelial opacification. Studies were individually evaluated by three readers blinded to patient data. Studies were reevaluated in consensus with discrepancies revealed, and final consensus results were labeled "truth".

RESULTS

Compared with consensus "truth", both computed tomography (CT) and magnetic resonance imaging were highly accurate for assessment of arterial and venous anatomy, although CT was superior for detection of late venous confluence as well as detection of renal stones. Both modalities were comparable in opacification of lower ureters and bladder; MRA underperformed CTA for opacification of upper urinary tracts.

CONCLUSIONS

3.0T MRA enabled excellent detection of comprehensive renal anatomy compared to CTA in LRDs.

Fully laparoscopic left-sided donor hepatectomy is safe and associated with shorter hospital stay and earlier return to work: A comparative study

Living donor liver transplantation has failed to become a major means of transplantation in the United States, where <5% of the transplants are performed with living donors. At least 30% to 50% of the complications of donor hepatectomy appear to be related to abdominal wall trauma, including hernia, bowel obstruction, and chronic abdominal discomfort. We analyzed our experience with laparoscopically procured donor hepatectomy. We compared 22 full laparoscopic donor hepatectomies to 20 open/hybrid hepatectomies over an 11-year period. Donor and recipient demographics, complications, and graft and recipient outcomes were analyzed. All 22 laparoscopically procured liver allografts were transplanted successfully. The laparoscopically procured grafts took longer to procure (7 hours 58 minutes versus 6 hours 38 minutes; P < 0.001). The laparoscopically procured cases had lower blood loss (177.3 versus 3753 cc; P < 0.001), a shorter length of stay, and significantly reduced days off work (P = .01). The 1-year graft survival was not different (90% in the laparoscopic group and 85% in the open group; P = 0.70). The 1-year patient survival was not different (95% in the laparoscopic group and 85% in the open group; P = 0.32). There was a trend toward lower wound issues in the laparoscopic group, but this did not reach significance (the hybrid/open group had a 15% hernia rate versus 5% for the laparoscopic group). In experienced living donor centers, laparoscopic liver donation appears to be feasible for all pediatric recipients and some adult recipients. Outcomes for the recipients of laparoscopically procured grafts do not appear significantly different from outcomes with hybrid/open techniques.

The role of adult living donor liver transplantation and recent advances

Twenty years since the first cases were described, adult living donor liver transplantation (ALDLT) is now considered a valid option to expand the donor pool in view of the ongoing shortage of organs and the high waiting list mortality rate. Despite the rapid evolution and acceptance of this complex process of donation and transplantation in clinical practice, the indications, outcome, ethical considerations and quality and safety aspects continue to evolve based on new data from large cohort studies. This article reviews the surgical and clinical advances in the field of liver transplantation, focusing on technical refinements and discussing the issues that may lead to a further expansion of this complex surgical procedure and the role of ALDLT.

Mini-laparoscopic live donor nephrectomy with the use of 3-mm instruments and laparoscope

PURPOSE

To analyze our preliminary outcomes on the use of 3 mm instruments for laparoscopic live donor nephrectomy (LLDN).

METHODS

Our series includes thirteen patients, who underwent LLDN using 3-mm instruments and laparoscope and 5-mm transumbilical trocar. The patients were followed at 7 and 14 days from discharge and were specifically asked about their cosmetic satisfaction. At follow-up, the recipient graft function was controlled, as well as the donor's cosmetic results. Eight months after surgery, all thirteen patients were asked to fill out the Patient Scar Assessment Questionnaire and Scoring System (PSAQ).

RESULTS

All patients presented good recovery after surgery. Regarding cosmetic outcomes, the donors expressed their satisfaction toward the minimal incision size and optimal esthetic results at 7 and 14 days from discharge home. The low scores on each section of the PSAQ confirmed the favorable outcomes. Early graft function was satisfactory at 1 and 3 months after the kidney transplantation. Furthermore, there were no major complications in the recipients.

