Retroperitoneoscopic Live Donor Nephrectomy Research Articles

Retroperitoneoscopic Procurement of Kidneys With Multiple Renal Arteries Does Not Affect Graft Survival and Ureteral Complications.

Objective: To assess the effect of kidney allografts with multiple renal arteries (MRA) on donor and recipient outcomes after retroperitoneoscopic live donor nephrectomy (RPLDN). Patients and Methods: From July 2001 to August 2010, 533 patientsunderwent live donor kidney transplants with allografts procured by RPLDN at our center. Of these, 406, 105, and 22 patients had one, two, and three renal arteries, respectively. We compared retrospectively the collected clinical data of each donor with MRA and the recipient with those with single renal artery (SRA) as controls. Results: Significant differences were found between the one and three renal artery groups regarding operative time, estimated blood loss, warm and cold ischemic time, and incidence of slow graft function (SGF). There were no significant differences regarding patient and graft survival among the three groups. Major complications, such as open conversion, bleeding, and blood transfusion were not found in patients with MRA. Five ureteral complications occurred. Of these, one patient with MRA had ureteral complications. In univariate analysis, MRA patients had a risk factor of developing SGF (p = 0.005) but not ureteral complications following RPDN. Conclusions: Kidneys with MRAafter RPLDN increasethe risk of SGF in recipients. However, they provide similar outcomes regarding long-term graft survival and complications compared with those of SRA. Renal artery multiplicity may not increase the risk of ureteral complications.

“Paired Kidney Exchange” Program - Is There Potential for European Cooperation? Single Czech Institution Experince With 26 Paired Transplants Since 2011.

Introduction: Kidney paired donation has been at first performed at our institution in 2003. Until 2011 only four 2-way exchanges were performed. Since 2011 the kidney exchange started at our institution as coordinated program. All the incompatible pairs are collected prospectively in the database. The matching run is performed every three monts with on average 20 pairs included for matching. Methods: There were in total 34 paired live kidney transplants (KTx) performed in Czech since 2003, of those 26 since 2011, those we assessed. There were eight 2-way, one 4-way, two 5-way and one 6- way domino kidney paired exchanges performed, two altruistic samaritan donors entered the scheme. There were 5 cases of re-transplant, of those four second and one third KTx, some 15% paired KTx. Two surgeons perfomed all the transplants, one did all the mininvasive nephrectomies using Hand Assisted Retroperitoneoscopic (HARS) live donor nephrectomy technique. Results: Mean recipient age was 45.7 years (SD 11.9), four patients had their second and one third transplant done, mean SCr on discharge was 126 umol/l (SD 48.5), equivalent of 1.43 mg/dl (SD 0.55). There was one case of delayed graft function due to early rejection observed. The program did help some 26 patients so far, the database includes around 40 pairs to the date. Conclusions: Kidney paired donation program can be run with success even at single institution, this limits some of the highly sensitised patients as well as blood group 0 recipients. Also, the bigger is the group for matching, the higher might bet the number of transplants. Possible cooperation within European centres would help to treat more patients with the best threatment modality - live donor kidney transplantion.

Hand Assisted Retroperitoneoscopic Live Donor Nephrectomy With No Side/anatomy Exclusions: Single Centre Experience With 139 Cases.

