1
|
Tabbara MM, Riella J, Gonzalez J, Gaynor JJ, Guerra G, Alvarez A, Ciancio G. Optimizing the kidney donor pool: transplanting donor kidneys after partial nephrectomy of masses or cysts. Front Surg 2024; 11:1391971. [PMID: 38726469 PMCID: PMC11080618 DOI: 10.3389/fsurg.2024.1391971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/08/2024] [Indexed: 05/12/2024] Open
Abstract
Background A limiting factor in expanding the kidney donor pool is donor kidneys with renal tumors or cysts. Partial nephrectomy (PN) to remove these lesions prior to transplantation may help optimize organ usage without recurrence of malignancy or increased risk of complications. Methods We retrospectively analyzed all recipients of a living or deceased donor graft between February 2009 and October 2022 in which a PN was performed prior to transplant due to the presence of one or more concerning growths. Donor and recipient demographics, perioperative data, donor allograft pathology, and recipient outcomes were obtained. Results Thirty-six recipients received a graft in which a PN was performed to remove suspicious masses or cysts prior to transplant. Majority of pathologies turned out to be a simple renal cyst (65%), followed by renal cell carcinoma (15%), benign multilocular cystic renal neoplasm (7.5%), angiomyolipoma (5%), benign renal tissue (5%), and papillary adenoma (2.5%). No renal malignancy recurrences were observed during the study period (median follow-up: 67.2 months). Fourteen complications occurred among 11 patients (30.6% overall) during the first 6mo post-transplant. Mean eGFR (± standard error) at 36 months post-transplant was 51.9 ± 4.2 ml/min/1.73 m2 (N = 23). Three death-censored graft losses and four deaths with a functioning graft and were observed. Conclusion PN of renal grafts with suspicious looking masses or cysts is a safe option to optimize organ usage and decrease the kidney non-use rate, with no observed recurrence of malignancy or increased risk of complications.
Collapse
Affiliation(s)
- Marina M. Tabbara
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
| | - Juliano Riella
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
| | - Javier Gonzalez
- Servicio de Urología, Unidad de Trasplante Renal, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jeffrey J. Gaynor
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
| | - Giselle Guerra
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Angel Alvarez
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
| | - Gaetano Ciancio
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, United States
| |
Collapse
|
2
|
Kim DH, Park HS, Bang JS, Shin HJ, Yoon BJ, Kim S, Jeong JC, Park S, Lee T. Routine Ureteral Stenting in Kidney Transplant Reduces Postoperative Hydronephrosis and Percutaneous Ureteral Interventions: A Single-Center Experience. EXP CLIN TRANSPLANT 2024; 22:9-16. [PMID: 38284370 DOI: 10.6002/ect.2023.0349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
OBJECTIVES The effect of routine ureteral stenting on postoperative hydronephrosis and percutaneous ureteral intervention in kidney transplant remains unknown. This study aimed to evaluate the effects of routine ureteral stenting on hydronephrosis and percutaneous ureteral intervention and the cost benefit of ureteral stenting in kidney transplant. MATERIALS AND METHODS We retrospectively analyzed patients who underwent kidney transplant at a tertiary institution between 2005 and 2021. We adopted a ureteral stentingprotocol in2017, anda comparisonwas performed with previous patients without stents. RESULTS In total, 539 patients underwent kidney transplant(271 with stents [51.3%], 268 without stents [49.7%]). Hydronephrosis was detected in 16 cases (5.9%) and 30 cases (11.2%) of groups with and without stents,respectively (P = .041). Among patients with hydronephrosis, the number of patients who underwent percutaneous ureteral intervention was significantly lower in the stent group than in the nostent group (1 [6.25%] vs 10 [33.33%]; P= .014).Twenty patients (3.71%) experienced major urologic complications (19 [7.1%] in the no-stent group, and 1 [0.4%] in the stent group; P = .001). No significant differences between the groups were shown in the incidence of urinary tract infections within 3 months of transplant (24 [8.9%] vs 22 [8.2%]; P = .846). No differences were shown between the groups in ureterovesical anastomosis time (24.4 vs 24.03 min; P = .699) or 1-year graft survival (97% vs 97.8%; P = .803). The healthcare cost was significantly lower in the stent group than in the no-stent group by $1702.05 ($15000.89 vs $16702.95; P < .001). CONCLUSIONS Routine ureteral stenting in kidney transplant significantly decreased the incidence of postoperative hydronephrosis and percutaneous ureteral intervention. Stenting did notlead to increased urinary tract infections and was cost-effective.
