Ex-Vivo Ureteroscopy at the Time of Live Donor Nephrectomy

Ex Vivo Surgical Removal Versus Conservative Management of Small Asymptomatic Kidney Stones in Living Donors and Long-term Kidney Transplant Outcomes

BACKGROUND

Donors with small asymptomatic kidney stones have been increasingly accepted because of organ shortages and advances in endoscopic urology. This study aims to evaluate and compare long-term living-donor kidney transplant outcomes following ex vivo surgical removal versus conservative management of donors' gifted asymptomatic stones.

METHODS

Between January 2007 and December 2021, 119 kidney transplant recipients received stone-bearing kidneys, divided into the removal group (N = 63) and observation group (N = 56). We evaluated posttransplant stone events, urinary infections, kidney function, delayed graft function, length of hospital stay, and survival outcomes.

RESULTS

After a median follow-up of 75.5 mo, the removal group had a 10.9% lower absolute incidence of stone events (7/56 [12.5%] versus 1/63 [1.6%]; hazard ratio, 0.08; 95% confidence interval, 0.01-0.77) and a 14.3% lower absolute incidence of urinary infections (16/56 [28.6%] versus 9/63 [14.3%]; hazard ratio, 0.42; 95% confidence interval, 0.19-0.95) than the observation group. The removal group also showed superior kidney graft function. The 2 groups had comparable length of hospital stay (11.0 versus 12.0 d; P  = 0.297) and exhibited similar delayed graft function incidence (1/56 [1.8%] versus 2/63 [3.2%]; P  = 1.000) and urinary stricture incidence (1/56 [1.8%] versus 3/63 [4.8%]; P  = 0.621). Graft survival ( P  = 0.350) and patient survival ( P  = 0.260) were comparable between 2 groups. Subgroup analyses in recipients who received kidneys with stones <4 mm also reported similar results.

CONCLUSIONS

Ex vivo surgical removal might outperform conservative management for donors' gifted asymptomatic kidney stones, improving long-term transplant outcomes and reducing stone events without increasing perioperative complications, even for stones <4 mm.

Current Perspectives on Endourological Ex Vivo Stone Interventions in Kidney Transplantation: A Systematic Review

OBJECTIVE

To conduct a systematic review (SR) of literature to assess the existing evidence concerning the success and complications of endourological ex vivo stone surgeries.

METHODS

Eligible studies for inclusion focused on investigating the success and/or complications related to endourological ex vivo surgeries in donors with nephrolithiasis. A SR was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search included databases of Web of Science, PubMed, and Scopus and only article in English were included. Studies published between 2002 and 2023 included in this SR.

RESULTS

After screening 1726 abstracts, this SR included 16 studies with a total of 209 patients. The mean stone size was 5.6 mm and majority of kidneys contained single stones, located in the lower calyx. After ex vivo endourological stone surgeries, the average stone-free rate was found to be 95.4%. The mean duration of ex vivo surgery was 17.3 minutes. Regarding intraoperative complications, two patients (1%) experienced mucosal injuries during pneumatic lithotripsy. As for postoperative complications, two patients (1%) experienced vascular complications. In terms of urological complications, hematuria was observed in 24 patients (11.5%), while one patient (0.5%) experienced clot formation in renal pelvis. Seven patients (3.3%) had urinary tract infections, and three patients (1.4%) developed urolithiasis during the follow-up. Additionally, one patient (0.5%) experienced complete occlusion of ureteroneocystostomy and required revision.

CONCLUSION

Given the advancements in current technology and techniques, endourological ex vivo stone surgeries are increasingly recognized as an effective and safe option for donors with nephrolithiasis.

TRIAL REGISTRATION

This systematic review was registered under the protocol registration number CRD42024538384/PROSPERO.

