Laparoscopic live donor right nephrectomy: a new technique with preservation of vascular length

Does the Side Matter? A Retrospective Cohort Study Comparing Left and Right Pure Laparoscopic Donor Nephrectomies

OBJECTIVES

Right laparoscopic donor nephrectomy (RLDN) is no longer regarded inferior to left LDN (LLDN). However, this knowledge is based on many studies suffering from inherent learning curves, center-specific imbalances, and different laparoscopic techniques.

METHODS

Pure LDNs at a high-volume referral center from 2011 to 2016 were retrospectively analyzed. Patient, graft characteristics, outcomes of LDNs, and corresponding open kidney transplantations were compared between LLDN and RLDN including a follow-up.

RESULTS

160 (78.4%) LLDNs and 44 (21.6%) RLDNs only differed regarding graft characteristics, as more right grafts had multiple veins (34.1 vs. 6.9%, p < 0.001) and worse scintigraphic function (44 vs. 51%, p < 0.001). RLDNs were shorter (201 vs. 220 min, p = 0.032) with longer warm ischemia time (165 vs. 140 s, p < 0.001), but left grafts were transplanted faster (160 vs. 171 min, p = 0.048). Recipients of right kidneys had more postoperative complications (grade 3: 25.6 vs. 11.3%, p = 0.020). At a follow-up of 45 (range 6-79) months, neither the kidney function, nor death-censored graft (5-year: LLDN 89 vs. 92%, p = 0.969) and patient survival (5-year: LLDN 95 vs. 98%, p = 0.747) differed.

CONCLUSIONS

Pure LLDN and RLDN can have different outcomes at high-volume centers, especially higher complications for recipients of right grafts. However, long-term function and graft survival are the same irrespective of the chosen side.

Open Management of the Renal Vein Is a Safe Modification in Right-Sided Laparoscopic Living Donor Nephrectomy to Maximize Graft Vein Length

BACKGROUND

The primary objective in living donor kidney transplantation is donor safety. In laparoscopic living donor nephrectomy, most centers prefer the left kidney for donation given the shorter renal vein, higher rate of thromboses, and more difficult surgical procedure for right kidney retrieval. The goal of this study was to demonstrate the feasibility of a hybrid technique using a Satinsky clamp in right-sided living donor nephrectomy to obtain maximal renal vein and to compare the outcome with standard left-sided laparoscopic donor nephrectomies.

MATERIAL AND METHODS

Between 2005 and 2013, 77 patients underwent a left (group L) and 54 a right (group R) living donor nephrectomy. In group R, after laparoscopic dissection and mobilization of the right kidney, two 12-mm trocar incisions in the right upper quadrant were connected in a 5-7 cm subcostal incision. The caval vein was partially clamped under direct vision prior to dissection of the renal vein. The venotomy was then closed with a running 4-0 Prolene suture. The two groups were compared with regard to surgical complications, graft function, and graft survival.

RESULTS

Using this technique, no significant difference with regard to complications or graft function was observed. Serum creatinine at discharge in donor group L was 1.23 (±0.43) mg/dL and in donor group R 1.21 (±0.37) mg/dL (P = .71). Graft survival at one year was 100% in both groups.

CONCLUSION

Open management of the renal vein is a safe alternative in laparoscopic right-sided donor nephrectomy and ensures maximal length of the vein.

Right-sided transperitoneal hand-assisted laparoscopic donor nephrectomy: is there an issue with the renal vessels?

OBJECTIVE

Short right renal vessels might complicate kidney transplantation, thus causing traction and difficulties during anastomosis. Single-center prospective comparison of right- and left-sided transperitoneal hand-assisted laparoscopic donor nephrectomy (HALDN) is presented.

PATIENTS AND METHODS

Eighty-two living kidney donors underwent HALDN between 2003 and 2008. Right-sided HALDN was performed in 46 living kidney donors. The operative technique of right-sided HALDN was modified to obtain the maximum length of right renal vessels. Outcome data in donors including quality of life as well as graft outcome in recipients were prospectively collected.

RESULTS

All procedures were laparoscopically completed with no conversion. Mean operative time was 127 minutes (vs. 138 minutes in left HALDN, p = 0.08). The mean warm ischemia time was 41 seconds (vs. 39 seconds in left HALDN, p = 0.23). There was no renal artery or vein thrombosis in any of the grafts. Mean blood loss was 81 mL (vs. 92 mL in left HALDN, p = 0.09). Hospital discharge was on an average of 3.6 days postoperative. Delayed graft function occurred in two recipients: one in the left group and the other in the right group. One-year graft survival rate was 95% in the left group versus 96.9% in the right group (p = 0.08). Further, no statistically significant difference in serum levels of creatinine was seen between the groups 1 year after the transplantation.

CONCLUSIONS

Right HALDN is technically safe and feasible and results in convenient extension of right renal vessels to full length with no increased incidence of vascular thrombosis.

