Complications of contemporary radical nephrectomy: comparison of open vs. laparoscopic approach

Increasingly, laparoscopy is being employed in the treatment of urologic malignancies. This is most apparent in kidney cancer, where laparoscopic radical nephrectomy is now considered to be a gold standard. Herein, we compared early postoperative morbidity in a contemporary series of open and laparoscopic radical nephrectomies. We reviewed all patients that underwent a radical nephrectomy between October 1999 and May 2001 at our institution. We then compared open radical nephrectomy patients to those undergoing laparoscopic approaches with specific attention to early complications. A total of 74 radical nephrectomies were performed: 41 open, 18 hand-assisted and 15 pure laparoscopic nephrectomies. Overall, complication rates between the open, hand-assist and pure laparoscopic groups were similar (10%, 17% and 12%, respectively, P = 0.133). There was no statistically significant difference in ASA score (P = 0.144), pre-operative hematocrit (P = 0.575) or intra-operative blood loss (P = 0.364). The open nephrectomy group had a statistically larger average tumor size (7.4 cm vs. 4.6 cm; P = 0.005) and younger average age (57 vs. 63; P = 0.019) than the laparoscopic group. Length of hospital stay was significantly shorter in the laparoscopic group (3.6 days vs. 1.7 days; P < 0.0001). Laparoscopic radical nephrectomy has an acceptably low complication rate and compares favorably to open radical nephrectomy. The low rate of complications combined with the advantages of laparoscopic surgery favor a laparoscopic approach for the majority of patients with stage T1 and T2 tumors.     

Comparison of laparoscopic versus hand-assisted live donor nephrectomy

BACKGROUND: The aim of the present study was to compare hand-assisted laparoscopic live donor nephrectomy with the classic laparoscopic method, using meta-analytical techniques. METHODS: A literature search was performed for studies comparing hand-assisted laparoscopic nephrectomy with classic laparoscopic nephrectomy for live kidney donation between 1999 and 2005. The following end points were evaluated: operative time, warm ischemia time, intraoperative adverse events, donor and recipient postoperative complications, and length of hospital stay. RESULTS: Nine comparative studies matched the selection criteria, reporting on 376 patients, of whom 202 (53.7%) had hand-assisted laparoscopic nephrectomy and 174 (46.3%) had the classic laparoscopic technique. Conversion to open surgery was 2.97% in the hand-assisted group and 4.60% in the laparoscopic group (P=0.35). Total operative and warm ischemia times were significantly shorter for hand-assisted laparoscopy by 30.03 minutes (P=0.02) and 1.14 minutes (P<0.001), respectively. The intraoperative blood loss was less for the hand-assisted laparoscopy group by 34.16 mL (P=0.008), although intraoperative (3.46% vs. 7.47%; P=0.24) and postoperative (5.94% vs. 10.34%; P=0.30) donor complications and recipient complications (including delayed graft function and primary nonfunction, 8.41% vs. 7.42%; P=0.32) were similar between the hand-assisted and laparoscopic groups. CONCLUSION: Hand-assisted laparoscopic nephrectomy appeared to have the same donor and recipient complication rate with standard laparoscopy but offered substantial advantages in terms of shortened operative and warm ischemia time as well as decreased intraoperative bleeding.     

手助式腹腔镜肾切除术围手术期并发症的处理

目的探讨手助式腹腔镜肾切除术围手术期并发症的处理方法。方法回顾性分析1998—2004年377例手助式腹腔镜肾切除术患者资料，其中根治性肾切除术206例，单纯性肾切除术91例，根治性肾、输尿管切除术49例，肾部分切除术31例，对围手术期并发症类型、发生率及处理方法进行统计分析。结果377例患者术中估计失血量平均315．6ml（30～7000m1）。术中发生脾脏损伤、难以控制的出血、肠道损伤、肾蒂血管损伤、胰腺损伤等并发症14例（3．7％）。中转开放手术13例（3．4％）。术后发生肠梗阻、肺炎、切口疝、继发性出血、冠心病发作、血管栓塞、低钠血症等并发症48例（12．7％）。死亡2例（0．5％）。有腹腔或腹膜后手术史者围手术期并发症和术式中转率高于无手术史者。结论手助式腹腔镜肾切除术仍会出现一些严重的围手术期并发症。局部粘连、肿瘤体积过大会增加并发症的发生。术中一旦出现严重出血、器官损伤等难以控制的并发症时应及时中转开放手术。充分的术前准备、正确熟练的手术操作可降低并发症的发生率。     

