Comparison of Surgical Techniques in Living Donor Nephrectomy: A Systematic Review and Bayesian Network Meta-Analysis

Robotically procured living donor kidneys transplanted into pediatric recipients

BACKGROUND

Use of living donors for kidney transplantation in pediatric recipients provides optimal long-term graft and patient survival; however, it accounts for only 28.5 % of transplants performed in the United States in 2021. Robotic-assisted living donor nephrectomy is shown to be a safe and feasible option, offering enhanced visualization and improved surgical dexterity, allowing for a potential increase in the living donor pool for pediatric kidney transplant recipients, even in cases of grafts with anatomical variants.

METHODS

We reviewed all pediatric patients (≤18 years of age) that received an open kidney transplant with a robotically procured living donor graft at our institution between October 2022 and July 2023. Recipient and living donor demographics, peri- and post-operative data, and graft characteristics were obtained and analyzed.

RESULTS

Eight pediatric recipients were evaluated. Mean recipient age was 11 years, and seven recipients were male. Four kidney grafts required back-table reconstruction: three underwent vascular reconstruction (two requiring deceased donor vascular grafts as extensions of renal veins; one requiring conjoining of two renal arteries), and one underwent cyst removal. Mean cold and warm ischemia time were 73 and 29 min, respectively. There were no cases of delayed graft function or post-operative vascular or urological complications. Mean serum creatinine value at 1, 3, 6, and 12 months post-transplant was 0.785 mg/dL (N = 8), 0.808 mg/dL (N = 8), 0.818 mg/dL (N = 8) and 0.9 mg/dL (N = 3), respectively.

CONCLUSION

Our study shows that robotically procured living donor kidney grafts, even with anatomical variants, are a safe and feasible source for pediatric kidney transplantation. Utilization of grafts with vascular abnormalities for transplantation after vascular reconstruction does not appear to increase the risk of developing complications and therefore, can increase the donor pool for pediatric transplant candidates.

Radiologic evaluation of the kidney transplant donor and recipient

The kidney is the most common solid organ transplant globally and rates continue to climb, driven by the increasing prevalence of end stage renal disease (ESRD). Compounded by advancements in surgical techniques and immunosuppression leading to longer graft survival, radiologists evermore commonly evaluate kidney transplant patients and candidates, underscoring their role along the transplant process. Multiphase computed tomography (CT) with multiplanar and 3D reformatting is the primary method for evaluating renal donor candidates, detailing renal size, vascular/collecting system anatomy, and identifying significant pathologies such as renal vascular diseases and nephrolithiasis. Ultrasound is the preferred initial postoperative imaging modality for graft evaluation due to its low cost, accessibility, noninvasiveness, and lack of radiation. CT and magnetic resonance imaging (MRI) may be useful adjunctive imaging techniques in diagnosing transplant pathology when ultrasound alone is not diagnostic. Kidney transplant complications are categorized by an approximate timeline framework, aiding in differential diagnosis based on onset, duration, and severity and include perinephric fluid collections, graft compression, iatrogenic injuries, vascular compromise, graft rejection, and neoplastic processes. This review discusses imaging strategies and important findings along the transplant timeline, from donor assessment to long-term recipient complications.

Retroperitoneoscopic Left Live Donor Nephrectomy

Background

Retroperitoneoscopic donor nephrectomy (RDN) approach is an unfamiliar approach to the donor surgeons in Australia and New Zealand due to the background General Surgery training. The learning curve when transitioning from transperitoneal to retroperitonoscopic donor nephrectomy is relatively short with minimal morbidity.

Methods

We detail our standardized surgical approach for performing RDN, including technical tips and maneuvers as well as visual aids that ensure the procedure's safety and efficacy.

Discussion

RDN demonstrates notable advantages over traditional laparoscopic methods, including shorter operative times, less postoperative pain, and quicker recovery, thereby enhancing donor safety and graft function. Our goal is to outline our institution's RDN technique, offering valuable insights to aid donor surgeons in incorporating this method into their surgical repertoire. This approach requires a precise surgical technique and adequate training to maximize outcomes and minimize donor complications.

