Laparoscopic Donor Nephrectomy Research Articles

Renal implications of pneumoperitoneum in laparoscopic surgery: mechanisms, risk factors, and preventive strategies.

Pneumoperitoneum, which is established for laparoscopic surgery, has systemic implications on the renal system and may contribute to acute kidney injury or postoperative renal dysfunction. Specifically, when the pressure exceeds 10 mmHg, pneumoperitoneum decreases renal blood flow, leading to renal dysfunction and temporary oliguria. The renal effects of pneumoperitoneum stem from both the direct effects of increased intra-abdominal pressure and indirect factors such as carbon dioxide absorption, neuroendocrine influences, and tissue damage resulting from oxidative stress. While pneumoperitoneum can exacerbate renal dysfunction in patients with pre-existing kidney issues, preserving the function of the remaining kidney is crucial in certain procedures such as laparoscopic live donor nephrectomy. However, available evidence on the effects of pneumoperitoneum on renal function is limited and of moderate quality. This review focuses on exploring the pathophysiological hypotheses underlying kidney damage, mechanisms leading to oliguria and kidney damage, and fluid management strategies for surgical patients during pneumoperitoneum.

Robot-assisted laparoscopic retroperitoneal donor nephrectomy: a safe and efficient improvement.

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. This was a retrospective study. From June 2016 to December 2020, 218living 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. There were 60male and 158female donors aged 36-72years, with an average age of 53.1 ± 6.8years. Three patients (1.4%) were converted to open surgery. The mean operation time was 115.4 ± 41.9min, the warm ischemia time was 206.6 ± 146.7s, and the length of stay was 4.1 ± 1.4days. 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 ± 21.6min and 142.5 ± 50.7s, respectively. Robot-assisted laparoscopic retroperitoneal donor nephrectomy is a safe and efficient technique that offers advantages of shorter operation time and no abdominal organ interference.

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.

Retroperitoneal hernia following laparoscopic living-donor nephrectomy: a case report and review of literature

BackgroundThe laparoscopic approach is the standard of care for living-donor nephrectomy. A rare postoperative complication is small bowel obstruction due to a retroperitoneal hernia. We present a case of an incidental finding of a retroperitoneal hernia in a patient with a history of laparoscopic donor nephrectomy.Case presentationAn adult male presented with diffuse abdominal pain, vomiting, and obstipation for 12 h. He had undergone laparoscopic donor nephrectomy two months prior. Plain abdominal radiograph revealed a dilated small bowel with homogenous opacity in the left lumbar region. Due to worsening diffuse abdominal pain and a high clinical suspicion of intestinal strangulation and ischemia after conservative management, an exploratory laparotomy was performed. Intraoperatively, an incarcerated small bowel segment herniating through an 8 cm descending mesocolon defect into the retroperitoneal space was discovered, forming a closed-loop obstruction. The bowel segment was reduced, and the mesocolon defect was repaired. The patient was discharged five days postoperatively with good recovery.ConclusionRetroperitoneal hernia following laparoscopic living-donor nephrectomy is a rare but significant complication. Mitigation to prevent mesenteric defect creation, routine inspection, and closure of the defect can reduce the risk of hernia. Non-specific abdominal pain in patients with a history of laparoscopic donor nephrectomy prompts rapid imaging evaluation to aid in the early diagnosis of possible retroperitoneal hernia and its intervention.

Updated Comparison of Robotic Versus Laparoscopic Donor Nephrectomy

Updated Comparison of Robotic Versus Laparoscopic Donor Nephrectomy

Comparison of Optical Trocar Access Versus Veress Needle Insertion Technique for Peritoneal Entry in Laparoscopic Donor Nephrectomy

