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.

Lean body mass in living kidney donors impacts postoperative renal function

PURPOSE

A living donor kidney transplant is the optimal treatment for chronic renal impairment. Our objective is to assess if lean skeletal muscle mass and donor factors such as body mass index, hypertension, and age impact on renal function following donor nephrectomy.

METHODS

Potential donors undergo CT angiography as part of their work-up in our institution. Using dedicated software (Horos®), standardized skeletal muscle area measured at the L3 vertebrae was calculated. When corrected for height, skeletal muscle index can be derived. Skeletal muscle mass index below predefined levels was classified as sarcopenic. The correlation of CT-derived skeletal muscle index and postoperative renal function at 12 months was assessed. Co-variables including donor gender, age, body mass index (BMI), and presence of pre-op hypertension were also assessed for their impact on postoperative renal function.

RESULTS

275 patients who underwent living donor nephrectomy over 10 years were included. Baseline pre-donation glomerular filtration rate (GFR) and renal function at one year post-op were similar between genders. 29% (n = 82) of patients met the criteria for CT-derived sarcopenia. Sarcopenic patients were more likely to have a higher GFR at one year post-op (69.3 vs 63.9 mL/min/1.73 m2, p < 0.001). The main factors impacting better renal function at one year were the presence of sarcopenia and younger age at donation.

CONCLUSION

When selecting donors, this study highlights that patients with low skeletal mass are unlikely to underperform in terms of recovery of their renal function postoperatively at one year when compared to patients with normal muscle mass and should not be a barrier to kidney donation.

Residual renal volume as a long-term independent predictive factor of developing chronic kidney disease after donor nephrectomy

To assess the long-term association between the residual renal volume and the progression of chronic kidney disease (CKD) in kidney donors following open or laparoscopic donor nephrectomy. A retrospective observational study involving 452 individuals who underwent open or laparoscopic donor nephrectomy at Ramathibodi Hospital, Bangkok, Thailand. The study spanned over a comprehensive 60-month monitoring period. Residual renal volume was determined through Computer Tomography. Patient characteristics, surgical techniques, donated kidney side, and estimated glomerular filtration rate (eGFR) were collected and analysed. In a multivariate analysis, a residual renal volume exceeding 50% of original volume is associated with an increased likelihood of developing CKD, with a hazard ratio (HR) of 1.675 (P < 0.05), and male gender has a hazard ratio (HR) of 4.013 (P < 0.001). Additionally, age is identified as a minor risk factor for developing CKD, with hazard ratio (HR) of 1.107 (P < 0.001). Higher residual renal volume, male gender, and older age were identified as independent risk factors for the development of CKD following open or laparoscopic donor nephrectomy during long-term follow-up.

Repair of lymphoperitoneal fistulae for chylous ascites following robotic-assisted partial nephrectomy: Anatomic foundation for left-sided predominance following renal surgery

Chylous ascites (CA) is a rare complication following renal surgery. Here we present the case of a 28-year-old female who developed CA after a robotic left partial nephrectomy. After failing conservative management, she underwent successful robotic-assisted diagnostic laparoscopy and ligation of lymphoperitoneal fistulae. The higher incidence of CA after left versus right-sided renal surgery may be explained by the para-aortic drainage of the intestinal lymphatic channels. Surgical intervention should be considered when conservative management fails.

Predicting new-baseline glomerular filtration rate (NBGFR) after donor nephrectomy: validation of a split renal function (SRF)-based formula

BACKGROUND

Accurate prediction of post-donor nephrectomy (DN) glomerular filtration rate is potentially useful for evaluating and counselling living kidney donors. Currently, there are limited tools to evaluate post-operative new-baseline glomerular filtration rate (NBGFR) in kidney donors. We aim to validate a conceptually simple formula based on split renal function (SRF) previously developed for radical nephrectomy patients.

METHODS

Eighty-three consecutive patients who underwent DN from 2010 to 2016 were included. Pre-operative CT imaging and functional data including pre-DN baseline Global GFR (108.2 ± 13.2 mL/min/1.73m2) were included. Observed NBGFR was defined as the latest eGFR 3-12 months post-DN. SRF, defined as volume of the contralateral non-resected kidney normalised by total volume of kidneys, was determined from pre-operative cross-sectional imaging (49.2 ± 2.36%). The equation derived from Rathi et al. is as detailed: Predicted NBGFR = 1.24 × (Global GFR Pre-DN) x (SRF).

RESULTS

The relationship between predicted NBGFR (66.0 ± 8.29 mL/min/1.73m2) and observed NBGFR (74.9 ± 16.4 mL/min/1.73m2) was assessed by evaluating correlation coefficients, bias, precision, accuracy, and concordance. The new SRF-based formula for NBGFR prediction correlated strongly with observed post-operative NBGFR (Pearson's r = 0.729) demonstrating minimal bias (median difference = 7.190 mL/min/1.73m2) with good accuracy (96.4% within ± 30%, 62.7% within ± 15%) and precision (IQR of bias =  - 0.094 to 16.227).