Laparoscopic clampless partial nephrectomy for T1 kidney tumor with subsequent successful transplantation

Kidney transplantation is considered the treatment of choice for patients with end-stage renal disease. However, the kidney transplantation rate has remained stable over the last few years while the waiting lists have been steadily increasing. Marginal organs such as kidneys with small renal masses have also been proposed as potential kidney transplants. We report the case of a 57-year-old woman who underwent clampless laparoscopic left partial nephrectomy, and subsequently, the remaining graft was successfully transplanted to her 59-year-old husband.

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.

Robot-assisted versus laparoscopic living donor nephrectomy: superior outcomes after completion of the learning curve

The use of robots in donor nephrectomy has increased in recent years. However, whether robot-assisted methods have better outcomes than traditional laparoscopic methods and how surgical experience influences these outcomes remains unclear. This meta-analysis compares the outcomes of robot-assisted donor nephrectomy (RADN) with those of laparoscopic donor nephrectomy (LDN) and to investigate the effects of surgical experience on these outcomes. A systematic literature search was conducted in Medline (through PubMed) and Web of Science databases. Perioperative data were extracted for meta-analysis. To assess the impact of the learning curve, a subgroup analysis was performed to compare outcomes between inexperienced and experienced surgeons. Seventeen studies with 6970 donors were included. Blood loss was lower (mean difference [MD] = - 13.28, p < 0.01) and the warm ischemia time was shorter (MD = - 0.13, p < 0.05) in the LDN group than the RADN group. There were no significant differences in terms of conversion to open surgery, operation time, surgical complications, hospital stay, costs, and delayed graft function between the groups. Subgroup analysis revealed that operation time (MD = - 1.09, p < 0.01) and length of hospital stay (MD = - 1.54, p < 0.05) were shorter and the rate of conversion to open surgery (odds ratios [OR] = 0.14, p < 0.0001) and overall surgical complications (OR = 0.23, p < 0.05) were lower in experienced RADN surgeons than in experienced LDN surgeons. Surgical experience enhances the perioperative outcomes following RADN more than it does following LDN. This suggests that RADN could be the method of choice for living donor nephrectomy as soon as surgeons gain sufficient experience in robotic surgery.

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

BACKGROUND

Although laparoscopic donor nephrectomy (LDN) represents the gold-standard technique for kidney living donation, robotic donor nephrectomy (RDN) settled as another appealing minimally invasive technique over the past decades. A comparison between LDN and RDN outcomes was performed.

METHODS

RDN and LDN outcomes were compared, focusing on operative time and perioperative risk factors affecting surgery duration. Learning curves for both techniques were compared through spline regression and cumulative sum models.

RESULTS

The study analyzed 512 procedures (154 RDN and 358 LDN procedures) performed between 2010 and 2021 in 2 different high-volume transplant centers. The RDN group presented a higher prevalence of arterial variations (36.2 versus 22.4%; P  = 0.001) compared with the LDN cohort. No open conversions occurred; operative time (210 versus 195 min; P  = 0.011) and warm ischemia time (WIT; 230 versus 180 s; P  < 0.001) were longer in RDN. Postoperative complication rate was similar (8.4% versus 11.5%; P  = 0.49); the RDN group showed shorter hospital stay (4 versus 5 d; P  < 0.001). Spline regression models depicted a faster learning curve in the RDN group ( P  = 0.0002). Accordingly, cumulative sum analysis highlighted a turning point after about 50 procedures among the RDN cohort and after about 100 procedures among the LDN group.Higher body mass index resulted as an independent risk factor for longer operative time for both techniques; multiple arteries significantly prolonged operative time in LDN, whereas RDN was longer in right kidney procurements; both procedures were equally shortened by growing surgical experience.

CONCLUSIONS

RDN grants a faster learning curve and improves multiple vessel handling. Incidence of postoperative complications was low for both techniques.