Nearly half of all complications in laparoscopic surgery occur at the intraperitoneal access. We compared direct optical entry (DOE) with Veress needle entry (VNE) in terms of abdominal entry time and entry-associated complications in patients who underwent laparoscopic donor nephrectomy (LDN). Between June 2010 and July 2023, data from 813 patients who underwent LDN were analyzed. Age, male-to-female ratio, American Society of Anesthesiologists (ASA) score, body mass index, operation side, previous abdominal surgery, abdominal entry technique, abdominal entry time, entry-associated complications, conversion to different abdominal entry techniques, and conversion to open surgery were evaluated. DOE and VNE were performed on 433 and 281 patients, respectively. Age (48.89 ± 12.11 vs 47.59 ± 11.34 years), male-to-female ratio (44.8% vs 40.9% males and 55.2% vs 59.1% females), ASA score (2 vs 2 median ASA score), body mass index (26.72 ± 6.11 vs 27.07 ± 5.83 kg/m2), and operation side (63.0% vs 61.3% left nephrectomy) were not statistically significant differences between the DOE and VNE groups (P > .05). However, abdominal entry time was significantly reduced in the DOE group compared with the VNE group (26.8 ± 20.8 vs 49.5 ± 34.1 seconds, P = .007, respectively). Entry-associated complications were observed in 8 (1.12%) patients. No major (grades 3-5) complications were observed. There were no statistically significant differences in overall (0.6% vs 1.7%, P = .291), grade 1, and grade 2 complication rates between the DOE and VNE groups (0.4% vs 1.4%, P = .366; 0.2% vs 0.3%, P = .714, respectively). DOE and VNE are not foolproof. DOE is a safe, feasible, and faster technique in patients who underwent LDN.

Comparison of Single-Port Robotic Donor Nephrectomy and Laparoscopic Donor Nephrectomy.

Purpose: To compare the intra- and postoperative outcomes of single-port robotic donor nephrectomies (SP RDNs) and laparoscopic donor nephrectomies (LDNs). Materials and Methods: We retrospectively reviewed our institutional database for patients who received LDN or SP RDN between September 2020 and December 2022. Donor baseline characteristics, intraoperative outcomes, postoperative outcomes, and recipient renal function were extracted and compared between LDN and SP RDN. SP RDN learning curve analysis based on operative time and graft extraction time was performed using cumulative sum analysis. Results: One hundred forty-four patients underwent LDN and 32 patients underwent SP RDN. LDN and SP RDN had similar operative times (LDN: 190.3 ± 28.0 minutes, SP RDN: 194.5 ± 35.1 minutes, p = 0.3253). SP RDN patients had significantly greater extraction times (LDN: 83.2 ± 40.3 seconds, SP RDN: 204.1 ± 52.2 seconds, p < 0.0001) and warm ischemia times (LDN: 145.1 ± 61.7 seconds, SP RDN: 275.4 ± 65.6 seconds, p < 0.0001). There were no differences in patient subjective pain scores, inpatient opioid usage, or Clavien-Dindo II+ complications. Short- and medium-term postoperative donor and recipient renal function were also similar between the groups. SP RDN graft extraction time and total operative time learning curves were achieved at case 27 and 13, respectively. Conclusion: SP RDN is a safe and feasible alternative to LDN that minimizes postoperative abdominal incisional scars and has a short learning curve. Future randomized prospective clinical trials are needed to confirm the findings of this study and to identify other potential benefits and drawbacks of SP RDNs.

Our Experience of Laparoscopic Living Donor Nephrectomy

Background Donor nephrectomy for living donor kidney transplantation using minimally invasive techniques is a safe procedure that has been used for more than 20 years with excellent results. The total minimally invasive approach offers decreased postoperative pain, better cosmesis, a lower chance of incisional hernia, and a faster recovery time. Methods We present the results of a series of 120 laparoscopic donor nephrectomies performed at our center. The procedures were performed with transperitoneal access using the standard five ports. The main renal artery and vein were ligated using a hemo-o-lock clip. The specimen was extracted through the additional inguinal incision. Results All procedures were performed laparoscopically without conversion to open surgery. The average warm ischemia time was 4.0 min. In all recipients, immediate kidney allograft function was seen. Conclusion Total laparoscopic living donor nephrectomy is a safe procedure that gives the highest benefit to the donor. It was performed successfully in all cases, with a short operative time and no morbidity or mortality.

