Transperitoneal Laparoscopic Living Donor Nephrectomy Research Articles

Đánh giá kết quả phẫu thuật nội soi lấy thận ghép sau phúc mạc và xuyên phúc mạc tại Bệnh viện Trung ương Huế

Abstract Introduction: Laparoscopic living donor nephrectomy (LLDN), which is standard technique, has more advantages than open nephrectomy. Today, there are two approachs in LLDN, including retroperitoneal and transperitoneal. We evaluate results of modified retroperitoneal and transperitoneal laparoscopic living donor nephrectomy, give selection criteria as well as the advantages and disadvantages of each approach. Materials and Methods: Prospective study of 84 voluntary living kidney donors who underwent modified retroperitoneal and transperitoneal laparoscopic living donor nephrectomy (RPLDN) and (TPLDN) in Transplant Center, Hue Central Hospital, between 1/2018 and 6/2020. Results: The difference in BMI among two groups was roughly 2 (Kg/m2) (p<0,05). The perioperative, postoperative complication rate and the conversion rate to open surgery were similar between the two groups. The surgical time and blood loss was significantly lower in RPLDN (139,38 ± 24,73 min, 46,35 ± 13,32 ml) than in TPLDN (174,39 ± 40,86 min, 67,92 ± 30,76 ml) (p<0,05). Comparing characteristics such as warm ischemic time, hospital stays, flatulence time, removal time of drainage and urinary catheter indicated that they were similar between the two groups (p>0,05). Conclusion: Both RPLDN and TPLDN are safe and effective procedures. RPLDN should be conducted in patients with low BMI (< 23 kg/m2), previous abdominal operations and wide flank space. Moreover, modified RPLDN has shorter operative time, less blood loss and good esthetic aspect comparing to TPLDN. Key word: Retroperitoneal laparoscopic, transperitoneal laparoscopic, nephrectomy living donor. Tóm tắt Đặt vấn đề: Phẫu thuật nội soi (PTNS) lấy thận ghép trên người hiến sống được xem là phương pháp có nhiều ưu điểm hơn so với mổ mở kinh điển. Hiện nay, có 2 phương pháp tiếp cận chính là sau phúc mạc (RPLDN) và xuyên phúc mạc (TPLDN). Chúng tôi đánh giá kết quả PTNS sau phúc mạc có cải biên và phẫu thuật xuyên phúc mạc để lấy thận ghép trên người hiến sống, đưa ra các tiêu chuẩn chọn lựa cho mỗi phương pháp và ưu nhược điểm của mỗi phương pháp. Phương pháp nghiên cứu: Nghiên cứu tiến cứu 84 người bệnh (NB) hiến thận tự nguyện được phẫu thuật lấy thận nội soi sau phúc mạc cải biên và xuyên phúc mạc tại Trung tâm Ghép tạng, Bệnh viện Trung ương Huế từ tháng 1/2018 đến tháng 6/2020. Kết quả: Chỉ số BMI có sự khác biệt giữa 2 nhóm RPLDN và TPLDN khoảng 2 (Kg/m2) (p<0,05). Tỷ lệ biến chứng trong mổ, tỷ lệ biến chứng sau mổ là tương đương nhau giữa 2 nhóm. Thời gian phẫu thuật và lượng máu mất của phương pháp nội soi sau phúc mạc là thấp hơn (139,38 ± 24,73 phút, 46,35 ± 13,32 ml) đáng kể so với xuyên phúc mạc (174,39 ± 40,86 phút, 67,92 ± 30,76 ml) (p<0,05). Thời gian thiếu máu nóng, thời gian hậu phẫu, thời gian có trung tiện, thời gian rút ống dẫn lưu, thời gian rút sonde tiểu, nghiên cứu của chúng tôi cũng cho thấy sự tương đồng giữa 2 nhóm (p>0,05). Kết luận: PTNS sau và xuyên phúc mạc là 2 phương pháp an toàn và hiệu quả trong lấy thận ghép trên người hiến sống. Nội soi sau phúc mạc nên áp dụng cho các ca hiến có chỉ số BMI thấp (< 23 kg/m2), khoảng hông lưng rộng hay có phẫu thuật vùng bụng trước đó. PTNS sau phúc mạc cải biên có thời gian phẫu thuật nhanh hơn, ít mất máu hơn nhưng ít thẩm mỹ hơn xuyên phúc mạc. Từ khóa: Nội soi sau phúc mạc, nội soi xuyên phúc mạc, lấy thận người hiến sống.