CONCLUSION

The SRF-based formula was also able to accurately discriminate all but one patient to an NBGFR of > 45 mL/min/1.73m2. We utilised the newly developed SRF-based formula for predicting NBGFR in a living kidney donor population. Counselling of donor post-operative renal outcomes may then be optimised pre-operatively.

Study of the predictive factors affecting outcomes of patients undergoing transperitoneal laparoscopic donor nephrectomy

PURPOSE

We aim to study the preoperative and intraoperative factors and compare against specific outcomes in patients undergoing transperitoneal laparoscopic donor nephrectomy and see if we could find what were the predictive factors for these outcomes.

METHODS

This is a prospective cohort study done in a single high-volume transplant center. 153 kidney donors were evaluated over a period of 1 year. The preoperative factors such as age, gender, smoking status, obesity, visceral obesity, perinephric fat thickness, number of vessels, anatomic abnormalities, comorbidities, and side of kidney and intraoperative factors such as lay of colon on the kidney, height of splenic or hepatic flexure of colon, loaded or unloaded colon, and sticky mesenteric fat were compared against specific outcomes such as duration of surgery, duration of hospital stay, postoperative paralytic ileus, and postoperative wound complications.

RESULTS

Multivariate logistic regression models were used to study the variables of interest against the various outcomes. There were three positive risk factors for increased hospital stay, which were perinephric fat thickness and height of splenic or hepatic flexure of colon and smoking history. There was one positive risk factor for postoperative paralytic ileus which is lay of colon with relation to kidney and there was one positive risk factor for postoperative wound complication which was visceral fat area.

CONCLUSION

The predictive factors for adverse postoperative outcomes after transperitoneal laparoscopic donor nephrectomy were perinephric fat thickness, height of splenic or hepatic flexure, smoking status, lay or redundancy of colon with relation to kidney and visceral fat area.

Robotic donor nephrectomy: optimizing outcomes beyond the limitations of laparoscopy

BACKGROUND

Robotic donor nephrectomy (RDN) has emerged as a safe alternate to laparoscopic donor nephrectomy (LDN), offering improved visualization, instrument dexterity and ergonomics. There is still concern about how to safely transition from LDN to RDN.

METHODS

We performed a retrospective review of 150 consecutive living donor operations (75 LDN and 75 RDN) at our center, comparing the first 75 RDN's with the last 75 LDN's performed prior to the initiation of the robotic transplant program. Operative times and complications were used as surrogates of efficiency and safety, respectively, to estimate the learning curve with RDN.

RESULTS

RDN was associated with a longer total operative time (RDN 182 vs LDN 144 min; P < 0.0001) but a significantly shorter post-operative length of stay (RDN 1.8 vs LDN 2.1 days; P = 0.0213). Donor complications and recipient outcomes were the same between both groups. Learning curve of RDN was estimated to be about 30 cases.

CONCLUSIONS

RDN is a safe alternate to LDN with acceptable donor morbidity and no negative impact on recipient outcomes even during the early part of the RDN learning curve. Surgeon preferences for the robotic approach compared to traditional laparoscopy will require further scrutiny to improve ergonomics and operative efficiency.

Right versus left fully robotic live donor nephrectomy and open kidney transplantation: Does the laterality of the donor kidney really matter?

Objective

Robotic-assisted live donor nephrectomy (LDN) is being gradually adopted across transplant centers. The left donor kidney is preferred over right due to anatomical factors and ease of procurement. We aimed to study donor and recipient outcomes after robotic procurement and subsequent open implantation of right and left kidneys.

Methods

All fully robotic LDNs and their corresponding open kidney transplants performed at our center between February 2016 and December 2021 were retrospectively analyzed.

Results

Out of 196 robotic LDN (49 [right] vs. 147 [left]), 10 (5.1%) donors had intra-operative events (6.1% [right] vs. 4.8% [left], p=0.71). None of the LDN required conversion to open surgery. The operative times were comparable for the two groups. Nausea (13.3%) was the most common post-operative complication. There was no mortality in either LDN group. Herein, we report our outcomes on 156 recipients (39 right and 117 left allografts) excluding robotic implants, exports, and pediatric recipients. There were no significant differences between right and left kidney recipients with respect to 1-year post-transplant patient survival (100.0% vs. 98.1%, p=0.45) or graft survival (93.9% vs. 97.1%, p=0.11), or delayed graft function (7.7% vs. 5.1%, p=0.55).

Conclusion

Non-hand-assisted robotic live donor nephrectomies can be safely performed with excellent outcomes. Right LDN was not associated with higher incidence of complications compared to left LDN. Open implantation of robotically procured right renal allografts was not associated with higher risk of recipient complications.

Robotic-assisted versus laparoscopic living donor nephrectomy for renal transplantation: a systematic review and meta-analysis

INTRODUCTION

Renal transplantation remains the definitive treatment for end-stage renal disease. Currently employed minimally invasive techniques include robotic-assisted laparoscopy and laparoscopy. This study aims to determine whether either method provides an advantage.

