Hand-assisted Retroperitoneoscopic Living Donor Nephrectomy Research Articles

The learning curve for modified hand-assisted retroperitoneoscopic living donor nephrectomy

BackgroundWe aimed to introduce our modified hand-assisted retroperitoneoscopic living donor nephrectomy (HARPLDN) technique and define the learning curve.MethodsOne hundred thirty-eight kidney donors who underwent modified HARPLDN by the same surgeon between May 2015 and March 2022 were included. A cumulative sum (CUSUM) learning curve analysis was performed with the total operation time as the study outcome.ResultsIn total, the mean operative time was 138.2 ± 32.1 min. The median warm ischemic time (WIT) and estimated blood loss were 90 s and 50 ml, respectively. The learning curve for the total operative time was best modeled as a second-order polynomial with the following equation: CUSUMOT (min) = (–0.09 case number2) + (12.88 case number) – 67.77 (R2 = 0.7875; p<0.05). The CUSUM learning curve included the following three unique phases: phase 1 (the initial 41 cases), representing the initial learning curve; phase 2 (the middle 43 cases), representing expert competence; and phase 3 (the final 54 cases), representing mastery. The overall 6-month graft survival rate was 99.3%, with 94.9% immediate onset of graft function without delayed graft function and 0.7% ureteral complications.ConclusionsOur modified method is safe and effective for living donor nephrectomy and has the advantages of a shorter operating time and optimized WIT. The surgeon can become familiar with the modified HARPLDN after 41 cases and effectively perform the next 97 cases.

Pure versus hand-assisted retroperitoneoscopic live donor nephrectomy: a retrospective cohort study of 1508 transplants from two centers.

Although minimally invasive procedures have been established as the standard for a donor nephrectomy, there are many different surgical techniques described in the literature. The aim of this study is to compare the outcomes of kidney transplant procedures using the pure retroperitoneoscopic donor nephrectomy (PRDN) and hand-assisted retroperitoneoscopic donor nephrectomy (HARDN) techniques. A retrospective study involving 1508 transplant procedures was conducted; 874 were PRDN procedures; and 634 were HARDN. We reviewed the outcomes of the PRDN and HARDN groups, which were performed at two different centers over an identical time period. Donors in the PRDN group had a longer operation time (P < 0.0001), reduced estimated blood loss (P < 0.0001), less open conversion (P = 0.0002), lower postoperative serum C-reactive protein levels (P < 0.0001), and a shorter postoperative hospital stay (P < 0.0001) than the HARDN group. Recipients in the PRDN group had lower serum creatinine levels at postoperative day 1-6 and the decreased incidence of slow graft function (P = 0.0017) than the HARDN group. The HARDN procedure was an independent risk factor for the incidence of acute rejection (P = 0.0211) and graft loss (P = 0.0193). Our study suggests that the PRDN procedure is less invasive for donors as it results in reduced blood loss, lower postoperative serum CRP levels, and a shorter postoperative stay than the HARDN procedure. Additionally, PRDN provides a better outcome for recipients as it lowers the incidence of acute rejection and improves graft survival compared to HARDN.

Optimizing a living kidney donation program: transition to hand-assisted retroperitoneoscopic living donor nephrectomy and introduction of a passive polarizing three-dimensional display system.

