A randomized, prospective, parallel group study of laparoscopic versus laparoendoscopic single site donor nephrectomy for kidney donation

Minimally Invasive Laparoscopic Donor Nephrectomy With a Pfannenstiel Incision Using Size-Reduced Trocars

BACKGROUND

Laparoendoscopic single-site surgery is performed during laparoscopic donor nephrectomy (LDN) to reduce donor invasiveness. However, the procedure is difficult and does not improve cosmesis when the incision is made at the umbilicus. Therefore, we proposed a minimally invasive LDN with a Pfannenstiel incision using size-reduced trocars (mLDN) to achieve cosmesis and operability and aimed to assess its efficacy and safety.

METHODS

A total of 27 patients who underwent mLDN were recruited. Data on estimated blood loss, operative time, pneumoperitoneum time, warm ischemic time (WIT), complication rate, non-steroidal anti-inflammatory drugs (NSAIDs) used, and recipient serum creatinine levels were collected retrospectively. In mLDN, the Pfannenstiel position was incised to approximately 6 cm to retrieve the kidney, and three size-reduced trocars were placed in the left upper abdomen (2.5 mm and 5 mm) and umbilicus (5 mm).

RESULTS

The median operation time and pneumoperitoneum time were 245 and 194 minutes, respectively. The median WIT was 276 seconds, and the serum creatinine levels of the recipients at seven days and one, three, six, and 12 months were significantly improved compared with baseline. No intra- and postoperative complications (Clavien-Dindo grade ≥ 2) were observed, and no patients used additional NSAIDs after the operation. The scarring in the mLDN group was unnoticeable postoperatively.

CONCLUSIONS

mLDN can be performed safely, with high cosmesis, and with operability similar to that of conventional LDN. Although the WIT tended to be long, the function of the harvested kidney was maintained, and the use of analgesic NSAIDs was lower in this procedure. Our procedure should be considered as an option for LDN.

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.

Surgical Complications Following Renal Transplantation in a Large Institutional Cohort

Background

Successful renal transplantation (RTx) relies on immunosuppression and an optimal surgical course with few surgical complications. Studies reporting the postoperative complications after RTx are heterogeneous and often lack systematic reporting of complications. This study aims to describe and identify postoperative short-term and long-term complications after RTx in a large institutional cohort and identify risk factors for a complicated surgical course.

Methods

The study is a retrospective single-center cohort of 571 recipients who underwent living or deceased donor open RTx between 2014 and 2021. Data were collected on background information and perioperative and postoperative data. Complications were defined as short-term (<30 d) or long-term (>30 d) after transplantation and graded according to the Clavien-Dindo classification. Multivariable logistic regression was performed to evaluate risk factors for serious short-term complications and multivariable time-dependent Cox regression to evaluate risk factors for long-term complications.

Results

A total of 351 patients received a graft from a deceased donor, and 144 of these grafts were on perfusion machine before transplantation. One or more short-term complications occurred in 345 (60%) patients. Previous RTx was associated with short-term Clavien-Dindo >2 complications in recipients (odds ratio = 2.08; 95% confidence interval [CI], 1.18-3.69; P = 0.01). Being underweight (body mass index <18.5) in combination with increasing age increased the odds of short-term Clavien-Dindo >2 and vascular complications. Increasing blood loss per 100 mL was associated with increased odds of short-term Clavien-Dindo >2 (odds ratio = 1.11; 95% CI, 1.01-1.21; P = 0.032). No associations were found for long-term complications after RTx. The 5-y cumulative incidence of graft loss was 12.6% (95% CI, 8.9-16.3).

Conclusions

Short-term complications are common after RTx, and risk factors for severe short-term complications include previous RTx, increasing age, and low body mass index. No risk factors were identified for severe long-term complications. Further studies should explore whether new surgical techniques can reduce surgical complications in RTx.

