Retroperitoneoscopic Donor Nephrectomy Research Articles

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 < 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.

The learning curve for pure retroperitoneoscopic donor nephrectomy by using cumulative sum analysis.

This study aimed to identify a precise learning curve for pure retroperitoneoscopic donor nephrectomy (RDN). Data from 172 consecutive kidney donors who underwent pure RDN between January 2010 and July 2019 were prospectively collected and evaluated. Cumulative sum (CUSUM) analysis was used for testing the operation time. Changepoints were determined by using the r program and BINSEG method. The cohort was divided into three groups - group 1: competence, including the first 10 cases; group 2: 11-48 cases as proficiency; and group 3: the subsequent 124 cases as expert level. Continuous variables were evaluated using one-way ANOVA, and categorical data were evaluated using the Chi-squared test. Right RDN was performed in 39 (22.7%) donors. The eighth patient was converted to open surgery due to vena cava injury and excluded from the CUSUM analysis. Depending on experience in pure RDN, a significant decrease was detected in operative time (p<0.001), warm ischemia time (p=0.006), and blood loss (p<0.001). Recipient complications and graft function were found to be statistically comparable. In our study, the attainment of expertise in pure RDN was observed after performing 50 cases. The transperitoneal technique, which is a feasible alternative, is far more widely used than pure RDN. We believe that understanding the learning curve associated with pure RDN could facilitate the adoption of this approach as a viable alternative to the transperitoneal approach.

Retroperitoneoscopic Donor Nephrectomy on the Right Side Provides Equivalent Outcomes and Donor Safety to That on the Left Side

The left kidney is typically selected for laparoscopic donor nephrectomy. In contrast, right kidney donation raises concerns for donor safety, and venous anastomosis may be difficult to achieve due to the short renal vein. We investigated the safety and operative outcomes of right donor nephrectomy compared with those of the left. We retrospectively analyzed the clinical records of living donor-kidney transplant donors and evaluated operative outcomes such as operative time, ischemic time, blood loss, and surgical complications in the donor. We identified 79 donors (left:right=62:17 cases) between May 2020 and March 2023. There were no significant differences between the 2 groups regarding age, sex, body mass index, and number of renal arteries. Although the operative time (left and right: 190 and 225 minutes, excluding waiting time; P=.009) and warm ischemic time (left and right: 143 and 193 seconds, P=.021) were significantly longer on the right side, the total ischemic time (82 and 86 minutes, P=.463) and blood loss (left and right: 35 and 25 mL, P=.159) were comparable between the groups. There were no significant differences between the groups regarding the surgical complications. Operative outcomes were similar in both donor sides in the retroperitoneoscopic donor nephrectomies. The right side should be considered for donation in this operative procedure.

P8.088: Mid Term Evolution of the Glomerular Filtration Rate in Living Kidney Donors

Introduction: Stable long term kidney function and safety of the donor nephrectomy are essential prerequisites for the living kidney donation. In our retrospective multicenter analysis we evaluated the impact of selected risk factors (age, BMI, arterial hypertension) on the severity of change in glomerular filtration rate (GFR) after kidney donation. Materials and Methods: In the period of years 2015 to 2019 there were 35 open and 46 hand assisted retroperitoneoscopic (HARS) donor nephrectomies performed in 4 transplant centers. 78 donors were eligible for analysis. Mean follow up of the donors was 3 ± 1,4 years. GFR was calculated according to CKD-EPI formula before donation (eGFR_baseline), at the time of maximal decrease (eGFR_min) and at the end of follow up (eGFR_end). ΔGFR refers to the change of eGFR in a donor and is expressed as a difference between eGFR_baseline and eGFR_min (ΔGFR_max) or eGFR_end (ΔGFR_end) respectively. We used unpaired t test, Fisher test and linear regression for statistical analysis. Results and Discussion: We found strong correlation between ΔGFR_end and eGFR_baseline, (r=0.5111, p< 0.0001). Age, BMI and eGFR_min did not correlate with ΔGFR_end. Hypertensive donors did not have significantly higher ΔGFR_end than normotensive donors (-26.9 vs. -24.6ml/min, p=0.49). 32 donors (41%) had eGFR_baseline between 60-90ml/min/1,73m2. In comparison with the subgroup of donors whose eGFR_baseline was more than 90 ml/min/1,73m2, these donors were older (52.2±8.8 vs 46.1±8.6 years, p=0.0034) and their ΔGFR_max and ΔGFR_end were lower (-28.2 ± 12.7 ml/min vs -43 ± 9.6ml/min, p<0.0001 for ΔGFR_max and -16.3 ± 13 ml/min vs -32.1 ± 10.4 ml/min, p<0.0001 for ΔGFR_end). No donor reached eGFR less than 30 ml/min/1,73m2 at the end of follow up. Conclusion: Our results demonstrate favourable mid term renal outcomes even in living kidney donors with slightly reduced predonation eGFR.

