Randomized Controlled Trial Comparing Hand-Assisted Retroperitoneoscopic Versus Standard Laparoscopic Donor Nephrectomy

Urologists' proficiency in various donor nephrectomy approaches: a real-life survey, systematic review, and meta-analysis of randomized controlled trials

INTRODUCTION

Donor nephrectomy (DN) is a unique surgical procedure in urological practice, as it involves exposing a healthy individual to the potential risks of surgery. This type of surgery exhibits heterogeneity in terms of approach (open, laparoscopic, or robotic), each with its unique set of advantages and disadvantages. Consequently, there is currently a lack of universally agreed upon clear guidelines. In these settings, this study aims to evaluate transplantation surgeons' knowledge through a real-life survey and compare it with data from published randomized controlled trials (RCTs).

EVIDENCE ACQUISITION

The study is divided into two parts, with the first part focusing on the outcomes of the real-life survey designed to assess surgeons' knowledge about different DN approaches and their real-world practices during the surgery. The second part involves a systematic review and meta-analysis of RCTs, specifically examining the outcomes of different surgical approaches to DN. The systematic review followed the PRISMA Guidelines and involved a search of PubMed and Web of Science for RCTs comparing the outcomes of different DN approaches. The risk of bias was assessed using the RoB-2 tool. The random effect model was mainly used to assess the mean difference of the included studies.

EVIDENCE SYNTHESIS

The study was conducted between July 2021 and January 2022 and surveyed 50 surgeons, of which 35 participants (70%) completed the survey. Regarding various approaches to DN, 97.14% of surgeons reported having experience with live DN, and 45.72% performed over 15 cases per year. The most performed approach was pure laparoscopic DN (68.57%). Pure laparoscopic DN was the preferred approach for 77.42% of respondents. The review process resulted in 335 articles, of which 35 were eligible for inclusion in the systematic review. In summary, most studies found that laparoscopic approaches, including standard, hand-assisted, LESS-DN, and mini-LDN, resulted in less postoperative pain, better cosmetic, and quicker recovery times compared to open approaches. The main limitation of the current study is the heterogeneity of the included studies.

CONCLUSIONS

The study provides valuable insights into the practices of renal transplantation surgeons, offering a comprehensive comparison to level 1 studies (RCTs) in the field. It underscores the continued significance of ODN in contemporary practice, particularly in light of recommendations from the EAU guidelines on renal transplantation. This reaffirms the need to consider the advantages and disadvantages of various approaches, including factors such as cost, postoperative pain, and cosmetic outcomes. While robotic-assisted DN holds promise, their adoption remains variable, potentially due to limited robust evidence.

Robotic versus laparoscopic versus open nephrectomy for live kidney donors

BACKGROUND

Waiting lists for kidney transplantation continue to grow. Live kidney donation significantly reduces waiting times and improves long-term outcomes for recipients. Major disincentives to potential kidney donors are the pain and morbidity associated with surgery. This is an update of a review published in 2011.

OBJECTIVES

To assess the benefits and harms of open donor nephrectomy (ODN), laparoscopic donor nephrectomy (LDN), hand-assisted LDN (HALDN) and robotic donor nephrectomy (RDN) as appropriate surgical techniques for live kidney donors.

SEARCH METHODS

We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing LDN with ODN, HALDN, or RDN were included.

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. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Thirteen studies randomising 1280 live kidney donors to ODN, LDN, HALDN, or RDN were included. All studies were assessed as having a low or unclear risk of bias for selection bias. Five studies had a high risk of bias for blinding. Seven studies randomised 815 live kidney donors to LDN or ODN. LDN was associated with reduced analgesia use (high certainty evidence) and shorter hospital stay, a longer procedure and longer warm ischaemia time (moderate certainty evidence). There were no overall differences in blood loss, perioperative complications, or need for operations (low or very low certainty evidence). Three studies randomised 270 live kidney donors to LDN or HALDN. There were no differences between HALDN and LDN for analgesia requirement, hospital stay (high certainty evidence), duration of procedure (moderate certainty evidence), blood loss, perioperative complications, or reoperations (low certainty evidence). The evidence for warm ischaemia time was very uncertain due to high heterogeneity. One study randomised 50 live kidney donors to retroperitoneal ODN or HALDN and reported less pain and analgesia requirements with ODN. It found decreased blood loss and duration of the procedure with HALDN. No differences were found in perioperative complications, reoperations, hospital stay, or primary warm ischaemia time. One study randomised 45 live kidney donors to LDN or RDN and reported a longer warm ischaemia time with RDN but no differences in analgesia requirement, duration of procedure, blood loss, perioperative complications, reoperations, or hospital stay. One study randomised 100 live kidney donors to two variations of LDN and reported no differences in hospital stay, duration of procedure, conversion rates, primary warm ischaemia times, or complications (not meta-analysed). The conversion rates to ODN were 6/587 (1.02%) in LDN, 1/160 (0.63%) in HALDN, and 0/15 in RDN. Graft outcomes were rarely or selectively reported across the studies. There were no differences between LDN and ODN for early graft loss, delayed graft function, acute rejection, ureteric complications, kidney function or one-year graft loss. In a meta-regression analysis between LDN and ODN, moderate certainty evidence on procedure duration changed significantly in favour of LDN over time (yearly reduction = 7.12 min, 95% CI 2.56 to 11.67; P = 0.0022). Differences in very low certainty evidence on perioperative complications also changed significantly in favour of LDN over time (yearly change in LnRR = 0.107, 95% CI 0.022 to 0.192; P = 0.014). Various different combinations of techniques were used in each study, resulting in heterogeneity among the results.

AUTHORS' CONCLUSIONS

LDN is associated with less pain compared to ODN and has comparable pain to HALDN and RDN. HALDN is comparable to LDN in all outcomes except warm ischaemia time, which may be associated with a reduction. One study reported kidneys obtained during RDN had greater warm ischaemia times. Complications and occurrences of perioperative events needing further intervention were equivalent between all methods.

Surgical Approaches and Outcomes in Living Donor Nephrectomy: A Systematic Review and Meta-analysis

CONTEXT

The use of living kidney donors is increasing and there are several surgical approaches for donor nephrectomy but it remains unknown which procedure is optimal for the patient and the graft.

