活体供肾移植:手助腹腔镜供肾切除优于常规腹腔镜供肾切除

目的　比较活体供肾移植中手助腹腔镜供肾切除 (Hand -assistedlaparoscopicdonornephrectomy ,HALDN)和完全腹腔镜活体供肾切除 (Laparoscopicdonornephrectomy,LDN)以及对供肾者和接受肾移植者的影响。　方法　回顾总结 1996年 10月～ 2 0 0 1年 2月MountSinai医学中心所有LDN和HALDN的病例资料。 1996年 10月开始行LDN手术 ,1999年 6月转而行HALDN手术。　结果　与LDN组相比 ,HALDN组手术时间明显缩短 ( ( 2 11± 7)minvs ( 2 5 7± 5 )min ,P <0 0 5 ) ,术中出血量明显减少 ( ( 12 2± 17)mlvs ( 2 86± 33)ml,P <0 0 5 ) ,肾脏热缺血时间明显缩短 ( ( 10 6± 6 )svs ( 2 5 7± 8)s,P <0 0 5 ) ,术后淋巴漏和血栓形成发生率 ( 0 %vs 13 7% ( 16例 ) ;2 5 % ( 2例 )vs 6 8% ( 8例 ) ,P <0 0 5 )明显下降。　结论　在活体供肾移植中 ,HALDN似乎优于LDN ,但尚需要前瞻性对照研究予以进一步证实。     

Laparoscopic donor nephrectomy

Background Several large series of laparoscopic donor nephrectomy (LDN) have been published, largely focusing on immediate results and short-term complications. The aim of this study was to examine the results of LDN and collect medium-term and long-term donor followup. Methods We examined the results of two surgeons who performed 500 consecutive LDNs from 1996 to 2005. Prospective databases were reviewed for both donors and recipients to record demographics, medical history, intraoperative events, and complications. Patients were followed between 1 month and 9 years after surgery to assess for delayed complications, especially hypertension, renal insufficiency, incisional hernia, bowel obstruction, and chronic pain. Results Left kidneys were procured in 86.2% of cases. Mean operative time was 3.5 h, and warm ischemia time averaged 3.4 min. Hand-assistance was used in 13.8%, and conversion rate was 1.8%. Intraoperative complication rate was 5.8% and was predominantly bleeding (93.1%). Most (86.2%) of the operative complications occurred during the initial 150 cases of a surgeon, compared with 10.3% in the subsequent 150 cases (p = 0.003). Operative time decreased by 87 min after the initial 150 cases (p < 0.001). Immediate graft survival was 97.5%. Delayed graft function occurred in 3.0% of recipients, and acute tubular necrosis occurred in 7.0%. Thirty-day donor complication rate was 9.8%. Mean donor creatinine was 1.24 on the first postoperative day, 1.27 at 2 weeks, and 1.24 at 1 year. At a mean followup of 32.8 months, long-term donor complications consisted of 11 cases of hypertension, 9 cases of prolonged pain or paresthesia, 2 incisional hernias, 1 small bowel obstruction requiring laparoscopic lysis of adhesions, and 1 hydrocele requiring repair. Conclusions LDN can be performed with acceptable immediate morbidity and excellent graft function. Operative time and complications decreased significantly after a surgeon performed 150 cases. Long-term complications were uncommon but included a likely underestimated incidence of hypertension.     

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     

Complications of retroperitoneoscopic living donor nephrectomy: single center experience after 164 cases