METHODS

Following PRISMA guidelines, a systematic review was conducted. Data were analysed using Review Manager 5.3.

RESULTS

A total of 12 studies were included. Operative time and operative bleeding were similar between both approaches, with a mean difference (MD) of 16min (95% confidence interval (CI) -4.06, 37.38; p = 0.11) and 10.44ml (95% CI -43.89, 64.78; p = 0.71), respectively. Robotics had longer warm ischemia time (MD 1.14min; 95% CI 0.65, 1.63; p = 0.00001) but reduced length of stay (LOS) (MD -0.23days; 95% CI -0.45, -0.01; p = 0.04) and pain (MD -1.26 VAS; 95% CI -1.77, 0.75). Similar complication and conversion rates were seen among groups.

CONCLUSIONS

Robotic approaches provide a viable alternative to laparoscopic surgery. Operative time, bleeding volumes, complications and conversion rates are similar between both techniques; apparent robotic advantages on LOS and Pain need to be better analysed by future studies.

Robotic Single-Port Donor Nephrectomy with the da Vinci SP® Surgical System

Objectives

The da Vinci SP® Surgical System received U.S. Food and Drug Administration approval for urological procedures in 2018. Here, we describe the first experience performing single-port robot-assisted donor nephrectomy (RADN) using the da Vinci SP® surgical system, present 90-day clinical outcomes, and discuss tips for operative success.

Methods

Seven consecutive patients underwent single-port RADN at a single institution between September 1, 2020 and March 31, 2021. Surgery was performed through a single, 60 mm Pfannenstiel incision with a 12 mm periumbilical assistant port for suction and vascular stapling. Donor characteristics, operative details, 90-day donor clinical outcomes, and recipient renal function were retrospectively evaluated.

Results

Four female and three male patients successfully underwent single-port RADN without conversion to standard multiport or open approach. Six cases were left-sided. Estimated blood loss for each procedure was ≤ 50 mL. Mean operative time, warm ischemia time, and extraction time were 218.3 minutes (standard deviation [SD]: 16.3 minutes), 5 minutes 4 seconds (SD: 56 seconds), and 3 minutes 37 seconds (SD: 38 seconds). Mean pre-operative creatinine and estimated glomerular filtration rate were 0.79 mg/dL and 107.3 mL/min/1.73m², respectively. At six week's follow up, they were 1.22 mg/dL and 66.1 mL/min/1.73m². Average pain score at 48 hours postoperatively was 1.7/10. There were no Clavien-Dindo grade ≥ III complications within 90 days. All recipients experienced immediate and sustained return of renal function post-transplant.

Conclusion

Single-port RADN is a technically feasible and safe procedure with the da Vinci SP® system and can confer acceptable functional and cosmetic outcomes. Future studies are needed to define long-term outcomes and compare with previously established techniques for donor nephrectomy.

The Differences Between the Right and Left Side Laparoscopic Donor Nephrectomy Outcomes: A Comparative Analysis of Single-Center Outcomes. Sisli Etfal Hastan Tip Bul. 2021;55:339-343. [PMID: 34712075 DOI: 10.14744/semb.2021.82085]

OBJECTIVE

This study aimed to compare the right and left side laparoscopic donor nephrectomy (LDN) outcomes of a single center.

MATERIALS AND METHODS

The outcomes of patients who underwent LDN in our clinic between 2008 and 2020 were evaluated retrospectively. Two groups were consisted according to the side of the donor kidney. The gender, age, body mass index, duration of operation, amount of bleeding, warm ischemia time, drain removal time, and duration of hospitalization and complications were compared between groups.

RESULTS

A total of 314 patients were included in the study. Sixty-six patients underwent right LDN and 248 underwent left LDN. There was no difference between groups in terms of age, duration of operation, amount of bleeding, warm ischemia time, and complications (p>0.05). However, drain removal time and duration of hospitalization were longer in the left LDN group (p<0.05).

CONCLUSIONS

The right LDN had similar intraoperative outcomes with the left LDN. However, failure on meticulous dissection of the lymphatic structures during left LDN might cause chylous drainage and prolonged hospitalization time.

Bipolar vessel sealing system versus silk ligation of lymphatic vessels in renal transplant recipient lymphatic complications: a randomized controlled trial

PURPOSE

This study was aimed to compare lymphatic complications of bipolar vessel sealing system with silk ligation of lymphatic vessels among renal transplant recipients.

METHODS

This was a prospective randomized controlled trial done among 68 patients undergoing renal transplantation in Tribhuvan University Teaching Hospital. They were randomly assigned to either silk ligation or Enseal bipolar vessel sealing lymphatic dissection. Postoperative drain volume and duration of drain placement were measured in all patients. Ultrasound was used to find lymphocele formation in six and 12 weeks.