OBJECTIVE

To review different surgical techniques for living donor nephrectomy and compare complication rates, warm ischemia time, and delayed graft function.

EVIDENCE ACQUISITION

A systematic review of prospective studies involving surgical complications following living donor nephrectomy was conducted in the MEDLINE/PubMed and EMBASE databases according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Baseline data, perioperative and postoperative parameters, and postoperative complications are reported. Overall complication rates between surgical techniques were compared via analysis of variance with post hoc analysis. We included 35 studies involving 6398 patients and representing six different surgical procedures for living donor nephrectomy.

EVIDENCE SYNTHESIS

Hand-assisted laparoscopic donor nephrectomy had a significantly higher overall complication rate compared to open, laparoscopic, retroperitoneoscopic, and laparoendoscopic single-site techniques (p < 0.005). The complication rates were low and no mortality was observed. The main limitation was varying reporting of complications, with only one-third of the studies using the Clavien-Dindo classification.

CONCLUSIONS

No specific surgical approach seems superior in terms of complications, which were generally low. Different factors such as warm ischemia time, blood loss, and surgeon expertise define which surgical approach should be chosen.

PATIENT SUMMARY

We looked at the different surgical methods for removing the kidney from a living kidney donor. Overall, the different surgical techniques were similar in terms of complications and no donors died in the studies we reviewed. The choice of procedure depends on multiple factors such as the expertise of the surgeon and the surgical center.

Reverse rolling-mat type lymph node dissection is the key step to solve the operative difficulties in hand-assisted laparoscopic D2 radical gastrectomy

Background

We have improved and named a new reverse rolling-mat type lymph node dissection, which effectively solves the dilemma faced by the traditional lymph node dissection in hand-assisted laparoscopic D2 radical gastrectomy through the optimization of the surgical procedure. However, the relevant clinical data are still scarce. The study aims to compare the clinical effects of two surgical procedure and explore the safety and feasibility of “reverse procedure”.

Study design

The clinicopathological data of 195 patients who underwent hand-assisted D2 radical total gastrectomy (HALTG) in our hospital from January 2011 to September 2017 were collected. A retrospective case–control study was used to compare the clinical outcomes of the two patterns of lymph node dissection. Among them, 89 patients underwent “cabbage type” lymph node dissection and 106 patients underwent the “reverse procedure” lymph node dissection.

Results

There were no significant differences between the two groups of patients in terms of gender, age, tumor location, incision length, postoperative hospitalization duration, pathological classification, recent complications, long-term recurrence and metastasis. The operation time of “cabbage type” group was shorter than that of “reverse procedure” group (178.35 ± 31.52 min vs 191.25 ± 32.77 min; P = 0.006). While, in the “reverse procedure” group, intraoperative blood loss was less (249.4 ± 143.12 vs 213.58 ± 101.43; P = 0.049), and there were more numbers of lymph nodes dissected (18.04 ± 7.00 vs 32.25 ± 14.23; P < 0.001).

Conclusion

The pattern of reverse rolling-mat type lymph node dissection in HALTG perform well in terms of safety and feasibility.

Deep neuromuscular block reduces the incidence of intra-operative complications during laparoscopic donor nephrectomy: a pooled analysis of randomized controlled trials

Study objective

To assess whether different intensities of intra-abdominal pressure and deep neuromuscular blockade influence the risk of intra-operative surgical complications during laparoscopic donor nephrectomy.

Design

A pooled analysis of ten previously performed prospective randomized controlled trials.

Setting

Laparoscopic donor nephrectomy performed in four academic hospitals in the Netherlands: Radboudumc, Leiden UMC, Erasmus MC Rotterdam, and Amsterdam UMC.

Patients

Five hundred fifty-six patients undergoing a transperitoneal, fully laparoscopic donor nephrectomy enrolled in ten prospective, randomized controlled trials conducted in the Netherlands from 2001 to 2017.

Interventions

Moderate (tetanic count of four > 1) versus deep (post-tetanic count 1–5) neuromuscular blockade and standard (≥10 mmHg) versus low (<10 mmHg) intra-abdominal pressure.

Measurements

The primary endpoint is the number of intra-operative surgical complications defined as any deviation from the ideal intra-operative course occurring between skin incision and closure with five severity grades, according to ClassIntra. Multiple logistic regression analyses were used to identify predictors of intra- and postoperative complications.

Main results

In 53/556 (9.5%) patients, an intra-operative complication with ClassIntra grade ≥ 2 occurred. Multiple logistic regression analyses showed standard intra-abdominal pressure (OR 0.318, 95% CI 0.118–0.862; p = 0.024) as a predictor of less intra-operative complications and moderate neuromuscular blockade (OR 3.518, 95% CI 1.244–9.948; p = 0.018) as a predictor of more intra-operative complications. Postoperative complications occurred in 31/556 (6.8%), without significant predictors in multiple logistic regression analyses.

Conclusions

Our data indicate that the use of deep neuromuscular blockade could increase safety during laparoscopic donor nephrectomy. Future randomized clinical trials should be performed to confirm this and to pursue whether it also applies to other types of laparoscopic surgery.

Trial registration

Clinicaltrials.gov LEOPARD-2 (NCT02146417), LEOPARD-3 trial (NCT02602964), and RELAX-1 study (NCT02838134), Klop et al. (NTR 3096), Dols et al. 2014 (NTR1433).

Comparison of Short-Term Outcomes Between Hand-assisted Laparoscopic Distal Gastrectomy and Laparoscopy-assisted Distal Gastrectomy in Gastric Cancer

Hand-assisted laparoscopic surgery is considered to provide the benefits of laparoscopic surgery in various diseases. However, limited information is available regarding the feasibility of hand-assisted laparoscopic distal gastrectomy (HALDG)-a subset of hand-assisted laparoscopic surgery-as a gastric cancer treatment. This study aimed to evaluate the usefulness of HALDG compared with laparoscopy-assisted distal gastrectomy (LADG). Consecutive patients who underwent HALDG (n=58) or LADG (n=90) for stage I gastric cancer between 2005 and 2016 were eligible. Operative time was significantly shorter and blood loss was significantly higher in HALDG than in LADG (P<0.001, both). Postoperative aminotransferase levels were significantly lower in HALDG than in LADG (P<0.001). There was no significant difference in perioperative complications, a number of analgesics, postoperative C-reactive protein levels, and 3-year relapse-free and overall survival rates between the groups. This study suggests that HALDG is a safe and feasible approach and could become an effective option for stage I gastric cancer treatment.

