Laparoendoscopic Single-site Donor Nephrectomy Research Articles

Safety and Efficacy of Laparoendoscopic Single-Site Donor Nephrectomy

Purpose: Laparoscopic living-donor nephrectomy is the main technique at high-volume renal transplant centers. Laparoendoscopic single-site donor nephrectomy (LESS-DN) is s an evolutionary minimally invasive surgery, which could be performed by transperitoneal or retroperitoneal approaches. We present a retrospective analysis of our single-institution donor nephrectomy series comparing the transperitoneal to retroperitoneal LESS-DN regarding operative outcomes. Materials and Methods: Seventeen patients who underwent LESS-DN from 2017–2020 were enrolled at our center. The same surgeon performed all cases. The two approaches were compared for the operation time, blood loss, warm ischemia time (WIT), postoperative pain, length of stay (LOS), postoperative wound size, postoperative pain, and the postoperative renal function for twelve months retrospectively. Results: Operating time (257 vs. 180 min, P = 0.016) and LOS (6.5 vs. 5 days, P = 0.013) were significantly longer in the transperitoneal group. The postoperative wound size (47.5 vs. 75 mm, P = 0.038) was substantially smaller in the transperitoneal group. There was no significant difference in other parameters, including blood loss, WIT, complication rate, and postoperative pain from day one to day three. Conclusion: Retroperitoneal LESS-DN results in similar perioperative outcomes as transperitoneal LESS-DN without compromising donor safety and providing a faster operation time, shorter LOS, and a trend toward a shorter WIT. Both approach methods may be safe and effective procedures for living kidney transplantation.

Outcome of Kidney Transplantation With Transumbilical Laparoendoscopic Single-Site Donor Nephrectomy: A Single-Center Experience

AimThe aim of this study is to present the outcome of kidney transplantation after laparoendoscopic single-site donor nephrectomy (LESS DN) compared with conventional laparoscopic donor nephrectomy (LDN) in a single-center experience. MethodsThis retrospective study compares data from the initial experience with 110 consecutive LESS DN donors and their recipients (group A) with 205 consecutive conventional LDN donors and their recipients (group B). ResultsThis study compared 110 LESS DNs completed in an 18-month period with 205 LDNs completed in the immediately preceding 42-month period. All procedures were performed by the same surgeon. In groups A and B, respectively, the incidence of immediate graft function was 90% vs 91.2%, slow graft function was 9% vs 5.3%, delayed graft function was 0.9% vs 2.9%, graft loss was 0.9% vs 2.9%, and death with a functioning graft was 0.9% vs 1.5%. The mean serum creatinine levels were 1.3 ± 0.93 mg/dL vs 1.4 ± 1.2 mg/dL (P = .447), 1.1 ± 0.33 mg/dL vs 1.2 ± 0.75 mg/dL (P = .184), and 1.05 ± 0.25 mg/dL vs 1.1 ± 0.39 mg/dL (P = .224) at 7, 30, and 365 days after transplantation. The estimated glomerular filtration rate at 1 year was 88 ± 18.2 vs 83 ± 12.2 mL/min/1.73 m2 (P = .004). The mean donor operative times in groups A and B were 175.9 ± 24.9 minutes vs 199.88 ± 37.06 minutes (P = .0001), respectively, and the mean warm ischemia time was 5.2 ± 1.02 minutes vs 3.64 ± 1.38 minutes, respectively (P = .0001). The mean body mass index, the incidence of complex vascular anatomy, and the rate of complications were the same in the 2 donor groups. ConclusionsThe outcome of kidney transplantation after LESS DN is comparable to conventional LDN. LESS DN can be employed as the primary approach for kidney donation with low donor risk and without compromising recipient outcomes.