Collapse
Affiliation(s)
- Dong-Hwan Kim
- >From the Department of Surgery, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Riella J, Ferreira R, Tabbara MM, Abreu P, Ernani L, Defreitas M, Chandar J, Gaynor JJ, González J, Ciancio G. Retroperitoneal kidney transplantation with liver and native kidney mobilization: a safe technique for pediatric recipients. World J Pediatr 2023; 19:489-501. [PMID: 36474085 PMCID: PMC10149446 DOI: 10.1007/s12519-022-00658-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pediatric kidney transplant (KT) using larger, deceased or living donor adult kidneys can be challenging in the pediatric population due to limited space in the retroperitoneum. Liver and native kidney (L/NK) mobilization techniques can be used in smaller and younger transplant recipients to aid in retroperitoneal placement of the renal allograft. Here, we compare the clinical outcomes of pediatric retroperitoneal KT with and without L/NK mobilization. METHODS We retrospectively analyzed pediatric renal transplant recipients treated between January 2015 and May 2021. Donor and recipient demographics, intraoperative data, and recipient outcomes were included. Recipients were divided into two groups according to the surgical technique utilized: with L/NK mobilization (Group 1) and without L/NK mobilization (Group 2). Baseline variables were described using frequency distributions for categorical variables and means and standard errors for continuous variables. Tests of association with the likelihood of using L/NK mobilization were performed using standard χ2 tests, t tests, and the log-rank test. RESULTS Forty-six pediatric recipients were evaluated and categorized into Group 1 (n = 26) and Group 2 (n = 20). Recipients in Group 1 were younger (6.7 ± 0.8 years vs. 15. 3 ± 0.7, P < 0.001), shorter (109.5 ± 3.7 vs. 154.2 ± 3.8 cm, P < 0.001) and weighed less (21.4 ± 2.0 vs. 48.6 ± 3.4 kg, P < 0.001) than those in Group 2. Other baseline characteristics did not differ between Groups 1 and 2. One urologic complication was encountered in Group 2; no vascular or surgical complications were observed in either group. Additionally, no stents or drains were used in any of the patients. There were no cases of delayed graft function or graft primary nonfunction. The median follow-up of the study was 24.6 months post-transplant. Two patients developed death-censored graft failure (both in Group 2, P = 0.22), and there was one death with a functioning graft (in Group 2, P = 0.21). CONCLUSIONS Retroperitoneal liver/kidney mobilization is a feasible and safe technique that facilitates implantation of adult kidney allografts into pediatric transplant recipients with no increased risk of developing post-operative complications, graft loss, or mortality.
Collapse
Affiliation(s)
- Juliano Riella
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1801 NW 9Th Ave, 7Th Floor, Miami, FL, 33136, USA
| | - Raphealla Ferreira
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1801 NW 9Th Ave, 7Th Floor, Miami, FL, 33136, USA
| | - Marina M Tabbara
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - Phillipe Abreu
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1801 NW 9Th Ave, 7Th Floor, Miami, FL, 33136, USA
| | - Lucas Ernani
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1801 NW 9Th Ave, 7Th Floor, Miami, FL, 33136, USA
| | - Marissa Defreitas
- Department of Pediatrics, Division of Nephrology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1801 NW 9Th Ave, 7Th Floor, Miami, FL, 33136, USA
| | - Jayanthi Chandar
- Department of Pediatrics, Division of Nephrology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1801 NW 9Th Ave, 7Th Floor, Miami, FL, 33136, USA
| | - Jeffrey J Gaynor
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1801 NW 9Th Ave, 7Th Floor, Miami, FL, 33136, USA
| | - Javier González
- Servicio de Urología, Unidad de Trasplante Renal, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gaetano Ciancio
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA.