CONCLUSIONS

Our persistent positive results with the use of 3-mm instruments during LLDN support this technique as a good alternative to the standard laparoscopic approach for minimizing the incision site, while maintaining safety and excellent clinical outcomes. The fact that the general laparoscopic standards are maintained could make this approach a very attractive alternative to the other minimally invasive approaches for live donor nephrectomy. The hope is in that the higher degree of satisfaction in the donor population demonstrated in this study may likely enhance living kidney donation.

Quality of life following laparoscopic living-donor nephrectomy

Kidney donors experience significant mental stress compared with those undergoing extirpative kidney surgery. Better preoperative counseling and postoperative monitoring is suggested by the authors.

Background and Objectives:

This study compares donor quality of life (QOL) with extirpative (simple or radical) patients' QOL after laparoscopic nephrectomy and analyzes factors predictive of mental QOL for donors.

Methods:

One hundred one donors and 48 extirpative laparoscopic nephrectomy patients filled out the SF-36v2 form at pre- and postoperative visits, and scores were transformed to norm-based. Donor characteristics were collected and analyzed using univariate analysis.

Results:

Donor patients had a decline in the mental summary at all time points that became significant at 7 months (–2.9), whereas extirpative patients trended positive at 7 months (+2.6). Both groups had a significant decline in the physical summary at 1 month, which rebounded by 4 months. Female gender, positive social/psychiatric history, and major graft recipient complications were all significant predictors of a decline in mental health at 1 month.

Conclusion:

Compared with patients who undergo extirpative surgery, kidney donors have significant mental stress associated with donation that persists beyond the postoperative period. Better preoperative counseling and postoperative monitoring might lead to better outcomes, especially for those in high-risk groups.

Inguinal incision as a successful route to extract the kidney during laparoscopic retroperitoneal live-donor nephrectomy

OBJECTIVES

We sought to evaluate the advantages of an inguinal incision in extracting the kidney during retroperitoneal laparoscopic live-donor nephrectomy.

MATERIALS AND METHODS

From May 2008 to June 2011, fifty-eight cases of retroperitoneal live-donor nephrectomy were performed at our hospital; all data were analyzed retrospectively. All donors were grouped in a test group (n=32, inguinal incision) or a control group (n=26, lumbar incision) according to the selected graft retrieval incision. Donors were compared with regard to operative time and warm ischemia time, operative blood loss, hospital stay, cosmetic satisfaction, and incision complications.

RESULTS

All 58 cases of retroperitoneal live-donor nephrectomy were successfully accomplished, without donor death, serious complications, and conversion to open surgery. There were no differences in mean operative time, mean blood loss, mean warm ischemic time, graft function, and 1-year graft survival rate between the groups. However, in a test group, the mean hospital stay was shorter (P < .01), and the satisfaction with cosmesis was higher (P < .01). The incidence rates of abdomen asymmetry (9/28), incision hernia (4/28), wound infection (5/28), and wound faulty union (6/28) were higher in the control group than they were in the test group.

CONCLUSIONS

Inguinal incision is a safe and practical graft retrieval incision in retroperitoneal laparoscopic donor nephrectomy and can be generally applied.

Role of MDCT angiography in selection and presurgical planning of potential renal donors

OBJECTIVE

The purpose of this study was to determine the prevalence and types of renal and extrarenal abnormalities that preclude renal donation or lead to alteration of the surgical approach on the basis of abdominal CT angiography (CTA) in a large group of potential renal donors.

MATERIALS AND METHODS

In this retrospective study, 654 potential renal donors undergoing dual-phase CTA were identified from January 2005 to January 2009. The CT reports were systemically reviewed by two radiologists to determine the presence of renal and extrarenal abnormalities. The operative notes of the renal donors were reviewed by one radiologist to determine whether the presence of renal pathology had affected the surgical approach. In the candidates who did not proceed to kidney donation, the reasons that precluded kidney donation were abstracted from the transplant database.

