A systematic review of laparoscopic live-donor nephrectomy

BACKGROUND: A systematic review was undertaken to assess the safety and efficacy of laparoscopic live-donor nephrectomy (LLDN) compared with open live-donor nephrectomy (OLDN). METHODS: Literature databases were searched from inception to March 2003 inclusive. Comparative studies of LLDN versus OLDN (randomized and nonrandomized) were included. RESULTS: There were 44 included studies, and the quality of the available evidence was average. There was only one randomized controlled trial and six nonrandomized comparative studies with concurrent controls identified. In terms of safety, for donors, there did not seem to be any distinct difference between the laparoscopic and open approaches. No donor mortality was reported for either procedure, and the complication rates were similar although the types of complications experienced differed between the two procedures. The conversion rate for LLDN to an open procedure ranged from 0% to 13%. In terms of efficacy, LLDN seemed to be a slower operation with longer warm ischemia times than OLDN, but this did not seem to have resulted in increased rates of delayed graft function for recipients. Donor postoperative recovery and convalescence seemed to be superior for LLDN, making it a potentially more attractive operation for living donors. Although in the short-term, graft function and survival did not seem to differ between the two techniques, long-term complication rates and allograft function could not be determined and further long-term follow-up is required. CONCLUSIONS: LLDN seems to be at least as safe and efficacious as OLDN in the short-term. However, it remains a technique in evolution. Further high-quality studies are required to resolve some of the outstanding issues surrounding its use, in particular, long-term follow-up of donor complications and recipient graft function and survival.     

Retroperitoneoscopic living donor nephrectomy: a comparison with the open approach in respect of early postoperative pain management

INTRODUCTION: We retrospectively compared perioperative donor outcomes and early postoperative pain control after retroperitoneoscopic (RLDN) and standard open (OLDN) living donor nephrectomy. METHODS: One hundred donors included fifty after RLDN (37 women/13 men) and 50 after OLDN (35 women/15 men) were retrospectively analyzed for basic analgesics, for opioid consumption, and for visual analog scale (VAS) to verify the experienced pain. The donors were questioned in the morning and evening of the first through fifth postoperative days. RESULTS: The mean age of both groups was equal. The mean operating time was 149.7 +/- 48.2 minutes (60 to 270) for RLDN and 164.1 +/- 30.3 minutes (60 to 240) for OLDN (P = NS). The mean warm ischemia time was 120 +/- 36 seconds (50 to 240) and 114 +/- 31 seconds (60 to 190) for the RLDN and OLDN groups, respectively (P = NS). The mean evening VAS for RLDN versus OLDN on postoperative days 1 to 5 was: 2.1 versus 2.2 (P = NS), 0.9 versus 1.8 (P = .009), 0.5 versus 1.3 (P = .016), 0.1 versus 0.7 (P = .013), and 0.1 versus 0.7 (P = .013), respectively. In both groups there was a tendency toward a higher VAS score in the morning than in the evening. RLDN donors showed significantly earlier period free of pain (VAS = 0) than those after OLDN. There was a significant difference of being free from any opiate between both groups after surgery. CONCLUSIONS: After RLDN donors experienced less postoperative pain than after OLDN over the early postoperative days. Therefore, postoperative regional anesthesia is not necessary for donors operated by a retroperitoneoscopic approach.     

Are there anatomical barriers to laparoscopic donor nephrectomy?

Background: The aim of this study was to analyse the effect of the right donor kidney and multiple arteries, on donor and recipient outcomes in the era of laparoscopic live donor nephrectomy (LLDN). Methods: We retrospectively analysed the 200 donors and recipients who underwent a planned laparoscopic nephrectomy at two hospitals between September 1998 and December 2006. The impact of donor right kidney and multiple donor renal arteries on operative time, hospital stay, graft function, and donor and recipient complications were analysed. Results: Of the total cohort (n = 200), 140 (70%) were classified as Simple LLDN (left live donor kidney with single renal artery). The Complex LLDN group (n = 60) contained all right‐sided kidney (n = 28) and left‐sided kidneys with multiple renal arteries (n = 32). Baseline characteristics, extraction time, conversion to open, length of admission, overall graft function and complication rates were similar between the simple and complex groups. The second warm ischaemic time in the Simple LLDN group was slightly shorter than the Complex LLDN group (32 versus 36 min P = 0.016). The 1‐month post‐operative recipient serum creatinine level was lower in the Simple LLDN group when compared with the Complex LLDN group (117 versus 125 µmol/L P = 0.025). There was no difference in post op dialysis, acute rejection within 3 months or graft survival between the Simple and Complex LLDN groups. Conclusion: Laparoscopic procurements of right kidneys and kidneys with multiple arteries were safe and yielded kidneys with excellent function comparable with those of laparoscopic left donor nephrectomy with single artery.     