Hand-assisted retroperitoneoscopic donor nephrectomy offers more liberal use of right kidneys: lessons learned from 565 cases - a retrospective single-center study

The introduction of laparoscopic donor nephrectomy caused a shift toward' left donor nephrectomy. Some centers report a significantly low rate of endoscopic right donor nephrectomy. Hand-assisted retroperitoneoscopic donor nephrectomy (HARP-DN) was introduced as a novel surgical technique, which aims to avoid intra-abdominal complications. It was also reported to provide technical advantages for right-sided DN. In this retrospective single-center study, we evaluated the impact of HARP-DN technique on utilization of right-sided DNs. After the implementation of HARP-DN on February 2009, a total of 565 DNs were performed until December 2015. The introduction of HARP-DN technique resulted in an immediate increase in the utilization of right kidneys from 6.1% to an average of 19.6% annually. The donors 'outcome was similar to the left-sided and right-sided DN groups, excluding the increased incidence of incisional hernias in left kidney donors. None of the donors developed intra-abdominal complications. In conclusion, the implementation of HARP technique significantly increased the use of right-sided DNs, which enables a more liberal use of donors in LDKT.

Learning curves of minimally invasive donor nephrectomy in a high-volume center: A cohort study of 1895 consecutive living donors

BACKGROUND

Few studies have investigated the learning curves of minimally invasive donor nephrectomy (MIDN) using the cumulative sum (CUSUM) analysis. In addition, no study has compared the learning curves of the different surgical MIDN techniques in one cohort study using the CUSUM analysis. This study aims to evaluate and compare learning curves for several MIDN using the CUSUM analysis.

METHODS

A retrospective review of consecutive donors, who underwent MIDN between 1997 and 2019, was conducted. Three laparoscopic-assisted techniques were applied in our institution and included for analysis: laparoscopic (LDN), hand-assisted retroperitoneoscopic (HARP), and robot-assisted laparoscopic (RADN) donor nephrectomy. The outcomes were compared based on surgeon volume to develop learning curves for the operative time per surgeon.

RESULTS

Out of 1895 MIDN, 1365 (72.0%) were LDN, 427 (22.5%) were HARP, and 103 (5.4%) were RADN. The median operative time and median blood loss were 179 (IQR, 139-230) minutes and 100 (IQR, 40-200) mL, respectively. The incidence of major complication was 1.2% with no mortality, and the median hospital stay was three (IQR, 3-4) days. The CUSUM analysis resulted in learning curves, defined by decreased operative time, of 23 cases in LDN, 45 cases in HARP, and 26 cases in RADN.

CONCLUSIONS

Our study shows different learning curves in three MIDN techniques with equal post-operative complications. The LDN and RADN learning curves are shorter than that of the hand-assisted donor nephrectomy. Our observations can be helpful for informing the development of teaching requirements for fellows to be trained in MIDN.

Retroperitoneoscopic Standard or Hand-Assisted Versus Laparoscopic Standard or Hand-Assisted Donor Nephrectomy: A Systematic Review and the First Network Meta-Analysis

BACKGROUND

At the present four minimally invasive procedures namely retroperitoneoscopic (RPDN), laparoscopic (LPDN), hand-assisted retroperitoneoscopic (HARDN) and hand-assisted laparoscopic donor nephrectomy (HALDN) are used to perform donor nephrectomies. The current evidence based on retrospective studies and on pairwise only meta-analyses is inconclusive. Up to authors' best knowledge there is no so far network meta-analysis to compare all the above-mentioned procedures. Therefore, a network meta-analysis was conducted to compare the feasibility, safety and reproducibility of the four donor nephrectomies procedures.

METHODS

Google Scholar, EMBASE, PubMed, and Cochrane library were used for a systematic literature search. Both updated pairwise and network meta-analyses were performed.

RESULTS

Compared to LPDN there was evidence of significantly more right kidneys retrieved with RPDN; nonsignificant differences demonstrated both with HALDN and HARDN compared to LPDN. There was evidence that the operative time was significantly shorter by 77 min in RPDN compared to LPDN; on the other hand, HARDN and HALDN did not demonstrate significant differences when compared to LPDN.

CONCLUSIONS

The present study demonstrates that each approach can be applied safely in adequately selected patients. Moreover, retroperitoneoscopic is reliable, safe and easily reproducible alternative of LPDN for both left and right kidneys.

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.

Outcomes and surgical complications following living-donor renal transplantation using kidneys retrieved with trans-peritoneal or retro-peritoneal hand-assisted laparoscopic nephrectomy

The best minimally invasive procedure for living-donor kidney retrieval remains debated. Our objective was to assess trans-peritoneal (TP) and retro-peritoneal (RP) hand-assisted laparoscopic donor nephrectomy (HALDN). In this single-center retrospective study, we analyzed results from 317 living-donor renal transplants (RT) performed between 2008 and 2016. Donor and recipient outcomes were compared between TP-HALDN (n = 235) and RP-HALDN (n = 82). Conversion to open nephrectomy (0.4% vs 0%; P = 1.000), intra-operative complications (1.7% vs 1.2%; P = 1.000), and 1-year overall post-operative complications (11.9% vs 17.1%; P = .258) rates were similar in TP-HALDN and RP-HALDN. Overall surgical site infections were higher in RP-HALDN (6.1% vs 1.7%; P = .053), whereas incisional hernias were only recorded following TP-HALDN (3.4% vs 0%; P = .118). The duration of the procedure was 11-minute shorter for TP-HALDN than RP-HALDN (P < .001) but extraction time was equivalent (2, IQR 1.5-2.5 minutes; P = 1.000). RT following TP-HALDN and RP-HALDN showed comparable one-year death-censored allograft survival (97% vs 98.8%; P = .685), primary non-function (0.4% vs 0%; P = .290), delayed graft function (1.3% vs 4.9%; P = .077), and urological complications (2.6% vs 4.9%; P = .290) rates. In our series, donor and recipient outcomes were not substantially affected by the approach used for donor nephrectomy. TP-HALDN and RP-HALDN were both safe and effective.

