Conservative management of appendicitis following Laparoscopic Live Donor Nephrectomy

Laparoscopic Living Donor Nephrectomy: A Look at Current Trends and Practice Patterns at Major Transplant Centers Across the United States

FATE OF DONOR KIDNEY: LAPAROSCOPIC VERSUS OPEN TECHNIQUE

Multidetector Computerized Tomography Angiography to Predict Lumbar Venous Anatomy Before Donor Nephrectomy

Laparoscopic live donor nephrectomy decreases disincentives to live kidney donation. Thus, many centers are interested in adopting this procedure. However, the high stakes involved for both the donor and the recipient, and the technical difficulties of the operation, have tempered the enthusiasm of some surgeons. Ideally, if early in their series, surgeons could select patients that would be the least challenging technically, it would facilitate the dissemination of this operation. The purpose of this study is to determine if anatomic or radiologic parameters can accurately assess pre-operatively the degree of technical difficulty of laparoscopic live donor nephrectomy for any individual patient. Abdominal spiral three-dimensional CT scanning was performed prior to laparoscopic donor nephrectomy. CT scans were reviewed for six radiographic anatomic parameters. Seven clinical anatomic measurements relating to body habitus were recorded upon induction anesthesia at the time of surgery. Demographic data for gender, age, race, weight, height, and smoking history were collected. Following laparoscopic live donor nephrectomy, the following six component parts of the operation were graded on a scale of 1-4 (1 = easy, 4 = very difficult) for technical difficulty: a) mobilization of the colon; b) mobilization of the upper pole; c) dissection of the renal vein; d) dissection of the renal artery; e) division of the adrenal vein; and f) dissection of the ureter. Also, operative time, estimated blood loss, and intra-operative fluid requirements were recorded as surrogate markers of operative difficulty. Forty-one patients were included in the study. Laparoscopic donor nephrectomy was successfully completed in all cases. The sum of the difficulty scores was 9.9+/-3.1 (mean) (range, 6-18). No anatomic, demographic, or radiologic parameters were predictive of the total operative difficulty score. Of the surrogate markers, only operative time correlated with total difficulty score (R = 0.47, p = 0.003). Donor weight and abdominal girth correlated with operative time (R = 0.50, p = 0.002; R = 0.38, p = 0.019) but not with total difficulty score (R = 0.10, p = 0.51; R = -0.02, p = 0.90, respectively). When the easiest cases and the hardest cases (< or = 25th percentile and > or =75th percentile total difficulty score, respectively) were segregated out, again no anatomic, demographic, or radiologic parameters were predictive of operative technical difficulty. In conclusion, laparoscopic live donor nephrectomy technical difficulty could not be predicted by body habitus from the variables examined in this study. Hence, it was equally likely that performing laparoscopic live donor nephrectomy using a heavy donor would be technically easy, as using a thin donor would be difficult. Although, in general, operative time increased with donor size and weight, it appears that laparoscopic live donor nephrectomy operative technical difficulty is dependent upon such factors as amount of laparoscopic working space, quality of tissue planes, and retractability of the colon and mesocolon; factors that, to date, are not quantifiable.

Laparoscopic Donor Nephrectomy After Seven Years

Laparoscopic Kidney Donation: Looking More than Skin Deep

Open Versus Laparoscopic Donor Nephrectomy: Perioperative Parameters and Graft Functions

Open Versus Laparoscopic Live Donor Nephrectomy: A Focus on the Safety of Donors and the Need for a Donor Registry

To review a single-institution 6-year experience with laparoscopic live donor nephrectomy detailing the technical modifications, clinical results, as well as the trends in donor and recipient morbidity. Since 1995, laparoscopic donor nephrectomy has had a significant impact on the field of renal transplantation, resulting in decreased donor morbidity, without jeopardizing procurement of a high-quality renal allograft. This technique has become the preferred method of allograft procurement for many transplantation centers worldwide but still remains technically challenging with a steep learning curve. Records from 381 consecutive laparoscopic donor nephrectomies were reviewed with evaluation of both donor and recipient outcomes. Trends in donor and recipient complications were assessed over time by comparing the outcomes between four equally divided groups. All 381 kidneys were procured and transplanted successfully with only 8 (2.1%) open conversions. Mean operative time was 252.9 +/- 55.7 minutes, estimated blood loss 344.2 +/- 690.3 mL, warm ischemia time 4.9 +/- 3.4 minutes, and donor length of stay was 3.3 +/- 4.5 days. There was a significant decline in total donor complications, allograft loss, and rate of vascular thrombosis with experience. The rate of ureteral complications declined significantly when comparing our early (Group A) versus later (Groups B-D) experience. Laparoscopic donor nephrectomy has remained a safe, less invasive, and effective technique for renal allograft procurement. Over our 6-year experience and with specific refinements in surgical technique, we have observed a decline in both donor and recipient morbidity following laparoscopic live donor nephrectomy.