Comparison of Single-Port Robotic Donor Nephrectomy and Laparoscopic Donor Nephrectomy

Purpose: To compare the intra- and postoperative outcomes of single-port robotic donor nephrectomies (SP RDNs) and laparoscopic donor nephrectomies (LDNs). Materials and Methods: We retrospectively reviewed our institutional database for patients who received LDN or SP RDN between September 2020 and December 2022. Donor baseline characteristics, intraoperative outcomes, postoperative outcomes, and recipient renal function were extracted and compared between LDN and SP RDN. SP RDN learning curve analysis based on operative time and graft extraction time was performed using cumulative sum analysis. Results: One hundred forty-four patients underwent LDN and 32 patients underwent SP RDN. LDN and SP RDN had similar operative times (LDN: 190.3 ± 28.0 minutes, SP RDN: 194.5 ± 35.1 minutes, p = 0.3253). SP RDN patients had significantly greater extraction times (LDN: 83.2 ± 40.3 seconds, SP RDN: 204.1 ± 52.2 seconds, p < 0.0001) and warm ischemia times (LDN: 145.1 ± 61.7 seconds, SP RDN: 275.4 ± 65.6 seconds, p < 0.0001). There were no differences in patient subjective pain scores, inpatient opioid usage, or Clavien-Dindo II+ complications. Short- and medium-term postoperative donor and recipient renal function were also similar between the groups. SP RDN graft extraction time and total operative time learning curves were achieved at case 27 and 13, respectively. Conclusion: SP RDN is a safe and feasible alternative to LDN that minimizes postoperative abdominal incisional scars and has a short learning curve. Future randomized prospective clinical trials are needed to confirm the findings of this study and to identify other potential benefits and drawbacks of SP RDNs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

PROSPERO CRD42023445407.

Renal Transplantation: Pretransplant Workup, Surgical Techniques, and Surgical Anatomy

End-stage renal disease continues to grow worldwide, and renal transplantation remains the primary and most effective treatment to handle this burden. Living-donor transplantation is the ideal mechanism for transplant recipients to have a successful allograft but carries both medical and surgical risks. Cadaveric kidneys have their own risks and can have a high rate of success as well. Multimodality imaging is crucial and has improved greatly during the last 20 years. Finally, a robust understanding of current surgical techniques can facilitate better postoperative imaging when early complications are a consideration.

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.

Simultaneous Living Donor Kidney Transplant and Laparoscopic Native Nephrectomy: An Approach to Kidney Transplant Candidates with Suspected Renal-Cell Carcinoma

Introduction: Kidney transplant candidates are occasionally found during the pre-transplant evaluation to have a suspicious mass in a native kidney. Further work-up and management of such a mass may delay transplantation for several months, which may create logistic barriers to transplant, particularly if there are timing constraints of the donor. In this study, we report our experience with simultaneous living donor kidney transplant and laparoscopic native nephrectomy, where the indication for nephrectomy was a suspicious lesion. Methods: We performed a retrospective review of patients who underwent simultaneous kidney transplant and native nephrectomy using prospectively collected data. We analyzed relevant patient characteristics, surgical details, pathologic results, and long-term follow-up. Results: We identified 16 patients who underwent simultaneous living donor kidney transplantation and laparoscopic native nephrectomy at our institution between 2013 and 2018. Ten (62.5%) patients were found to have renal-cell carcinoma (RCC) on the final pathology. No patients had recurrent RCC, at a median follow-up of 4 years. Conclusion: For patients who are planning to undergo a living donor kidney transplant and are found to have a small mass that is suspicious for RCC, a simultaneous living donor kidney transplant and laparoscopic native nephrectomy is a possible approach in selected patients.

Suprapubic-assisted laparoendoscopic single-site surgery versus standard laparoscopic nephrectomy: A propensity score-based analysis

OBJECTIVES

To compare suprapubic-assisted laparoendoscopic single-site surgery nephrectomy with standard laparoscopic nephrectomy.

METHODS

A retrospective case-control study comparing three surgeons' experience with 122 suprapubic-assisted laparoendoscopic single-site surgery nephrectomy and 107 standard laparoscopic nephrectomy was carried out. Operative time, estimated blood loss, intraoperative complications, intraoperative conversion, postoperative bowel recovery, postoperative analgesics, postoperative visual analog pain scale score, postoperative length of stay, days before going back to work, postoperative complications and Patient Scar Assessment Questionnaire were compared after propensity score matching.

