Laparoendoscopic single-site donor nephrectomy (LESS-DN) versus standard laparoscopic donor nephrectomy

Minimally Invasive Laparoscopic Donor Nephrectomy With a Pfannenstiel Incision Using Size-Reduced Trocars

BACKGROUND

Laparoendoscopic single-site surgery is performed during laparoscopic donor nephrectomy (LDN) to reduce donor invasiveness. However, the procedure is difficult and does not improve cosmesis when the incision is made at the umbilicus. Therefore, we proposed a minimally invasive LDN with a Pfannenstiel incision using size-reduced trocars (mLDN) to achieve cosmesis and operability and aimed to assess its efficacy and safety.

METHODS

A total of 27 patients who underwent mLDN were recruited. Data on estimated blood loss, operative time, pneumoperitoneum time, warm ischemic time (WIT), complication rate, non-steroidal anti-inflammatory drugs (NSAIDs) used, and recipient serum creatinine levels were collected retrospectively. In mLDN, the Pfannenstiel position was incised to approximately 6 cm to retrieve the kidney, and three size-reduced trocars were placed in the left upper abdomen (2.5 mm and 5 mm) and umbilicus (5 mm).

RESULTS

The median operation time and pneumoperitoneum time were 245 and 194 minutes, respectively. The median WIT was 276 seconds, and the serum creatinine levels of the recipients at seven days and one, three, six, and 12 months were significantly improved compared with baseline. No intra- and postoperative complications (Clavien-Dindo grade ≥ 2) were observed, and no patients used additional NSAIDs after the operation. The scarring in the mLDN group was unnoticeable postoperatively.

CONCLUSIONS

mLDN can be performed safely, with high cosmesis, and with operability similar to that of conventional LDN. Although the WIT tended to be long, the function of the harvested kidney was maintained, and the use of analgesic NSAIDs was lower in this procedure. Our procedure should be considered as an option for LDN.

Laparoendoscopic Single-Site Surgery (LESS) for Right Donor Nephrectomy in a Patient With Situs Inverses Totalis: A Novel Approach for Such a Case

Situs inversus totalis (SIT) is a rare congenital condition where the organs of the thorax and abdomen are arranged in a mirror image reversal of their normal position. Patients with SIT present unique challenges in surgical procedures, particularly in laparoscopic surgeries, due to the need to reverse the operator's perspective, technical difficulty in handling the instruments, anatomical variations, and an increased risk of intraoperative complications. In this case report, we present the first case in the English literature of a 49-year-old Arabic male patient with SIT who underwent a successful right laparoendoscopic single-site surgery donor nephrectomy. We described the surgical technique used and highlighted the key challenges faced and overcome during the procedure.

Robotic Single-Port Donor Nephrectomy with the da Vinci SP® Surgical System

OBJECTIVES

The da Vinci SP® Surgical System received U.S. Food and Drug Administration approval for urological procedures in 2018. Here, we describe the first experience performing single-port robot-assisted donor nephrectomy (RADN) using the da Vinci SP® surgical system, present 90-day clinical outcomes, and discuss tips for operative success.

METHODS

Seven consecutive patients underwent single-port RADN at a single institution between September 1, 2020 and March 31, 2021. Surgery was performed through a single, 60 mm Pfannenstiel incision with a 12 mm periumbilical assistant port for suction and vascular stapling. Donor characteristics, operative details, 90-day donor clinical outcomes, and recipient renal function were retrospectively evaluated.

RESULTS

Four female and three male patients successfully underwent single-port RADN without conversion to standard multiport or open approach. Six cases were left-sided. Estimated blood loss for each procedure was ≤ 50 mL. Mean operative time, warm ischemia time, and extraction time were 218.3 minutes (standard deviation [SD]: 16.3 minutes), 5 minutes 4 seconds (SD: 56 seconds), and 3 minutes 37 seconds (SD: 38 seconds). Mean pre-operative creatinine and estimated glomerular filtration rate were 0.79 mg/dL and 107.3 mL/min/1.73m2, respectively. At six week's follow up, they were 1.22 mg/dL and 66.1 mL/min/1.73m2. Average pain score at 48 hours postoperatively was 1.7/10. There were no Clavien-Dindo grade ≥ III complications within 90 days. All recipients experienced immediate and sustained return of renal function post-transplant.