BACKGROUND: Our study reports last 139 consecutive hand assisted retroperitoneoscopic live donor nephrectomies (HARS) performed at our institution since 6/2011. HARS nephrectomy technique has been introduced by the author in Prague/Czech Republic in January 2003, since June 2011 is being used for all the donors including right sided and complex anatomy cases (mutliple vessels and ureters, retroaortic renal vein, renal artery diseases, etc). The main benefit of HARS approach is increased safety for the donor. Risk of bleeding and intraabdominal injury is low thanks to hand assistance and extraperitoneal approach. METHODS: Data were collected prospectively. The operation is performed in the manner described by Wadström et al 2002, with minor modifications. Tere were all anatomical variations accepted for surgery, including right sided cases when indicated. RESULTS: There was no conversion to open nephrectomy, one donor was re-operated on the first postoperative day for bleeding from paraaortic lymphatics, this donor was also given two units of blood. The median blood loss was zero otherwise, meaning no use of suction or no blood in container. The median post-operative hospital stay was 2 days. We observed few minor complications including one wound infection, one wound seroma and three wound haematomas. There was one case of postoperative bleeding from paraaortic lyphatics mentioned above which required retroperitoneoscopic re-operation, there was one case of incisional hernia which occured some 8 months after surgery. All donors have life-long long follow up. There was one case of delayed graft function due to early rejection observed, all the other patients had immediate graft function. CONCLUSIONS: HARS is a safe way of performing living-donor nephrectomy with low risk of severe complications, minimal morbidity and fast recovery. It is safe alternative to the transperitoneal miniinvasive as well as other nephrectomy techniques. It can be used safely for all the anatomical variations as well as right sided cases.

Retroperitoneoscopic live donor nephrectomy: Review of the first 50 cases at Tygerberg Hospital, Cape Town, South Africa

Changing from an open to a laparoscopic live renal donor programme poses challenges and may affect donor and graft outcomes. To evaluate donor safety and graft outcomes for the first 50 retroperitoneoscopic live donor nephrectomies performed at Tygerberg Hospital, Cape Town, South Africa. The procedures were performed by a single surgeon from 8 April 2008 to 3 April 2012. Operative and anatomical data were prospectively collected. A flank approach with lateral and posterior placements was used. Vascular control was achieved with Hem-o-lok clips in the majority of cases. The mean age of the donors was 31.5 years (range 18 - 50), 28 (56.0%) were male, and the left kidney was harvested in 28 (56.0%) of cases. The mean operating time was 149.8 minutes (range 75 - 250), mean warm ischaemic time (WIT) 181.3 seconds (107 - 630), mean blood loss 139.7 ml (5 - 700) and mean hospital stay 3.2 days (2 - 5). Mean WIT was significantly longer for right-sided than left-sided nephrectomy (213 v. 162 seconds). In two right-sided cases the renal vein was too short and vena profunda femoris was used to create length. No donor received a blood transfusion. Comparing the last 25 with the first 25 cases showed a significant decrease in mean WIT (158 v. 204 seconds) and operating time (128 v. 172 minutes). No major complications occurred. Our initial 50 retroperitoneoscopic live donor nephrectomies were performed without major complications. Donor safety was maintained during the early learning curve of the transition to minimal-access donor nephrectomy.

Utility of inguinal incision in retroperitoneoscopic live donor nephrectomy

Retroperitoneoscopic live donor nephrectomy has been performed in many countries. The purpose of this study was to evaluate the inguinal incision as a route for hand-assisted manipulation and allograft retrieval. From April 2011 to June 2012, a prospective clinical study of 21 cases of retroperitoneal live donor nephrectomy was performed at our hospital. All donors were grouped in a test group (n = 11, inguinal incision) or a control group (n = 10, lumbar incision). The operative time, warm ischaemia time, blood loss, hospital stay, cosmetic satisfaction, incision complications, and recipient's serum creatinines were compared between groups. All 21 cases of retroperitoneal live donor nephrectomy were accomplished successfully without serious complications. There was no difference in blood loss and operative time between groups. The mean warm ischaemic time and hospital stay was shorter (P < 0.01), and satisfaction with cosmesis was greater (P < 0.05) in the test group. The abdominal asymmetry (4/10) and wound dehiscence occurred only in the control group. The recipient's serum creatinine was lower in the test group at 1 day (P < 0.01) and 3 days (P < 0.05) after transplantation. The inguinal incision offers an ideal route for hand-assisted manipulation and allograft retrieval during retroperitoneoscopic live donor nephrectomy, and has a potential to be generally applied in the future.

