Laparoscopic versus open live donor nephrectomy: the first randomized clinical trial

Robotic versus laparoscopic versus open nephrectomy for live kidney donors

BACKGROUND

Waiting lists for kidney transplantation continue to grow. Live kidney donation significantly reduces waiting times and improves long-term outcomes for recipients. Major disincentives to potential kidney donors are the pain and morbidity associated with surgery. This is an update of a review published in 2011.

OBJECTIVES

To assess the benefits and harms of open donor nephrectomy (ODN), laparoscopic donor nephrectomy (LDN), hand-assisted LDN (HALDN) and robotic donor nephrectomy (RDN) as appropriate surgical techniques for live kidney donors.

SEARCH METHODS

We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing LDN with ODN, HALDN, or RDN were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Thirteen studies randomising 1280 live kidney donors to ODN, LDN, HALDN, or RDN were included. All studies were assessed as having a low or unclear risk of bias for selection bias. Five studies had a high risk of bias for blinding. Seven studies randomised 815 live kidney donors to LDN or ODN. LDN was associated with reduced analgesia use (high certainty evidence) and shorter hospital stay, a longer procedure and longer warm ischaemia time (moderate certainty evidence). There were no overall differences in blood loss, perioperative complications, or need for operations (low or very low certainty evidence). Three studies randomised 270 live kidney donors to LDN or HALDN. There were no differences between HALDN and LDN for analgesia requirement, hospital stay (high certainty evidence), duration of procedure (moderate certainty evidence), blood loss, perioperative complications, or reoperations (low certainty evidence). The evidence for warm ischaemia time was very uncertain due to high heterogeneity. One study randomised 50 live kidney donors to retroperitoneal ODN or HALDN and reported less pain and analgesia requirements with ODN. It found decreased blood loss and duration of the procedure with HALDN. No differences were found in perioperative complications, reoperations, hospital stay, or primary warm ischaemia time. One study randomised 45 live kidney donors to LDN or RDN and reported a longer warm ischaemia time with RDN but no differences in analgesia requirement, duration of procedure, blood loss, perioperative complications, reoperations, or hospital stay. One study randomised 100 live kidney donors to two variations of LDN and reported no differences in hospital stay, duration of procedure, conversion rates, primary warm ischaemia times, or complications (not meta-analysed). The conversion rates to ODN were 6/587 (1.02%) in LDN, 1/160 (0.63%) in HALDN, and 0/15 in RDN. Graft outcomes were rarely or selectively reported across the studies. There were no differences between LDN and ODN for early graft loss, delayed graft function, acute rejection, ureteric complications, kidney function or one-year graft loss. In a meta-regression analysis between LDN and ODN, moderate certainty evidence on procedure duration changed significantly in favour of LDN over time (yearly reduction = 7.12 min, 95% CI 2.56 to 11.67; P = 0.0022). Differences in very low certainty evidence on perioperative complications also changed significantly in favour of LDN over time (yearly change in LnRR = 0.107, 95% CI 0.022 to 0.192; P = 0.014). Various different combinations of techniques were used in each study, resulting in heterogeneity among the results.

AUTHORS' CONCLUSIONS

LDN is associated with less pain compared to ODN and has comparable pain to HALDN and RDN. HALDN is comparable to LDN in all outcomes except warm ischaemia time, which may be associated with a reduction. One study reported kidneys obtained during RDN had greater warm ischaemia times. Complications and occurrences of perioperative events needing further intervention were equivalent between all methods.

Laparoscopic Donor Nephrectomy in the Republic of North Macedonia

Introduction: Hand-assisted laparoscopic living donor nephrectomy has become the technique of choice for living donor kidney donations. Since 2018, 30 procedures have been performed at our clinic using this technique. The goal of this comparative analysis was to determine how surgical technique, specifically, hand-assisted laparoscopic living donor nephrectomy with hand assistance may affect early graft function when compared to open classical nephrectomy. Material and methods: Retrospective analyses were performed, comparing the two techniques of kidney donation. Kidney transplantation was performed with the open standard technique in both groups. The primary outcome was early graft function, and levels of urine output, and plasma creatinine were analyzed at three time points. A secondary outcome was the quality of the operative technique, which was determined by the time of warm ischemia, blood loss, and duration of surgery. Additionally, we noted all complications, length of hospital stay, and patient satisfaction. Results: In terms of warm ischemia time, there was no statistically significant difference between donors in both groups. It is important to note that in 2 recipients from Group II we did not observe diuresis at the conclusion of the operation. The recipients' diuresis was 515 ml ± 321SD in group I and 444 ml ± 271SD in group II. At 3, 12, and 36 hours postoperatively, there were statistically significant differences in the average serum creatinine values (p 0.05) in favor of group I. Similar results were observed in the second time measurement at 12 h and the third time measurement at 36 h for serum urea levels in recipients. The difference in serum urea values between the recipients in the groups at the first measurement (3h) following surgery was not statistically significant. Conclusion: Hand-assisted laparoscopic donor nephrectomy is recognized as a safe and effective treatment. Donors in this situation have a different profile from other surgical patients; hence, they do not undergo surgery due to their own medical condition but for an altruistic reason, and with hand-assisted living donor nephrectomy. Such patients receive all the advantages of minimally invasive surgery. The two main objectives of a donor nephrectomy are to give the recipient the best possible kidney and to ensure the donor's complete safety.