Peri-Incisional Infiltration and Intraperitoneal Instillation of Local Anesthetic for Reducing Pain After Laparoscopic Donor Nephrectomy: A Prospective, Randomized, Double-Blind Control Trial

The analgesic efficacy of peri-incisional infiltration and intraperitoneal instillation of ropivacaine in laparoscopic donor nephrectomy has not been clearly established. This randomized, controlled, double-blind trial allocated living donors undergoing left-sided laparoscopic donor nephrectomy to one of the following 4 groups: peri-incisional normal saline (NS) and intraperitoneal NS (group A, n=30), peri-incisional 0.375% ropivacaine and intraperitoneal NS (group B, n=31), peri-incisional NS and intraperitoneal 0.15% ropivacaine (group C, n=31), and peri-incisional 0.375% and intraperitoneal 0.15% ropivacaine (group D, n=32). Pain status was assessed using the visual analog scale at rest and during coughing at 2, 12, 24, and 48 hours postoperatively. Patient-controlled analgesia and additional rescue analgesic consumption were calculated by conversion to an equivalent dosage of morphine. This study did not include prisoners or those individuals who were coerced or paid as study participants. The patient demographics and perioperative outcomes, including operative time, blood loss, and incision length, were comparable between the groups. The pain scores and number of patients who experienced shoulder pain at all postoperative time points did not differ significantly among the 4 groups. Postoperative analgesic consumption was similar in all groups, and there was no difference in the length of hospital stay. Peri-incisional infiltration and intraperitoneal instillation of ropivacaine did not reduce postoperative pain or analgetic consumption.

Safety of Patients with Renal Artery Aneurysm to Proceed with Living Donation.

Renal artery aneurysm (RAA) is a rare condition that involves dilation of all layers of the arterial wall of the renal artery. The risk of rupture is rare, but intervention is recommended for larger aneurysms. Surgical decision-making regarding live donor renal transplantation (LDRT) centers around safety for the living donor, and laterality of the donated kidney is based on providing the donor with the best longevity pertaining to the remaining kidney. We looked to review our long-term outcomes surrounding live donor transplants from donors with RAA with ex vivo resection and reconstruction prior to implantation. A retrospective review was done of all laparoscopic live donor transplant nephrectomies with ex vivo aneurysm resection, reconstruction, and implantation at a single center. Three pairs of patients underwent successful laparoscopic donor nephrectomy, RAA resection, reconstruction, and transplantation of kidney. 2 males and 1 female ages 47 to 58years of age underwent transplantation. The donors at 5years of follow-up were noted to be functioning appropriately with no long-term sequelae of their donation and a mean remanent kidney function of 63mL/min. For potential live donors with asymptomatic, unilateral renal artery aneurysm and no systemic disease, live donation with ex vivo resection and reconstruction can be performed with excellent long-term donor and recipient outcomes.

A bidirectional cohort study to compare the outcomes of transperitoneal and retroperitoneal approaches in subjects undergoing laparoscopic live donor nephrectomy

Abstract Background Laparoscopic transperitoneal donor nephrectomy (LDN) is currently the standard procedure for renal donation from living donors. Only a handful of clinical studies have compared the outcomes of retroperitoneoscopic donor nephrectomy (RLDN) and LDN. More robust data and systematic comparative analyses of the outcomes and complications of these 2 techniques are needed. This study aimed to elucidate the noninferiority of RLDN to LDN. Materials and methods All live renal donors who underwent either RLDN or LDN at our institution during the period of January 2015 to March 2021 were considered subjects, excluding those who refused to participate in the study. This was a bidirectional cohort study. Demographic and clinical data were collected and analyzed using standard statistical methods. Statistical significance was set at p &lt; 0.05. Results Our study included 89 subjects: 40 in the LDN group and 49 in the RLDN group. The RLDN group had significantly shorter warm ischemia time (2.85 vs. 6.04 minutes), a lower fall in hemoglobin on postoperative day (POD)-1 (1.73 vs. 2.24 g/dL), lower estimated blood loss (601.93 vs. 797.27 mL), and lower pain on POD-1 (0.78 vs. 1.28). The improvement in recipient’s estimated glomerular filtration rate on POD-30 was significantly higher in the RLDN group (79.98 vs. 63.73 mL/min/1.73 m2). There was a significantly higher fall in estimated glomerular filtration rate of donor after nephrectomy in RLDN group on POD-30 (35.53 vs. 30.60 mL/min/1.73 m2). However, there were no significant differences in other parameters. Conclusions Our study, conducted in India, showed that the majority of RLDN outcomes were better than those of LDN. Hence, RLDN is clearly non-inferior to the gold standard LDN. A well-designed randomized controlled study is required to elucidate the statistical superiority of one approach over another.