RESULTS

Four hundred seventeen potential donors (269 men and 385 women; mean age, 44.0 years; age range, 17-79 years) proceeded to renal donation and 237 did not. The most common renal abnormalities were cysts (34%) and renal stones (4.4%). Renal artery disease was identified in 3.4% of potential donors, including renal artery stenosis, possible fibromuscular dysplasia, and renal artery aneurysm. Suspicious renal masses were incidentally found in 0.5% of potential donors. The most common extrarenal pathology was an incidental adrenal nodule (2.6%). Other significant extrarenal pathology identified included gallbladder mass (0.2%), Crohn disease (0.2%), ovarian mass (0.2%), and possible sarcoidosis (0.2%). Although renal and extrarenal abnormalities were present in 41% of potential renal donors, abnormalities seen on CT only contributed to exclusion of 27 potential donors (4.1%). The most common reason for exclusion was the presence of renal stones or scarring (1.8%). Significant CT findings also contributed to the selection of the right kidney in 29 donors, most commonly due to presence of ipsilateral vascular disease or complex left vascular anatomy.

CONCLUSION

Renal parenchymal and vascular abnormalities are common in asymptomatic potential kidney donors. Although most of these represent incidental CT findings, abnormalities can exclude potential renal donors and alter the surgical approach in a small minority of cases.

Technical modifications of hand-assisted retroperitoneoscopic living donor nephrectomy: a single-center experience

OBJECTIVES

To report a single-center experience and technical modifications of hand-assisted retroperitoneoscopic living donor nephrectomy (HARLDN).

METHODS

A total of 78 living donors underwent HARLDN from June 2004 to November 2009. We used a three-port, finger-dissecting, routine retroperitoneal approach. After almost complete mobilization of the kidney, the renal pedicle was dissected to expose the renal vessels. The ureter was dissected and divided at the level of the iliac vessels. An approximately 7-cm Gibson incision was made as the hand-assisted port. The surgeon's hand was introduced through this incision directly. With hand assistance, the renal artery was clipped using two Hem-o-lok clips at the proximal end, and then sheared by scissors without any clips on the kidney side. The renal vein was controlled similarly. Then the kidney was rapidly removed through the incision by hand.

RESULTS

HARLDN was effectively and safely completed in 78 (100%) donors. No conversion to an open operation was necessary. The mean operative time and mean warm ischemic time were 121 minutes (range, 90-134) and 146 seconds (range, 112-247) respectively. The mean blood loss was 61 mL (range, 32-85). Clavien 1 complications including subcutaneous emphysema in 5.1% (4/78). The mean visual analog scales on postoperative days 1 to 5 were: 2.5, 1.2, 0.8, 0.5, and 0.1, respectively. The mean time to resume oral diet was 1.5 days. The mean hospital stay was 4.5 days (range, 4-5). The mean level of postoperative serum creatinines of the donors at 7 days and 1 month thereafter were 1.06 mg/dL (range, 0.74-1.43) and 1.15 mg/dL (range, 0.79-1.61) mg/dL, respectively. The mean level of postoperative serum creatinines of the recipients at 7 days and 1 month were 1.40 mg/dL (range 0.81-1.67) and 1.52 mg/dL (range, 0.76-1.83), respectively. The mean incision length was 6.5 cm (range, 6.0-7.2).

CONCLUSIONS

The modified HARLDN combines the purely laparoscopic technique with quicker, safer organ retrieval by the open access.

Laparoscopy in Liver Transplantation: The Future has Arrived

In the last two decades, laparoscopy has revolutionized the field of surgery. Many procedures previously performed with an open access are now routinely carried out with the laparoscopic approach. Several advantages are associated with laparoscopic surgery compared to open procedures: reduced pain due to smaller incisions and hemorrhaging, shorter hospital length of stay, and a lower incidence of wound infections. Liver transplantation (LT) brought a radical change in life expectancy of patients with hepatic end-stage disease. Today, LT represents the standard of care for more than fifty hepatic pathologies, with excellent results in terms of survival. Surely, with laparoscopy and LT being one of the most continuously evolving challenges in medicine, their recent combination has represented an astonishing scientific progress. The intent of the present paper is to underline the current role of diagnostic and therapeutic laparoscopy in patients waiting for LT, in the living donor LT and in LT recipients.