RESULTS

Total of 30 patients in silk ligation group and 28 patients in bipolar vessel sealing group were analyzed. The baseline characteristics of the patients in each group were similar. Overall, lymphatic complications (either lymphorrhea or lymphocele formation) were in 16 cases (27.58%), 7 (25%) in the bipolar group, and 9 (30%) in the silk ligation group (p = 0.67). A total of 13 patients (22.41%) had lymphorrhea, 6 (21.4%) patients in the bipolar group, and 7 (23.3%) patients in the silk ligation group. Median drain volume was 415 ml (Q1 275 ml, Q3 675 ml) in the bipolar group and 542 ml (Q1 290, Q3 775) in silk group (p = 0.72). Median drain removal day was 5 in each bipolar and silk group with Q1 and Q3 being 5 days in each arm (p = 0.95). A total of five patients (8.62%) developed symptomatic lymphocele, two (7.1%) in the bipolar group, and three (10%) in the silk ligation group, but the difference was not statistically significant. In univariate analysis, double renal arteries in the donor's kidney (p = 0.03) and graft rejection (p = 0.04) were risk factors for the development of lymphatic complications. However, in multivariable analysis, these factors were not statistically significant.

CONCLUSIONS

This study did not find any significant differences in lymphatic complications between bipolar vessel sealing system and silk ligation. However, large sample multi-centric studies should be done to add evidences on lymphatic complications differences between these two techniques.

TRIAL REGISTRATION NUMBER

UMIN000039354, Date of registration-2020, Feb 01.

Is obesity a contraindication for kidney donation?

INTRODUCTION

To enlarge the donor pool, kidney donors with obesity have been considered. We hypothesized that it is safe for patients with obesity to serve as living kidney donors.

METHODS

In this single-center retrospective analysis, we examined the effect of obesity (body mass index (BMI) of 30-35 kg/m²) on glomerular filtration rate (GFR) and creatinine in patients undergoing laparoscopic donor nephrectomy. Other outcomes included intraoperative, 30-, and 90-day complications. We examined the trajectory between patients with obesity versus patients without obesity over time using mixed effects models for the outcomes of creatinine in mg/dL and GFR in mL/min/1.73 m^2. RESULTS: Among donors with obesity versus donors without obesity, there were no significant differences in demographics or comorbidities. Baseline creatinine in donors with obesity was significantly greater than that of donors without obesity (p = 0.02). Operative time was significantly longer in donors with obesity versus without obesity (p = 0.03). There was no significant difference in 30-day morbidity between donors with obesity versus without obesity (6.52 vs. 3.57%, respectively; p = 0.38). The rate of graft complications was 8.7% in donors with obesity versus 7.1% in donors without obesity (p = 1.0). 90-day complications were infrequent, and not significant different between the groups. At 6, 12, and 24-month postoperative follow-up, the mean creatinine level in patients with obesity was not significantly different from that of patients without obesity (1.23 vs. 1.31, 1.23 vs. 1.26, and 1.17 vs. 1.19 at 6, 12, and 24 months, respectively). Mean GFR was also not significantly different at 6, 12, and, 24 months.

CONCLUSION

Postoperative creatinine and GFR changes were not significantly different in patients with obesity versus without obesity after laparoscopic donor nephrectomy. These findings suggest that carefully screened living kidney donors with obesity do not experience decreased postoperative renal function.

Mayo Adhesive Probability (MAP) score of non-donated kidney aids in predicting post-operative renal function following donor nephrectomy

Background

To examine the association of preoperative Mayo Adhesive Probability (MAP) scores in the donor (MAP_d) and non-donor kidneys (MAP_nd) with post-donation renal function.

Methods

Three hundred thirty-one patients undergoing hand assisted laparoscopic donor nephrectomy (HALDN) were reviewed. MAP_d and MAP_nd were obtained. Estimated glomerular filtration rate (eGFR) was recorded preoperatively and at 1 day, 1 month, and 6 months postoperatively.

Results

Two hundred females and 131 males were evaluated with median BMI 26.4 kg/m² (range 17.1–39.6) and median age 45 years (range 19–78). MAP_d score was 0 for 231 patients (69.8%) and > 0 for 100 patients (30.2%). MAP_nd score was 0 for 234 patients (70.7%) and > 0 for 97 patients (29.3%). The median preoperative eGFR was 86.6 ml/min/1.73m² (range 48.8–138.4). After adjusting for preoperative eGFR, BMI, ASA score, and kidney sidedness, postoperative eGFR was associated with MAP score in the non-donated kidney (p = 0.014) but not in the donated kidney (p = 0.24). Compared to donors with MAP_nd = 0, donors with a MAP_nd > 0, mean eGFR was − 2.33 ml/min/1.73m² lower at postoperative day 1 (95% CI − 4.24 to − 0.41, p = 0.018), − 3.02 ml/min/1.73m² lower at 1 month (95% CI − 5.11 to − 0.93, p = 0.005), and − 2.63 ml/min/1.73m² lower at 6 months postoperatively (95% CI − 5.01 to − 0.26, p = 0.030).

Conclusions

MAP score > 0 in the non-donated kidney is associated with worse renal function in the 6 months following HALDN.