Transumbilical laparoendoscopic single-site donor nephrectomy: evolving trends

We report our experience with laparoendoscopic single-site donor nephrectomy (LESS DN). Retrospective comparative study of data from 200 Consecutive left LESS DN (group A) compared to 205 consecutive conventional laparoscopic donor nephrectomy (LDN) (group B). Standard laparoscopic instruments were used in all patients. Right nephrectomies were excluded. From 05/2015 to 12/2017, 200 LESS DN (group A) and from 10/2011 till 04/2015, 205 LDN (group B) were performed. In group A and B, respectively, the mean operative time was 175.9 ± 24.9 versus 199.88 ± 37.06min (p = 0.0001), the mean warm ischemia time was 5.2 ± 1.02 versus 3.64 ± 1.38min (p = 0.0001), the mean BMI was 24.8 ± 4.5 versus 25.2 ± 4.7kg/m2, complex vascular anatomy was found in 60 (30%) and 68 (33.2%), average length of incision was 5.2 versus 7.7cm (p = 0.001), scar satisfaction rate 8 versus 6 (p = 0.004), mean morphine equivalents 81.0 versus 70.5mg; (p = 0.03), average timing for return to work was 42 versus 50days; (p = 0.001). There was no conversion to open surgery in both groups. One case converted to hand-assisted laparoscopic nephrectomy in group A. Pure LESS-DN was successfully completed in 169 patients (84.5%). In group A, due to technical difficulties, additional 1 or 2, 5-mm port(s) was added in 21 and 10 cases, respectively. Two negative explorations were performed in the first post-operative week for picture of small bowel obstruction. We had port site hernia in one donor, superficial wound infection in three donors and blood transfusion was required in two donors in group A. Our experience with LESS-DN is encouraging. LESSDN can be integrated as a standard approach for renal donation without additional donor risk. Moreover, LESS DN gives more flexibility by possibility to add one or more 5-mm ports in case of technical difficulties.

Retroperitoneal Single Port Versus Transperitoneal Multiport Donor Nephrectomy: A Prospective Randomized Control Trial.

Laparoscopic donor nephrectomy (LDN) converted a retroperitoneal (RP) procedure into a transperitoneal (TP) operation with reports of bowel and solid organ injuries leading to mortality in occasional cases. Laparoscopic RP donor nephrectomy can reduce these risks but never became popular because of the muscle cutting approach. Lumbotomy incision can be used to approach retroperitoneum by incising fascial planes, eliminating disadvantages of the RP approach. This report compares the outcomes of the standard multiport TP LDN with translumbar laparoendoscopic single-site donor nephrectomy (LESS-DN). Between January 2016 and June 2017, 50 voluntary kidney donors out of 267 donors were randomized to undergo LESS-DN vs LDN. Donors with body mass index ≥30 kg/m2, multiple renal arteries, and right-sided nephrectomy were excluded from the study. Postoperative pain, duration of surgery, length of graft vessels and ureter, warm ischemia time, intraoperative blood loss, incision length, convalescence period, duration of hospital stay, and recipients' creatinine at discharge were compared among both the groups. Pain assessment was done using visual analogue scale (VAS). The RP group experienced lesser pain (VAS score 0.3 ± 0.3 vs 1.1 ± 0.0, p = 0.000), lesser analgesic requirement (186 ± 51.07 mg vs 254 ± 62.7 mg, p = 0.000), and faster convalescence (7.0 ± 3.0 days vs 10.7 ± 3.3 days, p = 0.00) related to smaller cumulative incision (7.8 ± 0.8 cm vs12.4 ± 2.0 cm, p = 0.00), and had reduced operative time (142 ± 26.2 minutes vs 170.8 ± 34.75 minutes, p = 0.001) and blood loss. Other recorded parameters were similar in both the groups. The single port RP approach significantly reduced postoperative pain and hastened recovery when compared with the TP approach. Converting to a RP approach presents an opportunity for surgeons to further reduce morbidity associated with the donor nephrectomy.

A single-center 4-year experience with 47 pediatric renal transplants: Evolving trends.

