Retroperitoneoscopic live-donor nephrectomy: 5-year single-center experience in China

Clip or staple in laparoscopic live donor nephrectomy? A systematic literature review

INTRODUCTION

Ligation of the renal pedicle is a crucial step in laparoscopic renal harvesting. Currently, two devices are widely used: Hem-o-Lok® clips and staplers. Each has its advantages and disadvantages.

METHODS

A systematic literature review was conducted following the PRISMA methodology on PubMed, EMBASE, and Cochrane databases with no time restrictions. Registered in the PROSPERO database (CRD42023460585), the study's primary outcome measures include the failure rate of the ligation tool, conversion to open surgery, rate of severe bleeding, and device-related death. Other secondary variables are also explored. An assessment of the quality of included comparative studies was performed using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool.

RESULTS

Out of 393 articles identified using our keywords, 32 were included. Overall, clips have a lower failure rate during application, elongate graft vessel length, and are more cost-effective. Staples are associated with a shorter warm ischemia time and lower blood loss. There is no significant difference between the two devices in terms of conversion, severe bleeding, death, and blood transfusion.

CONCLUSION

There is no perfect modality for renal pedicle control during laparoscopic harvesting, as each instrument has its pros and cons. Hem-o-Lok® clips are a safe and cost-effective option, particularly suitable for right-sided harvesting or in cases of vascular variations. However, they are still associated with a risk of secondary displacement with potentially serious consequences. Certain technical tricks can mitigate this risk.

Strategies to Perform Pure Retroperitoneoscopic Donor Nephrectomy: A Single-Center Cohort Study

Background: Considering the increase in a number of vascular complications, right laparoscopic donor nephrectomy is less preferred due to achieving not only shorter renal vein but also longer renal artery. However, recent studies have indicated that the side of the surgery would not affect the outcomes. Aim: The aim of this study is to evaluate the outcomes and strategies to increase the safety of pure retroperitoneoscopic donor nephrectomy (RDN). Methods: We analyzed the prospectively collected medical records of 158 kidney donors who underwent RDN from January 2010 to August 2018. The patients were divided into two groups based on their side of surgery. Right- and left-sided RDNs were compared in terms of demographics, intraoperative, and postoperative data, including the development of incisional hernia (IH). The outcomes of the recipients were also evaluated. Results: Right RDN was performed in 40 (25.3%) and left RDN was performed in 118 (74.7%) donors. Operation time (P = .593), warm ischemia time (P = .271), blood loss (P = .787), and length of hospital stay (P = .908) were statistically similar in right and left RDN groups. Intraoperative and postoperative complications were statistically showed no difference between right and left RDNs. No IH was observed in any group. One-year and five-year patient survival and graft survival rates were 100% versus 97% (P = .299) and 100% versus 95% (P = .126) on both sides, respectively. Conclusion: Right RDN is an effective and safe method as on the left side. RDN has an additional advantage in the absence of IH. Experience with other retroperitoneoscopic urological interventions may have had a positive effect on the outcomes of pure RDN.

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.

Impact of right-sided nephrectomy on long-term outcomes in retroperitoneoscopic live donor nephrectomy at single center

Objective. To assess the long-term graft survival of right-sided retroperitoneoscopic live donor nephrectomy (RPLDN), we compared the outcomes of right- and left-sided RPLDN. Methods. Five hundred and thirty-three patients underwent live donor renal transplantation with allografts procured by RPLDN from July 2001 to August 2010 at our institute. Of these, 24 (4.5%) cases were selected for right-sided RPLDN (R-RPLDN) according to our criteria for donor kidney selection. Study variables included peri- and postoperative clinical data. Results. No significant differences were found in the recipients' postoperative graft function and incidence of slow graft function. Despite significant increased warm ischemic time (WIT: mean 5.9 min versus 4.7 min, P < 0.001) in R-RPLDN compared to that in L-RPLDN, there was no significant difference between the two groups regarding long-term patient and graft survival. The complication rate in R-RPLDN was not significantly different compared to that in L-RPLDN (17% versus 6.5%, P = 0.132). No renal vein thrombosis was experienced in either groups. Conclusions. Although our study was retrospective and there was only a small number of R-RPLDN patients, R-RPLDN could be an option for laparoscopic live donor nephrectomy because of similar results, with the sole exception of WIT, in L-RPLDN, and its excellent long-term graft outcomes.

Do multiple renal arteries in the remnant kidney have a negative influence on kidney donors after kidney donation?

