Short-term impact of carbon dioxide, helium, and gasless laparoscopic donor nephrectomy on renal function and histomorphology in donor and recipient

BACKGROUND: Laparoscopic donor nephrectomy has the potential to increase the number of living kidney donations by reducing donor morbidity. However, studies have shown that raised intraabdominal pressure can result in transient renal dysfunction. Therefore, laparoscopically procured kidneys might be at higher risk for suffering a period of ischemia during pneumoperitoneum. The objective of this study was to investigate the short-term impact of pneumoperitoneum used for laparoscopic donor nephrectomy on renal function and histomorphology in donor and recipient. METHODS: EXPERIMENT 1: KIDNEY DONOR: Initially, 36 brown Norway (BN) rats were randomized for three procedures: 2 h of carbon dioxide (CO2) insufflation (8 mmHg), 2 h of helium insufflation (8 mmHg), and 2 h of gasless technique (0 mmHg). After this, a unilateral nephrectomy was performed in all the animals. EXPERIMENT 2: RECIPIENT: Subsequently, 36 donor BN rats were subjected to a similar insufflation protocol, but after nephrectomy, a syngeneic kidney transplantation (BN-BN) was performed. Urine and blood samples were collected on postoperative days 1, 3, 7, and 14 for determination of renal function. Subsequently, donor and recipient kidneys were removed for histomorphologic and immunohistochemical analysis. RESULTS: In both donors and recipients, no significant changes in serum creatinine, proteinuria, or glomular filtration were detected between the CO2, the helium, and the gasless control groups. In both experiments, histologic analysis of Kidney specimens did not show any deleterious effects from abdominal gas insufflation. Although kidney grafts exposed to CO2 showed significantly higher numbers of CD45+ leukocytes 3 days after transplantation, immunohistochemical analysis did not show significant differences in number of infiltrating cells (CD4, CD8, ED1, OX6, OX62) between the two insufflation groups and the gasless control subjects. CONCLUSIONS: Abdominal gas insufflation does not have an adverse effect on the renal function of the kidney donor 1 week after laparoscopic donor nephrectomy. No differences in renal function or histomorphology were detected between syngeneic kidney grafts exposed to pneumoperitoneum and gasless control subjects.     

The effect of pneumoperitoneum on kidney function in laparoscopic donor nephrectomy

Between June 1999 and November 2001 a prospective study was conducted to evaluate the effects of pneumoperitoneum during laparoscopic donor nephrectomy on kidney function using two different pressure settings (15 and 10 mm Hg). The effects were evaluated in both the donor's remaining kidney and the procured kidney in the recipient. There was no statistical significant difference in donors and recipients in regard to age, gender, and body mass index. In the two donor groups there was no difference in operative time (2.77 +/- 0.51 vs 2.70 +/- 0.52 hours; P = 0.579), intraoperative fluid (16.53 +/- 4.72 vs 19.54 +/- 7.04, P = 0.056), and urine output (1.81 +/- 0.53 vs 1.75 +/- 0.96 mL/kg/hour, P = 0.782) respectively. Donors' preoperative and first-day postoperative serum creatinine concentrations also did not differ for the groups (preoperative 0.87 +/- 0.21 vs 0.88 +/- 0.17 mg/dL; and postoperative 1.44 +/- 0.32 vs 1.38 +/- 0.29 mg dL, respectively; P = 0.696). Recipients' preoperative and postoperative serum creatinine concentrations on days 1, 2, 3, 7, 14, and 30 differed over time (P < 0.001) but not between groups (P = 0.541). We conclude that procurement of kidneys under either 10 or 15 mm Hg abdominal pressure gives equally good intraoperative and postoperative results.     

The effect of laparoscopic and open donor nephrectomy on the long-term renal function in donor and recipient: a retrospective study

Pneumoperitoneum, as used in laparoscopic donor nephrectomy (LDN), may result in negative effects on renal function in donor and recipient. This study compares long-term serum creatinine in donor and recipient after laparoscopic and open donor nephrectomy (ODN). A retrospective analysis of 120 LDN and 100 ODN donors and their recipients was performed. Serum creatinine of donor and recipient was recorded and analyzed. The follow-up period posttransplantation was 3 years. Serum creatinine in the recipients was significantly higher in the LDN groups the first week after transplantation. Serum creatinine in the donor was significantly higher in the LDN group at 1 day, 3 months, and 1 year posttransplant. Finally, creatinine levels remained 40% higher compared to preoperative values in both donor groups. LDN results in higher short-term serum creatinine levels in donor and recipient. Long-term serum creatinine levels were comparable after LDN or ODN in donor and recipient.     

