Laparoscopic Live Donor Nephrectomy Research Articles

The Significance of the Circumaortic Left Renal Vein and Other Venous Variations in Laparoscopic Living Donor Nephrectomies

Among the several vascular variation those concerning the venous system of the kidneys show the most significant variability. They often play an important role when it comes to choosing the kidney to be removed for transplantation. Based on our prior studies, we have surveyed these variations. When performing a laparoscopic living donor nephrectomy owing to the limited field of vision and the restricted possibilities for preparation, preoperative radiologic planning is of utmost importance. We evaluated 55 donors who underwent laparoscopic nephrectomies using the 16-section multidetector-row computed tomography angiography. Among the donors who underwent surgeries we observed circumaortic veins (CAV) in three cases, retroaortic veins in 6 cases, multiple renal veins in 10 cases, and a lumbar vein draining into the left renal vein (RV) in 30 cases. In the 2 cases wherein CAVs were discovered, the team decided to use the other kidney. In 1 case, due to a short right RV, we chose the left kidney. The complex development of the CAV that is sometimes difficult to reconstruct in 3D poses a challenge for both the radiologist and the surgeon.

Open Versus Laparoscopic Donor Nephrectomy: Perioperative Parameters and Graft Functions

Objective With the developments in laparoscopic surgery, open donor nephrectomy has been widely replaced by laparoscopic donor nephrectomy. Presented herein is the comparison of laparoscopic live donor nephrectomy (LLDN) and open live donor nephrectomy (OLDN) results performed at our institute. Materials and Methods Patients who underwent OLDN between July 2006 and August 2008 or LLDN between August 2008 and July 2010 were included in this retrospective age- and gender-matched case-controlled study. OLDN was performed with a 45° semi-flank position using a self-retaining retractor. LLDN operations were performed used a 90° flank position by the transperitoneal route under 12–15 mm Hg carbon dioxide (CO 2) pressure. A Pfannenstiel incision was used in all LLDN for graft extraction. The renal artery and vein were controlled with Satinsky clamps in OLDN, whereas renal arteries were controlled with nonabsorbable polymer locking clips and renal veins with 2.5/45 mm EndoGIA vascular staplers in LLDN. Results Thirty patients underwent OLDN and 31 LLDN. The mean ages among the OLDN and LLDN patients were 44.9 ± 21.9 and 46.3 ± 18.4, respectively. There was no significant difference in mean age and gender distribution of patients between OLDN and LLDN groups by the design of the study. The OLDN group consisted of 4 (13%) right and 26 (87%) left nephrectomies; the LLDN group consisted of 3 (9%) right and 28 (91%) left nephrectomies. Mean operative time was 110 ± 18 and 101 ± 28 minutes for OLDN and LLDN, respectively ( P < .05; Mann-Whitney U test). Estimated blood loss was 35 ± 15 mL among the OLDN group and 15 ± 24 mL for the LLDN group. Mean hospitalization time in the OLDN and LLDN groups were 3.8 ± 0.5 and 2.6 ± 0.6 days, respectively. There were no conversions to open surgery in the LLDN group. Mean warm ischemia time in the OLDN and LLDN groups were 140 ± 58 seconds and 203 ± 21 seconds, respectively ( P < .05; Mann-Whitney U test). There was no difference in recipient serum creatinine levels at 1 week after surgery. Conclusion LLDN was superior to OLDN in terms of operative time, estimated blood loss, length of hospital stay, and postoperative pain. Longer warm ischemia time in the LLDN group did not translate into worse graft function in the recipients.

Feasibility of Transvaginal Natural Orifice Transluminal Endoscopic Surgery–Assisted Living Donor Nephrectomy: Is Kidney Vaginal Delivery the Approach of the Future?