Open versus laparoscopic donor nephrectomy: perioperative parameters and graft functions

Objective

With the developments in laparoscopic surgery, open donor nephrectomy has been widely replaced by laparoscopic donor nephrectomy. Presented herein is the comparison of laparoscopic live donor nephrectomy (LLDN) and open live donor nephrectomy (OLDN) results performed at our institute.

Materials and Methods

Patients who underwent OLDN between July 2006 and August 2008 or LLDN between August 2008 and July 2010 were included in this retrospective age- and gender-matched case-controlled study. OLDN was performed with a 45° semi-flank position using a self-retaining retractor. LLDN operations were performed used a 90° flank position by the transperitoneal route under 12-15 mm Hg carbon dioxide (CO₂) pressure. A Pfannenstiel incision was used in all LLDN for graft extraction. The renal artery and vein were controlled with Satinsky clamps in OLDN, whereas renal arteries were controlled with nonabsorbable polymer locking clips and renal veins with 2.5/45 mm EndoGIA vascular staplers in LLDN.

Results

Thirty patients underwent OLDN and 31 LLDN. The mean ages among the OLDN and LLDN patients were 44.9 ± 21.9 and 46.3 ± 18.4, respectively. There was no significant difference in mean age and gender distribution of patients between OLDN and LLDN groups by the design of the study. The OLDN group consisted of 4 (13%) right and 26 (87%) left nephrectomies; the LLDN group consisted of 3 (9%) right and 28 (91%) left nephrectomies. Mean operative time was 110 ± 18 and 101 ± 28 minutes for OLDN and LLDN, respectively (P < .05; Mann-Whitney U test). Estimated blood loss was 35 ± 15 mL among the OLDN group and 15 ± 24 mL for the LLDN group. Mean hospitalization time in the OLDN and LLDN groups were 3.8 ± 0.5 and 2.6 ± 0.6 days, respectively. There were no conversions to open surgery in the LLDN group. Mean warm ischemia time in the OLDN and LLDN groups were 140 ± 58 seconds and 203 ± 21 seconds, respectively (P < .05; Mann-Whitney U test). There was no difference in recipient serum creatinine levels at 1 week after surgery.

Conclusion

LLDN was superior to OLDN in terms of operative time, estimated blood loss, length of hospital stay, and postoperative pain. Longer warm ischemia time in the LLDN group did not translate into worse graft function in the recipients.     

Retroperitoneoscopic donor nephrectomy: donor outcome and complication rate in comparison with three different techniques

Four surgical techniques for living donor nephrectomy were analyzed retrospectively in terms of perioperative outcome and early complication rate. A total of 182 donor nephrectomies including 69 open (OLDN), 14 fully laparoscopic (LDN), 34 hand-assisted laparoscopic (HLDN) and 65 retroperitoneoscopic (RLDN) nephrectomies were analyzed. There was a significant difference in mean operating time (OPT) between the OLDN (160 min) and RLDN (150 min) as compared to the LDN (212 min) and HLDN group (192 min) (P<0.001). Mean warm ischemia time (WIT) was significantly shorter with OLDN (114 s), RLDN (121 s) and HLDN (128 s) when compared to LDN (238 s) (P<0.001). Major complication rate was comparable among the groups. Independent of the preferred technique, donor nephrectomy is associated with complication rates. RLDN is comparable to OLDN in terms of OPT, WIT. Learning endoscopic donor nephrectomy could be associated with a higher complication rate.     

Hand-Assisted Laparoscopic Living-Donor Nephrectomy Versus Open Surgery: Evaluation of Surgical Trauma and Late Graft Function in 82 Patients

Objective

We evaluated and quantified surgical trauma and late graft function in cases of hand-assisted laparoscopic living-donor nephrectomy (HALLDN) versus open living-donor nephrectom (OLDN).