Surgical Approaches and Outcomes in Living Donor Nephrectomy: A Systematic Review and Meta-analysis

CONTEXT

The use of living kidney donors is increasing and there are several surgical approaches for donor nephrectomy but it remains unknown which procedure is optimal for the patient and the graft.

OBJECTIVE

To review different surgical techniques for living donor nephrectomy and compare complication rates, warm ischemia time, and delayed graft function.

EVIDENCE ACQUISITION

A systematic review of prospective studies involving surgical complications following living donor nephrectomy was conducted in the MEDLINE/PubMed and EMBASE databases according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Baseline data, perioperative and postoperative parameters, and postoperative complications are reported. Overall complication rates between surgical techniques were compared via analysis of variance with post hoc analysis. We included 35 studies involving 6398 patients and representing six different surgical procedures for living donor nephrectomy.

EVIDENCE SYNTHESIS

Hand-assisted laparoscopic donor nephrectomy had a significantly higher overall complication rate compared to open, laparoscopic, retroperitoneoscopic, and laparoendoscopic single-site techniques (p < 0.005). The complication rates were low and no mortality was observed. The main limitation was varying reporting of complications, with only one-third of the studies using the Clavien-Dindo classification.

CONCLUSIONS

No specific surgical approach seems superior in terms of complications, which were generally low. Different factors such as warm ischemia time, blood loss, and surgeon expertise define which surgical approach should be chosen.

PATIENT SUMMARY

We looked at the different surgical methods for removing the kidney from a living kidney donor. Overall, the different surgical techniques were similar in terms of complications and no donors died in the studies we reviewed. The choice of procedure depends on multiple factors such as the expertise of the surgeon and the surgical center.

Laparoscopic donor nephrectomy: technique and outcome, a single-center experience

Background

Laparoscopic donor nephrectomy (LDN) has been established as a surgical standard for living kidney donation. The aim of this work is to report our own experience with LDN regarding outcome and technique.

Methods

We prospectively identified 110 LDN cases between May 2017 and April 2020. Donor case files and operative notes were analyzed for age, sex, laterality, body mass index, warm ischemia time (WIT), intraoperative and postoperative complications, operative time, and length of hospital stay (LOS). Data were analyzed using SPSS version 10 (SPSS: An IBM Company, IBM Corporation, Armonk, NY, the USA).

Results

The mean age was 38 years, and 77% were males. Three cases (2.72%) required conversion to conventional open donor nephrectomy (ODN). Nevertheless, none of cases required intraoperative blood transfusion. The mean WIT was 2.6 min. Two cases (1.8%) developed major vascular injury (Clavien grade IIIb) and required conversion to ODN. Postoperatively, one patient (0.9%) needed transfusion of one unit of packed RBCs (Clavien grade II). The mean LOS was 2 days. Most common early postoperative complication was ileus (Clavien grade II) that developed in 4 (3.6%) cases. Incisional hernia (Clavien grade IIIb) was encountered in two (1.8%) cases. Two (1.8%) cases developed wound infection at the incision site and treated conservatively (Clavien grade I).

Conclusions

LDN is a safe technique with accepted intraoperative and postoperative morbidity. It offers short hospital stay, better cosmesis and early convalescence. In experienced hands, it can effectively deal with various vascular and ureteral anomalies without compromising early graft function.

Safe transition from open to pure laparoscopic donor nephrectomy: Approach and results

Introduction

Laparoscopic living donor nephrectomy (LLDN) offers many advantages compared to open living donor nephrectomy. However, the perceived difficulty in learning LLDN has slowed its wider implementation. Herein, we describe the evolution of LLDN at a single center, emphasizing the approach and technical modifications and its impact on outcome.

Methods

The series included a 2½-year period and three different surgeons. We started with two-stage plan for establishing LLDN at the institute (introduction and consolidation). Data of laparoscopic donor nephrectomy performed at the institution were prospectively evaluated regarding donor and recipient outcome.

Results

From December 2016 to April 2019, 221 donors underwent LLDN. Three donors required conversion to open surgery. The mean operation time was 96.4 (62-158) min and the mean warm ischemia time was 186 (149-423) s. The complications were observed in 11.6% of donors from LLDN group and all complications were Class I and Class II only (Clavien-Dindo classification). No Class III and Class IV complications occurred. In the present study, there was some learning curve effect observed only in operative time (OT) with longer OT in initial cases. However, the overall operative complications were minimal, showing that this learning curve had no deleterious effects on donor safety.

Conclusion

The present study demonstrates that with proper planning, team approach, and a few technical modifications, the transition from open to LLDN could be safe and effective.

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.

Evolution of Laparoscopic Donor Nephrectomy Techniques and Outcomes: A Single-Center Experience with More than 1000 Cases

Background

Laparoscopic donor nephrectomy (LDN) has evolved and has been established as a surgical standard of care for kidney transplantation.

Material/Methods

This study retrospectively reviews 1132 patients who underwent 4 different laparoscopic living-donor nephrectomies: hand-assisted laparoscopic nephrectomy (HALDN), pure laparoscopic donor nephrectomy (PLDN), laparoendoscopic single-site plus 1-port donor nephrectomy (LESSOP-DN), and mini laparoscopic donor nephrectomy (MLDN).