- Department of Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA.
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1801 NW 9Th Ave, 7Th Floor, Miami, FL, 33136, USA.
| |
Collapse
|
4
|
Riella J, Tabbara MM, Alvarez A, DeFreitas MJ, Chandar J, Gaynor JJ, González J, Ciancio G. Pediatric kidney transplants with multiple renal arteries show no increased risk of complications compared to single renal artery grafts. Front Pediatr 2022; 10:1058823. [PMID: 36589161 PMCID: PMC9800822 DOI: 10.3389/fped.2022.1058823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/18/2022] [Indexed: 12/23/2022] Open
Abstract
Background Kidney allografts with multiple renal arteries (MRA) are not infrequent and have been historically associated with a higher risk of developing vascular and urologic complications. Reports of kidney transplantation using MRA allografts in the pediatric population remain scarce. The aim of this study was to evaluate if transplantation of allografts with MRA with a surgical intent of creating a single arterial inflow using vascular reconstruction techniques when required, and without the routine use of surgical drains or ureteral stents, is associated with an increased risk of complications when compared to single renal artery (SRA) grafts. Methods We retrospectively analyzed all pediatric renal transplant recipients performed by a single surgeon at our center between January 2015 and June 2022. Donor and recipient demographics, intraoperative data, and recipient outcomes were included. Recipients were divided into two groups based on SRA vs. MRA. Baseline variables were described using frequency distributions for categorical variables and means and standard errors for continuous variables. Comparisons of those distributions between the two groups were performed using standard chi-squared and t-tests. Time-to-event distributions were compared using the log-rank test. Results Forty-nine pediatric transplant recipients were analyzed. Of these, 9 had donors with MRA (Group 1) and 40 had donors with SRA (Group 2). Native kidney and liver mobilization was performed in 44.4% (4/9) of Group 1 vs. 60.0% (24/40) of Group 2 cases (p = 0.39). There were no cases of delayed graft function or graft primary nonfunction. No surgical drainage or ureteral stents were used in any of the cases. One patient in Group 2 developed a distal ureter stricture. The geometric mean serum creatinine at 6- and 12-months posttransplant was 0.7 */ 1.2 and 0.9 */ 1.2 mg/dl in Group 1 and 0.7 */ 1.1 and 0.7 */ 1.1 mg/dl in Group 2. Two death-censored graft failures were observed in Group 2, with no significant difference observed between the two groups (p = 0.48). Conclusions Our study demonstrates that pediatric renal transplantation with MRA grafts, using a surgical approach to achieve a single renal artery ostium, can be safely performed while achieving similar outcomes as SRA grafts and with a low complication rate.
Collapse
Affiliation(s)
- Juliano Riella
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
| | - Marina M. Tabbara
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
| | - Angel Alvarez
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
| | - Marissa J. DeFreitas
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
- Department of Pediatrics, Division of Nephrology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
| | - Jayanthi Chandar
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
- Department of Pediatrics, Division of Nephrology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
| | - Jeffrey J. Gaynor
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
| | - Javier González
- Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gaetano Ciancio
- Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
- Department of Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, United States
| |
Collapse
|
5
|
Nino-Torres L, Garcia-Lopez A, Patino-Jaramillo N, Giron-Luque F, Nino-Murcia A. Risk Factors for Urologic Complications After Kidney Transplantation and Impact in Graft Survival. Res Rep Urol 2022; 14:327-337. [PMID: 36196091 PMCID: PMC9527029 DOI: 10.2147/rru.s371851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/06/2022] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose Kidney transplantation (KT) is the best therapy for chronic kidney disease (CKD). Major urologic complications (MUCs) are the second etiology associated to morbidity and graft loss following KT, after rejection episodes. The objective of this study was to estimate the incidence, risk factors and impact on graft survival associated to urological complications in KT patients. Patients and Methods A retrospective cohort based on electronic patient files of kidney transplant recipients from Colombiana de Trasplantes was created for the period August 2008 to September 2019. Initiation of follow-up was defined as the date of transplantation up to 3 years post-transplantation. Incidence of ureteral stenosis, ureteral obstruction, and ureteral leak was measured. A logistic regression multivariate model was adjusted to determine the associated factors to MUCs (yes/no). Patient and graft survival time were analyzed using a Kaplan-Meier method. Results A total of 1584 KT patients were included in the cohort. MUCs were present in 195 (12.6%) KT patients. We found that dialysis duration (OR: 1.004; p = 0.02) remained significant for the incidence of MUCs in KT patients of deceased donors. Probability of graft and patient survival at 3 years of follow-up was 90.5% and 85.5%, respectively. No significant difference was found on graft and patient survival in KT patients with or without MUCs. Conclusion MUCs are frequent complications for KT. We did not observe significant differences in graft or patient survival according to the presence of MUCs. The identification of MUCs and risk factors may guide transplant teams for future surgical and clinical decisions.
