Hand-assisted laparoscopic live-donor nephrectomy

Graft retrieval incisions in minimally invasive donor nephrectomy: Systematic review and network meta-analysis

BACKGROUND

Various incisions are employed for graft extraction during minimally invasive donor nephrectomy, but an overarching synthesis of associated short-term donor outcomes is lacking.

METHODS

An electronic literature search was conducted on PubMed, EMBASE and Scopus for studies comparing ≥2 graft extraction incisions in laparoscopic or robotic donor nephrectomy with ≥10 patients per arm. Eligible study designs included randomized trials, case-control, and cohort studies. Primary outcomes were donor length of stay (LOS); in-hospital analgesic requirement; and postoperative complications. Secondary outcomes were warm ischemia time (WIT), total operation time (TOT), and estimated blood loss (EBL). Random-effects Frequentist network meta-analyses were conducted for all outcomes.

RESULTS

Twenty-nine studies (4702 patients) were shortlisted. Six incisions were analyzed: iliac, Pfannenstiel, midline hand-assisted laparoscopic (HAL), midline umbilical, flank and transvaginal natural orifice transluminal endoscopic surgery (NOTES). The flank incision had significantly longer LOS than all other incisions. LOS was significantly longer in Pfannenstiel than iliac incision (mean difference [MD] = 0.29, 95%CI = 0.002-0.58 days). Midline HAL had significantly shorter TOT than most other incisions. Midline umbilical incisions had significantly higher WIT than midline HAL and Pfannenstiel incisions. Midline HAL had shorter WIT than transvaginal NOTES (MD = 0.80, 95%CI = 0.05-1.56 min). No major differences were seen in analgesia requirement, postoperative complications and EBL.

CONCLUSION

Six different incisions for graft retrieval are broadly comparable across most short-term outcomes although long-term outcomes remain to be elucidated. Iliac and Pfannenstiel incisions yielded similar outcomes besides marginally lower LOS for the former. Midline incision for HAL may be associated with shorter TOT, and transvaginal NOTES is an effective technique for selected female donors.

TRIAL REGISTRATION

PROSPERO CRD42023445407.

Robotic-assistance does not enhance standard laparoscopic technique for right-sided donor nephrectomy

Robotic-assistance did not improve outcomes associated with laparoscopic donor nephrectomy in this study.

Objective:

To examine donor and recipient outcomes after right-sided robotic-assisted laparoscopic donor nephrectomy (RALDN) compared with standard laparoscopic donor nephrectomy (LDN) and to determine whether robotic-assistance enhances LDN.

Materials & Methods:

From December 2005 to January 2011, 25 patients underwent right-sided LDN or RALDN. An IRB-approved retrospective review was performed of both donor and recipient medical charts. Primary endpoints included both intraoperative and postoperative outcomes.

Results:

Twenty right-sided LDNs and 5 RALDNs were performed during the study period. Neither estimated blood loss (76.4mL vs. 30mL, P=.07) nor operative time (231 min vs. 218 min, P=.61) were significantly different between either group (LDN vs. RALDN). Warm ischemia time for LDN was 2.6 min vs. 3.8 min for RALDN (P=.44). Donor postoperative serum estimated glomerular filtration rates (eGFR) were similar (53 vs. 59.6mL/min/1.73m², LDN vs. RALDN, P=.26). For the recipient patients, posttransplant eGFR were similar at 6 months (53.4 vs. 59.8mL/min/1.73m², LDN vs. RALDN, P=.53).

Conclusion:

In this study, robotic-assistance did not improve outcomes associated with LDN. Larger prospective studies are needed to confirm any perceived benefit of RALDN.

Retroperitoneal laparoscopic hand-assisted live-donor nephrectomy: our initial experience

Since the introduction of the hand port in laparoscopic surgery 4 years ago, only a few articles have appeared in the medical literature discussing its use in live-donor nephrectomy. None of these procedures was performed by the retroperitoneal laparoscopic approach. This paper presents our initial experience of three hand-assisted retroperitoneoscopic live-donor nephrectomies. The procedure was performed with the patient in a lateral position, using a total of three ports: a hand port, camera port and working port. The surgeon, standing at the front, made the hand-port incision in the anterior abdominal wall and deepened it down to the parietal peritoneum, by either splitting or dividing the muscles. Once the retroperitoneal space had been dissected down to the kidney and the ureter, the surgeon moved to the back of the patient. The procedure was successful in all three patients and there were no complications in either the donors or recipients, with a mean follow-up of 10 weeks. The surgeon was seated comfortably throughout the procedure, with the hand-port arm resting on the pelvis of the patient. The mean operative time was 118 min. The mean estimated blood loss was 50 mL and the warm ischaemia time 92 s. Retroperitoneal laparoscopic hand-assisted donor nephrectomy is a viable alternative for those who prefer the extraperitoneal approach for their laparoscopic procedures.