Results

The mean estimated blood loss (EBL) for the HALDN group was meaningfully higher than those of LESSOP-DN and MLDN (57.5±52.2 mL versus 21.0±30.0 mL versus 18.2±28.7 mL) (P<0.001). The EBL for PLDN (53.3±35.3 mL) was also significantly higher than those of LESSOP-DN and MLDN (P<0.001). Length of stay (LOS) for HALDN was longer than that for LESSOP-DN (4.2±1.2 day versus 4.0±1.4 days, P=0.002). There was 1 intraoperative open conversion in the HALDN group and 2 HALDN surgeries that required postoperative exploratory laparotomy. LESSOP-DN had 3 (0.8%) postoperative incisional hernias. For recipients, the results revealed no significant differences between all 4 groups in terms of estimated glomerular filtration rate (eGFR) and the 1-year graft failure rate.

Conclusions

The LESSOP-DN group was associated with a shorter incision length than those of HALDN and PLDN and shorter LOS than that of HALDN. Recipient results showed no meaningful difference regarding laparoscopic donor nephrectomy technique.

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.

Transition from laparoscopic to retroperitoneoscopic approach for live donor nephrectomy

BACKGROUND

Laparoscopic donor nephrectomy has become the standard of care due to multiple benefits. Currently, there are various techniques employed with two different approaches: transperitoneal (TLDN) or retroperitoneoscopic (RLDN) approach. There is a lack of data to determine which technique is superior, although the RLDN offers an anatomical advantage by avoidance of manipulation of the intraperitoneal organs. The aims of this study were to explore the merits of RLDN to TLDN and assess the learning curve of transition from TLDN to RLDN.

METHODS

From January 2010 to February 2017, 106 live donor nephrectomies were performed: 56 by TLDN and 50 by RLDN. Data on patient demographics, perioperative parameters, analgesic consumption, pain scores, and kidney graft function were collected and analysed. Data were compared with a Student's t test or Mann-Whitney test. A CUSUM analysis was performed to investigate the learning curve.

RESULTS

All live donor nephrectomies were successful with no conversion to open surgery. There was no blood transfusion, readmission, or mortality. No postoperative complications were graded over Clavien II. Kidney function was comparable in both groups. The follow-up period ranged from 3 to 78 months.

CONCLUSION

Retroperitoneoscopic live donor nephrectomy is a safe approach with comparable results to TLDN. RLDN has an anatomical advantage as it avoids manipulating the intraperitoneal organs and retains a virgin abdomen and hence translates to a lower perioperative complication risk.

Laparoscopic donor nephrectomy, complications and management: a single center experience

OBJECTIVE

To present our experience with laparoscopic donor nephrectomy (LDN), our complications and management modalities. Material and methods: Fifty-one transperitoneal LDNs performed in our clinic between the years 2011, and 2015, were evaluated retrospectively. Demographic characteristics of the patients, operative and postoperative data and complications were evaluated.

RESULTS

Nineteen female and 32 male patients with ages ranging from 24 to 65 years underwent left- (n=44), and right-sided (n=7) LDNs. Six patients had two, and one patient three renal arteries. Mean operation time was 115±11 (min-max: 90-150) minutes, and mean warm ischemia time 111±9 (min-max: 90-140 sec) seconds. Mean hospital stay was found to be 2.5±0.5 days. No patient needed to switch to open surgery. In one patient, lumbar vein was ruptured, and hemostatic control was achieved laparoscopically. Postoperative paralytic ileus developed in two patients. Three patients had postoperative atelectasis, and a febrile (38.1°C) episode.

CONCLUSION

LDN is a minimally invasive method with advantages of short hospital stay, less analgesic requirement, and better cosmetic results. However it should be performed by surgeons with advanced laparoscopic experience.

The role of laparoscopy and robotic surgery in the management of small renal masses

Increased utilization of cross-sectional abdominal imaging has led to a significant increase in the incidence of small renal masses. There is a growing body of literature suggesting that these lesions have a low malignant potential, thus supporting surveillance as a therapeutic option, particularly in the elderly population. Over the last decade, there has been an explosion of minimally invasive techniques for managing these lesions, including laparoscopic nephrectomy, laparoscopic partial nephrectomy, cryotherapy, radiofrequency ablation and, more recently, robotic-assisted surgery. The aim of this article is to review recent literature and assess the role of laparoscopic and robotic-assisted surgery in the management of small renal masses.

Laparoscopic versus open nephrectomy for live kidney donors

BACKGROUND

Waiting lists for kidney transplantation continue to grow and live organ donation has become more important as the number of brain stem dead cadaveric organ donors continues to fall. The major disincentive to potential kidney donors is the pain and morbidity associated with open surgery.

OBJECTIVES

To identify the benefits and harms of using laparoscopic compared to open nephrectomy techniques to recover kidneys from live organ donors.

SEARCH METHODS

We searched the online databases CENTRAL (in The Cochrane Library 2010, Issue 2), MEDLINE (January 1966 to January 2010) and EMBASE (January 1980 to January 2010) and handsearched textbooks and reference lists.

SELECTION CRITERIA

Randomised controlled trials comparing laparoscopic donor nephrectomy (LDN) with open donor nephrectomy (ODN).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary.