Evaluating the differences in the early laparoscopic donor nephrectomy learning curves of a Swiss high volume transplant program and a South African low volume transplant program after knowledge transfer

BackgroundTo describe the retroperitoneoscopic donor nephrectomy learning curve differences between a high volume (training) hospital in Basel, Switzerland, and a low volume (trainee) hospital in Cape Town, South Africa, after knowledge transfer. The South African hospital is resource constraint in hospital and training equipment. Techniques for performing the surgery were near identical.MethodsBoth units maintained prospective databases. Comparisons were made of the first 74 cases in each database: Basel’s series were from 19 January 2001 until 28 June 2004, while the Cape Town Hospital were from 8 April 2008 until 15 July 2008. Four surgeons operated in the Basel group, while only one surgeon operated in the Cape Town group. Variables compared include operating time (first skin incision until kidney was extracted), warm ischaemic time (renal arterial occlusion until cold bench reperfusion), blood loss, graft function, and hospital stay. We also analysed the first and last 25 cases of each series. Subgroup analysis of a single Basel surgeon was conducted.ResultsDonor age (means: Basel vs. Cape Town 54 vs. 33 p < 0.0001) and gender (males vs. females Cape Town 57% male and Basel 31% male) differed widely. The Basel group did more left-sided operations (72% vs. 58%). Operative times, blood loss and donor creatinine did not differ. Warm ischaemic time was significantly shorter in the Basel group (Cape Town mean 204 s Basel mean 130 s P = 0.0023). There was double the number of early graft failures in the South African group (six vs. three)—not related to donor surgery. Both groups showed a decline in operating times, plateauing at 30–34 cases.ConclusionsThere are statistically significant differences in some aspects of the learning curves of the Swiss (training) and South African (trainee) hospitals. These differences are clinically not pronounced, and the knowledge transfer was worth the effort.

P0333 - The learning curve for pure retroperitoneoscopic donor nephrectomy by using CUSUM analysis

P0333 - The learning curve for pure retroperitoneoscopic donor nephrectomy by using CUSUM analysis

Predicting Operation Time and Creating a Difficulty Scoring System in Donor Nephrectomy.

Background: To determine predictive formulas for operation time and surgical difficulty in laparoscopic living-donor kidney transplantation. Methods: We retrospectively analyzed data for 222 living donors aged >20 years and recorded factors affecting operation time from patients' CT images and medical records. We used the factors significantly affecting operation time to create a formula to predict operation time and designed a model to predict surgical difficulty based on the standardized partial regression coefficient, β. We also analyzed the relationship between surgical difficulty (high vs low) and operation time. Results: This study involved 111 pure retroperitoneoscopic donor nephrectomies (PRDN) and 111 hand-assisted laparoscopic donor nephrectomies (HALDN). Patients' mean age was 55.7 years, and 59.5% were women; 5.0% underwent right nephrectomy, and 77.0% vs 23.0% had single- vs multiple renal arteries. The average estimated kidney graft weight was 160.0 g, and actual average graft weight was 155.3 g. The following factors were significantly correlated with operation time in the regression analysis: number of renal arteries, Mayo adhesive probability score, estimated kidney graft weight, right nephrectomy, and operation type (PRDN). These five factors were used to create the operation time prediction equation and difficulty scoring system. The multiple r2 value was 0.40 for the operation time prediction equation. Receiver operating characteristic curve analysis of the difficulty scoring system revealed the following: sensitivity: 78.0%, specificity: 64.9%, and c-statistic: 0.76 (95% confidence interval: 0.70 to 0.83). Conclusions: The equation to predict operation time and the surgical difficulty prediction model created in this study are easy to calculate and are accurate. Both may help in selecting an appropriately skilled surgeon and in improving safety in living-donor kidney transplantation.

