Risk factors for perioperative complications in hand-assisted laparoscopic donor nephrectomy

Cost-effectiveness of four living-donor nephrectomy techniques from a hospital perspective

BACKGROUND

In Europe, transplantation centres use different nephrectomy techniques: open surgery, and standard, hand-assisted and robot-assisted laparoscopies. Few studies have analysed the disparity in costs and clinical outcomes between techniques. Since donors are healthy patients expecting minimum pain and fast recovery, this study aimed to compare the cost-effectiveness of four nephrectomy techniques focusing on early surgical outcomes, an essential in the donation act.

METHODS

A micro-costing approach was used to estimate the cost of implementation from a hospital perspective. Estimates took into account sterilization costs for multiple-use equipment, costs for purchasing single-use equipment, staff and analgesics. The study recruited donors in 20 centres in France. Quality of life by EuroQol-5D was assessed preoperatively, and 4 and 90 days post-operatively. Two effectiveness indicators were built: quality-of-life recovery and post-operative pain days averted (PPDA). The study was registered at ClinicalTrials.gov NCT02830568, on 10 June 2010.

RESULTS

A total of 264 donors were included; they underwent open surgery (n = 65), and standard (n = 65), hand-assisted (n = 65) and robot-assisted laparoscopies (n = 69). Use of the nephrectomy techniques differed greatly in cost of implementation and immediate post-operative outcomes but not in clinical outcomes at 90 days. At 4 days, hand-assisted laparoscopy provided the lowest cost per quality-of-life recovery unit of effectiveness (%) and PPDA (days) (€2056/40.1%/2.3 days, respectively). Robot-assisted laparoscopy was associated with the best post-operative outcomes but with the highest cost (€3430/59.1%/2.6 days).

CONCLUSION

Hand-assisted, standard and robot-assisted laparoscopies are cost-effective techniques compared with open surgery. Hand-assisted surgery is the most cost-effective procedure. Robot-assisted surgery requires more healthcare resource use but enables the best clinical outcome.

The Association between Body Composition Measurements and Surgical Complications after Living Kidney Donation

Obesity is considered a risk factor for peri- and postoperative complications. Little is known about this risk in overweight living kidney donors. The aim of this study was to assess if anthropometric body measures and/or surgical determinants are associated with an increased incidence of peri- and postoperative complications after nephrectomy. We included 776 living kidney donors who donated between 2008 and 2018 at the University Medical Center Groningen. Prenephrectomy measures of body composition were body mass index (BMI), body surface area (BSA), waist circumference, weight, and waist-hip ratio. Incidence and severity of peri- and postoperative complications were assessed using the Comprehensive Complication Index. Mean donor age was 53 ± 11 years; 382 (49%) were male, and mean BMI at donor screening was 26.2 ± 3.41 kg/m2. In total, 77 donors (10%) experienced peri- and postoperative complications following donor nephrectomy. Male sex was significantly associated with fewer surgical complications (OR 0.59, 0.37-0.96 95%CI, p = 0.03) in binomial logistic regression analyses. Older age (OR: 1.03, 1.01-1.05 95%CI, p = 0.02) and a longer duration of surgery (OR: 1.01, 1.00-1.01 95%CI, p = 0.02) were significantly associated with more surgical complications in binomial logistic regression analyses. Multinomial logistic regression analyses did not identify any prenephrectomy measure of body composition associated with a higher risk of surgical complications. This study shows that higher prenephrectomy BMI and other anthropometric measures of body composition are not significantly associated with peri- and postoperative complications following living donor nephrectomy.

Hand-assisted laparoscopic nephrectomy in a high risk overweight donor with left-sided IVC, and previous abdominal surgery

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Surgical planning based on preoperative CTA is necessary in patients with vascular anomalies in order to avoid complications.

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Intrabdominal adhesions are common in patients with previous abdominal surgery and can affect the surgical approach for donor nephrectomy.

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Considering the extension of the donor eligibility criteria, it is expected to see cases with congenital vascular anomalies.

Introduction

The extension of donor eligibility criteria represents one of the possible ways to increase the organ shortage, thus decreasing the waiting time for kidney transplantation. Expectedly, this strategy is associated with a growing number of more technically demanding living donor nephrectomy procedures requiring careful assessment, and sound surgical experience in order to avoid intraoperative complications.

Case presentation

After a thorough evaluation through preoperative imaging, we performed a hand-assisted left laparoscopic living donor nephrectomy in a 56 year-old overweight patient with history of prior abdominal surgery, harboring a left-sided inferior vena cava (IVC).

Discussion/conclusion

This case describes our comprehensive approach in this complex surgical scenario to preserve donor safety and provide an optimal kidney graft.

Perioperative Complications During Living Donor Nephrectomy: Results From a Multicenter Cohort Study

BACKGROUND

While living kidney donation is considered safe in healthy individuals, perioperative complications can occur due to several factors.

OBJECTIVE

We explored associations between the incidence of perioperative complications and donor characteristics, surgical technique, and surgeon's experience in a large contemporary cohort of living kidney donors.

DESIGN

Living kidney donors enrolled prospectively in a multicenter cohort study with some data collected retrospectively after enrollment was complete (eg, surgeon characteristics).

SETTING

Living kidney donor centers in Canada (n = 12) and Australia (n = 5).

PATIENTS

Living kidney donors who donated between 2004 and 2014 and the surgeons who performed the living kidney donor nephrectomies.

MEASUREMENTS

Operative and hospital discharge medical notes were collected prospectively, with data on perioperative (intraoperative and postoperative) information abstracted from notes after enrollment was complete. Complications were graded using the Clavien-Dindo system and further classified into minor and major. In 2016, surgeons who performed the nephrectomies were invited to fill an online survey on their training and experience.

METHODS

Multivariable logistic regression models with generalized estimating equations were used to compare perioperative complication rates between different groups of donors. The effect of surgeon characteristics on the complication rate was explored using a similar approach. Poisson regression was used to test rates of overall perioperative complications between high- and low-volume centers.

RESULTS

Of the 1421 living kidney donor candidates, 1042 individuals proceeded with donation, where 134 (13% [95% confidence interval (CI): 11%-15%]) experienced 142 perioperative complications (55 intraoperative; 87 postoperative). The most common intraoperative complication was organ injury and the most common postoperative complication was ileus. No donors died in the perioperative period. Most complications were minor (90% of 142 complications [95% CI: 86%-96%]); however, 12 donors (1% of 1042 [95% CI: 1%-2%]) experienced a major complication. No statistically significant differences were observed between donor groups and the rate of complications. A total of 43 of 48 eligible surgeons (90%) completed the online survey. Perioperative complication rates did not vary significantly by surgeon characteristics or by high- versus low-volume centers.

LIMITATIONS

Operative and discharge reporting is not standardized and varies among surgeons. It is possible that some complications were missed. The online survey for surgeons was completed retrospectively, was based on self-report, and has not been validated. We had adequate statistical power only to detect large effects for factors associated with a higher risk of perioperative complications.

CONCLUSIONS

This study confirms the safety of living kidney donation as evidenced by the low rate of major perioperative complications. We did not identify any donor or surgeon characteristics associated with a higher risk of perioperative complications.

TRIAL REGISTRATIONS

NCT00319579: A Prospective Study of Living Kidney Donation (https://clinicaltrials.gov/ct2/show/NCT00319579)NCT00936078: Living Kidney Donor Study (https://clinicaltrials.gov/ct2/show/NCT00936078).