Hand-Assisted Retroperitoneoscopic Donor Nephrectomy Compared to Anterior Approach Open Donor Nephrectomy: Improved Long-Term Physical Component Score in Health-Related Quality of Life in Living Kidney Donors

BACKGROUND

Health-related quality of life (HRQL), fatigue, anxiety, and depression are crucial for the living kidney donor (LKD). Follow-up data for HRQL of LKDs comparing surgical techniques, especially regarding hand-assisted retroperitoneoscopic donor nephrectomy (HARP), are sparse. The aim of this study was to evaluate the influence of abdominal wall trauma minimized by HARP in comparison to open anterior approach donor nephrectomy (AA) on HRQL and additional psychosocial aspects of LKDs during the long-term follow-up.

MATERIAL AND METHODS

This is a cross-sectional study comparing psychosocial aspects of LKD between HARP and AA.

RESULTS

This study included 100 LKDs (68 HARP, 28 AA, and 4 were excluded secondary to incomplete data). The time to follow-up was 22.6 ± 11.7 (HARP) vs 58.7 ± 13.9 (AA) months (P < .005). Complications ≥3a° due to Clavien-Dindo classification was 0% in both groups. There were higher scores in all physical aspects for HARP donors vs AA donors at that time (physical function: 89.8 ± 14.6 vs 80.0 ± 19.9, P = .008, and the physical component score: 53.9 ± 7.6 vs 48.6 ± 8.5, P = .006). One year later (follow-up time + 12 months), HRQL for HARP donors was still higher. Mental items showed no significant differences. HARP donors showed better physical scores compared to the age-matched nondonor population (AA donors had lower scores). Neither the Multidimensional Fatigue Inventory-20 (MFI-20) or the Hospital Anxiety and Depression Scale (HADS) showed any differences between the 2 groups. Fatigue scores were higher for HARP and for AA compared to the age-matched population.

CONCLUSIONS

LKDs undergoing HARP showed better physical performance as part of HRQL in the long-term follow-up.

Protein and calorie restriction may improve outcomes in living kidney donors and kidney transplant recipients

Previously, we and others showed that dietary restriction protects against renal ischemia-reperfusion injury in animals. However, clinical translation of preoperative diets is scarce, and in the setting of kidney transplantation these data are lacking. In this pilot study, we investigated the effects of five days of a preoperative protein and caloric dietary restriction (PCR) diet in living kidney donors on the perioperative effects in donors, recipients and transplanted kidneys. Thirty-five kidney donors were randomized into either the PCR, 30% calorie and 80% protein reduction, or control group without restrictions. Adherence to the diet and kidney function in donors and their kidney recipients were analyzed. Perioperative kidney biopsies were taken in a selected group of transplanted kidneys for gene expression analysis. All donors adhered to the diet. From postoperative day 2 up until month 1, kidney function of donors was significantly better in the PCR-group. PCR-donor kidney recipients showed significantly improved kidney function and lower incidence of slow graft function and acute rejection. PCR inhibited cellular immune response pathways and activated stress-resistance signaling. These observations are the first to show that preoperative dietary restriction induces postoperative recovery benefits in humans and may be beneficial in clinical settings involving ischemia-reperfusion injury.

Structured introduction of retroperitoneoscopic donor nephrectomy provides a high level of safety and reduces the physical burden for the donor compared to an anterior mini incision: A cohort study

INTRODUCTION

A major goal in living donor kidney transplantation is to reduce the physical burden for the donor. Key-hole surgery for donor nephrectomy is a safe procedure, but concerns regarding donor safety during the learning phase might be the reason for surgeons' reluctance to change to a minimal invasive approach.

MATERIAL AND METHODS

We analyzed the first 100 retroperitoneoscopic donor nephrectomies (RPDN) performed at our institution and compared the results to the last 50 mini incision donor nephrectomies (MIDN) regarding donor and recipient outcome, and analyzed the learning curves of RPDN.

RESULTS

The learning phase of RPDN was very short with significantly shorter operative times compared to MIDN (118 vs. 175 min, p < 0.001) and significantly fewer surgical complications (p = 0.03). RPDN patients rated the physical burden (p = 0.01) as lower, and they felt less bothered by the surgical scar (p = 0.03).

CONCLUSION

Introducing RPDN is safe, even during the learning phase of the surgeons. Changing surgical technique from MIDN to RPDN reduces the surgical burden of the procedure. Our study might encourage more transplant centres to adopt a minimally invasive approach.

Introducing Robot-Assisted Laparoscopic Donor Nephrectomy after Experience in Hand-Assisted Retroperitoneoscopic Approach

BACKGROUND

Robot-assisted laparoscopic donor nephrectomy (RALDN) can help to improve donor safety by enabling enhanced precision, flexibility, control, and vision. We are presenting our initial series during the introduction of RALDN by comparing our adopted surgical technique, hand-assisted retroperitoneoscopic donor nephrectomy (HARPDN), performed at the same time interval.

METHODS

We performed 12 RALDN and 27 HARPDN with Pfannenstiel incision between March 2018 and July 2018. We evaluated the demographics, operation duration, warm/cold ischemia time, estimated blood loss, length of hospital stay, postoperative complications, and donor and recipient serum creatinine levels retrospectively.

RESULTS

Demographics including sex, mean of age, and body mass index of the 2 groups were similar. Five cases were right sided nephrectomy in the HARPDN group. We performed only left sided donor nephrectomy in the RALDN group. The duration of operation and warm ischemia time was significantly longer in the robot-assisted group (P < .001). Postoperative major complications were not detected in any of the donors. The function of the transplanted kidneys in both groups was good on the fifth day and 1 month postoperatively.

