Comparison of open, laparoscopic, and hand-assisted approaches to live-donor nephrectomy

Learning curve analysis for hand-assisted laparoscopic living donor nephrectomy: an analysis of 96 consecutive cases performed by a trained gastrointestinal surgeon

Purpose

This study aims to analyze the learning curve of hand-assisted laparoscopic living donor nephrectomy (HLDN) conducted by a trained gastrointestinal surgeon.

Methods

A retrospective analysis was performed on the perioperative clinical data of 96 consecutive patients who underwent HLDN from May 2013 to March 2023. The learning curve was evaluated using the cumulative sum (CUSUM) test based on operation time and risk-adjusted CUSUM for postoperative complications. Patients were divided into three groups (novice, development, and competency phases) based on changes in operation time. Patient demographics and perioperative outcomes were compared between each group.

Results

Among the patients, 35 were male, with a mean age of 48.9 ± 11.3 years and a mean body mass index (BMI) of 24.5 ± 3.2 kg/m2. The novice phase (phase 1) included the first 30 cases, with the development phase (phase 2) up to the 65th case. Operation times were significantly different across phases, averaging 263.2 ± 33.4, 211.1 ± 34.4, and 161.1 ± 31.3 minutes for phases 1, 2, and 3, respectively (P < 0.001). Blood loss decreased gradually across phases (phase 1, 264.7 ± 144.4 mL; phase 2, 239.7 ± 166.3 mL; phase 3, 198.8 ± 103.5 mL), though not statistically significant. BMI impacted operation time only in phase 1. Overall postoperative complications occurred in 13 cases (Clavien-Dindo grade I, 4 cases; grade II, 9 cases), with no significant differences across phases.

Conclusion

HLDN can be safely performed by a trained gastrointestinal surgeon, with approximately 30 cases needed to achieve proficiency.

Laterality in laparoscopic hand assisted donor nephrectomy - Does it matter anymore? Outcomes of a large retrospective series

This retrospective study was performed to analyse if laterality of the retrieved living donor kidney had any effect on donor and recipient outcomes after hand assisted laparoscopic donor nephrectomy (HALDN). 739 donors who underwent HALDN between January 2006 and January 2018 at a large tertiary transplant centre in the United Kingdom were included. Donor outcomes in individuals undergoing right versus left HALDN were compared with respect to conversion rates, morbidity, warm and cold ischaemia times and recipient failure rates, vascular and ureteric complications. 604 (81.7%) underwent left HALDN and 135 (18.3%) underwent right HALDN, mean age was 47.1 years and 46.8 years respectively with comparable gender distribution. The operative time was shorter for the left side (p = 0.003) and improved during the study for the left but not the right side. In recipients who received left kidneys there were more early technical failures observed (8 versus 1) though not statistically significant. Most centres prefer performing a left nephrectomy and recipient surgeons prefer a left kidney for transplantation primarily because of having a longer vein. This large study provides reassurance that right HALDN nephrectomy is a safe procedure with similar outcomes to left HALDN.

Comparison of Surgical Techniques in Living Donor Nephrectomy: A Systematic Review and Bayesian Network Meta-Analysis

Background

The aim of this study was to compare and evaluate surgical techniques used for living donor nephrectomy (LDN).

Material/Methods

We performed a meta-analysis to compare 4 surgical techniques: open LDN (OLDN), laparoscopic LDN (LLDN), hand-assisted LLDN (HALLDN), and robot-assisted LLDN (RLDN).

Results

No significant differences were found among these surgical techniques in terms of BMI, donor postoperative complications, 1-year graft survival, and DGF. Compared to the OLDN, the other 3 surgical techniques preferred to harvest the left kidney. When the right kidney was chosen as a donor, OLDN was the first-choice surgical technique. EBL was significantly lower in the HALLDN, LLDN, and RLDN groups when compared to the OLDN group. However, operative time and WIT were significantly shorter in the OLDN group. The RLDN group had an increased rate of donor intraoperative complications and a significantly lower VAS on day 1. The OLDN group required more morphine intake than the LLDN group. The length of hospital stay was significantly longer and AR was significantly higher in the OLDN group than in the LLDN and HALLDN groups.

Conclusions

There are no significant differences in donor postoperative complications, recipient DGF, and graft survival among the 4 surgical techniques. OLDN reduces WIT and operation time, but increases EBL and AR. RLDN and LLDN reduce the length of hospital stay, morphine intake, and VAS, and thus accelerate recovery. However, RLDN is associated with increased intraoperative complications.

Hand-Assisted laparoscopic donor nephrectomy PERiumbilical versus Pfannenstiel incision and return to normal physical ACTivity (HAPERPACT): study protocol for a randomized controlled trial

Background

Hand-assisted laparoscopic living donor nephrectomy (HALDN) using a periumbilical or Pfannenstiel incision was developed to improve donor outcome after a kidney transplant. The aim of this study was to investigate two methods of hand assistance and kidney removal during HALDN and their effect on the time it takes for the donor to return to normal physical activity.

Methods/design

This study was initiated in November 2017 and is expected to last for 2 years. To be eligible for the study, donors must be more than 20 years of age and must not be receiving permanent pain therapy. Only donors with a single artery and vein in the graft are being enrolled in this trial. Donors with infections or scars in the periumbilical or hypogastric area, bleeding disorders, chronic use of immunosuppressive agents, or active infection will be excluded. Donors will be randomly allocated to either a control arm (periumbilical incision) or an intervention arm (Pfannenstiel incision). The sample size was calculated as 26 organ donors in each group. The primary endpoint is the number of days it takes the donor to return to normal physical activity (up to 4 weeks after the operation). Secondary endpoints are intraoperative outcomes, including estimated blood loss, warm ischemia time, and duration of the operation. Postoperative pain will be assessed using the visual analog scale, rescue analgesic use, and peak expiratory flow rate. Length of hospital stay, physical activity score, time to return to work, donor satisfaction, cosmetic score, postoperative complications, and all-cause mortality in living donors will also be reported. Delayed graft function, primary non-function, serum creatinine levels, and glomerular filtration rate will also be assessed in the recipients after transplantation.