Routine left robotic-assisted laparoscopic donor nephrectomy is safe and effective regardless of the presence of vascular anomalies

The classic approach to donor nephrectomy consists of preferential procurement of the kidney without vascular anomalies. We studied the effect of routine procurement of the left kidney regardless the presence of multiple arteries on the outcomes of robotic-assisted laparoscopic living donor nephrectomy (LLDN) with particular reference to the incidence of urological complications. From August 2000 to July 2005, 209 left LLDNs were performed. We analyzed the outcomes of donors and recipients in relation to the presence of multiple vessels versus normal anatomy. We divided the patients into two groups: group A (n = 148) with normal vascular anatomy and group B (n = 61) with vascular anomalies. In the donors, no significant difference in conversion to open surgery rate, blood loss, length of stay, was noted between the two groups; operative time and warm ischemia time were slightly higher in group B. One-year patient survival was 98% in both groups while the 1-year graft survival was 96.6% in group A and 96% in group B. Only one urological complication was noted in the group with normal anatomy (0.7%) versus none in the group with multiple arteries. Left kidney procurement using robotic-assisted laparoscopic technique is safe and effective, even in the presence of vascular anomalies.

Hand-Assisted Laparoscopic Donor Nephrectomy: A Low Rate of Complications

Background

Laparoscopic donor nephrectomy is associated with a higher incidence of ureteral complications. Hand-assisted dissection minimizes the use of instruments for intraoperative retraction and handling of periureteric tissue, and may reduce posttransplant complications.

Objective

To assess the outcome of hand-assisted laparoscopic donor nephrectomy, in particular ureteral complications.

Methods

Records of 143 kidney transplant recipients who received allografts removed using the hand-assisted laparoscopic technique were retrospectively studied.

Results

Total operating time was 2.0±0.55 (range 1.08–4) hours. Warm ischemia time was 1.45±0.60 (range 0.58–3.00) minutes. Length of artery, vein, and ureter was 2.4±0.5 cm, 3.0±0.5 cm, and 10.3±2.1 cm, respectively. Estimated blood loss averaged 86.3±55.6 mL. Intraoperative suction was not needed in 65% of patients. Two donors developed incisional hernias and 1 had a postoperative ileus. Four of 143 (2.8%) recipients developed ureteral complications: reoperations for ureteral necrosis (1), stenting for ureteral stenosis (2), and urethral catheterization for ureterovesical leak (1). Graft loss in the first year after transplantation occurred because of renal vein thrombosis, thrombosis of revised arterial anastomosis, arterial thrombosis due to myocardial infarction, vasculitis, focal segmental glomerulosclerosis, and chronic rejection. Delayed graft function developed in 3 recipients. The acute rejection rate was 14.6%. Mean serum creatinine levels at 1 and 3 years were 134±61 μmol/L (1.52±0.69 mg/dL) and 121±35 μmol/L (1.37±0.40 mg/dL), respectively.

Conclusions

Hand-assisted laparoscopic donor nephrectomy is associated with a low incidence of ureteral complications; may reduce the technical difficulty of the operation and minimize retraction with instruments, resulting in fewer complications for donors and recipients; and minimizes donor blood loss.

Favorable outcomes among recipients of living-donor nephrectomy using video-assisted minilaparotomy

BACKGROUND

Minimally invasive, living-donor nephrectomy (LDN) is an attractive procedure for the donor in kidney transplantation (KTx). Its advantages include better cosmesis, shorter hospital stay, and rapid recovery. The most commonly performed, minimally invasive nephrectomy is done laparoscopically. However, the technical challenges, a steep learning curve for the surgeon, the risk of impaired early graft function, and the high cost of the procedure, have prevented minimally invasive LDN from gaining wide acceptance. To overcome these problems, we have developed a new surgical procedure named video-assisted minilaparotomy (VAM) for LDN. VAM-LDN is performed entirely with a small retrieval incision. Moreover, it does not require the induction of pneumoperitoneum, thereby avoiding potential vascular and renal complications.