Collapse
Affiliation(s)
- Laura Nino-Torres
- Department of Transplantation Surgery, Colombiana de Trasplantes, Bogotá, Colombia
| | - Andrea Garcia-Lopez
- Department of Transplantation Research, Colombiana de Trasplantes, Bogotá, Colombia
| | | | - Fernando Giron-Luque
- Department of Transplantation Surgery, Colombiana de Trasplantes, Bogotá, Colombia
| | - Alejandro Nino-Murcia
- Department of Transplantation Surgery, Colombiana de Trasplantes, Bogotá, Colombia
- Correspondence: Alejandro Nino-Murcia, Transplant Surgeon, Colombiana de Trasplantes, Av Carrera, 30 No. 47 A-74, Bogota, 111311, Colombia, Tel +57 3112499999, Email
| |
Collapse
|
6
|
Complex Vascular Reconstruction of an En Bloc Pediatric Kidney Damaged during Organ Procurement. Case Rep Transplant 2022; 2022:3242809. [PMID: 35756169 PMCID: PMC9225888 DOI: 10.1155/2022/3242809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/27/2022] [Indexed: 11/17/2022] Open
Abstract
En bloc pediatric kidney (EBPK) allografts are a potential solution to expand the organ donor pool; however, EBPK transplantation has been traditionally considered suboptimal due to concerns of perioperative vascular and urologic complications. Accidental organ or vasculature injury during harvest is not uncommon; however, this does not necessarily mean that the organ should be discarded. Careful vascular reconstruction can be performed using donor vascular grafts, salvaging the organ without stenosis or thrombosis of the vessels. We report an extensive vascular reconstruction of the right renal artery, aorta, and inferior vena cava of a damaged EBPK allograft using a donor pediatric aorta vascular patch with the goal of avoiding postoperative vascular complications.
Collapse
|
7
|
Predictors of Kidney Delayed Graft Function and Its Prognostic Impact following Combined Liver-Kidney Transplantation: A Recent Single-Center Experience. J Clin Med 2022; 11:jcm11102724. [PMID: 35628851 PMCID: PMC9146237 DOI: 10.3390/jcm11102724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 12/04/2022] Open
Abstract
Combined liver−kidney transplantation (CLKT) improves patient survival among liver transplant recipients with renal dysfunction. However, kidney delayed graft function (kDGF) still represents a common and challenging complication that can negatively impact clinical outcomes. This retrospective study analyzed the incidence, potential risk factors, and prognostic impact of kDGF development following CLKT in a recently transplanted cohort. Specifically, 115 consecutive CLKT recipients who were transplanted at our center between January 2015 and February 2021 were studied. All transplanted kidneys received hypothermic pulsatile machine perfusion (HPMP) prior to transplant. The primary outcome was kDGF development. Secondary outcomes included the combined incidence and severity of developing postoperative complications; development of postoperative infections; biopsy-proven acute rejection (BPAR); renal function at 1, 3, 6, and 12 months post-transplant; and death-censored graft and patient survival. kDGF was observed in 37.4% (43/115) of patients. Multivariable analysis of kDGF revealed the following independent predictors: preoperative dialysis (p = 0.0003), lower recipient BMI (p = 0.006), older donor age (p = 0.003), utilization of DCD donors (p = 0.007), and longer delay of kidney transplantation after liver transplantation (p = 0.0003). With a median follow-up of 36.7 months post-transplant, kDGF was associated with a significantly increased risk of developing more severe postoperative complication(s) (p < 0.000001), poorer renal function (particularly at 1 month post-transplant, p < 0.000001), and worse death-censored graft (p = 0.00004) and patient survival (p = 0.0002). kDGF may be responsible for remarkable negative effects on immediate and potentially longer-term clinical outcomes after CLKT. Understanding the important risk factors for kDGF development in CLKT may better guide recipient and donor selection(s) and improve clinical decisions in this increasing group of transplant recipients.