Objectives  Retroperitoneoscopic living donor nephrectomy (RLDN) is used by only a few centers worldwide. Similar to laparoscopic living donor nephrectomy it offers the donor rapid convalescence and excellent cosmetic results. However, concerns have been expressed over the safety of endoscopic living donor nephrectomy. Methods  We review the results of 164 consecutive RLDN from November 2001 to November 2007. Complications were classified into intra- and early postoperative. Results  Mean donor age was 53.4 ± 10.7 years (27–79). Left kidneys were harvested in 76% of cases. Mean operation time was 146 ± 44 min (55–270), and warm ischemia time 131 ± 45 s (50–280). In two patients (1.2%) conversion to open nephrectomy was necessary. The intraoperative complication rate was 3.0%. In the postoperative period we observed in 17.7% minor complications with no persisting impairments for the donor. The rate of major complications in the early postoperative period was 4.3%. Three patients (1.8%) necessitated revision, due to laceration of the external iliac artery in one patient and chyloretroperitoneum in two patients. Mean donor creatinine was 113.1 ± 26.6 mg/dl (63–201) on the first postoperative day, and 102.0 ± 22.2 mg/dl (68–159) on the fifth postoperative day. Conclusion  Retroperitoneoscopic living donor nephrectomy can be performed with acceptable intraoperative and early postoperative morbidity. Operation times and warm ischemia times are comparable to the open approach.     

平均直径7cm肾癌腹膜后镜与开放根治性肾切除术5年经验比较

目的:判断腹膜后镜根治性肾切除术对于平均直径7cm肾癌的临床治疗价值。方法:回顾性分析36例2002年1月~2006年7月行腹膜后镜根治性肾切除术患者的资料,并与同期46例行开放根治性肾切除术患者的临床资料进行比较。腹膜后镜组肿瘤直径为4~9(7.4±1.5)cm,开放组为4~10(7.6±1.2)cm(P>0.01)。所有患者术后病理均证实为肾细胞癌。结果:腹膜后镜治疗组与开放治疗组的手术时间分别为80~220(172±35)min,60~190(165±40)min(P>0.01);术中出血量两组分别为40~300(210±30)ml,50~450(410±100)ml(P<0.01);术后进普食天数两组分别为3~8(3.9±1.0)天,5~11(7.4±2.0)天(P<0.01);术后平均住院日两组分别为5~8(7.0±1.3)天,7~13(8.5±1.8)天(P<0.01)。所有患者平均随访27(9~50)个月,随访期间均未出现手术切口种植转移。结论:腹膜后镜根治性肾切除术具有创伤小,出血少,术后恢复快的优点,随访中发现两种治疗方式对于患者短期的生存率没有影响。对于直径4~10cm肾肿瘤,腹膜后镜根治性肾切除术可以取代开放根治性肾切除术。     

Laparoscopic vascular control techniques in donor nephrectomy: Effects on vessel length.

BACKGROUND: Various techniques for vascular control have been used during urologic laparoscopic procedures. The importance of optimizing the vessel length and securing reliable vascular control are critical for procedures like laparoscopic donor nephrectomy. We aimed to determine the length of vessel lost by using 4 common techniques of vascular control in a fresh human cadaveric vascular model. METHODS: The techniques include application of 2 non-absorbable polymer-ligating clips (10-mm Hem-o-Lok MLX Weck Closure Systems, Research Triangle Park, NC), Endo-GIA II stapler (30-mm length, 2.5-mm staples, Auto Suture, US Surgical, Norwalk, CT), Endopath ETS35 stapler (35 mm length, 2.5mm staples, Ethicon Endo-Surgery), and the Endo Ta-30 stapler (30-mm length, 2.5-mm staples, Auto Suture, US Surgical, Norwalk, CT). RESULTS: The Endo-TA-30 stapler and the polymer clips resulted in significantly less compromise of the vessel length, when compared with the other methods of vascular control. CONCLUSIONS: The Endo-TA-30 stapler and the polymer clips can be applied during laparoscopic procedures where optimizing vascular length is important.     