Discussion

This is the first randomized controlled trial to compare the time it takes the living donor to return to normal physical activity after HALDN using two different types of incision. The comprehensive findings of this study will help decide which nephrectomy procedure is best for living donors with regard to patient comfort and satisfaction as well as graft function in the recipient after transplantation.

Trial registration

ClinicalTrials.gov, NCT03317184. Registered on 23 October 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2775-4) contains supplementary material, which is available to authorized users.

Laparoscopic and hand-assisted laparoscopic donor nephrectomy: A systematic review and meta-analysis

Objective

To compare the perioperative outcomes of hand-assisted laparoscopic donor nephrectomy (HALDN) and pure LDN, as HALDN and LDN are the two most widely used techniques of DN to treat end-stage renal disease.

Methods

In this systematic review and meta-analysis, we performed a literature search of PubMed, Embase, Web of Science, and Cochrane from 01/01/1995 to 31/12/2014. The primary outcome was conversion to an open procedure. Secondary outcomes were warm ischaemia time (WIT), operation time (OT), estimated blood loss (EBL), complications, and length of stay (LOS). Data analysed were presented as odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs), I², and P values. Subgroup analysis was performed.

Results

There were 24 studies included in the meta-analysis; three randomised controlled trials (RCTs), one randomised pilot study, two prospective, and 18 retrospective cohort studies. There were no differences in conversion to an open procedure between the two techniques for both RCTs (OR 0.42, 95% CI 0.06, 2.90; I² = 0%, P < 0.001) and cohort studies (OR 1.06, 95% CI 0.63, 1.78; I² = 0%, P = 0.84). WIT was shorter for the HALDN (-41.79 s, 95% CI -71.85, -11.74; I² = 96%, P = 0.006), as was the OT (-26.32 min, 95% CI -40.67, -11.97; I² = 95%, P < 0.001). There was no statistically significant difference in EBL, complications or LOS.

Conclusion

There is little statistical evidence to recommend one technique. HALDN is associated with a shorter WIT and OT. LDN has equal safety to HALDN. Further studies are required.

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.

Comparison of Minimal Skin Incision Technique in Living Kidney Transplantation and Conventional Kidney Transplantation

Background:

Recently, the most common incision for kidney transplantation (KT) is an inverted J-shaped incision known as the “hockey-stick.” However, demands for minimally invasive surgery in KT are increasing as in other various fields of surgery. Hence, we evaluated whether there is difference between minimal skin incision technique in kidney transplantation (MIKT) and conventional KT (CKT).

Methods:

Between June 2006 and March 2013, a total of 452 living kidney transplant patients were enrolled. The MIKT group included 17 young unmarried women whose body mass index was <25 kg/m² and had no anatomic variation. The CKT group included 435 patients. The MIKT operation technique restricted to the 10 cm-sized skin incision in the lower right abdomen from laterally below the anterior superior iliac spine to the midline just above the pubis was performed. We compared the baseline clinical characteristics and postoperative results between two groups. For proper comparison, propensity score matching was implemented.

Results:

There was no difference in graft function, survival, and postoperative complication rate between MIKT and CKT groups (all P > 0.05). The 5-year graft survival was 92.3% and 85.7% in MIKT and CKT groups, respectively (P = 0.786).

Conclusions:

Our results indicated that MIKT showed more favorable cosmetic results, and there were no statistical differences in various postoperative factors including graft function, survival, and complications compared with CKT. Hence, we suggested that MIKT is an appropriate method for selected patients in living KT.

A comparison of technique modifications in laparoscopic donor nephrectomy: a systematic review and meta-analysis

OBJECTIVE

To compare the effectiveness of different technique modifications in laparoscopic donor nephrectomy.

DESIGN

Systematic review and meta-analyses.

DATA SOURCES

Searches of PubMed, EMBASE, Web of Science and Central from January 1st 1997 until April 1st 2014.

STUDY DESIGN

All cohort studies and randomized clinical trials comparing fully laparoscopic donor nephrectomy with modifications of the standard technique including hand-assisted, retroperitoneoscopic and single port techniques, were included.

DATA-EXTRACTION AND ANALYSIS

The primary outcome measure was the number of complications. Secondary outcome measures included: conversion to open surgery, first warm ischemia time, estimated blood loss, graft function, operation time and length of hospital stay. Each technique modification was compared with standard laparoscopic donor nephrectomy. Data was pooled with a random effects meta-analysis using odds ratios, weighted mean differences and their corresponding 95% confidence intervals. To assess heterogeneity, the I2 statistic was used. First, randomized clinical trials and cohort studies were analyzed separately, when data was comparable, pooled analysis were performed.

RESULTS

31 studies comparing laparoscopic donor nephrectomy with other technique modifications were identified, including 5 randomized clinical trials and 26 cohort studies. Since data of randomized clinical trials and cohort studies were comparable, these data were pooled. There were significantly less complications in the retroperitoneoscopic group as compared to transperitoneal group (OR 0.52, 95%CI 0.33-0.83, I2 = 0%). Hand-assisted techniques showed shorter first warm ischemia and operation times.