Hand-assisted surgery improves outcomes for laparoscopic nephrectomy

Laparoscopy has become the preferred method for nephrectomy in many medical centers. We compared our experience with hand-assisted laparoscopic nephrectomy (HALN) and standard laparoscopic nephrectomy (LN). Data were prospectively collected on 119 consecutive patients undergoing laparoscopic nephrectomy between August 2000 and November 2002. Outcomes were compared for LN versus HALN using Wilcoxon rank sum test for quantitative outcomes and Fisher exact test and chi2 for qualitative outcomes. Thirty-nine patients underwent LN: 16 live donor, 16 radical, and 7 simple nephrectomies. Eighty patients were treated with HALN: 47 live donor, 32 radical, and 1 simple nephrectomy. There were no differences in mean age (49.2 years LN vs. 47.7 years HALN, P = 0.60) or weight (192.2 lb LN, 179.2 lb HALN, P = 0.12). Mean tumor size (4.77 cm LN vs. 7.12 cm HALN, P = 0.07) and length of extraction incision (8.37 cm LN vs. 7.87 cm HALN, P = 0.08) were similar. Total hospital charges (19,352 dollars vs. 18,505 dollars, P = 0.29) and length of stay (3.68 days vs. 3.72 days, P = 0.15) were equivalent for LN and HALN. Average operative time for HALN was significantly shorter (202 minutes vs. 258 minutes, P = 0.0001), and blood loss was less for HALN (71.7 cc vs. 113.1 cc, P = 0.007). Wound complications rates were similar (6.5% HALN vs. 13% LN, P = 0.34), but overall morbidity rates were higher after LN (28.2% vs. 6.3%, P = 0.001). Compared with pure laparoscopic nephrectomy, the hand-assisted approach reduces operative time and blood loss without increasing total hospital charges or length of stay. In our patients, HALN was also associated with fewer postoperative complications than standard laparoscopic nephrectomy. Hand-assisted laparoscopy may allow for the performance of increasingly complex procedures while maintaining the benefits of minimally invasive surgery.     

Hand-assisted laparoscopic surgery

Hand-assisted laparoscopic surgery has been used to perform nephrectomies. This report contrasts the efficacy, postoperative morbidity, length of stay, analgesic use, and time to recovery for hand-assisted laparoscopic nephrectomy, to standard laparoscopic and open nephrectomy. The technique for hand-assisted laparoscopic nephrectomy used at two institutions is described. The results from these two institutions are contrasted to results in the literature for standard laparoscopic and open nephrectomy. Standard and hand-assisted laparoscopic nephrectomy seem similar in terms of efficacy of surgery, time of surgery, estimated blood loss, length of stay, and time to full recovery. The two laparoscopic techniques seem to show advantage over open surgery in respect to shorter hospital stay, faster full recovery, and less analgesic use. The operative time for the laparoscopic surgeries is longer than the open surgery operating time. Hand-assisted laparoscopic surgery seems to be equivalent to standard laparoscopy. As urologists around the world are trained in hand-assisted laparoscopic nephrectomy, a more refined look at these early results will be possible.     

Comparison of Robot-Assisted Nephrectomy with Laparoscopic and Hand-Assisted Laparoscopic Nephrectomy

Objective:

To compare the initial perioperative outcomes of our robot-assisted laparoscopic nephrectomies with laparoscopic and hand-assisted nephrectomies performed by 2 experienced laparoscopic surgeons.

Patients and Methods:

We retrospectively evaluated all patients who underwent laparoscopic (LN), hand-assisted (HALN), and robot-assisted laparoscopic nephrectomy (RALN) for benign and malignant diseases between August 2006 and December 2008. Data collected included patient age, body mass index, operative times, estimated blood loss, complications, and hospital stay. Radical nephrectomy was performed for renal neoplasms, and simple nephrectomy was performed for suspected benign diseases. In addition, average direct costs and total costs were calculated for each laparoscopic approach.