Optimization of cardiac preload during laparoscopic donor nephrectomy: A preliminary study of central venous pressure versus esophageal doppler monitoring

Background: While the popularity of laparoscopic donor nephrectomy (LDN) has increased, concern persists about the potential deleterious effects of pneumoperitoneum on renal function. Thus, preload optimization with vigorous intravenous hydration has been recommended. The purpose of this study was to compare central venous pressure (CVP) monitoring with a noninvasive measure of cardiac preload (esophageal Doppler) during LDN. Methods: Thirteen patients were studied. Following induction of general anesthesia, a Doppler probe was inserted in the lower third of the esophagus to measure flow time corrected for heart rate (FTc), which is an index of preload. In 10 patients, a catheter was placed in the right internal jugular vein and CVP measured. CVP and FTc were measured at baseline in the supine and right lateral decubitus positions, then 15 and 60 min after the establishment of CO₂ pneumoperitoneum (12–15 mmHg). IV fluids were increased if the FTc fell below 300 msec. Results are expressed as means (±SD). Data were analyzed using repeated measures ANOVA. Results: Lateral positioning and pneumoperitoneum significantly increased CVP from baseline (p < 0.01), while the FTc did not change (p = 0.57). After 60 min of pneumoperitoneum, the FTc was <300 msec in only one patient. Conclusion: CVP is not an accurate guide for administration of IV fluids during LDN. Esophageal Doppler monitoring can be used to noninvasively follow changes in preload during LDN and is worthy of further study. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, March 2003 Financial Disclosure. This work was supported by an unrestricted educational grant from Tyco Healthcare.     

经腹膜后腹腔镜活体供肾切取(附22例报告)

目的  总结经腹膜后腹腔镜活体供肾切取的治疗经验。方法 对2012年1月至2014年5月在中山大学附属第一医院采用经腹膜后腹腔镜活体供肾切取术的22例供者的临床资料进行回顾性分析。手术先采用纯腹腔镜手术方式分离输尿管、肾血管及肾周脂肪, 然后采用腹股沟上内侧平行切口(利用腹侧穿刺口)为取肾切口, 最后在手辅助下离断肾血管并取出肾脏。记录供者手术过程、术后随访情况。结果 取右侧供肾1例, 左侧供肾21例。22例手术过程顺利, 均无中转开放手术, 手术时间(123±31)min。取肾手术切口长度为(7.2±0.5)cm。术中出血15~80 ml, 热缺血时间60~150 s。供肾的肾动脉长度为2.0~3.2 cm, 肾静脉长度为1.0~3.5 cm。随访1~21个月, 术后1 d、1周和1个月后的血清肌酐(Scr)水平分别为(120±57)、(95±25)、(90±21)μmol/L。22例供者中, 术后并发肾窝血肿、伤口愈合不良各1例。术后1周供者疼痛评分0~5分, 术后1个月0~1分。无供者感觉捐肾对总体健康有明显影响, 1例供者觉得对体力有一定影响。结论 在严格选择供体的情况下, 开展经腹膜后腹腔镜活体供肾切取具有良好的安全性。由于其切口较小, 术后疼痛程度轻, 对供者的生存质量影响较小。      

A comparison of traditional open,minimal-incision donor nephrectomy and laparoscopic donor nephrectomy

Laparoscopic donor nephrectomy (LDN) and minimal-incision donor nephrectomy (MILD) are less invasive procedures than the traditional open donor nephrectomy approach (ODN). This study compares donor and recipient outcome following those three different procedures. Sixty consecutive donor nephrectomies were studied (n=20 in each group). Intra-operative variables, analgesic requirements, donor recovery, donor/recipient complications and allograft function were recorded prospectively. Operating and first warm ischaemia times were longer for LDN than for ODN and MILD (232±35 vs 121±24 vs 147±27 min, P<0.001; 4±1 vs 2±2 vs 2±1 min, P<0.01). Postoperative morphine requirements were significantly higher after ODN than after MILD and LDN (182±113 vs 86±48 vs 71±45 mg; P<0.0001). There was no episode of delayed graft function in this study. Donors returned to work quicker after LDN than after ODN and MILD (6±2 vs 11±5 vs 10±7; P=0.055). Donor and recipient complication rates and recipient allograft function were comparable. We concluded that MILD and LDN reduce postoperative pain and allow a faster recovery without compromising recipient outcome.     