CONCLUSIONS

Hand-assistance reduces the operation and first warm ischemia times and may improve safety for surgeons with less experience in laparoscopic donor nephrectomy. The retroperitoneoscopic approach was significantly associated with less complications. However, given the, in general, poor to intermediate quality and considerable heterogeneity in the included studies, further high-quality studies are required.

TRIAL REGISTRATION

The review protocol was registered in the PROSPERO database before the start of the review process (CRD number 42013006565).

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.

Laparoscopic pancreaticoduodenectomy: a systematic literature review

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD) is gaining momentum, but there is still uncertainty regarding its safety, reproducibility, and oncologic appropriateness. This review assesses the current status of LPD.

METHODS

Our literature review was conducted in Pubmed. Articles written in English containing five or more LPD were selected.

RESULTS

Twenty-five articles matched the review criteria. Out of a total of 746 LPD, 341 were reported between 1997 and 2011 and 405 (54.2 %) between 2012 and June 1, 2013. Pure laparoscopy (PL) was used in 386 patients (51.7 %), robotic assistance (RA) in 234 (31.3 %), laparoscopic assistance (LA) in 121 (16.2 %), and hand assistance in 5 (0.6 %). PL was associated with shorter operative time, reduced blood loss, and lower rate of pancreatic fistula (vs LA and RA). LA was associated with shorter operative time (vs RA), but with higher blood loss and increased incidence of pancreatic fistula (vs PL and RA). Conversion to open surgery was required in 64 LPD (9.1 %). Operative time averaged 464.3 min (338-710) and estimated blood 320.7 mL (74-642). Cumulative morbidity was 41.2 %, and pancreatic fistula was reported in 22.3 % of patients (4.5-52.3 %). Mean length of hospital stay was 13.6 days (7-23), showing geographic variability (21.9 days in Europe, 13.0 days in Asia, and 9.4 days in the US). Operative mortality was 1.9 %, including one intraoperative death. No difference was noted in conversion rate, incidence of pancreatic fistula, morbidity, and mortality when comparing results from larger (≥30 LPD) and smaller (≤29 LPD) series. Pathology demonstrated ductal adenocarcinoma in 30.6 % of the specimens, other malignant tumors in 51.7 %, and benign tumor/disease in 17.5 %. The mean number of lymph nodes examined was 14.4 (7-32), and the rate of microscopically positive tumor margin was 4.4 %.

CONCLUSIONS

In selected patients, operated on by expert laparoscopic pancreatic surgeons, LPD is feasible and safe.

[Surgical aspects of living donor nephrectomy]

CONTEXT

Living donor renal transplant surgery has evolved from the classical nephrectomy by lumbotomy to less invasive surgery, the laparoscopic and robotic nephrectomy currently being the most important. It is important to know the available evidence on whether nephrectomy in patients with multiple arteries, right kidney and in obese patients can be performed safely when there is a correct indication.

OBJECTIVE

To perform a review of the different surgical techniques in living donor nephrectomy, adapted to the current surgical evidence and other aspects related to the indication.

EVIDENCE ACQUISITION

A systematic review was made in PubMed (1997-2011). This included previous reviews randomized controlled clinical studies, cohort studies, and meta-analyses of this surgical aspects of living donor nephrectomy.

CONCLUSIONS

Currently, there is sufficient evidence to consider living donor laparoscopic nephrectomy as the technique of choice, although the role of hand-assisted retroperitoneoscopic technique is still not totally clear. Open surgery techniques using mini-incision are an acceptable alternative for the sites that have not yet implemented laparoscopic surgery. Right kidney nephrectomy, of those cases that present multiple pedicles and in obese donors, is justified in selected cases.

Morbidity of 200 consecutive cases of hand-assisted laparoscopic living donor nephrectomies: a single-center experience

Background. Recipients of laparoscopically procured kidneys have been reported to have delayed graft function, a slower creatinine nadir, and potential significant complications. As the technique has evolved laparoscopic donor nephrectomy technique is becoming the gold standard for living donation. Study Design. We retrospectively reviewed the data of the first 200 hand-assisted laparoscopic living donor nephrectomies performed between January 2003 and February 2009. The initial 41 donors and their recipients (Group 1) were compared to the next 159 donors and their recipients (Group 2). The estimated blood loss, serum creatinine at discharge and 6 months, and the incidence of delayed graft function and perioperative complications were analyzed. Results. The median donor serum creatinine at discharge and 6 months was 1.2 mg/dL in each group. None of the laparoscopic procedures required conversion to an open procedure, and none of the donors required perioperative blood transfusion. The median recipient serum creatinine at 6 months after transplant was 1.2 mg/dL for each group. No ischemic ureteral complications related to the laparoscopic technique were seen. Conclusions. HALDN with meticulous surgical technique allows kidney procurement with very low morbidity and no mortality. This improved safety and decreased invasiveness from laparoscopic approach may further decrease morbidity of the procedure and increase organ donation.

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.

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.

Comparison of hand-assisted laparoscopy versus open and laparoscopic techniques in urology procedures: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Hand-assisted laparoscopic surgery (HALS) is an integral part of the urologist's armamentarium. We aimed to perform a comprehensive meta-analysis comparing HALS renal surgery with open and laparoscopic techniques.

METHODS

A systematic review and meta-analysis of HALS renal procedures (donor nephrectomy, nephrectomy, or nephroureterectomy) from 1996 to 2007 was performed.