MAIN RESULTS

Six studies were identified that randomised 596 live kidney donors to either LDN or ODN arms. All studies were assessed as having low or unclear risk of bias for selection bias, allocation bias, incomplete outcome data and selective reporting bias. Four of six studies had high risk of bias for blinding. Various different combinations of techniques were used in each study, resulting in heterogeneity in the results. The conversion rate from LDN to ODN ranged from 1% to 1.8%. LDN was generally found to be associated with reduced analgesia use, shorter hospital stay, and faster return to normal physical functioning. The extracted kidney was exposed to longer warm ischaemia periods (2 to 17 minutes) with no associated short-term consequences. ODN was associated with shorter duration of procedure. For those outcomes that could be meta-analysed there were no significant differences between LDN or ODN for perioperative complications (RR 0.87, 95% CI 0.47 to 4.59), reoperations (RR 0.57, 95% CI 0.09 to 3.64), early graft loss (RR 0.31, 95% CI 0.06 to 1.48), delayed graft function (RR 1.09, 95% CI 0.52 to 2.30), acute rejection (RR 1.41, 95 % CI 0.87 to 2.27), ureteric complications (RR 1.51, 95% CI 0.69 to 3.31), kidney function at one year (SMD 0.15, 95% CI -0.11 to 0.41) or graft loss at one year (RR 0.76, 95% CI 0.15 to 3.85).

AUTHORS' CONCLUSIONS

LDN is associated with less pain compared with open surgery; however, there are equivalent numbers of complications and occurrences of perioperative events that require further intervention. Kidneys obtained using LDN procedures were exposed to longer warm ischaemia periods than ODN-acquired grafts, although this has not been reported as being associated with short-term consequences.

Laparoscopic animal surgery for training without sacrificing animals; introducing the rabbit as a model for infantile laparoscopy

INTRODUCTION

Improvement in laparoscopic skills requires practicing, and it is mostly beneficial when live animal models are considered for use. Apart from pelvic trainer, dogs and rabbits are used as the animal models for training laparoscopic surgeries at our center. Every effort is made to keep the animals alive after surgery.

MATERIALS AND METHODS

From January 2007 to January 2010, German shepherd dogs and Angora rabbits were selected as the animal models for laparoscopic skill training. Under general anesthesia, trainees performed several laparoscopic surgeries under the supervision of experienced surgeons.

RESULTS

A total number of 72 animals including 54 dogs and 18 rabbits were used for training laparoscopy. In total, some 107 different laparoscopic procedures were performed by trainees including nephrectomy, nephropexy, vesicotomy and vesicorrhaphy, vasectomies, spermatic cord ligation, and unilateral oophrectomy. There were one vascular and two visceral injuries in the rabbit model that were laparoscopically controlled, and conversion to open surgery happened in one case due to the failure in extracting the specimen from the abdominal cavity. Three visceral and six vascular injuries occurred in the canine model. Total mortality was five including three rabbits and two dogs.

CONCLUSIONS

The sacrifice of the animal is important to be avoided from both ethical and technical stand points. Dogs and rabbits are good models for laparoscopic training in urology, and it is possible to keep the animals alive after surgery by close monitoring. We also found the rabbit to be a good model for practicing infantile laparoscopic surgery, as it simulates the real surgery in this difficult age group.

Development of laparoscopic donor nephrectomy: a strategy to increase living kidney donation incentive and maintain equivalent donor/recipient outcome

BACKGROUND/PURPOSE

Laparoscopic donor nephrectomy (LDN) has emerged as the preferred technique worldwide, and has contributed to a dramatic increase in living kidney donation during the past decade. We adopted LDN in 2002 with the intention of increasing living kidney donation incentive and maintaining equivalent donor/recipient outcome.

METHODS

Forty-five LDNs were performed between September 2002 and November 2007. Donor demographics, operative characteristics, perioperative complications and donor/recipient outcome were reviewed retrospectively. The LDN series was divided into earlier and later groups for comparison. To confirm the safety and efficacy of LDN, we compared the results with those of previous series and our open donor nephrectomy (ODN) series.

RESULTS

All 45 LDN kidneys were procured and transplanted successfully. Mean donor operation time was 327.7+/-10.2 minutes, blood loss was 286.0+/-48.3 mL, and warm ischemia time was 233.9+/-19.6 seconds. Two (4.4%) open conversions happened in the earlier group. There was a significant decrease in warm ischemia time and donor intraoperative complications in the later group. There was no donor mortality and there were no repeat surgical procedures. Delayed graft function occurred in 8.9% of cases and three (6.7%) recipients developed ureteral complications. All but one recipient was discharged with adequate renal function. Graft function continued in 41 of the 43 harvested kidneys (95.3%). Compared with ODN, there was a significant decrease in donor postoperative stay in the LDN series (p=0.00). There was no difference between the series with regard to donor safety, donor outcome, and immediate and long-term recipient outcome.

CONCLUSION

The number of living kidney donations increased significantly after adopting LDN in our series. The equivalent donor/recipient outcome of the LDN series compared with that of previous and ODN series was achieved with increasing experience.

[Renal transplantation with living donors. A critical analysis of surgical procedures based on 40 years of experience]

INTRODUCTION

Absolute priority in an LDKT programme are donnor safety and kidney optimal anatomical and functional preservation. Reduced donnor morbidities, both at short and long term, are important objectives. Excellent technical grafting is a must as are the strategies employed for facilitatig it. We revised the incidences of our whole LDKT programme (40 years 243 donors) to confirm if these exigences have been acomplished or a change to new surgical procedures is recommended.