CONCLUSION

We introduced the robot-assisted approach for donor candidates who are not suitable candidates for HARPDN in our center. The operation time and warm ischemia time was longer in the RALDN group, but it did not have any impact on outcome. The robot-assisted donor nephrectomy technique can be introduced safely in centers experienced in the hand-assisted approach.

Hand-Assisted Nephrectomy Predisposes Incisional Herniation in Obese Living Donors

BACKGROUND

Living kidney donation from donors with a body mass index (BMI) over 30 can bring risks for the donor and the recipients. In this retrospective study, we evaluated the effect of a donor's obesity on a donor's long-term surveillance and the recipient outcomes.

METHOD

We performed hand-assisted retroperitoneoscopic donor nephrectomy in 565 living kidney transplantations between February 2009 and December 2015. One hundred fifty-two donors (26.9%) had a BMI > 30 and were described as the obese group. Four hundred thirteen donors (73.1%) were described as the nonobese group and had a BMI < 30. Incision to kidney removal time, mean follow-up period, postoperative complications, weight gained after surgery, and serum creatinine level (postop day 1-end of follow-up) were recorded for the donors. Serum creatinine level (postop day 5-end of follow-up) and immediate function of transplanted kidney were recorded for the recipients.

RESULTS

The obese donors were older, and the female sex was dominant. Mean incision to kidney removal period was longer in the obese patients (P = .012). The mean follow-up period was 49.97 ± 28.40 months for the donors. There was no significant difference in donor kidney function between the groups. The incidence of herniation was significantly higher in the obese group (P = .021). There was no significant difference between the recipient early and late serum creatinine levels and slow and delayed graft functions after the transplantation.

CONCLUSION

Postoperative kidney functions concerning the outcomes of the obese and nonobese living donors were similar in our series. Donor BMI had no influence on early and late kidney functions of the recipients. There was no difference in postoperative complications, except incisional hernia, that was statistically more significant in the obese donors.

The Evolution of Kidney Transplantation Surgery Into the Robotic Era and Its Prospects for Obese Recipients

Robotic-assisted kidney transplantation (RAKT) represents the most recent innovation in the evolution of kidney transplantation surgery. Vascular techniques enabling kidney transplantation have existed since the early 20th century and contributed to the first successful open kidney transplant procedure in 1954. Technical advances have since facilitated minimally invasive laparoscopic and robotic techniques in live-donor surgery, and subsequently for the recipient procedure. This review follows the development of surgical techniques for kidney transplantation, with a special focus on the advent of robotic-assisted transplantation because of its potential to facilitate transplantation of those deemed previously too obese to transplant by standard means. The different techniques, indications, advantages, disadvantages, and future directions of this approach will be explored in detail. Robot-assisted kidney transplantation may become the preferred means of transplanting morbidly obese recipients, although its availability to such recipients remains extremely limited and strategies targeting weight loss pretransplantation should never be abandoned in favor of a "RAKT-first" approach.

Chronic pain after hand-assisted laparoscopic donor nephrectomy

BACKGROUND

Data on chronic pain after kidney donation are sparse. The aim of this study was to assess the incidence of chronic pain after hand-assisted laparoscopic nephrectomy.

METHODS

Living kidney donors who donated between 2011 and 2017 at the University Medical Centre Groningen were included. All patients underwent hand-assisted laparoscopic donor nephrectomy. Postdonation pain and movement disabilities were assessed using the Carolinas Comfort Scale (CCS) and a visual analogue scale (VAS). The prevalence, severity of pain and the need for analgesics were reported.

RESULTS

Some 333 living kidney donors with a mean age of 56 years were included. At a median of 19 (i.q.r. 10-33) months after donation, 82 donors (24·6 per cent) had a CCS score above 0, of which 58 (71 per cent) had a CCS score of at least 2 and 57 (70 per cent) reported movement limitations. Some 110 donors (33·0 per cent) had a VAS score of more than 0. Complaints mainly occurred during bending over (12·3 per cent) and exercising (12·4 per cent). Thirty-two donors (9·7 per cent) required analgesics during follow-up between donation and the time of measurement, and six of 82 (7 per cent) reported chronic inguinal pain. In multivariable analysis, donor age (odds ratio (OR) 0·97, 95 per cent c.i. 0·95 to 0·99; P = 0·020) and length of hospital stay (OR 1·21, 1·01 to 1·51; P = 0·041) were independently associated with chronic pain.

CONCLUSION

One-quarter of donors experienced chronic postdonation pain or discomfort, most of which was bothersome. Younger donors and those with a longer postoperative hospital stay had more symptoms.

3D Endoscopic Donor Nephrectomy Versus Robot-assisted Donor Nephrectomy: A Detailed Comparison of 2 Prospective Cohorts

BACKGROUND

There are 2 endoscopic surgical techniques that implement 3-dimensional (3D) vision to overcome visual misperception: 3D endoscopy and the da Vinci surgical system. 3D endoscopy has several advantages, such as the presence of tactile feedback and easy implementation, at lower costs. We aimed to assess whether 3D endoscopy could be an alternative to the robot during living donor nephrectomy.

METHODS

Between April 2015 and April 2016, we prospectively collected data on 40 patients undergoing 3D endoscopic living donor nephrectomies in 1 center, performed by a da Vinci-certified surgeon. Data on donors' perioperative results and recipient and graft survival were collected. These data were compared to 40 robot-assisted donor nephrectomies performed in the same center (between January 2012 and May 2014).

RESULTS

Baseline characteristics for both groups were comparable. Intraoperative results showed a significantly shorter median skin-to-skin time of 138.5 minutes (125.8-163.8) versus 169.0 (141.5-209.8) minutes in favor of the 3D group (P = 0.001). Warm ischemia time (P = 0.003) and hilar phase for both single (1 artery and vein) and multiple anatomies (≥1 artery and/or vein [P = 0.002 and P = 0.010, respectively]) were also significantly reduced in favor of the 3D group, with a flat learning curve. Follow-up demonstrated no readmissions nor significant differences for donors, recipients, and graft survival.

CONCLUSIONS

3D endoscopy may be a good alternative to robot-assisted donor nephrectomy because morbidity, graft, and recipient survival were comparable, with a significantly shorter median skin-to-skin time, warm ischemia time, and hilar dissection phase. Furthermore, implementation was easy and at lower costs, whereas tactile feedback was preserved.