RESULTS

A total of 97 matched pairs were obtained after propensity score matching. There were no statistically significant differences between the suprapubic-assisted laparoendoscopic single-site surgery nephrectomy and standard laparoscopic nephrectomy groups with respect to operative time, estimated blood loss, intraoperative complications, intraoperative conversion, postoperative bowel recovery, length of stay and postoperative complications. Suprapubic-assisted laparoendoscopic single-site surgery nephrectomy group had decreased postoperative analgesics (20.9 vs 23.5, P = 0.04), visual analog pain scale score at 24 h (4.28 vs 5.28, P = 0.000), visual analog pain scale score at discharge (1.01 vs 1.47, P = 0.000), days before going back to work (28.4 vs 31.9, P = 0.000) and Patient Scar Assessment Questionnaire score (34.0 vs 42.0, P = 0.000), compared with the standard laparoscopic nephrectomy group.

CONCLUSIONS

Suprapubic-assisted laparoendoscopic single-site surgery nephrectomy and standard laparoscopic nephrectomy are equivalent in terms of the safety and efficacy. However, suprapubic-assisted laparoendoscopic single-site surgery nephrectomy confers less postoperative pain, fewer days before going back to work and better cosmetic result when compared with standard laparoscopic nephrectomy.

Robotic Assisted Living Donor Nephrectomies: A Safe Alternative to Laparoscopic Technique for Kidney Transplant Donation

OBJECTIVE

To review outcomes after laparoscopic, robotic-assisted living donor nephrectomy (RLDN) in the first, and largest series reported to date.

SUMMARY OF BACKGROUND DATA

Introduction of minimal invasive, laparoscopic donor nephrectomy has increased live kidney donation, paving the way for further innovation to expand the donor pool with RLDN.

METHODS

Retrospective chart review of 1084 consecutive RLDNs performed between 2000 and 2017. Patient demographics, surgical data, and complications were collected.

RESULTS

Six patients underwent conversion to open procedures between 2002 and 2005, whereas the remainder were successfully completed robotically. Median donor age was 35.7 (17.4) years, with a median BMI of 28.6 (7.7) kg/m. Nephrectomies were preferentially performed on the left side (95.2%). Multiple renal arteries were present in 24.1%. Median operative time was 159 (54) minutes, warm ischemia time 180 (90) seconds, estimated blood loss 50 (32) mL, and length of stay 3 (1) days. The median follow-up was 15 (28) months. Complications were reported in 216 patients (19.9%), of which 176 patients (81.5%) were minor (Clavien-Dindo class I and II). Duration of surgery, warm ischemia time, operative blood loss, conversion, and complication rates were not associated with increase in body mass index.

CONCLUSION

RLDN is a safe technique and offers a reasonable alternative to conventional laparoscopic surgery, in particular in donors with higher body mass index and multiple arteries. It offers transplant surgeons a platform to develop skills in robotic-assisted surgery needed in the more advanced setting of minimal invasive recipient operations.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of modified transumbilical laparoendoscopic single-site nephroureterectomy and retroperitoneal laparoscopic nephroureterectomy: initial experience

Introduction

Owing to the development of the laparoendoscopic single-site (LESS) procedure, transumbilical LESS nephroureterectomy (LESS-NU) has become a new approach for treating upper tract urothelial carcinoma.

Aim

The aim of this study is to introduce a modified LESS-NU procedure with bladder cuff excision for treating upper tract urothelial carcinoma (UTUC). We compared its clinical efficacy and postoperative outcomes in terms of follow-up time with traditional retroperitoneal laparoscopic nephroureterectomy (RL-NU).

Material and methods

From May 2014 to May 2019, we performed nephroureterectomy on 42 patients using the retroperitoneal approach and a modified LESS approach. A retrospective analysis was conducted for the evaluation of the clinical and postoperative outcomes between the two groups.

Results

The study included 25 LESS-NU and 17 RL-NU patients. All the procedures were completed successfully. The LESS-NU group had a significantly shorter mean operative time than the RL-NU group (204.4 min, 236.18 min, p = 0.005). The differences in skin incision length (2.88 cm, 8.94 cm, p < 0.001) and oral analgesic dose (n = 1.12, n = 2.75, p < 0.001) between LESS-NU and RL-NU were statistically significant.

Conclusions

Modified LESS-NU is a feasible and safe procedure. Compared with the retroperitoneal laparoscopic approach, the single-site approach did not alter the patients' position. LESS-NU is a better procedure for treating UTUC than RL-NU in terms of cosmetic result and postoperative pain.

Living donor nephrectomy

OBJECTIVE

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors.