MATERIAL AND METHODS

Between 1968-2008 243 nephrectomies and grafting has been performed, a reduced number per year (A cadaver programme has been running simultaneously since 1964). For the nephrectomies a Turner-Warrick apprach was inititialy used and since 1973 a miniincisional, anterior, extraperitoneal approach of approximately 10 cm in length. The right kidney was removed in 75% of the cases and the right iliac area for the implant in 85% In adjacent opperating rooms, one team performs the nephrectomy while the other prepares and dissects free the grafting vessels. Most of the time the same senior surgeon performed both operatios: the nephrectomy and the implant. Peroperative and postoperative complications were evaluated by urologists and nephrologists in charge.

RESULTS

No donors dead, organs lost or major complications in the donors have been documented. Minor complications such as intestinal paresia, wound infection, persistent incisional pain were common. Miniincisional abdominal approach reduced postoperative pain and hospital stay (4 days). At long term no incisional hernia or abdominal paresia have been documented. Simultaneous work reduces ischemia time (30-45 s warm: 30-45 min cold) and opperatig room occupation(patient preparation plus anesthesia plus operation) estimated in 90-120 min for the nephrectomy and 120-160 for the grafting. The responsibility of the senior surgeon in both procedures facilitates vessel selection for the grafting.

CONCLUSIONS

No reasons have been found to reconvert our current nephrectomy procedure to laparoscopic or modify current surgical strategy. Superior safety of open surgery for donors and organs is confirmed. Pain and recovery time are reduced in laparoscopic surgery but not as much when compared with miniincisional approach. Open surgery permits optimal anatomical and functional organ extration facilitatig the quality of the implant. As numbers matter in laparoscopic surgery open nephrectomy is recommended for reduced LDKT programmes.

[Comparative analysis of renal graft function after open vs. laparoscopic nephrectomy: experimental model]

INTRODUCTION

Living donor renal transplant reports a higher patient and graft survival in comparison to cadaver donor and represents a good alternative facing the current lack of organs for transplant.

GOALS

To analyze comparatively in an experimental model (pig) the influence of ischemia-reperfusion and functional outcome of renal graft retrieved by open Vs laparoscopic nephrectomy.

MATERIAL AND METHODS

30 lab pigs were nephrectomized (left kidney): 15 by laparoscopy and 15 by open surgery, as living donors, in a model of renal autotransplant. Renal blood flow (RBF) was measured by means of an electromagnetic probe and creatinine levels during the first week after the implant.

RESULTS

Comparative analysis of RBF during the immediate 60 min after unclamping showed a significant reduction of average RBF in laparoscopic group in comparison to open group (p < 0.001), with a more evident reduction of RBF in the laparoscopic group during the 5-min period after unclamping (p < 0.001) and a progressive recuperation of RBF during the 1st hour, slowest in laparoscopic group. Creatinine levels in the first week after the transplant decreased progressively from 1.3 to 0.8 mgrs/dl in the open group and from 2 to 1.1 mg/dl in laparoscopic group (p < 0.001).

CONCLUSIONS

Renal grafts retrieved by laparoscopy presents a more evident ischemia-reperfusion syndrome shown by a lower average RBF after unclamping and a significant deterioration of renal function during the first week after transplant.

Open versus laparoscopic live donor nephrectomy: a focus on the safety of donors and the need for a donor registry

PURPOSE

A review of the existing literature showed that the subject of live donor nephrectomy is a seat of underreporting and underestimation of complications. We provide a systematic comparison between laparoscopic and open live donor nephrectomy with special emphasis on the safety of donors and grafts.

MATERIALS AND METHODS

The PubMed literature database was searched from inception to October 2006. A comparison was made between laparoscopic and open live donor nephrectomy regarding donor safety and graft efficacy.

RESULTS

The review included 69 studies. There were 7 randomized controlled trials, 5 prospective nonrandomized studies, 22 retrospective controlled studies, 26 large (greater than 100 donors), retrospective, noncontrolled studies, 8 case reports and 1 experimental study. Most investigators concluded that, compared to open live donor nephrectomy, laparoscopic live donor nephrectomy provides equal graft function, an equal rejection rate, equal urological complications, and equal patient and graft survival. Analgesic requirements, pain data, hospital stay and time to return to work are significantly in favor of the laparoscopic procedure. On the other hand, laparoscopic live donor nephrectomy has the disadvantages of increased operative time, increased warm ischemia time and increased major complications requiring reoperation. In terms of donor safety at least 8 perioperative deaths were recorded after laparoscopic live donor nephrectomy. These perioperative deaths were not documented in recent review articles. Ten perioperative deaths were reported with open live donor nephrectomy by 1991. No perioperative mortalities have been recorded following open live donor nephrectomy since 1991. Regarding graft safety, at least 15 graft losses directly related to the surgical technique of laparoscopic live donor nephrectomy were found but none was emphasized in recent review articles. The incidence of graft loss due to technical reasons in the early reports of open live donor nephrectomy was not properly documented in the literature.

CONCLUSIONS

We are in need of a live organ donor registry to determine the combined experience of complications and long-term outcomes, rather than short-term reports from single institutions. Like all other new techniques, laparoscopic live donor nephrectomy should be developed and improved at a few centers of excellence to avoid the loss of a donor or a graft.

[Laparoscopic nephrectomy in a living donor]

Kidney transplantation is the therapeutic option of choice for patients with end-stage renal disease. With the advent of safer harvesting techniques and immunosuppression, both donor and recipient outcomes have markedly improved in recent years. Kidney donation from Living donors remains the single most important factor responsible for improving patient and graft survival. The laparoscopic donor nephrectomy has revolutionized renal transplantation, allowing expansion of the donor pool by diminishing surgical morbidity while maintaining equivalent recipient outcome. This technique is now becoming the gold-standard harvesting procedure in transplant centres worldwide, despite its technical challenge and ongoing procedural maturation, especially early in the learning curve. Previous contraindications to laparoscopic donor nephrectomy are no longer absolute. In the following analysis, the procedural aspects of the laparoscopic donor nephrectomy are detailed including pre-operative assessment, operative technique and a review of the current literature delineating aspects of both donor and recipient morbidity and mortality compared with open harvesting techniques.