Optimizing a living kidney donation program is important to guarantee a high grade of acceptance among potential donors. Hand-assisted retroperitoneoscopic donor nephrectomy (HARP) is an alternative to the open anterior approach (AA) technique. Problems associated to the learning curve could hinder a transition. 3D display technique seems to ease minimally invasive surgery. Aim of this study was to evaluate the learning curve during the transition from AA to HARP and the influence of the 3D display system on the established technique. Observational study (n=207) during transition to HARP and introduction of 3D display technique. Operation time (OT), warm ischemia time (WIT) and blood loss (BL) of HARP decreased during transition. Pairwise group comparison for OT showed a significant learning effect for the first 30 out of 50 HARPs without influence on graft function. Between AA and HARP no significant difference in OT (133±24 vs. 127±19min, p=0.25) but for WIT (23±28 vs. 126±40s, p<0.005) and BL (328±207 vs. 54±35ml, p<0.005) was seen. There was neither a significant difference in donors' nor recipients' eGFR. OT (98±16 vs. 106±19min, p=0.036) and WIT (97±37 vs. 120±57s, p=0.023) were significantly shorter for the 3D technique compared to 2D. A transition to HARP is possible without additional risk for the donor or loss of quality for the recipient. The learning curve for HARP is steep and short. The introduction of 3D display technique after transition facilitates the surgical preparation and could further help to optimize HARP.

Postoperative Continuous Infusion of Local Anesthesia in Hand-Assisted Retroperitoneoscopic Living Donor Nephrectomy.

Postoperative pain management in living kidney donor nephrectomy plays a key role in donor comfort and is important for the further acceptance of living kidney donation in times of organ shortage. Standard pain treatment (SPT) based on opioids is limited due to related side effects. Continuous infusion of local anesthesia (CILA) into the operative field is a promising alternative. The aim of this study was to evaluate whether CILA could reduce the dose of opioids in living kidney donors operated with hand-assisted retroperitoneoscopic donor nephrectomy (HARP). An observational study on 30 living donors was performed. The primary outcome was the difference of morphine equivalents (MEQ) administered between CILA and SPT. On day 0 and 1, living donors with CILA received significant less MEQ compared to the SPT group, although on day 1 this effect was not statistically significant (day 0: 6.3 mg, interquartile range [IR] 4.2-11.2 vs 16.8 mg, IR 10.5-22.1, P= .009; day 1: 5.25 mg, IR 2.1-13.3 vs 13.3 mg, IR 6.7-23.8, P= .150). On days 2 and 3 there was no difference (day 2: 13.3 mg, IR 0.0-20.0 vs 13.3 mg, IR 6.7-13.3, P= .708; day 3: 13.3 mg, IR 0.0-26.7 vs 13.3 mg, IR 6.7-20, P= .825). Overall (days 0 to3) MEQ was also less for CILA without reaching statistical significance (39.6 mg, IR 10.9-70.5 vs 59.6 mg, IR 42.4-72.9, P= .187). CILA seems to be an effective instrument for donor pain management in the first 24 hours after HARP. Its effect abates by 48 hours after surgery, especially if highly potent nonopioids are given.

Modified Hand-Assisted Retroperitoneoscopic Living Donor Nephrectomy with a Mini-Open Muscle Splitting Gibson Incision

Background: We aimed to confirm the advantages of a modified hand-assisted retroperitoneoscopic living donor nephrectomy (HARPLDN) compared to the performance of standard retroperitoneoscopic living donor nephrectomy (RPLDN). Methods: One hundred twenty-eight consecutive surgical cases were categorized into 2 groups, one receiving standard RPLDN (group 1) and one receiving modified HARPLDN (group 2). Perioperative factors of both groups were evaluated retrospectively, including donors' demographics, overall operating time, warm ischemia time (WIT), graft vessel length, blood loss, complications, pain visual analogue scale (VAS) scores, hospital stay, and matched recipients' perioperative outcomes. One-year follow-up data were also examined. Results: The standard RPLDN group (n = 44) and modified HARPLDN group (n = 84) had comparable age, gender, and body mass index. The RPLDN group donors had longer operative time, shorter vein length and longer WIT than the modified HARPLDN (all p < 0.001). RPLDN had higher VAS scores (p < 0.001), longer carminative time (p = 0.002) and higher morphine requirement (p = 0.039) than the modified HARPLDN. No complications occurred in either group. All recipients and grafts had survived at 1-year follow-up. Conclusion: The modified HARPLDN technique is safe and effective for living donor nephrectomy and has shorter operating time, shorter WIT and better pain control. Further study is required to evaluate donors' long-term quality of life and recipients' long-term outcomes.