Retroperitoneoscopic Living Donor Nephrectomy: Short Learning Curve and Our Original Hybrid Technique

To evaluate the effect of the learning curve for the hybrid technique of retroperitoneoscopic living donor nephrectomy (RDN) on donor and recipient outcomes. We retrospectively reviewed 120 consecutive patients who underwent RDN, performed by a laparoscopic surgeon, at Sendai Shakaihoken Hospital between May 2005 and September 2011. A new hybrid technique, in which 2 laparoscopic ports were inserted through a hand-port device and all the procedures except mobilization and taping of ureter and extracting kidney were performed with nonhand-assisted technique, was used. These 120 patients were classified into 4 groups (groups 1-4) of 30 patients each on the basis of the order in which they were operated on by the surgeon. Baseline data including donors' age, gender, and body mass index did not differ among the groups. The time required for graft extraction and overall operative time were significantly longer in group 1 than in the other 3 groups. However, warm ischemia time, blood loss, length of postoperative hospital stay, and graft function did not differ among the groups. These results indicate that the hybrid technique of RDN could be performed by surgeons with acceptable outcomes, in donors and recipients, even during the early stages of practicing RDN. Although the time required for graft extraction and overall operative time were much longer during the learning phase, the learning curve was short and improved rapidly after performing only 30 procedures.

Impact of Right-Sided Nephrectomy on Long-Term Outcomes in Retroperitoneoscopic Live Donor Nephrectomy at Single Center

Objective. To assess the long-term graft survival of right-sided retroperitoneoscopic live donor nephrectomy (RPLDN), we compared the outcomes of right- and left-sided RPLDN. Methods. Five hundred and thirty-three patients underwent live donor renal transplantation with allografts procured by RPLDN from July 2001 to August 2010 at our institute. Of these, 24 (4.5%) cases were selected for right-sided RPLDN (R-RPLDN) according to our criteria for donor kidney selection. Study variables included peri- and postoperative clinical data. Results. No significant differences were found in the recipients' postoperative graft function and incidence of slow graft function. Despite significant increased warm ischemic time (WIT: mean 5.9 min versus 4.7 min, P < 0.001) in R-RPLDN compared to that in L-RPLDN, there was no significant difference between the two groups regarding long-term patient and graft survival. The complication rate in R-RPLDN was not significantly different compared to that in L-RPLDN (17% versus 6.5%, P = 0.132). No renal vein thrombosis was experienced in either groups. Conclusions. Although our study was retrospective and there was only a small number of R-RPLDN patients, R-RPLDN could be an option for laparoscopic live donor nephrectomy because of similar results, with the sole exception of WIT, in L-RPLDN, and its excellent long-term graft outcomes.

Technical Modifications of Retroperitoneoscopic Live Donor Nephrectomy

Objectives: To introduce single-center experience and technical modifications of retroperitoneoscopic live donor nephrectomy (RPLDN). Materials and methods: 152 three-port RPLDNs were carried out at our institution. The tributaries of renal artery and vein were transected by harmonic scalpel: after both ends of the tributary were coagulated intermittently till the colors turned light yellow, transection was made between with coagulating shift. A longitudinal 6-8 cm skin incision was extended inferiorly from the primary trocar with muscles kept intact. The renal artery was clipped by two Hem-o-Lok clips at the proximal end, and then sheared by scissors without any clips on the kidney side. The renal vein was controlled similarly. The graft was retrieved by insertion of a hand through the longitudinal lumbar incision. Results: The mean operation time and warm ischemic time was 118.2 and 3.3 minutes. No blood transfusion or open conversion was required. None of the donors encountered major complication, and 9 suffered from minor complications. Preoperative and postoperative mean levels of serum creatinine of the donors were 1.12 and 1.17 mg/dL. The mean levels of serum creatinine of the recipients postoperatively at day 1 and month 1 were 5.37 and 1.56mg/dL. Conclusions: The modified approach of RPLDN could be a good alternative with flexible control of the renal vessels and tributaries and easy retrieval of the graft.