Methods

This study is a retrospective nonrandomized single-center analysis. Between 1995 and January 2008, 82 patients with end-stage renal disease received kidney transplantations from living donors. Open living-donor nephrectomy was performed in 37 donors, and 45 underwent laparoscopic hand-assisted nephrectomy. Demographic data and perioperative and postoperative data, such as markers of acute phase (C-reactive protein; serum amyloid A) and biochemical markers of glomerular filtration (serum creatinine, serum cystatin C), were compared at serial time points.

Results

The mean operative times for HALLDN and OLDN were 165 min and 195 min, respectively. The average warm ischemia time was 45 seconds for laparoscopy and 87 seconds for open surgery. The evaluation of acute phase markers demonstrated a minimally invasiven nature of laparoscopy, with same late graft function compared with open surgery.

Conclusion

When the surgery was performed by experienced surgeons, hand-assisted living- donor nephrectomy showed shorter operative and warm ischemia times than open surgery, offering at least the same functional results and decreasing surgical complications compared with a completely laparoscopic technique.     

Laparoscopic nephrectomy: safe and comfortable surgical alternative for living donors and for good results of graft function

Laparoscopic nephrectomy for kidney donation from living related donors has the advantages of a less invasive surgical access, better cosmesis, and a shorter hospital stay for the donor. However, some workers have reported up to 10% life-threatening complications for the donor using this technique. The purpose of our study was to evaluate hand-assisted laparoscopic nephrectomy for living donors of kidney transplants in terms of graft function. Thirty donors who underwent open nephrectomy (ON) were compared with 27 who had hand-assisted nephrectomy (HALN). Surgery and ischemia times, hospital stay, bleeding, graft function, remaining kidney function, and complications were compared in both groups. Mean surgery time was 126.9 minutes for ON and 98 minutes for HALN (P = .0005), warm ischemia time was 3 minutes versus 6 for ON vs HALN, respectively (P = .02). Hospitalization stay was 6.3 days for ON versus 4.8 days for HALN (P = .0015). Differences in change in hematocrit and in serum creatinine levels were not significant; graft outcomes were also similar. Complications were minimal. We conclude that HALN is a valid, safe technique to obtain kidneys from living related donors, significantly reducing the hospital stay and allowing return to normal activities sooner, with risks falling within those reported in the literature.     

Learning laparoscopic donor nephrectomy safely: a report on 100 cases

HYPOTHESIS: There is concern that learning laparoscopic live donor nephrectomy (LLDN) is associated with increased morbidity. We propose that with a team approach LLDN can be learned safely, without increased donor morbidity or graft failure, even during the early portion of a learning curve. DESIGN: Case series with cohort comparison. SETTING: Tertiary referral center. PATIENTS: The laparoscopic group consisted of 100 donors and 100 recipients; the open group, 50 donors and 50 recipients. INTERVENTIONS: A team approach that combines laparoscopic and urologic expertise was used to perform 100 cases of LLDN. MAIN OUTCOME MEASURES: Donor morbidity and graft function in the laparoscopic group were compared with those in the open group. RESULTS: Laparoscopic live donor nephrectomy was completed in 99 patients. One patient required conversion to open donor nephrectomy because of intraoperative hemorrhage. Minor complications occurred in 6 laparoscopic group donors (6%) and 3 open group donors (6%). Laparoscopic and open group donors were of similar age. Operative times were longer for laparoscopic group donors (231 vs 209 minutes). Mean hospital stay was shorter for laparoscopic group donors (3.3 vs 4.7 days). Graft function was comparable between the laparoscopic and open groups, with equivalent postoperative creatinine levels. Graft survival was comparable. Recipient ureteral complications occurred with less frequency (2% vs 6%) in the laparoscopic group. CONCLUSIONS: By forming an operative team that combines expertise in laparoscopy with expertise in live donor nephrectomy, surgeons can learn LLDN safely. Adoption of the techniques developed by those who pioneered the procedure can further minimize the morbidity associated with a learning curve.     