CONCLUSION

Single-port RADN is a technically feasible and safe procedure with the da Vinci SP® system and can confer acceptable functional and cosmetic outcomes. Future studies are needed to define long-term outcomes and compare with previously established techniques for donor nephrectomy.

Laparoendoscopic single-site simultaneous bilateral nephrectomy: first reported case series

Bilateral renal tumors in patients on dialysis are usually managed with bilateral nephrectomy. With traditional laparoscopy, this procedure requires the insertion of multiple trocars. Laparoendoscopic single-site surgery (LESS) uses a single umbilical incision to insert multiple instruments and is also employed for extraction of specimens. This technique appears especially useful for bilateral nephrectomy, since many access ports can be spared. We describe 5 cases of simultaneous bilateral radical nephrectomies performed at a single academic institution. We had no intraoperative complications and a mean operating time of 155 minutes. Four patients could be resected using this approach; one case was converted to a traditional laparoscopy. One case had a postoperative complication. We believe this technique is feasible, and can be accomplished with acceptable morbidity and ade-quate operative time.

Genetic analysis of endometriosis and depression identifies shared loci and implicates causal links with gastric mucosa abnormality

Evidence from observational studies indicates that endometriosis and depression often co-occur. However, conflicting evidence exists, and the etiology as well as biological mechanisms underlying their comorbidity remain unknown. Utilizing genome-wide association study (GWAS) data, we comprehensively assessed the relationship between endometriosis and depression. Single nucleotide polymorphism effect concordance analysis (SECA) found a significant genetic overlap between endometriosis and depression (P_{Fsig-permuted} = 9.99 × 10^-4). Linkage disequilibrium score regression (LDSC) analysis estimated a positive and highly significant genetic correlation between the two traits (r_G = 0.27, P = 8.85 × 10^-27). A meta-analysis of endometriosis and depression GWAS (sample size = 709,111), identified 20 independent genome-wide significant loci (P < 5 × 10^-8), of which eight are novel. Mendelian randomization analysis (MR) suggests a causal effect of depression on endometriosis. Combining gene-based association results across endometriosis and depression GWAS, we identified 22 genes with a genome-wide significant Fisher's combined P value (FCP_gene < 2.75 × 10^-6). Genes with a nominal gene-based association (P_gene < 0.05) were significantly enriched across endometriosis and depression (P_{binomial-test} = 2.90 × 10^-4). Also, genes overlapping the two traits at P_gene < 0.1 (P_{binomial-test} = 1.31 × 10^-5) were significantly enriched for the biological pathways 'cell-cell adhesion', 'inositol phosphate metabolism', 'Hippo-Merlin signaling dysregulation' and 'gastric mucosa abnormality'. These results reveal a shared genetic etiology for endometriosis and depression. Indeed, additional analyses found evidence of a causal association between each of endometriosis and depression and at least one abnormal condition of gastric mucosa. Our study confirms the comorbidity of endometriosis and depression, implicates links with gastric mucosa abnormalities in their causal pathways and reveals potential therapeutic targets for further investigation.

A comparison of laparoendoscopic single-site surgery versus conventional procedures for laparoscopic donor nephrectomy: a Japanese multi-institutional retrospective study

PURPOSE

Laparoendoscopic single-site donor nephrectomy (LESSDN) is a feasible and effective procedure because of its non-invasiveness and better cosmetic outcomes. However, there have been few multi-institutional studies conducted by multiple surgeons on LESSDN. We retrospectively compared the clinical data and outcomes between LESSDN and conventional laparoscopic donor nephrectomy (LDN) at multiple institutes in Japan.

MATERIALS AND METHODS

From 2009 to 2015, the clinical data of 223 donors who underwent LESSDN and 151 donors who underwent LDN were collected from 10 institutes. All LESSDNs were performed transperitoneally, whereas LDNs were performed transperitoneally (P-LDN) in 75 patients and retroperitoneally (R-LDN) in 76 patients.

RESULTS

In the LESSDN group, the single-incision site was pararectal in 155 (69.5%) patients and umbilical in 65 (29.1%) patients. Multiple surgeons (one to eight per institute) performed the LESSDN. No significant differences were observed between the three groups regarding estimated blood loss and warm ischemic time. The operative time was significantly shorter in the LESSDN group than in the R-LDN group (p = 0.018). No significant differences were observed regarding the rates of blood transfusion, open conversion, visceral injuries, and postoperative complications. Furthermore, no significant differences were observed regarding the dose of analgesic and the rate of delayed graft function. One patient required open conversion due to injury to the renal artery. Selection of LESS procedure was not an independent risk factor for the median serum creatinine level of above 1.27 mg/dL in recipients at 1 year after kidney transplantation.