CONCLUSIONS

The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Clinical Usefulness of a Self-Retaining Internal Organ Retractor for Laparoendoscopic Single-Site Adrenalectomy

INTRODUCTION

Although laparoendoscopic single-site adrenalectomy (LESS-A) is feasible, it is still considered as a challenging procedure because of technical limitations. Making an optimal retraction is one of major obstacles in LESS-A, and it sometimes requires additional ports or needlescopic devices. Internal organ retractor (IOR) is a novel retraction device that is applied intracorporeally without additional port. In this study, we investigated the clinical usefulness of IOR in LESS-A.

MATERIALS AND METHODS

Medical records of 73 consecutive patients who underwent LESS-A from March 2009 to December 2014 were reviewed. Twenty-two patients underwent LESS-A with IOR and 51 patients without IOR.

RESULTS

Mean age, body mass index, tumor size, operation time, estimated blood loss, and hospital stay were not significantly different between two groups. In IOR group, median number of applied IOR was 2.0 (1.0-3.0) per single operation. Mean time for application and removal was 80.0 and 46.5 seconds for a single IOR, respectively. There were no complications related to the IOR. In without IOR group, there were nine cases that needed needlescopic trocars, six cases that needed 5 mm or larger trocars, and one case that was converted to hand-assisted laparoscopy. However, we did not use any needlescopic instrument or additional trocar in IOR group. There was no case of open conversion in both groups.

CONCLUSION

LESS-A could be done effectively and safely using IOR. IOR system maintained optimal retraction throughout the operation. Its application and removal are intuitive and take only a few minutes. We think IOR system is an attractive retraction method in LESS-A.

Laparoendoscopic Single-site Plus 1-port Donor Nephrectomy: Division of Roles to Shorten Warm Ischemic Time

BACKGROUND

In this study we present our new surgical procedure, laparoendoscopic single-site surgery plus 1 for donor nephrectomy (LESS+1-DN), which shortens warm ischemic time (WIT) and improves surgical outcomes.

METHODS

From January 2013 to February 2017, 15 patients who underwent LESS-DN and 41 patients who underwent LESS+1-DN at our institution were evaluated retrospectively. Patients were divided into 3 groups: group A, 15 cases of LESS-DN; group B, the first 15 patients who underwent LESS+1-DN; and group C, 26 patients who underwent subsequent LESS+1-DN. To reduce WIT, we clearly defined the roles of the surgeon and first assistant in the 26 subsequent LESS+1-DN cases. The surgeon dissected the renal pedicle and harvested the kidney graft using a recovery bag and the first assistant held the recovery bag.

RESULTS

The mean operative time in group C (213.7 minutes) was significantly shorter than that in groups A (253.3 minutes) and B (253.8 minutes). The WIT in group C (195.2 seconds) was significantly shorter than that in groups A (389.8 seconds) and B (313.2 seconds). Open conversion was required in 1 case in group A. None of the donors required conversion to open surgery and no perioperative complications occurred in groups B and C. Linear regression analysis of the LESS+1-DN operative times and consecutive case numbers demonstrated a shallow learning curve (R² = 0.392, P < .05).

CONCLUSION

Our new procedure that divides the roles of the operator and the first assistant contributed significantly to a shortening of WIT. Dividing roles can facilitate a safer laparoscopic donor nephrectomy.

Hand-assisted laparoscopic retroperitoneal donor nephrectomy: A single-institution experience of over 500 cases-Operative technique and clinical outcomes

OBJECTIVE

Although there are several variations of laparoscopic living-donor nephrectomies, there is no consensus as to the best technique. Our objective was to describe our technique and assess the outcomes of our approach to hand-assisted laparoscopic retroperitoneal donor nephrectomies.

METHODS

From July 2001 to October 2015, 507 consecutive hand-assisted laparoscopic retroperitoneal donor nephrectomies were performed. Their clinical information was retrospectively reviewed including warm ischemia time, skin incision to kidney ready time, estimated blood loss, adverse intraoperative events, and postoperative complications.

RESULTS

Mean incision time to kidney removal was 135 minutes (55-260), mean warm ischemia time was 125 seconds (30-390), and mean blood loss was 83 mL (20-500). Average length of stay was 3 days (1-6). There were no significant differences between left and right kidney donors based on demographics, length of hospital stay, or warm ischemia time. There were no conversions to open surgery. Complications occurred in 4.9% of patients (25/507), including 4 cases of perioperative bleeding.