METHODS

We evaluated the outcome of transplant recipients receiving kidneys with the VAM-LDN procedure by retrospectively comparing the surgical outcomes of patients who underwent KTx with the conventional open nephrectomy (group I, n=82) and VAM-LDN (group II, n=70) procedures from March 1, 1997, to June 30, 2002, at our institution. We compared postoperative complications, patient and graft survival, and graft functions between these two groups during a 12-month follow-up period.

RESULTS

There were no differences in demographic data, ABO compatibility, degree of human leukocyte antigen matching, or method of immunosuppression between the two groups (P >0.05). No significant difference was observed in complications such as delayed graft function, acute rejection, ureter complication, graft failure, or patient's mortality. There was no difference in graft function between the two groups, as determined by serum creatinine level measured during the 12-month follow-up.

CONCLUSION

The short-term recipient outcome was favorable in patients who underwent KTx with the VAM-LDN procedure.

A systematic review of hand-assisted laparoscopic live donor nephrectomy

We provide a systematic review of hand-assisted laparoscopic live donor nephrectomy (HALDN), a relatively new procedure. Medline search of HALDN between 1995 and 2002 was conducted. Published studies were scored by two independent assessors using a modified form of 11 generic questions. All questions required one of three responses: 0--criterion not reported, 1--criterion reported but inadequate, 2--criterion reported and adequate. The studies were placed according to their scores in category A (score 20-22), category B (17-19) and category C (16 or less). Higher scores indicate better quality of studies. Where possible, statistical analysis of comparative data was performed. Most reports of HALDN are expert series, some comparative and a few prospective. There was good correlation between the assessors (r = 0.91), and of the seven published series on HALDN, two fell into category B and five into category C. At present, there is only one published randomised-controlled trial of HALDN vs. open donor nephrectomy; this is the only such trial in laparoscopic urology. HALDN allows kidneys to be harvested with short operating and warm ischaemia times and fewer ureteric complications. HALDN is a relatively new and effective technique, designed to make kidney donation more attractive and minimally invasive without affecting recipient outcomes. More prospective data of this technique is needed, and wide variation in reported outcome parameters need to be standardised to allow meaningful comparison.

Hand-assisted laparoscopic live donor nephrectomy

Background

Hand-assisted laparoscopic donor nephrectomy (HLDN) may have advantages over laparoscopic donor nephrectomy, such as shorter learning curve, operation and warm ischaemia times. The aim of this study was to evaluate the feasibility and safety of HLDN.

Methods

Between January 2000 and October 2002, 50 consecutive HLDN procedures were performed through a low transverse abdominal incision, 23 right sided and 27 left sided.

Results

The median age of the donors was 44 years. No HLDN required conversion to an open procedure. The median operating time for HLDN was 153 min. The median warm ischaemia time was 3 (range 1·0–4·5) min and the median blood loss was 50 (range 20–500) ml in both left- and right-sided procedures. Eight patients suffered ten minor complications during their admission. The duration of hospital stay was 5 days for donors. Three recipients developed graft failure owing to acute rejection, renal vein thrombosis and ischaemic necrosis.

Conclusion

Both left- and right-sided HLDN procedures were feasible and safe through a low transverse abdominal incision.

Maximizing renal artery length in right laparoscopic donor nephrectomy by retrocaval exposure of the aortorenal junction

Laparoscopic donor nephrectomy (LDN) has become the standard of care at increasing numbers of renal transplant programs worldwide. As in open donor nephrectomy, the left kidney has remained the preferred organ for LDN because of the greater renal vessel lengths. Currently, the overwhelming majority of donor operations are performed on the left kidney. This disparity may be due to an unfamiliarity with the technique of right LDN and technical difficulties encountered in obtaining adequate arterial and venous vessel lengths. Modifications in the laparoscopic technique have increased the length of the renal vein obtained from either side; however, further techniques are needed to maximize the length of the right renal artery in LDN. Herein the authors present a technique to provide exposure of the right aortorenal junction that provides maximal length of the right renal artery. This technique has currently been used in 20 consecutive right LDN operations without vascular complications or technical graft losses.