Collapse
|
8
|
Tabbara MM, Guerra G, Riella J, Abreu P, Alvarez A, Vianna R, Chen L, Morsi M, Gaynor JJ, Gonzalez J, Ciancio G. Creating a Single Inflow Orifice From Living Donor Kidney Allografts With Multiple Renal Arteries. Transpl Int 2022; 35:10212. [PMID: 35497891 PMCID: PMC9046561 DOI: 10.3389/ti.2022.10212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 03/08/2022] [Indexed: 11/15/2022]
Abstract
Background: Multiple renal arteries (MRA) are often encountered during living-donor kidney transplantation (LDKT), requiring surgeons to pursue complex renovascular reconstructions prior to graft implantation. With improvements in reconstruction and anastomosis techniques, allografts with MRA can be successfully transplanted with similar outcomes to allografts with a single renal artery. Here, we describe in detail various surgical techniques for reconstruction of MRA grafts with the intent of creating a single arterial inflow. Methods: We retrospectively reviewed the medical records of all LDKT recipients with laparoscopically procured MRA kidneys between March 2008 and July 2021. Recipient and donor characteristics, operative data, type of reconstruction, and recipient outcomes were analyzed. The primary outcomes were the incidence of developing delayed graft function (DGF) and/or a vascular or urological complication within 12 months post-transplant. Results: Seventy-three LDKT recipients of MRA donor allografts were evaluated. Two renal arteries (RA) were encountered in 62 allografts (84.9%) and three RA in 11 allografts (15.1%). Renal artery reconstruction was performed in 95.8% (70/73) of patients. Eighteen different reconstruction techniques of MRA were utilized, the most common being side-to-side anastomosis in allografts with two RA (N = 44) and side-to-side-to-side anastomosis in allografts with three RA (N = 4). Interposition grafting was performed in seven cases (9.6%). A single ostium was created in 69 cases (94.5%), and the median warm ischemia time was 27 (range 20–42) minutes. None of the patients developed DGF or post-operative vascular or urological complications. Median creatinine at 3, 6, and 12 months post-transplant remained stable at 1.1 mg/dl. With a median follow-up of 30.4 months post-transplant, only one graft failure has been observed–death-censored graft survival was 98.6%. Conclusion: Complex reconstruction techniques to create a single renal artery ostium for graft implantation anastomosis in allografts with MRA show acceptable warm ischemic times, with no increased risk of post-operative vascular or urological complications.
