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.

Initial Experience With Hand-Assisted Laparoscopic Living Donor Nephrectomy: Training and Clinical Practice as a General Surgeon

BACKGROUND

To analyze our initial results of hand-assisted laparoscopic living donor nephrectomy, executed by a skilled gastrointestinal surgeon.

METHODS

A total of 22 consecutive patients underwent the hand-assisted laparoscopic living donor nephrectomy between December 2014 and January 2017. We retrospectively analyze the patient's perioperative clinical data, which were collected prospectively.

RESULTS

The right kidney was harvested in 12 patients. The mean operative time and intraoperative blood loss was 241.0 ± 43.4 minutes (range, 140-310 min) and 293.2 ± 203.1 mL (range, 50-700 mL), respectively. The mean warm ischemic time was 288.4 ± 103.4 seconds (range, 179-610 s). Postoperative complications included chyle leakage in 2 patients who were left kidney donors and oliguria in 1 patient who was a right kidney donor. All patients recovered with conservative care, and the mean hospital stay was 7.5 ± 1.7 days. The mean creatinine level was 0.7 ± 0.2 mg/dL before surgery, 1.1 ± 0.3 mg/dL at postoperative day (POD) 1, and 1.0 ± 0.2 mg/dL after discharge. The mean glomerular filtration rate was 97.9 ± 18.2 mL/min/1.73 m² before surgery, 60.7 ± 10.4 at POD 1, and 67.3 ± 11.1 after discharge. Operation time was not associated with patient body mass index and case number. No significant differences, other than postoperative complications, were found in the perioperative data for the side of kidney donation.

CONCLUSION

A skilled surgeon with experience in laparoscopic abdominal surgery (such as gastrectomy or colectomy) might safely perform hand-assisted donor nephrectomy. However, we could not identify a clear case number to complete the learning curve.

Laparoscopic kidney transplant by extra peritoneal approach: the safe transition from laboratory to the clinic

The aim of this study is to develop a novel laparoscopic surgery by extra-peritoneal approach for kidney transplant and pave the way of safe transition from laboratory to the clinic. The study was established to explore the feasibility and safety of human laparoscopic kidney transplant. The experiment was first conducted on the deceased animals, then live animals and human cavader before human kidney transplant was approved. The study patient was a 49-year-old male who received the kidney for laparoscopic kidney transplant by extra-peritoneal approach. The control patient received the contralateral kidney for open kidney transplant. The estimated blood loss was minimal during surgery. Both kidneys experienced delayed graft function but the kidneys started function on Day 6 postoperation. The analgesia consumption was significantly less in the study patient. There is no surgical complication during 6-month follow-up. This study has developed a new technique for laparoscopic kidney transplant by extra-peritoneal approach. It has retained the advantages of open kidney transplant, which allows the graft located in the extra-peritoneal space without violating peritoneum. This study has also paved the way of safe transition for a novel laparoscopic surgery from laboratory to the clinic.

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

Few prospective, randomized studies have assessed the benefits of laparoendoscopic single site donor nephrectomy (LESS-DN) over laparoscopic donor nephrectomy (LDN). Our center initiated such a trial in January 2011, following subjects randomized to LESS-DN versus LDN from surgery through 5 years postdonation. Subjects complete recovery/satisfaction questionnaires at 2, 6 and 12 months postdonation; transplant recipient outcomes are also recorded. One hundred subjects (49 LESS-DN, 51 LDN) underwent surgery; donor demographics were similar between groups, and included a predominance of female, living-unrelated donors, mean age of 47 years who underwent left donor nephrectomy. Operative parameters (overall time, time to extraction, warm ischemia time, blood loss) were similar between groups. Conversion to hand-assist laparoscopy was required in 3 LESS-DN (6.1%) versus 2 LDN (3.9%; p = 0.67). Questionnaires revealed that 97.2% of LESS-DN versus 79.5% of LDN (p = 0.03) were 100% recovered by 2 months after donation. No significant difference was seen in satisfaction scores between the groups. Recipient outcomes were similar between groups. Our randomized trial comparing LESS donor nephrectomy to LDN confirms that LESS-DN offers a safe alternative to conventional LDN in terms of intra- and post-operative complications. LDN and LESS-DN offer similar recovery and satisfaction after donation.

Another option for laparoscopic living donor nephrectomy: a single center experience comparing two-port versus hand-assisted technique

PURPOSE

To compare the clinical outcomes of two-port laparoscopic donor nephrectomy (TPLDN) vs hand-assisted laparoscopic donor nephrectomy (HALDN).

PATIENTS AND METHODS

Between November 2010 and March 2012, 100 kidney donors scheduled for left nephrectomy were alternatively assigned to HALDN or TPLDN in a 1:1 fashion. All procedures were performed by the same laparoscopic surgeon. Demographic data and intraoperative and early postoperative data were collected prospectively and analyzed.