Outcome of pediatric kidney transplantation (KT) has improved over the last several decades. We retrospectively reviewed the outcomes pediatric KT in King Faisal Specialist Hospital and Research Center-Jeddah, Saudi Arabia. Between May 2013 and November 2016, we performed renal transplantation in 47 children, 30 (64%) males, and 17 (36%) females. All patients received antibody induction with basiliximab or antithymocyte globulin along with triple immunosuppressive therapy with tacrolimus, mycophenolate mofetil and steroids. Twenty-four (51%) and 14 (30%) patients were on hemodialysis and peritoneal dialysis, respectively. Average duration on dialysis was 18.3 months. Nine patients (19%) had preemptive transplant. Forty-five patients (95.7%) received kidneys from living donors, 38 (83%) males and nine (17%) females, mean age (years), and body mass index were 30.8 ± 8.82 and 23.8 ± 4.54, respectively. Forty-one donors had left nephrectomy. Four right nephrectomies were reported, all of them were through open nephrectomy. Open nephrectomy was reported in 21 (46%) patients. Several laparoscopic nephrectomy techniques were performed; conventional laparoscopic donor nephrectomy, laparo-endoscopic single-site donor nephrectomy, and hand-assisted laparoscopic surgery in 10, 11, and three patients, respectively. The most common etiologies of end-stage renal disease were focal segmental glomerulosclerosis 19%, posterior urethral valve 8.5%, and congenital abnormalities 8.5% respectively. With a mean follow-up of 54 months, one and 4-year graft survival rates were 95.7% and 91.5%, respectively. One-and four-year patient survival rates were 100%. Outcomes were similar in patients < or ≥10 years. The graft survival was comparable in laparoscopic versus open donor nephrectomy (P = 0.72). Average serum creatinine was 0.85, 0.79, 0.79, and 0.84 at 7, 30, 90, 365 days, respectively. Four patients lost their graft due to renal vein thrombosis, chronic allograft nephropathy (cadaveric donor), Antibody-mediated rejection, and hemolytic-uremic syndrome at 0.75, 9, 19, and 24 months, respectively. The incidences of acute rejection and major infection were 2% and 4%, respectively. One patient developed posttransplant lympho-proliferative disease that was treated and is still with excellent graft function. Our pediatric KT experience is encouraging. Acute rejection, patient, and graft survival rates are similar and even better than many of western reports.

Surgical complications of laparoendoscopic single-site donor nephrectomy: a retrospective study.

The single-port approach has been associated with an unacceptably high rate of umbilical port hernias in large series of patients undergoing single-port cholecystectomy and colectomy and with additional surgical risks thought secondary to technical and ergonomic limitations. A retrospective review of 378 consecutive laparoendoscopic single-site(LESS) donor nephrectomies performed between 04/15/2009 and 04/09/2014 was conducted. Twelve patients (3%) developed an umbilical hernia. Eleven (92%) were female and eight (73%) of these patients had a prior pregnancy. Hernias were reported 13.5 ± 6.9 months after donation, and the mean size was 5.1 ± 3.7 cm. Seven additional cases (1.9%) required a return to the operating room for internal hernia (2), evisceration (1), bleeding (1), enterotomy (1), and wound infection (2). The original incision was utilized for reexploration. One patient required emergent conversion to an open procedure for bleeding during the initial donation. There were no mortalities. Recipient patient and graft survival were 99% and 99% at 1 year, respectively. Although reports associated with earlier experiences with single-site procedures suggested an unacceptably high rate of hernias at the surgical site, this does not seem to be the case at our center. This technique is a reliable surgical technique for left donor nephrectomy at this institution.

Comparison of Two Different Laparoscopic Donor Nephrectomy With Vaginal Extraction Techniques—A Single-Center Experience

ObjectiveThe aim of this study was to compare the results of standard laparoscopic donor nephrectomy with vaginal extraction (SLDN-VE) and laparoendoscopic single-site donor nephrectomy with vaginal extraction (LESSDN-VE). MethodsWe analyzed the data of 95 female donors who underwent SLDN-VE (group I; n = 87) and LESSDN-VE (group II; n = 8) in our center. Parameters regarding donor age, body mass index (BMI), length of hospitalization, duration of surgical procedure, amount of blood loss, warm and cold ischemia times, side of graft nephrectomy, number of renal arteries and veins, postoperative visual analog pain scores at 6th and 12th hours (VAS6, VAS12), peri-and postoperative complications of donors and recipients, and graft function at discharge and follow-up were compared between the 2 groups. ResultsNo significant difference regarding donor age, mean operative time, amount of blood loss, or warm ischemia time was observed between the 2 groups. However, BMI (P = .018) and pain scores (VAS6: P = .047; VAS12: P = .009) were lower and length of hospitalization (P = .005) shorter in group II. On the other hand, cold ischemia time (P = .047) was lower in group I. No peri- or postoperative complications occurred for donors and recipients in both groups. Graft function at discharge and during follow-up were similar in both groups. ConclusionsBecause our first priority is to minimize the morbidity of donors, LESSDN-VE can be chosen in selected female donors for not only decreased pain and hospital stay, but also for better cosmetic outcomes.