Results:

Forty-six patients underwent LN, 20 underwent HALN, and 13 underwent RALN. The median operative time was 171, 210, and 168 minutes, respectively. LN, HALN, and RALN groups had similar median EBL [(100mL (IQR=113mL), 100mL (IQR=150mL), and 100mL (IQR=125mL); P=0.695], length of hospital stay [2.0d (IQR=1.0d), 3.0d (IQR=2.0d), and 2.0d (IQR=3.0d); P=0.233], and postoperative morphine equivalent analgesic requirements [33mg (IQR=43mg), 45mg (IQR=50mg), and 30mg (IQR=16mg); P=0.766]. Three patients (6%) in the LN group had complications, 2 (10%) in the HALN group had complications, and 4 (30%) in the RALN group had complications. The average total direct operating room costs were $5,500, $6,979, and $6,869 for the LN, HALN, and RALN groups, respectively.

Conclusions:

Early experience with robotic assistance for radical and simple nephrectomy offers no significant advantage over traditional laparoscopic or hand-assisted approaches. It was also more costly.     

Hand-assisted vs. retroperitoneal laparoscopic nephrectomy.

PURPOSE: We retrospectively compared our initial experience with the hand-assisted and retroperitoneal laparoscopic nephrectomy techniques to determine if there are important differences between these approaches. PATIENTS AND METHODS: Twenty-four laparoscopic cases consisting of 12 hand-assisted and 12 retroperitoneal nephrectomies were compared. All cases but one were radical nephrectomies with intact specimen extraction performed for suspected stage T1 neoplasms. Data were collected from medical records and a postoperative questionnaire. To determine if significant learning curves existed, the first six nephrectomies in each group were compared with the second six nephrectomies on the basis of operative criteria. The two groups did not differ significantly in age, body mass index, ASA rating, or number of previous abdominal operations. RESULTS: Although the mean tumor volume was greater in the hand-assisted group than the retroperitoneal group, the difference did not quite reach statistical significance (91.19 v 24.7 cc3; P = 0.06). The mean operative time, estimated blood loss, narcotic use (milligrams of intravenous morphine equivalent), hours to oral intake, hospital stay, and estimated percent activity at 2 weeks for the hand-assisted group (238.33 min, 293.75 mL, 35.7 mg, 17.56 hours, 4.4 days, 74.75%, respectively) were not significantly different from the values in the retroperitoneal group (255.83 min, 141.67 mL, 24.5 mg, 22.36 hours, 3.6 days, 76.91%). We found no significant difference in the mean operative times for the first and second six cases in either group. CONCLUSION: In the initial experience and comparison of hand-assisted and retroperitoneal laparoscopic nephrectomy, we found no significant differences in operative time, estimated blood loss, narcotic usage, hours to oral intake, hospital stay, or activity level at 2 weeks postoperatively. A randomized trial is under way at our institution.     

Prospective, case matched comparison of hand assisted laparoscopic and open surgical live donor nephrectomy

PURPOSE: The technical difficulty of standard laparoscopic live donor nephrectomy has limited its application. Hand assistance, which takes advantage of the incision necessary for organ removal, facilitates laparoscopy without significant impact on patient recovery. We prospectively compared open surgical and hand assisted laparoscopic donor nephrectomy. MATERIALS AND METHODS: Our first 10 laparoscopic live donor nephrectomies were matched with 40 open donor nephrectomies by gender, age and body mass index. Data were obtained by pain scales, SF-12 survey instruments, questionnaires and chart abstraction. RESULTS: Operative time was longer for the laparoscopic approach (mean 95 versus 215 minutes). However, laparoscopic group patients had a shorter hospital stay compared to those undergoing open surgery (mean 2.9 versus 1.8 days), returned sooner to nonstrenuous activity (mean 19.0 versus 9.9 days) and reported less pain 6 weeks postoperatively (mean 2.3 versus 0.6) (p 相似文献   

Hand-assisted laparoscopic radical nephrectomy: the experience of the inexperienced