Laparoscopic donor nephrectomy: The Middle East experience

OBJECTIVES

To summarize the experience of the Middle East in laparoscopic donor nephrectomy (LDN), to discuss the associated advantages and salient problems, to examine the learning curve encountered compared with that of the pioneering centres in the West, and the contribution of the regional centres to the worldwide experience.

METHODS

We searched Medline and PubMed for all centres performing LDN in the Middle East. Questionnaires were e-mailed to the regional transplantation centres, and programme directors, and leading urological and transplant surgeons were contacted by telephone.

RESULTS

LDN in the Middle East was first introduced in 2000; this approach has been pioneered and practised at seven transplant centres within five countries in the region, and was restricted to only three Arab countries, i.e. Lebanon, Egypt and Kuwait. Data collection yielded a total of 888 procedures over one decade, representing only 2% of the total of ≈50,000 transplants during the same period. Despite variability of accurate reporting the overall outcomes were similar to those of open DN. The spectrum of complications was comparable to that from major centres in the USA during their learning curve.

CONCLUSIONS

The introduction of LDN in the Middle East has been gratifying. The relative hesitancy in introducing LDN in the rest of the Arab Middle East is multifaceted. The advantages conferred to the donor underscore the need for further expansion of this approach for kidney retrieval.

Retrospective evaluation of donor pain and pain management after laprascopic nephrectomy

PURPOSE

The purpose of this study was to evaluate donor pain and pain management beginning immediately postoperatively until hospital discharge.

METHODS

All kidney donors were included from 2008 and 2009. Demographic data, operative data, pain scores in the postanesthesia care unit, and visual analog pain scale (VAS) scores were collected for each patient. Standardization for comparison was made by converting doses to intravenous morphine equivalents (ME).

RESULTS

Eighty-five patients were identified as donors, all of which underwent laparoscopic nephrectomy. Daily analgesic requirement was significantly reduced from postoperative day 1 to postoperative day 2 (42.2 mg ME versus 19.7 mg ME, P < .0001). The use of patient-controlled analgesia (PCA) did not demonstrate improved pain management with similar VAS scores for users and nonusers on the day of operation (5.4 vs 5.6, P = .87), postoperative day 1 (4.9 vs 5.4, P = .5), and postoperative day 2 (4.7 vs 4.5, P = .65), respectively. Even though similar VAS scores were found for PCA users and nonusers, PCA users had significantly higher opioid use on the day of operation (P = .007) and postoperative day 1 (P = .004).

CONCLUSIONS

The average VAS score on the day of operation was 5.5, with patients experiencing a significant reduction in VAS score on postoperative day 1. PCA delivery did not provide any additional benefit in pain relief in this cohort.

Is LESS really more?

In the last decade, laparoendoscopic single-site surgery (LESS) has been touted to be the part of the 'evolution' of minimally invasive surgery. The hope is that reduced access points will ultimately decrease pain, morbidity, convalescence, and improve cosmesis. However, what is unique about LESS is that while laparoscopic literature sought to demonstrate superiority of the technique over that of open surgery, the publications on LESS generally seem to seek to demonstrate equivalence with laparoscopy, with the major focus being on cosmesis. Unfortunately, even in that regard the objective cosmesis data is lacking. Furthermore, patients rate cosmesis the least important of all factors. LESS has also been associated with increased risk of complication, increased surgical cost, and longer operative times. In the current review, an objective assessment of the literature will be used for comparison between current standard laparoscopic techniques and LESS with the hopes of answering the question: is LESS really more?

Laparoscopic live donor nephrectomy with the use of 3-mm instruments and laparoscope: initial experience at a tertiary center

Laparoscopy has become the standard of care for kidney recovery during live donor nephrectomy (LDN) because of the well-documented better outcomes of minimally invasive surgery compared with the open approach. Especially in the donor population, the cosmetic results are of great importance; therefore, an effort to reduce the incision size should be attempted while maintaining the safe general principles of surgery. We present our initial experience with the use of 3-mm instruments for laparoscopic LDN.