Ureteral complications in the renal transplant recipient after laparoscopic living donor nephrectomy

OBJECTIVES: We report on ureteral and surgical complications in our first 110 consecutive recipients of kidneys procured with laparoscopic living donor nephrectomy (LLDN). METHODS: The records of all living donor transplants with LLDN performed between February 1999 and December 2004, including 10 pediatric transplants, were reviewed retrospectively. Three urologists performed LLDN using a pure laparoscopic non-hand-assisted transperitoneal technique. Kidney transplantation was performed in a standard fashion. For ureteroneocystostomy, the intravesical Politano-Leadbetter (P-L) technique was used. RESULTS: Two-year patient and graft survival was 99% and 98%, respectively. Serum creatinine at 12 months was 1.36+/-0.1mg/dl in adult and 0.99+/-0.23 mg/dl in pediatric recipients. Nineteen right donor kidneys were transplanted into adult recipients. Surgical complications included three symptomatic lymphoceles, one peritransplant haematoma and one kinking of a lower pole artery. All five (4.5%) ureteral complications occurred in adult recipients with a mean age of 33.2+/-2.8 years. The incidence of ureteral complications was not clustered around the early phase of our LLDN experience. Of the three (2.7%) patients diagnosed with ureteral obstruction, two required ureteral reimplantation, and one was managed conservatively. Another two patients (1.8%) with a urinary leak received a double J stent and a cystostomy catheter for 3 and 5 months, respectively. Of the five patients with a ureteral complication, three had received a donor kidney with more than one renal artery. CONCLUSIONS: LLDN combined with the intravesical (P-L) ureteral implantation technique provides excellent graft outcomes with low recipient morbidity. Renal artery multiplicity may increase the risk of ureteral complications.     

Early and late recipient graft function and donor outcome after laparoscopic vs open adult live donor nephrectomy for pediatric renal transplantation

BACKGROUND: Laparoscopically procured live donor kidney grafts are increasingly transplanted into pediatric recipients. The safety and efficacy of this changed surgical practice are unknown. HYPOTHESIS: Outcomes of laparoscopic vs open donor grafts in recipients 18 years and younger are equivalent. DESIGN AND SETTING: Retrospective review at an academic tertiary care referral center. PATIENTS: Eleven consecutive pediatric recipients of laparoscopically procured kidneys between April 1, 1997, and December 31, 2001, were pair matched for age with 11 recipients of openly procured kidneys between December 1, 1991, and March 31, 1997; the 22 adult donors were also studied. MAIN OUTCOME MEASURES: Recipients: surgical complications, graft function and survival. Donors: perioperative morbidity and length of hospital stay. RESULTS: Twenty (91%) of 22 kidneys were donated by a parent of the recipient. In recipients of laparoscopically procured grafts, we observed significantly lower creatinine clearances and higher creatinine levels on days 1, 4, and 6, but by 1 month, graft function was similar in both groups. No significant differences in surgical complications, delayed function, acute and chronic rejection, and graft survival rates were found. No laparoscopic or open donor required blood transfusion, reoperation, or hospital readmission. One laparoscopic donor (9%) was converted to open nephrectomy. For laparoscopic vs open donors, median operative time was longer (difference, 67 min; P =.08), but median postoperative length of stay was significantly shorter (3 vs 5 days; P =.02). CONCLUSIONS: Laparoscopic live donor nephrectomy has no adverse impact on pediatric recipient outcomes. For donors, the laparoscopic operation is safe and the hospital stay is shortened. These results support the continued use of laparoscopically procured live donor kidneys in pediatric renal transplantation.     

Impact of intraoperative donor management on short-term renal function after laparoscopic donor nephrectomy

OBJECTIVE: To determine whether intraoperative diuresis, postoperative recovery, and early graft function differ between laparoscopic open nephrectomy (LDN) and open donor nephrectomy (ODN). SUMMARY BACKGROUND DATA: Laparoscopic donor nephrectomy can reduce donor complications in terms of decreased pain and shorter convalescence. Although its technical feasibility has been established, concerns have been raised about the impaired renal function resulting from pneumoperitoneum and short- and long-term function of kidneys removed by LDN. METHODS: Between December 1997 and December 2000, 89 LDNs were performed at the authors' institution. These were compared with 83 conventional ODNs performed between January 1994 and December 1997. Graft function, intraoperative variables, and clinical outcome were compared. RESULTS: Laparoscopic donor nephrectomy was attempted in 89 patients and completed in 91% (81/89). Length of hospital stay was significantly shorter in the laparoscopic group. During kidney dissection, the amount of fluids administered and intraoperative diuresis were significantly lower for LDN. In recipients, mean serum creatinine was higher after LDN compared with ODN 1 day after surgery. From postoperative days 2 until 28, there were no differences in serum creatinine. Graft survival rates were similar for LDN and ODN. CONCLUSIONS: Donors can benefit from an improvement in postoperative recovery after LDN. Assessment of an adequate perioperative hydration protocol is mandatory to ensure optimal kidney quality during laparoscopic procurement. The initial graft survival and function rates justify continued development and adoption of LDN.     