PURPOSE: We retrospectively examined the experience of novice laparoscopic surgeons performing hand-assisted laparoscopic radical nephrectomy. The purpose was to determine if urologists with minimal laparoscopic training could perform hand-assisted laparoscopic nephrectomies in a safe and efficient manner. MATERIALS AND METHODS: The first six hand-assisted laparoscopic radical nephrectomies performed by four different urology residents at the Chicago Lakeside VA hospital were reviewed. The residents included three chief urology residents and one postgraduate year 3 urology resident. None of the residents had taken any laparoscopic course, and all had limited exposure to the hand-assisted technique. In all cases, the residents performed the entire operation. The patients were evaluated for operative time, tumor size, body mass index, and ASA score. RESULTS: All six procedures were completed without conversion to the open technique. The average operating time was 215.8 minutes, and the time from incision to organ removal averaged 140.8 minutes. The average estimated blood loss was 166 mL. Complications included an intraoperative diaphragmatic injury (recognized and repaired laparoscopically) and one postoperative ileus. CONCLUSION: Hand-assisted laparoscopic radical nephrectomy can be performed safely and efficiently by urologists with minimal laparoscopic experience.     

后腹腔镜及经腹膜外径路腹腔镜技术在泌尿外科器官保留、功能重建手术中的应用

目的：探讨后腹腔镜及经腹膜外径路腹腔镜技术在泌尿外科器官保留、功能重建手术中的应用方法,并评价其治疗效果。方法：2000年7月～2005年8月完成后腹腔镜及经腹膜外径路泌尿外科器官保留、功能重建手术71例,包括重复肾切除术4例,肾部分切除术8例,肾盂成形术13例,肾盂输尿管切开取石术30例,腔静脉后输尿管成形术2例,先天性巨输尿管成形术1例,膀胱部分切除术4例,前列腺癌根治术9例。结果：71例均一次成功,手术时间30～270min,平均85min,术中出血少。术后腹膜后及腹膜外引流量少,3～5天拔出引流管,多无明显并发症。术后5天～2周出院（平均8．6K）。结论：经腹膜外径路腹腔镜手术具有创伤小、安全、术后恢复快、住院时间短、并发症少等优点,在泌尿外科器官保留及功能重建手术中具有明显优势。     

Complications in laparoscopic nephrectomy

ObjectiveTo report the complications and their respective management in our series of laparoscopic nephrectomy.Material and methodsBetween November 1992 and March 2004, 319 patients underwent laparoscopic ablative renal surgery: 152 were women and 167 were men, mean age was 45 years (range: 0,5 - 82 years). There were 70 radical nephrectomies, 16 radical nephroureterectomies, 63 partial nephrectomies, 124 simples nephrectomies, 15 simples nephroureterectomies, 8 heminephrectomies and 23 living donor nephrectomies.ResultsThe complication rate was 5.64%. The most frequent complications were bleeding (2.5%) and retroperitoneal haematoma (1.2%). There was not statically difference in complications rate by age, sex, or approach via: transperitoneal versus retroperitoneal. Complication rate was alike with laparoscopic or hand assisted technique. There was not mortality in the series.ConclusionsWe have a low complication rate in laparoscopic nephrectomy. We believe that laparoscopy is a safe technique for patients that require ablative renal surgery when the surgical team has experience in advanced laparoscopic surgery.     

Hand-Assisted Laparoscopic Living-Donor Nephrectomy as an Alternative to Traditional Laparoscopic Living-Donor Nephrectomy

