Technical modification for laparoscopic donor nephrectomy to minimize testicular pain: a complication with significant morbidity

Testicular Pain Following Laparoscopic Donor Nephrectomy: An Underreported Complication

Introduction: Testicular pain (TP) after laparoscopic donor nephrectomy (LDN) is a relatively underreported complication. This study aimed to investigate the incidence, characteristics, and factors associated with ipsilateral TP after left-sided LDN. Materials and Methods: This study prospectively collected baseline data and surgical details for all patients who underwent left-sided LDN during the study period. Each patient underwent scrotal ultrasonography 1 month postoperation. Donors were categorized by the level of gonadal vein ligation (level 1 at the renal vein confluence and level 2 at or below the iliac vessel crossing) and the presence or absence of TP. The characteristics of pain and demographics were compared across the groups. Results: Among 61 male patients who underwent left-sided LDN between March 2017 and December 2018, 54.1% (33/61) experienced ipsilateral TP. TP was more frequent in level 2 donors (64.3%) than in level 1 (45.5%), but the difference was not statistically significant (p = 0.141). Most TP occurred within a week (60.6%), was mild (75.8%), and resolved within 3 months (63.7%). The incidence of varicocele and hydrocele was 32.8% and 34.4%, respectively. The occurrence of TP was not significantly associated with the presence of varicocele or hydrocele and other factors. Conclusion: More than half of the male donors who underwent LDN experienced TP. The findings emphasize the importance of discussing this potential complication during preoperative counseling. This study found no significant association between TP and the level of gonadal vein ligation or the presence of varicocele, warranting further investigation into the cause of TP.

Post-Laparoendoscopic Single-Site Donor Nephrectomy Ipsilateral Testicular Pain, Does Operative Technique Matter? A Single Center Experience and Review of Literature

Aim

To assess incidence and characteristics of post-laparoendoscopic single-site donor nephrectomy (LESS DN) testicular pain.

Materials and Methods

A prospective comparative study of all male donors post-left LESS DN (group A) vs. postopen nephrectomies (group B) was performed at our center. Patients' demographics, perioperative data, and postoperative consultation reports were reviewed. Testicular pain, swelling, numbness, urinary symptoms, and sexual dysfunction were evaluated. Patients with a history of scrotal pathology or surgical procedure were excluded. Pain and tenderness were scored on a standard 10-point scale.

Results

From September 2017 to December 2020, 85 and 35 male patients of groups A and B met the evaluation criteria. Ipsilateral testicular pain developed in 11 patients (15.3%) and 2 patients (9.5%) in groups A and B, respectively. In most instances, the pain was mild to moderate in severity, started after 6 ± 2.1 and 4 ± 1.1 days postoperatively in groups A and B, respectively. Six patients in group A were evaluated with transscrotal ultrasonography that showed no abnormalities. All patients in both groups responded well to medical treatment.

Conclusions

Post-LESS DN ipsilateral testicular pain is usually mild and self-limited. Preoperative patient education and discussion of the possibility of development of testicular pain and its management should be an integral component of laparoscopic donor nephrectomy informed consent.

[Living donor nephrectomy: The French guidelines from CTAFU]

OBJECTIVE

To propose surgical recommendations for living donor nephrectomy.

METHOD

Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU regarding functional and anatomical assessment of kidney donors, including which side the kidney should be harvested from. Distinct surgical techniques and approaches were evaluated. References were considered with a predefined process to propose recommendations with the corresponding levels of evidence.

RESULTS

The recommendations clarify the legal and regulatory framework for kidney donation in France. A rigorous assessment of the donor is one of the essential prerequisites for donor safety. The impact of nephrectomy on kidney function needs to be anticipated. In case of modal vascularization of both kidneys without a relative difference in function or urologic abnormality, removal of the left kidney is the preferred choice to favor a longer vein. Mini-invasive approaches for nephrectomy provide faster donor recovery, less donor pain and shorter hospital stay than open surgery.

CONCLUSION

These French recommendations must contribute to improving surgical management of candidates for kidney donation.

Persistent orchialgia after laparoscopic living-donor nephrectomy: an underestimated complication requiring information adjustment

PURPOSE

Laparoscopic living-donor nephrectomy (LLDN) is the gold-standard procedure for kidney procurement. Ipsilateral orchialgia has barely been described. Some authors reported that ligation of gonadal vein (GV) above iliac vessel bifurcation could prevent orchialgia. We aimed to assess incidence and duration of orchialgia after LLDN in male donors despite distal ligation of GV.

METHODS

Patients who underwent LLDN from 2014 to 2017 were included. Standard procedure consisted in distal ligation of GV, close to the renal vein confluence and proximal ureteral ligation. Patients' demographics, per-operative data, and post-operative consultation reports were retrospectively reviewed. Orchialgia and scrotal symptoms were assessed through a non-validated questionnaire by phone interview.