BackgroundNatural orifice transluminal endoscopic surgery (NOTES) uses natural orifices to access the abdominal cavity. We adapted NOTES to perform transvaginal NOTES-assisted laparoscopic nephrectomy in living donors. ObjectiveTo assess the feasibility and reproducibility of this procedure and compare it with conventional laparoscopic living donor nephrectomy (LLDN). Design, setting, and participantsFrom July 2009 to October 2010, 20 women underwent transvaginal NOTES-assisted living donor nephrectomy (LDN) in our centre. We compared the prospectively collected clinical data of each donor with those of a contemporaneous matched pair of conventional LLDNs (40 donors). Surgical procedureThe procedure was performed using three abdominal trocars and one trocar through the vaginal wall. MeasurementsVariables evaluated for donors were procedure length, blood loss, warm ischaemia time (WIT), complications, hospital stay, and first-month creatinine nadir. In the transvaginal LDN group, sexual function was assessed with the Female Sexual Function Index questionnaire before and after surgery. Variables evaluated for recipients were complications, graft function, and creatinine evolution. Results and limitationsThe procedure was completed in all cases. Operative variables were similar for both groups except for WIT, which was longer in the transvaginal LDN group (p<0.001) without consequences for graft functioning. One transvaginal LDN case had postoperative bleeding requiring immediate open surgery. All transvaginal LDN donors reported unaltered sexual function after surgery and satisfaction with the results. All recipients had immediate urine output, and all had a functioning graft at last follow-up except for one recipient of the transvaginal LDN group who required transplantectomy. Despite promising results, randomised controlled studies with longer follow-up are warranted to further elucidate the potential of this novel technique. ConclusionsTransvaginal NOTES-assisted LDN appears to be a feasible and reproducible surgical technique. The WIT was longer in the transvaginal group, and there was no effect on graft function after the short follow-up.

Overcoming the learning curve in hand-assisted laparoscopic live donor nephrectomy - a study in the animal model.

The demand for kidneys in South Africa is staggering. Only 38% of the kidney transplants done in 2008 were from related living donors. Laparoscopic living donor nephrectomy has been shown to have the advantages of decreased postoperative pain, better cosmesis and a quicker return to work when compared with the open technique. With limited surgical expertise, a realistic model was needed to overcome the learning curve. Methods. A total of 21 nephrectomies were performed on 12 pigs. The transperitoneal hand-assisted laparoscopic technique was used. Results. The median operative time was 75 minutes and the median warm ischaemic time 88 seconds. Three cases were aborted owing to major vascular injuries. Discussion. The advent of laparoscopic techniques has been associated with an increase in morbidity and complications in donor and recipient during the initial learning curve. We found that with our porcine model, 21 nephrectomies were adequate in overcoming the learning curve. After 15 nephrectomies no complications were noted.

Laparoscopic Live Donor Nephrectomy: A Technical Road Map

Laparoscopic live donor nephrectomy is a safe, minimally invasive alternative to the customary open approach. During the past two decades, laparoscopic renal surgery has increased the availability of renal allograft specimens for transplantation. Specifically, the laparoscopic approach has minimized postoperative pain and duration of recovery, making it a more attractive option for potential altruistic organ donors. Here we detail the techniques, challenges, and troubleshooting approaches necessary for this technically challenging, yet valuable operation.

Retroperitoneal laparoscopic live donor nephrectomy: Report of 105 cases

Retroperitoneal laparoscopic live donor nephrectomy offers an intrinsic advantage over conventional transperitoneal laparoscopic nephrectomy because of the potentially lower risk for early and late donor intraperitoneal complications. Herein we presented our experience performing retroperitoneal laparoscopic live donor nephrectomy in 105 donors. All donor nephrectomy was successful. There were no donor deaths and no conversion to open surgery. Mean operation time was 112 min (range, 70-200 min). Intraoperative blood loss was 10-150 mL with an average of 30 mL. Warm ischemia time was 1.3 to 6 min with an average of 3.1 min. Postoperative retroperitoneal hematoma occurred in only one case and there were no other surgical complications. Donors were discharged from the hospital 5 to 10 days postoperation. Average postoperative hospital stay was 6.4 days. One graft was removed due to acute rejection. Delayed graft function occurred in two recipients but renal function returned to normal within four weeks. The other recipients had normal renal function in two weeks except three recipients in four weeks. We believe that retroperitoneal laparoscopic live donor nephrectomy is safe, reliable, and less invasive.