Right laparoscopic live donor nephrectomy: a single institution experience

BACKGROUND: Laparoscopic live donor nephrectomy (LLDN) is increasingly used by transplantation centers worldwide. As in open live donor nephrectomy, the left kidney is preferred for LLDN; however, not all potential donors have anatomy conducive to left nephrectomy. The purpose of our study, therefore, was to report on a large, single-institution experience with right LLDN performed using a hand-assisted, transperitoneal approach. METHODS: We performed a retrospective review of 40 consecutive patients who underwent transperitoneal right hand-assisted LLDN at our institution. Information on donor age, relation to recipient, and indication for right-sided donation was collected. Surgical demographics included operative time, warm ischemia time, and estimated blood loss. Recipients were followed for graft loss and for long-term renal allograft function. RESULTS: The indications for right-sided donor nephrectomy were a difference in split renal function of greater than 10%, multiple left renal vessels, and right renal cysts. The mean surgical time in our series was 115.8 min, with a mean estimated blood loss of 85.7 mL and a warm ischemia time of 116.0 seconds. Surgical and postoperative complications were limited. Mean serum creatinine levels in the recipients were 1.6 mg/dL on day 7, 1.4 mg/dL on day 30, and 1.4 mg/dL at 1 year after transplantation. CONCLUSIONS: Right LLDN using a hand-assisted, transperitoneal technique was performed with minimal morbidity and favorable graft function. We believe that offering hand-assisted LLDN to patients with an indication for right-sided donation can safely and effectively increase the pool of donor organs available to patients with end-stage renal disease.     

Introduction of hand-assisted retroperitoneoscopic living donor nephrectomy at Karolinska University Hospital Huddinge

Living donor kidney transplantation accounts for about 50% of the total number of renal transplantations at our center. From 1999 through 2005, 75 out of 220 living donor nephrectomies were performed with a laparoscopic technique (LLDN). In June 2005, we introduced the technique of hand-assisted retroperitoneoscopic nephrectomy (HARS) for living donors. Since the introduction until the end of 2005, 11 out of 18 living donor nephrectomies (LDN) were performed with HARS. Reduced operation time was observed for the HARS group (mean, 166 minutes) compared with the LLDN (mean, 244 minutes). Two grafts showed delayed function, one in the LLND group and one in the HARS group. No major perioperative or postoperative complications were observed in the HARS group, whereas one patient who underwent LLDN developed severe pancreatitis. So far in our hands HARS is a fast and safe procedure with results comparable with open LDN. Compared to LLDN, we experienced reduced operation time together with the advantage of retroperitoneal access.     

Left or right kidney in hand-assisted donor nephrectomy? A randomized controlled trial

BACKGROUND: There is an ongoing discussion in living renal transplantation whether the right or the left donor nephrectomy is to be preferred if both kidneys are equal, due to the lack of prospective studies. METHODS: A prospective single-center randomized trial was conducted from April 2002 to September 2006, in which 60 eligible consecutive donors were randomized to either left-sided or right-sided hand-assisted laparoscopic donor nephrectomy (HALDN). Primary endpoint was operation time. Secondary endpoints were donor morbidity, warm ischemia time, delayed graft function, urological complications, quality of life, and graft survival. RESULTS: Median operating time for left-sided HALDN (180 min) was significantly longer compared with right-sided HALDN (150 min; P=0.021). There were no conversions in both groups. There were no major intra- or postoperative complications. One-year graft survival rate was 96% in the left group versus 93% in the right group (P=0.625, log rank). CONCLUSIONS: Operating time of HALDN of the right kidney is significantly shorter than HALDN of the left kidney. No differences were detected in complication rates and graft survival between left and right-sided donor nephrectomy.     

Morbidity and Mortality After Living Kidney Donation, 1999–2001: Survey of United States Transplant Centers

There have been two recent trends in living kidney donation: increased acceptance of living donors and increased acceptance of laparoscopic nephrectomy (LN). We surveyed 234 UNOS-listed kidney transplant programs to determine current living donor morbidity and mortality for open nephrectomy, hand-assisted LN, and non-hand-assisted LN. Of the 234 centers, 171 (73%) responded. Between 1/1/1999 and 7/1/2001, these centers carried out 10 828 living donor nephrectomies: 52.3% open, 20.7% hand-assisted LN, and 27% non-hand-assisted LN. Two donors (0.02%) died from surgical complications and one is in a persistent vegetative state (all after LN). Reoperation was necessary in 22 (0.4%) open, 23 (1.0%) hand-assisted LN, and 21 (0.9%) non-hand-assisted LN cases (p = 0.001). Complications not requiring reoperation were reported for 19 (0.3%) open, 22 (1.0%) hand-assisted LN, and 24 (0.8%) non-hand-assisted LN cases (p = 0.02). Readmission rate was higher for LN (1.6%) vs. open (0.6%) donors (p < 0.001), almost entirely as a result of an increase in gastrointestinal complications in LN donors. Morbidity and mortality for living donor nephrectomy at transplant centers in the United States remain low. We provide current data from which comprehensive informed consent can be obtained from donors.     