Hand-assisted retroperitoneoscopic donor nephrectomy offers more liberal use of right kidneys: lessons learned from 565 cases - a retrospective single-center study.

The introduction of laparoscopic donor nephrectomy caused a shift toward' left donor nephrectomy. Some centers report a significantly low rate of endoscopic right donor nephrectomy. Hand-assisted retroperitoneoscopic donor nephrectomy (HARP-DN) was introduced as a novel surgical technique, which aims to avoid intra-abdominal complications. It was also reported to provide technical advantages for right-sided DN. In this retrospective single-center study, we evaluated the impact of HARP-DN technique on utilization of right-sided DNs. After the implementation of HARP-DN on February 2009, a total of 565 DNs were performed until December 2015. The introduction of HARP-DN technique resulted in an immediate increase in the utilization of right kidneys from 6.1% to an average of 19.6% annually. The donors 'outcome was similar to the left-sided and right-sided DN groups, excluding the increased incidence of incisional hernias in left kidney donors. None of the donors developed intra-abdominal complications. In conclusion, the implementation of HARP technique significantly increased the use of right-sided DNs, which enables a more liberal use of donors in LDKT.

Impact of the introduction of pure retroperitoneoscopic living‐donor nephrectomy on perioperative donor outcomes: A propensity score matching comparison with hand‐assisted laparoscopic living‐donor nephrectomy

We previously reported that the outcomes of pure retroperitoneoscopic donor nephrectomy are superior to those of hand-assisted retroperitoneoscopic donor nephrectomy. Consequently, we introduced pure retroperitoneoscopic donor nephrectomy in our hospital. Here, we compared perioperative outcomes between hand-assisted intra-abdominal laparoscopic donor nephrectomy and pure retroperitoneoscopic donor nephrectomy. We retrospectively reviewed data from 315 living-donor kidney transplantation procedures performed between October 2015 and December 2020 (213 involving hand-assisted intra-abdominal laparoscopic donor nephrectomy, October 2015 to June 2019; 102 involving pure retroperitoneoscopic donor nephrectomy, May 2019 to December 2020). After propensity score matching, 90 transplantations were included in each group (n=180 overall). Donors in the pure retroperitoneoscopic donor nephrectomy group had longer warm ischemia times (P< .001), lower serum C-reactive protein concentrations and white blood cell counts on postoperative day 1 (P< .001 and P< .001, respectively), and shorter postoperative stays (P< .001) than donors in the hand-assisted intra-abdominal laparoscopic donor nephrectomy group. Five (5.6%) modified Clavien-classifiable complications occurred in the hand-assisted intra-abdominal laparoscopic donor nephrectomy group; no complications occurred in the pure retroperitoneoscopic donor nephrectomy group (P= 0.008). One recipient in the hand-assisted intra-abdominal laparoscopic donor nephrectomy group had donor-related delayed graft function. There were no significant differences between groups in recipient estimated glomerular filtration on postoperative day 7. The introduction of pure retroperitoneoscopic donor nephrectomy was safe and effective. Moreover, it was less invasive and less harmful for donors, compared with hand-assisted intra-abdominal laparoscopic donor nephrectomy; recipient outcomes were equivalent.