Single-Site Laparoscopic Living Donor Nephrectomy Offers Comparable Perioperative Outcomes to Conventional Laparoscopic Living Donor Nephrectomy at a Higher Cost

Single-Site Laparoscopic Living Donor Nephrectomy Offers Comparable Perioperative Outcomes to Conventional Laparoscopic Living Donor Nephrectomy at a Higher Cost

Perioperative nursing of the patients accepting laparoscopic living donor nephrectomy

Objective To summarize the nursing experience of the patients who had accepted laparoscopic living donor nephrectomy and give the guidance to the nursing work. Methods 26 patients who had undergone laparoscopic living donor nephrectomy were recruited and treated with specific nursing and the nursing measures were summarized. Results All the 26 patients recovered well and discharged. There were no complications from 2 to 34 months' following up time. Their renal functions were all normal and the quality of life was not evidently different from that of preoperative. Conclusions Retroperitoneal laparoscopic liying donor nephrectomy could speed up the rehabilitation of donor and ensue their quality of life. Key words: Retroperitoneal laparoscopic; Living donor nephrectomy; Donor; Perioperative period; Nursing

Laparoscopic Live Donor Nephrectomy with Vaginal Extraction: Initial Report

Laparoscopic Live Donor Nephrectomy with Vaginal Extraction: Initial Report

Laparoscopic donor nephrectomy

Kidney transplantation is a definitive treatment of end-stage renal disease. Laparoscopic donor nephrectomy (LDN) has been widely accepted around the world since its introduction in 1995 as a minimum invasive procedure. We report our clinical experience of 141 consecutive LDNs performed in two tertiary hospitals in Western Australia. From December 2000 (Royal Perth Hospital) and January 2005 (Sir Charles Gairdner Hospital) to January 2009, 141 LDNs were performed in two tertiary hospitals by four urologists. All donors underwent rigorous work-up prior to surgery. Donor age ranged from 23 years to 81 years (49.85 ± 11.30 years). The male to female ratio was 1 to 1.3. Donor body mass index (BMI) was 26.77 ± 4.31, and glomerular filtration rate was 96.25 ± 12.33 mL/min/1.73 sqm. The laparoscopic technique was transperitoneal approach exclusively. All LDNs were performed successfully without hand assistance. The warm ischaemic time ranged from 3 to 11 min. The hospital stay was 4.16 ± 1.30 days. The overall complication rate was 17.0%, with three major complications (2.1%): a splenetic infarction, a chylous ascites and a pulmonary embolism occurred. Donors' demographic data (age, sex, BMI, side of surgery) did not show a statistically significant association with surgical complications. Transperitoneal laparoscopic live donor nephrectomy is a safe and effective procedure. Combined use of vascular stapler and Hem-o-Lok is very important for management of the renal artery stump. It is our current practice to administer anticoagulants during and post-surgery for at least 2 weeks.

Comparison of effect between retroperitoneal laparoscopic living donor nephrectomy and open surgery

Objective To study the advantage of retroperitoneal laparoscopic living donor nephrectomy through comparative study on postoperative care between retroperitoneal laparoscopic living donor nephrectomy and open surgery. Methods During the period from August 2007 to December 2009, living donor nephrectomy were divided into 25 cases of retroperitoneal laparoscopic surgery and 20 cases of open surgery. The nursing characteristics were compared. Results The operation and recovery of all patients are successful. The drainage tube indwelling days, urinary catheter indwelling days, postoperative bed time, days of absolute diet and hospitalization in retroperitoneal laparoscopic surgery group were significantly shorter than those in open surgery group(P <0. 01). Conclusions Retroperitoneal laparoscopic living donor nephrectomy has the advantages of minimally invasive, rapid recovery and fewer hospital days, Worth being popularized in clinical otolaryngology application Key words: Retroperitoneal laparoscopic liviny donor nephrectomy; Open surgery; Nursing

Retroperitoneoscopic Living Donor Nephrectomy: Experience of 425 Cases at a Single Center