Technical Modifications of Hand-Assisted Retroperitoneoscopic Living Donor Nephrectomy: A Single-Center Experience

ObjectivesTo report a single-center experience and technical modifications of hand-assisted retroperitoneoscopic living donor nephrectomy (HARLDN). MethodsA total of 78 living donors underwent HARLDN from June 2004 to November 2009. We used a three-port, finger-dissecting, routine retroperitoneal approach. After almost complete mobilization of the kidney, the renal pedicle was dissected to expose the renal vessels. The ureter was dissected and divided at the level of the iliac vessels. An approximately 7-cm Gibson incision was made as the hand-assisted port. The surgeon's hand was introduced through this incision directly. With hand assistance, the renal artery was clipped using two Hem-o-lok clips at the proximal end, and then sheared by scissors without any clips on the kidney side. The renal vein was controlled similarly. Then the kidney was rapidly removed through the incision by hand. ResultsHARLDN was effectively and safely completed in 78 (100%) donors. No conversion to an open operation was necessary. The mean operative time and mean warm ischemic time were 121 minutes (range, 90–134) and 146 seconds (range, 112–247) respectively. The mean blood loss was 61 mL (range, 32–85). Clavien 1 complications including subcutaneous emphysema in 5.1% (4/78). The mean visual analog scales on postoperative days 1 to 5 were: 2.5, 1.2, 0.8, 0.5, and 0.1, respectively. The mean time to resume oral diet was 1.5 days. The mean hospital stay was 4.5 days (range, 4–5). The mean level of postoperative serum creatinines of the donors at 7 days and 1 month thereafter were 1.06 mg/dL (range, 0.74–1.43) and 1.15 mg/dL (range, 0.79–1.61) mg/dL, respectively. The mean level of postoperative serum creatinines of the recipients at 7 days and 1 month were 1.40 mg/dL (range 0.81–1.67) and 1.52 mg/dL (range, 0.76–1.83), respectively. The mean incision length was 6.5 cm (range, 6.0–7.2). ConclusionsThe modified HARLDN combines the purely laparoscopic technique with quicker, safer organ retrieval by the open access.

Introducing Hand-Assisted Retroperitoneoscopic Live Donor Nephrectomy: Learning Curves and Development Based on 413 Consecutive Cases in Four Centers

Hand-assisted and retroperitoneoscopic techniques reduce the risk of bleeding and intraabdominal complications in living donor nephrectomy (LDN). This study reports on our four-center experience, development, and learning curves from the first 413 LDNs using a hand-assisted retroperitoneoscopic (HARS) technique. The first 413 consecutive donors operated on using HARS were included in the study. Donor demographics, perioperative and postoperative data, complications, and recipient outcomes have been compiled. The data were analyzed as a whole and separately for each center, looking at center differences and learning curves over time. Significant differences were found in donor demographics between centers for the variables: age, body mass index, number of arteries, and side of operation. Mean operating time was 170.2 min, with significant differences between centers. Operating time was also significantly influenced by learning curves, sex/body mass index, and side of operation. Warm ischemia time differed significantly between centers and was influenced by center-wise learning and number of arteries. Overall conversion rate was 2.4% and differed significantly between centers. There was no mortality and no intraabdominal complications. Apart from the conversions and one pulmonary embolism, there were no major intraoperative or postoperative complications. Overall 3-month graft survival was 99%, with 96% immediate onset of function and 1% ureteral complications. The HARS technique reduces the risk of intraabdominal complications. It can be implemented with excellent donor and recipient outcomes despite different population demographics and center/surgeon-related tradition and experience. On the basis of our experience, we recommend the technique to increase the safety margin of LDN.