1008 - Impact of an additional trocar on clinical outcome, inflammatory cytokines, and cosmetic satisfaction in laparoendoscopic single-site donor nephrectomy

1008 - Impact of an additional trocar on clinical outcome, inflammatory cytokines, and cosmetic satisfaction in laparoendoscopic single-site donor nephrectomy

Successful introduction of laparoendoscopic single-site donor nephrectomy after experience with laparoscopic single-site plus-one trocar donor nephrectomy.

To assess the feasibility, safety, and efficacy of the laparoendoscopic single-site (LESS) donor nephrectomy (LESSDN) procedure after experience with the LESS-plus-one-trocar donor nephrectomy (LEPODN) procedure. From 2009 to 2014, 126 left laparoscopic donor nephrectomies (LDNs) were performed, including 59 Standard (Std)-LDN, 30 LEPODN, and 37 LESSDN. In the LEPODN procedure, a 5-mm trocar was added as a right-hand working trocar to the LESSDN procedure. A GelPOINT(®) platform was applied on a pararectal single incision in both LEPODN and LESSDN procedures. After performing the LEPODN procedure several times, each surgeon performed the LESSDN procedure. Std-LDN, LEPODN, and LESSDN procedures were performed by 10, 10, and 7 surgeons, respectively. The mean operative time, estimated blood loss, warm ischemia time, time to ambulation, and length of postoperative hospital stay were the shortest for the LESSDN procedure (P<0.012, P=0.007, P<0.001, P=0.027, and P=0.001, respectively). No significant difference in the complication rate, delayed graft function rate, and mean 7-day post-transplant serum creatinine levels was observed among the three procedures. Individual results of the operative time and estimated blood loss for the LESSDN procedure were not significantly inferior to those of Std-LDN and LEPODN procedures for each surgeon. The LESSDN procedure can be introduced safely and effectively without compromising the operative time, complication rate, and graft function after experience with the LEPODN procedure among multiple surgeons. The LEPODN procedure may be an effective bridge from standard multiport LDN to LESSDN.

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.

MP72-14 PERIOPERATIVE INJECTION OF LIPOSOMAL BUPIVACAINE REDUCES NARCOTIC MEDICATION REQUIREMENT AFTER LAPARO-ENDOSCOPIC SINGLE SITE DONOR NEPHRECTOMY WITH SHORTER OPERATING TIME THAN SUB-FASCIAL CONTINUOUS LOCAL ANESTHESIA