Comparison of transversus abdominis plane block and intrathecal morphine for laparoscopic donor nephrectomy: Randomised controlled trial

Background and Aims:

Postoperative pain following laparoscopic donor nephrectomy (LDN) is significant and no suitable analgesic technique is described. Opioid analgesia in standard doses is often suboptimal and associated with numerous adverse effects. Transversus abdominis plane (TAP) block has been evaluated in various laparoscopic procedures. Intrathecal morphine (ITM) has been seen to provide long-lasting analgesia of superior quality in laparoscopic colorectal procedures.

Methods:

The present study was undertaken to evaluate the analgesic efficacy of single-dose ITM 5 μg/kg for LDN. After ethics approval, 60 adult patients scheduled for LDN were randomised to receive intravenous fentanyl, ultrasound-guided TAP block or ITM for postoperative analgesia. Postoperative 24-h patient-controlled analgesia (PCA) fentanyl consumption, visual analogue scale (VAS) score and intraoperative fentanyl and muscle relaxant requirements were compared. Statistical analysis was performed using appropriate statistical tests by using Stata 11.1 software.

Results:

Haemodynamic stability at pneumoperitoneum and in the post anaesthesia care unit was significantly better in patients receiving ITM. Intraoperative rescue fentanyl requirement (P = 0.01) and postoperative fentanyl requirement until 24 h (P = 0.000) were significantly lower in the morphine group. Postoperative VAS at rest and on movement was significantly lower in the morphine group at all points of assessment (P = 0.000).

Conclusion:

ITM 5 μg/kg provides better intraoperative and postoperative analgesia and reduces postoperative PCA fentanyl requirement in laparoscopic donor nephrectomy compared to TAP block or intravenous fentanyl.

Application of the 2017 KDIGO Guideline for the Evaluation and Care of Living Kidney Donors to Clinical Practice

The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 "Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors" was developed to assist medical professionals who evaluate living kidney donor candidates and provide care before, during, and after donation. This guideline Work Group concluded that a comprehensive approach to donor candidate risk assessment should replace eligibility decisions on the basis of assessments of single risk factors in isolation. To address all issues important to living donors in a pragmatic and comprehensive guideline, many of the guideline recommendations were on the basis of expert consensus opinion even when no direct evidence was available. To advance available evidence, original data analyses were also undertaken to produce a "proof-of-concept" risk projection model for kidney failure. This was done to illustrate how the community can advance a new quantitative framework of risk that considers each candidate's profile of demographic and health characteristics. A public review by stakeholders and subject matter experts as well as industry and professional organizations informed the final formulation of the guideline. This review highlights the guideline framework, key concepts, and recommendations, and uses five patient scenarios and 12 guideline statements to illustrate how the guideline can be applied to support living donor evaluation and care in clinical practice.

First live donor nephrectomy with abdominal tortuous aorta and two renal arteries: A renal transplantation case report

46-year-old wife (donor) and 52-year-old husband (recipient) admitted to our clinic for kidney transplantation. CT angiography of the donor showed us there were bilateral renal double artery and a tortuous aorta that is deviated to the left side. The main artery cannot be reached by laparoscopy because of the upper level of renal artery and deviation of the aorta and an open conversion was performed. Presence of tortuous aorta with multiple renal arteries makes laparoscopic donor nephrectomy a challenging procedure even preformed by an experienced surgeon. The possibility of open conversion should always be kept in mind in these cases.

A comparison of laparoendoscopic single-site surgery versus conventional procedures for laparoscopic donor nephrectomy: a Japanese multi-institutional retrospective study

PURPOSE

Laparoendoscopic single-site donor nephrectomy (LESSDN) is a feasible and effective procedure because of its non-invasiveness and better cosmetic outcomes. However, there have been few multi-institutional studies conducted by multiple surgeons on LESSDN. We retrospectively compared the clinical data and outcomes between LESSDN and conventional laparoscopic donor nephrectomy (LDN) at multiple institutes in Japan.

MATERIALS AND METHODS

From 2009 to 2015, the clinical data of 223 donors who underwent LESSDN and 151 donors who underwent LDN were collected from 10 institutes. All LESSDNs were performed transperitoneally, whereas LDNs were performed transperitoneally (P-LDN) in 75 patients and retroperitoneally (R-LDN) in 76 patients.

RESULTS

In the LESSDN group, the single-incision site was pararectal in 155 (69.5%) patients and umbilical in 65 (29.1%) patients. Multiple surgeons (one to eight per institute) performed the LESSDN. No significant differences were observed between the three groups regarding estimated blood loss and warm ischemic time. The operative time was significantly shorter in the LESSDN group than in the R-LDN group (p = 0.018). No significant differences were observed regarding the rates of blood transfusion, open conversion, visceral injuries, and postoperative complications. Furthermore, no significant differences were observed regarding the dose of analgesic and the rate of delayed graft function. One patient required open conversion due to injury to the renal artery. Selection of LESS procedure was not an independent risk factor for the median serum creatinine level of above 1.27 mg/dL in recipients at 1 year after kidney transplantation.

