Robotic Versus Laparoscopic Donor Nephrectomy: A Retrospective Bicentric Comparison of Learning Curves and Surgical Outcomes From 2 High-volume European Centers

Living donor transplant: Right vs left kidney

Khan et al’ single-centre, retrospective study on the use of right or left kidneys in living-donor renal transplantation, offers the opportunity to further discuss a complex and debated topic in clinical transplantation. In brief, the authors confirm that, despite the historical preference for left kidneys, attributed to their anatomical advantages during donor nephrectomy and recipient transplantation, right kidneys can provide excellent outcomes when donors and recipients are carefully selected, and a meticulous surgical technique is applied in every step of the process. Usefully, the article includes some practical tips to help less experienced surgeons address the technical challenges of right kidney transplantation, such as extended renal vein dissection or full mobilization of the iliac vein of the recipient to minimize tension during anastomosis. Although limited by the selective use of minimally invasive (MI) nephrectomy for left kidneys, this work underscores the importance of expanding the living-donor pool, challenging the traditional taboos, and facilitating access to transplantation for a wider population of patients around the globe. Properly designed studies with larger sample size, comparable MI surgical techniques, prospective data collection, and long-term donor and recipient outcomes are warranted.

Improved robotic-assisted cardiac surgery outcomes with greater hospital volume: a national representative cohort analysis of 10,543 cardiac surgery surgeries

Robot-assisted surgical techniques have enhanced surgical precision, control, stability, and vision, particularly in cardiac interventions. However, the relationship between hospital volume and the clinical and readmission outcomes of robot-assisted cardiac surgery remains undefined. This retrospective cohort study analyzed Nationwide Readmissions Database (NRD) data from 2010 to 2020. Patients who underwent various cardiac procedures were categorized into three groups based on hospital volume of robot-assisted cardiac surgery: low-volume centers (LVCs), medium-volume centers (MVCs), and high-volume centers (HVCs). Our primary outcome variables of interest were the incidence of perioperative complications, 30-day readmission, and in-hospital mortality. 10,543 patients were included in the analysis. Compared with those treated in LVCs, the adjusted OR of 30-day readmission [OR, 0.70; (95% CI 0.53-0.92), P = 0.014] was lower in HVCs. However, higher perioperative bleeding rates were observed in MVCs (OR, 1.38; (95% CI 1.14-1.66), P = 0.001) and HVCs (OR, 1.84; (95% CI 1.52-2.21), P = 0.001). No significant differences were found in in-hospital mortality. Our research demonstrated that higher hospital surgical volume was associated with better outcomes in robot-assisted cardiac surgery, despite higher perioperative bleeding rates.

Trends, outcomes, and predictors of open conversion during minimally invasive radical nephroureterectomy for upper tract urothelial carcinoma: a national analysis from 2010 to 2020

We evaluated trends, predictors, and outcomes of unplanned open conversion for patients with upper tract urothelial carcinoma (UTUC) undergoing robotic radical nephroureterectomy (R-RNU) or laparoscopic RNU (L-RNU). The National Cancer Database was queried from 2010 to 2020 for patients with non-metastatic UTUC treated with RNU. Trends in surgical approach and conversion were evaluated. Demographics and outcomes including lymph node dissection, lymph node yield, positive surgical margins (PSM), prolonged length of stay (PLOS) (≥ 90th percentile), unplanned readmission (UR), and 30- and 90-day mortality were compared between converted and unconverted cases. Multivariate logistic regression evaluated predictors of conversion and whether conversion predicted adverse clinical outcomes. 25,523 cases were included (robotic = 40.4%, laparoscopic = 36.9%, open = 22.7%), where 3.2% and 9.2% of R-RNU and L-RNU cases were converted, respectively. From 2010 to 2020, robotic cases increased while open and laparoscopic approaches decreased, p < 0.001. A higher T-stage and a ureteral tumor site predicted conversion while a higher R-RNU and L-RNU facility volume, respectively, were protective against conversion, all p < 0.05. Compared to unconverted cases, conversion generally resulted in a higher rate of all adverse outcomes, and was predictive of 30-day mortality, PLOS, UR, and PSM, all p < 0.05. Conversion to open RNU is becoming less frequent but is more common with a laparoscopic approach. Oncologic complexity and facility surgical volume influence conversion rates which in turn are associated with higher rates of morbidity, mortality, and greater resource utilization when compared to unconverted cases.

