后腹腔镜活体供肾切取术115例总结

目的总结后腹腔镜下亲属活体供肾切取术115例的经验。方法我院自2003年12月至2008年11月共行后腹腔镜下亲属活体供肾切取术115例,手术常规取腰部3个穿刺点入路,在肾脂肪囊内游离肾脏后,输尿管游离至肾脏下极7．8cm处剪断,肾动脉和肾静脉用直线切割器（Endo—cut）切断或用hem—o—lok（Weck,USA）夹闭后剪断,立即取出肾脏用4℃肾脏保存液（HCA）灌注肾脏。用直线切割器处理肾血管3例,用hem—o—lok处理肾血管112例。结果115例手术均获得成功,手术时间90min（60～180min）。术中出血量60ml（20-200ml）,所有供者不需输血。供肾热缺血时间4．5min（3～8min）。发生手术并发症3例,为术后肾区血肿,均自行吸收,无不良影响,其余供者均无异常。术后住院时间平均为5．7d（4～9d）。115例供者中95例得到随访,平均随访42个月（1．58个月）,均健康。结论后腹腔镜下亲属活体供肾切取术安全、可靠,可替代传统开放取肾手术,但要求术者有娴熟的腹腔镜技术。     

后腹腔镜活体供肾切取术(附视频)

目的总结后腹腔镜下亲属活体供肾切取术经验。方法 2003年12月至2011年12月北京大学第三医院泌尿外科共行后腹腔镜下亲属活体供肾切取术151例,手术常规取腰部3个穿刺点入路,在脂肪囊内游离肾,输尿管游离至肾下极7～8cm处夹闭远端剪断,肾动脉和肾静脉用直线切割器切断(3例)或用hem-o-lok(148例)夹闭后剪断,立即取出肾,用4℃肾保存液灌注。结果 151例手术均顺利,平均手术时间(86.0±13.6)min(54～180min),术中出血量(57.1±12.3)mL(20～200mL),所有供者均不需输血。供肾平均热缺血时间(3.6±1.2)min(2～8min)。发生术后肾区血肿3例,均自行吸收,无不良影响,其余供者均无异常。术后住院(4.8±1.7)d(3.5～9d)。受者均无移植物功能延迟发生。结论后腹腔镜下亲属活体供肾切取术安全可靠,经不断的技术改进可降低术者学习曲线,提高供肾质量。     

3D后腹腔镜下活体供肾切取术的临床分析

目的总结3D后腹腔镜下活体供肾切取术的经验,并探讨其临床效果和安全性。方法收集19例3D后腹腔镜下活体供肾切取术的临床资料。记录手术时间、术中失血量、肾脏热缺血时间、肾动脉长度、肾静脉长度、输尿管长度、切口长度、手术并发症。观察供、受者术后肾功能的情况等。结果 19例活体供肾切取术均在3D后腹腔镜下顺利完成,无术中改为常规腹腔镜和中转开放者。3D后腹腔镜下活体供肾切取术手术时间80.5~125.2(平均102.3)min;术中出血量40.6~90.4(60.8)ml;肾脏热缺血时间100~230(161)s。供肾动脉长度2.6~3.2(2.9)cm;供肾静脉长度2.2~3.0(2.6)cm;供肾输尿管长度8~13(10)cm;切口长度约5~6 cm,伤口愈合良好;供者术后24 h尿量2 000~2 500 ml;术后3 d查血清肌酐轻度增高1例,术后7 d和1个月复查血清肌酐恢复正常。术后住院时间5~7(6)d。移植手术均获成功,未发生移植肾功能延迟恢复。结论 3D腹腔镜手术系统可有效提高术中操作的精准性,3D后腹腔镜下活体供肾切取术安全可行。     

六基因修饰巴马小型猪活体供肾切取研究报告

目的 总结基因修饰猪活体供肾切取的经验及其实践价值。方法 采用活体供肾切取技术,切取六基因修饰猪左侧肾脏。首先阻断输尿管,游离下腔静脉及腹主动脉后,切取过程中依次完成输尿管、肾静脉、肾动脉的显露、游离。在腹主动脉、下腔静脉上阻断钳,离断肾动脉、静脉后立即用4℃肾保存液进行灌注,保存在冰生理盐水中准备移植。同时完成供体腹主动脉、下腔静脉缺口的缝合。记录手术时间,出血量,热缺血和冷缺血时间,并发症发生情况以及供、受体存活情况。结果 成功切取基因修饰猪左肾,取肾术中出血5 mL,热缺血时间45 s,冷缺血时间2.5 h。供、受体均未输血,植入受体内的肾脏恢复泌尿功能。切取左肾后供体健康存活8个月余。结论 基因修饰猪活体供肾切取技术安全可靠,游离肾脏过程中同时处理分支血管,减少了修肾过程,缩短了冷缺血时间,活体供肾切取有助于后续供体存活并进行其他科学研究。     