Hand-Assisted Retroperitoneoscopic Donor Nephrectomy Compared to Anterior Approach Open Donor Nephrectomy: Improved Long-Term Physical Component Score in Health-Related Quality of Life in Living Kidney Donors

BackgroundHealth-related quality of life (HRQL), fatigue, anxiety, and depression are crucial for the living kidney donor (LKD). Follow-up data for HRQL of LKDs comparing surgical techniques, especially regarding hand-assisted retroperitoneoscopic donor nephrectomy (HARP), are sparse. The aim of this study was to evaluate the influence of abdominal wall trauma minimized by HARP in comparison to open anterior approach donor nephrectomy (AA) on HRQL and additional psychosocial aspects of LKDs during the long-term follow-up. Material and MethodsThis is a cross-sectional study comparing psychosocial aspects of LKD between HARP and AA. ResultsThis study included 100 LKDs (68 HARP, 28 AA, and 4 were excluded secondary to incomplete data). The time to follow-up was 22.6 ± 11.7 (HARP) vs 58.7 ± 13.9 (AA) months (P < .005). Complications ≥3a° due to Clavien-Dindo classification was 0% in both groups. There were higher scores in all physical aspects for HARP donors vs AA donors at that time (physical function: 89.8 ± 14.6 vs 80.0 ± 19.9, P = .008, and the physical component score: 53.9 ± 7.6 vs 48.6 ± 8.5, P = .006). One year later (follow-up time + 12 months), HRQL for HARP donors was still higher. Mental items showed no significant differences. HARP donors showed better physical scores compared to the age-matched nondonor population (AA donors had lower scores). Neither the Multidimensional Fatigue Inventory-20 (MFI-20) or the Hospital Anxiety and Depression Scale (HADS) showed any differences between the 2 groups. Fatigue scores were higher for HARP and for AA compared to the age-matched population. ConclusionsLKDs undergoing HARP showed better physical performance as part of HRQL in the long-term follow-up.

HAND-ASSISTED RETROPERITONEOSCOPIC DONOR NEPHRECTOMY - SINGLE CENTER EXPERIENCE FROM 450 CONSECUTIVE DONORS

Introduction: Living donor nephrectomies has been performed since 1964 at our hospital. Since 2005 the handassisted retroperitoneoscopic donor nephrectomy has been used. It is considered safe and is associated with good results and outcome. Materials and Methods: All living donor nephrectomies in the year 2005-2018 at our institution has been included, in total 457 donors. 88 % (402/457) was left-sided donations. All donors had 3-month follow-up at our institution. All peroperative and postoperative complications has been recorded. No death. The most common peroperative complication was vascular (arterial) injury 1,7% (8/457) to the donor kidney, followed by bleeding 0,8% (4/457). Reoperation rate was low, 0,6% (3/457). Urinary tract infection 4,5% (21/457), followed by wound infection 3,2% (15/457) was the most common postoperative complications. Pulmonary embolism was diagnosed in 0,8%(4/457) of the donors.Results: Peroperative and early postoperative complications in 457 consecutive donors are presented. There were no deaths in this time-period. The most common peroperative complication was injury to vessel to the donor kidney and postoperative urinary- and wound infections.Discussion: In this consecutive series of donor nephrectomies some small changes has occurred over time. The anti-coagulation has been increased from Dalteparin 2500 ie to 5000 ie x1 starting the night before surgery. The antibiotic prophylaxis has remained the same. The Pfannenstiel incision was originally horizontally but has been vertically since 2014. Pain medication was changed from patient-controlled morphine pumps to automatic local anesthetic wound infiltration (Ropivacaine) in 2012. Conclusion: The handassisted retroperitoneoscopic donor nephrectomy method is safe and can be used for living donor nephrectomies with acceptable complication rates.