VE23 - Robot-assisted laparoscopic donor nephrectomy in patients with complex hilar vessel anatomy

VE23 - Robot-assisted laparoscopic donor nephrectomy in patients with complex hilar vessel anatomy

SP3.11 Laparoscopic Donor Nephrectomy (LDN) Training in the UK. A National Re-Audit of the Trainee Experience

Abstract Purpose An Independent National-Trainee-Survey reported poor LDN training opportunities in the UK in 2014. It recommended LDN fellowships and LDN training as a part of the Transplant Curriculum. A Re-audit of the initial study was done to gauge improvement. Methods A short electronic survey was disseminated to surgical trainees via a web-based link (Survey-monkey) placed on the Herrick-Society forum and email/paper invitations to renal transplant units across the UK. Results 57 (53 in 2013) responses were received from the UK in 2022. Women in transplant training are still scarce OR 0.91 (0.40-2.06, p=0.49). 03% of units in the UK offer robotic-assisted LDN at present. In comparison to 2013, in 2022, 16%vs 20% of trainees were PGY1-3; 25% vs. 14% PGY 4-6; 17% vs. 18% post-residency training; 32 % vs. 31% IMG-non-training&amp;gt; 2 yr. transplant experience; 10%vs 09% IMG-non training &amp;lt; 2 yr. transplant experience (p=0.67). 92% vs. 91% of trainees reported that they had performed &amp;lt;01 LDN as primary-surgeon OR 0.87 (0.32-2.37, p=0.50). Only 33 % of trainees had been on a course for LDN. There was no correlation to seniority in training grade performing donor nephrectomies as a primary surgeon (p=0.76). There was no significant advantage to trainees on rotation (p=0.71) to service trainees (p=0.69) to perform LDN as primary surgeons. The likelihood of a trainee performing &amp;gt;01 LDN as a primary surgeon is &amp;lt;1 in 30 compared to &amp;lt; 1 in 25 (2013). Conclusions This study reports no improvement in training opportunities in LDN. The Trainers have yet to utilize the previous 2014 report to augment training opportunities in the UK.

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

Although laparoscopic donor nephrectomy (LDN) represents the gold-standard technique for kidney living donation, robotic donor nephrectomy (RDN) settled as another appealing minimally invasive technique over the past decades. A comparison between LDN and RDN outcomes was performed. RDN and LDN outcomes were compared, focusing on operative time and perioperative risk factors affecting surgery duration. Learning curves for both techniques were compared through spline regression and cumulative sum models. The study analyzed 512 procedures (154 RDN and 358 LDN procedures) performed between 2010 and 2021 in 2 different high-volume transplant centers. The RDN group presented a higher prevalence of arterial variations (36.2 versus 22.4%; P = 0.001) compared with the LDN cohort. No open conversions occurred; operative time (210 versus 195 min; P = 0.011) and warm ischemia time (WIT; 230 versus 180 s; P < 0.001) were longer in RDN. Postoperative complication rate was similar (8.4% versus 11.5%; P = 0.49); the RDN group showed shorter hospital stay (4 versus 5 d; P < 0.001). Spline regression models depicted a faster learning curve in the RDN group ( P = 0.0002). Accordingly, cumulative sum analysis highlighted a turning point after about 50 procedures among the RDN cohort and after about 100 procedures among the LDN group.Higher body mass index resulted as an independent risk factor for longer operative time for both techniques; multiple arteries significantly prolonged operative time in LDN, whereas RDN was longer in right kidney procurements; both procedures were equally shortened by growing surgical experience. RDN grants a faster learning curve and improves multiple vessel handling. Incidence of postoperative complications was low for both techniques.

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

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

How Does Surgeons' Autonomic Physiology Vary Intraoperatively?: A Real-time Study of Cardiac Reactivity.