Retroperitoneoscopy in urology: a systematic review

INTRODUCTION

In the past years, several authors have focused on the role of retroperitoneoscopic laparoscopy in the treatment of urological diseases. Aim of our study is to systematically review the available literature on retro-peritoneoscopic laparoscopy in urology.

EVIDENCE ACQUISITION

A systematic review of the literature using the Medline, Scopus, and Web of Science databases for relevant articles published until June 2018 was performed using both the Medical Subjects Heading and free test protocols. The MeSH search was conducted by combining the following terms: "retroperitoneoscopy," "posterior laparoscopy," "retroperitoneoscopic." Only randomized clinical trials were included in the analysis. Risk of bias assessment and forest plots were used to summarize data.

EVIDENCE SYNTHESIS

Nine RCTs on simple, partial and radical nephrectomy, pyeloplasty, ureterolithotomy and nephrolithotomy comparing RP to other techniques were included in the analysis. Retroperitoneoscopic approach in simple or radical nephrectomy is to be considered a valid alternative to transperitoneal laparoscopic approach. Outcomes and safety profiles (6-8% conversion rate) are similar and the approach depends on surgeon's preferences. Randomized studies analyzing retroperitoneoscopic pyeloplasty showed better results in terms of perioperative morbidity (tramadol use: 147 vs. 179 mg, P=0.002) and return to normal activities when compared to either anterior laparoscopic either to minimally invasive open approach. Two randomized studies have confirmed the efficacy (stone-free rate: 94%) and safety (no Clavien-Dindo >II complications) of ureterolithotomy and nephrolithotomy (stone-free rate: 95%) in the management of large renal and ureteral stones.

CONCLUSIONS

Retroperitoneoscopic approach in urological diseases is a valid alternative to the anterior approach. Evidence suggest lower morbidity for the retroperitoneoscopic approach however technical complexity may limit its widespread.

Multivariate Analysis of Health-related Quality of Life in Donors After Live Kidney Donation

BACKGROUND

Live-kidney donation has a low mortality rate. Evidence suggests that live-kidney donors experience a quality of life (QoL) comparable to or even superior to that of the general population. There is limited information on factors associated with a decrease in QoL in particular for baseline factors, which would improve information to the donor, donor selection, and convalescence.

METHODS

QoL data on 501 live donors included in three prospective studies between 2001 and 2010 were used. The 36-item short form health survey (SF-36) was used to measure QoL up to 1 year after the procedure. Longitudinal effects on both the mental (MCS) and physical component scales (PCS) were analyzed with multilevel linear regression analyses. Baseline variables were age, gender, body mass index (BMI), pain, operation type, and comorbidity. Other covariates were loss of the graft, glomerular filtration rate, and recipient complications.

RESULTS

After 1 year we observed a small decrease in PCS (effect size = -0.24), whereas the MCS increased (effect size = 0.32). Both PCS and MCS were still well above the norm of the general Dutch population. Factors associated with a change in PCS were BMI (Cohen's d = -0.17 for 5 BMI points) and age (d = -0.13 for each 10 years older).

CONCLUSIONS

Overall, QoL after live-donor nephrectomy is excellent. A lowered PCS is related to age and body weight. Expectations towards a decreased postoperative QoL at 1 year are unjustified. However, one should keep in mind that older and obese donors may develop a reduced physical QoL after live-kidney donation.

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.

Hand-assisted living-donor nephrectomy: a retrospective comparison of two techniques

BACKGROUND

Living-donor nephrectomy (LDN) is challenging, as surgery is performed on healthy individuals. Minimally invasive techniques for LDN have become standard in most centers. Nevertheless, numerous techniques have been described with no consensus on which is the superior approach. Both hand-assisted retroperitoneoscopic (HARS) and hand-assisted laparoscopic (HALS) LDNs are performed at Zurich University Hospital. The aim of this study was to compare these two surgical techniques in terms of donor outcome and graft function.

METHOD

Retrospective single-center analysis of 60 consecutive LDNs (HARS n = 30; HALS n = 30) from June 2010 to May 2012, including a one-year follow-up of the recipients.

RESULTS

There was no mortality in either group and little difference in the overall complication rates. Median warm ischemia time (WIT) was significantly shorter in the HARS group. The use of laxatives and the incidence of postoperative vomiting were significantly greater in the HALS group. There was no difference between right- and left-sided nephrectomies in terms of donor outcome and graft function.

CONCLUSIONS

Both techniques appear safe for both donors and donated organs. The HARS technique is associated with a shorter WIT and a reduced incidence of postoperative paralytic ileus. Therefore, we consider HARS LDN a valuable alternative to HALS LDN.

Robot-Assisted Transplant Surgery - Vision or Reality? A Comprehensive Review

Minimally invasive surgery is standard procedure for many operations. Further refinements include the introduction of robotic surgery which is still an emerging field especially in laparoscopic surgery. Since the successful introduction of the da Vinci Robotic Surgical System, the robotic approach in organ transplantation has become of great interest in both the live donor organ retrieval and the recipient operation. Robotic surgery for kidney, liver, and pancreas transplantation is feasible. Over 700 donor nephrectomies and 100 kidney transplantations have been performed already, and robotic surgery is standard in a small number of pioneer centers; however, larger series and most importantly randomized controlled trials for the highest evidence are needed. Longer warm ischemia time and higher costs limit these procedures at the moment.

Transition from laparoscopic to retroperitoneoscopic approach for live donor nephrectomy

BACKGROUND

Laparoscopic donor nephrectomy has become the standard of care due to multiple benefits. Currently, there are various techniques employed with two different approaches: transperitoneal (TLDN) or retroperitoneoscopic (RLDN) approach. There is a lack of data to determine which technique is superior, although the RLDN offers an anatomical advantage by avoidance of manipulation of the intraperitoneal organs. The aims of this study were to explore the merits of RLDN to TLDN and assess the learning curve of transition from TLDN to RLDN.