The benefits of laparoscopic living-donor nephrectomy (LDN) are well described, while similar data on hand-assisted laparoscopic living-donor nephrectomy (HALDN) are lacking. We compare hand-assisted laparoscopic living-donor nephrectomy with open donor nephrectomy. One hundred consecutive hand-assisted laparoscopic living-donor nephrectomy (10/98-8/01) donor/recipient pairs were compared to 50 open donor nephrectomy pairs (8/97-1/00). Mean donor weights were similar (179.6 +/- 40.8 vs. 167.4 +/- 30.3 lb; p = NS), while donor age was greater among hand-assisted laparoscopic living-donor nephrectomy (38.2 +/- 9.5 vs. 31.2 +/- 7.8 year; p < 0.01). Right nephrectomies was fewer in hand-assisted laparoscopic living-donor nephrectomy [17/100 (17%) vs. 22/50 (44%); p < 0.05]. Operative time for hand-assisted laparoscopic living-donor nephrectomy (3.9 +/- 0.7 vs. 2.9 +/- 0.5 h; p < 0.01) was longer; however, return to diet (6.9 +/- 2.8 vs. 25.6 +/- 6.1 h; p < 0.01), narcotics requirement (17.9 +/- 6.3 vs. 56.3 +/- 6.4h; p < 0.01) and length of stay (51.7 +/- 22.2 vs. 129.6 +/- 65.7 h; p < 0.01) were less than open donor nephrectomy. Costs were similar ($11072 vs. 10840). Graft function and 1-week Cr of 1.4 +/- 0.9 vs. 1.6 +/- 1.1 g/dL (p = NS) were similar. With the introduction of HALDN, our laparoscopic living-donor nephrectomy program has increased by 20%. Thus, similar to traditional laparoscopic donor nephrectomy, hand-assisted laparoscopic living-donor nephrectomy provides advantages over open donor nephrectomy without increasing costs.     

Hand-assisted laparoscopic nephrectomy

The introduction of hand-assisted laparoscopy should benefit every laparoscopic urologist. Hand assistance will shorten the learning curve for many urologists interested in performing laparoscopic renal procedures, including nephrectomy and nephroureterectomy. Advanced laparoscopists will be able to undertake more challenging procedures, including nephrectomies for inflamed, infected kidneys and live-donor nephrectomies. A step-by-step approach is presented for hand-assisted laparoscopic nephrectomy.     

Laparoscopic nephrectomy outcomes of elderly patients in the 21st century

BACKGROUND AND PURPOSE: As life expectancy continues to increase, we will be faced with the need to counsel older patients on the risks and benefits of undergoing surgery. It is clear that laparoscopic renal surgery has significant benefits over open renal surgery. However, contemporary data on whether these benefits carry over to the elderly is less robust. The objective of this study is to compare the perioperative outcomes of laparoscopic nephrectomy in patients age 70 and over to those under age 70. Outcomes from the study can be used to assist in preoperative counseling for older patients. PATIENTS AND METHODS: Between February 2000 and December 2005, 405 consecutive patients underwent laparoscopic nephrectomy for benign or malignant conditions. To decrease selection bias, kidney donors, bilateral nephrectomies, partial nephrectomies, as well as patients under the age of 17 were excluded. Laparoscopic nephrectomies included simple nephrectomies, radical nephrectomies, and nephroureterectomies. A total of 158 patients were included in the analysis. Patient demographics and perioperative data were recorded prospectively. The preoperative American Society of Anesthesiologists (ASA) score was used to reflect patient co-morbidity. Subset analysis between pure laparoscopic nephrectomy (LN) and hand-assisted laparoscopic nephrectomy (HALN) was also performed. RESULTS: Average hospital stay for patients 70 years and older was 3.6 days versus 2.6 days for their younger counterparts (p = 0.02). All other demographic and perioperative parameters were comparable between groups, including incidence of intraoperative or postoperative complications, blood transfusions, and conversions to open surgery. In a subset analysis of patients undergoing HALN, despite having similar co-morbid conditions (ASA score 2.57 vs. 2.56, p = 0.9), the elderly group had a significantly increased length of stay compared to patients younger than 70 years (3.0 vs. 4.2 days, p < 0.05). However, in the group undergoing LN, there was no statistically significant difference in hospital stay (3.1 vs. 2.4 days, p = 0.22), despite the older group having higher co-morbid conditions (ASA score 2.55 vs. 2.10, p < 0.01). CONCLUSION: Other than an increased hospital stay by one day, patients 70 years and older undergoing laparoscopic nephrectomy can expect comparable perioperative outcomes to those achieved in younger patients. Such differences in the length of hospital stay may be mitigated by pure laparoscopic nephrectomy as opposed to hand-assisted laparoscopic nephrectomy in patients 70 years or older. These data may be useful in preoperative decision-making and counseling in this growing subset of patients.     

HAND ASSISTED LAPAROSCOPIC NEPHRECTOMY: COMPARISON TO STANDARD LAPAROSCOPIC NEPHRECTOMY

Purpose

We report our initial experience with hand assisted laparoscopic nephrectomy, and compare it to our results of standard laparoscopic nephrectomy.