Hand-assisted laparoscopic nephrectomy versus transperitoneal anterior approach in living donors for renal transplantation

The objective of this study was to compare two surgical approaches for living donor nephrectomy: transperitoneal anterior approach and the hand-assisted laparoscopic nephrectomy. Between January 2001 and October 2003 we performed 63 kidney transplantations from living donors. The transperitoneal anterior approach was used in 36 cases and the hand-assisted laparoscopic nephrectomy in 27. Outcomes were compared in terms of hospital stay, postoperative analgesia, and graft quality. Mean hospital stay was 4.7 days in the transperitoneal anterior approach group and 3.7 days in the hand-assisted laparoscopic group (P < .005). Postoperative analgesia dosage was significantly lower in the hand-assisted laparoscopic group (P < .001). Surgical complications and graft quality were similar. We concluded that hand-assisted laparoscopic nephrectomy patients had shorter hospital stays and less pain in the postoperative period, with better cosmetic results and equivalent graft quality compared to transperitoneal anterior approach patients.     

Donor nephrectomy: mini-incision muscle-splitting open approach versus laparoscopy

BACKGROUND: The introduction of laparoscopic donor nephrectomy (LDN) has encouraged the development of less invasive open techniques. Aim of the present study was to compare short-term outcomes between contemporary cohorts of donors who underwent either mini-incision open or laparoscopic kidney donation. METHODS: From May 2001 to September 2004 data of all living kidney donations and transplantations were prospectively collected. Fifty-one donors underwent mini-incision, muscle-splitting open donor nephrectomy (MIDN) and 49 donors underwent LDN. RESULTS: Baseline characteristics of donors and recipients in the study groups were comparable except for donors' gender. Median incision length in MIDN was 10.5 cm. In two patients LDN was converted to open. MIDN resulted in significantly shorter warm ischemia and operation time (2.5 vs. 6.5 min and 157 vs. 240 min respectively). During MIDN, donors had more blood loss (200 vs. 120 ml, P=0.02). Disposables used for MIDN were cheaper (328 vs. 1784 Euros). In the LDN group 4 (8%) major intraoperative and 2 (4%) major postoperative complications occurred versus no major complications in the MIDN group. Morphine requirement, pain and nausea perception, and time to dietary intake did not significantly differ between the groups. Following MIDN, donors were discharged later (4 vs. 3 days, P=0.02). Transplantation of kidneys procured by either approach led to a similar decline in serum creatinine throughout the first year. One-year graft survival was 100% following MIDN and 86% following LDN (P=0.005). CONCLUSION: MIDN and LDN both lead to satisfactory results. Both techniques can be used to expand living donor programs.     

Routine left robotic-assisted laparoscopic donor nephrectomy is safe and effective regardless of the presence of vascular anomalies

The classic approach to donor nephrectomy consists of preferential procurement of the kidney without vascular anomalies. We studied the effect of routine procurement of the left kidney regardless the presence of multiple arteries on the outcomes of robotic-assisted laparoscopic living donor nephrectomy (LLDN) with particular reference to the incidence of urological complications. From August 2000 to July 2005, 209 left LLDNs were performed. We analyzed the outcomes of donors and recipients in relation to the presence of multiple vessels versus normal anatomy. We divided the patients into two groups: group A (n = 148) with normal vascular anatomy and group B (n = 61) with vascular anomalies. In the donors, no significant difference in conversion to open surgery rate, blood loss, length of stay, was noted between the two groups; operative time and warm ischemia time were slightly higher in group B. One-year patient survival was 98% in both groups while the 1-year graft survival was 96.6% in group A and 96% in group B. Only one urological complication was noted in the group with normal anatomy (0.7%) versus none in the group with multiple arteries. Left kidney procurement using robotic-assisted laparoscopic technique is safe and effective, even in the presence of vascular anomalies.     