机器人辅助腹腔镜活体供肾切取术(附2例报告)

目的:探讨机器人辅助腹腔镜活体供肾切取术的安全性和可行性。方法:对2例亲属活体供肾者行机器人辅助腹腔镜活体供肾切取术。结果:术前机器人定位时间28min,平均手术时间80min,出血约50ml,热缺血时间3min。开放血流后,2例移植肾脏均在1 min内开始分泌尿液。2例受者术后1周内血肌酐均降至正常,无手术并发症,无排斥反应。2例供者术后复查肾功能正常,住院5~6d,无手术并发症。结论:机器人精细的解剖分离和高效的止血提高了术者手术技巧,机器人辅助腹腔镜活体供肾切取术安全可行。     

后腹腔镜技术活体亲属供肾切取的可行性研究(附10例报告)

目的 :探讨利用后腹腔镜技术行活体亲属供肾切取的安全性和可行性。方法 :在对供受者进行全面的免疫学检查 ,对供者作详细的安全性评价 ,行SPECT检查了解分侧肾功能 ,用DSA了解肾血管的变异情况之后 ,采用后腹腔镜技术对 10例活体亲属供肾进行切取 ,按常规方法移植给受者。结果 :10例均成功切取左肾并移植给受者 ,平均手术时间 (10 2 .6± 19.3)min ,平均术中出血量 (13.0± 9.8)ml,热缺血时间平均 (14 1.8± 72 .1)s,受体血管开放后供肾均泌尿 ,其中 1例患者移植后 1周发生输尿管远端坏死漏尿 ,再次手术后恢复正常。术后无排斥反应及其他与操作技术有关的并发症发生。结论 :利用腹腔镜技术行活体亲属供肾切取对供者损伤小 ,术后恢复快 ,对供肾功能无明显影响 ,技术上安全可行     

自制单孔多通道设备行后腹腔镜活体供肾切取术（附4例报告）

目的：探讨单孔后腹腔镜活体供肾切取术的安全性和可行性。方法：对4例亲属活体供肾者取腰部7cm切口,采用自制单孔多通道设备、常规腹腔镜操作器械完成单孔后腹腔镜活体供肾切取术。结果：本组平均手术时间160min,出血30-350ml,热缺血时间2～4min。开放血流后,4例供肾均在1min内泌尿,移植肾功能术后3天内均恢复正常;供者术后肾功能正常,5～6天出院,无手术并发症。结论：自制单孔多通道设备行后腹腔镜活体供肾切取术临床可行,安全可靠,费用低,可进一步减轻供者创伤,是一种有广阔应用前景的手术方式;能否替代传统腹腔镜活体供肾切取术还需进行前瞻、随机、对照研究。     

腹腔镜活体亲属供肾切取术临床疗效观察(附5例报告)

目的：总结腹腔镜技术行活体亲属供肾切取术的临床经验，探讨其安全性及临床效果。方法：分别采用经腹腔及经后腹腔途径的腹腔镜技术行活体亲属供肾切取术5例。结果：手术平均用时4h 45min，出血50～1000ml，热缺血时间1min 55s～3min 10s；开放血流后10-30s供肾泌尿，供者术后肾功能正常，7天拆线出院，无手术并发症。结论：与传统手术切取供肾相比，腹腔镜活体亲属供肾切取术使供肾者损伤小，恢复快，且供肾质量仍可得到保障。     

自制单孔设备经腹膜后入路腹腔镜活体供肾切取11例体会

目的 探讨用自制单孔设备行经腹膜后入路腹腔镜亲属活体供肾切取术的安全性和可行性.方法 2011年1月到2012年6月间采用自制单孔多通道设备及常规腹腔镜操作器械,先后完成11例经腹膜后入路腹腔镜亲属活体供肾切取手术.结果 供肾均为左肾,平均手术时间为149.5 min,术中出血量为20～350 ml,供肾热缺血时间为2～4 min.供者术后5～6 d出院,未发生手术并发症.结论 采用自制单孔多通道设备完成经腹膜后入路腹腔镜活体供肾切取术在技术上是可行的 ;与传统腹腔镜供肾切取手术相比,手术创伤小,恢复快.     