Treatment of donors' asymptomatic small kidney stones and post-transplant outcomes: a meta-analysis

Kidney donors with asymptomatic small kidney stones were increasingly accepted in kidney transplantation (KT) due to organ shortage and advances in endoscopic urology. However, recipients' clinical outcomes using these donors remained unclear. We conducted a meta-analysis to summarize transplant outcomes using these donors with asymptomatic small kidney stones. Finally, 15 retrospective studies were included. The prevalence of asymptomatic small kidney stones was 5.3% (95%CI 3.5-7.8%). After transplantation, low incidence of urinary fistula (0%, 95%CI 0-1.0%), obstruction (0%, 95%CI 0-1.1%), relapse of kidney graft stone (0.3%, 95%CI 0-2.5%), and delayed graft function (0.6%, 95%CI 0-3.5%) was reported. Pooled serum creatinine was 1.3 (95%CI 1.2-1.5) mg/dl and 1.4 (95%CI 1.2-1.6) mg/dl at post-transplant 1 month and 1 year, respectively. Notably, we observed numerically higher relapse rate after conservative management (1.8% [0-9.2%] vs 0% [0-1.8%]) but numerically higher DGF rate after surgical removal of asymptomatic stones (1.8% [0-7.0%] vs 0% [0-1.9%]). Overall, short-term transplant outcomes using kidneys with asymptomatic small stones were acceptable. However, long-term transplant outcomes remained unexplored. Well-designed prospective studies are also needed to compare the efficacy of conservative management with surgical removal of "donors' gifted" asymptomatic kidney stones.

Donor kidney lithiasis and back-table endoscopy: a successful combination

INTRODUCTION

Urolithiasis in renal allografts is relatively rare with an incidence of 0.17-4.40%. It is nonetheless an important issue, as there is a risk of obstruction, sepsis and even loss of the renal allograft. The management of stones in renal allografts remains challenging because of the anatomy, the renal denervation and the use of immunosuppressive medication.

CASE PRESENTATION

This report discusses the ex-vivo treatment of asymptomatic nephrolithiasis in a living donor kidney allograft. A CT abdomen revealed a lower pole stone (5.9 × 5.5 × 5.0 mm; 920 HU) in the right kidney of the potential donor. After multidisciplinary discussion, it was decided to procure the right kidney despite the presence of a documented nephrolithiasis. After discussion with both donor and recipient, an ex-vivo flexible ureterorenoscopy for stone removal on the back table just before implantation of the allograft was planned. The stone was found in the lower pole covered by a thin film of the urothelium. The thin film of urothelium was opened with a laser and the stone fragments were retrieved with a basket. CT after one month showed no residual stones in the transplanted kidney.

CONCLUSION

Back-table endoscopy in a renal allograft is a feasible technique and should be discussed as an option in case of urolithiasis in a kidney that is considered for transplantation. Furthermore, the appropriate treatment of donor kidney lithiasis is another, although rare, method to expand the living donor renal allograft pool.

Ex vivo removal of stones in donor kidneys by pyelotomy prior to renal transplantation: a single-center case series

Background

Donors with incidentally discovered asymptomatic renal stones was considered a relative contraindication to the kidney donation because of a potential increased morbidity risk for renal transplant recipients. Stone clearance from the donors should be done before donation to ensure safety of the recipient. This study aimed to observe the safety and efficacy of kidney transplantation from donors with nephrolithiasis who received pyelolithotomy before transplantation.

Methods

Between January 2015 and March 2021, 14 deceased organ donors at The Second Affiliated Hospital of Guangzhou Medical University were found to have kidney stones during predonation evaluation. After donor kidney repair, all of the donor kidneys underwent ex vivo pyelolithotomy. Then the organs were transplanted to the right iliac fossa of 17 patients with end-stage renal failure. Data were analyzed for technical feasibility, intraoperative and postoperative complications, and stone clearance. Ultrasonography and urinal routine were followed at the 1-, 3-, and 6-month postoperatively.