Transperitoneal laparoscopic live donor nephrectomy: Current status

Renal transplantation is the treatment of choice for a suitable patient with end stage renal disease. Unfortunately, the supply of donor organs is greatly exceeded by demand. In many countries the use of kidneys from living donors has been widely adopted as a partial solution. Traditionally donor nephrectomy has been performed via a open flank incision however with some morbidity like pain and a loin scar. Currently, the donor nephrectomy is increasingly being performed laparoscopically with the objective of reducing the morbidity. It is also hoped that this will lead to increasing acceptance of living donation. The first minimally invasive living donor nephrectomy was carried out in 1995 at the Johns Hopkins Medical Center and since then many centers have undertaken laparoscopic living donor nephrectomy. The laparoscopic approach substantially reduces the donor morbidity and wound related problems associated with open nephrectomy. The laparoscopic techniques thus have the potential to increase the number of living kidney donors. The present article attempts to review the safety and efficacy of transperitoneal laparoscopic donor nephrectomy.

Laparoscopic donor nephrectomy for pediatric recipient

INTRODUCTION

To present our outcome of laparoscopic donor nephrectomy for pediatric recipients, who may pose special challenges.

MATERIALS AND METHODS

Since March 2003, we performed more than 400 laparoscopic donor nephrectomies for 39 pediatric recipients (age less than 17 years of age). The preoperative, intraoperative, and postoperative data were reviewed to analyze the outcomes of these cases. We used the left kidney in 26 and the right kidney in 13 cases. Seven cases had double renal arteries, which were reconstructed on the bench.

RESULTS

The mean donor and recipient ages were 31 +/- 5 years and 13 +/- 4 years, respectively. The mean donor operative time was 2.1 hours (range 1.2 to 3.2). The warm ischemia time averaged 3 +/- 0.6 minutes. In 27 cases, we used the common iliac artery and common iliac vein for vascular anastomosis. In 12 cases, the anastomosis was performed to the aorta and vena cava. Seven patients had prior augmentation cystoplasty, and the ureter was anastomosed to the pouch directly. All grafts functioned immediately, with a mean creatinine at 24 hours of 1.5 +/- 0.3 mg/dL. At last follow-up (mean 13.6 months), the mean creatinine was 0.9 mg/dL. One patient lost the graft due to severe rejection that was resistant to antithymocyte globulin.

CONCLUSIONS

Laparoscopic donor nephrectomy for pediatric recipients is safe and provides quality organs with excellent function. Outcome is comparable to those after open donor nephrectomy.

Complications after a 5-year experience with laparoscopic donor nephrectomy: the Indiana University Experience

BACKGROUND

Laparoscopic donor nephrectomy (LDN) is becoming the standard of care for living donor nephrectomy. However, questions have been raised about the safety of LDN for the donor and about the potentially increased rates for ureteral complications experienced by the recipient. In this report, the authors review their 5-year experience with 253 living laparoscopic donor nephrectomies.

METHODS

A retrospective chart review was performed for 253 laparoscopic live donors. Graft function and survival were compared using recipient postoperative creatinine values up to 12 months.

RESULTS

The overall rate of complications in the investigated series was 10.3%. There were seven intraoperative complications (2.8%), three of which required open conversion. There were 19 postoperative complications (7.5%), three of which required reexploration for bleeding. The majority of complications were minor including 62% grade 1, 8% grade 2, 31% grade 3, and no grade 4 or 5 complications. There were no intraoperative complications in the right-sided donor group. There was a 5% complication rate for patients with a body mass index (BMI) exceeding 25. The findings showed that 11.2% of the recipients had slow graft function, and 4.4% had delayed graft function. Less than 1% of the recipients experienced ureteral stricture requiring permanent stent placement or reoperation. Overall, there was a 2% graft loss rate.

CONCLUSIONS

The findings show a low rate of intraoperative and postoperative complications, most of which were minor complications. There was an increase in operative time and hospital stay in the right-sided group, but no increase in complication rate. There was no significant difference in outcome or complication rate for the overweight patients.

Laparoscopic Donor Nephrectomy: Effects of Learning Curve on Surgical Outcomes

Our objective was to determine the effect of an experienced laparoscopic surgeon's learning curve with laparoscopic donor nephrectomy (LDN) on patient outcome and graft function.

MATERIALS AND METHODS

Retrospective review of the medical records of the initial 73 consecutive LDN patients and corresponding transplant recipients was performed. All of the LDN were performed by a single, experienced laparoscopic surgeon (C.P.S.). The method of LDN was slightly different between the groups.