A comparison of recipient renal outcomes with laparoscopic versus open live donor nephrectomy

BACKGROUND: Laparoscopic donor nephrectomy (laparoNx) has the potential to increase living kidney donation rates by reducing the pain and suffering of the donor. However, renal function outcomes of a large series of recipients of laparoNx have not been studied. METHODS: We retrospectively reviewed the records of 132 recipients of laparoNx done at our center between 3/96 and 11/97 and compared them to 99 recipients of kidneys procured by the open technique (openNx) done between 10/93 and 3/96. RESULTS: Significantly more patients in the laparoNx group (25.2%) were taking tacrolimus within the first month than those in the openNx group (2.1%). Mean serum creatinine was higher in laparoNx compared with openNx at 1 week (2.8+/-0.3 and 1.8+/-0.2 mg/dl, respectively; P=0.005) and at 1 month (2.0+/-0.1 and 1.6+/-0.1 mg/dl, P=0.05) after transplant. However, by 3 and 6 months, the mean serum creatinine was similar in the two groups (1.7+/-0.1 versus 1.5+/-0.05 mg/dl, and 1.7+/-0.1 versus 1.7+/-0.1, respectively). By 1 year posttransplant, the mean serum creatinine for laparoNx was actually less than that for openNx (1.4+/-0.1 and 1.7+/-0.1 mg/dl, P=0.03). Although patients in the laparoNx compared to the openNx group were more likely to have delayed graft function (7.6 versus 2.0%) and ureteral complications (4.5 versus 1.0%), the rate of other complications, as well as hospital length of stay, patient and graft survival rates were similar in the two groups. CONCLUSION: Although laparoNx allografts have slower initial function compared with openNx, there was no significant difference in longer term renal function.     

Warm ischemia time does not correlate with recipient graft function in laparoscopic donor nephrectomy

Background: Laparoscopic donor nephrectomy (LDN) has been shown to be a safe and effective option for renal procurement. Studies comparing open nephrectomy and hand-assisted laparoscopy have emphasized decreased warm ischemia time when compared with pure laparoscopic retrieval. However, no data exist that define exactly what constitutes a prolonged warm ischemia time in terms of recipient graft function. The aim of this study was to use a large, single-institution experience with LDN to determine if warm ischemia time correlates with recipient graft function as measured by serum creatinine levels. Methods: A total of 640 LDNs were performed from March 1996 to August 2001. Warm ischemia times were prospectively collected and were defined as the time from renal artery occlusion to immersion in iced saline. Serial recipient creatinine levels were measured at 1 week and 1, 3, 6, and 12 months (when possible) from the transplant. Data were analyzed using Pearson correlation analysis at a confidence interval of 95%. Results: Mean warm ischemia time was 151 s with a standard error of 3.4 s and ranged from 35 to 720 s. Recipient creatinine mean at 1 week was 1.94 mg/dl with a standard error of 0.06 mg/dl and ranged from 0.5 to 10.5 mg/dl. Recipient creatinine mean at 1 month was 1.68 mg/dl with a standard error of 0.06 mg/dl and ranged from 0.6 to 8.5 mg/dl. Recipient creatinine mean at 3 months was 1.60 mg/dl with a standard error of 0.04 mg/dl and ranged from 0.6 to 8.8 mg/dl. Recipient creatinine mean at 6 months was 1.63 mg/dl with a standard error of 0.06 mg/dl and ranged from 0.7 to 13.5 mg/dl. Recipient creatinine mean at 12 months was 1.70 mg/dl with a standard error of 0.07 mg/dl and ranged from 0.5 to 14.5 mg/dl. No correlation was found between warm ischemia time and recipient creatinine levels at 1 week (p = 0.4737), 1 month (p = 0.9180), 3 months (p = 0.6227), 6 months (p = 0.8349), or 12 months (p = 0.2835). Conclusions: Warm ischemia time does not correlate with recipient graft function in LDN within the range of times studied. Shorter warm ischemia time associated with open donor nephrectomy and hand-assisted LDN does not necessarily offer a measurable advantage in recipient graft function. During extraction of the kidney, expediency to minimize warm ischemia time should not supersede controlled and safe maneuvers in renal vessel division and extraction of the kidney.     