Results

The stones were successfully removed ex vivo by pyelotomy with an average time of 41.0±12.8 minutes. Seventeen recipients successfully underwent renal transplantation, and their renal function recovered well. Slight gross hematuria occurred in 12 cases after operation, and hematuria disappeared after conservative treatment. Ureteral stents were removed within two months after the procedure. There were no complications such as delayed recovery of renal function, acute rejection, ureteral necrosis, and urinary fistula. The serum creatinine of 17 patients 1 month after the operation was 136.8±26.7 µmol/L. None of the 17 patients included in the study suffered from stone recurrence or graft dysfunction in the follow-up period.

Conclusions

Ex vivo removal of stones by pyelotomy was a technically feasible means of safely and efficiency rendering a stone-bearing donor kidney stone-free. The procedure obtained good early-middle outcomes in kidney transplantation and is therefore worthy of clinical application.

Update on the Management of Urological Problems Following Kidney Transplantation

Urological problems in kidney transplant recipients are not limited only to posttransplantation urological complications. These problems are a cause of significant patient mortality and morbidity that have wide-ranging effects on graft survival throughout the entire life of the graft. Ultimately, the transplant comprises a major portion of the urinary system; therefore, the transplant team should be prepared for foreseeable and unforeseeable urological problems in the short and long terms. These mainly include postoperative urological complications (urine leakage, ureteral stenosis, and vesicoureteral reflux), bladder outlet obstruction, and graft urolithiasis. In recent years, significant advances have been made in the management of urological complications, especially due to advances in endourologic interventions. The aim of this review is to summarize the management of urological problems after kidney transplantation in the context of the current literature.

[Urinary stones in renal transplant recipients and donors: The French guidelines from CTAFU]

OBJECTIVE

To define guidelines for the management of kidney stones in kidney transplant (KTx) donor or recipients.

METHOD

Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU to report kidney stone epidemiology, diagnosis and management in KTx donors and recipients with the corresponding level of evidence.

RESULTS

Prevalence of kidney stones in deceased donor is unknown but reaches 9.3% in living donors in industrialized countries. Except in Maastrich 2 donors, diagnosis is done on systematic pre-donation CT scan according to standard french procedure. No prospective study has compared therapeutic strategies available for the management of kidney stones in KTx donor: ureteroscopy or an extra corporeal lithotripsy in case of living donor prior to donation, ex vivo approach (pyelotomy or ureteroscopy), ureterocopy in the KTx recipient or surveillance. De novo kidney stones result from a lithogenesis process to be identified and treated in order to avoid recurrences. The context of solitary functional kidney renders the prevention of recurrence of great importance. Diagnosis is suspected when identification of a renal graft dysfunction, hematuria or urinary tract infection with renal pelvis dilatation. Stone size and location are determined by computed tomography. There are no prospective, controlled studies on kidney stone management in the KTx. The therapeutic strategies are similar to standard management in general population.

CONCLUSION

These French recommendations should contribute to improve kidney stones management in KTx donor and recipients.

Outcomes of Renal Stone Surgery Performed Either as Predonation or Ex Vivo Bench Procedure in Renal Grafts from Living Donors: A Systematic Review

AIMS

We aimed to summarize available evidence about intraoperative and postoperative donors' and recipients' outcomes following stone surgery in renal grafts from living donors performed either before donation or as ex vivo bench surgery at the time of living-donor nephrectomy.

METHODS

A systematic review of PubMed, ISI Web of Knowledge, and Scopus databases was performed in September 2020. We included full papers that met the following criteria: original research, English language, human studies, and describing the results of stone surgery in renal grafts from living donors performed either before transplantation or as ex vivo bench surgery.

RESULTS

We identified 11 studies involving 106 patients aged between 22 and 72 years. Predonation and bench stone surgery was performed in 9 (8.5%) and 96 (90.6%) patients, respectively. Predonation stone surgery involved extracorporeal shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy in 8, 1, and 1 patient, respectively. The overall success rate of predonation stone surgery was 78%, and the complication rate was 0%. Bench stone surgery involved ureteroscopy, pyelolithotomy, or a combination of both in 79 (82.3%), 10 (10.4%), and 7 (7.3%) cases, respectively, with an overall success rate of 95.8% and an overall complication rate of 9.37%.