RESULTS

Sixty-two studies of 30 donor nephrectomy, 21 radical nephrectomy, and 14 nephroureterectomy procedures in 5446 patients were included in the analysis. In donor nephrectomy, estimated blood loss (EBL) was statistically significant for HALS vs the open and laparoscopic cohorts, -69.0 mL (95% confidence interval [CI], -129.7, -8.2) and -40.1 mL (95% CI, -68.2, -12.0), respectively. Length of stay (LOS) was shorter compared with the open group, -1.7 days (95% CI, -2.3, -1.1). For nephroureterectomy, EBL (-29.9 mL (95% CI, -242.3, 182.5)), and LOS (-1.5 d [95% CI, -2.8, -0.3]) again favored HALS vs open procedures. Operating room (OR) time and warm ischemia time (WIT) were statistically significant in favor of HALS donor nephrectomy vs the laparoscopic cohort; -36.8 minutes (95% CI, -61.3, -12.3) and -1.3 minutes (95% CI, -1.8, -0.7), respectively. For radical nephrectomy, both EBL -232.9 mL (95% CI, -383.6, -82.2) and LOS -2.4 days (95% CI, -3.5, -1.3) were statistically significant, favoring HALS vs the open group.

CONCLUSION

We report the largest meta-analysis of HALS renal surgery to date. When compared with open surgery, HALS allows for a significant decrease in EBL and LOS. Compared with laparoscopic donor nephrectomy, HALS resulted in a significant decrease in blood loss, OR time, and WIT.

Single port donor nephrectomy

In 2007, Rane presented the first single port nephrectomy for a small non-functioning kidney at the World Congress of Endourology. Since that time, the use of single port surgery for nephrectomy has expanded to include donor nephrectomy. Over the next two years the technique was adopted for many others types of nephrectomies to include donor nephrectomy. We present our technique for single port donor nephrectomy using the Gelpoint device. We have successfully performed this surgery in over 100 patients and add this experience to our experience of over 1000 laparoscopic nephrectomies. With the proper equipment and technique, single port donor nephrectomy can be performed safely and effectively in the majority of live donors. We have found that our operative times and most importantly our transplant outcomes have not changed significantly with the adoption of the single port donor nephrectomy. We believe that single port donor nephrectomy represents a step forward in the care of living donors.

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.

Article Commentary: The Role of Laparoscopic Donor Nephrectomy in Renal Transplantation

Renal transplantation is an effective treatment for patients with end-stage renal disease. Unfortunately, the number of patients waiting for transplantation greatly exceeds the number of suitable organs. Use of live kidney donors can increase the donor pool. Historically, donor nephrectomy was performed as an open technique. Its associated prolonged convalescence and long-term morbidity was likely a disincentive to donate. Laparoscopic donor nephrectomy, however, has been shown to have fewer long-term complications without compromising graft function. Since its inception, there has been an increase in the number of live donor renal transplantations performed.

Laparoscopic donor nephrectomy - safety in a small-volume transplant center

INTRODUCTION

Laparoscopy is a standard surgical option for live donor nephrectomy (LDN) at the majority of transplant centers. Equivalent graft survival with shorter convalescence has been reported by several large volume centers. With the arrival of an experienced laparoscopic surgeon in 2002, we began to offer laparoscopic LDN at our institution. We report our experience as a large volume laparoscopic surgery program but a low volume transplant center.

METHODS

A retrospective review of the previous 34 LDN (17 open, 17 laparoscopic) performed at the University of Missouri were included. A single laparoscopic surgeon performed all laparoscopic procedures. Hand assisted laparoscopy was performed in 15 and standard laparoscopy with a pfannenstiel incision in two. Open procedures were performed through anterior subcostal or flank incision. A single surgeon performed all open procedures.

RESULTS

There was no statistical difference in age, body mass index or American Society of Anesthesiologies Score between the two groups. Mean operative time, estimated blood loss and hospital stay were 229 minutes, 324 cc and 2.2 days respectively in the laparoscopic group compared to 202 minutes, 440 cc and five days for the open group. Average warm ischemia time was 179 seconds. Recipient creatinine for the two groups at one week, one month and one year was not statistically significantly different. Each group had one graft loss due to medication noncompliance.

CONCLUSION

For small transplant centers with an advanced laparoscopic program, laparoscopic LDN is a safe procedure with comparable outcomes to major transplant centers.

Laparoscopic donor nephrectomy

Laparoscopic live donor nephrectomy (LDN) has removed disincentives of potential donors and may bear the potential to increase kidney donation. Multiple modifications have been made to abbreviate the learning curve while at the same time guarantee the highest possible level of medical quality for donor and recipient. We reviewed the literature for the evolution of the different LDN techniques and their impact on donor, graft and operating surgeon, including the subtleties of different surgical accesses, vessel handling and organ extraction. We performed a literature search (PubMed, DIMDI, medline) to evaluate the development of the LDN techniques from 1995 to 2003. Today more than 200 centres worldwide perform LDN. Hand-assistance has led to a spread of LDN. Studies comparing open and hand-assisted LDN show a reduction of operating and warm ischaemia times for the hand-assisted LDN. Different surgical access sites (trans- or retroperitoneal), different vessel dissection approaches, donor organ delivery techniques, delivery sites and variations of hand-assistance techniques reflect the evolution of LDN. Proper techniques and their combination for the consecutive surgical steps minimize both warm ischaemia time and operating time while offering the donor a safe minimally invasive laparoscopic procedure. LDN has breathed new life into the moribund field of living kidney donation. Within a few years LDN could become the standard approach in living kidney donation. Surgeons working in this field must be trained thoroughly and well acquainted with the subtleties of the different LDN techniques and their respective advantages and disadvantages.