RESULTS

Sixty-nine donors were included. Orchialgia incidence and testicular swelling were 31.9% (n = 22) and 15.9% (n = 11), respectively. Median symptom duration was 15.5 months. Orchialgia led to medical consultation in 41.7% (n = 10) of cases. All patients declared having been informed, prior to donation, about possible residual pain but not specifically orchialgia.

CONCLUSION

Orchialgia after LLDN affects more than 30% of donors, despite distal ligation of GV and led less than 50% of them to medical consultation, suggesting a large underestimation in clinical practice. Emphasis should be put on this complication during pre-donation information.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Prevention of Orchialgia After Left-Sided Laparoscopic Donor Nephrectomy-A Prospective Study

BACKGROUND AND PURPOSE

Etiology of orchialgia or testicular pain after laparoscopic donor nephrectomy (LDN) has been found to be related to injury of the spermatic plexus during gonadal (testicular) vein (GV) or ureteral ligation. This study aimed to evaluate and validate the impact of the level of ligation of GV and ureter in relation to the crossing of iliac vessels (CIV) on incidence of orchialgia.

PATIENTS AND METHODS

A prospective study was conducted on 70 males who underwent left LDN from January 2008 to December 2010 (group A) to determine the correlation between orchialgia and level of ligation of the GV and ureter with respect to CIV; this revealed that the ligation of the GV and/or ureter above the level of the CIV (level 1, n=40) is less likely to cause orchialgia than ligating them at or below (level 2, n=30). Subsequently, in 45 male patients (group B) for left LDN from January 2011 to June 2013, we ensured that clipping of the ureter and GV be performed above the CIV to validate the above findings. Patients with a history of scrotal pathology or surgical procedure were excluded. One-sided Z-test with pooled variance was used to calculate the sample size.

RESULTS

In group A, orchialgia was seen in 10 (14.3%) patients. The clipping of the ureter and GV at level 2 (orchialgia, n=9) was associated with a significantly higher incidence of orchialgia than clipping them at level 1 (orchialgia, n=1) (P=0.001,95% confidence interval=0.0707 to 0.2471). In group B, 43 patients were finally analyzed, and none had orchialgia.

CONCLUSION

The level of ligation of the GV and ureter has significant impact on the incidence of orchialgia. Ipsilateral testicular pain in patients with left-sided LDN is preventable, if the ureter and GV are ligated or clipped above the level of iliac vessels bifurcation.

Innovations in organ donation

The growing disparity between organ availability for transplantation and the number of patients in need has challenged the donation and transplantation community of practice to develop innovative processes, ideas, and techniques to bridge the gaps. Advances in the sharing of best practices in the donation community have contributed greatly over the last 8 years. Broader sharing of updated guidelines for declaration of brain death in conjunction with improvements in deceased donor management have increased opportunities for organ donation. New techniques for organ preservation and organ resuscitation have allowed for better utilization of the potential donor pool. This review will highlight processes, ideas, and techniques in organ donation.

Orchialgia after laproscopic renal surgery: a common problem with questionable etiology. Are there any predictors?

PURPOSE

Orchialgia after laproscopic renal surgery has been rarely reported in literature, and gonadal vein ligation is considered the main etiology. Our objective was to study the incidence, intensity and to find out any specific factors that could lead to orchialgia.

MATERIALS AND METHODS

All patients planned for laproscopic renal surgery between Jan 2009 and July 2011 had a history and physical examination before surgery, in postoperative period, and after discharge. Pain was scored on a standard 10-point scale approved by the NIH. Baseline, perioperative, and postoperative data were collected prospectively.

RESULTS

A total of 460 laproscopic renal surgeries were performed on males out of which 440 met our criteria of evaluation. A total of 38 patients had ipsilateral orchialgia (8.52 %). The pain was more common for left-sided procedures. Mean pain intensity was 3.2. On statistical analysis, there was no difference in the operative parameters between patients of pain and those without pain except that the level of ligation of ureter and that of gonadal vein were significantly associated with orchialgia (p value <0.001 and 0.003, respectively) with the odds ratio for ligating them below the crossing of iliac vessels being 6.443 (3.098-13.397) and 4.457 (2.165-9.176), respectively.

CONCLUSION

Ipsilateral orchialgia is common in patients undergoing laproscopic renal surgery specially after radical nephroureterectomy and nephrectomy specially when the ureter and gonadal vein are taken down at or below their crossing of iliac vessels. Taking down ureter above, rather than below, the iliac vessels whenever possible may be preventive as is the preservation of gonadal vein.