手助腹腔镜活体供肾切取术21例报告

目的评价手助腹腔镜活体供肾切取术(HLDN)的手术效果和近期疗效。方法回顾性分析2004年4月至2005年7月采用HLDN方法获取活体供肾21例的临床资料。供者男13例,女8例。年龄31～60岁,平均43岁。其中18例供者为血缘关系亲属供肾,3例为非血缘关系夫妻供肾。通过受者移植后肾功能恢复情况,评价HLDN的效果。结果手术皆取左肾,手术时间100～150 min,失血量30～100 ml。供肾热缺血时间2～3 min,冷缺血时间45～60 min。平均供肾动脉长度2.3 cm,静脉长度3.5 cm。HLDN手术全部成功,无中转开放,无手术并发症,术后6～7 d出院。21例受者肾移植后未发生肾功能延迟恢复,术后1周内肾功能均达到正常值。结论HLDN结合了腹腔镜活体供肾切取术和开放手术活体供肾切取术的优点,既保证了对供者的微创,又保证了供肾质量,有利于推动活体供肾移植的开展。     

A Necessary Step Toward Kidney Donor Safety: The Transition From Locking Polymer Clips to Transfixion Techniques in Laparoscopic Donor Nephrectomy

Donor safety is of paramount importance in addressing end-stage renal failure through living kidney transplantation. The United States Food and Drug Administration (FDA) issued a Class II recall on the use of Hem-o-lok (Teleflex, Limerick, Pennsylvania, United States) polymer clips on the renal artery in laparoscopic donor nephrectomy (LDN) in June 2006 following 3 reported cases of donor deaths secondary to slipped ligature. The National University Hospital of Singapore made the transition regarding hilar control in minimally invasive donor nephrectomy, from using polymer and titanium clips to transfixion techniques (pure or hand-assisted laparoscopic) via laparoscopic staples or intracorporeal suturing, respectively. This study assessed safety during the transition in arterial transfixion techniques in minimally invasive donor nephrectomy for both donors and recipients. Forty-five consecutive kidney donors underwent donor nephrectomy over a 2-year period starting from June 2010. A total of 37 donors who underwent LDN (pure laparoscopic or hand-assisted laparoscopic) were included in the analysis. Of the 37 patients, 23 kidney donors had renal arterial control using Hem-o-lok while 14 patients from November 2011 onward underwent transfixion of the renal artery. The 2 groups of donor who underwent renal arterial control by either clips ligature or transfixion technique were comparable. The outcomes for the recipients in each group were similar with no statistical difference between postoperative creatinine level, incidence of delayed graft function, or graft survival at 1 year. We conclude that the transition in renal arterial control technique to transfixion techniques in LDN in line with FDA recommendation is feasible and affords equivalent donor and recipient outcomes.     

Renal vessel reconstruction in kidney transplantation using a polytetrafluoroethylene (PTFE) vascular graft.

BACKGROUND: We report a rare experience in reconstructing short renal vessels in kidney transplantation using polytetrafluroethylene (PTFE) vascular grafts. METHODS: The short renal vessels in three kidney grafts were managed by the interposition of PTFE vascular grafts. Two grafts were from deceased donors and the third was a renal auto-transplant graft. RESULTS: PTFE grafts were used to lengthen short renal veins in two kidney grafts and a short renal artery in one. The warm ischaemia time was under 1 h and all kidneys functioned well post-operatively. Excellent blood perfusion in the three renal grafts was present on postoperative MAG 3 renal scan. No intra-operative or post-operative complications were encountered. CONCLUSIONS: In the three described patients, the use of PTFE vascular graft presented no additional morbidity to the kidney transplant operation and no post-oerative complication was related to its use. However, more data are necessary to conclude that PTFE graft can be used safely in kidney transplantation.     

Donors with renal artery stenosis: fit to donate

Kidney donation from hypertensive donors is now an accepted norm in live related kidney transplantation. The use of hypertensive donors with renal artery stenosis due to atherosclerosis and fibromuscular dysplasia is still debated. The prime concern is about the deleterious effect of hypertension on the donor and the risk of recurrence of such lesions in the solitary kidney. Even as the response of atherosclerotic renal artery stenosis to revascularisation is unpredictable, there is an improvement in blood pressure following revascularisation of kidneys with fibro-muscular dysplasia. The first use of such kidney donors was reported in 1984 and, since then, there have been a few reports of successful use of kidneys from donors with renal artery stenosis. We report here two interesting cases of successful transplantation of kidneys from live related kidney donors with hypertension due to renal artery stenosis who became normotensive with good graft function in the recipient. We conclude that moderately hypertensive donors with renal artery stenosis are fit to donate.     