Collapse
Affiliation(s)
- Marina M Tabbara
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida.,Miami Transplant Institute, Miller School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida
| | - Giselle Guerra
- Division of Nephrology, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida.,Miami Transplant Institute, Miller School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida
| | - Juliano Riella
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida.,Miami Transplant Institute, Miller School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida
| | - Phillipe Abreu
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida.,Miami Transplant Institute, Miller School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida
| | - Angel Alvarez
- Miami Transplant Institute, Miller School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida
| | - Rodrigo Vianna
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida.,Miami Transplant Institute, Miller School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida
| | - Linda Chen
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida.,Miami Transplant Institute, Miller School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida
| | - Mahmoud Morsi
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida.,Miami Transplant Institute, Miller School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida
| | - Jeffrey J Gaynor
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida.,Miami Transplant Institute, Miller School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida
| | - Javier Gonzalez
- Department of Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gaetano Ciancio
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida.,Miami Transplant Institute, Miller School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida.,Department of Urology, Miller School of Medicine, University of Miami, Miami, Florida
| |
Collapse
|
9
|
Astolfi RH, Aguiar WF, Viana L, Cristelli M, Junior HTS, Pestana JM. A STENTLESS MODIFIED LICH-GREGOIR TECHNIQUE FOR SAFE EARLY BLADDER CATHETER REMOVAL IN LIVING AND DECEASED KIDNEY TRANSPLANTS. Urology 2022; 165:336-342. [PMID: 35065141 DOI: 10.1016/j.urology.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/09/2022] [Accepted: 01/09/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe a stentless modified Lich-Gregoir technique (mLG) for ureteroneocystostomy in renal transplantation (RT), with early bladder catheter (BC) removal (under 48 hours), and compare the postoperative results with those of the traditional technique (LG) with routine bladder catheter removal (4 to 5 days). The modification consists of maintaining a thin layer of detrusor fibers covering the bladder mucosa during dissection, which is incorporated into the anastomosis to reinforce the ureteroneocystostomy. MATERIALS AND METHODS This retrospective cohort study compared the postoperative outcomes of 100 consecutive patients who underwent mLG with early removal of BC between October 2018 to November 2019 with those of a historical cohort of 165 consecutive patients transplanted using stentless LG and routine removal of BC, who underwent surgery between July 2017 and September 2018. All transplants were performed by the same surgeon. Follow-up was 6 months. RESULTS Demographic characteristics were comparable, although patients in the mLG group had a higher mean preoperative urine volume (911±753.8mL vs. 629±638.6mL, p=0.016). Patients in the mLG group successfully underwent early BC removal (2.2±0.9 vs. 4.8±4.8 days, p<0.001), with no differences in the incidence of surgical or clinical complications, including urine leaks (1 vs. 3%, p=0.284). In addition, mLG patients presented a shorter mean length of hospital stay (6.5±5.0 vs. 7.1±6.2 days, p=0.023). CONCLUSION This stentless modified Lich-Gregoir technique enables safe early bladder catheter removal and is associated with reduced hospital length of stay.
Collapse
Affiliation(s)
- Rafael H Astolfi
- Department of Urology, Endourology Division, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, Brazil.
| | - Wilson F Aguiar
- Department of Urology, Endourology Division, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, Brazil; Nephrology Division, Hospital do Rim, UNIFESP, Sao Paulo, SP, Brazil
| | - Laila Viana
- Nephrology Division, Hospital do Rim, UNIFESP, Sao Paulo, SP, Brazil
| | - Marina Cristelli
- Nephrology Division, Hospital do Rim, UNIFESP, Sao Paulo, SP, Brazil
| | - Helio T S Junior
- Nephrology Division, Hospital do Rim, UNIFESP, Sao Paulo, SP, Brazil
| | - Jose M Pestana
- Nephrology Division, Hospital do Rim, UNIFESP, Sao Paulo, SP, Brazil
| |
Collapse
|
10
|
Garcia LE, Parra N, Gaynor JJ, Baker L, Guerra G, Ciancio G. Clinical Outcomes Following Single vs. Multiple Vessel Living-Donor Kidney Transplantation: A Retrospective Comparison of 210 Patients. Front Surg 2021; 8:693021. [PMID: 34195224 PMCID: PMC8236516 DOI: 10.3389/fsurg.2021.693021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background: The use of living-donor kidney allografts with multiple vessels continues to rise in order to increase the donor pool. This requires surgeons to pursue vascular reconstructions more often, which has previously been associated with a higher risk of developing early post-transplant complications. We therefore wanted to investigate the prognostic role of using living-donor renal allografts with a single artery (SA) vs. multiple arteries (MA) at the time of transplant. Methods: We retrospectively analyzed a cohort of 210 consecutive living-donor kidney transplants performed between January, 2008 and March, 2019, and compared the incidence of developing postoperative complications and other clinical outcomes between SA vs. MA recipients. Results: No differences were observed between SA (N = 161) and MA (N = 49) kidneys in terms of the incidence of developing a postoperative (or surgical) complication, a urologic complication, hospital length of stay, delayed graft function, estimated glomerular filtration rate at 3 or 12 mo post-transplant, and graft survival. Conclusions: The use of live-kidney allografts with MA requiring vascular reconstruction shows excellent clinical outcomes and does not increase the risk of developing postoperative complications or other adverse outcomes when compared with SA renal allografts.