CONCLUSION

The results showed the technical feasibility of LESSDN compared with the standard LDNs in a multi-institutional and multi-surgeon setting. A few observed non-negligible complications and the significantly higher levels of serum creatinine in patients who underwent LESSDN indicate that this procedure should be employed cautiously when performed by surgeons without ample experience in performing LESS procedures.

Intraperitoneal nebulization versus intraperitoneal instillation of ropivacaine for postoperative pain management following laparoscopic donor nephrectomy

BACKGROUND

Laparoscopic donor nephrectomy is considered less painful than open nephrectomy but is still associated with significant postoperative pain. Studies reported that intraperitoneal instillation of local anesthetics provides uncertain pain relief after laparoscopic surgery. This randomized, double-blind study evaluated the effect of intraperitoneal nebulization of ropivacaine on postoperative pain relief after laparoscopic donor nephrectomy.

METHODS

Sixty patients undergoing elective laparoscopic donor nephrectomy were randomly assigned to receive either an instillation of 20 ml 0.5% ropivacaine after the induction of pneumoperitoneum or nebulization of 5 ml 1% ropivacaine before and after surgery. The primary outcome was the degree of pain relief (static and dynamic) after surgery. The secondary outcomes were postoperative fentanyl consumption, incidence of shoulder pain, unassisted walking and postoperative nausea and vomiting (PONV). Data were collected in the postanesthesia care unit (PACU) and at 6, 24, and 48 h after surgery.

RESULTS

Compared to patients in the instillation group, those in the nebulization group showed significant reductions in postoperative pain and fentanyl consumption, and none complained of significant shoulder pain (visual analog scale score ≥ 30 mm). Within 20 h of surgery, 13.3% of patients in the instillation group and 93.3% in the nebulization group started unassisted walking (absolute risk reduction, 38%; P = 0.001). In the nebulization group, PONV was significantly reduced in the PACU and at 6 h.

CONCLUSIONS

Intraperitoneal nebulization of ropivacaine reduced postoperative pain, fentanyl consumption, referred shoulder pain, and PONV while enabling earlier mobility without any difference in the length of hospital stay.

Lower rate of delayed graft function is observed when epidural analgesia for living donor nephrectomy is administered

Background

The beneficial effects of epidural analgesia (EDA) in terms of pain control and postoperative convalescence are widely known and led to a frequent use for patients who underwent living donor kidney nephrectomy. The objective of this study was to determine whether general anesthesia (GA) plus EDA compared to GA only, administered for living donor nephrectomy has effects on postoperative graft function in recipients.

Methods

In this monocentric, retrospective cohort analysis we analyzed the closed files of all consecutive donor- recipient pairs who underwent living donor kidney transplantations from 2008 to 2017. The outcome variable was delayed graft function (DGF), defined as at least one hemodialysis within seven days postoperatively, once hyperacute rejection, vascular or urinary tract complications were ruled out. Statistical analyses of continuous variables were calculated using the two-tail Student’s t test and Fisher exact test for categorical variables with a significance level of p < 0.05, respectively.

Results

The study enclosed 291 consecutive living donor kidney transplantations. 99 kidney donors received epidural analgesia whereas 192 had no epidural analgesia. The groups showed balanced pretransplantational characteristics and comparable donors´ and recipients’ risk factors. 9 out of all 291 recipients needed renal replacement therapy (RRT) during the first 7 days due to delayed graft function; none of these donors received EDA. The observed rate of DGF in recipients whose kidney donors received epidural analgesia was significantly lower (0% vs. 4.6%; p = 0.031).

Conclusions

In our cohort we observed a significantly lower rate of DGF when epidural analgesia for donor nephrectomy was administered. Due to restrictions of the study design this observation needs further confirmation by prospective studies.

Visceral obesity in Asian living kidney donors significantly impacts early renal function after donor nephrectomy

INTRODUCTION

Obesity may be a risk factor for kidney donors to develop reduced renal function. The Framingham heart study suggested that visceral adipose tissue (VAT) confers a more adverse metabolic profile compared with subcutaneous adipose tissue (SAT). Asians tend to have a higher VAT composition and it is unclear if their kidney function is affected differently. We hypothesized that Asian living kidney donors who have visceral obesity are at a higher risk of renal function deterioration 1 year after donation.

METHODS

Between 2011 and 2014, we retrospectively evaluated data from 73 consecutive patients (52% male; mean age 44.9 ± 11.7 years) before they underwent donor nephrectomy and at their 1 year routine follow-up. VAT and SAT were measured at the level of the umbilicus on pre-operative computerized tomography (CT). Visceral obesity (VO) was defined as a VAT > 100 cm [2] and patients were then further divided and compared in two subgroups: VAT > 100 and < 100 cm [2]. Estimated glomerular filtration rate (eGFR, mL/min per 1.73 m [2]) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation pre-operatively and 1 year post-operatively.