Laparoscopic living donor nephrectomy (LLDN) is a standard method of donor nephrectomy. Most cases of LLDN are transperitoneal. Retroperitoneal access, however, implies a direct approach to the retroperitoneal organs without interfering with any of them. Since 2001, we have been trying to establish the technique of retroperitoneoscopic live donor nephrectomy (RPLDN). To assess the safety, feasibility, and usefulness of RPLDN, we reviewed the experience with this technique at our institution. From July 2001 to March 2009, 425 patients underwent live donor renal transplantation at our institution with allografts procured by RPLDN. Study variables included operative time, time to retrieval of the kidney, blood loss, warm ischemia time, length of hospital stay, number and length of renal vessels, graft function, and complications. Mean follow-up was 53 months. Donor nephrectomy was performed successfully in all patients. The complication rate was 4.9%. In one case, the procedure was changed to open donor nephrectomy because of severe adhesion in the renal hilum from previous surgery. Ureteral complications occurred in four patients, who were successfully treated with retrograde ureteral stent placement. None of the donors needed readmission. Mean warm ischemia time was 4.8 minutes. Creatinine levels returned to normal in all patients, and long-term allograft function was good. Serum creatinine levels at postoperative days 1, 7, and 14 were 3.7 mg/dL, 1.4 mg/dL, and 1.4 mg/dL on average, respectively. Slow graft function was noted in four (1.1%) cases but returned to the normal level within 2 weeks after surgery. One-year donor survival was 99%, and 1-year graft survival was 98.2%. Excellent donor safety and allograft function were obtained with RPLDN. These results suggest that RPLDN could be an option for LLDN.

Transperitoneal Deviceless Hand-Assisted Laparoscopic Living Donor Nephrectomy: An Alternative Technique for Kidney Recovery

Deviceless hand-assisted laparoscopic living donor nephrectomy is an alternative surgical technique that relies on the classic laparoscopic approach, supported by insertion of the surgeon's hand during kidney recovery without the need to use any device because of the sealing effect of the particular wall incision. From 2006 to 2008, deviceless hand-assisted laparoscopic living donor nephrectomy was performed in 25 patients (M/F = 7/18; mean age = 53 years; range = 30-68). One right nephrectomy was performed. We made a lateral paramedian incision. No sealing device is required in our technique because the pneumoperitoneum is maintained by the sealing effect of two complexes: the peritoneum/deep rectus abdominis muscle fascia and muscle itself/lateral edge of the double fascial incision. These structures clench around the surgeon's wrist, preventing leakage of CO₂. After dissection, the kidney is removed through the hand port without an endobag. Mean surgical time was 105 minutes (range = 60-150), estimated blood loss was 50 to 200 mL, and mean warm ischemia time was 3.5 minutes (range = 2-11). Mean hospital stay was 4 days (range = 3-6). One uncontrollable hemorrhage due to a renal vein lesion required conversion to open surgery. As to graft function, recipient serum creatinine on day 7 ranged from 0.8 to 2.6 mg/dL. The ability to better control bleeding by manual compression, as well as the advantages related to decreased donor morbidity, shorter hospital stay, cost saving, and excellent graft function, make this deviceless technique a good option for kidney recovery.

Are there anatomical barriers to laparoscopic donor nephrectomy?

The aim of this study was to analyse the effect of the right donor kidney and multiple arteries, on donor and recipient outcomes in the era of laparoscopic live donor nephrectomy (LLDN). e retrospectively analysed the 200 donors and recipients who underwent a planned laparoscopic nephrectomy at two hospitals between September 1998 and December 2006. The impact of donor right kidney and multiple donor renal arteries on operative time, hospital stay, graft function, and donor and recipient complications were analysed. Of the total cohort (n=200), 140 (70%) were classified as Simple LLDN (left live donor kidney with single renal artery). The Complex LLDN group (n=60) contained all right-sided kidney (n=28) and left-sided kidneys with multiple renal arteries (n=32). Baseline characteristics, extraction time, conversion to open, length of admission, overall graft function and complication rates were similar between the simple and complex groups. The second warm ischaemic time in the Simple LLDN group was slightly shorter than the Complex LLDN group (32 versus 36 min P=0.016). The 1-month post-operative recipient serum creatinine level was lower in the Simple LLDN group when compared with the Complex LLDN group (117 versus 125 µmol/L P=0.025). There was no difference in post op dialysis, acute rejection within 3 months or graft survival between the Simple and Complex LLDN groups. Laparoscopic procurements of right kidneys and kidneys with multiple arteries were safe and yielded kidneys with excellent function comparable with those of laparoscopic left donor nephrectomy with single artery.