Editorial

Controlled ligation and division of the renal hilum are critical steps during laparoscopic living donor nephrectomy. Major hemorrhage from technical failure, although an infrequent occurrence, can cause significant, yet preventable, morbidity or death. Polymer-secured nontransfixion clips are used worldwide for renal pedicle control during laparoscopic nephrectomy, but their use is contraindicated for renal artery ligation during laparoscopic living donor nephrectomy. Laparoscopic staplers are reliable transfixion systems for controlling kidney pedicle. However, stapler malfunction is not negligible, reaching up to 1.7%. A new double shank (DS) titanium-secured nontransfixion clip can dodge legal concerns on polymer-secured clips, while maintaining most of their advantages, without technical failures that may be seen in laparoscopic staplers. New alternatives must be proposed and explored to reach an agreement of the urological community. The new DS-titanium-secured clips could be a step forward toward a safer surgery for kidney donors, at least equivalent to hand ties to occlude the renal artery.

Testicular Pain Following Laparoscopic Renal Surgery

Laparoscopic live donor nephrectomy is the preferred method of kidney donation in high-volume US transplant centers, but for small transplant programs the question of the minimal case load per year necessary to reach the quality standards is open. From 1996 to 2007 we performed 130 live kidney donations including 93 laparoscopic donor nephrectomies followed by transplantation in a community hospital with an average case load of 10 laparoscopic cases per year. We compared the results after 37 open and 93 laparoscopic live donor operations with respect to operating time, conversion rate, complications, and recipients' outcome. There were no significant differences in terms of safe outcome of donor patients after open or laparoscopic donor nephrectomy. The mean operating time was significantly shorter (p < 0.001) in the open group (125 min, OG) than in the laparoscopic group (150 min, LG). Mean hospital stay was significantly shorter (p < 0.001) in LG (6.8 days) versus OG (9.7 days). The conversion rate was 3.2% in the LG. Postoperative complication of donors consisted of temporary nerve irritation (two patients) and retroperitoneal hematoma (one patient) in the LG, and wound infection followed by hernia formation (one patient) and ileus 1 year after organ donation (one patient) in the OG. Safe outcome of the recipients after open (RaOD) or laparoscopic donation (RaLD) was similar. Uneventful transplantation occurred in 94.6% of the RaOD and in 92.5% of the RaLD. One kidney was lost due to renal vein thrombosis (RaLD). Mean postoperative creatinine after 4 weeks showed no difference between RaOD (1.6 mg/dl) and RaLD (1.7 mg/dl). Approximately ten cases per year may be enough to ensure safety and quality of laparoscopic live donor nephrectomy.

Laparoscopic live donor nephrectomy has become the new gold standard for kidney procurement in many high-volume transplant centres worldwide, but it is often limited to left-sided donor kidneys. Concerns about adequate anatomical renal vessel length and sufficient surgical exposure are the main obstacles to the use of the laparoscopic approach for right kidney live donors as well. From 1998 to 2006 we performed laparoscopic kidney procurement in 73 live kidney donors on an intention-to-treat basis, harvesting a total of 48 left (LKG) and 25 right kidneys (RKG) for transplantation. We compared these two groups with respect to operating time, conversion rate, complications, hospital stay, and recipient outcome. There were no differences in outcome of donor patients after left (D-LKG) or right laparoscopic donor nephrectomy (D-RKG). Operating time was 160 min in D-RKG versus 164 min in D-LKG. Warm ischemia was below 150 s in both groups. Hospital stay was 7.0 (D-RKG) versus 6.7 days (D-LKG). Negative events on the donor site were one temporary nerve irritation in each group and one postoperative retroperitoneal hematoma in the left kidney group. Reasons to convert to open nephrectomy were bleeding in two patients in the left kidney group and adhesions in one patient in the right kidney group. The outcome of the recipients after left (R-LKG) or right kidney (R-RKG) transplantation was similar. One kidney was lost due to renal vein thrombosis (R-LKG). Postoperative ureter complications occurred in one patient of each group. One patient of the R-RKG and two patients of the R-LKG required lymphocele fenestration. All other kidney transplants worked without problems. Laparoscopic donor nephrectomy is a safe procedure and has been established as the method of choice for live kidney donation in our clinic. Laparoscopic procurement of right and left kidneys can be performed with comparable quality and outcome for donors and recipients.

Introduction: Renal replacement therapy is the best management for end stage renal failure. Laparoscopic Donor Nephrectomy (LDN), which is considered safe and effective, began in our unit in July 2003 with an average transplant rate of 12 per year. The aim of this study is to compare the donor morbidity, recovery and costs between Open Donor Nephrectomy (ODN) and LDN.Method: A retrospective consecutive series of all Donor Nephrectomies since June 2002 were included in this study. Operative details, postoperative donor recovery, donor and recipients renal functions were reviewed. The total costs will also be calculated and compared.Results: There were 18 LDN and 18 ODN (Total 36 cases) included in this series and equal number of male to female cases.Average operative time for ODN was 2.07 h and LDN was 3.36 h. There was no intra‐operative conversion from LDN to ODN and no peri‐operative morbidities in either group. The transplanted renal vessel lengths were also compared which showed an average artery length of 40 mm and vein length of 50 mm in the LDN group versus an average of 35 mm artery length and 30 mm vein length in the ODN group. The outcome of the recipient's renal function was not affected whether the donor had OPD or LDN. Average length of hospital stay was 6 days in ODN and 4.5 days in LDN. Costs data to follow.Conclusion: Laparoscopic Donor Nephrectomy (LDN) is safe and effective in a smaller renal transplant unit.