Hand-assisted laparoscopic living-donor nephrectomy as an alternative to traditional laparoscopic living-donor nephrectomy

The benefits of laparoscopic living-donor nephrectomy (LDN) are well described, while similar data on hand-assisted laparoscopic living-donor nephrectomy (HALDN) are lacking. We compare hand-assisted laparoscopic living-donor nephrectomy with open donor nephrectomy. One hundred consecutive hand-assisted laparoscopic living-donor nephrectomy (10/98-8/01) donor/recipient pairs were compared to 50 open donor nephrectomy pairs (8/97-1/00). Mean donor weights were similar (179.6 +/- 40.8 vs. 167.4 +/- 30.3 lb; p = NS), while donor age was greater among hand-assisted laparoscopic living-donor nephrectomy (38.2 +/- 9.5 vs. 31.2 +/- 7.8 year; p < 0.01). Right nephrectomies was fewer in hand-assisted laparoscopic living-donor nephrectomy [17/100 (17%) vs. 22/50 (44%); p < 0.05]. Operative time for hand-assisted laparoscopic living-donor nephrectomy (3.9 +/- 0.7 vs. 2.9 +/- 0.5 h; p < 0.01) was longer; however, return to diet (6.9 +/- 2.8 vs. 25.6 +/- 6.1 h; p < 0.01), narcotics requirement (17.9 +/- 6.3 vs. 56.3 +/- 6.4h; p < 0.01) and length of stay (51.7 +/- 22.2 vs. 129.6 +/- 65.7 h; p < 0.01) were less than open donor nephrectomy. Costs were similar ($11072 vs. 10840). Graft function and 1-week Cr of 1.4 +/- 0.9 vs. 1.6 +/- 1.1 g/dL (p = NS) were similar. With the introduction of HALDN, our laparoscopic living-donor nephrectomy program has increased by 20%. Thus, similar to traditional laparoscopic donor nephrectomy, hand-assisted laparoscopic living-donor nephrectomy provides advantages over open donor nephrectomy without increasing costs.

Comparison of open, laparoscopic, and hand-assisted approaches to live-donor nephrectomy

BACKGROUND

Minimally invasive donor nephrectomy has become a favored procedure for the procurement of kidneys from live donors. The optimal minimally invasive surgical approach has not been determined. In the current work, we compared the outcome of kidneys procured using the traditional open approach with two minimally invasive techniques: the standard laparoscopic procedure and a hand-assist procedure.

METHODS

The function of live-donor kidneys procured by open versus minimally invasive procedures was compared (procedures compared were the traditional open donor nephrectomy [ODN], the standard laparoscopic [LAP] approach, and the hand-assisted [HA] laparoscopic technique). The length of donor operation, donor length of stay in the hospital, surgical complications, and cost of hospitalization for three groups of patients were assessed in a series of 150 live-donor nephrectomies.

RESULTS

We found that both minimally invasive procedures yielded kidney allografts with excellent early function and a minimum of complications in the donor. The open procedure was associated with a reduced operative time but increased donor length of stay in the hospital. Resource utilization analysis revealed that both minimally invasive techniques were associated with a slight increase in costs compared with the open procedure, despite a shorter hospital stay.

CONCLUSIONS

Minimally invasive donor nephrectomy is safe and effective for procuring normally functioning organs for live-donor transplantation. Of the two minimally invasive approaches examined, the hand-assisted technique was found to afford a number of important advantages, including facilitating teaching of residents and students, that it is more readily mastered by transplant surgeons, and that it may provide an additional margin of safety for the donor.

Laparoscopic donor nephrectomy: an update

Laparoscopic donor nephrectomy was developed primarily to increase the number of kidneys available for donation. Further evidence of the safety and efficacy of laparoscopic donor nephrectomy has been reported in the literature, as have studies on the cost-effectiveness of this procedure and its role in removing disincentives for renal donation. Specific technical modifications have been developed and refined that improve outcomes when performing laparoscopic harvesting of right kidneys. Other technical modifications have been developed for use in obese patients. With the adoption of these modified techniques, equivalent results to open donor nephrectomy have been reported. Recently, a wide range of alternative approaches (hand-assisted, retroperitoneal, and gasless laparoscopy) have been utilized for laparoscopic donor nephrectomy.