RESULTS

There was no difference in the operating time (133±12 vs 142±17 min, P=0.07), blood loss (55±46 vs 58±52 mL, P=0.84), complication rate (10% vs 12%, P=0.74), and length of hospital stay (3.8±0.8 vs 4.1±2.8 days, P=0.5) between the HALDN and TPLDN groups. The warm ischemia time was longer in the TPLDN group (2.2±0.7 vs 3.5±0.9 min, P<0.001). No statistically significant differences were found in the analgesic requirement and the visual analog pain scores. There was a trend toward quicker return to 100% recovery in the TPLDN group (60±46 vs 39±15 days, P=0.05). The TPLDN group had a significantly smaller surgical incision (8.2±0.6 vs 5.5±0.4 cm, P<0.001) and higher scar satisfaction score (7.8±1.5 vs 8.6±1.3, P=0.02) than the HALDN group. No differences were found in the recipient serum creatinine values or in the incidence of delayed graft function.

CONCLUSIONS

In comparing TPLDN and HALDN, there was no significant difference in a majority of the operative and postoperative parameters. TPLDN might be associated with smaller surgical incision, improved cosmetic satisfaction, and equivalent recipient graft function.

Long-term graft function in a randomized clinical trial comparing laparoscopic versus open donor nephrectomy

OBJECTIVES

To evaluate and compare the long-term graft and survival rates in kidney transplant recipients who had undergone laparoscopic donor nephrectomy versus those who underwent open donor nephrectomy.

MATERIALS AND METHODS

Our study was done with 100 cases of laparoscopic donor nephrectomy and 100 cases of open donor nephrectomy, performed between July 2001 and September 2003. Mean follow-up of recipients in this study was 6.6 ± 2.4 years (range, 1-9.3 y). This study has a longer follow-up than previous randomized clinical trials. We compared patient and graft survival in recipients of laparoscopic donor nephrectomy versus those who had open donor nephrectomy.

RESULTS

Mean duration of kidney warm ischemia time was 8.7 ± 2.7 minutes for laparoscopic donor nephrectomy and 1.8 ± 0.92 minutes for open donor nephrectomy. There were no significant differences in 5-year graft survival between the laparoscopic donor nephrectomy and open donor nephrectomy groups (89.5% vs 84.3%; P = .96). There were no differences in delayed graft function between the laparoscopic donor nephrectomy and open donor nephrectomy groups (8 and 11 patients; P = .135). There was a significant difference in 5-year graft survival between recipients with a history of delayed graft function and those without delayed graft function (63.2% vs 89.7%; P = .04). Despite a longer warm ischemia time in laparoscopic donor nephrectomy group (8.69 vs 1.87 min; P = .0001), warm ischemia time had no effect on graft outcome in long-term follow-up.

CONCLUSIONS

Although earlier experiences with laparoscopic donor nephrectomies were associated with concerns about long-term effects of laparoscopic donation on the graft function in the recipient, our long-term results confirm that laparoscopic donor nephrectomy provides similar graft outcome to open donor nephrectomy.

Renal vein lengthening using gonadal vein reduces surgical difficulty in living-donor kidney transplantation

BACKGROUND

During living-donor kidney transplantation, to maximally decrease donor injury, the right kidney with lower glomerular filtration rate often is selected as the donor kidney. However, the renal vein of the right kidney is relatively short for transplantation. The gonadal vein is essentially useless and is easily accessed during the donor nephrectomy.

METHODS

Seventeen live kidney donors received right kidney nephrectomy for living-donor kidney transplantation. Short renal veins were lengthened by circular anastomosis or spiral anastomosis of longitudinally cut gonadal veins. The renal function of receivers was evaluated using creatinine clearance.

RESULTS

The renal veins were extended by 2.0-2.7 cm with circular anastomosis and 4.1-4.5 cm with spiral anastomosis with an average of 2.5 ± 0.7 cm. Lengthening of renal veins averaged 20.4 ± 4.2 min. All surgeries were successful, significantly reducing difficulty of vascular anastomosis during transplantation. No poor early graft function occurred. No side effects were observed in donors.

CONCLUSIONS

When donor renal veins are too short for effective kidney transplantation and may affect reliability of vascular anastomosis, they can be lengthened by using gonadal veins without increasing injury to the donor. Successful extension of donor kidney renal veins expands the indication for right donor kidneys.

Laparoscopic Living Kidney Donation at a Single Center: An Examination of Donor Outcomes with Increasing Experience

This study was undertaken to examine short-term outcomes of laparoscopic donor nephrectomy performed by transplant surgeons at a medium volume institution, with the specific goal of determining the presence of a learning curve effect. With institutional review board approval, a retrospective chart review was performed examining patient demographics, operative factors, and in-hospital outcomes over a 12-year period. Specific attention was paid to differences in outcomes between patients undergoing operation in the first versus the most recent 6-year period. Continuous and categorical variables were examined using the Wilcoxon rank sum test and χ2 analysis, respectively. The study group consisted of 129 patients. Median operative time was 234 minutes with a median estimated blood loss of 100. The median preoperative creatinine was 0.9, with a postoperative median creatinine of 1.3. The overall complication rate was 12.4 per cent, with ileus being the most common. There were two cases of post op acute renal failure, both of which were self limited and did not require dialysis. No patients died. Patients in the most recent 6 years (n = 77) enjoyed a shorter length of stay (2 vs 3 days, P < 0.001) than patients in the first 6-year period (n = 52). Additionally, there was a trend towards decreased complications in the second era that did not reach significance (9.1% vs 17.3%, P = 0.17). Laparoscopic donor nephrectomy is an attractive means of donation, and can be performed with low risk to the donor and minimal learning curve effect.