CONCLUSION

The results showed the technical feasibility of LESSDN compared with the standard LDNs in a multi-institutional and multi-surgeon setting. A few observed non-negligible complications and the significantly higher levels of serum creatinine in patients who underwent LESSDN indicate that this procedure should be employed cautiously when performed by surgeons without ample experience in performing LESS procedures.

Laparoscopic renal surgery is here to stay

Objectives

To review the current literature comparing the outcomes of renal surgery via open, laparoscopic and robotic approaches.

Materials and methods

A comprehensive literature search was performed on PubMed, MEDLINE and Ovid, to look for studies comparing outcomes of renal surgery via open, laparoscopic, and robotic approaches.

Results

Limited good-quality evidence suggests that all three approaches result in largely comparable functional and oncological outcomes. Both laparoscopic and robotic approaches result in less blood loss, analgesia requirement, with a shorter hospital stay and recovery time, with similar complication rates when compared with the open approach. Robotic renal surgeries have not shown any significant clinical benefit over a laparoscopic approach, whilst the associated cost is significantly higher.

Conclusion

With the high cost and lack of overt clinical benefit of the robotic approach, laparoscopic renal surgery will likely continue to remain relevant in treating various urological pathologies.

Effectiveness of deep versus moderate muscle relaxation during laparoscopic donor nephrectomy in enhancing postoperative recovery: study protocol for a randomized controlled study

BACKGROUND

Postoperative recovery after live donor nephrectomy is largely determined by the consequences of postoperative pain and analgesia consumptions. The use of deep neuromuscular blockade has been shown to reduce postoperative pain scores after laparoscopic surgery. In this study, we will investigate whether deep neuromuscular blockade also improves the early quality of recovery after live donor nephrectomy.

METHODS

The RELAX-study is a phase IV, multicenter, double-blinded, randomized controlled trial, in which 96 patients, scheduled for living donor nephrectomy, will be randomized into two groups: one with deep and one with moderate neuromuscular blockade. Deep neuromuscular blockade is defined as a post-tetanic count of 1-2. Our primary outcome measurement will be the Quality of Recovery-40 questionnaire (overall score) at 24 h after extubation.

DISCUSSION

This study is, to our knowledge, the first randomized study to assess the effectiveness of deep neuromuscular blockade during laparoscopic donor nephrectomy in enhancing postoperative recovery. The study findings may also be applicable for other laparoscopic procedures.

TRIAL REGISTRATION

clinicaltrials.gov, NCT02838134 . Registered on 29 June 2016.

Single-incision laparoscopy surgery: a systematic review

Background

Laparoscopic surgery is a modern surgical technique in which operations are performed far from their location through small incisions elsewhere in the body.

Objective

This systematic review is aimed to overview single-incision laparoscopy surgery.

Methods

This systematic review was carried out by searching studies in PubMed, Medline, Web of Science, and IranMedex databases. The initial search strategy identified about 87 references. In this study, 54 studies were accepted for further screening and met all our inclusion criteria [in English, full text, therapeutic effects of single-incision laparoscopy surgery and dated mainly from the year 1990 to 2016]. The search terms were “single-incision,” “surgery,” and “laparoscopy.”

Results

Single-incision laparoscopy surgery is widely used for surgical operations in cholecystectomy, sleeve gastrectomy, cholecystoduodenostomy, hepatobiliary disease, colon cancer, obesity, appendectomy, liver surgery, rectosigmoid cancer, vaginal hysterectomy, vaginoplasty, colorectal lung metastases, pyloroplasty, endoscopic surgery, hernia repair, nephrectomy, rectal cancer, colectomy and uterus-preserving repair, bile duct exploration, ileo-ileal resection, lymphadenectomy, incarcerated inguinal hernia, anastomosis, congenital anomaly, colectomy for cancer.

Conclusion

Based on the findings, single-incision laparoscopy surgery is a scarless surgery with minimal access. Although it possesses lots of benefits, including less incisional pain and scars, cosmesis, and the ability to convert to standard multiport laparoscopic surgery, it has some disadvantages, for example, less freedom of movement, fewer number of ports that can be used, and the proximity of the instruments to each other during the operation.