Novel technique for hand assisted laparoscopic right donor nephrectomy

PURPOSE: Most surgeons divide the renal vein with a laparoscopic stapler during laparoscopic donor nephrectomy. The right renal vein is usually shorter than the left one and using the stapler on the right side can result in a higher incidence of vascular complications for right kidney recipients. We present our experience with a new technique for hand assisted laparoscopic right donor nephrectomy. MATERIALS AND METHODS: We designed a new vascular clamp to be completely inserted into the peritoneal cavity through the hand port incision in hand assisted laparoscopy. The renal vein with a cuff of the inferior vena cava was then excised. The defect in the inferior vena cava was sutured intracorporeally. RESULTS: A total of 80 kidney donors underwent hand assisted laparoscopic right donor nephrectomy using the new technique. Mean +/- SD operative time was 184 +/- 36 minutes. Operative time was decreased in the last 30 patients to 152 +/- 22 minutes. Intracorporeal suture time on the inferior vena cava was 16 +/- 3 minutes. No intraoperative complications were noted and there was no partial or total graft loss. Mean blood loss was 50 +/- 35 cc. Mean warm ischemia time was 4 +/- 2 minutes. Hospital discharge was on postoperative day 1 or 2 in 81% of patients. Graft function was normal in 78 recipients with a day 5 postoperative serum creatinine of 1.6 +/- 0.9 mg/dl. Two recipients showed delayed graft function and were treated medically. CONCLUSIONS: This technique for hand assisted laparoscopic right donor nephrectomy has proved to be safe and reproducible. We recommend practicing laparoscopic inferior vena cava suturing in the animal laboratory before performing it in humans.     

Can right‐sided hand‐assisted retroperitoneoscopic donor nephrectomy be advocated above standard laparoscopic donor nephrectomy: a randomized pilot study

Endoscopic techniques have contributed to early recovery and increased quality of life (QOL) of live kidney donors. However, laparoscopic donor nephrectomy (LDN) may have its limitations, and hand‐assisted retroperitoneoscopic donor nephrectomy (HARP) has been introduced, mainly as a potentially safer alternative. In a randomized fashion, we explored the feasibility and potential benefits of HARP for right‐sided donor nephrectomy in a referral center with longstanding expertise on the standard laparoscopic approach. Forty donors were randomly assigned to either LDN or HARP. Primary outcome was operating time, and secondary outcomes included QOL, complications, pain, morphine requirement, blood loss, warm ischemia time, and hospital stay. Follow‐up time was 1 year. Skin‐to‐skin time did not significantly differ between both groups (162 vs. 158 min, P = 0.98). As compared to LDN, HARP resulted in a shorter warm ischemia time (2.8 vs. 3.9 min, P < 0.001) and increased blood loss (187 vs. 50 ml, P < 0.001). QOL, complication rate, pain, or hospital stay was not significantly different between the groups. Right‐sided HARP is feasible but does not confer clear benefits over standard right‐sided LDN yet. Further studies should explore the value of HARP in difficult cases such as the obese donor and the value of HARP for transplantation centers starting a live kidney donation program (Dutch Trial Register number: NTR3096). Nevertheless, HARP is a valuable addition to the surgical armamentarium in live donor surgery.     

Hand-assisted laparoscopic and open living donor nephrectomy in Korea

BACKGROUND: We compared the results of hand-assisted laparoscopic living donor nephrectomy (LLDN) and conventional open living donor nephrectomy (OLDN). METHODS: The clinical data on 49 hand-assisted LLDN and 21 OLDN on the left side performed at two institutions in Korea from January 2001 to February 2003 were reviewed. Demographic data of donors and recipients were similar in the two groups. RESULTS: There was one conversion to an open procedure due to bleeding in the LLDN group. The median operation times (180 min in LLDN versus 170 min in OLDN) and warm ischemic times (2.5 min in LLDN versus 2.0 min in OLDN) in the two groups were similar. The estimated mean blood loss, duration of hospital stay and complication rate was also similar in the two groups. The LLDN group reported less pain (visual analog scale) postoperatively (4.1 versus 5.3), but this was not significant (P=0.058). The time to oral intake in the LLDN group was significantly longer by an average of 1 day (P=0.001). Return to work was sooner in the LLDN group (4.0 weeks versus 6.0 weeks; P=0.026). The recipient graft function was equivalent between the two groups. Hand-assisted LLDN appears to be a safe and effective alternative to OLDN. CONCLUSION: Our findings suggest that this technique may give the ability provide grafts of similar quality to OLDN, while extending to the donors the advantages of a traditional LLDN procedure.     