RESULTS

Patients were divided into early and late groups with 37 and 36 patients, respectively. There was no statistically significant difference in mean estimated blood loss (245 +/- 671.2 vs 84.7 +/- 63.9 mL), warm ischemia time (159.7 +/- 66.3 vs 150.8 +/- 63.0 seconds), postoperative creatinine levels (1.34 +/- 0.24 vs 1.29 +/- 0.26 mg/dL,), recipient mean creatinine level at 1 month (1.57 +/- .98 vs 1.53 +/- 0.46 mg/dL), and hospital stay (2.49 +/- 0.87 vs 2.47 +/- 0.56 days) between the early and late groups. However, the difference in mean operative time between early and late groups was statistically significant (255.2 +/- 42.4 vs. 209.1 +/- 30.8 minutes, P < .05). In addition, there were 8 (21.6%) vs 4 (11.1%) instances of slow graft function and 3 (8.1%) vs 0 instances of delayed graft function among the recipients in early group versus the late group. There were four (10.8%) vs two (5.6%) minor complications among donors of the early and late groups, respectively.

CONCLUSION

There is a significant decrease in operating time and incidence of delayed graft function following the first 37 patients who underwent LDN by an experienced laparoscopist. Improvement in operative technique decreased operative time and improved perioperative graft function as evidenced by decreased slow graft function and delayed graft function in the late group.

Postoperative pain and convalescence in living kidney donors-laparoscopic versus open donor nephrectomy: a randomized study

The aim of the present study was to compare postoperative pain and convalescence in patients randomized to laparoscopic or open donor surgery in a prospective, controlled trial. The donors were randomly assigned to undergo laparoscopic (n = 63) or open (n = 59) donor nephrectomy. Our end points were amount of administered analgesics in the recovery period, postoperative pain on the second postoperative day and at one month after surgery and duration of sick leave. There was a significant difference in favor of the laparoscopic group regarding administered analgesics on day of surgery (p < 0. 02). No difference was observed between groups regarding self-reported pain on the second postoperative day. One month post donation, significantly fewer donors in the laparoscopic group reported pain (p < 0. 02) or had used analgesics (p < 0.05). The duration of sick leave was significantly shorter in the laparoscopic group (p = 0.01). The laparoscopic group experienced a more rapid convalescence and a shorter period of sick leave. Although immediate postoperative pain can be managed efficiently regardless of procedure, a lower consumption of opioids and incidence of pain in the convalescent period suggest a clinically relevant patient-experienced benefit from a successful laparoscopic procedure.

Pedicular Vascular Control in Laparoscopic Living Donor Nephrectomy: The Use of Clips Instead of Stapler in 341 Donors

PURPOSE

To demonstrate a less expensive approach for laparoscopic donor nephrectomy.

MATERIALS AND METHODS

Left donor nephrectomy was done transperitoneally in flank position. Renal vein and artery were exposed and prepared for nephrectomy. Nondisposable trocars and instruments were used. The adrenal vein was clipped and its arteries were bipolar coagulated. Both renal artery and vein were clip-ligated using three medium large nonautomatic metallic clips and divided, instead of using rather expensive vascular endostapler. Kidney was hand-extracted from suprapubic incision (no Endobag was used).

RESULTS

Donor nephrectomy was performed in 341 donors. Mean warm ischemia time was 8.17 minutes. Mean operative time was 260.3 minutes. Conversion and reoperation was required in 2.1% and 3.8% of donors, respectively. Ureteral complications were observed in 2.1% of recipients. No vascular accident occurred from pedicular vessels. One-year graft survival in recipients was 92.6%. By this approach, at least $600 was saved in each nephrectomy.

CONCLUSION

Laparoscopic donor nephrectomy can be performed with a less expensive setup without adverse effects on graft outcome. Vascular control using nonautomatic clips instead of more costly vascular endostapler and also hand extraction of the kidney is safe, practical, and economical.

Laparoscopic Right Nephrectomy Using a Novel Technique to Excise an Inferior Vena-Caval Cuff in a Porcine Model

BACKGROUND AND PURPOSE

Laparoscopic right nephrectomy has been performed using laparoscopic staplers to clamp and divide the renal vessels. In patients who have a tumor thrombus in the renal vein and in rightkidney donors, it is necessary to excise a cuff of the inferior vena cava (IVC) with the renal vein. We present a new technique for excising a cuff of the IVC and suturing it intracorporally using a new vascular clamp designed in our institution.

MATERIALS AND METHODS

The vascular clamp was designed to be completely inserted into the peritoneal cavity through the hand-port incision. The renal vein with a cuff of the IVC was then excised, and the defect in the IVC was sutured with a vascular stitch intracorporally. This procedure was performed in the animal laboratory using a porcine model.

RESULTS

A total of 20 hand-assisted right laparoscopic nephrectomies were performed. In the first five operations, the clamp dimensions and angles were modified until the ideal design was reached. In the next five operations, different suture materials and needle sizes were tried to find the best combination for the intracorporal IVC sutures. The first and second operations were not completed because of the difficulty in applying the initial version of the clamp to the IVC. In the 4th and 6th operations, bleeding occurred from the suture line: because of a missed stitch in the back wall of the IVC in one case and a needle stick to the IVC in the other case. The last 14 operations were successful without any bleeding or injuries. Suturing of the IVC was completed in 13 to 22 minutes.

CONCLUSION

Right hand-assisted laparoscopic nephrectomy with excision of a cuff of the IVC using an intracorporal vascular clamp is safe and reproducible in a porcine model. In our hands, a learning curve of 10 cases was required.

