Hand-assisted and pure laparoscopic living donor nephrectomy: a matched-cohort comparison over 10 yr at a single institute

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.

Evolution of Laparoscopic Donor Nephrectomy Techniques and Outcomes: A Single-Center Experience with More than 1000 Cases

Background

Laparoscopic donor nephrectomy (LDN) has evolved and has been established as a surgical standard of care for kidney transplantation.

Material/Methods

This study retrospectively reviews 1132 patients who underwent 4 different laparoscopic living-donor nephrectomies: hand-assisted laparoscopic nephrectomy (HALDN), pure laparoscopic donor nephrectomy (PLDN), laparoendoscopic single-site plus 1-port donor nephrectomy (LESSOP-DN), and mini laparoscopic donor nephrectomy (MLDN).

Results

The mean estimated blood loss (EBL) for the HALDN group was meaningfully higher than those of LESSOP-DN and MLDN (57.5±52.2 mL versus 21.0±30.0 mL versus 18.2±28.7 mL) (P<0.001). The EBL for PLDN (53.3±35.3 mL) was also significantly higher than those of LESSOP-DN and MLDN (P<0.001). Length of stay (LOS) for HALDN was longer than that for LESSOP-DN (4.2±1.2 day versus 4.0±1.4 days, P=0.002). There was 1 intraoperative open conversion in the HALDN group and 2 HALDN surgeries that required postoperative exploratory laparotomy. LESSOP-DN had 3 (0.8%) postoperative incisional hernias. For recipients, the results revealed no significant differences between all 4 groups in terms of estimated glomerular filtration rate (eGFR) and the 1-year graft failure rate.

Conclusions

The LESSOP-DN group was associated with a shorter incision length than those of HALDN and PLDN and shorter LOS than that of HALDN. Recipient results showed no meaningful difference regarding laparoscopic donor nephrectomy technique.

Blood Transfusions in Laparoscopic Living Donor Nephrectomy: Single Center Experience from 500 Cases

INTRODUCTION

Laparoscopic surgery has been acknowledged to reduce the morbidity rate thus improving patient safety. During the LLDN, the most frequent complication is renal vessels injuries, which often requires a blood transfusion. Besides the need for a blood transfusion, major bleeding caused by renal vessels injuries requires open conversion and repair. Thus, this study would like to descript and analyze the need for blood transfusion in laparoscopic living donor nephrectomy surgery in our center.

METHODS

We performed a retrospective cohort study in the Department of Urology at Cipto Mangunkusumo National Hospital. The records of all kidney transplantation donor patients who underwent LLDN procedures carried out at our institution from November 2011 to October 2017 were reviewed. Data including donor age, preoperative hemoglobin level, postoperative hemoglobin level, intraoperative bleeding, number of artery(ies), number of vein(s), donor side, conversion to open surgery, surgery duration, and donor BMI were collected and analyzed. These data were further correlated with the transfusion rate.

RESULTS

There were 500 patients underwent laparoscopic living donor nephrectomy procedure at our institution. All of the patients had LLDN with a transperitoneal approach. The difference in blood transfusion rate proportion between male patients with 0.9% compared to 0.6% in female patients was not significant (p=0.782). There is no significant difference in blood transfusion rate proportion regarding renal side (p=0.494), number of artery (p=0.362), age (p=0.978), BMI (p=0.569), and preoperative hemoglobin (p=0.766). Median estimated blood loss in patients who received intraoperative blood transfusion was significantly much greater than in patients who did not receive a blood transfusion (p<0.001).

CONCLUSION

Based on this study, we suggest that in our institution, preoperative blood products are not necessarily needed. The surgeon's learning curve and technique play a significant role in preventing intraoperative complications and blood loss.

Endo-Satinsky Clamp Hybrid In Situ Perfusion in Retroperitoneoscopic Donor Nephrectomy For Right-sided Kidney

OBJECTIVE

To introduce our hybrid technique using an endo-Satinsky clamp and in situ cold perfusion for right-sided retroperitoneoscopic donor nephrectomy (RDN) and to investigate efficacy and safety compared with those standard right-sided RDN.