Robotic Assisted Laparoscopic Donor Nephrectomy: An Update

PURPOSE OF THE REVIEW

To review the outcomes of robotic-assisted laparoscopic donor nephrectomy in the published literature.

RECENT FINDINGS

Robotic-assisted laparoscopic donor nephrectomy has demonstrated to be a safe, efficient and effective technique of minimally invasive surgery, that offers multiple advantages to the surgeon, and good outcomes for the kidney donor and recipient. Although still a recent technique, it has been adopted by multiple centers worldwide. Robotic donor nephrectomy studies demonstrated consistent perioperative outcomes with low complication rates. Mean operative time was approximately 208 min, which is within acceptable limits. Mean warm ischemia time of 3.84 min remains well below the threshold for graft function preservation. Blood loss during is consistently low, below 150 mL, and conversion to open surgery remains rare, with a rate of 1.08%. These findings suggest that robotic-assisted procedures are feasible and safe for donor nephrectomy.

Clinical predictors associated with prolonged pneumoperitoneum time in laparoscopic living donor nephrectomy

BACKGROUND

Kidney transplantation (KT) is a useful treatment option for patients with end-stage chronic kidney disease to avoid dialysis and achieve a good quality of life. In Japan, approximately 90% of kidneys for KT are obtained from living kidney donors. Laparoscopic renal nephrectomy (LDN) is the most commonly performed KT procedure in Japan. We aimed to determine the clinical variables that influence the prolongation of pneumoperitoneum time (PT) in LDN.

METHOD

This retrospective study was carried out on 218 consecutive patients who underwent LDN at Gifu University Hospital. T The enrolled patients were divided into two groups according to the third quartile of PT in the LDN, with those in the lower third quartile (Q3) as Group 1 and those in the upper Q3 as Group 2. The primary endpoint was identification of predictive factors for prolonged PT.

RESULT

In total, 178 patients were included in the analysis. For all patients, the median PT, estimated blood loss, and warm ischemic time were 170 min, 20 mL, and 4 min, respectively. Significantly longer PT was observed in Group 2 than in Group 1. Multiple regression analysis results showed that male donors, body mass index ≥ 25 kg/m2, and donors with more than two renal arteries were independent predictive factors for PT prolongation.

CONCLUSION

Male sex, BMI ≥ 25 kg/m2, and two or more renal arteries are predictive factors for prolonged PT for donors in LDN.

[Status of Robotics in Living Donor Liver and Kidney Transplantation - Review of the Literature and Results of a Survey among German Transplant Centres]

The advantages of minimally invasive surgical techniques are undisputed. With the introduction of robotic assistance systems, classic laparoscopy has been further developed and is now also being utilized in transplant surgery, which was previously mainly characterised by open surgical procedures, particularly in living donor liver and kidney donations. In order to assess the current implementation status of robotic assistance systems in transplant surgery, international studies in this field were summarized and correlated with a national survey on the use of robotic assistance systems in living donation.First, a narrative summary of the MEDLINE-listed publications on robotic living kidney and liver donation was carried out. In addition, an online survey was conducted among German transplant centres with ten questions on the utilization of robotic techniques in Germany.Retrospective cohort studies at a small number of transplant centres worldwide report particular advantages of robotics, especially regarding blood loss, patient comfort and length of hospital stay. One-third of German transplant centres already perform living kidney donations with robotic assistance, and one-fifth of centres even use this technique in over 90% of cases. In contrast, living liver donations are only performed in one German transplant centre using robotic assistance for left lateral liver resection of the donor.In the context of living donation, advocates of robotics emphasise technical advantages, greater patient comfort and a steeper learning curve. A persistent and significant point of criticism regarding robotic surgical techniques remains the prolonged warm ischemia time, especially during learning curves. The survey results presented here demonstrate that there is still a substantial need for discussion on this current topic. However, there is a lack of prospective randomised controlled studies.