Living Donor Nephrectomy: Open versus Laparoscopic Technique

Background

The living donor nephrectomy has to be safe and effective, allowing a good graft function in the recipient. In the past, donor nephrectomy was performed only by open technique; more recently this nephrectomy has also been performed by laparoscopic technique. The best technique has not been established in literature. The purpose of this study is to report the results of open and laparoscopic nephrectomy in living donors.

Materials and Methods

From January 1992 to August 2008, 37 living donor nephrectomies were performed. 23 nephrectomies were achieved by laparoscopic procedure (LDN) and 14 by open technique (ODN). The 2 groups were comparable regarding both donor and recipient characteristics.

Results

All laparoscopic nephrectomies were successfully performed without conversion to open procedure. No donor deaths were reported in either groups. 3 complications (13%) in the LDN group and 1 (7.1%) in the ODN group (p=0.6) were observed. Mean operative time was higher in the LDN group (p<0.036). Mean warm and cold ischemia time, resumption of oral intake and hospital stay were shorter in the LDN group (p<0.04)(p<0.03) (p<0.0001), whereas the return to normal occupational life was similar (p<0.52). We had no significant differences in the surgical complication rates, graft and patient survival.

Conclusions

Our experience suggests that both procedures can be used safely and efficiently, and assure a good renal function in the recipient. Laparoscopic nephrectomy, although more difficult, provides post-operative advantages. However, laparoscopic procedure must be performed by experienced centres only to prevent serious complications in the donor.

A comparison of hand-assisted and pure laparoscopic techniques in live donor nephrectomy

PURPOSE

To compare hand-assisted laparoscopic donor nephrectomy and pure laparoscopic live donor nephrectomy techniques in live donor nephrectomy.

METHODS

In this retrospective study, we included all patients submitted to hand-assisted laparoscopic donor nephrectomy and pure laparoscopic live donor nephrectomy between May 2002 and December 2007. The operative data and post-operative courses were reviewed. Information was collected on the operative time, warm ischemia time, estimated blood loss, intra-operative complications, time to first oral intake, length of hospital stay, and post-operative complications. The data were analyzed using Student's t -tests and Fisher exact tests as appropriate, with statistical significance defined as p < 0.05.

RESULTS

The means of the operative duration, warm ischemia time and intra-operative bleeding were 83 min, 3.6 min and 130.9 cc, respectively, for hand-assisted laparoscopic donor nephrectomy, and 78.4 min, 2.5 min and 98.9 cc, respectively, for pure laparoscopic live donor nephrectomy (p=0.29, p<0.0001 and p=0.08, respectively). Intra-operative complications occurred in 6% of patients submitted to hand-assisted laparoscopic donor nephrectomy and in 4.5% of those submitted to pure laparoscopic live donor nephrectomy (p=0.68). Only one patient from each group required conversion to open surgery; one person receiving hand-assisted laparoscopic donor nephrectomy had bleeding and one person receiving pure laparoscopic live donor nephrectomy had low carbon dioxide levels during the warm ischemia period. Compared with patients receiving hand-assisted laparoscopic donor nephrectomy, patients submitted to pure laparoscopic live donor nephrectomy were able to take their first meal earlier (12.5 vs. 9.2 hours, p=0.046), were discharged home sooner (2.8 vs. 1.4 days, p<0.0001) and had fewer post-operative complications (7.5% vs. 0.6%, p=0.04).

CONCLUSIONS

Pure laparoscopic live donor nephrectomy had some advantages over hand-assisted laparoscopic donor nephrectomy in terms of the warm ischemia time, time to first oral intake, length of hospital stay, and post-operative donor complications.

Laparoscopic donor nephrectomy

Since it first was performed in 1995, laparoscopic donor nephrectomy (LDN) has grown to be the standard of care in most transplant centers in the United States. This article reviews the current indications, selection criteria, surgical approaches, outcomes, and complications of LDN.

Renal transplantation today

BACKGROUND

The first successful renal transplant was carried out more than five decades ago between identical twins. At these early days, acute rejection was the limiting factor.

DISCUSSION

Due to tremendous progress in immunosuppressive therapy and surgical technique, today, renal transplantation is the gold standard therapy for patients with end-stage renal disease. In fact, in comparison with chronic hemodialysis, renal transplantation offers an increase in quality of life while reducing comorbidities associated with dialysis treatment.

RESULTS

Despite numerous beneficial achievements, no further improvement regarding patient outcome can be observed over the last two decades. Graft survival rates remain unchanged. The leading causes for graft loss are chronic allograft nephropathy and death with functioning graft. This might be related to a constant increase of the proportion of donors presenting extended donor criteria as well as a more liberal acceptance of candidates for a renal transplant.

CONCLUSION

In the near future, one has to focus more closely on the posttransplant patient care to minimize factors associated with chronic allograft damage. These include post-transplant diabetes, hyperlipidemia, high blood pressure, cytomegalovirus infection, etc.

[Technical and economic reasons to set up robotic surgery in a public health system (Spanish model)]

Radical prostatectomy (RP) is today, in any of its four approaches (perineal (PRP), retropubic (ARP), laparoscopic (LRP) or robotic (RRP), the standard surgical treatment in localized prostate cancer. It looks clear that the minimum invasive approaches (laparoscopy and robotics) are able to reduce hospital stay as well as blood loss and therefore transfusion requirement. Also, laparoscopic results at mid and robotics at short term, seem to indicate, that both are safe oncologically and able to obtain same or even superior, functional results. Our objective has been to evaluate the economic impact that these techniques have to consider their definitive implantation, as well as the advantages and disadvantages of its potential implementation in our health system.