Materials and Methods

The results of 21 hand assisted and standard laparoscopic nephrectomies (15 simple and 4 radical nephrectomies, and 2 nephroureterectomies) were reviewed. Hand assisted laparoscopic nephrectomy was performed with a hand placed intra-abdominally using the Pneumo Sleeve,^* in addition to standard laparoscopic instruments manipulated through laparoscopic ports. Standard laparoscopic nephrectomy was performed using laparoscopic instruments alone. Perioperative data were recorded and questionnaires, including visual analog pain scales, were administered prospectively to 17 of 21 cases.

Results

The average operative time for 13 hand assisted laparoscopic nephrectomies was 240 minutes, which was significantly less than the 325-minute average for 8 standard laparoscopic nephrectomies (p = 0.04). Major complications tended to be more frequent in the standard group (38 versus 8%, p = 0.10). Hospital stay, return to normal activity and corrected 2-week abdominal/flank pain score in the hand assisted group (3.1 days, 14 days and 0.8, respectively) were not significantly different from the standard group (3.0 days, 10 days and 0.2, respectively).

Conclusions

Compared to standard laparoscopic techniques, hand assistance appears to facilitate the operative speed and safety of laparoscopic nephrectomy without sacrificing the benefits of minimally invasive surgery. Hand assistance may make laparoscopic nephrectomy more appealing to urologists without advanced laparoscopic experience, may facilitate the laparoscopic management of demanding pathological conditions and is particularly useful when intact specimens are required. Hand assistance, by improving manipulative ability and tactile sense, is helpful for select cases of laparoscopic nephrectomy.     

Hand-assisted retroperitoneoscopic living-donor nephrectomy: initial 10 cases

BACKGROUND: Most living-donor nephrectomies are performed either by transperitoneal laparoscopy, with or without hand assistance, or by retroperitoneal open surgery, with or without video assistance. We therefore started to combine the benefits of these techniques: hand assistance to increase safety and control of the laparoscopic technique, and the retroperitoneal approach to minimize the risk of complications associated with the transabdominal approach. Herein, we report on our first 10 donors nephrectomized with hand-assisted retroperitoneoscopy. RESULTS: Only left nephrectomies were performed. One donor had two renal arteries and two donors had retroaortic renal veins. There were no intra- or postoperative complications. Mean operating time was 155 min (110-230 min). CONCLUSIONS: Hand-assisted retroperitoneoscopy in living-donor nephrectomy is a promising new method that could reduce the risks of traditional transperitoneal laparoscopy and should be further evaluated.     

Nefrectomía radical laparoscópica en piezas quirúrgicas de gran tamaño

IntroductionThe retroperitoneal surgery is the clearer indication for the laparoscopic approach. Still there are indications for open surgery because of the complexity of the patient and the surgeon experience.ObjectivesThe main objective is to report our experience of laparoscopic radical nephrectomies in patient with tumors greater than 7 cm. or surgical specimens with more than 700 g of weight. We analyze their characteristics, complications rate, surgical time, postoperative outcome and hospital stay.Materials and methodsSince july 2004 to july 2008 we have performed 104 laparoscopic radical nephrectomies. We have selected 41 patients with characteristics of big surgical specimens.ResultsThe average surgical time has been of 184,3 min. Only 1 case has been converted into open surgery and only 1 intraoperative death because of cardiologic arrhythmia. The average hospital stay has been of 3,51 days. The complications rate and postoperative outcome are similar to the whole series.DiscussionLaparoscopic nephrectomy is technically less complex than radical prostatectomy. However, their possible complication implies a much bigger severity. The more complex cases must be approach laparoscopically only after a wide experience. Actually, in our department we usually indicate an open approach when surgical specimen crossover the abdominal middle line and in those cases where the tumoral thrombus affect the main renal vein and/or the vena cava.     