AIM

To investigate whether the presence of multiple renal arteries in the remnant kidney has implications for lower renal function or increased incidence of hypertension.

METHODS

We reviewed the intraoperative and follow-up data of 101 live kidney donors who underwent nephrectomies at our institution. Sixty-nine donors (68.3%) had single artery in the remnant kidney (Group A), while 32 donors (31.7%) had multiple renal arteries in the remnant kidney (Group B). We compared the demographic and intraoperative data between the two groups. The follow-up data of donors in each group were divided into three subgroups based on the length of the follow-up period (12-24 months, 24-48 months and ≥48 months). Subgroups were created based on blood pressure and serum creatinine level. The δblood pressure (follow-up blood pressure minus preoperative blood pressure) and δserum creatinine (follow-up serum creatinine minus preoperative serum creatinine) in each subgroup in Group A were compared with the counterparts in Group B.

RESULTS

Renal arterial stenosis and calcification of renal arterial wall were not observed in all donors. There were no significant differences in the intraoperative characteristics (e.g. age, body mass index, operative duration and estimated blood loss) between the two groups. In addition, the blood pressure and serum creatinine level among subgroups within each group were similar. Furthermore, significant differences in δblood pressure and δserum creatinine were not observed between subgroups within the same follow-up period. Recipient survival rate and serum creatinine level were similar and acceptable in both groups.

CONCLUSIONS

The presence of multiple renal arteries in the remnant kidney does not have additional negative influence on kidney donors after kidney donation.

Laparoscopic retroperitoneal extirpative and reconstructive renal surgery

Retroperitoneal laparoscopy for renal surgery is a viable and versatile alternative to transperitoneal access. Location of the kidneys in the retroperitoneum makes it an attractive approach. The development of both approaches paralleled during the last two decades; however, retroperitoneal laparoscopy witnessed a steep learning curve because of the constraint of working space, lack of obvious landmarks, and appropriate instrumentations. This approach has several advantages and is currently being used for extirpative and reconstructive procedures for various renal pathologic conditions. After creation of retroperitoneal space, the techniques can be tailored to the desired indication for successful culmination. The learning curve can be shortened by adequate training; subsequently, with experience, this can be used proficiently.

Prospective Swiss cohort study of living-kidney donors: study protocol

Background Offering living kidney donation raised the concern that donors are exposed to unknown risks. All Swiss transplant centres therefore decided to start a prospective cohort study of living kidney donors in Switzerland. This paper describes the rationale for and implementation of this cohort study. Methods/design All kidney donors in Switzerland are registered and examined before donation and biennially after donation starting in the first year after nephrectomy. Before each follow-up visit, the study centre sends a package to the kidney donor containing the health questionnaire, blood and urine tubes and a prepaid envelope for sending the samples to the central laboratory. The donor makes an appointment with their family physician, who examines the donor and reports findings such as pain and other complaints, blood pressure, creatinine, albumin, all major health events and the state of mental and social well-being to the study centre. The family doctor draws the blood sample and mails it with the urine sample in the prepaid envelope. All data are centrally managed. All abnormal findings in the follow-up of individual donors are regularly discussed with the principal investigator, and necessary clinical changes made and recorded in the database. The health insurance of the recipient covers all costs of the donor follow-up. The main outcomes are the occurrence of albuminuria, hypertension and renal insufficiency. The secondary outcomes are major somatic and social events such as death, cardiovascular disease, stroke and depression. Discussion This prospective cohort offers unique opportunities to assess the risks of living kidney donation and will allow us to examine the risks associated with the methods used for nephrectomy in Switzerland (various forms of open surgery and laparoscopic nephrectomy). The prospective collection of all clinically relevant data and the regular monitoring of donors will allow timely interventions at early stages before serious kidney and general health problems occur.

Retroperitoneal renal laparoscopy

The retroperitoneal laparoscopic approach to the kidney offers a minimally invasive access that mimics the open surgical techniques of renal surgery. It allows renal surgery without violation of the peritoneal cavity with its attendant complications such as bowel injury and ileus. Over the last two decades, all renal surgery has been shown to be feasible through this technique. This includes complicated procedures such as a donor nephrectomy and radical nephroureterectomy for upper tract transitional cell cancers. We began performing retroperitoneoscopic renal surgery in the early 1990s and have developed a number of modifications to existing techniques so as to make this surgery easy and cost effective. In this review, we discuss the evolution of retroperitoneoscopic renal surgery, the indications, techniques and outcome of all types of retroperitoneoscopic renal surgery.