RESULTS

Both subgroups had similar baseline kidney function (P = NS) pre-operatively. At the 1 year follow-up, patients with VO experienced a more significant decline of renal function (109 ± 9 to 89 ± 8 mL/min per 1.73 m²), compared to those without VO (111 ± 12 to 96 ± 11 mL/min per 1.73 m², P = 0.013). VO was associated with a body mass index (BMI) > 25 kg/m² (P < 0.001), male gender (P < 0.001) and older age at the time of donor nephrectomy (48.0 vs 39.5 years, P = 0.01). The presence of hypertension or hyperlipidaemia pre-operatively, choice of surgical approach, and post-operative complication rates, did not differ significantly between the subgroups.

CONCLUSIONS

Visceral obesity as defined by VAT > 100 cm² at the level of the umbilicus on cross-sectional imaging, may have a significant impact on early renal function after donor nephrectomy. Adiposity markers, as measured by cross-sectional CT imaging, may be incorporated into routine pre-operative kidney donor workup.

Laparoscopic renal surgery is here to stay

Objectives

To review the current literature comparing the outcomes of renal surgery via open, laparoscopic and robotic approaches.

Materials and methods

A comprehensive literature search was performed on PubMed, MEDLINE and Ovid, to look for studies comparing outcomes of renal surgery via open, laparoscopic, and robotic approaches.

Results

Limited good-quality evidence suggests that all three approaches result in largely comparable functional and oncological outcomes. Both laparoscopic and robotic approaches result in less blood loss, analgesia requirement, with a shorter hospital stay and recovery time, with similar complication rates when compared with the open approach. Robotic renal surgeries have not shown any significant clinical benefit over a laparoscopic approach, whilst the associated cost is significantly higher.

Conclusion

With the high cost and lack of overt clinical benefit of the robotic approach, laparoscopic renal surgery will likely continue to remain relevant in treating various urological pathologies.

Transition from laparoscopic to retroperitoneoscopic approach for live donor nephrectomy

BACKGROUND

Laparoscopic donor nephrectomy has become the standard of care due to multiple benefits. Currently, there are various techniques employed with two different approaches: transperitoneal (TLDN) or retroperitoneoscopic (RLDN) approach. There is a lack of data to determine which technique is superior, although the RLDN offers an anatomical advantage by avoidance of manipulation of the intraperitoneal organs. The aims of this study were to explore the merits of RLDN to TLDN and assess the learning curve of transition from TLDN to RLDN.

METHODS

From January 2010 to February 2017, 106 live donor nephrectomies were performed: 56 by TLDN and 50 by RLDN. Data on patient demographics, perioperative parameters, analgesic consumption, pain scores, and kidney graft function were collected and analysed. Data were compared with a Student's t test or Mann-Whitney test. A CUSUM analysis was performed to investigate the learning curve.

RESULTS

All live donor nephrectomies were successful with no conversion to open surgery. There was no blood transfusion, readmission, or mortality. No postoperative complications were graded over Clavien II. Kidney function was comparable in both groups. The follow-up period ranged from 3 to 78 months.

CONCLUSION

Retroperitoneoscopic live donor nephrectomy is a safe approach with comparable results to TLDN. RLDN has an anatomical advantage as it avoids manipulating the intraperitoneal organs and retains a virgin abdomen and hence translates to a lower perioperative complication risk.

Pure retroperitoneoscopic donor nephrectomy in duplication of inferior vena cava: A series of four cases

Aim:

Complex vascular anatomy poses a major challenge to the donor surgeon. Here, we have described the technical nuances in retroperitoneoscopic living donor nephrectomy for the left kidney in the situations of a rare vascular anomaly of duplication of inferior vena.

Materials and Methods:

Between September 2005 and June 2016, 1460 retroperitoneoscopic living donor nephrectomy were carried out in single surgical unit of our institution. Out of these four donors were found to have duplication of inferior vena cava (IVC). We retrospectively analyzed the prospectively collected data of these donors and studied the operative details for managing the duplicated limb of the IVC.

Results:

The mean age of the donors was 42.5 (range 30–54) years. Mean body mass index was 26.9 (range 25.2–28.6) kg/m². Mean operative time (defined as between giving skin incision to the skin closure [O. T]), was 230 (range 185–310 min). Mean Warm ischemia time (defined from clamping of the renal artery to the starting of the cold HTK perfusion, [WIT]) was 136 s (range 105–178 s). In two cases, the renal vein could be controlled distal to the duplicated limb. In one case, the duplicated limb was clipped while in another a stapler was used to take a cuff of IVC.

Conclusion:

Retroperitoneoscopic donor nephrectomy can be performed safely in cases of duplication of IVC. Preoperative computerized tomography angiography with vascular reconstruction and surgical expertise is desirable in carrying out the procedure.