Collapse
Affiliation(s)
- Leonardo E Garcia
- Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Natalia Parra
- Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jeffrey J Gaynor
- Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States.,Departments of Surgery and Urology, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Lauren Baker
- Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Giselle Guerra
- Division of Nephrology, Department of Medicine, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gaetano Ciancio
- Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States.,Departments of Surgery and Urology, University of Miami Miller School of Medicine, Miami, FL, United States
| |
Collapse
|
11
|
Vincenzi P, Alvarez A, Gonzalez J, Guerra G, Ciancio G. Transplantation of 2-Month-Old En Bloc Pediatric Kidneys After a Complex Vascular Reconstruction - Traveling 2500 Miles to Get Transplanted: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931124. [PMID: 34016943 PMCID: PMC8147900 DOI: 10.12659/ajcr.931124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/14/2021] [Accepted: 04/05/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND En bloc pediatric kidneys (EBPK) are one potential solution to increase the number of organs available in the donor community, thus promoting transplantation of these allografts into adult recipients. However, EBPK transplantation has been traditionally considered suboptimal due to concerns for perioperative complications, mainly vascular thrombosis. We report an en bloc kidney transplantation using vascular grafts from another deceased donor to extend the EBPK aorta and vena cava and create a tension-free anastomosis with recipient external iliac vessels. CASE REPORT A pair of 2-month-old female en bloc kidneys weighting 6 kg were transplanted to a 30-year-old adult male. Prolonged cold ischemic time (CIT) was related to high refusal rate and long travel from Nevada to Miami. Prior to transplantation, the EBPK were connected to the LifePort Renal Preservation Machine® and deemed transplantable only after showing a significant improvement in perfusion parameters. Back-table reconstruction was conducted through an end-to-end anastomosis between an adult deceased donor common iliac artery and vein grafts to the inferior vena cava and aortic distal ends, respectively. The patient displayed immediate graft function (IGF) without any postoperative complications, showing a creatinine of 1.5 mg/dl at 4-month follow-up. CONCLUSIONS Use of renal preservation machine (RPM) and refined back-table reconstruction of these allografts are important tools to improve the significant discard rate and improve outcomes of EBPK.