Donante vivo renal. experiencia de cirugía abierta y laparoscópica. hospital la paz

Laparoscopic live donor nephrectomy is a rare operation in our country because the complexity of the technique and the expansion of the cadaveric donor. We present our open and laparoscopic live donor nephrectomy from 1984.Material and MethodsFrom 1984 to 2007 we have done 84 live donor nephrectomies; 64 open, 20 laparoscopic surgeries. The transperitoneal approach is preferred in laparoscopy and lumbotomy for the open surgery.ResultsIn the open technique the operating time is 112min (70-155), ischaemia time 20 seconds (15-47) and postoperative hospital stay 4,8 days (3-9). Laparoscopic cases, the operating time is 146 min (90-210), ischaemia time 3 min 15 sec (2-3,25 min) and postoperative hospital stay 3,4 days (2-9).ConclusionsThe laparoscopic live donor nephrectomy is a difficult and demanding technique. It should be done by experienced team in laparoscopic renal surgery. The kidney from a live donor is a very good alternative for the cronic renal failure. It should be offered in our main hospitals.     

Complications of laparoscopic nephrectomy: the Mayo clinic experience

PURPOSE: We present the incidence of complications and conversions during laparoscopic nephrectomy performed for various indications and discuss methods to help prevent future complications. MATERIALS AND METHODS: From June 1999 to February 2003 at our institution 285 laparoscopic nephrectomy cases were performed, consisting of 113 radical nephrectomies, 101 donor nephrectomies, 27 simple nephrectomies, 23 partial nephrectomies and 21 nephroureterectomies. We reviewed the data base of patients who underwent laparoscopic nephrectomy to examine complications and analyze factors related to conversion to an open surgical procedure. RESULTS: Major complications occurred in 16 patients (5.6%). Major complications were surgical in 12 patients and medical in 4. Of the major surgical complications 3, 6, 1, 1 and 1 occurred during laparoscopic radical nephrectomy, donor nephrectomy, nephroureterectomy, simple nephrectomy and partial nephrectomy, respectively. The predominant major surgical complication was bleeding requiring conversion to an open surgical procedure. The overall conversion rate was 4% (12 patients), consisting of 6 emergency and 6 elective conversions. The remaining 27 patients experienced minor surgical or postoperative medical problems, such as urinary retention or wound infection. The mortality rate in our series was 0%. CONCLUSIONS: Laparoscopic renal surgery is becoming a routine procedure in the armamentarium of many urologists. Complications that are unique to laparoscopy exist but they should decrease with time with repetition and experience. We have learned many different precautions and procedures that should help decrease the risk of future complications associated with laparoscopic renal surgery.     

Comparison of outcomes in noncomplicated and in higher-risk donors after standard versus hand-assisted laparoscopic nephrectomy

Hand-assisted techniques facilitated dissemination of the laparoscopic approach in live kidney donors and addressed concerns regarding potential procedural complications. We report our experience with both standard and hand-assisted laparoscopic nephrectomy in routine, complicated, and higher-risk donors. From July 1999 to September 2002, 47 donors underwent standard laparoscopic donor nephrectomy (SLDN; n = 29) or hand-assisted laparoscopic donor nephrectomy (HALDN; n = 18). Donors were "complicated" if they were > 60 years of age, obese, refused blood-product transfusion, had multiple renal arteries or veins, or had right nephrectomies. "Higher-risk" donors had two or more risk factors. Results for SLDN and HALDN were compared for the overall groups and for the "complicated" and "higher-risk" groups. No donor required blood transfusion or reoperation. Warm-ischemia times were shorter in left nephrectomies (191 +/- 72 seconds vs. 337 +/- 95 seconds, P = 0.005), and blood loss was greater in patients with a body mass index > or = 30 kg/m2 (296 +/- 232 mL vs. 170 +/- 139 mL, P = 0.03). Higher-risk donors had an increased operative blood loss and longer hospital stay than low-risk donors. Mean donor creatinine at discharge was 1.19 +/- 0.2 mg/dL. Comparison of SLDN versus HALDN revealed shorter operating times for the latter, which approached statistical significance. Warm-ischemia time, operative blood loss, length of hospitalization, and donor and recipient discharge creatinines were similar for both groups. Laparoscopic donor nephrectomy can be applied to selected higher-risk donors with outcomes comparable to uncomplicated donors. Hand-assisted techniques facilitate the procedure during the learning curve, with advantages similar to standard laparoscopic techniques.