CONCLUSIONS

This is a single-center series describing the safety and efficacy of the hand-assisted laparoscopic retroperitoneal donor nephrectomy for both right and left sides. It does not require intraperitoneal manipulation and allows for safe extraction of either kidney with minimal warm ischemia time.

A randomized, prospective study of laparoendoscopic single-site plus one-port versus mini laparoscopic technique for live donor nephrectomy

PURPOSE

To compare the clinical outcomes of laparoendoscopic single-site plus one-port donor nephrectomy (LESSOP-DN) and mini laparoscopic donor nephrectomy (MLDN).

METHODS

A prospective randomized controlled trial was conducted from December 2014 to February 2016 in donors scheduled for left donor nephrectomy. Donor and recipient demographics and clinical outcomes including pain scores and questionnaires (BIQ: body image questionnaire, SF-36, patient-reported overall convalescence) were also compared.

RESULTS

A total of 121 eligible donors were recruited, of which 99 donors who were scheduled to undergo an operation on their left side were randomized into LESSOP-DN (n = 50) and MLDN (n = 49) groups. There were no significant demographic differences between the two groups. The renal extraction time in the LESS-DN group was shorter than that in the MLDN group (75.89 ± 13.01 vs. 87.31 ± 11.38 min, p < 0.001). Other perioperative parameters and complication rates were comparable between the two groups. The LESSOP-DN group had a smaller incision length than the MLDN group (4.89 ± 0.68 vs. 6.21 ± 1.11 cm, p < 0.001), but cosmetic scores and body image scores were similar in the two groups (p = 0.905, 0.217). Donor quality of life (SF-36) and recovery and satisfaction data were comparable between the two groups. Delayed graft function (DGF) occurred in one recipient undergoing MLDN procedure (2.1%) and progressed to graft failure.

CONCLUSIONS

There were no differences in cosmetic satisfaction between groups despite the smaller incision size of LESSOP-DN. Safety parameters and subjective measures of postoperative morbidity were similar between the two groups.

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.

Laparoendoscopic single-site surgeries: A multicenter experience of 469 cases in Japan

OBJECTIVE

To report on a multi-institutional series of non-robotic urological laparoendoscopic single-site surgery in Japan.

METHODS

Consecutive cases of laparoendoscopic single-site surgery carried out between February 2009 and December 2012 at nine academic institutions were included. We examined the surgical outcomes, including conversion and complications rates.

RESULTS

Four hundred and sixty-nine cases were included in the analysis. The most common procedure was adrenalectomy (n = 177) and the second most common procedure was radical nephrectomy (n = 143). The procedures also included nephroureterectomy (n = 40), living donor nephrectomy (n = 40), pyeloplasty (n = 30), urachal remnant excision (n = 9), simple nephrectomy (n = 7), radical prostatectomy (n = 6) and others (n = 17). The access sites included umbilicus (n = 248, 53%) and other sites (n = 221, 47%). A transperitoneal approach was used in 385 cases (82%), and retroperitoneal approach in 84 cases (18%). The median operation time of all procedures was 198 min. Conversion to reduced port surgery, conventional laparoscopy, or open surgery was noted in 27 cases (5.8%), 12 cases (2.6%), and two cases (0.4%), respectively, with an overall conversion rate of 8.7%. Intraoperative complications occurred in 10 cases (2.1%). Post-operative complications were noted in 29 cases (6.2%), including five major complications (1.1%). No mortality was recorded in this series.

CONCLUSIONS

Non-robotic laparoendoscopic single-site surgery is technically feasible and safe for various urologic diseases in Japan. Furthermore, urological laparoendoscopic single-site surgery is a promising minimally invasive surgical option that is feasible for experienced urological surgeons in intermediate-volume centers as well as high-volume centers.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Novel method of laparoendoscopic single-site and natural orifice specimen extraction for live donor nephrectomy: single-port laparoscopic donor nephrectomy and transvaginal graft extraction

Laparoscopic live donor nephrectomy (DN) has been established as a useful alternative to the traditional open methods of procuring kidneys. To maximize the advantages of the laparoendoscopic single-site (LESS) method, we applied natural orifice specimen extraction to LESS-DN. A 46-year-old woman with no previous abdominal surgery history volunteered to donate her left kidney to her husband and underwent single-port laparoscopic DN with transvaginal extraction. The procedure was completed without intraoperative complications. The kidney functioned well immediately after transplantation, and the donor and recipient were respectively discharged 2 days and 2 weeks postoperatively. Single-port laparoscopic DN and transvaginal graft extraction is feasible and safe.