IJU this issue

In this issue, a Guideline with Editorial Comment, a Review Article with Editorial Comment, five Original Articles with three Editorial Comments and a Urological Note were published in the International Journal of Urology. Interstitial cystitis/bladder pain syndrome (BPS) bothers both patients and urologists. Homma et al. (Tokyo, Japan) revised the previous guidelines completing articles identified by the PubMed database published from 2016 to 2019. In this article, the authors clearly defined Hunner-type interstitial cystitis (HIC) associated with Hunner’s ulceration and non-Hunner-type BPS featuring glomerulations or bladder bleeding after distension are different entities of disorder in terms of pathophysiology. Interestingly, HIC shows immunological inflammatory reaction accompanied by B-cell clonal expansion, which demonstrates HIC is genetically different from BPS. Urologists should keep in mind that patients should be treated differently based on the diagnosis of HIC or BPS, which requires cystoscopy to determine the presence or absence of Hunner lesions. Malignant ureteral obstruction, defined as either intrinsic or extrinsic compression caused by metastasis, lymphadenopathy or direct extension of the tumors, is an unfortunate finding that most urologists encounter in the daily practice. Tabib et al. (New York, USA) reviewed many types of ureteral stents, including tandem stents or metallic stents that aim for the resolution of malignant ureteral obstruction, and attempted to provide considerations regarding the treatment and management of malignant ureteral obstruction. Ochi et al. (Chiba, Japan) examined the anatomical relationship between the urinary system and perirenal fat using computed tomography images from 50 men, as well as macroscopic imaging in nine cadavers. They found that perirenal fat belongs to the connective tissue of the gonad and the adrenal gland. The urinary system is separated from perirenal fat, and is located on the dorsal side inside the renal fascia. The authors concluded that this anatomical finding might help aid in the isolation of periureteric fat from perinephric fat in retroperitoneoscopic donor nephrectomy. A substantial number of non-classic angiomyolipomas (AML), including fat-poor or epithelioid AML, are encountered in daily practice, and are occasionally difficult to discriminate from renal cell carcinoma. Kaneko et al. (Tokyo, Japan) retrospectively evaluated the incidence of epithelioid AML (17.9%) out of 39 renal tumors diagnosed as non-classical AML. They found that magnetic resonance imaging findings (apparent diffusion coefficient value) are potentially useful to differentiate between epithelioid and fat-poor AML. A recent trend for the treatment of metastatic castration-sensitive prostate cancer (CSPC) is upfront intensification therapy including androgen deprivation therapy (ADT) plus docetaxel, ADT plus abiraterone acetate, ADT plus enzalutamide and ADT plus apalutamide. However, indication is limited in high-risk (LATITUDE criteria) or high-volume (CHARRTED criteria) patients. Hatakeyama et al. (Hirosaki, Japan) retrospectively evaluated 679 patients with metastatic castration-sensitive prostate cancer. They found that the overall survival from the initiation of castration-resistant prostate cancer in patients with low-volume disease and those with high-volume disease was not significantly different, and concluded that upfront intensification therapy might be beneficial to patients with low-volume disease, because approximately half of patients with low-volume disease experienced metastatic castration-resistant prostate cancer progression in real-world practice. The Editorial Comment by Kato (Nagoya, Japan) is worthwhile to correctly evaluate this article. As most of the metastatic spread is reported to be in a hematogenous fashion in renal cell carcinoma, the impact of regional lymph node metastases on subsequent distant metastasis remains unknown. Yang et al. (Rochester, USA) retrospectively evaluated 1049 patients (135 pN1, 914 pN0/x) who were surgically treated at the Mayo Clinic. They found that pN1 nodal status in M0 patients treated with nephrectomy for renal cell carcinoma is associated with more frequent early metastasis to sites conferring poor prognosis when compared with pN0/x in the lung, bone and non-regional lymph nodes. Interestingly, pN1 status did not affect subsequent liver metastasis, one of the most hematogenous metastatic organs. Although this article involves several limitations, their finding might stimulate discussion of the predictive/therapeutic role of regional lymph node dissection during renal cancer surgery. None declared.

Hand-Assisted Laparoscopic vs Hand-Assisted Retroperitoneoscopic Living-Donor Nephrectomy: A Retrospective, Single-Center, Propensity-Score Analysis of 840 Transplants Using 2 Techniques