Laparoscopic donor nephrectomy

Laparoscopic live donor nephrectomy (LDN) has removed disincentives of potential donors and may bear the potential to increase kidney donation. Multiple modifications have been made to abbreviate the learning curve while at the same time guarantee the highest possible level of medical quality for donor and recipient. We reviewed the literature for the evolution of the different LDN techniques and their impact on donor, graft and operating surgeon, including the subtleties of different surgical accesses, vessel handling and organ extraction. We performed a literature search (PubMed, DIMDI, medline) to evaluate the development of the LDN techniques from 1995 to 2003. Today more than 200 centres worldwide perform LDN. Hand-assistance has led to a spread of LDN. Studies comparing open and hand-assisted LDN show a reduction of operating and warm ischaemia times for the hand-assisted LDN. Different surgical access sites (trans- or retroperitoneal), different vessel dissection approaches, donor organ delivery techniques, delivery sites and variations of hand-assistance techniques reflect the evolution of LDN. Proper techniques and their combination for the consecutive surgical steps minimize both warm ischaemia time and operating time while offering the donor a safe minimally invasive laparoscopic procedure. LDN has breathed new life into the moribund field of living kidney donation. Within a few years LDN could become the standard approach in living kidney donation. Surgeons working in this field must be trained thoroughly and well acquainted with the subtleties of the different LDN techniques and their respective advantages and disadvantages.

Laparoscopic donor nephrectomy

Since it first was performed in 1995, laparoscopic donor nephrectomy (LDN) has grown to be the standard of care in most transplant centers in the United States. This article reviews the current indications, selection criteria, surgical approaches, outcomes, and complications of LDN.

Novel Technique for Hand Assisted Laparoscopic Right Donor Nephrectomy

PURPOSE

Most surgeons divide the renal vein with a laparoscopic stapler during laparoscopic donor nephrectomy. The right renal vein is usually shorter than the left one and using the stapler on the right side can result in a higher incidence of vascular complications for right kidney recipients. We present our experience with a new technique for hand assisted laparoscopic right donor nephrectomy.

MATERIALS AND METHODS

We designed a new vascular clamp to be completely inserted into the peritoneal cavity through the hand port incision in hand assisted laparoscopy. The renal vein with a cuff of the inferior vena cava was then excised. The defect in the inferior vena cava was sutured intracorporeally.

RESULTS

A total of 80 kidney donors underwent hand assisted laparoscopic right donor nephrectomy using the new technique. Mean +/- SD operative time was 184 +/- 36 minutes. Operative time was decreased in the last 30 patients to 152 +/- 22 minutes. Intracorporeal suture time on the inferior vena cava was 16 +/- 3 minutes. No intraoperative complications were noted and there was no partial or total graft loss. Mean blood loss was 50 +/- 35 cc. Mean warm ischemia time was 4 +/- 2 minutes. Hospital discharge was on postoperative day 1 or 2 in 81% of patients. Graft function was normal in 78 recipients with a day 5 postoperative serum creatinine of 1.6 +/- 0.9 mg/dl. Two recipients showed delayed graft function and were treated medically.

CONCLUSIONS

This technique for hand assisted laparoscopic right donor nephrectomy has proved to be safe and reproducible. We recommend practicing laparoscopic inferior vena cava suturing in the animal laboratory before performing it in humans.

Right laparoscopic donor nephrectomy and the use of inverted kidney transplantation: an alternative technique

OBJECTIVES

To report a novel approach to overcome the problems associated with a short right renal vein harvested by clipping the vein during right laparoscopic donor nephrectomy (RLDN).

PATIENTS AND METHODS

This prospective study included 32 donors and their recipients; all donors had transperitoneal RLDN. The right renal artery and vein were ligated by Hem-o-lok and titanium clips, which resulted in a very short renal vein (<1.5 cm). When the kidney was positioned inverted in the recipient, the renal vein was placed posteriorly, adjacent to the external iliac vein, making a safe and simple venous anastomosis possible.

RESULTS

All RLDN were completed with no conversion or re-operation. The mean (range) warm ischaemia time was 9.59 (3-17) min and there was no malfunction of the vascular clips on the major vessels. After a mean follow-up of 14 months the recipient survival rate was 97%. Graft function was excellent, with a mean (sd) serum creatinine level of 1.35 (0.31) mg/dL at 3 months after surgery, and there was no renal artery or vein thrombosis in any of the grafts. There were two ureteric complications (6%), i.e. one ureterocutaneous fistula resolved by secondary ureteroureterostomy, and one stricture at the site of ureteric anastomosis, which was managed by ureteroneocystostomy.

CONCLUSION

The right renal vein obtained by LDN, after clipping the renal vein, is quite short, but by placing the kidney upside-down in the right iliac fossa transplantation is possible with no increased incidence of vascular thrombosis. This simple modification might obviate the need for removing a patch from the inferior vena cava, which is a challenging procedure for laparoscopic surgeons during RLDN.