后腹腔镜肾切除术肾蒂血管处理方法探讨 (附39例报告)

目的:探讨后腹腔镜肾切除术中用腔内直线切割器(Endo-cut)和威克外科结扎锁(Hem-o-lok)处理肾蒂血管的安全有效性、经济性及优越性。方法:回顾性分析行后腹腔镜肾切除术39例,包括单纯性肾切除23例,根治性肾切除11例,肾输尿管全切除5例;其中用Endo-cut同时处理肾动、静脉18例,用Hem-o-lok分别处理肾动、静脉21例。结果:手术均获得成功,均未中转开放手术。1例Endo-cut离断肾动、静脉后残端严重渗血,近心端加用2个钛夹夹闭后未再渗血,其他处理肾蒂血管均顺利,术中、术后均未出现血管并发症。手术时间136～220min,平均160min;术中估计出血量60～320ml,平均125ml;腹膜后引流管于术后2～3天拔除,术后住院时间5～9天。结论:后腹腔镜肾切除术中用Endo-cut和Hem-o-lok处理肾蒂血管均安全有效,但Hem-o-lok更经济、便捷;对于肾蒂粘连严重,肾动、静脉无法游离者,用Endo-cut有优越性。     

Trasplante renal mediante reconstrucción de conducto vascular en riñones de donantes fallecidos con arterias renales múltiples y venas renales cortas

BackgroundTransplantation of kidneys with vascular anatomical variants remains a challenge. Due to its varying success in regard to graft function after transplantation, these organs have been frequently discarded assuming in advance an unaffordable rate of vascular complications.Patients and methodsWe performed three kidney transplants using organs from deceased donors harboring vascular variants (multiple arteries and short veins), including an unsplittable horseshoe kidney. Different grafts harvested from the same donor aorta, common iliac artery, and inferior vena cava, were used to reconstruct the initial vascular configuration by creating single arterial and venous conduits aimed to simplify the vascular anastomoses in the recipient.ResultsNo post-operative complications were recorded. Warm ischemia times remained comparable to single artery renal allografts. No delayed graft function was noted in any case, and every patient regained normal renal function after transplantation.ConclusionsVascular reconstruction using arterial and venous grafts harvested from the same deceased donor may result a helpful tool to simplify vascular anastomoses during transplantation surgery, thus avoiding their discard in advance, minimizing perioperative complications, and enabling normal graft function rates in the long-term follow-up. The successful outcome obtained by using this approach would help to expand the donor criteria for the inclusion of organs containing vascular anatomical variants.     

Results of transplantation of kidneys from related living donors

Between 1973 and 1981 23 transplantations of kidneys from living related donors have been performed in Frankfurt/Main. Donor complications were haematopneumothorax (1 case) and reversible urinary tract infections (3 cases). All donors were discharged after 8-12 days, all have until now (6 months to 8 years postoperatively) normal excretory renal function and normal arterial blood pressure. Patient-survival in the recipients is 5 years postoperatively 96% and graft-survival is 90%. Nine patients received HLA-identical kidneys, all have excellent to fair function of the grafts, 7 patients are off steroids. In 14 cases kidneys were transplanted, although donor and recipient shared only one haplotype. In these patients 5-year graft survival is 84%. Seven patients have normal graft function, whereas 6 patients have a reduced function or have rejected. One patient died. Results of kidney transplantation using living related donors are--even when donors with only one haplotype-identity are accepted--much better than those obtainable when using cadaveric donors. When renal transplantation is considered, patients should be informed about the favourable results attainable with kidneys from living related donors.     

Pediatric cadaver kidneys for transplantation.

A group of 24 kidneys from donors ranging in age from 1 1/2 to 10 years were transplanted singly into adults and were compared to a group of 44 adult cadaveric kidneys transplanted into adults. There were no vascular complications in either group. There were two urological complications in the 24 pediatric donor cases and none with the adult donor cases. During the first month after transplantation, the mean creatinine clearance was lower in the pediatric donor group; later the function of the pediatric donor kidneys was at least as good as the function of the adult donor grafts. In the group of pediatric donor kidneys, the outcome using kidneys from donors younger than 3 years of age was less satisfactory than for donors 3 to 10 years of age. These data suggest that transplantation of a single pediatric kidney into an adult, particularly if the pediatric donor is at least 3 years of age, will provide satisfactory renal function.     

Technique of organ removal and fate of kidney grafts from liver donors.

The fate of 42 kidney grafts taken from heart-beating, ventilated donors at the same time as removal of the liver for allografting is reported, and is compared with 50 kidney grafts taken from heart-beating, ventilated donors whose ventilators were electively switched off either during or immediately before kidney removal. The fate of 32 kidney grafts taken from donors classified as "dead on arrival" at the admitting hospital is also reported. Onset of life-supporting graft function was significantly earlier among kidneys from the "liver donor" group. Consequently, immediate postoperative dialysis requirements were significantly less in recipients of this group of kidneys. Early graft survival, the incidence of graft primary nonfunction, failure of first and second kidney grafts, and recipient survival were not significantly different when comparing liver donor and "ventilator switch off" kidneys. No constant relationship was apparent in any donor group between graft fate and the anoxic and ischaemic times the graft was exposed to during organ removal and reimplantation.