Transperitoneal laparoscopic left versus right live donor nephrectomy: Comparison of outcomes

Right and left living donor nephrectomy and operative approach: A systematic review and meta-analysis of donor and recipient outcomes

INTRODUCTION

The left kidney is preferable in living donor nephrectomy (LDN). We aimed to investigate the safety and efficacy of right versus left LDN in both donor and recipients. A subgroup analysis of outcomes based on operative approach was also performed.

METHODS

A systematic review and meta-analysis was performed as per PRISMA guidelines. Outcomes of interest were extracted from included studies and analysed.

RESULTS

There were 31 studies included with 79,912 transplants. Left LDN was performed in 84.1 % of cases and right LDN in 15.9 %. Right LDN was associated with reduced EBL (P = 0.010), intra-operative complications (P = 0.030) and operative time (P = 0.006), but higher rates of conversion to open surgery (1.4 % vs 0.9 %). However, right living donor renal transplantation (LDRT) had higher rates of delayed graft function (5.4 % vs 4.2 %, P < 0.0001) and graft loss (2.6 % vs 1.1 %, P < 0.0001). Graft survival was reduced in right LDRT at 3 years (92.0 % vs 94.2 %, P = 0.001) but comparable to left LDRT at 1- and 5-years. Otherwise, donor and recipient peri-operative outcomes and serum creatinine levels were comparable in both groups. Hand-assisted LDN was associated with shorter warm ischaemia time (P < 0.0001) but longer length of stay (LOS) than laparoscopic LDN and robotic-assisted LDN (P < 0.0001). RA-LDN was associated with less EBL and shorter LOS (both P < 0.0001) while patients who underwent L-LDN had a lower mean serum creatinine (SCr) level on discharge (P < 0.0001).

CONCLUSION

Right LDRT has higher rates of delayed graft function and graft loss compared to left LDRT. Minimally-invasive surgical approaches potentially offer improved outcomes but further large-scale randomised controlled trials studies are required to confirm this finding.

Laparoscopic Live Donor Nephrectomy: Experience of High-Volume Center with 2,477 Cases

OBJECTIVE

Donors' health and safety are mandatory in the living-donor kidney transplantation procedure. Laparoscopic live donor nephrectomy (LLDN) provides an increase in donor numbers with its benefits and becomes a standard of care. We aimed to explain the results, complication rates, tips, and tricks of the largest number of LLDN case series ever performed in the literature.

MATERIALS AND METHODS

Between August 2012 and December 2019, 2,477 live donor case files were analyzed retrospectively. Age, gender, hospitalization times, body mass index, warm ischemia times, operation times, numbers of arteries, side of the kidneys, and complications were noted.

RESULTS

1,421 (57.4%) of 2,477 donors were female (p = 0.007). Operation times and warm ischemia times were found longer in right-sided LLDN and donors with multiple renal arteries (p = 0.046, <0.001, and <0.001, respectively). Obesity (BMI >30 kg/m2) did not affect warm ischemia times while prolonging the operation times (p = 0.013). Hospitalization times and numbers of complications were higher in obese donors.

CONCLUSIONS

LLDN seems to be a reliable solution with fewer complications and higher satisfaction rates. We hope to illuminate the way with tips and trick points for beginner transplant surgeons based on the experience obtained from 2,477 LLDN cases.

Laparoscopic living donor right nephrectomy: Assessment of outcome and association of BMI to length of right renal vein

AIMS

The aim of this study was to describe outcomes of laparoscopic living donor right nephrectomy (LLDRN) and study factors affecting the length of right renal vein from the donors.

MATERIAL AND METHODS

This study was conducted in 60 donors (48 males and 12 females) from January 2016 to December 2017. We performed a retrospective review of consecutive patients who underwent transperitoneal right laparoscopic living donor nephrectomy at our unit.