CONCLUSIONS

Predonation and bench stone surgery in grafts from living donors represents efficacious and safe procedures. Further studies on wider series with a longer follow-up are required.

Ex Vivo Removal of Stones in Donor Kidneys by Flexible Ureteroscopy Prior to Renal Transplantation: A Case Report

Patient: Male, 33

Final Diagnosis: Donation after cardiac death (DCD)

Symptoms: None

Medication:—

Clinical Procedure: Ex vivo removal of stones in donor kidneys by flexible ureteroscop

Specialty: Transplantology

Increasing the Use of Kidneys From Unconventional and High-Risk Deceased Donors

In this paper, we have reviewed the literature and report on kidney donors that are currently used at relatively low rates. Kidneys from donors with acute kidney injury (AKI) seem to have outcomes equivalent to those from donors without AKI, provided one can rule out significant cortical necrosis. Kidneys from donors with preexisting diabetes or hypertension may have marginally lower aggregate survival but still provide patients with a significant benefit over remaining on the wait list. The Kidney Donor Profile Index derives only an aggregate association with survival with a very modest C statistic; therefore, the data indicated that this index should not be the sole reason to discard a kidney, except perhaps in patients with extremely low estimated posttransplant survival scores. It is important to note that the Scientific Registry of Transplant Recipients models of risk adjustment should allay concerns regarding regulatory issues for observed outcomes falling below expectations. The successful utilization of kidneys from donation after cardiac death over the past decade shows how expanding our thinking can translate into more patients benefiting from transplantation. Given the growing number of patients on the wait list, broadening our approach to kidney acceptance could have an important impact on the population with end-stage renal disease. Many lives could be prolonged by carefully considering use of kidneys that are often discarded.

Expanding living kidney donor criteria with ex-vivo surgery for renal anomalies

INTRODUCTION

Renal transplantation remains the gold standard treatment for end-stage renal disease, with living donor kidneys providing the best outcomes in terms of allograft survival. As the number of patients on the waitlist continues to grow, solutions to expand the donor pool are ongoing. A paradigm shift in the eligibility of donors with renal anomalies has been looked at as a potential source to expand the living donor pool. We sought to determine how many patients presented with anatomic renal anomalies at our transplant centre and describe the ex-vivo surgical techniques used to render these kidneys suitable for transplantation.

METHODS

A retrospective review was performed of all patients referred for surgical suitability to undergo laparoscopic donor nephrectomy between January 2011 and January 2015. Patient charts were analyzed for demographic information, perioperative variables, urological histories, and postoperative outcomes.

RESULTS

96 referrals were identified, of which 81 patients underwent laparoscopic donor nephrectomy. Of these patients, 11 (13.6%) were identified as having a renal anomaly that could potentially exclude them from the donation process. These anomalies included five patients with unilateral nephrolithiasis, four patients with large renal cysts (>4 cm diameter), one patient with an angiomyolipoma (AML) and one patient with a calyceal diverticulum filled with stones. A description of the ex-vivo surgical techniques used to correct these renal anomalies is provided.

CONCLUSIONS

We have shown here that ex-vivo surgical techniques can safely and effectively help correct some of these renal anomalies to render these kidneys transplantable, helping to expand the living donor pool.

Novel Use of Ex Vivo Uretero-Pyeloscopy in Autotransplantation: A Systematic Review and Case Report

Background: Autotransplant has been practiced for decades but is regaining popularity in the nephron-sparing era. Initially for benign disease, autotransplantation has a select role in malignant processes that warrants new techniques and ideas to ensure patient safety. We review the use of ex vivo uretero-pyeloscopy and frozen section to ensure kidneys may be utilized in a patient with suspected malignancy.