Comparison of Laparoscopic Versus Hand-Assisted Live Donor Nephrectomy

BACKGROUND

The aim of the present study was to compare hand-assisted laparoscopic live donor nephrectomy with the classic laparoscopic method, using meta-analytical techniques.

METHODS

A literature search was performed for studies comparing hand-assisted laparoscopic nephrectomy with classic laparoscopic nephrectomy for live kidney donation between 1999 and 2005. The following end points were evaluated: operative time, warm ischemia time, intraoperative adverse events, donor and recipient postoperative complications, and length of hospital stay.

RESULTS

Nine comparative studies matched the selection criteria, reporting on 376 patients, of whom 202 (53.7%) had hand-assisted laparoscopic nephrectomy and 174 (46.3%) had the classic laparoscopic technique. Conversion to open surgery was 2.97% in the hand-assisted group and 4.60% in the laparoscopic group (P=0.35). Total operative and warm ischemia times were significantly shorter for hand-assisted laparoscopy by 30.03 minutes (P=0.02) and 1.14 minutes (P<0.001), respectively. The intraoperative blood loss was less for the hand-assisted laparoscopy group by 34.16 mL (P=0.008), although intraoperative (3.46% vs. 7.47%; P=0.24) and postoperative (5.94% vs. 10.34%; P=0.30) donor complications and recipient complications (including delayed graft function and primary nonfunction, 8.41% vs. 7.42%; P=0.32) were similar between the hand-assisted and laparoscopic groups.

CONCLUSION

Hand-assisted laparoscopic nephrectomy appeared to have the same donor and recipient complication rate with standard laparoscopy but offered substantial advantages in terms of shortened operative and warm ischemia time as well as decreased intraoperative bleeding.

Laparoscopic donor nephrectomy

BACKGROUND

Several large series of laparoscopic donor nephrectomy (LDN) have been published, largely focusing on immediate results and short-term complications. The aim of this study was to examine the results of LDN and collect medium-term and long-term donor followup.

METHODS

We examined the results of two surgeons who performed 500 consecutive LDNs from 1996 to 2005. Prospective databases were reviewed for both donors and recipients to record demographics, medical history, intraoperative events, and complications. Patients were followed between 1 month and 9 years after surgery to assess for delayed complications, especially hypertension, renal insufficiency, incisional hernia, bowel obstruction, and chronic pain.

RESULTS

Left kidneys were procured in 86.2% of cases. Mean operative time was 3.5 h, and warm ischemia time averaged 3.4 min. Hand-assistance was used in 13.8%, and conversion rate was 1.8%. Intraoperative complication rate was 5.8% and was predominantly bleeding (93.1%). Most (86.2%) of the operative complications occurred during the initial 150 cases of a surgeon, compared with 10.3% in the subsequent 150 cases (p = 0.003). Operative time decreased by 87 min after the initial 150 cases (p < 0.001). Immediate graft survival was 97.5%. Delayed graft function occurred in 3.0% of recipients, and acute tubular necrosis occurred in 7.0%. Thirty-day donor complication rate was 9.8%. Mean donor creatinine was 1.24 on the first postoperative day, 1.27 at 2 weeks, and 1.24 at 1 year. At a mean followup of 32.8 months, long-term donor complications consisted of 11 cases of hypertension, 9 cases of prolonged pain or paresthesia, 2 incisional hernias, 1 small bowel obstruction requiring laparoscopic lysis of adhesions, and 1 hydrocele requiring repair.

CONCLUSIONS

LDN can be performed with acceptable immediate morbidity and excellent graft function. Operative time and complications decreased significantly after a surgeon performed 150 cases. Long-term complications were uncommon but included a likely underestimated incidence of hypertension.

Objective assessment comparing hand-assisted and conventional laparoscopic surgery

BACKGROUND

Although several reports have subjectively highlighted the benefits of hand-assisted as compared with conventional laparoscopic surgery, there has been little objective analysis comparing these two techniques.

METHODS

For this study, 12 trained laparoscopic surgeons completed standardized knot-tying and dissection tasks in a laparoscopic trainer using both hand-assisted (HandPort) and traditional laparoscopic techniques. Motion analysis with the Imperial College Surgical Assessment Device was used to assess performance, measuring the number of movements made, the path length of hand travel, and the time taken. Mann-Whitney U tests were used to compare hand-assisted (HA) and conventional laparoscopic (L) performance. A p value less than 0.05 was deemed significant. Means and standard deviations are shown in the results.

RESULTS

In knot tying, for both the dominant and nondominant hands, hand-assisted rather than conventional laparoscopic techniques resulted in reduced movements (dominant: HA [114 +/- 50] vs L [321 +/- 118, p < 0.001], nondominant: HA [89 +/- 36] vs L [296 +/- 96, p < 0.001]); path length (dominant: HA [1,083 +/- 680 mm] vs L [3,637 +/- 1,852 mm, p < 0.001], nondominant: HA [549 +/- 339 mm] vs L [2,556 +/- 1,042 mm, p < 0.001]); and time taken (HA [162 +/- 50 s] vs L [460 +/- 179 s, p < 0.001]). However, there was no statistical difference for any measured variable with respect to the dissection task.

CONCLUSION

Hand-assisted surgery significantly improves the knot-tying ability among trained laparoscopic surgeons. However, there appears to be no improvement in performance for this specific dissection task.

Third Prize: Randomized Trial of Laparoscopic Donor Nephrectomy with and without Hand Assistance

PURPOSE

To compare the early results of standard laparoscopic (SL) and hand-assisted laparoscopic (HAL) donor nephrectomy in a randomized study.