Intra-corporeal robotic renal auto-transplantation

Renal auto-transplantation (RATx) is a suitable option for managing patients with long upper ureteric or pan-ureteric strictures. The current gold standard approach to RATx is a laparoscopic nephrectomy followed by open auto-transplantation. The advent of robotic-assisted laparoscopic surgery has allowed us to apply minimally-invasive techniques to ever-more complex surgical procedures. We present the case of a 38-year-old patient referred to our institution for management of a failed laparoscopic pyeloplasty resulting in a long upper ureteric stricture with complete ureteric obstruction. After complete evaluation, RATx was determined as a suitable management option. Completely intracorporeal right RATx was performed robotically with intraperitoneal cold perfusion. Total operative time was 6.5 hours, with total ischemia time of only 79 minutes (4 minutes warm ischemia, 48 minutes cold ischemia, 27 minutes re-warming time), comparable to the gold standard approach for RATx. To our knowledge, this is the first reported case of a completely intracorporeal robotic RATx in Canada.

Living Donor Kidney Transplantation: Improving Efficiencies in Live Kidney Donor Evaluation--Recommendations from a Consensus Conference

The education, evaluation, and support of living donors before, during, and after donation have historically been considered the roles and responsibilities of transplant programs. Although intended to protect donors, ensure true informed consent, and prevent coercion, this structure often leaves referring nephrologists unclear about the donor process and uncertain regarding the ultimate outcome of potential donors for their patients. The aim of this article is to help the referring nephrologist understand the donor referral and evaluation process, help the referring nephrologist understand the responsibilities of the transplant program, and offer suggestions about how the referring nephrologist can help to improve efficiencies in the process of donor education and evaluation. A partnership between referring nephrologists and transplant programs is an important step in advancing living kidney donation. The referring nephrologists are the frontline providers and are in a unique position to offer education about living donation and improve efficiencies in the process. Understanding the donor referral and evaluation process, the responsibilities of the transplant program, and the potential role referring nephrologists can play in the process is critical to establishing such a partnership.

Technical aspects for live-donor organ procurement for liver, kidney, pancreas, and intestine

PURPOSE OF REVIEW

This article reviews current strategies for living-donor organ procurement in liver, kidney, pancreas, and intestinal transplant.

RECENT FINDINGS

Here we summarize current open and laparoscopic approaches to living donation of abdominal organs.

SUMMARY

Living donation strategies expand the organ pool in the setting of a significant organ shortage.

Long-term health-related quality of life of living kidney donors: a single-center experience

PURPOSE

Over the last few years, the evaluation of the health-related quality of life (HRQoL) of living kidney donors (LKD) has become of particular interest. The present study sought to evaluate the physical and mental HRQoL after kidney removal. The clinical and paraclinical course of these patients was examined, and the impact of preoperative donor evaluation, donor nephrectomy, and surgical recovery was evaluated. These data were compared with reference data of the general population.

METHODS

Between 1998 and 2010, 72 living kidney donations were performed at our institution. To assess the HRQoL, two questionnaires-the Short Form 36 (SF-36) and a special LKD questionnaire-were sent to all 72 living donors. The records of the follow-up examinations of all 72 donors were retrospectively analyzed in order to assess the clinical and paraclinical data after kidney donation.

RESULTS

Out of 72 donors, 55 (76.4 %) responded to the questionnaires. There was no change in systolic and diastolic blood pressure during the 7-year follow-up (p > 0.05). Mild proteinuria (>150 mg/l) was observed in six cases. Kidney donors had a higher HRQoL compared to the general population with mean values of the physical and mental summation scale (PCS and MCS, respectively) being 51.3 (SD = 7.6) and 50.6 (SD = 8.1). Peri- or postoperative complications were associated with lower values for physical function and physical component summary (PCS) (p < 0.05).

DISCUSSION

Living donor kidney transplantation appears to be safe for donors. The HRQoL is excellent. To ensure a positive outcome for donors, a good clinical evaluation of potential donors is essential.