RESULTS

LLDRN was successfully performed in all subjects by the same surgeons. Among 60 cases, 47 donors had single renal artery and vein, 2 cases had one artery and 2 veins, and 5 donors had 2 arteries and one vein, and the rest had 2-3 arteries with 1-3 veins. Operative time was 142.60±33.73min. Warm ischemic time was 2.64±0.76min. The mean hospital stay was 6.69±0.63 days. The median length of right renal vein was 1.92±0.41cm. All transplanted kidneys showed immediate function. No graft losses were recorded. Almost no gender differences were found in study variables except BMI and warm ischemic time, that was higher BMI but shorter warm ischemic time in female versus male donors. Further analysis showed a negative correlation between BMI and right renal vein (r=-0.282, P<0.05), but a positive correlation between operative time and estimate blood loss (r=0.37, P<0.01).

CONCLUSIONS

LLDRN is a feasible safe procedure, less traumatic approach, and provides good outcomes kidney for recipients. Notably, in the study group the higher BMI was associated with resulting more difficult LLDRN and kidney transplantation.

Chylous Ascites: Complication of Laparoscopic Donor Nephrectomy. Case Report and Review of Literature

BACKGROUND

Chylous ascites (CA) is an extremely rare complication after laparoscopic donor nephrectomy (LDN). It can increase the hospital stay, morbidity in postoperative period and thus negating the benefits of laparoscopic surgery. Most of the cases were managed conservatively, but surgical intervention may be occasionally required. This report describes the importance of accurate localization of the leaking chyle duct and its repair by endosuturing in a renal donor not responding to conservative treatment.

METHODS

A comprehensive review of literature regarding this rare complication after LDN was performed with Pubmed/Medline and Google Scholar using "chyle," "complications," and "laparoscopic donor nephrectomy" as keywords. The demographic profile and management of patients is discussed in detail. The various surgical modalities used to manage these patients are described.

RESULTS

Fifty-four cases of chyle leak/ascites have been reported after LDN in literature to date. Around 77% donors with CA could be successfully managed conservatively with dietary measures and total parenteral nutrition. Surgical intervention was required in nearly 23% donors ranging from clip application, use of argon coagulation, endosuturing with application of glue after 36.1 ± 19.07 days of failed conservative treatment. Donors with massive ascites or requiring frequent large-volume paracentesis on conservative treatment are likely to require surgical therapy. The present case was successfully managed with laparoscopic endosuturing and has no recurrence at 6 month follow-up.

CONCLUSIONS

Chylous ascites is a rare complication after donor nephrectomy in experienced centers. Although conservative management remains the first line of treatment, early surgical treatment shall be undertaken in cases of massive ascites.

Comparison of Both Sides for Retroperitoneal Laparoscopic Donor Nephrectomy: Experience From a Single Center in China

BACKGROUND

Laparoscopic donor nephrectomy (LDN) has gradually become the main approach to obtain live donor kidneys. However, the shorter right renal vein limits its wider application. The aim of this study was to compare the outcomes of left- and right-side retroperitoneal LDN.

METHODS

We reviewed the perioperative data of 527 consecutive donors receiving retroperitoneal pure LDN with a new method at our center between April 2009 and April 2014. The patients were divided into group A (the first 100 patients) and group B (the remaining 427 patients). A total of 423 cases of left donor surgery and 104 cases of right donor surgery were compared. The comparison of the laterality of LDN was also performed between group A and group B.

RESULTS

This is currently the largest case series of LDN in our country. Although right-side LDN patients had longer operation time and a slightly higher incidence of intraoperative complications compared with left-side LDN patients, the operation time was shorter in both the groups compared with previous reports. In group B, patients undergoing right-side LDN had longer operation time and more frequent complications. Once the learning curve of 100 cases was completed, the incidence of complications and operation time were greatly reduced in both sides for LDN. There was no significant difference in the serum creatinine levels in recipients at 6 months of follow-up.

CONCLUSIONS

Despite a slightly higher incidence of complications and longer operation time, right-side LDN can achieve equally safe and effective transplantation outcomes. This expands the source of potential donor kidneys.

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.