PATIENTS AND METHODS

Forty donors were randomly assigned in equal numbers to either SL or HAL. Two donors in the SL group and three patients in the HAL group underwent right nephrectomy; the others underwent left nephrectomy. In the SL group, specimen extraction was performed via a Pfannenstiel incision and in HAL group through a periumbilical midline incision. Objective intraoperative, hospital stay, and postoperative data as well as pain analog scores were collected prospectively. Patients completed the quality-of-life (QoL) SF-36 questionnaire preoperatively and at 1 month and 3 months of follow-up.

RESULTS

There was a statistically significant difference in the mean operative time in the two groups (200 +/- 20.8 minutes for SL v 219 +/- 28.3 minutes for HAL; P = 0.02). There was no difference in the mean estimated blood loss (141.5 +/- 221.8 mL v 97.4 +/- 73 mL, respectively; P = 0.41), warm ischemia time (157.5 +/- 76.3 seconds v 135.5 +/- 53.7 seconds; P = 0.32), length of postoperative hospital stay (1.9 +/- 0.5 days v 2.1 +/- 0.5 days; P = 0.61), intravenous analgesia (22.1 +/- 14.0 mg v 28.3 +/- 14.8 mg of morphine sulfate equivalent; P = 0.18), or pain score on postoperative day 1 (6.1 +/- 1.0 v 6.2 +/- 1.1) and 2 (3.3 +/- 1.2 and 3.4 +/- 1.3). There were five minor complications in the SL group and three in the HAL group. The mean preoperative (89.7 +/- 4.8 v 89.2 +/- 7.4; P = 0.84), 1-month (63.4 +/- 13.9 v 64.5 +/- 12.6; P = 0.82), and 3-month (82.7 +/- 7.4 v 80.2 +/- 8.4; P = 0.41) postoperative QoL scores did not differ significantly between the groups. None of the recipients required postoperative dialysis, and there was no statistical difference between the two groups in the serum creatinine concentration.

CONCLUSION

Laparoscopic and hand-assisted donor nephrectomies have similar outcomes and postoperative pain. Both approaches are well tolerated with minimal complication rates and have similar impact on patients' quality of life.

Postoperative pain and convalescence in living kidney donors-laparoscopic versus open donor nephrectomy: a randomized study

The aim of the present study was to compare postoperative pain and convalescence in patients randomized to laparoscopic or open donor surgery in a prospective, controlled trial. The donors were randomly assigned to undergo laparoscopic (n = 63) or open (n = 59) donor nephrectomy. Our end points were amount of administered analgesics in the recovery period, postoperative pain on the second postoperative day and at one month after surgery and duration of sick leave. There was a significant difference in favor of the laparoscopic group regarding administered analgesics on day of surgery (p < 0. 02). No difference was observed between groups regarding self-reported pain on the second postoperative day. One month post donation, significantly fewer donors in the laparoscopic group reported pain (p < 0. 02) or had used analgesics (p < 0.05). The duration of sick leave was significantly shorter in the laparoscopic group (p = 0.01). The laparoscopic group experienced a more rapid convalescence and a shorter period of sick leave. Although immediate postoperative pain can be managed efficiently regardless of procedure, a lower consumption of opioids and incidence of pain in the convalescent period suggest a clinically relevant patient-experienced benefit from a successful laparoscopic procedure.

Meta-analysis of the complications of laparoscopic renal surgery: comparison of procedures and techniques

PURPOSE

We performed a meta-analysis of the literature to define the current expectations of complications during laparoscopic renal surgery.

MATERIALS AND METHODS

References were searched in the MEDLINE database from 1995 to 2004 using the terms complications and laparoscopic nephrectomy. Inclusion criteria were any series with greater than 20 cases, patient age older than 16 years and any complications listed for certain procedures, including laparoscopic radical nephrectomy, HA laparoscopic radical nephrectomy, LPN, HALPN, laparoscopic donor nephrectomy, HA laparoscopic donor nephrectomy, laparoscopic simple nephrectomy, laparoscopic nephroureterectomy and retroperitoneal laparoscopic nephrectomy. A data extraction form was created to categorize major or minor complications. A 5 member panel adhered to the strict criteria and extracted data from articles that met inclusion criteria. Data were entered into a spreadsheet and a meta-analysis was performed.

RESULTS

Initial review identified 73 of 405 references that were acceptable for retrieval and data extraction, of which 56 met inclusion criteria. The overall major and minor complication rates of laparoscopic renal surgery were 9.5% and 1.9%, respectively. There was a significant difference between the major complication rates of LPN and HALPN (21.0% vs 3.3%, p <0.05).

CONCLUSIONS

Our results show that patients who undergo laparoscopic renal surgery may have an overall major complication rate of 9.5%. The highest major complication rate is associated with technically challenging LPN (21%). There appears to be a significantly higher wound complication rate associated with HA surgery in comparison to that of standard laparoscopy (1.9% vs 0.2%, p <0.05).

Hand-assisted right laparoscopic live donor nephrectomy

PURPOSE

Laparoscopic live donor nephrectomy has acquired an important role in the era of minimally invasive surgery. Laparoscopic harvesting of the right kidney is technically more challenging than that of the left kidney because of the short right renal vein and the need to retract the liver away from the right kidney. The aim of this article is to report our experience with right laparoscopic live donor nephrectomies.

MATERIALS AND METHODS

We performed a retrospective review of 28 patients who underwent right laparoscopic donor nephrectomies at our service. Operative data and postoperative outcomes were collected, including surgical time, estimated blood loss, warm ischemia time, length of hospital stay, conversion to laparotomy and complications.