Open versus laparoscopic live donor nephrectomy: a focus on the safety of donors and the need for a donor registry

PURPOSE: A review of the existing literature showed that the subject of live donor nephrectomy is a seat of underreporting and underestimation of complications. We provide a systematic comparison between laparoscopic and open live donor nephrectomy with special emphasis on the safety of donors and grafts. MATERIALS AND METHODS: The PubMed literature database was searched from inception to October 2006. A comparison was made between laparoscopic and open live donor nephrectomy regarding donor safety and graft efficacy. RESULTS: The review included 69 studies. There were 7 randomized controlled trials, 5 prospective nonrandomized studies, 22 retrospective controlled studies, 26 large (greater than 100 donors), retrospective, noncontrolled studies, 8 case reports and 1 experimental study. Most investigators concluded that, compared to open live donor nephrectomy, laparoscopic live donor nephrectomy provides equal graft function, an equal rejection rate, equal urological complications, and equal patient and graft survival. Analgesic requirements, pain data, hospital stay and time to return to work are significantly in favor of the laparoscopic procedure. On the other hand, laparoscopic live donor nephrectomy has the disadvantages of increased operative time, increased warm ischemia time and increased major complications requiring reoperation. In terms of donor safety at least 8 perioperative deaths were recorded after laparoscopic live donor nephrectomy. These perioperative deaths were not documented in recent review articles. Ten perioperative deaths were reported with open live donor nephrectomy by 1991. No perioperative mortalities have been recorded following open live donor nephrectomy since 1991. Regarding graft safety, at least 15 graft losses directly related to the surgical technique of laparoscopic live donor nephrectomy were found but none was emphasized in recent review articles. The incidence of graft loss due to technical reasons in the early reports of open live donor nephrectomy was not properly documented in the literature. CONCLUSIONS: We are in need of a live organ donor registry to determine the combined experience of complications and long-term outcomes, rather than short-term reports from single institutions. Like all other new techniques, laparoscopic live donor nephrectomy should be developed and improved at a few centers of excellence to avoid the loss of a donor or a graft.     

Follow-up interviews of 12 living kidney donors one yr after open donor nephrectomy

Very few studies have prospectively followed living kidney donors the first year after donor surgery. In 2003, we in-depth interviewed living kidney donors one wk after donation to explore their immediate experiences of going through nephrectomy. The aim of the current investigation was to explore experiences regarding physical and psychosocial health during the first year after donor surgery. Twelve donors going through open donor nephrectomy were interviewed by telephone at one yr after donation. The analysis was carried out with an empirical phenomenological method. All participants expressed an overall positive experience about being a donor a year after transplantation. However, several participants experienced physical disincentives longer than expected post-donation. Emotional distress, such as mild depression and a feeling of loss, was also part of the donor experiences. Donors experiencing unsuccessful recipient outcome reported severe physical and mental reactions. This study provides insights on the physical and mental cost to living kidney donation. Awareness of how donors may experience their situations can help transplantation professionals in their efforts to understand and provide support.     

Therapeutic living donor nephrectomy

Therapeutic living donor nephrectomy is defined as a nephrectomy that is performed as therapy for an underlying medical condition. The patient directly benefits from having their kidney removed, but the kidney is deemed transplantable. The kidney is subsequently used as an allograft for an individual with advanced renal disease. Therapeutic donor nephrectomy can be successfully utilized for a heterogenous cohort of disease processes as both treatment for the donor and to increase the number of suitable organs available for transplantation. We describe four cases of therapeutic donor nephrectomy that were performed at our institution. Of the four cases, two patients elected to undergo therapeutic donor nephrectomy as treatment for loin pain hematuria syndrome; one after blunt abdominal trauma that resulted in complete proximal ureteral avulsion; and the fourth after being diagnosed with a small renal mass. Based on our data presented to the United Network for Organ Sharing Board of Directors (UNOS) in December 2015, living donor evaluation has been made simpler for patients electing to undergo therapeutic donor nephrectomy. UNOS eliminated the requirement for a psychosocial evaluation for these patients. As the organ shortage continues to limit transplantation, therapeutic donor nephrectomy should be considered when appropriate.     