Effects of low versus standard pressure pneumoperitoneum on renal syndecan-1 shedding and VEGF receptor-2 expression in living-donor nephrectomy: a randomized controlled study

BackgroundLaparoscopic nephrectomy is a preferred technique for living kidney donation. However, positive-pressure pneumoperitoneum may have an unfavorable effect on the remaining kidney and other distant organs due to inflamed vascular endothelium and renal tubular cell injury in response to increased systemic inflammation. Early detection of vascular endothelial and renal tubular response is needed to prevent further kidney injury due to increased intraabdominal pressure induced by pneumoperitoneum. Transperitoneal laparoscopic living donor nephrectomy represented a human model of mild increasing intraabdominal pressure. This study aimed to assess the effect of increased intraabdominal pressure on vascular endothelium and renal tubular cells by comparing the effects of low and standard pressure pneumoperitoneum on vascular endothelial growth factor receptor-2 (VEGFR-2) expression and the shedding of syndecan-1 as the early markers to a systemic inflammation.MethodsWe conducted a prospective randomized study on 44 patients undergoing laparoscopic donor nephrectomy. Subjects were assigned to standard (12 mmHg) or low pressure (8 mmHg) groups. Baseline, intraoperative, and postoperative plasma interleukin-6, syndecan-1, and sVEGFR-2 were quantified by ELISA. Syndecan-1 and VEGFR-2 expression were assessed immunohistochemically in renal cortex tissue. Renal tubule and peritubular capillary ultrastructures were examined using electron microscopy. Perioperative hemodynamic changes, end-tidal CO2, serum creatinine, blood urea nitrogen, and urinary KIM-1 were recorded.ResultsThe low pressure group showed lower intra- and postoperative heart rate, intraoperative plasma IL-6, sVEGFR-2 levels and plasma syndecan-1 than standard pressure group. Proximal tubule syndecan-1 expression was higher in the low pressure group. Proximal-distal tubules and peritubular capillary endothelium VEGFR-2 expression were lower in low pressure group. The low pressure group showed renal tubule and peritubular capillary ultrastructure with intact cell membranes, clear cell boundaries, and intact brush borders, while standard pressure group showed swollen nuclei, tenuous cell membrane, distant boundaries, vacuolizations, and detached brush borders.ConclusionThe low pressure pneumoperitoneum attenuated the inflammatory response and resulted in reduction of syndecan-1 shedding and VEGFR-2 expression as the renal tubular and vascular endothelial proinflammatory markers to injury due to a systemic inflammation in laparoscopic nephrectomy.Trial registrationClinicalTrials.gov NCT:03219398, prospectively registered on July 17th, 2017.

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.

UP-01.16: Retroperitoneal versus transperitoneal laparoscopic live donor nephrectomy: results from a prospective randomized trial

UP-01.16: Retroperitoneal versus transperitoneal laparoscopic live donor nephrectomy: results from a prospective randomized trial

Comparison of right and left laparoscopic live donor nephrectomy

To compare the anatomy and function of right and left kidneys retrieved by laparoscopic live donor nephrectomy (LDN). In all, 84 transperitoneal LDNs were performed, 66 left and 18 right. Two different right-sided LDN techniques were used: initially, the inferior vena cava (IVC) was controlled with a Satinsky clamp introduced through a 6-8 cm right upper quadrant incision, through which the kidney was also removed (six patients). Subsequently, the IVC was completely mobilized by laparoscopic retrocaval dissection (in 12 patients), allowing the use of a linear stapler-cutter, including the caval ostium with the renal vein. The kidney was then removed through a short Pfannenstiel incision. Left kidneys had longer renal veins (38 vs 27 mm; P < 0.05), but there were no differences in arterial length (32 vs 31 mm). Three right kidneys required back-table renal vein lengthening. The operative duration was shorter for right-sided LDNs (132 vs 182 min; P < 0.05). The serum creatinine level at 3 months was 131 vs 134 mmol/L for right and left kidneys, respectively. Despite faster surgery suggesting that the right LDN is technically easier, there is a greater need for back-table reconstruction of the renal vein. The functional results of right and left kidneys are equivalent.

Laparoscopic Live Donor Nephrectomy

Since the first successful renal transplant between identical twins in Boston, USA, in 1954, no major surgical advance was made in the technique of live donor renal transplantation until 1995, when a team from Johns Hopkins University, USA, performed the first human laparoscopic live donor nephrectomy (LLDN). Since then, more than 5,000 LLDNs have been performed worldwide, with excellent outcomes in donors and recipients. Despite this, LLDN remains a controversial operation in many renal transplant centers. This article reviews results from some of the larger published series, and summarizes our practice at Westmead Hospital, where we have performed over 100 transperitoneal LLDNs since 1998.

Hand-assisted transperitoneal laparoscopic living donor nephrectomy

Objective We introduced and evaluated the advantages and disadvantages of the hand-assisted transperitoneal laparoscopic technique for living donor nephrectomy. Materials and methods In December 2001, we started using the technique of hand-assisted transperitoneal laparoscopic living donor nephrectomy (HLDN) in 10 cases. The procedure utilizes a hand-assisted device to increase safety and control of the laparoscopic technique. Results Only left nephrectomy was performed. The mean total operating and the warm ischemia times were 130 minutes and 3.0 minutes, respectively. Average lengths of renal artery and vein were 1.95 cm and 2.8 cm, respectively. There were no intraoperative or postoperative complications. Conclusions HLDN is an easier procedure than the traditional laparoscopic living donor nephrectomy and can greatly mitigate the learning curve. HLDN has shortened warm ischemia time and operating time. It is also good for trocar placement, prevention of torsion of the kidney, control of potential bleeding at the final stage of vascular stapling, and kidney removal. Therefore, HLDN is a promising method for living donor nephrectomy.