Case Presentation: A systematic review (PRISMA standard) of ex vivo uretreo–pyeloscopy was undertaken. We then present the case of a 37-year-old Caucasian female who was suspected of having ureteral obstructing malignancy; she had previous treatment of the bladder with bacillus Calmette–Guerin (BCG) for recurrent urothelial malignancy. The lesion biopsies and cytology were suspicious but inconclusive, indicating nephroureterectomy was a likely course of management.

Results: On reviewing the literature, we found that the use of ex vivo uretero-pyeloscopy has been described for urolithiasis to remove stones before transplantation but not specifically to exclude malignancy. Ultimately, in this case, the patient underwent a renal autotransplantation for obstruction that was caused by a granuloma on the background of the previous BCG treatment. Intraoperatively, ex vivo uretero-pyeloscopy and frozen section were crucial in guiding this case by allowing for appropriate identification and resection of the ureteral lesion. In addition, the preservation of ureteral length allowed for autotransplantation, which remains effective at follow-up.

Conclusion:Ex vivo urteroscopy has been used effectively in donor kidneys to treat urolithiasis with minimal complications. We believe that this is the first documented case of ex vivo uretero-pyeloscopy being used effectively in renal autotransplantation to exclude urothelial malignancy.

Ex vivo pyelotomy, nephroscopy and holmium laser lithotripsy of a staghorn stone in a donor kidney prior to renal transplant

This case report presents the diagnostic and treatment procedures of stone removal from the kidney of a 67-year-old donor, the transplantation of the kidney to a 65-year-old recipient, and the postoperative course until the end of hospitalization. Computed tomography performed before collecting the organ showed a staghorn stone in the renal pelvis and lower calyces in the right donor kidney. The stones were removed ex-vivo using a rigid ureteroscope and a holmium laser prior to transplantation. Then the organ was transplanted to the left iliac fossa of a 65-year-old man with end-stage renal failure. The authors think there is a possibility of increasing the kidney pool, by using organs containing large calculi. In such cases stones should be removed before the operation and the patient should be monitored regularly, especially in the first months after the transplant.

Urological Consequences following Renal Transplantation: A Review of the Literature

Renal transplant (RT) represents the treatment of choice for end-stage renal disease (ESRD) but harbours a wide range of possible complications and therapeutic challenges of urological competence. Dialysis years and clinical medical background of these patients are risk factors for sexual dysfunction and lower urinary tract symptoms (LUTS). On the contrary, RT itself may have a number of possible surgical complications such as ureteral stenosis and urinary leakage, while immunosuppressive treatment is a known risk factor for de-novo malignancies.

The present review describes the main urologic problems of RT patients and their up-to-date treatment options according to the most recently available literature evidences.

Increasing the donor and recipient pool-expanded criteria in living kidney donors

To increase the donor and recipient pool in living related renal transplantation, kidneys from expanded criteria living donors are used more frequently to reduce the general problem of organ shortage. This article presents an overview of the current literature concerning this topic to further improve donor selection and transplant decision making.

Single center experience with elective surgical patients as living kidney donors

PURPOSE

To report a single center experience with elective surgical patients as living kidney donors.

METHODS

We retrospectively analyzed a prospective database of 458 living kidney donors from September 2005 to May 2011. Fifteen (3.2%) of them were elective surgical patients simultaneously undergoing living donor nephrectomy. We reviewed age, gender, operative time, intraoperative blood transfusion, intra- and postoperative complications, as well as length of hospital stay. Recipients were evaluated for delayed graft function. Four hundred forty-three patients undergoing living donor nephrectomy alone composed the control group.

RESULTS

Among the elective surgical patients group, the mean (range) operative time was 155 (90 to 310) minutes and mean (range) length of hospital stay was 3 (2 to 9) days. One (6.7%) recipient displayed delayed graft function. Among the regular living kidney donors group, the mean (range) operative time was 100 (70 to 150) minutes, mean (range) length of hospital stay was 3 (2 to 5) days, and delayed graft function was observed in 5.6% of recipients. Only operative time (P = .03) was significantly different between the groups.

CONCLUSIONS

Elective surgical patients are potential donors who may be treated at the same time as the living donor nephrectomy.