Beneficial effects of a new fluid regime on kidney function of donor and recipient during laparoscopic v open donor nephrectomy

BACKGROUND AND PURPOSE: Laparoscopic donor nephrectomy (LDN) has been associated with delayed graft function compared with open donor nephrectomy (ODN). We have recently shown that the adverse effect of pneumoperitoneum (PP) on hemodynamics could be prevented by a new fluid regime. The aim of this study was to test the effect of this fluid regime on the kidney function of the donor and recipient after LDN and ODN. PATIENTS AND METHODS: We prospectively collected data of 51 donors undergoing ODN and 59 donors undergoing LDN as well as data from the corresponding recipients. All donors and recipients were treated with a standardized anesthesia and fluid regime. This fluid regime consisted of preoperative overnight hydration together with a bolus of colloid administered before induction of anesthesia and before introduction of PP. Follow-up was 2 years. RESULTS: Baseline characteristics of the two groups were comparable. Hemodynamics and urine output until nephrectomy were comparable between both groups. Donor kidney function did not differ after ODN and LDN. Estimated glomerular filtration rate, graft survival, and recipient survival did not differ between open and laparoscopically procured transplants. No adverse effects of the novel fluid regime (eg, pulmonary edema or additional oxygen supply) were observed in the donors. CONCLUSION: In contrast to our earlier findings, the kidney function of the donor and recipient is comparable between ODN and LDN after introduction of a new fluid regime.     

The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy

Authors from Cleveland assessed the impact of warm ischaemia on renal function, using their large database of laparoscopic partial nephrectomies for tumour. While agreeing that renal hilar clamping is essential for precise excision of the tumour, and other elements of the operation, the authors indicate that warm ischaemia may potentially damage the kidney. However, they found that there were virtually no clinical sequelae from warm ischaemic of up to 30 min. They also found that advancing age and pre-existing renal damage increased the risk of postoperative renal damage. OBJECTIVE: To assess the effect of warm ischaemia on renal function after laparoscopic partial nephrectomy (LPN) for tumour, and to evaluate the influence of various risk factors on renal function. PATIENTS AND METHODS: Data were analysed from 179 patients undergoing LPN for renal tumour under warm ischaemic conditions, with clamping of the renal artery and vein. Renal function was primarily evaluated in two groups of patients: 15 with tumour in a solitary kidney, who were evaluated by serial serum creatinine measurements; and 12 with two functioning kidneys undergoing unilateral LPN, and evaluated by renal scintigraphy before and 1 month after LPN to quantify differential renal function. Also, in all 179 patients, mean serum creatinine data at baseline, 1 day after LPN, at hospital discharge, and at the last follow-up were provided as supportive evidence. Logistic regression analyses were used to assess the effect of various risk factors on renal function after LPN, i.e. patient age, baseline serum creatinine, tumour size, solitary kidney status, duration of warm ischaemia, pelvicalyceal suture repair, urine output and intravenous fluids during LPN. RESULTS: In the group of patients with a solitary kidney the mean warm ischaemia time was 29 min, kidney parenchyma excised 29%, and serum creatinine at baseline, discharge, the peak after LPN and at the last follow-up (mean 4.8 months) 1.3, 2.3, 2.8, and 1.8 mg/dL, respectively. One patient (6.6%) required temporary dialysis. In the second group, assessed by renal scintigraphy, the function of the operated kidney was reduced by a mean of 29%, commensurate with the amount of parenchyma excised. For all 179 patients, a combination of age > or = 70 years and a serum creatinine level after LPN of > or = 1.5 mg/dL correlated with a higher serum creatinine after LPN. On logistic regression, baseline serum creatinine and solitary kidney status were the only variables significant for serum creatinine status after LPN. CONCLUSIONS: The bloodless field provided by renal hilar clamping is important for precise tumour excision, pelvicalyceal suture repair and securing parenchymal haemostasis during LPN. However, renal hilar clamping causes warm ischaemia. These data indicate that the clinical sequelae of warm ischaemic renal injury of approximately 30 min are minimal. Advancing age and pre-existing azotaemia increase the risk of renal dysfunction after LPN, especially when the warm ischaemia exceeds 30 min.     