METHODS

From January 2010 to February 2017, 106 live donor nephrectomies were performed: 56 by TLDN and 50 by RLDN. Data on patient demographics, perioperative parameters, analgesic consumption, pain scores, and kidney graft function were collected and analysed. Data were compared with a Student's t test or Mann-Whitney test. A CUSUM analysis was performed to investigate the learning curve.

RESULTS

All live donor nephrectomies were successful with no conversion to open surgery. There was no blood transfusion, readmission, or mortality. No postoperative complications were graded over Clavien II. Kidney function was comparable in both groups. The follow-up period ranged from 3 to 78 months.

CONCLUSION

Retroperitoneoscopic live donor nephrectomy is a safe approach with comparable results to TLDN. RLDN has an anatomical advantage as it avoids manipulating the intraperitoneal organs and retains a virgin abdomen and hence translates to a lower perioperative complication risk.

KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.

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.

Death of recipients after kidney living donation triples donors' risk of dropping out from follow-up: a retrospective study

Although kidney transplantation from the donation of a living donor is a safe treatment for end-stage renal disease, inferences about safety of living kidney donors might be biased by an informative censoring caused by the noninclusion of a substantial percentage of donors lost to follow-up. With the aim of assessing the presence of a potential informative censoring in living kidney donation outcomes of Catalan donors for a period of 12 years, 573 donors followed and lost to follow-up were compared. Losses of follow-up over time were also assessed by univariate and multivariate survival analysis, along with Cox regression. Younger and older ages, and the death of their recipient differentiated those donors who were lost to follow-up over time. The risk of dropping out from follow-up was more than twofold for the youngest and oldest donors, and almost threefold for those donors whose recipient died. Results of studies on postdonation outcomes of Catalan living kidney donors might have overlooked older and younger cases, and, remarkably, a percentage of donors whose recipient died. If these donors showed a higher incidence of psychological problems, conclusions about living donors' safety might be compromised thus emphasizing the necessity of sustained surveillance of donors and prompt identification of these cases.

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.

Hand-assisted laparoscopic donor nephrectomy: a single centre experience

Introduction

The advantages of a minimally invasive nephrectomy are a faster recovery and better quality of life for the donors. Until recently, the majority of donor nephrectomies in Poland were done by open surgery.

Aim

To present a single centre experience in hand-assisted laparoscopic donor nephrectomy (HALDN).

Material and methods

The first videoscopic left donor nephrectomy in Poland was performed in our department in 2003 using a hand-assisted retroperitoneal approach. From 2011, we changed the method to a transperitoneal approach and started to harvest also right kidneys. Since then, it has become the method of choice for donor nephrectomy and has been performed in 59 cases. Preoperatively, kidneys were assessed by scintigraphy and by angio-computed tomography. We harvested 32 left and 27 right kidneys. There were double renal arteries in 2 cases and triple renal arteries in 1 case. The warm ischaemia time (WIT) was 80–420 s (average 176.13 s); operative time was 85–210 min (average 140 min).

Results

All procedures were uncomplicated, and all donors were discharged after 2–8 days with normal creatinine levels. The average follow-up period lasted 23 months (1–51 months). Out of all of the cases, 1 case had two minor complications, while all others were uneventful. None of the donors were lost to follow-up. All of the kidneys were transplanted. There were 2 cases of delayed graft function (DGF) and 2 cases of ureter necrosis. One of those kidneys was lost in the third postoperative week.

Conclusions

Our limited experience shows that HALDN is a safe method and should be used routinely instead of open surgery.

Five-year follow-up after live donor nephrectomy - cross-sectional and longitudinal analysis of a prospective cohort within the era of extended donor eligibility criteria

To establish the outcome of live kidney donors 5 years after donation, we investigated the risk for progressive renal function decline and quality of life (QoL). Data on estimated glomerular filtration rate (eGFR), creatinine, hypertension, QoL and survival were assessed in a prospective cohort of 190 donors, who donated between 2008 and 2010. Data were available for >90%. The mean age predonation was 52.8 ± 11.5 years, 30 donors having pre-existent hypertension. The mean follow-up was 5.1 ± 0.9 years. Eight donors had died due to non-donation-related causes. After 5 years, the mean eGFR was 60.2 (95% CI 58.7-62.7) ml/min/1.73 m² , with a median serum creatinine of 105.1 (95% CI 102.5-107.8) μmol/l. eGFR decreased to 33.6% and was longitudinally lower among men than women and declining with age (P < 0.001), without any association on QoL. Donors with pre-existent and new-onset hypertension demonstrated no progressive decline of renal function overtime compared to nonhypertensives. No donors were found with proteinuria, microalbuminuria or at risk for end-stage renal disease. After an initial decline postdonation, renal function remained unchanged overtime. Men and ageing seem to affect renal function overtime, while decreased renal function did not affect QoL. These data support further stimulation of living kidney donation programmes as seen from the perspective of donor safety.

Towards a standardised informed consent procedure for live donor nephrectomy: the PRINCE (Process of Informed Consent Evaluation) project-study protocol for a nationwide prospective cohort study

INTRODUCTION

Informed consent is mandatory for all (surgical) procedures, but it is even more important when it comes to living kidney donors undergoing surgery for the benefit of others. Donor education, leading to informed consent, needs to be carried out according to certain standards. Informed consent procedures for live donor nephrectomy vary per centre, and even per individual healthcare professional. The basis for a standardised, uniform surgical informed consent procedure for live donor nephrectomy can be created by assessing what information donors need to hear to prepare them for the operation and convalescence.

METHODS AND ANALYSIS

The PRINCE (Process of Informed Consent Evaluation) project is a prospective, multicentre cohort study, to be carried out in all eight Dutch kidney transplant centres. Donor knowledge of the procedure and postoperative course will be evaluated by means of pop quizzes. A baseline cohort (prior to receiving any information from a member of the transplant team in one of the transplant centres) will be compared with a control group, the members of which receive the pop quiz on the day of admission for donor nephrectomy. Donor satisfaction will be evaluated for all donors who completed the admission pop-quiz. The primary end point is donor knowledge. In addition, those elements that have to be included in the standardised format informed consent procedure will be identified. Secondary end points are donor satisfaction, current informed consent practices in the different centres (eg, how many visits, which personnel, what kind of information is disclosed, in which format, etc) and correlation of donor knowledge with surgeons' estimation thereof.