To measure the physiological responses of surgical team members under varying levels of intraoperative risk. Measurement of intraoperative physiological responses provides insight into how operation complexity, phase of surgery, and surgeon seniority impact stress. Autonomic nervous system responses (interbeat intervals, IBIs) were measured continuously during different surgical operations of various complexity. The study investigated whether professional role (eg attending surgeon), operative risk (high vs. low), and type of primary operator (attending surgeon vs. resident) impacted IBI reactivity. Physiological synchrony captured the degree of correspondence between individuals' physiological responses at any given time point. A total of 10,005 observations of IBI reactivity were recorded in 26 participants during 16 high-risk (renal transplant and laparoscopic donor nephrectomy) and low-risk (arteriovenous fistula formation) operations. Attending surgeons showed greater IBI reactivity (faster heart rate) than residents and nurses during high-risk operations and while actively operating (Ps<0.001). Residents showed lower reactivity during high-risk (relative to low-risk) operations (P<0.001) and similar reactivity regardless of whether they or the attending surgeon was operating (P=0.10). Nurses responded similarly during low-risk and high-risk operations (P=0.102) but were more reactive when the resident was operating compared to when the attending surgeon was the primary operator (P<0.001). In high-risk operations, attending surgeons had negative physiological covariation with residents and nurses (P<0.001). In low-risk operations, only attending surgeons and nurses were synchronized (P<0.001). Attending surgeons' physiological responses were well-calibrated to operative demands. Residents' and nurses' responses were not callibrated to the same extent. This suggests that risk sensitivity is an adaptive response to stress that surgeons acquire.

Laparoscopic to robotic living donor nephrectomy: Is it time to change surgical technique?

We aimed to explore differences in outcomes of robotic and laparoscopic donor nephrectomies (LDN). This study compared robotic and laparoscopic surgical techniques for live donor nephrectomies in 153 patients at a single centre. Left nephrectomies were more common in both groups, but with no significant difference between the groups (76.6% vs. 77.6%, p=0.88). The robotic donor nephrectomies (RDN) group experienced significantly less blood loss (60 vs. 134mL, p<0.01), but warm ischaemia time was similar between groups (3.2 vs. 3.7min, p=0.54).The RDN group had decreased subjective pain scores (3.54 vs. 4.21, p=0.04) and shorter length of hospitalisation (2.22 vs. 3.04days, p<0.01).There were also fewer complications in the RDN than the LDN group (4 vs. 8, p=0.186). This study demonstrated that RDN is a safe and alternative to LDN. Decreased blood loss and hospital stays and fewer complications may reflect decreased tissue manipulation with robotic assistance.

MRI measurement of the effects of moderate and deep neuromuscular blockade on the abdominal working space during laparoscopic surgery, a clinical study

BackgroundConflicting data exist regarding the effects of deep neuromuscular blockade (NMB) on abdominal dimensions during laparoscopic procedures.We performed a clinical study to establish the influence of moderate and deep neuromuscular blockade (NMB) on the abdominal working space, measured by Magnetic Resonance Imaging (MRI), during laparoscopic donor nephrectomy with standard pressure (12 mmHg) pneumoperitoneum under sevoflurane anaesthesia.MethodsTen patients were intraoperatively scanned three times in the lateral decubitus position, with pneumoperitoneum maintained by a mobile insufflator. The first scan without NMB (T1) was followed by scans with moderate (T2) and deep NMB (T3). The skin-sacral promontory (S-SP) distance was measured, and 3D pneumoperitoneum volumes were reconstructed.ResultsThe mean difference in the S-SP distance was -0.32 cm between T2 and T3 (95% CI -1.06 - 0.42 cm; p = 0.344) and + 2.1 cm between T1 and T2 (95% CI 0.81 - 3.39 cm; p = 0.006). The mean differences in pneumoperitoneum volume were 166 mL between T2 and T3 (95% CI, 5 - 327 mL; p = 0.044) and 108 mL between T1 and T2 (95% CI, -273 - 488 mL; p = 0.525). The pneumoperitoneum volume showed high inter-individual variability and no increase in three patients with a high volume at T1.ConclusionsDuring laparoscopic surgery in the lateral decubitus position with standard pressure under sevoflurane anaesthesia, deep NMB did not increase the S-SP distance compared to moderate NMB. Moderate NMB increased the S-SP distance by a mean of 2.1 cm (15.2%) compared with no NMB. The mean pneumoperitoneum volume increased slightly from moderate to deep NMB, with high inter-individual variability.Trial registrationClinicaltrials.gov ID: NCT03287388.

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

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. This is a prospective cohort study done in a single high-volume transplant center. 153 kidney donors were evaluated over a period of 1year. 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. 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. 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.

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. 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. RDN was associated with a longer total operative time (RDN 182 vs LDN 144min; P < 0.0001) but a significantly shorter post-operative length of stay (RDN 1.8 vs LDN 2.1days; 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. 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.