Robotic-Assisted Nephrectomy for Living Kidney Donation-Single Center Initial Experience (Case Series) and Review of the Literature

Background: Robotic-assisted nephrectomy for living kidney-donation (RANLD) has the potential of becoming the leading technique of harvesting kidney, if expertise is available. The aim of this work is to present our initial experience with robotic technique with additional hand-assistance. Materials and Methods: We initiated RANLD at our clinic using the DaVinci System in September 2022, since then harvesting six kidneys, four left and two right; in two cases, multiple arteries existed. The renal vessels were ligated using vascular staplers. All the operations included a hand-assist with the use of Gelport. The mean operation time was 119.2 min (SD 12 min). Results: There were no conversions or donors' post-operative complications. Time of discharge from the hospital was 4.5 days post-operatively. Total hospital length of stay was 7.8 days. All the harvested kidneys were transplanted, five of them with adequate function, three with initially delayed function, and one needed to be removed due to thrombotic complications. Post-operative was pain assessed on the VAS scale and overall pain was assessed according to the NRS scale. At the discharge day, donors' performance status was about 87.5% according to the Karnofsky scale. The donors resumed their normal life activity within 15.7 days and returned to work within 45.2 days. The serum mean creatinine level before the donation was 0.85 mg/dL (SD 0.1 mg/dL), and mean eGFR (MDRD) = 91.8 mL/min/1.73 m2 (SD 16.1 mL/min/1.73 m2). Conclusions: Further development of RANLD could lead to an increase in the number of living kidney donors, particularly in Poland where the number is currently lower than that of deceased donors. Prolonged operation time, longer warm ischemic time, and high equipment costs are significant drawbacks of RANLD.

Trends in gastric surgery operative experience among general surgery residents in the United States: A nationwide retrospective analysis

BACKGROUND

Gastric surgery is a crucial component of general surgery training. However, there is a paucity of high-quality data on operative volume and the diversity of surgical procedures that general surgery residents are exposed to.

METHODS

We conducted a retrospective analysis of operative case logs of all general surgery residents graduating from the American College of Graduate Medical Education-accredited program from 2009 to 2022. Data on the mean number of gastric procedures, including the mean in each subcategory, were retrieved. A Mann-Kendall trend test was used to investigate trends in operative volume.

RESULTS

Between 2009 and 2022, the mean overall logged gastric procedures rose significantly (τ = 0.722, P < .001) from 36.2 in 2009 to 49.2 in 2022 (35.9% increase). The most substantial growth was seen in laparoscopic gastric reduction for morbid obesity (mean 1.9 in 2017 to 19 in 2022; τ = 0.670, P = .009). A statistically significant increase was also seen in laparoscopic partial gastric resections, repair of gastric perforation, and "other major stomach procedures" (P < .05 for all comparisons). Open gastrostomy, open partial gastric resections, and open vagotomy all significantly decreased (P < .05 for all comparisons). There was no significant change in the volume of laparoscopic gastrectomy, total gastric resections, and non-laparoscopic gastric reductions for morbid obesity (P > .05 for all comparisons).

CONCLUSION

There has been a substantial increase in the volume of gastric surgery during residency over the past 14 years, driven mainly by an increase in laparoscopic gastric reduction. However, there may still be a need for further gastric surgical training to ensure well-rounded general surgeons.

Robot-assisted laparoscopic retroperitoneal donor nephrectomy: a safe and efficient improvement

PURPOSE

Reducing operative injuries is important in living donor nephrectomy. The robot-assisted transperitoneal approach has some advantages than traditional laparoscopic techniques. However, longer operation time and risks of abdominal complications indicate the need for improved techniques. The aim of this study is to present the robot-assisted laparoscopic retroperitoneal donor nephrectomy and evaluate its safety and feasibility.

METHODS

This was a retrospective study. From June 2016 to December 2020, 218 living donors underwent robot-assisted laparoscopic retroperitoneal donor nephrectomy. Perioperative data such as operation time, warm ischemia time, length of stay and complications were collected and analyzed. To evaluate the feasibility of this surgical technique, the cumulative summation method was used to construct a learning curve.

RESULTS

There were 60 male and 158 female donors aged 36-72 years, with an average age of 53.1 ± 6.8 years. Three patients (1.4%) were converted to open surgery. The mean operation time was 115.4 ± 41.9 min, the warm ischemia time was 206.6 ± 146.7 s, and the length of stay was 4.1 ± 1.4 days. Complications were reported in 22 patients (10.1%), three of whom (1.4%) had Clavien‒Dindo IIIa complications. No ileus occurred. No donors were readmitted. Four patients had delayed graft function. The cumulative summation curve showed that the number needed to reach proficiency was 33. The operation time and warm ischemia time after technical proficiency were 100.4 ± 21.6 min and 142.5 ± 50.7 s, respectively.

CONCLUSION

Robot-assisted laparoscopic retroperitoneal donor nephrectomy is a safe and efficient technique that offers advantages of shorter operation time and no abdominal organ interference.