IntroductionLiving-donor kidney transplantation (LDKT) is the most realistic option for patients with end-stage kidney disease because of a severe shortage of deceased donors. Hand-assisted laparoscopic donor nephrectomy (HALDN) and hand-assisted retroperitoneoscopic donor nephrectomy (HARDN) have been undertaken at our institute. We compared these 2 surgical procedures with respect to donor outcome and the graft function of recipients. MethodsWe reviewed data from 840 consecutive live-donor kidney transplants from October 2003 to April 2019. Propensity scores were calculated for each patient using bivariate logistic regression. ResultsAfter propensity-score matching, the 2 groups each contained 205 patients. Donors in the HALDN group had a longer procedure time (217 minutes, P < .0001), less estimated blood loss (51 mL, P < .0001), lower serum levels of C-reactive protein at postoperative day (POD) 1 (7.9 mg/dL, P < .0001) than those in the HARDN group. There were 22 modified Clavien-classifiable complications among the study groups. A significantly higher conversion to open surgery was noted in the HARDN group (P = .0181) than in the HALDN group, but there was no significant difference in the prevalence of complications in either group. There was no significant difference in the estimated glomerular filtration rate of recipients at POD14 between the 2 groups. ConclusionsSafety and early graft function of HALDN in LDKT are comparable to or even better than that of HARDN.

Zoning inside the renal fascia: The anatomical relationship between the urinary system and perirenal fat

ObjectivesTo examine the anatomical relationship between the urinary system and perirenal fat, and to clarify the zoning inside the renal fascia.MethodsUsing computed tomography images from 50 men, we examined perinephric veins to reveal vessel communication in perirenal fat. Nine cadavers were dissected to investigate connective tissue continuity and vessel communication inside the renal fascia. Eight retroperitoneal specimens were macroscopically observed: four from the anterior and four from the posterior aspects. One specimen was used to obtain retroperitoneal transverse sections to study macroscopic anatomy and histology.ResultsPerinephric veins were classified into four types (superior, middle, inferior and lateral) using computed tomography. Most of the inferior perinephric veins were connected to the ipsilateral gonadal vein. In the cadaveric study, the superior and middle perinephric veins communicated with veins deriving from the ipsilateral adrenal gland. A fibrous connective tissue gap between perirenal fat and renal hilar fat was observed in posterior aspect dissection. From the gap, we could dissect the urinary system from perirenal fat en bloc along with a thin fibrous connective tissue layer. Communicating vessels between perirenal fat and the urinary system were rare.ConclusionsOur results suggest that perirenal fat belongs to the connective tissue of the gonad and the adrenal gland. The urinary system is separate from perirenal fat, and is located on the dorsal side inside the renal fascia. This concept of zoning inside the renal fascia is valuable particularly in retroperitoneoscopic donor nephrectomy.

Strategies to Perform Pure Retroperitoneoscopic Donor Nephrectomy: A Single-Center Cohort Study.

Background: Considering the increase in a number of vascular complications, right laparoscopic donor nephrectomy is less preferred due to achieving not only shorter renal vein but also longer renal artery. However, recent studies have indicated that the side of the surgery would not affect the outcomes. Aim: The aim of this study is to evaluate the outcomes and strategies to increase the safety of pure retroperitoneoscopic donor nephrectomy (RDN). Methods: We analyzed the prospectively collected medical records of 158 kidney donors who underwent RDN from January 2010 to August 2018. The patients were divided into two groups based on their side of surgery. Right- and left-sided RDNs were compared in terms of demographics, intraoperative, and postoperative data, including the development of incisional hernia (IH). The outcomes of the recipients were also evaluated. Results: Right RDN was performed in 40 (25.3%) and left RDN was performed in 118 (74.7%) donors. Operation time (P = .593), warm ischemia time (P = .271), blood loss (P = .787), and length of hospital stay (P = .908) were statistically similar in right and left RDN groups. Intraoperative and postoperative complications were statistically showed no difference between right and left RDNs. No IH was observed in any group. One-year and five-year patient survival and graft survival rates were 100% versus 97% (P = .299) and 100% versus 95% (P = .126) on both sides, respectively. Conclusion: Right RDN is an effective and safe method as on the left side. RDN has an additional advantage in the absence of IH. Experience with other retroperitoneoscopic urological interventions may have had a positive effect on the outcomes of pure RDN.