“First, do no harm”: monitoring outcomes during the transition from open to laparoscopic live donor nephrectomy in a Canadian centre

Objective

During the learning curve for laparoscopic live donor nephrectomy (LLDN), donor morbidity and poorer graft function may be increased. To minimize these risks, a dedicated team of laparoscopic, urologic and transplant specialists worked together to introduce the technique. This study was undertaken to validate this approach by comparing donor and recipient outcomes and studying our learning curve during the transition from open (OLDN) to LLDN.

Methods

We compared 59 LLDNs with 34 OLDNs performed for adult recipients. Data were collected prospectively for LLDN and retrospectively for OLDN. We compared donor outcomes and recipient graft function in the 2 groups, and we used the cumulative sum (CUSUM) method to generate learning curves; p < 0.05 was considered statistically significant.

Results

From the donor standpoint, the complication rate was 10% in the laparoscopic group, compared with 21% in the open group. Length of stay was shorter after LLDN (3 v. 5 d, p < 0.001). Among the recipients, there were no significant differences in the incidences of ureteral complications, delayed graft function (DGF), creatinine levels, acute rejection or patient and graft survival. When we used the incidence of DGF after OLDN as a benchmark, CUSUM analysis revealed a downward inflection point for DGF after 30 cases, consistent with an improvement in performance.

Conclusion

At our institution, a team approach has allowed the safe introduction of LLDN without a significant negative impact on recipient outcomes and with a reduction in donor length of stay. Using DGF as an outcome, we observed improved performance after 30 cases.     

手助腹腔镜肾切取术在活体供肾移植中的应用体会(附30例报告)

目的:评价手助腹腔镜活体供肾切取术的安全性及临床效果。方法:分析2013年8月至2016年8月采用手助腹腔镜活体供肾切取术获取30例活体供肾的临床资料。供者男7例,女23例,均取左肾,供受体关系为:父—子5例,母—子13例,母—女2例,兄弟2例,兄—妹4例,妻—夫3例,叔—侄1例。供肾者32~63岁,平均(51.8±8.5)岁。血型相同29例,相容1例,群体反应性抗体、淋巴毒均为阴性。30例患者均行手助腹腔镜活体供肾切取,切取后常规移植给受者,记录手术时间、出血量、供体冷热缺血时间、供者住院时间、术中副损伤及供受者术后恢复情况。结果:供者均切取左肾,手术成功,无一例中转开腹,供肾切取时间105~160 min,平均(100.4±19.5)min;失血量50~110 ml,平均(52.5±24.5)ml;供肾热缺血时间2.0~3.8 min,平均(2.4±0.5)min;冷缺血时间60~90 min,平均(68.2±26.7)min。供者术后1~3 d即可进食并下床活动,平均(2.5±0.6)d;住院3~6 d,平均(4.0±1.6)d。供受体无任何手术并发症发生,受者手术均获成功。随访3个月~3年,供体肾功能均正常。2例受者分别于肾移植术后1年8个月、1年2个月因自行减药,发生排斥反应,导致移植肾肾功能丢失,恢复透析,其余受体肾功能均正常。结论:手助腹腔镜活体供肾切取术结合了腹腔镜活体供肾切取术与开放手术的优点,既减轻了手术对供者的创伤,又保证了供肾质量,是安全、可靠的手术方法。     

Comparison of graft survival in live donor nephrectomy: hand-assisted laparoscopic v open procedures

PURPOSE: Laparoscopic donor nephrectomy is associated with decreased morbidity while maintaining similar graft function in short-term follow-up compared with open surgery. We investigated hand-assisted laparoscopic donor nephrectomy (HALDN) in comparison with standard open donor nephrectomy (ODN) in living donors. PATIENTS AND METHODS: Two hundred patients who received a living-donor kidney and were followed up for more than 1 year were enrolled. The procedure was performed exclusively on the left kidney through either HALDN or ODN from January 2001 to July 2004. The probability of graft survival was determined using the Kaplan-Meier method. Multivariate analysis using a Cox regression hazard model was performed to identify the predictors of graft survival. RESULTS: The mean operative time, estimated blood loss, warm ischemic time, and operation-related complications were compared. There was no difference in graft function. The cumulative graft survival at 1 and 3 years was similar in the two groups: 98% and 97%. Episodes of acute rejection were an independent predictor of graft survival. CONCLUSIONS: Hand-assisted laparoscopic nephrectomy in living donors is safe and effective with results similar to those of open nephrectomy with regard to graft function.     

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.     

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.