Laparoscopic and open live donor nephrectomy: a cost/benefit study

Recently, laparoscopic live-donor nephrectomy has been developed in order to increase organ donation. In this study we compare and review the records of 10 donors operated by open extraperitoneal approach and of 10 donors operated by a laparoscopic transperitoneal approach (LSC). Results show less use of postoperative parenteral narcotics in the LSC group (109 mg vs 272 mg; P < 0.0005) than in the extraperitoneal group. Morbidity was similar in both groups. There was no difference in postoperative stay. Allograft kidney function was similar in both groups until 6 months after donation. The use of disposable laparoscopic material bears an extra cost of 900 US$. We can thus conclude that laparoscopic live-donor nephrectomy is a safe procedure that significantly reduces postoperative pain, and is not detrimental to the allograft. The total cost of the laparoscopic procedure will be lower than that of the open approach if the length of postoperative stay is cut by 3 days. Received: 17 July 1998/Revised: 12 January 1999/Accepted: 13 September 1999     

机器人辅助腹腔镜活体供肾切取术31例报告

目的  评估机器人辅助腹腔镜活体供肾切取术的安全性和有效性。 方法  回顾性分析2013年11月至2015年8月第四军医大学西京医院实施的31例机器人辅助腹腔镜活体供肾切取术的供、受者的临床资料。 结果  31例均顺利完成供肾切取术,手术时间110~190 min,术中出血量20~100 ml,供肾热缺血时间100~160 s,保留肾静脉长度1.8~3.0 cm,肾动脉长度1.4~2.3 cm。2例供肾取出时发生脾脏损伤,行脾脏修补术;1例供者术后出血,经止血、纠正贫血后好转。31例供者术后均随访6个月以上,均未发生远期并发症。31例受者中,1例出现移植肾功能延迟恢复,经治疗后于术后1个月血清肌酐恢复正常。移植肾存活率为100%。 结论  机器人辅助腹腔镜活体供肾切取术具有安全、可靠、创伤小、恢复快、不影响供肾功能等优势,可作为供肾切取有效而安全的手术方式。     

Retroperitoneoscopic living donor nephrectomy: initial experience with a unique hand‐assisted approach

Capolicchio J‐P, Feifer A, Plante MK, Tchervenkov J. Retroperitoneoscopic living donor nephrectomy: initial experience with a unique hand‐assisted approach.
Clin Transplant 2011: 25: 352–359. © 2010 John Wiley & Sons A/S. Abstract: The retroperitoneoscopic (RP) approach to live donor nephrectomy (LDN) may be advantageous for the donor because it avoids mobilization of peritoneal organs and provides direct access to the renal vessels. Notwithstanding, this approach is not popular, likely because of the steeper learning curve. We feel that hand‐assistance (HA) can reduce the learning curve and in this study, we present our experience with a novel hand‐assist approach to retroperitoneoscopic live donor nephrectomy (HARP‐LDN). Over a one‐yr period, 10 consecutive patients underwent left HARP‐LDN with a mean body mass index of 29 and three with prior left abdomen surgery. The surgical technique utilizes a 7 cm, muscle‐sparing incision for the hand‐port with two endoscopic ports. Operative time was an average of 155 min., with no open conversions. Mean blood loss was 68 mL, and warm ischemia time was 2.5 min. Hospital stay averaged 2.7 d with postoperative complications limited to one urinary retention. Our modified HARP approach to left LDN is safe, effective and can be performed expeditiously. Our promising initial results require a larger patient cohort to confirm the advantages of the hand‐assisted retroperitoneal technique.     

Open donor, laparoscopic donor and hand assisted laparoscopic donor nephrectomy: a comparison of outcomes