Laparoscopic versus open nephrectomy for live kidney donors

BACKGROUND

Waiting lists for kidney transplantation continue to grow and live organ donation has become more important as the number of brain stem dead cadaveric organ donors continues to fall. The major disincentive to potential kidney donors is the pain and morbidity associated with open surgery.

OBJECTIVES

To identify the benefits and harms of using laparoscopic compared to open nephrectomy techniques to recover kidneys from live organ donors.

SEARCH METHODS

We searched the online databases CENTRAL (in The Cochrane Library 2010, Issue 2), MEDLINE (January 1966 to January 2010) and EMBASE (January 1980 to January 2010) and handsearched textbooks and reference lists.

SELECTION CRITERIA

Randomised controlled trials comparing laparoscopic donor nephrectomy (LDN) with open donor nephrectomy (ODN).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary.

MAIN RESULTS

Six studies were identified that randomised 596 live kidney donors to either LDN or ODN arms. All studies were assessed as having low or unclear risk of bias for selection bias, allocation bias, incomplete outcome data and selective reporting bias. Four of six studies had high risk of bias for blinding. Various different combinations of techniques were used in each study, resulting in heterogeneity in the results. The conversion rate from LDN to ODN ranged from 1% to 1.8%. LDN was generally found to be associated with reduced analgesia use, shorter hospital stay, and faster return to normal physical functioning. The extracted kidney was exposed to longer warm ischaemia periods (2 to 17 minutes) with no associated short-term consequences. ODN was associated with shorter duration of procedure. For those outcomes that could be meta-analysed there were no significant differences between LDN or ODN for perioperative complications (RR 0.87, 95% CI 0.47 to 4.59), reoperations (RR 0.57, 95% CI 0.09 to 3.64), early graft loss (RR 0.31, 95% CI 0.06 to 1.48), delayed graft function (RR 1.09, 95% CI 0.52 to 2.30), acute rejection (RR 1.41, 95 % CI 0.87 to 2.27), ureteric complications (RR 1.51, 95% CI 0.69 to 3.31), kidney function at one year (SMD 0.15, 95% CI -0.11 to 0.41) or graft loss at one year (RR 0.76, 95% CI 0.15 to 3.85).

AUTHORS' CONCLUSIONS

LDN is associated with less pain compared with open surgery; however, there are equivalent numbers of complications and occurrences of perioperative events that require further intervention. Kidneys obtained using LDN procedures were exposed to longer warm ischaemia periods than ODN-acquired grafts, although this has not been reported as being associated with short-term consequences.

Mini-donor nephrectomy: a viable and effective alternative

Live kidney donation is an excellent way of increasing the donor pool. The introduction of the laparoscopic donor nephrectomy has resulted in an increase in live organ donation in the western hemisphere. There is no data on its impact on organ donation in India. However attractive as it may seem, the procedure is associated with a definite learning curve and does compromise donor safety. The procedure is also expensive in terms of the equipment required. The mini-donor nephrectomy is an excellent alternative, has no learning curve and is ideally suited for donors in India who have a low BMI. The procedure is also relatively inexpensive. We are in need of a donor registry rather than reports from single institutions to fully evaluate the risks and benefits of both procedures.

Health-related quality of life after living donor nephrectomy: a randomized controlled trial of laparoscopic versus open nephrectomy

BACKGROUND

The aim of this study was to compare patient-reported health status and quality of life after randomization to laparoscopic donor nephrectomy (LDN) or short-incision open donor nephrectomy (ODN).

METHODS

Live kidney donors were randomized in a 2:1 ratio to LDN (n=56) or ODN (n=28). Health-related quality of life was assessed using the Short Form 36 questionnaire preoperatively and at 6 weeks postdonation.