Minimally Invasive Renal Auto-Transplantation: The First Report

Regarding transplant surgery, the minimally invasive revolution was started in 1995 by laparoscopic living donor nephrectomy (L-LDN). In 2006, we made the first report on a minimally invasive technique for kidney transplantation; restricted to a 7-9 cm transverse incision targeted on the anastomotic area of the iliac vessels, and with the meticulously prepared kidney placed in a fitting, retroperitoneal pouch lateral to the skin incision. By combining "hand-assisted laparoscopic nephrectomy" and "minimally invasive kidney transplantation" - using the same incision (7-8 cm) for hand-assistance, kidney harvesting, and transplantation - we have during 2009 conducted "minimally invasive renal auto-transplantation" in two patients. In both cases, the postoperative course was uneventful. When examined 3 mo postoperatively, both auto-transplants were shown to have excellent function by renal scintigraphy. Renal auto-transplantation, a traditionally major surgical procedure, can be made minimally invasive by a similar incision as that used for L-LDN. Taking into regard the highly traumatic conventional incisions, we expect the generally proven minimally invasive benefits to be considerable.

Significance and Imaging of Lumbar Veins and Early-Branching Arteries in Planning Living-Donor Laparoscopic Nephrectomy: Two Case Reports From 21 Months' Experience

A key aspect in planning laparoscopic living-donor nephrectomy is mapping of vascular variations. Lumbar veins and early-branching renal arteries are of utmost importance. To date, 43 candidates including 18 men and 25 women aged 25 to 67 years have been examined at our clinic using 16-section multidetector-row computed tomography angiography. Each examination was double-checked by an experienced radiologist. Of the 43 patients, 31 underwent surgery. In 29 of 31 patients (93.5%), the anatomy observed during surgery was identical to that demonstrated on the preoperative computed tomography scan. In 1 of 2 patients, 2 separate arteries were found at surgery, rather than the prognosticated early-branching arteries. In this patient, conversion to open surgery was necessary. In the other patient, a lumbar vein running into a retroaortic renal vein was discovered. In this patient, a 6-mm length of the joint stem contained the wall of the aorta and the periaortic tissue; thus, technically they were of separate origins. Careful mapping of the anatomy helps to prevent unexpected operative complications that are difficult to manage. Correct interpretation of the data must always be based on agreement between the radiologist and the surgeon.

Open and Laparoscopic Donor Nephrectomy: Activity and Outcomes From all Australasian Transplant Centers

Laparoscopic donor nephrectomy (LapDN) has been widely adopted despite a lack of randomized trials comparing recipient outcomes with open surgery. Review of registry data now seems the most realistic mechanism to compare outcomes. The Australia and New Zealand Dialysis and Transplant Registry prospectively captures data on all renal transplants performed in Australia and New Zealand including long-term follow-up of recipients. AIM.: To compare graft outcomes among recipient of kidneys from donors undergoing nephrectomy using open and laparoscopic techniques, through analysis of the Australia and New Zealand Dialysis and Transplant Registry after the introduction of laparoscopic donor surgery in Australia and New Zealand in 1997. Operative technique data for live donor transplants were collected from all surgeons performing live kidney donation procedures from May 1997 to December 2003; the outcomes of all live donor transplants were examined with follow-up to December 2007. Donor and recipient demographic variables and graft outcomes were compared between the laparoscopic and the open donor groups. One thousand four hundred seventy-four live donor transplants were performed in 27 transplant centers. Of these, 315 (21%) were performed laparoscopically in 11 centers. Nineteen laparoscopic cases (6%) were converted to open. Total ischemic time was longer in the LapDN group (3.16 hr) than in the open donor group (1.61 hr, P<0.0001). The LapDN group experienced a lower incidence of rejection episodes (29.2% vs. 38.6%, P=0.002). Delayed graft function and technical failure rates were statistically equal across the groups. There were a total of 242 graft failures (175 graft losses and 67 deaths with a functioning graft, NS). Among surviving grafts, there was no consistent difference in serum creatinine at any time point. Graft and patient survivals were similar in both groups during 10-year follow-up. This study suggests that there is no difference in short- or long-term recipient outcomes for open and laparoscopic live donor nephrectomy.