Laparoscopic donor nephrectomy

Of the various options for patients with end stage renal disease, kidney transplantation is the treatment of choice for a suitable patient. The kidney for transplantation is retrieved from either a cadaver or a live donor. Living donor nephrectomy has been developed as a method to address the shortfall in cadaveric kidneys available for transplantation. Laparoscopic living donor nephrectomy (LLDN), by reducing postoperative pain, shortening convalescence, and improving the cosmetic outcome of the donor nephrectomy, has shown the potential to increase the number of living kidney donations further by removing some of the disincentives inherent to donation itself. The technique of LLDN has undergone evolution at different transplant centers and many modifications have been done to improve donor safety and recipient outcome. Virtually all donors eligible for an open surgical procedure may also undergo the laparoscopic operation. Various earlier contraindications to LDN, such as right donor kidney, multiple vessels, anomalous vasculature and obesity have been overcome with increasing experience. Laparoscopic live donor nephrectomy can be done transperitoneally or retroperitoneally on either side. The approach is most commonly transperitoneal, which allows adequate working space and easy dissection. A review of literature and our experience with regards to standard approach and the modifications is presented including a cost saving model for the developing countries. An assessment has been made, of the impact of LDN on the outcome of donor and the recipient.

Laparoscopic versus Open Living-Donor Nephrectomy: Experiences from a Prospective, Randomized, Single-Center Study Focusing on Donor Safety

BACKGROUND

Very few randomized studies on laparoscopic (L) versus open (O) living-donor nephrectomy (LDN) have been presented. The largest randomized series reported so far included 80 donors. In 2000, an Australian safety group concluded that the evidence base for L-LDN is inadequate to make recommendations regarding safety and efficacy.

METHODS

With this background, at our single national center, 122 donors were randomized to left-sided L-LDN (n=63) or O-LDN (n=59), from February 2001 to May 2004. This article summarizes our experiences, in particular regarding complications and safety.

RESULTS

There were significant differences in favor of O-LDN regarding operative time, warm ischemia time, and vessel lengths, whereas the analgesic requirements and pain data were significantly in favor of the laparoscopic procedure. In the L-LDN group, there were five major postoperative complications resulting in reoperations (8%), including two intestinal perforations. No major complications occurred in the O-LDN group.

CONCLUSIONS

These results from our randomized study do suggest that conventional O-LDN is a very secure procedure, superior to L-LDN regarding donor safety. There has been an unacceptably high rate of reoperations in our L-LDN series but without mortality or significant sequelae. A careful look at some other L-LDN series also suggests increased morbidity/mortality. Our data do, however, support the view that a perfect, uncomplicated L-LDN appears to be the superior procedure, and the laparoscopic procedure is still evolving. Donor safety may be improved by avoiding obese donors, stapling of the renal artery (not clipping), and perhaps by hand assistance. Furthermore, we will consider the retroperitoneal approach.

Comparison of laparoscopic and open donor nephrectomy: a randomized controlled trial

Authors from Iran compare various outcomes between laparoscopic and open donor nephrectomy in kidney transplantation; they carried out a large comparative trial, and found that laparoscopic donor nephrectomy gave better donor satisfaction and morbidity, with equivalent graft outcome.

OBJECTIVE

To compare the graft survival, donor and recipient outcome, donor satisfaction, and complications of laparoscopic (LDN) and open donor nephrectomy (ODN) in kidney transplantation.

PATIENTS AND METHODS

In a randomized controlled trial, 100 cases each of LDN and ODN were compared. We modified the standard LDN procedure to make it less expensive.

RESULTS

The mean (sd) operative duration was 152.2 (33.9) min for ODN and 270.8 (58.5) min for LDN, and the mean duration of kidney warm ischaemia was 1.87 min for ODN and 8.7 min for LDN. Only one LDN required conversion to ODN because of bleeding. The mean follow-up in the LDN and ODN groups was not significantly different (406.1 vs 403.8 days). The mean (sd) score for donor satisfaction was 17.3 (3.5) for ODN and 19.6 (1.0) for LDN. The rate of ureteric complications was 2% for ODN and none for LDN. As determined by serum creatinine levels at 3, 21-30, 90, 180 and 365 days after surgery, graft function was not significantly different between ODN and LDN. Long-term graft survival was 93.8% for LDN and 92.7% for ODN.

CONCLUSIONS

Compared to ODN, LDN was associated with greater donor satisfaction, less morbidity and equivalent graft outcome.

New concepts in organ transplantation

Over the past several decades, many factors have led to higher rates of patient and graft survival in organ transplantation. These factors include enhanced immunosuppressants available in recent years such as Neoral, Prograf, sirolimus, mycophenolate mofetil and anti-interleukin-2 receptor monoclonal antibodies. In addition, other new drugs, such as FTY 720, FK 778, anti-CD20, anti-CD40, and anti-CH52 monoclonal antibodies, are now being tested in clinical studies. Furthermore, there have been advances in surgical techniques, such as the piggyback method without venovenous bypass, side-to-side anastomosis of the hepatic veins, use of vascular staplers, biliary duct-to-duct anastomosis with or without tube drainage, microsurgical hepatic artery anastomosis and laparoscopic donor nephrectomy. Finally, better patient and donor selection criteria with regard to HBV- and HCV-seropositive donors, diabetic donors, donors with malignancies, older donors, ABO-incompatible donors, and non-heart-beating donors have been combined with optimal timing of transplantation, better options for treating early surgical and late medical complications, and improved management in intensive-care units. Other noteworthy scientific and social development are on the horizon namely genetic advances in xenografting and cell transplantation, and induction of immunologic tolerance. This article reviews the current developments that have significantly improved graft and patient survival among solid-organ transplants.