1902: Hand-Assisted Retroperitoneoscopic Live Donor Nephrectomy

You have accessJournal of UrologyModerated Poster 60, Wednesday, May 23,2007, 1:00 - 3:00 pm1 Apr 20071902: Hand-Assisted Retroperitoneoscopic Live Donor Nephrectomy Sanjaya Kumar, Michael Malone, Sayeed Malek, and Stefan G. Tullius Sanjaya KumarSanjaya Kumar More articles by this author , Michael MaloneMichael Malone More articles by this author , Sayeed MalekSayeed Malek More articles by this author , and Stefan G. TulliusStefan G. Tullius More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)32075-5AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "1902: Hand-Assisted Retroperitoneoscopic Live Donor Nephrectomy." The Journal of Urology, 177(4S), p. 632 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 177Issue 4SApril 2007Page: 632 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Sanjaya Kumar More articles by this author Michael Malone More articles by this author Sayeed Malek More articles by this author Stefan G. Tullius More articles by this author Expand All Advertisement PDF DownloadLoading ...

Retroperitoneoscopic Live Donor Nephrectomy in a Patient with a Double Inferior Vena Cava

Vascular anomalies are considered a contraindication for laparoscopic live donor nephrectomy. We report a successful hand-assisted retroperitoneoscopic live donor nephrectomy from a donor with a double inferior vena cava. A 37-year-old woman wanted to donate a kidney to her 44-year-old boyfriend who had hypertensive nephropathy. Preoperative donor imaging showed a double inferior vena cava. Each renal vein drains into the ipsilateral inferior vena cava division, making the left renal vein short. A single renal artery, vein, and ureter were noted on both sides. A hand-assisted retroperitoneoscopic left nephrectomy was performed. Blood loss was minimal and the warm ischemia time was 2 minutes. Renal transplantation was performed with good initial perfusion and urine output. Cold ischemia and rewarming time was 25 minutes. The donor postoperative period was uneventful with infrequent need for pain relief. The donor was discharged in good condition 3 days postoperatively. The donor's kidney functions were within the normal range at follow-up 4 months postoperatively. The recipient was discharged in good condition 7 days postoperatively. The recipient is alive with good graft function and unremarkable complications at 4 month follow-up. Although vascular anomalies present a surgical challenge, we have shown the feasibility of performing hand-assisted retroperitoneoscopic live donor nephrectomy in a donor with a double vena cava and short renal vein. With comprehensive preoperative assessment, laparoscopic live donor nephrectomy can be done safely in donors with anatomical anomalies. This may increase the number of living donor kidney transplants as it offers lower postoperative morbidity and economic disincentives for potential donors.

Outcome of right hand–assisted retroperitoneoscopic living donor nephrectomy

Objectives To compare the results of right and left hand-assisted retroperitoneoscopic living donor nephrectomy (HARDN) and assess the usefulness and feasibility of right HARDN. Methods A total of 68 HARDNs performed from July 2001 to February 2005 in Akita University Medical Center were entered into this study. Of these, 12 cases were right-sided HARDN. The reasons for selecting right HARDN were wandering right kidney in 4, multiple left renal arteries in 3, lower glomerular function presenting in the right kidney in 2 patients, and left renal stone, right renal cyst, and right renal aneurysm in 1 patient each. We compared the perioperative and postoperative results of the 12 right-sided HARDNs with those of the 56 left HARDNs. Results No significant differences were found between the two groups in the demographic data (ie, age, sex, number of renal arteries), except for the body mass index. None of the right HARDNs resulted in major complications or open conversion, but two left HARDNs required conversion to open surgery. No difference was found between the two groups regarding estimated blood loss, warm ischemia time, or time to oral intake, although the right HARDN group had a longer mean operative time. No significant differences were found in the recipient’s postoperative graft function or in the frequency of delayed graft function. Conclusions Right HARDN provided almost similar perioperative and postoperative outcomes compared with those of left HARDN. Our results indicate that right HARDN is a choice for living donor nephrectomy because of its technical feasibility, safety, and minimal invasiveness, which are comparable to those of left HARDN.