PURPOSE: In experienced hands laparoscopic surgery has been shown to be safe for procuring kidneys for transplantation that function identically to open nephrectomy controls. While searching for a safer and easier approach to laparoscopic donor nephrectomy, hand assisted laparoscopic techniques have been added to the surgical armamentarium. We compare allograft function in patients with greater than 1-year followup who underwent open donor (historic series), classic laparoscopic and hand assisted laparoscopic nephrectomy. MATERIALS AND METHODS: The charts of 48 patients who underwent open donor, laparoscopic donor or hand assisted laparoscopic nephrectomy were reviewed. Only patients with greater than 1-year followup and complete charts were included in our study. Of these patients 34 underwent consecutive laparoscopic live donor nephrectomy and 14 underwent open donor nephrectomy. Mean patient age plus or minus standard deviation (SD) was 36.5 +/- 8.4 years for donors and 29 +/- 17 for recipients at transplantation (range 13 months to 69 years). In the laparoscopic group 11 patients underwent the transperitoneal technique, and 23 underwent hand assisted laparoscopic nephrectomy. RESULTS: Total operating time was significantly reduced with the hand assisted laparoscopic technique compared with classic laparoscopy, as was the time from skin incision to kidney removal and warm ischemic time. Average warm ischemic time plus or minus SD was 3.9 +/- 0.3 minutes for laparoscopic nephrectomy and 1.6 +/- 0.2 for hand assisted laparoscopy (p <0.05). Long-term followup of serum creatinine levels revealed no significant differences among the 3 groups. Comparison of those levels for recipients of open nephrectomy versus laparoscopic and hand assisted laparoscopic techniques revealed p values greater than 0.5. No blood transfusions were necessary. Complications included adrenal vein injury in 1 patient, small bowel obstruction in 2, abdominal hernia at the trocar site in 1 and deep venous thrombosis in 1. CONCLUSIONS: Classic laparoscopic donor and hand assisted laparoscopic donor nephrectomies appear to be safe procedures for harvesting kidneys. The recipient graft function is similar in the laparoscopic and open surgery groups.     

Periarterial application of papaverine during laparoscopic donor nephrectomy improves early graft function after kidney transplantation in pigs

Background: Laparoscopic donor nephrectomy (LDN) increases incentives to donation by subjects who might refuse an open operation. However, the incidence of delayed graft function is higher after LDN than after open operation. This may be caused by the reduction of renal perfusion as a result of the raised intraabdominal pressure and mechanically induced renal angiospasm during the operation. We conducted experiments to find out whether the application of papaverine around the renal artery during LDN could improve early graft function after transplantation. Methods: Renal function was studied in 10 male pigs (weight ~25 kg). The left kidney was harvested laparoscopically (intraabdominal pressure 8 mmHg). Five animals were randomly selected to have perivascular application of 50 mg papaverine (treatment group) before preparation of the vessels. In controls no papaverine was used. After LDN and open right nephrectomy the left kidney was autotransplanted. The main outcome measures were volume of urine produced and creatinine clearance during the first 20 h after the transplant. Results: The groups were comparable in respect of body weight, hemodynamic values, amount of infusions, warm and cold ischemia time, and duration of anastomosis. Urine output and creatinine clearance were significantly higher in pigs treated with papaverine than in controls. Conclusions: Papaverine substantially improved early graft function in pigs when applied around the renal artery during LDN. Whether this is applicable to procurement of human kidneys remains to be evaluated. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and IPEG, Los Angeles, CA, USA, 10–15 March 2003     

Laparoscopic versus open live donor nephrectomy: outcomes analysis of 266 consecutive patients

Background  Minimally invasive surgical techniques have become the preferred method for live donor nephrectomy (DN) in many centers. We compared our experience with laparoscopic and open DN in a single institution. Methods  Data for 266 consecutive live DNs were collected. Demographic, intraoperative, and postoperative data were compared. Results  A total of 199 hand-assisted laparoscopic (HAL) DNs, 18 totally laparoscopic (TL), and 49 open DNs were performed. Laparoscopic DN was associated with a shorter operative time (p < 0.013), less blood loss (p < 0.0001), and shorter hospital stay (p < 0.0001) than open DN. Warm ischemia time was less for HAL versus TL DN (59.9 vs. 90.0 seconds; p < 0.0001). Compared with open DN, laparoscopic patients had fewer complications (p < 0.03), fewer wound infections (p < 0.004), less wound paresthesias (p < 0.0009), and fewer complaints of chronic incisional pain (p < 0.0001). Delayed graft function during the first 24 h postoperatively was significantly less for the laparoscopic DN versus the open cases (12.9% vs. 30.4%; p = 0.003), but the need for hemodialysis for the recipient was similar between groups (6.9% vs. 5%; p = not significant). Conclusions  Laparoscopic DN resulted in less blood loss, reduced operative time, and shorter hospital stay than open DN. Hand-assisted laparoscopic DN has the potential to decrease warm ischemia time for renal allografts. Donors managed laparoscopically had fewer complications, significantly less wound-related morbidity, and less delayed graft function than patients who underwent open DN.     