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

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

Laparoscopic Donor Nephrectomy: Single-Center Experience

ObjectiveLaparoscopic living donor nephrectomy (LLDN) has become the standard procedure for renal transplantation. This technique is considered less invasive for the donor, allowing lower postoperative analgesic requirements and a faster return to daily activities. In Japan, 1123 renal transplantation were performed in 2009. And, almost 83% were living related procedures. The aim of this study was a retrospective assessment of the safety and outcomes of LLDN on renal transplantations. Material and methodsWe retrospectively analyzed the intraoperative data and surgical complications for 21 patients who underwent retroperitoneoscopic living donor nephrectomy between June 2009 and March 2011. ResultsLLDN was successfully completed in all patients, without conversion to open surgery. Mean operative time was 243.5 ± 46.0 minutes with an average blood loss of 46.0 ± 46.1 mL. Warm ischemic time was 2.1 ± 0.62 minutes. Hospital stay was 11.1 ± 2.7 days. There were no major donor complications. One patient presented a wound infection responding to conservative treatment. ConclusionsLLDN is a safe effective procedure. The vascular stapler is useful to manage the renal vessels.

A successful live donor kidney transplantation after large angiomyolipoma excision

INTRODUCTIONAngiomyolipoma is the most common benign neoplasm of the kidney. Successful transplantation of an AML affected kidney has been reported. However it is still often seen as a contraindication to transplantation. PRESENTATION OF CASEA 47-year-old female underwent assessment for a direct specified kidney donation to her husband who had end stage renal failure, due to adult polycystic kidney disease. Routine pre-operative CT angiography demonstrated a large 6cm×4cm AML arising from the upper pole of the right kidney. Right-side hand assisted retro-peritoneoscopic live donor nephrectomy with bench tumour excision was subsequently performed. Recipient implantation was unremarkable with no haemorrhage. DISCUSSIONHistology confirmed a 7cm AML. At 36 months follow up, the recipient's serum creatinine was 158μmol/l and eGFR 40ml/min without the need for dialysis at any stage. CONCLUSIONAML should not be a contraindication for specified live kidney donation, despite a size of 7cm.

Retroperitoneoscopic left donor nephrectomy with duplicated IVC

Vascular anomalies increase the difficulty during live donor nephrectomy. We herein report a left-sided retroperitoneoscopic living donor nephrectomy performed in a donor with a duplicated inferior vena cava (IVC). Computed tomography angiography provided accurate delineation of the venous anatomy and allowed preoperative planning. The duplicated IVC was clipped and divided just below its confluence with the left renal vein. The length of the left renal vein was sufficient for anastomosis in the recipient, and the recipient's serum creatinine was 1.21% on day 7. The donor made an uneventful recovery. Duplicated IVC is not a contraindication for left retroperitoneoscopic donor nephrectomy.

Retroperitoneoscopic living donor nephrectomy: initial experience with a unique hand‐assisted approach

The retroperitoneoscopic (RP) approach to live donor nephrectomy (LDN) may be advantageous for the donor because it avoids mobilization of peritoneal organs and provides direct access to the renal vessels. Notwithstanding, this approach is not popular, likely because of the steeper learning curve. We feel that hand-assistance (HA) can reduce the learning curve and in this study, we present our experience with a novel hand-assist approach to retroperitoneoscopic live donor nephrectomy (HARP-LDN). Over a one-yr period, 10 consecutive patients underwent left HARP-LDN with a mean body mass index of 29 and three with prior left abdomen surgery. The surgical technique utilizes a 7 cm, muscle-sparing incision for the hand-port with two endoscopic ports. Operative time was an average of 155 min., with no open conversions. Mean blood loss was 68 mL, and warm ischemia time was 2.5 min. Hospital stay averaged 2.7 d with postoperative complications limited to one urinary retention. Our modified HARP approach to left LDN is safe, effective and can be performed expeditiously. Our promising initial results require a larger patient cohort to confirm the advantages of the hand-assisted retroperitoneal technique.