Impact of Hand-Assisted Laparoscopic Living Donor Nephrectomy on Donor's Quality of Life, Emotional, and Social State

Background Laparoscopic donor nephrectomy has become the preferred method for live kidney donation in many centers. Herein we have reported on donor-related quality of life (QoL) and social state after laparoscopic hand-assisted nephrectomy (HALDN) for living kidney donation. Patients and Methods Between December, 2003 and May, 2008, we performed 48 HALDN. To evaluate QoL, we mailed to the donors a structured questionnaire based on a combination of the WHOQOL-BREF questionnaire and the 36-item health survey (SF-36) with slight modifications. The QoL scores were compared with data from a matched group of the German healthy population. We evaluated clinical results in donors and recipients by reviewing the records, and calculated 1-year graft survival according to the Kaplan-Meier method. Results In all domains, the QoL scores were higher than those among the normal population. The higher QoL was independent of time since donation. When asked to rate their health at the time of the questionnaire, 91% rated it as good, very good, or excellent, 6% as fair, and 3% as poor. When asked to rate the pain around their scar, 91% rated it as mild or absent: Of the patients, 94% were likely to say that they would donate again, if it were possible. For 6% of the patients the overall experience was stressful. Conclusion HALDN is safe. QoL changes after kidney donation are low and comparable to those of the healthy population.

Laparoscopic donor nephrectomy – safety in a small‐volume transplant center

Laparoscopy is a standard surgical option for live donor nephrectomy (LDN) at the majority of transplant centers. Equivalent graft survival with shorter convalescence has been reported by several large volume centers. With the arrival of an experienced laparoscopic surgeon in 2002, we began to offer laparoscopic LDN at our institution. We report our experience as a large volume laparoscopic surgery program but a low volume transplant center. A retrospective review of the previous 34 LDN (17 open, 17 laparoscopic) performed at the University of Missouri were included. A single laparoscopic surgeon performed all laparoscopic procedures. Hand assisted laparoscopy was performed in 15 and standard laparoscopy with a pfannenstiel incision in two. Open procedures were performed through anterior subcostal or flank incision. A single surgeon performed all open procedures. There was no statistical difference in age, body mass index or American Society of Anesthesiologies Score between the two groups. Mean operative time, estimated blood loss and hospital stay were 229 minutes, 324 cc and 2.2 days respectively in the laparoscopic group compared to 202 minutes, 440 cc and five days for the open group. Average warm ischemia time was 179 seconds. Recipient creatinine for the two groups at one week, one month and one year was not statistically significantly different. Each group had one graft loss due to medication noncompliance. For small transplant centers with an advanced laparoscopic program, laparoscopic LDN is a safe procedure with comparable outcomes to major transplant centers.

Outcomes of Laparoscopic Donor Nephrectomy Without Intraoperative Systemic Heparinization

Intravenous heparin has traditionally been given during living donor laparoscopic nephrectomy despite the paucity of evidence supporting its use. We present the results of our experience with laparoscopic donor nephrectomy done without intraoperative systemic heparinization. We retrospectively reviewed the records of 167 consecutive laparoscopic donor nephrectomies done without intravenous heparin from July 2005 to October 2007 at our institution. We evaluated preoperative donor characteristics, intraoperative and postoperative complications, recipient renal function and graft outcomes. All 138 left nephrectomies were done using a conventional laparoscopic approach while 25 of 29 right nephrectomies were done using the hand assisted technique. Warm ischemia time was approximately 3.0 minutes in each group. Mean +/- SE estimated blood loss was 183 +/- 29 ml for left and 115 +/- 16 ml for right nephrectomy. Postoperatively hematocrit decreased an average of 4.5%. There were no intraoperative complications or open conversion requirements. The postoperative complication rate was 4.8%, including 2 patients (1.2%) in whom retroperitoneal hematoma developed. Only 1 of these patients (0.6%) required blood transfusion. Two grafts (1.2%) were lost due to vascular thrombosis in the immediate postoperative period and another 2 recipients experienced delayed graft function. Average 6, 12 and 24-month serum creatinine was 1.5, 1.5 and 1.6 mg/dl, respectively. Renal allograft survival was 97% 2 years after transplantation. Results indicate that laparoscopic donor nephrectomy can be successfully done without systemic heparinization with few donor complications, and excellent recipient graft survival and renal function up to 2 years after transplantation.