RESULTS

Postoperative morphine requirement was lower in the LDN group (median [range], 59 [6-136]) versus ODN group (90 [35-312] mg; P=0.001). Norm adjusted physical components scores decreased significantly at 6 weeks in both the LDN and ODN groups. The bodily pain domain score of physical components score at 6 weeks returned to baseline in the laparoscopic group (86.4±19.8 vs. 81.8±15.9; P=0.2277) but not in the open group (87.3±18.3 vs. 69.0±25.0; P=0.05). The mental component score decreased in the ODN group (53.5±7.6 vs. 45.3±10.1; P=0.0084) but returned to baseline 6 weeks after LDN (53.8±6.5 vs. 51.9±7.2; P=0.2931).

CONCLUSIONS

Donors undergoing laparoscopic nephrectomy reported less bodily pain in the first 6 weeks postdonation, and this was associated with an improved mental health component of quality of life compared with ODN (51.9±7.2 vs. 45.3±10.1; P=0.0009).

Long-term follow-up of a randomized trial comparing laparoscopic and mini-incision open live donor nephrectomy

Long-term physical and psychosocial effects of laparoscopic and open kidney donation are ill defined. We performed long-term follow-up of 100 live kidney donors, who had been randomly assigned to mini-incision open donor nephrectomy (MIDN) or laparoscopic donor nephrectomy (LDN). Data included blood pressure, glomerular filtration rate, quality of life (SF-36), fatigue (MFI-20) and graft survival. After median follow-up of 6 years clinical and laboratory data were available for 47 donors (94%) in both groups; quality of life data for 35 donors (70%) in the MIDN group, and 37 donors (74%) in the LDN group. After 6 years, mean estimated glomerular filtration rates did not significantly differ between MIDN (75 mL/min) and LDN (76 mL/min, p = 0.39). Most dimensions of the SF-36 and MFI-20 did not significantly differ between groups at long-term follow-up, and most scores had returned to baseline. Twelve percent of the donors reported persistent complaints, but no major complications requiring surgical intervention. Five-year death-censored graft survival was 90% for LDN, and 85% for MIDN (p = 0.50). Long-term outcome of live kidney donation is excellent from the perspective of both the donor and the recipient.

Quality of life comparison between open and retroperitoneal video-assisted minilaparotomy surgery for kidney donors

This study compared open and video-assisted minilaparotomy surgery in live kidney donors for quality of life (QoL), pain, cosmesis, and recovery. Between January 2003 and March 2006, we reviewed data from 205 patients who underwent live-donor nephrectomy: 116 by video-assisted minilaparotomy and 89 by open surgery. Pain and satisfaction were evaluated using scales from 1 to 10, and QoL, with the 36-item Short Form questionnaire. Hospital stay was significantly shorter among the video-assisted (5.1 +/- 1.6 days) than the open group (6.9 +/- 1.3 days; P < .01). Time to resumption of walking without difficulty and normal activity was significantly shorter among the video-assisted than the open group (P<.01). The video-assisted group showed better QoL scores in 6 of 8 QoL categories, including physical role (P < .01), bodily pain (P < .01), general health (P < .01), vitality (P < .01), emotional health (P < .01), and mental health (P < .01). Patients in the video-assisted group (score, 7.3 +/- 2.4) were more satisfied with the cosmetic outcome than those in the open group (score, 5.1 +/- 3.0; P < .01). In conclusion, donors who underwent nephrectomy via video-assisted minilaparotomy showed better outcomes regarding pain, convalescence, cosmesis, and QoL than those who underwent open surgery.

Incompatible kidney transplantation: lessons from a decade of desensitization and paired kidney exchange

Human leukocyte antigen (HLA) sensitization and ABO incompatibility continue to pose significant barriers to further expansion of live donor renal transplantation. However, the recent development of effective desensitization protocols and creative paired donation strategies demonstrates that the presence of circulating donor HLA-specific antibodies and the use of ABO incompatible organs should no longer be considered contraindications for renal transplantation. It is estimated that as many as 6,000 patients on the kidney transplant waiting list have incompatible living donors and could benefit from these treatments. Furthermore, as our understanding of these treatment modalities has improved, it is now possible to predict whether desensitization, kidney paired donation or a combination of both will provide an individual patient with their best chance for successful renal transplantation.