[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.

Right laparoscopic donor nephrectomy: The Washington Hospital Center experience

OBJECTIVES

To review 167 consecutive laparoscopic living donor nephrectomies performed at the Washington Hospital Center to determine whether the side of extraction, right versus left, affects the operative outcomes.

METHODS

From January 2003 to June 2005, 167 consecutive patients (127 left and 40 right) underwent laparoscopic living donor nephrectomy. The right-sided and left-sided procedures were compared in the following categories: operative time, warm ischemia time, length of stay, and complications.

RESULTS

The mean operative time for a right donor nephrectomy was 220 minutes versus 228 minutes for a left. The mean estimated blood loss was 115 mL for right donor nephrectomy versus 106 mL for the left. The corresponding mean warm ischemia times were 5.32 minutes and 4.91 minutes. The median length of stay was 3 days in both groups. Five minor and three major complications occurred, including 2 patients with recognized bowel injuries and 1 patient who required reoperation for a bladder injury.

CONCLUSIONS

Historically, laparoscopic living donor nephrectomy has been performed solely on the left side because of the increased length of the left renal vein. However, in our experience, the operative parameters and postoperative results were equivalent in the right and left laparoscopic donor nephrectomy groups. Therefore, we recommend removal of the more appropriate kidney, regardless of side.

Laparoscopy for living donor nephrectomy - particularities of the currently applied techniques

Today, laparoscopic donor nephrectomy (LDN) in many centers features the standard approach for kidney retrieval in living donors. More than 60% of the centers in the USA currently perform LDN and numbers are rising in Europe as well. Today's variety of laparoscopic approaches reflects the evolution in the field of LDN. Multiple modifications have been made for the laparoscopic approach, with consequences for intraoperative handling of the kidney, operating and ischemic times and with impact on donor, organ, and recipient. We reviewed the literature from 1995 to 2004 and critically evaluated the different technical modifications, their specific advantages and disadvantages and their impact for the operation. The article aims to help the surgeon choose the technique he feels most safe with for performing laparoscopic kidney retrieval safely and with good results for donor and recipient.

Comparison of Nonabsorbable Polymer Ligating and Standard Titanium Clips with and without a Vascular Cuff

PURPOSE

To compare the efficacy of nonabsorbable polymer ligating (NPL) and titanium clips applied with and without a 1-mm vascular cuff at physiologic and supraphysiologic pressures.

MATERIALS AND METHODS

An in vitro equine-vessel model was created to test clip occlusion strength. Ten-millimeter NPL and standard Ti clips were applied to veins (10 mm) and arteries (10, 6, and 5 mm) with and without a 1-mm cuff and tested until they held a pressure of 300 mm Hg (veins) or 760 mm Hg (arteries) for 2 minutes or leaked.

RESULTS

The NPL clip was statistically more secure on 10-mm veins with and without a cuff, 10-mm arteries with and without a cuff, and 6-mm arteries with a cuff than was the Ti clip. Leaving a 1-mm cuff resulted in a statistically higher leak point in all vessels tested except the 6-mm arteries secured with the Ti clip.

CONCLUSIONS

The NPL clip was more secure than the Ti clip on larger arteries and veins. A 1-mm vascular cuff enhances the security of both NPL and Ti clips in vessels of all sizes. The NPL clip is secure and reliable in securing both arteries and veins.

Control of the Renal Artery and Vein with the Nonabsorbable Polymer Ligating Clip in Hand-Assisted Laparoscopic Donor Nephrectomy

BACKGROUND

The large and variable size of the renal vein has prompted most surgeons to select linear stapling devices to secure the vein during laparoscopic donor nephrectomy. Although effective, these stapling devices have a potential for misfire. Use of the nonabsorbable polymer ligating (NPL) clip during laparoscopic donor nephrectomy provides increased graft vessel length compared with the stapling device, and the NPL clip has a locking mechanism which may increase security compared with standard titanium clips. The objective of this study was to evaluate the safety and efficacy of the NPL clip for control of the renal artery and vein during hand-assisted laparoscopic donor nephrectomy (HALDN).

METHODS

A retrospective chart review of 50 consecutive HALDN patients was conducted where two parallel NPL clips were used to control both the renal artery and vein. Information collected included demographic data, operative and postoperative data, and complications.

RESULTS

Mean donor age was 33.4 years and body mass index was 25.8 kg/m2. Mean operative time was 266.0 min, mean hospital stay was 3.2 days, and mean warm ischemia time was 123.3 seconds. There were no transfusions, open conversions, or complications related to use of the NPL clip. A US 16,300 dollars disposable cost savings was seen during this 1-year period alone.

CONCLUSIONS

The NPL clip was 100% safe and effective in controlling the renal artery and vein during HALDN, allowed for additional vessel length, and resulted in a disposable cost savings of US 362 dollars per patient.