Obese living kidney donors: a comparison of hand-assisted retroperitoneoscopic versus laparoscopic living donor nephrectomy

BackgroundThe aim of this study was to examine the difference in outcome between hand-assisted retroperitoneoscopic and laparoscopic living donor nephrectomy in obese donors, and the impact of donor body mass index on outcome.MethodsOut of 1108 living donors who underwent hand-assisted retroperitoneoscopic or laparoscopic donor nephrectomy between 2010 and 2018, 205 were identified having body mass index ≥ 30. These donors were included in this retrospective study, analyzing postoperative outcomes and remnant renal function.ResultsOut of 205 donors, 137 (66.8%) underwent hand-assisted retroperitoneoscopic donor nephrectomy and 68 donors (33.2%) underwent laparoscopic donor nephrectomy. Postoperative outcome did not show any significant differences between the hand-assisted retroperitoneoscopic donor nephrectomy group and the laparoscopic donor nephrectomy group in terms of major complications (2.2% vs. 1.5%, P = 0.72), postoperative pain scale (4 vs. 4, P = 0.67), and the length of stay (3 days vs. 3 days, P = 0.075). The results of kidney function in donors after nephrectomy demonstrated no significant differences between the groups. Additional analysis of 29 donors with body mass index ≥ 35 (14.1%) as compared with 176 donors with body mass index 30–35 (85.9%) revealed no significant differences between groups in postoperative outcomes as well as kidney function after donation.ConclusionOur results show that laparoscopic living donor nephrectomy for obese donors is safe and feasible with good postoperative outcomes. There were no significant differences regarding postoperative outcome between hand-assisted retroperitoneoscopic and laparoscopic donor nephrectomy. Furthermore, the outcome in donors with body mass index ≥ 35 was comparable to donors with body mass index 30–35.

Incisional Complications and Cosmetic Evaluation After Hand-assisted Retroperitoneoscopic Donor Nephrectomy

PurposeHand-assisted retroperitoneoscopic (HARP) donor nephrectomy prevents major complications, but incision site complications may be more frequent in hand-assisted approach. We evaluated long-term incisional complication rates and cosmetic outcomes after HARP donor nephrectomy in our series. Materials and MethodsA total of 609 donors who underwent nephrectomy between February 2009 and June 2016 were invited for physical examination and face-to-face interview. A total of 209 donors (35.3%) participated to the study. Sex, age, body mass index (BMI), mean follow-up period, incision-related outcomes of cosmesis, and postoperative complications were evaluated. Body image scale (BIS) and cosmetic scale (CS) (scar test) questionnaires were applied. Higher cosmesis and body image scores indicated greater satisfaction. ResultsA total of 191 donors had paramedian (91.4%), and 18 donors had Pfannenstiel incision (8.6%); 121 donors were female (57.9%). The donor mean age and BMI were 49.1 (SD, 1.8) years and 29.7 (SD, 5.1), respectively. Body mass index was significantly lower in the Pfannenstiel group (P < .001). The mean BIS score was 18.9 (SD, 1.8), and the CS questionnaire score was 19.3 (SD, 4,7). The BIS score was significantly better in donors with Pfannenstiel incisions (P < .001), but there was no statistical significance in CS score. The total rate of wound infection was 4.8%, and rate of incisional hernia was 4.8%. The rate of incisional hernia was more frequent in donors with paramedian incision (5.2%), but there was no statistical significance. Six donors (2.9%) required rehospitalization because of incision site complications. ConclusionHand-assisted retroperitoneoscopic donor nephrectomy avoids intra-abdominal complications, but rate of incision site complications can be higher in hand-assisted procedure. The donors were convinced from the cosmetic outcome after HARP donor nephrectomy. The ones who had Pfannenstiel incision had better satisfaction according to BIS score.