You have accessJournal of UrologyTransplantation & Vascular Surgery II1 Apr 2014MP72-14 PERIOPERATIVE INJECTION OF LIPOSOMAL BUPIVACAINE REDUCES NARCOTIC MEDICATION REQUIREMENT AFTER LAPARO-ENDOSCOPIC SINGLE SITE DONOR NEPHRECTOMY WITH SHORTER OPERATING TIME THAN SUB-FASCIAL CONTINUOUS LOCAL ANESTHESIA Adam B. Hollander, Jason M. Scovell, Miguel A. Mercado, Judy M. Choi, Edward J. Sanchez, Lambros Stamatakis, Alvin Goh, Richard E. Link, and Wesley A. Mayer Adam B. HollanderAdam B. Hollander More articles by this author , Jason M. ScovellJason M. Scovell More articles by this author , Miguel A. MercadoMiguel A. Mercado More articles by this author , Judy M. ChoiJudy M. Choi More articles by this author , Edward J. SanchezEdward J. Sanchez More articles by this author , Lambros StamatakisLambros Stamatakis More articles by this author , Alvin GohAlvin Goh More articles by this author , Richard E. LinkRichard E. Link More articles by this author , and Wesley A. MayerWesley A. Mayer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2253AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Improving pain control after donor nephrectomy may shorten recovery and reduce barriers to donation. We previously presented data showing that sub-fascial continuous local anesthesia (SFCLA) reduced the need for narcotic medication after laparo-endoscopic single site donor nephrectomy (LESS-DN). Here, we examine our experience with liposomal bupivacaine (LB), a long-acting injectable local anesthetic, and compare its efficacy to SFCLA and patient-controlled analgesia (PCA). METHODS We retrospectively analyzed all cases of LESS-DN at our institution by three surgeons (AG, REL, WAM). Patients who received adjunct perioperative analgesia were administered either LB (Exparel®, Pacira Pharmaceuticals, Parsippany NJ) or SFCLA (On-Q Pain Buster®, I-Flow, Lake Forest CA); the others received morphine PCA. In the first group, 20 mL of 1.3% LB was diluted with 40 mL normal saline and injected sub-facially before closure of the fascia. For the SFCLA group, sub-fascial tunneled catheters and a ropivacaine pump were placed. Total narcotic use was converted to IV morphine equivalents. Maximum visual analog pain scores (VAS) were noted. Cost of adjunct perioperative analgesia was compared. Statistical analysis consisted of student’s T-test, Chi-square, and ANOVA, with significance < 0.05. RESULTS 195 patients underwent LESS-DN between October 2011 and September 2013. Pain was managed with LB (n=50), SFCLA (n=68), or PCA (n=77). Patients managed with PCA used more narcotics than those on LB (63.3 mg vs. 29.4 mg, p<0.01) or SFCLA (vs. 32.9 mg, p<0.01). Narcotic use was similar between LB and SFCLA (p=0.43). PCA patients had a lower max VAS than patients on LB (5.2 vs. 6.3, p=0.02) or SFCLA (vs. 6.2, p=0.04). Operating time was longer for SFCLA compared to LB (219.8 min vs. 199.3 min, p<0.01) and PCA (vs. 202 min, p<0.01). There was no difference in length of stay (p=0.89), age (p=0.45), gender (p=0.85), BMI (p=0.20), operative side (p=0.98), or pre- and post-operative GFR (p=0.95, p=0.45). The cost of LB is approximately $285; the cost of SFCLA is approximately $460 for the device plus $400 for the ropivacaine. CONCLUSIONS LB is as effective as SFCLA in providing perioperative analgesia while decreasing OR time, likely due to its comparative ease of administration. Although patients with PCA showed slightly lower maximum VAS scores than those with LB or SFCLA, it is not likely clinically significant. Cost of LB is significantly lower than SFCLA. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e828-e829 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Adam B. Hollander More articles by this author Jason M. Scovell More articles by this author Miguel A. Mercado More articles by this author Judy M. Choi More articles by this author Edward J. Sanchez More articles by this author Lambros Stamatakis More articles by this author Alvin Goh More articles by this author Richard E. Link More articles by this author Wesley A. Mayer More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoendoscopic Single-Site Donor Nephrectomy Video

Introduction: Laparoendoscopic single-site (LESS) surgery is a modification of multiport or conventional laparoscopy. Utilizing a single site for access, LESS attempts to minimize the number of scars produced. This may result in improvements in pain, convalescence, and cosmesis. Outcomes, however, must not be compromised using this approach. At our institution, we have performed LESS donor nephrectomy (LESS-DN) and have compared it to conventional laparoscopic donor nephrectomy (LDN) in a prospective, randomized fashion to assure that LESS-DN outcomes are not inferior to LDN. The technique and the outcomes of our trial are outlined in the video. Methods: LESS-DN access is obtained through the extraction pfannenstiel incision. Three ports are placed within this incision and donor nephrectomy is performed with the aid of the EndoEye articulating scope. The colon is reflected after incising the white line of Toldt, and the ureter is identified. Dissection toward the hilum is performed and the renal artery and vein are skeletonized with branching vessels ligated and transected with hemolock clips. The lateral and upper pole renal attachments are freed and the renal artery and vein are staple ligated. The kidney is placed in an endocatch bag and extracted through the pfannenstiel incision. Results: LDN and LESS-DN were performed in 14 and 15 patients, respectively. Patients had similar parameters on study entry and had similar outcomes with LESS-DN patients enjoying less pain on postoperative days 1 and 2. Conclusion: LESS-DN is safe, feasible, and comparable to LDN. LESS-DN may result in improvement in pain and convalescence. Number of scars are decreased with the use of LESS-DN. No competing financial interests exist. Runtime of video: 5 mins 37 secs

Development of a Human Cadaver Model for Training in Laparoscopic Donor Nephrectomy and Laparoendoscopic Single Site Donor Nephrectomy

Development of a Human Cadaver Model for Training in Laparoscopic Donor Nephrectomy and Laparoendoscopic Single Site Donor Nephrectomy