ETHICS AND DISSEMINATION

Approval for this study was obtained from the medical ethical committee of the Erasmus MC, University Medical Center, Rotterdam, on 18 February 2015. Secondary approval has been obtained from the local ethics committees in six participating centres. Approval in the last centre has been sought.

RESULTS

Outcome will be published in a scientific journal.

TRIAL REGISTRATION NUMBER

NTR5374; Pre-results.

Robotic surgery rapidly and successfully implemented in a high volume laparoscopic center on living kidney donation

BACKGROUND

It is important to minimize risks associated with live donor nephrectomy. In this study we evaluated the results of left-sided robot-assisted donor nephrectomies in comparison with standard techniques.

METHODS

Data on perioperative results, kidney function, and recipient and graft survival were collected. All left-sided laparoscopic and hand-assisted procedures were selected as control groups.

RESULTS

Fifty-nine robot-assisted procedures were performed by two surgeons. Operative time was significantly longer in the robot-assisted group compared with both control groups. However, it decreased significantly during procedures 40-59 compared with procedures 20-39 (P = 0.014) to median 172.5 (114.0-242.0) min. One conversion to the open approach occurred in the robot group due to a bleeding of the renal artery stump. No difference was found between all techniques at 3 months post-donation.

CONCLUSION

Left-sided robot-assisted donor nephrectomy is feasible with over time a significant decrease in operative time with good outcomes for donor and recipient. Copyright © 2016 John Wiley & Sons, Ltd.

LOng-term follow-up after liVE kidney donation (LOVE) study: a longitudinal comparison study protocol

Background

The benefits of live donor kidney transplantation must be balanced against the potential harm to the donor. Well-designed prospective studies are needed to study the long-term consequences of kidney donation.

Methods

The “LOng-term follow-up after liVE kidney donation” (LOVE) study is a single center longitudinal cohort study on long-term consequences after living kidney donation. We will study individuals who have donated a kidney from 1981 through 2010 in the Erasmus University Medical Center in Rotterdam, The Netherlands. In this time period, 1092 individuals donated a kidney and contact information is available for all individuals. Each participating donor will be matched (1:4) to non-donors derived from the population-based cohort studies of the Rotterdam Study and the Study of Health in Pomerania. Matching will be based on baseline age, gender, BMI, ethnicity, kidney function, blood pressure, pre-existing co-morbidity, smoking, the use of alcohol and highest education degree. Follow-up data is collected on kidney function, kidney-related comorbidity, mortality, quality of life and psychological outcomes in all participants.

Discussion

This study will provide evidence on the long-term consequences of live kidney donation for the donor compared to matched non-donors and evaluate the current donor eligibility criteria.

Trial registration

Dutch Trial Register NTR3795.

Long-term, self-reported health outcomes in kidney donors

Background

The wide use of healthy persons as kidney donors calls for awareness of risks associated with donation. Live kidney donation may impair quality of life (QOL) and result in fatigue. Long-term data on these issues are generally lacking in the donor population. Thus we aimed to investigate long-term self-reported health outcomes in a nationwide donor cohort.

Methods

We assessed self-reported QOL, fatigue and psychosocial issues after donation in 217 donors representing 63 % of those who donated 8–12 years ago. QOL was measured using the generic Short Form-36 Health Survey (SF-36), fatigue using the Multidimensional Fatigue Inventory (MFI) and psychosocial issues using donor specific questions. For each of the 8 domains of SF-36 and the 5 domains of MFI, we performed generalized linear regression.

Results

Donors scored high on QOL with mean scores between 63.9 and 91.4 (scale 1–100) for the 8 subscales. Recognition from family and friends was associated with higher QOL scores in four domains. There were no significant gender differences. Fatigue scores were generally low. Females generally scored higher than males on all five dimensions of fatigue, although significantly only on two. Recipient still alive was associated with lower scores on mental fatigue. Regretting donors scored higher than average on all domains of fatigue. Recipient death, worries about own health and worsened relationship with the recipient influenced willingness to donate in retrospect. Donor age did not affect long-term health outcomes.

Conclusions

Eight till 12 years after donation QOL scores were generally high and improved with recogniton from family and friends. Fatigue was independent of donor age and more pronounced in females and in those who regretted donation.

The Course and Predictors of Health-Related Quality of Life in Living Kidney Donors: A Systematic Review and Meta-Analysis

A better understanding of the course and risk factors for impaired long-term health-related quality of life (HRQoL; ie, physical, psychological, and social-relational functioning) after kidney donation might help clinicians improve the care of live kidney donors. This systematic review and meta-analysis summarizes prospective studies about the course and predictors of HRQoL in living kidney donors. Studies indicate that shortly after donation, donors have lower HRQoL, with minor to moderate changes in psychological and social-relational functioning and major changes in physical functioning. At 3-12 months after donation, HRQoL returned to baseline or was slightly reduced, particularly for fatigue, but scores were still comparable to general population norms. Results were mainly robust across surgery techniques. A limited number of studies examined risk factors for impaired HRQoL, with low psychological functioning before donation as the most consistent predictor. Based on these results, clinicians can inform potential donors that, on average, kidney donors have high long-term HRQoL; however, donors with low psychological functioning at baseline are those most at risk of impaired long-term HRQoL. Future studies should focus on other potentially relevant predictors of postdonation HRQoL, including donor eligibility criteria and donor-recipient relationships, to optimize screening and interventions for donors at risk.

Rotterdam: main port for organ transplantation research in the Netherlands

This overview describes the full spectrum of current pre-clinical and clinical kidney-, liver-, heart- and lung transplantation research performed in Erasmus MC - University Medical Centre in Rotterdam, The Netherlands. An update is provided on the development of a large living donor kidney transplantation program and on optimization of kidney allocation, including the implementation of a domino kidney-donation program. Our current research efforts to optimize immunosuppressive regimens and find novel targets for immunosuppressive therapy, our recent studies on prevention of ischemia-reperfusion-induced graft injury, our newest findings on stimulation of tissue regeneration, our novel approaches to prevent rejection and viral infection, and our latest insights in the regulation of allograft rejection, are summarized.