100-MINUTE RETROPERITONEOSCOPIC RADICAL NEPHRECTOMY: A NEW RETROPERITONEAL APPROACH WITH A HAND ASSISTED METHOD

A new approach for retroperitoneoscopic radical nephrectomy is introduced. The point of our surgical method is the application of a combination of hand assistance and pure laparoscopic procedures with appropriate surgical steps via the retroperitoneal approach. In our early series we had good surgical results and we completed radical nephrectomy in about 100 minutes using this procedure. A total of 20 consecutive patients with renal cell carcinoma (cT1-2) who were operated on with this surgical method were analyzed. Surgical procedures occurred in 5 steps. In step 1 the retroperitoneal space was created manually from a pararectal incision at the umbilicus level. In step 2 the lateroconal fascia was incised and the renal hilar area was exposed with hand assistance. In step 3 hilar dissection was performed by pure laparoscopic procedure with another surgical instrument inserted from the hand device. Step 4 involved the application of hand assistance again for the quick mobilization of the kidney and adrenal gland. In step 5 the intact surgical specimen was retrieved from the hand device. Mean operative time and estimated blood loss were 103 +/- 21 minutes (range 70 to 145) and 49 +/- 85 ml (range 5 to 360), respectively. Mean days to oral intake and ambulation were 1.0 and 1.1, respectively. Operative times of the steps of hilar dissection and mobilization of the kidney and adrenal were shorter than in other series performed by standard retroperitoneoscopic radical nephrectomy. Major complications were not experienced. At this point, no metastasis has been experienced. Our surgical method may have the benefits of the retroperitoneal approach and hand assistance. The retroperitoneoscopic hand assisted method may be another important option in the 3 major approaches for laparoscopic radical nephrectomy, although longer-term followup is clearly required.

Retroperitoneoscopic Living Donor Nephrectomy: A Safe and Minimally Invasive Procedure for the Donor

A living kidney donor surgery must be safe and minimally invasive. In addition the removed kidney must be in good condition. Retroperitoneoscopic nephrectomy has the advantage that it does not risk intra-abdominal organ injuries and provides direct access to the renal artery/vein despite the small working space. An abdominal wall-lifting method combined with the pneumoretroperitoneum provides sufficient space to use a hand skillfully in retroperitoneoscopic surgery. Introduction of hand-assisted retroperitoneoscopic living donor nephrectomy with the abdominal wall-lifting method yielded safer and easier operations as well as shorter warm ischemia (mean: 3 minutes; 7 seconds) and operative times (mean: 3 hours; 28 minutes) in the current 10 cases. The procedure is a useful alternative to procure a kidney graft.

Hand-Assisted Retroperitoneoscopic Live Donor Nephrectomy in Comparison to Open and Laparoscopic Procedures: A Prospective Study on Donor Morbidity and Kidney Function

No AccessJournal of UrologyUrological Survey: Urolithiasis, Endourology and Laparoscopy1 Feb 2005Hand-Assisted Retroperitoneoscopic Live Donor Nephrectomy in Comparison to Open and Laparoscopic Procedures: A Prospective Study on Donor Morbidity and Kidney Function Ralph V. ClaymanM.D. Ralph V. ClaymanRalph V. Clayman More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)60513-7AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Hand-Assisted Retroperitoneoscopic Live Donor Nephrectomy in Comparison to Open and Laparoscopic Procedures: A Prospective Study on Donor Morbidity and Kidney Function." The Journal of Urology, 173(2), pp. 480–481 © 2005FiguresReferencesRelatedDetails Volume 173Issue 2February 2005Page: 480-481 Advertisement Copyright & Permissions© 2005MetricsAuthor Information Ralph V. Clayman More articles by this author Expand All Advertisement PDF DownloadLoading ...