Validity of an estimating formula to minimize the length of single incision in laparoendoscopic single-site donor nephrectomy

Validity of an estimating formula to minimize the length of single incision in laparoendoscopic single-site donor nephrectomy

Pfannenstiel laparoendoscopic single‐site (LESS) vs conventional multiport laparoscopic live donor nephrectomy: a prospective randomized controlled trial

To present outcomes of a randomized, patient-blinded controlled trial on Pfannenstiel laparoendoscopic single-site (LESS) vs conventional multiport laparoscopic live donor nephrectomy. Patients presenting as left kidney donors between January 2009 and November 2011 were randomized to LESS donor nephrectomy (LESS-DN: n = 15) or conventional laparoscopic donor nephrectomy (LDN: n = 14). Patients were blinded to the surgical approach preoperatively and attempts to continue patient blinding postoperatively were made by applying dressings consistent with multiple conventional laparoscopic incisions for all patients. De-identified data related to the operation, peri-operative course and postoperative follow-up were prospectively collected and compared between the two groups with an intention-to-treat analysis. There were no significant differences between the groups when comparing operating time, estimated blood loss (EBL), i.v. fluid administration, renal allograft warm ischaemia time (WIT), length of hospital stay (LOS) and total inpatient analgesic requirements. Quantitative pain assessment was not significantly different on postoperative day (POD) #0, however, it was significantly lower in the LESS-DN group, beginning on POD #1 (P < 0.05). The changes in haematocrit and serum creatinine in the two groups were not significantly different, and there were no blood transfusions in either group, nor was there a decline in estimated glomerular filtration rate to <60 mL/min per 1.73 m² of body surface area in any patients. Two patients in the LESS-DN group were converted to conventional LDN, both because of failure to progress effectively. All allografts were functional at the time of transplantation and revascularization, with no cases of hyperacute rejection. Peri-operative variables including EBL, WIT and LOS were equivalent when comparing Pfannenstiel LESS-DN with conventional LDN. Patient-reported visual analogue pain scale scores were significantly lower in the LESS-DN group beginning on the first postoperative day.

2121 RANDOMIZED CONTROLLED TRIAL OF LAPAROENDOSCOPIC SINGLE SITE DONOR NEPHRECTOMY VERSUS. CONVENTIONAL LAPAROSCOPIC DONOR NEPHRECTOMY FOR LIVING KIDNEY DONORS

INTRODUCTION AND OBJECTIVES: Laparoendoscopic single site (LESS) surgery has been increasingly used to perform donor nephrectomies. However it remains unclear if the benefits of LESS are limited to improved cosmesis. We performed a randomized controlled trial of LESS versus conventional laparoscopic donor nephrectomy (LDN) to assess potential benefits in clinical outcomes. METHODS: After IRB approval, 100 consecutive patients were randomized to a donor nephrectomy utilizing either the LESS or LDN technique starting January 2011 at a single center. Donors were stratified by laterality, single or multiple arteries, and body mass index (BMI). All LESS procedures utilized the GelPoint system (Applied Medical, RanchoSanta Margarita, CA). Subjects are followed postdonation for complications and satisfaction with validated questionnaires at 2-, 6-, and 12-months. Ninety-three patients had follow-up data for at least 2 months postoperatively. RESULTS: Baseline characteristics were similar between the two treatment arms. There were no significant differences in the overall operative time, warm ischemia time, estimated blood loss, and conversion to hand-assisted laparoscopy rates (p 0.05). There were similarly no differences in the 30and 90-day postoperative complication rates (p 0.05). Of those with follow up of at least 2 months (n 93), 97% of those who underwent LESS reported full recovery at two months, compared to 80% of LDN (p 0.03). There were no significant differences in surgical scar rating or overall satisfaction between LESS and LDN (p 0.05). All allografts had immediate graft function, and donor and graft survival are 100% to date. CONCLUSIONS: In this randomized controlled trial, we found that LESS donor nephrectomies could be performed with similar operative outcomes and postoperative complication rates. LESS donor nephrectomies have a significantly faster recovery time compared to LDN, with no impact on allograft function. Table 1: Outcomes in LDN vs LESS

2111 SUB-FASCIAL CONTINUOUS LOCAL ANESTHESIA DRAMATICALLY REDUCES NARCOTIC MEDICATION REQUIREMENTS FOLLOWING LAPARO-ENDOSCOPIC SINGLE SITE DONOR NEPHRECTOMY