RESULTS

The procedure was performed successfully in all 28 patients. The mean operative time was 83.8 minutes (range 45 to 180 minutes), with an estimated blood loss of 111.4 mL (range 40 to 350 mL) and warm ischemia time of 3 minutes (range 1.5 to 8 minutes). No donor needed conversion to open surgery and all kidneys showed immediate function after implantation. The average time to initial fluid intake was 12 hours (range 8 to 24 hours). Two cases of postoperative ileus and a case of hematoma on the hand-port site were observed. The mean postoperative hospital stay was 3 days (range 1 to 7 days).

CONCLUSIONS

Our data confirm the safety and feasibility of right laparoscopic donor nephrectomy and we believe that the right kidney should not be avoided for laparoscopic donor nephrectomy when indicated.

200 Consecutive Hand Assisted Laparoscopic Donor Nephrectomies: Evolution of Operative Technique and Outcomes

PURPOSE

Despite the popularity of hand assisted laparoscopic donor nephrectomy published experience is less than that with standard laparoscopic donor nephrectomy and few critical assessments of operative maneuvers have been described.

MATERIALS AND METHODS

We describe the impact of changes in operative technique made by a single surgeon during 200 hand assisted laparoscopic donor nephrectomies.

RESULTS

With a mean operative time of 229 minutes and hospital stay of 1.9 days the rates of conversion to open surgery, intraoperative complications and major postoperative complications were 1%, 1.5% and 6%, respectively. Lasting changes in technique were dissection of a ureteral/gonadal packet, bipolar cautery use on gonadal/adrenal/lumbar veins and resting the kidney before removal. The incidence of ureteral complications decreased from 8% to 5.1% with dissection of the ureter in conjunction with the gonadal vein rather than isolating it. Warm ischemia time decreased from a mean of 186 to 143 seconds with bipolar electrocautery instead of clips to control gonadal/adrenal/lumbar veins. After starting to rest the kidney before removal the incidence of primary graft nonfunction and delayed function decreased from 6.7% to 0% and 30% to 11.8%, respectively, with a corresponding improvement in 2-year graft survival from 83% to 95%.

CONCLUSIONS

This large series of hand assisted donor laparoscopic nephrectomies with a mean followup approaching 3 years demonstrates that the procedure is safe for the donor and procures a good specimen. Decreases in ureteral complications, warm ischemia time and graft dysfunction might be attributable to specific changes in our operative technique.

Retroperitoneoscopic donor nephrectomy: donor outcome and complication rate in comparison with three different techniques

Four surgical techniques for living donor nephrectomy were analyzed retrospectively in terms of perioperative outcome and early complication rate. A total of 182 donor nephrectomies including 69 open (OLDN), 14 fully laparoscopic (LDN), 34 hand-assisted laparoscopic (HLDN) and 65 retroperitoneoscopic (RLDN) nephrectomies were analyzed. There was a significant difference in mean operating time (OPT) between the OLDN (160 min) and RLDN (150 min) as compared to the LDN (212 min) and HLDN group (192 min) (P < 0.001). Mean warm ischemia time (WIT) was significantly shorter with OLDN (114 s), RLDN (121 s) and HLDN (128 s) when compared to LDN (238 s) (P < 0.001). Major complication rate was comparable among the groups. Independent of the preferred technique, donor nephrectomy is associated with complication rates. RLDN is comparable to OLDN in terms of OPT, WIT. Learning endoscopic donor nephrectomy could be associated with a higher complication rate.

Nefrectomía radical laparoscópica

In this article, we review the different surgical approaches to carry out radical laparoscopic nephrectomy: transperitoneal approach, retroperitoneal approach and hand-assisted approach. We describe the advantages and drawbacks of each alternative and summarize the most important references in the medical literature. In spite of this being a relatively new surgical approach, less than 15 years old, it has become a standard treatment and, today, is considered as the elective surgical treatment for T1 and T2 renal tumours in many centres.

Hand-Assisted Retroperitoneoscopic Live Donor Nephrectomy: Experience from the First 75 Consecutive Cases

BACKGROUND

The two major life-threatening complications associated with laparoscopic live donor nephrectomy are sudden severe bleeding and intestinal injury. A combined technique-hand-assisted and retroperitoneoscopic (HARS)-reduces the risk of these life-threatening complications. In this study, we report on our experience from the first 75 consecutive HARS operations.

METHODS

The data has been collected prospectively according to intention to treat and includes all consecutive donors operated with the HARS technique. Warm ischemia time, operating time, and blood loss were recorded. Complications, convalescence, and allograft outcome were followed postoperatively with a mean follow-up of 701 (range 60-1438) days.

RESULTS

The mean operating time was 138 (range 85-260) minutes and the mean warm ischemia time 175 (85-510) seconds. The operative time was significantly longer in male donors. The mean bleeding was 176 (50-700) ml. There were no conversions to open surgery. Major complications comprised one pulmonary embolus and one donor required 2 units of blood transfusion. One donor was reoperated due to suspicion of trocar hernia. Nine patients experienced minor complications (fever, n=4; urinary tract infection, n=2; chylous ascites, n=1; orchialgia, n=1; subcostal pain, n=1). All except two kidneys had immediate onset of function. Neither of these could, however, be attributed to the donor operation. One recipient experienced urinary leakage and one a stenosis. Recipient and graft survival were 99% and 96%, respectively.

CONCLUSIONS

We conclude that HARS facilitates the procedure by enabling short operating times and at the same time significantly reducing the risks associated with endoscopic live donor nephrectomy.