Manual specimen retrieval without a pneumoperitoneum preserving device for laparoscopic live donor nephrectomy

PURPOSE: We present a novel method of kidney retrieval based on a modified Pfannenstiel incision and insertion of the assistant hand into the abdominal cavity without a device for pneumoperitoneum preservation. This maneuver is performed as the last step in pure laparoscopic live donor nephrectomy. Also, we assessed the effect of this technique on warm ischemia time compared with the standard laparoscopic bag retrieval technique. MATERIALS AND METHODS: A total of 70 laparoscopic live donor nephrectomies were performed at our institutions between October 1998 and March 2001. The first 43 cases were completed using an EndoCatch bag device (Auto Suture, Norwalk, Connecticut) for specimen retrieval, while the last 27 were done using a novel manual retrieval technique through a modified Pfannenstiel incision. We retrospectively analyzed the results in regard to warm ischemia time and intraoperative complications related to the procedure. RESULTS: A statistically significant difference was noted in the EndoCatch and manual retrieval groups in regard to warm ischemia time (p <0.001). There were 2 complications related to the EndoCatch device and none related to the manual technique. No differences were detected regarding recipient outcomes. CONCLUSIONS: Manual specimen retrieval after live donor nephrectomy allows shorter warm ischemia time, while saving the cost of an EndoCatch bag or pneumoperitoneum preserving device that would be used during hand assisted live donor nephrectomy. It was shown to be a safe method without increased donor morbidity.     

The impact of introducing laparoscopic donor nephrectomy to an established renal transplant program

Background Although the advent of hand-assisted laparoscopic donor nephrectomy (HLDN) has had a positive impact on the donor pool, there is still some concern about its safety. The aim of this study was to assess the impact of a change in surgical access to live-donor nephrectomy on donor-related complication rates, the renal function of the donor, and the graft function of the recipient.Methods At our hospital, HLDN was introduced in 1998. Thereafter, we compared 49 consecutive donors undergoing open donor nephrectomy (ODN) between 1987 and 2002 with 57 consecutive donors undergoing HLDN between 1998 and 2002. Donor renal and recipient graft functions were assessed by measuring creatinine levels and urine output, with the addition of warm and cold ischemia time and dialysis requirements in the latter group. Data are presented as means (±SD) and analyzed with the Student t-test or Fishers exact test.Results The ODN and HLDN donors were comparable for age, gender, body mass index, renovascular anatomy, and preoperative creatinine. Estimated blood loss (370 ± 280 vs 168 ± 160 ml, p < 0.0001), time to resumption of oral intake (1.7 ± 0.5 vs 1.3 ± 0.7 days, p = 0.01), duration of intravenous narcotic requirements (23 ± 0.7 vs 1.7 ± 1.0 days, p < 0.0001), and hospital stay (4.2 ± 1.4 vs 2.9 ± 1.3 days, p < 0.0001) were significantly decreased after HLDN. There were no significant differences between ODN and HLDN in operating time (204 ± 46 vs 202 ± 49 min), donor-related complication rates (12.2% vs 14%), or donor renal and recipient graft functions.Conclusion The introduction of HLDN to an established renal transplant program led to an improved short-term outcome without any increase in donor-related complication rates or delay in recipient graft function.     

手辅助腹腔镜在亲属活体供肾切取中的应用25例报告

目的 探讨手辅助腹腔镜在亲属活体供肾切取中的应用.方法 回顾性分析25名亲属活体供肾者的资料.25名供者中,男性6名,女性19名,年龄(42±17)岁.23例为亲属血缘关系供肾,2例为夫妻间供肾.分析供者选择手辅助腹腔镜下取肾术的原因、供者的手术时间、供肾热缺血时间、术中出血量、肾脏及周围脏器损伤情况、术后恢复情况及移植肾功能恢复情况,评价手辅助腹腔镜下取肾术的临床应用效果.结果 对25名亲属供者应用手辅助腹腔镜下取肾术均获成功,无中转开放手术;24例取左肾,1例取右肾;手术时间(138±42)min,供肾热缺血时间为(145±22)s,术中出血量(53±32)m1;无供肾损伤,无切口相关并发症,仅有1例发生脾包膜撕裂;术后住院时间为(7.2±1.7)d,供者均满意.调查显示,供者选择手辅助腹腔镜下取肾术的主要原因是手术损伤小、切口对外观影响较小、心理负担轻.亲属活体供肾移植后,仅有1例受者发生移植肾功能恢复延迟,其余受者的血肌酐水平均在1周内下降至正常.结论 手辅助腹腔镜下取肾术综合了传统腹腔镜技术和开放性手术取肾的优点,微创,操作方便,供肾损伤机会少,切口对外观影响较小,供者易于接受.