Efficacy and Safety of Continuous Local Infusion of Ropivacaine after Retroperitoneoscopic Live Donor Nephrectomy

Morphine-based analgesia is effective but can compromise donor safety. We investigated whether continuous infusion of local anesthetics (CILA) can provide sufficient pain control and reduce morbidity related to opiate analgesics after hand-assisted retroperitoneoscopic (HARS) live donor nephrectomy. Forty consecutive live kidney donors underwent HARS and were treated with the ON-Q system providing CILA with 0.5% ropivacaine through two SilvaGard catheters placed in the retroperitoneal cavity and the rectus sheath, respectively. The case control group consisted of 40 donors matched with regard to sex, age, BMI and surgical technique. All donors were maintained on standardized multimodal analgesia combining nurse-controlled oxycodone treatment and acetaminophen. CILA donors had lower median cumulative consumption of morphine equivalents (CCME) (7 mg [0-56] vs. 42 mg [15-127]; p < 0.0000001), lower incidence of nausea (18 [45%] vs. 35 [87.5%] donors; p < 0.001), shorter time in postoperative care unit (160 vs. 242.5 min; p < 0.001) and shorter hospital stay (4 [4-7] vs. 6 [4-11] days; p < 0.001). In 32.5% of CILA donors the CCME was 0 mg (0% in matched control group, p < 0.001). CILA with 0.5% ropivacaine provides effective postoperative pain relief, reduces the need for opioid treatment and promotes postoperative recovery.

Acceptable Residual Renal Function after Retroperitoneoscopic Kidney Donation in Elderly Donors

Recent studies suggest that the overall survival and risk of end-stage renal disease among renal transplant donors are similar to those of the general population, but few studies focused on elderly donors. Among 88 donors who underwent retroperitoneoscopic live donor nephrectomies; 20 (22.7%) were elderly, namely, older than 65 years. Perioperative characteristics, such as sex, donor kidney side (left or right), body mass index, operative time, blood loss, and complication rate were not significantly different among groups classified by age: young (<50), middle (50–65), or elderly (>65). One month after kidney donation, the serum, creatinine values in the young, middle, and elderly groups increased to 1.05 ± 0.25, 0.96 ± 0.24, and 1.06 ± 0.15 mg/dL ( P = .103) and the estimated glomerular filtration rate (eGFR) decrease to 63 ± 10, 63 ± 14, 56 ± 8 mL/min/1.73m 2, respectively ( P = .037). At three months and at three years after donation these parameters showed the same degree of improvement in all groups. Percentage of eGFR (% eGFR) of its pre-donation value in the young and middle groups improved up to 21% and up to 9%, respectively, until four years after donation, whereas that of the elderly group remained unchanged below 1%. In conclusion residual renal function after retroperitoneoscopic kidney donation in elderly donors was stable and acceptable during mid-term observation. Our retroperitoneoscopic approach was safe.

Technical Modifications of Retroperitoneoscopic Live Donor Nephrectomy: Chinese Experience

Objective The objective of this article is to report a single-center experience and technical modifications of retroperitoneoscopic live donor nephrectomy (RPLDN). Materials and Methods One hundred twenty-one 3-port RPLDNs were performed at our institution. No prisoners or organs from prisoners were used to collect the data for this study. The tributaries of renal artery and vein were transected using a harmonic scalpel after both ends of the tributary were coagulated intermittently until the color turned light yellow. Transection was made using shifting coagulation. A longitudinal 6–8-cm skin incision was extended inferiorly from the primary trocar with muscles intact. The renal artery was clipped using two Hem-o-Lok clips at the proximal end, and then sheared by scissors without any clips on the kidney side. The renal vein was controlled similarly. The graft was retrieved by insertion of a hand through the longitudinal lumbar incision. Results The mean operative time and warm ischemia time were 126.1 and 3.6 minutes, respectively. No blood transfusion or open conversion was required. None of the donors encountered a major complication, but 7 suffered minor complications. Preoperative and postoperative mean serum creatinine levels of the donors were 1.00 and 1.29 mg/dL, respectively. The mean serum creatinine levels of the recipients postoperatively at day 1 and month 1 were 5.48 and 1.60 mg/dL, respectively. Conclusions The modified approach of RPLDN may be a useful alternative with flexible control of the renal vessels and tributaries and easy retrieval of the graft.