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Renal Vascular Surgery1 Apr 20132111 SUB-FASCIAL CONTINUOUS LOCAL ANESTHESIA DRAMATICALLY REDUCES NARCOTIC MEDICATION REQUIREMENTS FOLLOWING LAPARO-ENDOSCOPIC SINGLE SITE DONOR NEPHRECTOMY Miguel A. Mercado, Lambros Stamatakis, Shawn Mathur, Judy M. Choi, Edward M. Sanchez, Wesley A. Mayer, and Richard E. Link Miguel A. MercadoMiguel A. Mercado Houston, TX More articles by this author , Lambros StamatakisLambros Stamatakis Houston, TX More articles by this author , Shawn MathurShawn Mathur Houston, TX More articles by this author , Judy M. ChoiJudy M. Choi Houston, TX More articles by this author , Edward M. SanchezEdward M. Sanchez Houston, TX More articles by this author , Wesley A. MayerWesley A. Mayer Houston, TX More articles by this author , and Richard E. LinkRichard E. Link Houston, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2020AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Improving pain control after donor nephrectomy may shorten convalescence and reduce barriers to kidney donation. In thoracic and abdominal surgery, sub-fascial continuous local anesthesia (SFCLA) has proven beneficial in reducing the need for narcotic pain medications in the postoperative setting. Herein, we present our experience with SFCLA with laparo-endoscopic single site donor nephrectomy (LESS-DN). METHODS We retrospectively compared all cases of LESS-DN with or without SFCLA performed at our institution by two surgeons (WAM, REL) from October 2011 to August 2012. The On-Q Pain Buster ® with Silver Soaker ™ (I-Flow, Lake Forest CA) catheter system was used for SCFLA. Bilateral catheters were tunneled into the abdominal wall under direct laparoscopic visualization just superficial to the anterior peritoneum. A bolus of 20 mL of 0.5% ropivicaine was administered per catheter, followed by infusion of the same drug at 5 mL/hour from a 725 mL reservoir. The quantity of narcotic pain medicine used +/− SFCLA during the postoperative course was converted to morphine equivalents and compared. Visual analog pain scores at discharge were also recorded. Statistical analysis was performed using the student's t-test. RESULTS Fifty cases of LESS-DN with SCFLA and 77 cases without SCFLA were performed. SCFLA significantly reduced the administered postoperative morphine equivalents by 51% (32.7 mg with SCFLA and 63.2 without SCFLA, p<0.001). No significant differences were noted in hospital length-of-stay or discharge visual analog pain scores between the groups.SCFLA placement increased operative time by 13.6 minutes (p= 0.04). No SCFLA related complications were noted. CONCLUSIONS SFCLA significantly reduces postoperative pain following LESS-DN surgery, as assessed by the amount of narcotic needed to achieve adequate pain control. Although operative time was increased slightly, there were no complications noted. This technique may be valuable in decreasing the perioperative morbidity of laparoscopic donor nephrectomy. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e865 Peer Review Report Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Miguel A. Mercado Houston, TX More articles by this author Lambros Stamatakis Houston, TX More articles by this author Shawn Mathur Houston, TX More articles by this author Judy M. Choi Houston, TX More articles by this author Edward M. Sanchez Houston, TX More articles by this author Wesley A. Mayer Houston, TX More articles by this author Richard E. Link Houston, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Comparison of laparoendoscopic single site (LESS) and conventional laparoscopic donor nephrectomy at a single institution