Collapse
Affiliation(s)
- Paolo Vincenzi
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, U.S.A
| | - Angel Alvarez
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, U.S.A
| | - Javier Gonzalez
- Department of Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Giselle Guerra
- Department of Medicine, Division of Nephrology, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, U.S.A
| | - Gaetano Ciancio
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, U.S.A
- Department of Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, U.S.A
| |
Collapse
|
12
|
Ciancio G, Farag A, Gaynor JJ, Morsi M, Chen L, Burke GW. Midline Rotation of the Right Renal Hilum During Hand-Assisted Laparoscopic Living Donor Nephrectomy. JSLS 2021; 25:e2021.00018. [PMID: 34248334 PMCID: PMC8241287 DOI: 10.4293/jsls.2021.00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/OBJECTIVES Laparoscopic living donor nephrectomy (LLDN) of the right kidney is currently considered as part of standard of care; however, dealing with the renal hilum when performing ligation/division of its renal vessels is still a main concern. Here, we describe a simple-to-perform technique, i.e., flipping the fully mobilized right kidney to the midline so that the renal artery becomes anteriorly, which offers better visualization and easier dissection of the renal vessels (achieving maximized lengths) when performing hand-assisted LLDN of the right kidney. METHODS Living donors who underwent hand-assisted LLDN of the right kidney, along with their respective renal transplant recipients, were included in this report. Donor characteristics included renal artery and vein lengths; recipient characteristics included creatinine at months 12 - 36. Graft vein and arterial anastomosis data were also reported. RESULTS Nineteen living donors and 19 recipients, with median donor and recipient ages being 39 (24 - 60) and 53 (3 - 81) years, respectively, were included. None of the 38 patients had intra- or postoperative complications. Donor renal vein was anastomosed to the right external iliac vein (n = 16), right common iliac vein (n = 2), and inferior vena cava (n = 1). Gonadal vein (n = 1) and deceased donor iliac vein (n = 2) were used to increase the right renal vein length in 3 cases. Four donor kidneys had 2 arteries reconstructed side by side. None of the recipients developed any vascular or urological complications. CONCLUSIONS The laparoscopic technique described is safe and allows better visualization of the right hilum, mainly the renal artery, and helps in stapling the renal vein and renal artery.
Collapse
Affiliation(s)
- Gaetano Ciancio
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Ahmed Farag
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Jeffrey J Gaynor
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Mahmoud Morsi
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Linda Chen
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - George W Burke
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| |
Collapse
|
13
|
Farag A, Gaynor JJ, Serena G, Ciancio G. Evidence to support a drain-free strategy in kidney transplantation using a retrospective comparison of 500 consecutively transplanted cases at a single center. BMC Surg 2021; 21:74. [PMID: 33541328 PMCID: PMC7863357 DOI: 10.1186/s12893-021-01081-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/13/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Routine placement of surgical drains at the time of kidney transplant has been debated in terms of its prognostic value. Objectives To determine whether the placement of a surgical drain affects the incidence rate of developing wound complications and other clinical outcomes, particularly after controlling for other prognostic factors. Methods Retrospective analysis of 500 consecutive renal transplant cases who did not (Drain-free, DF) vs. did (Drain, D) receive a drain at the time of transplant was performed. The primary outcome was the development of any wound complication (superficial or deep) during the first 12 months post-transplant. Secondary outcomes included the development of superficial wound complications, deep wound complications, DGF, and graft loss during the first 12 months post-transplant. Results 388 and 112 recipients had DF/D, respectively. DF-recipients were significantly more likely to be younger, not have pre-transplant diabetes, receive a living donor kidney, receive a kidney-alone transplant, have a shorter duration of dialysis, shorter mean cold-ischemia-time, and greater pre-transplant use of anticoagulants/antiplatelets. Wound complications were 4.6% (18/388) vs. 5.4% (6/112) in DF vs. D groups, respectively (P = 0.75). Superficial wound complications were observed in 0.8% (3/388) vs. 0.0% (0/112) in DF vs. D groups, respectively (P = 0.35). Deep wound complications were observed in 4.1% (16/388) vs. 5.4% ((6/112) in DF vs. D groups, respectively (P = 0.57). Higher recipient body mass index and ≥ 1 year of pre-transplant dialysis were associated in multivariable analysis with an increased incidence of wound complications. Once the prognostic influence of these 2 factors were controlled, there was still no notable effect of drain use (yes/no). The lack of prognostic effect of drain use was similarly observed for the other clinical outcomes. Conclusions In a relatively large cohort of renal transplant recipients, routine surgical drain use appears to offer no distinct prognostic advantage.
Collapse
Affiliation(s)
- Ahmed Farag
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.,Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Surgery, Zagazig University School of Medicine, Zagazig, Egypt
| | - Jeffrey J Gaynor
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.,Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Giuseppe Serena
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, USA
| | - Gaetano Ciancio
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA. .,Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA. .,Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, USA. .,Department of Surgery and Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA. .,Miami Transplant Institute, 1801 NW 9th Ave, 7th Floor, Miami, FL, 33136, USA.
| |
Collapse
|