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.

The Transition From Laparoscopic to Retroperitoneoscopic Live Donor Nephrectomy: A Matched Pair Pilot Study

Retroperitoneoscopic live donor nephrectomy (RetroNeph) offers an intrinsic advantage over conventional transperitoneal laparoscopic nephrectomy (LapNeph) because of the potentially lower risk for early and late intraperitoneal donor complications. RetroNeph, however, is infrequently performed and has not been systematically and directly compared with LapNeph in nonselected donors. In November 2007, after 10 years of programmatic experience with transperitoneal LapNeph, we implemented RetroNeph at once for all live donor nephrectomies. Donor selection criteria, laparoscopic port positions, and hand-assistance mode were identical for RetroNeph and preceding LapNeph donors. We compared outcomes of retroperitoneoscopically completed cases with those of previous transperitoneal LapNeph cases that were pair matched for donor sex, body mass index, and donor kidney laterality. Of the first 52 donor nephrectomies (48 left, 4 right) consecutively started with the intent to perform a RetroNeph November 2007 to April 2009, 45 (87%) were completed retroperitoneoscopically, and seven (13%) were switched intraoperatively to transperitoneal LapNeph. We observed no conversions to open nephrectomy, donor blood transfusions, readmissions, or reoperations. Matched-pair analysis of the 45 RetroNeph versus 45 LapNeph cases showed no significant differences for warm ischemia time and other donor outcomes, delayed graft function rates, recipient creatinine at 1 week, and 1-year graft survival. Implementation of a RetroNeph program had no adverse impact on donor morbidity and quality of early graft function. Our pilot experience suggests that the RetroNeph learning curve is short. Given the potential advantages of an extraperitoneal approach for the donor, RetroNeph is an attractive alternative to LapNeph, particularly for surgeons with previous LapNeph experience.

Retroperitoneoscopic live‐donor nephrectomy: 5‐year single‐center experience in China

To evaluate the efficacy and the learning-curve period of our modified retroperitoneoscopic live-donor nephrectomy. From December 2003 to May 2009, 138 consecutive retroperitoneoscopic live-donor nephrectomies were carried out at our institution. Donors were separated into four groups in consecutive sequence in order to determine the learning-curve period. Groups 1-3 included forty consecutive cases each, whereas group 4 included the last eighteen cases. The renal artery and vein were controlled with two plastic locking clips at proximal ends without any clips on the kidney side. The kidney was manually retrieved through lumbar incision. Mean operative times were 160.5, 116.9, 101.4 and 109.2 min in groups 1-4, respectively (group 1 vs group 2, 3 or 4, P < 0.01). Mean warm ischemic time was 3.5 min. Mean estimated blood loss was 88.8, 73.0, 69.3 and 43.9 mL in groups 1-4, respectively (group 1 vs group 4, P < 0.01). No blood transfusion or open conversion was required. Mean hospital stay was 7.8, 6.9, 6.6 and 5.8 days in groups 1-4, respectively (group 1 vs group 4, P < 0.05). Eight donors and seven grafts suffered from complications. Complication rates were 22.5%, 7.5%, 5.0% and 6.0% in groups 1-4, respectively (group 1 vs group 3, P < 0.05). Our modified retroperitoneoscopic live-donor nephrectomy can be carried out safely with a learning-curve period of about 40 cases.

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

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