Introducing Robot-Assisted Laparoscopic Donor Nephrectomy after Experience in Hand-Assisted Retroperitoneoscopic Approach

BackgroundRobot-assisted laparoscopic donor nephrectomy (RALDN) can help to improve donor safety by enabling enhanced precision, flexibility, control, and vision. We are presenting our initial series during the introduction of RALDN by comparing our adopted surgical technique, hand-assisted retroperitoneoscopic donor nephrectomy (HARPDN), performed at the same time interval. MethodsWe performed 12 RALDN and 27 HARPDN with Pfannenstiel incision between March 2018 and July 2018. We evaluated the demographics, operation duration, warm/cold ischemia time, estimated blood loss, length of hospital stay, postoperative complications, and donor and recipient serum creatinine levels retrospectively. ResultsDemographics including sex, mean of age, and body mass index of the 2 groups were similar. Five cases were right sided nephrectomy in the HARPDN group. We performed only left sided donor nephrectomy in the RALDN group. The duration of operation and warm ischemia time was significantly longer in the robot-assisted group (P < .001). Postoperative major complications were not detected in any of the donors. The function of the transplanted kidneys in both groups was good on the fifth day and 1 month postoperatively. ConclusionWe introduced the robot-assisted approach for donor candidates who are not suitable candidates for HARPDN in our center. The operation time and warm ischemia time was longer in the RALDN group, but it did not have any impact on outcome. The robot-assisted donor nephrectomy technique can be introduced safely in centers experienced in the hand-assisted approach.

Hand-Assisted Nephrectomy Predisposes Incisional Herniation in Obese Living Donors

BackgroundLiving kidney donation from donors with a body mass index (BMI) over 30 can bring risks for the donor and the recipients. In this retrospective study, we evaluated the effect of a donor’s obesity on a donor’s long-term surveillance and the recipient outcomes. MethodWe performed hand-assisted retroperitoneoscopic donor nephrectomy in 565 living kidney transplantations between February 2009 and December 2015. One hundred fifty-two donors (26.9%) had a BMI > 30 and were described as the obese group. Four hundred thirteen donors (73.1%) were described as the nonobese group and had a BMI < 30. Incision to kidney removal time, mean follow-up period, postoperative complications, weight gained after surgery, and serum creatinine level (postop day 1-end of follow-up) were recorded for the donors. Serum creatinine level (postop day 5-end of follow-up) and immediate function of transplanted kidney were recorded for the recipients. ResultsThe obese donors were older, and the female sex was dominant. Mean incision to kidney removal period was longer in the obese patients (P = .012). The mean follow-up period was 49.97 ± 28.40 months for the donors. There was no significant difference in donor kidney function between the groups. The incidence of herniation was significantly higher in the obese group (P = .021). There was no significant difference between the recipient early and late serum creatinine levels and slow and delayed graft functions after the transplantation. ConclusionPostoperative kidney functions concerning the outcomes of the obese and nonobese living donors were similar in our series. Donor BMI had no influence on early and late kidney functions of the recipients. There was no difference in postoperative complications, except incisional hernia, that was statistically more significant in the obese donors.

Endo-Satinsky Clamp Hybrid In Situ Perfusion in Retroperitoneoscopic Donor Nephrectomy For Right-sided Kidney

ObjectiveTo introduce our hybrid technique using an endo-Satinsky clamp and in situ cold perfusion for right-sided retroperitoneoscopic donor nephrectomy (RDN) and to investigate efficacy and safety compared with those standard right-sided RDN. MethodsThis retrospective study included 16 transplant donors who underwent right-sided RDN from January 2016 to January 2018. Donors received either hybrid RDN (n = 6) or standard RDN (n = 10). Perioperative outcomes, including operative time, estimated blood loss, warm ischemic time, hospital stay, length of renal vein obtained as well as postoperative renal function of their recipients were collected and compared between the hybrid RDN and standard RDN groups. ResultsProcedures were performed successfully in all 16 donors. The hybrid RDN group required longer operation times (135 vs 115 minutes), demonstrated increased blood loss (175 vs 140 mL), but shorter warm ischemic times (1.5 vs 5.5 minutes) and resulted in longer length of the procured renal vein (2.8 vs 1.7 cm) as compared with the standard RDN group. No difference in perioperative complication rates was witnessed between the 2 groups. Also, there were no significant differences in serum creatinine levels and glomerular filtration rates of recipients between the 2 groups at both postoperative day 3 and 1 month. ConclusionThe hybrid RDN potentially extends the length of the right donor renal vein. The perioperative outcomes of hybrid RDN were comparable with those of the standard RDN. This hybrid technique can be a technically safe and feasible option for right kidney donation.