Retroperitoneoscopic live donor nephrectomy: Extended experience in a single center

Introduction Retroperitoneoscopic live donor nephrectomy (RPLDN) was performed because it is considered to be less invasive than open live donor-nephrectomy (OLDN) or transperitoneal laparoscopic live donor nephrectomy. Patients and methods Between July 2001 and May 2003, 118 consecutive live donor kidney grafts were procured using RPLDN or OLDN. The patients who underwent RPLDN were divided into 2 groups: an initial group 1 (n = 38) and a subsequent group 2 (n = 48).Thirty-two patients who underwent OLDN during the same period were used as controls (group 3). The patients were placed in the lateral position. Three retroperitoneoscopic ports were inserted. The kidneys were retrieved through a 5-cm flank incision just below the 11th rib in group 1. In group 2, a 5-cm Pfannenstiel incision was used to extract the kidney. Results The operative time was 307 ± 88 minutes, 245 ± 42 minutes, and 215 ± 70 minutes in groups 1, 2, and 3, respectively (group 1 vs group 2 or 3, P < .01). The mean postoperative pentazocine (painkiller) requirements were 12 mg, 4.4 mg, and 22 mg in groups 1, 2, and 3, respectively (group 2 vs group 1 or 3, P < .01). The hospital stay was 6.6 ± 1.6, 4.9 ± 0.7, and 7.0 ± 0.1 days in groups 1, 2, and 3, respectively (group 2 vs group 1 or 3, P < .01). There were no serious complication, such as massive bleeding or bowel injury. Conclusions RPLDN may be safer and less invasive than open donor nephrectomy.

A CONSECUTIVE SERIES OF 70 LAPAROSCOPIC LIVE DONOR NEPHRECTOMIES DEMONSTRATING THE SAFETY OF THIS NEW OPERATION

P147 Aims: Laparoscopic live donor nephrectomy (LDN) has the potential to overcome some of the disincentives to live kidney donation but has yet to be widely adopted in the UK. This study presents the results of a consecutive series of 70 LDN from a single centre with an emphasis postoperative complication rates and donor recovery times. Methods: 70 live donors (39 women and 31 men; mean age 46 yrs) underwent transperitoneal LDN. Two consultant surgeons working together performed all operations. There was no selection on the basis of donor body mass index (range 18-45 kg/m2) or because of difficult vascular anatomy. All patients received postoperative analgesia using a patient controlled analgesia system. Donors were allowed to resume normal activities and return to work at their own discretion. Results: There was no donor mortality and no episodes of thromboembolic disease. One operation was converted to an open procedure because of bleeding from the renal artery. The following postoperative complications were recorded: chest infection 4(6%); paraesthesiae of L1 dermatome 3 (4%) wound infection 2 (3%); unilateral pulmonary oedema 2 (3%); ileus 2 (3%); testicular pain 2 (3%); persistent wound pain 1 (1.4%). Two (3%) patients were re-laparoscoped for division of adhesions. Donor recovery rates (mean ±) are shown in the table. Recipient transplantation was complicated by ureteric stenosis in 2 cases (3%) but there were no vascular thromboses.FigureConclusions: LDN is a safe procedure with low postoperative morbidity and no compromise to the procured graft. Nonetheless, some unexpected complications such as L1 paraesthesia, testicular pain and pulmonary oedema were recorded. LDN is associated with short recovery times.

Right retroperitoneal versus left transperitoneal laparoscopic live donor nephrectomy

Objectives To describe our preferred method of right laparoscopic live donor nephrectomy (LDN) using a retroperitoneoscopic approach to determine the indications for, and overall rate of, right LDN and to compare the donor and recipient early outcomes of right retroperitoneal LDN to those of left transperitoneal LDN in a consecutive single-institution series. Methods At our institution, LDN for allotransplantation was performed in 143 consecutive patients. The indications for right LDN (n = 29) included multiple left renal vessels (n = 18), early branching of the left renal artery (n = 1), left renal vein anomaly (n = 2), right renal arterial fibromuscular dysplasia (n = 2), right renal cyst (n = 3), mild right hydronephrosis with delay on renal scan (n = 1), or right nephrolithiasis (n = 2). Results Right LDN was performed in 29 (20.3%) of 143 patients using a retroperitoneal approach in all but the first case. Right retroperitoneal LDN was associated with decreased blood loss and operative time compared with left transperitoneal LDN. The hospital stay, analgesic use, and donor serum creatinine at discharge were similar in both groups. Despite a statistically significantly increased warm ischemia time and decreased renal vein length, right retroperitoneal LDN was associated with recipient functional outcomes at 5 and 30 days after transplant that were no different from those after left transperitoneal LDN. Conclusions Right retroperitoneal laparoscopic LDN provides similar donor and recipient outcomes when compared with the left transperitoneal approach and obviates most of the technical challenges encountered with a right transperitoneal approach.