METHODS

This retrospective study included 16 transplant donors who underwent right-sided RDN from January 2016 to January 2018. Donors received either hybrid RDN (n = 6) or standard RDN (n = 10). Perioperative outcomes, including operative time, estimated blood loss, warm ischemic time, hospital stay, length of renal vein obtained as well as postoperative renal function of their recipients were collected and compared between the hybrid RDN and standard RDN groups.

RESULTS

Procedures were performed successfully in all 16 donors. The hybrid RDN group required longer operation times (135 vs 115 minutes), demonstrated increased blood loss (175 vs 140 mL), but shorter warm ischemic times (1.5 vs 5.5 minutes) and resulted in longer length of the procured renal vein (2.8 vs 1.7 cm) as compared with the standard RDN group. No difference in perioperative complication rates was witnessed between the 2 groups. Also, there were no significant differences in serum creatinine levels and glomerular filtration rates of recipients between the 2 groups at both postoperative day 3 and 1 month.

CONCLUSION

The hybrid RDN potentially extends the length of the right donor renal vein. The perioperative outcomes of hybrid RDN were comparable with those of the standard RDN. This hybrid technique can be a technically safe and feasible option for right kidney donation.

Evaluation of the Learning Curve of Hand-Assisted Laparoscopic Donor Nephrectomy

BACKGROUND In this study, we analyzed the learning curve of hand-assisted laparoscopic donor nephrectomy (HALDN). MATERIAL AND METHODS The first 198 consecutive donors (110 cases by expert surgeon and 88 cases by newbie surgeon) operated on using HALDN were included in this study. The primary outcome measures were warm ischemic time (WIT), total operation time and estimated blood loss (EBL). The secondary outcome measures included length of hospital stay (LOS), graft outcome, and surgery-related complications. We used the cumulative sum (CUSUM) method to generate learning curves. RESULTS Except for WIT, all operative and convalescence parameters of donors and graft outcomes were similar for the 2 groups, including the total operation time (174.13 minutes vs. 171.75 minutes, P=0.140), EBL (108.27 cc vs. 116.82 cc, P=0.494), LOS (4.80 days vs. 4.92 days, P=0.144), and overall rates of intraoperative and postoperative complications (P>0.05). A significant difference was observed in WIT between the 2 groups (140.59 sec vs. 106.85 sec, P=0.027). Upon visual assessment of the CUSUM plots, a downward inflexion point for decreasing WIT was observed in 4 cases, total operation time in 12 cases, and EBL in 15 cases. CONCLUSIONS HALDN has a relatively short learning curve and similar results may be expected from newbie urologists who are trained in minimally invasive surgery fellowship.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Perioperative Events and Complications in Minimally Invasive Live Donor Nephrectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive live donor nephrectomy has become a fully implemented and accepted procedure. Donors have to be well educated about all risks and details during the informed consent process. For this to be successful, more information regarding short-term outcome is necessary.

METHODS

A literature search was performed; all studies discussing short-term complications after minimally invasive live donor nephrectomy were included. Outcomes evaluated were intraoperative and postoperative complications, conversions, operative and warm ischemia times, blood loss, length of hospital stay, pain score, convalescence, quality of life, and costs.

RESULTS

One hundred ninety articles were included in the systematic review, 41 in the meta-analysis. Conversion rate was 1.1%. Intraoperative complication rate was 2.3%, mainly bleeding (1.5%). Postoperative complications occurred in 7.3% of donors, including infectious complications (2.6%), of which mainly wound infection (1.6%) and bleeding (1.0%). Reported mortality rate was 0.01%. All minimally invasive techniques were comparable with regard to complication or conversion rate.

CONCLUSIONS

The used techniques for minimally invasive live donor nephrectomy are safe and associated with low complication rates and minimal risk of mortality. These data may be helpful to develop a standardized, donor-tailored informed consent procedure for live donor nephrectomy.