The influence of periarterial papaverine application on intraoperative renal function and blood flow during laparoscopic donor nephrectomy in a pig model

Background: The transplantation of live donor kidneys harvested laparoscopically is associated with a higher incidence of delayed graft function than the transplantation of grafts harvested via the open technique. The delay is believed to be due to a decrease in renal blood flow during laparoscopic donor nephrectomy (LDN). The aim of this study was to evaluate whether renal function and blood perfusion can be enhanced by the periarterial application of papaverine during LDN. Methods: Renal function and blood flow were studied in a porcine model that included a total of 24 pigs (20–30 kg). In 12 of the pigs, urine output and creatinine clearance were determined as measures of renal function. In the other 12 pigs, renal blood flow was determined using fluorescent-labeled microspheres. In each group, the pigs were randomized into two subgroups, one with and one without a perivascular injection of 50 mg papaverine. Results: As compared to the controls, the animals receiving papaverine had a significantly higher urine output (3.1 ± 1.6 vs 0.9 ± 0.45 ml/h/kg; p = 0.02), superior creatinine clearance (2.22 ± 0.5 vs 0.95 ± 0.1 ml/min/kg; p = 0.038), and enhanced renal blood flow (4.9 ± 2.2 vs 2.1 ± 0.8 ml/min/g; p = 0.008). Conclusions: When applied to the tissue surrounding the renal artery, papaverine substantially improves renal function and blood flow during laparoscopic live kidney donation. Whether graft optimization during kidney procurement also translates into improved posttransplantation function remains to be established. Presented at the 8th World Congress of Endoscopic Surgery, Society of American Gastrointestinal Endoscopic Surgeons (SAGES) meeting, New York, NY, USA, 13–16 March     

The performance of three estimates of glomerular filtration rate before and after live donor nephrectomy

Serum creatinine‐based estimates of glomerular filtration rate (GFR) are inaccurate in healthy individuals. Therefore, their use in assessment prior to live donor nephrectomy has been restricted. There are less data on their use postdonor nephrectomy. This study assessed three GFR estimates against Cr⁵¹ EDTA radioisotope GFR (iGFR) in the same cohort of patients before and after donor nephrectomy. A total of 206 patients underwent iGFR measurement prior to donor nephrectomy and this was repeated in 187 patients 6–8 weeks postsurgery. The iGFR was compared with the modification of diet in renal disease (eGFR), Cockcroft–Gault (cgGFR) and Mayo Clinic equation (mcGFR) estimates of GFR. Preoperatively, all GFR estimates performed poorly against iGFR; however, mcGFR provided the most reliable estimate. The eGFR underestimated iGFR by 23.60 ± 16.43 ml/min/1.73 m², cgGFR by 15.54 ± 18.13 ml/min/1.73 m² and mcGFR overestimated by 0.72 ± 18.11 ml/min/1.73 m². Postdonation, all estimates again performed poorly, but eGFR and mcGFR outperformed cgGFR. The eGFR underestimated iGFR by 9.13 ± 10.11 ml/min/1.73 m², mcGFR by 9.44 ± 13.80 ml/min/1.73 m² and cgGFR overestimated by 6.42 ± 14.49 ml/min/1.73 m². No GFR estimate performed sufficiently well to supersede iGFR measurement prior to donor nephrectomy. Performance postdonation was little better. In addition, there was no correlation between fall in iGFR and fall in GFR estimates postdonation.