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Most transplant centres harvest living donor kidneys via a conventional laparoscopic surgical approach. Laparoendoscopic single-site donor nephrectomy (LESS-DN) is a relatively novel minimally invasive approach that allows the surgery to be performed via a single incision. This technique may be advantageous in decreasing surgical morbidity and improving cosmetic outcomes, thus plausibly reducing the barriers to kidney donation. The study demonstrates the safety and feasibility of LESS-DN in a large consecutive series of kidney donors. Comparative analysis between LDN and LESS-DN showed that there was a significant decrease in intra-operative blood loss and allograft warm ischaemia time in the LESS-DN group, but also a significant increase in operating time. Other peri-operative outcomes were similar between the two approaches. Evaluation of the LESS-DN cases alone revealed that, the operating times did not significantly change through the course of the series. Using this outcome as a surrogate for technical difficulty suggests a relatively shallow learning curve for LESS-DN. To present a comparative analysis of peri-operative outcomes for >200 cases of conventional laparoscopic donor nephrectomy (LDN) and laparoendoscopic single site donor nephrectomy (LESS-DN). From 2006 to 2011, 213 donor nephrectomies were performed by two surgeons (R.E.L and W.A.M.) at a tertiary transplant centre. The approach changed from conventional LDN to LESS-DN over the course of the series. The two approaches were compared retrospectively and evaluated for differences in peri-operative outcomes. Statistical significance was assessed using Student's t-test and chi-squared analysis. A total of 111 patients underwent LDN and 102 patients underwent LESS-DN. Total operating time was significantly longer in the LESS-DN group (206.1 vs 181.9 min, P < 0.001), but LESS-DN resulted in less intra-operative blood loss (61.5 mL vs 85.9 mL, P < 0.001) and shorter warm ischaemia times (4.4 vs 5.0 min, P = 0.01). There were no significant differences in analgesic requirements, subjective pain scores, length of hospital stay, postoperative graft function, or donor's postoperative glomerular filtration rate between the two approaches. Complication rates were low regardless of the approach, and there were no major complications (>grade II) in the LESS-DN group. In experienced hands, LESS-DN results in peri-operative outcomes similar to those of conventional LDN without compromising donor safety, while providing a desirable cosmetic result. For surgeons familiar with LDN, transitioning to the LESS approach using this technique appears to have a relatively short learning curve.

Trans-umbilical laparo-endoscopic single-site donor nephrectomy without the use of a single-port access device

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.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.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).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.

Transperitoneal laparoendoscopic single-site (LESS) live donor nephrectomy: the first clinical case in China

Objective To summarize out experience in the first case of transperitoneal laparoendoscopic single-site live donor nephrectomy(LESS-DN) in mainland China and to assess its safety and feasibility.Methods The female donor was aged 59-year-old,with a body mass index(BMI) of 21.6 kg/m2 and a preoperative serum creatinine level of 45 μmol/L. Tc 99m-DTPA was used to determine the glomerular filtration rate(GFR).The preoperative unilateral renal function was 50 ml/min for the left side and 56 ml/min for the right side.Recipient was a 41-year-old male,with a BMI of 19.5 kg/m2 and a preoperative serum creatinine level of 1,446 μmol/L,and who was to receive transplantation due to chronic renal dysfunction(renal failure stage).On Nov.9th,2011,the LESS-DN was performed via a multi-channel TriPortTM(Advanced Surgical Concepts,Wicklow,Ireland) through a 5 cm skin incision at our institute.The dissection of the kidney was facilitated with the standard laparoscopic instruments at all the steps.The renal artery and the renal vein were skeletonized after the adrenal vein and the lumber vein,if any,were clipped.The ureterogonadal packet was left en bloc and transected at the level when crossing the common iliac vessels.The kidney was entrapped,and the mouth of the bag loosely cinched around the intact renal artery and vein.The renal artery and the vein were separated.The pre-entrapped kidney was extracted through the original incision after generous cranial and caudal extension of the rectus fascia incision.Results The procedure was smoothly completed without any extra skin incision.The operating time was 210 min,with an estimated blood loss of 50 ml,and a warm ischemia time of 3.8 min.The lengths of harvested renal artery,vein and ureter were 3.6 cm,4.5 cm and 13 cm,respectively. The length of skin incision at closure was 5 cm.Allograft functioned immediately on transplantation.Donor Visual Analog Pain Scores at postoperative day 1,2 and 3 were 2.5/10,1/10,and 0/10,respectively.The recovery of the donor was uneventful and she was discharged on the 4th postoperative day.Postoperative serum creatinine levels of the recipient at 12 h,24 h,2 d,3 d,4 d,5 d,6 d,7 d,discharge day,and 1 month postoperatively were 475,282,148,145,117,100,103,98,80,and 84 μmol/L,respectively.He was discharged on the 10th day after transplantation.Conclusion Our initial experience shows that the laparoendoscopic single-site live donor nephrectomy is a safe,feasible and effective procedure.It has the clinical benefits of less pain,rapid recovery and good cosmesis,with an encouraging future.But more clinical experience needs to be accumulated.