Comparative study of laparoscopic and mini-incision open donor nephrectomy: have we heard the last word in the debate?

Donor Nephrectomy Through Mini-Flank Incision: A Single-Centre Experience Among Nigerian Patients

Background and objective

The field of kidney transplantation in sub-Saharan Africa is still in the rudimentary stages. The majority of patients with chronic kidney disease have no access to renal replacement therapy, leading to very high mortality rates. Donor nephrectomy (DN) is an important aspect of kidney transplantation. Over the last two decades, open DN (ODN) has given way to minimally invasive techniques like laparoscopic DN (LDN) and robotic-assisted DN. In this study, we aimed to describe our experience with mini-flank incision donor nephrectomy (MIDN) at a Nigerian renal transplant center.

Materials and methods

We conducted a retrospective review of all DN cases performed at a single Nigerian kidney transplantation center over a three-year period. Information obtained from these patients was classified into pre-, intra-, and postoperative. The data included sociodemographic characteristics, preoperative preparation, details of intraoperative techniques, and postoperative findings. These were entered into a proforma and analyzed using SPSS Statistics version 21 (IBM Corp., Armonk, NY).

Results

A total of 230 patients underwent ODN during the study period. The majority of the donors were males (92.8%) with a mean age of 30.83 ±8.43 years. The body mass index (BMI) of most (76.1%) of the donors was within the normal range (18.5-24.9 kg/m²). The duration of DNs ranged from 72 to 154 minutes with a mean duration of 130 ±28 minutes. The length of flank incisions ranged from 7.8 to 12 cm with a mean incision length of 10.8 ±1.0 cm. Donors who had MIDN attained satisfactory postoperative pain control with about 90% of them having a BMI of <30 kg/m². Oral intake and ambulation were commenced on the first postoperative day, and the cosmetic outcomes were deemed acceptable in over 90% of kidney donors.

Conclusion

Mini-incision for DN through the flank approach is a suitable alternative to LDN in the developing world where facilities and skills for LDN or robotic nephrectomies are largely unavailable. It offers a short recovery time, early ambulation, and excellent allograft outcomes.

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.

Mini-incision Living Donor Nephrectomy and Trans-peritoneal Laparoscopic Nephrectomy: Will There Be a Place for New Evidence?

OBJECTIVES

To compare mini-incision donor nephrectomy (MDN) with laparoscopic donor nephrectomy (LDN) performed by the same surgical team, regarding short- and long-term outcomes.

METHODS

Three hundred and five patients, who underwent donor nephrectomy in our institution, through an MDN (n = 141) between January 1998-November 2011 and LDN (n = 164) since June 2010-December 2017, were compared.

RESULTS

The mean operative time for MDN (120 ± 29 minutes) was not significantly different when compared to LDN (113 ± 34 minutes), but when comparing the first 50 LDN and the 50 most recent, we found a reduction in the duration of the procedure. Laparoscopic donors had a shorter warm ischemia time (229 seconds vs 310 seconds, P = .01), particularly the 50 most recent, hospital stay (4.3 days vs 5.9 days, P < .001), and postoperative complications (P = .03). The incidence of graft acute tubular necrosis (ATN) was superior in the MDN (89% vs 25%, P < .001), although there was no significant difference regarding first-year serum creatinine (SCr) and glomerular filtration rate (GFR) (SCr 1.38 mg/dL vs SCr 1.33 mg/dL and GFR 63.7 mL/min vs 63.1 mL/min) comparing the 2 groups. Long-term graft survival did not significantly differ between groups. There was also no relationship between postoperative ATN events and long-term graft function.

CONCLUSIONS

With the growing experience of the high-volume centers and with specialized teams, LDN could be considered the most suitable technique for living donor nephrectomy with better results in short-term results (warm ischemia time, hospital stay, and postoperative complications), without difference in long-term outcomes.

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.

Ischemia Techniques in Nephron-sparing Surgery: A Systematic Review and Meta-Analysis of Surgical, Oncological, and Functional Outcomes

CONTEXT

The optimal ischemia technique at partial nephrectomy (PN) for renal masses is yet to be determined.

OBJECTIVE

To summarize and analyze the current evidence about surgical, oncological, and functional outcomes after different ischemia techniques (cold, warm, and zero ischemia) at PN.

EVIDENCE ACQUISITION

A computerized systematic literature search was performed by using PubMed (MEDLINE) and Science Direct. Identification and selection of the studies were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria. Outcomes of interest were estimated blood loss (EBL), overall complications, positive surgical margins, local tumor recurrence, and renal function preservation. Meta-analysis and forest-plot diagrams were performed. Overall pooled estimates, together with 95% confidence intervals (CIs), of the incidence of all parameters were obtained using a random effect model (RE-Model) on the log transformed means (MLN), proportion, or standardized mean change, as deemed appropriate.

EVIDENCE SYNTHESIS

One hundred and fifty-six studies were included. No clinically meaningful differences were found in terms of EBL after cold (mean: 215.5; 95% CI: 154.2-276.8m), warm (mean: 201.8; 95% CI: 175.0-228.7ml), or zero (mean: 261.2; 95% CI: 171.0-351.3ml) ischemia technique. Overall, postoperative complications were recorded in 14.1% (95% CI: 6.7-27.4), 11.1% (95% CI: 10.0-12.3), and 9.7% (95% CI: 7.7-12.2) of patients after cold, warm, and zero ischemia (p<0.01), respectively. Positive surgical margins were recorded in 4.8% (95% CI: 1.9-10.9), 4.0% (95% CI: 3.4-4.8), and 5.6% (95% CI: 3.1-9.8) of patients after cold, warm, and zero ischemia (p<0.01), respectively. Local recurrence was recorded in 3.2% (95% CI: 1.9-5.2) and 3.1% (95% CI: 0.7-11.5) of patients after warm and zero ischemia (p<0.01), respectively. The log₂ of estimated glomerular filtration ratio mean changes were-1.37 (95% CI:-3.42 to 0.68),-1.00 (-2.04 to 0.03), and-0.71 (-1.15 to-0.27) ml/min after cold, warm, and zero ischemia, respectively. Low level of evidence, retrospective nature of most of included studies, a high risk of selection bias, and heterogeneity within included studies limited the overall quality of the analysis.

CONCLUSIONS

The effect of ischemia technique at PN is still debatable and subject to confounding by several factors, namely, patients' selection criteria, surgical technique used, and percentage of functional parenchyma spared during surgery. These confounders bias available evidence and were addressed by only a small part of available studies. Unfortunately, the overall quality of literature evidences and the high risk of selection bias limit the possibility of any causal interpretation about the relationship between the ischemia technique used and surgical, oncological, or functional outcomes. Thus, none of the available ischemia technique could be recommended over the other.

PATIENT SUMMARY

The present analysis shows that none of the available ischemia techniques, namely, cold, warm, or zero ischemia, is universally superior to the others, and other factors play a role in the surgical outcome.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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