An account of the anesthetist's vigilance and prevention of adversity during donor nephrectomy

Here, we present the case of a 42 year old female patient, ASA1 and donor for renal transplant surgery of her husband. The pre-anesthesia visit did not reveal any co-morbidity on history and the physical examination was also within normal limits. The patient was taken to the operating room and routine monitoring in the form of non-invasive blood pressure (NIBP), SpO₂ probe and five lead electrocardiogram were applied. Anesthesia was induced with midazolam 1mg intravenous (i/v), fentanyl 100 μg i.v, propofol 100mg i/v and vecuronium bromide 5 mg. i/v. At the end of surgery, anesthesia was reversed and breathing attempts were observed. Suddenly the monitor displayed a drop in the ETCO2 to 5-6 mmHg. Immediately the ventilator circuit was checked which was found to be in place and on chest auscultation, bilateral equal air entry was heard. Sudden bradycardia with heart beat dropping to 32 beats per minute and a blood pressure reading of 90/50 mmHg was displayed on the monitor. Surgeons were informed about the possibility of an intra-abdominal bleed. On surgical exploration, the renal artery pedicle ligature was found to have slipped away resulting in torrential amount of bleeding. The bleeder having been identified was secured and a complete inspection of other possible bleeding sites was done. Post operatively, the patient was shifted to the intensive care unit with inotropic support. It was decided to keep the patient mechanically ventilated on volume control mode of ventilation. The patient remained stable on post-operative day 5, the patient was shifted to the ward.

A randomized, prospective, parallel group study of laparoscopic versus laparoendoscopic single site donor nephrectomy for kidney donation

Few prospective, randomized studies have assessed the benefits of laparoendoscopic single site donor nephrectomy (LESS-DN) over laparoscopic donor nephrectomy (LDN). Our center initiated such a trial in January 2011, following subjects randomized to LESS-DN versus LDN from surgery through 5 years postdonation. Subjects complete recovery/satisfaction questionnaires at 2, 6 and 12 months postdonation; transplant recipient outcomes are also recorded. One hundred subjects (49 LESS-DN, 51 LDN) underwent surgery; donor demographics were similar between groups, and included a predominance of female, living-unrelated donors, mean age of 47 years who underwent left donor nephrectomy. Operative parameters (overall time, time to extraction, warm ischemia time, blood loss) were similar between groups. Conversion to hand-assist laparoscopy was required in 3 LESS-DN (6.1%) versus 2 LDN (3.9%; p = 0.67). Questionnaires revealed that 97.2% of LESS-DN versus 79.5% of LDN (p = 0.03) were 100% recovered by 2 months after donation. No significant difference was seen in satisfaction scores between the groups. Recipient outcomes were similar between groups. Our randomized trial comparing LESS donor nephrectomy to LDN confirms that LESS-DN offers a safe alternative to conventional LDN in terms of intra- and post-operative complications. LDN and LESS-DN offer similar recovery and satisfaction after donation.

Management of intestinal obstruction following laparoscopic donor nephrectomy

Internal hernias are a rare cause of small bowel obstruction. Following laparoscopic bariatric surgery, specifically gastric bypass and laparoscopic colonic resections, there has been an increase in the incidence of internal hernias. This has been due to either a mesenteric or mesocolic defect being not closed or completely missed. Small bowel loops usually herniate through these defects and present as intestinal obstruction. Internal hernia following laparoscopic donor nephrectomy is a rare complication. The need for presenting this case is the rarity of its occurrence, to stress the fact that following major abdominal laparoscopic surgery the mesenteric or mesocolic defects should be closed, and that this complication was managed laparoscopically, through the same port sites as used earlier for the donor nephrectomy.

Transumbilical laparoendoscopic single-site donor nephrectomy: Without the use of a single port access device

Introduction:

Laparoendoscopic single-site donor nephrectomy (LESS-DN) is a procedure in evolution. Currently described techniques utilize single port access devices and articulating, flexible, and bent working instruments. We describe a modified technique of transumbilical LESS-DN with conventional laparoscopic instruments in five kidney donors.

Materials and Methods:

Three standard laparoscopic ports (10 mm × 1, 5 mm × 2) were placed through a 4.5 cm vertical transumbilical incision. A 10 mm 45°, long bariatric lens (Karl Storz) was used. Renal mobilization was performed using conventional rigid laparoscopy instruments. A port closure needle loaded with a blunt plastic needle cap was used for traction. After hilar clamping, an incision was made connecting the three ports, and the kidney was extracted using a preplaced suture over the lower pole fat. All data were prospectively recorded.

Results:

LESS-DN was performed successfully in all five patients. The mean operative time was 157.2 minutes (range, 134–184) and the mean warm ischemia time was 3.2 minutes (range, 3–4). All donors were discharged on postoperative day 3 and were able to resume normal physical activity by 2 weeks after the procedure. All donors had an excellent cosmetic outcome. The mean serum creatinine (recipient) at discharge was 1.14 mg% (range, 0.9–1.4).

Conclusions:

Transumbilical LESS-DN can be cost-effectively performed using conventional laparoscopy instruments and without the need for a single port access device. Warm ischemia times with this technique are comparable with that during conventional multiport laparoscopic donor nephrectomy.