Technique, indications and outcomes of pure laparoscopic right donor nephrectomy

PURPOSE: Laparoscopic nephrectomy for living renal transplantation has emerged as the gold standard. Nevertheless, experience with this technique for procuring right kidneys is limited. We report our single institution results of pure laparoscopic right donor nephrectomy. MATERIALS AND METHODS: Laparoscopic donor nephrectomy was initiated at the our institution in November 1999. Patient selection was initially limited to the left kidney but right surgery was started 2 years later after 97 operations had been performed. We prospectively acquired data on the donor and recipient, and specifically analyzed outcomes of the right kidneys. RESULTS: In a 40-month period 300 laparoscopic donor operations were performed. Overall 44 procedures (15%) were on the right side with the fraction greater (22%) after removing exclusion of the right kidney from laparoscopic selection criteria. In this cohort mean operative time was 170 minutes, significantly less than the 190 minutes for 50 contemporaneous left kidneys (p = 0.001). No case of right donor nephrectomy required open conversion and vessels were of adequate length. Donor and recipient complications were similar in the 2 groups without technical graft loss in the entire series. CONCLUSIONS: Our method of laparoscopic right donor nephrectomy yields excellent graft quality with adequate vascular length and without the need for elaborate modifications or hand assistance. Moreover, the right operation is technically easier and it achieved comparable donor morbidity and recipient renal function. With sufficient experience the right kidney should be procured laparoscopically when indicated.     

Donor nephrectomy: A comparison of techniques and results of open, hand assisted and full laparoscopic nephrectomy

PURPOSE: Laparoscopic donor nephrectomy (LAP) has been gaining more popularity among kidney donors and transplant surgeons. There have been some concerns about the function of kidney grafts harvested by laparoscopic procedures. We report our results of LAP. MATERIALS AND METHODS: Prospective data were collected for our donor nephrectomy operations. A telephone survey was done by an independent investigator on the impact of surgery on quality of life. Graft function was also evaluated by serial serum creatinine and mercaptoacetyltriglycine renal nuclear scans. RESULTS: A total of 100 patients were included in the study; of whom 55 underwent open donor nephrectomy (OD), 28 underwent LAP and 17 underwent hand assisted donor nephrectomy (HAL). Mean patient age was 39 +/- 12 years and it was similar in all groups. Mean operative time was 306 +/- 40 minutes for LAP, 294 +/- 42 minutes for HAL and 163 +/- 24 minutes for OD (p = 0.001). Laparoscopic operative time was decreased to 180 +/- 56 minutes for LAP and 155 +/- 40 minutes for HAL in the last 10 patients. Mean estimated blood loss was 200 +/- 107 cc for LAP, 167 +/- 70 cc for HAL and 320 +/- 99 cc for OD (p = 0.0001). Mean warm ischemia time was 3 +/- 2 minutes for LAP, 2 +/- 2 minutes for HAL and 2 +/- 1 minutes for OD (p = 0.002). Postoperative hospitalization was 2 +/- 2 days for LAP and 3 +/- 2 days for OD (p = 0.01). LAP required 30% less narcotic medicine than OD postoperatively (p = 0.04). There were no major complications in LAP cases and no complete or partial graft loss was noted. Mean followup was 7 months. Recipient creatinine was not significantly different for kidneys harvested by LAP or OD (p = 0.5). Diuretic mercaptoacetyltriglycine renograms were performed in all recipients 1 to 3 days after surgery and mean effective renal plasma flow was similar for the 3 groups (p = 0.9). According to telephone survey results 85% of LAP, 71% of HAL and 43% of OD patients reported a return to normal physical activity within 4 weeks after surgery. Similarly 74% of LAP, 62% of HAL and 26% of OD patients were able to return to work within 4 weeks after surgery. CONCLUSIONS: Our data show no significant difference in graft function between LAP and OD. LAP and HAL were safe and complications were minimal. The main difference was that patients treated with LAP and HAL returned to normal physical activity and work significantly earlier than those who underwent OD.     

Laparoscopic donor nephrectomy in obese donors: easier to implement in overweight women?

Laparoscopic donor nephrectomy (LDN) has been proven feasible in overweight individuals, but remains technically challenging. As the perirenal fat distribution and consistency significantly differ between men and women, we investigated possible differences between the genders. Prospectively collected data of 37 female and 39 male donors with a body mass index (BMI) over 27 who underwent total LDN were compared. Ninety-one donors with a BMI <25 served as controls. Clinically relevant differences were not observed between men and women of normal weight. In overweight donors, two (5%) procedures were converted to open in females and five (13%) in males. None of these conversions in females, but four conversions in males, appeared to be related to the donor's perirenal fat (P = 0.05). Operation time (median 210 vs. 241 min, P = 0.01) and blood loss (median 100 vs. 200 ml, P = 0.04) were favorable in female donors. The number of complications did not significantly differ. Total LDN in overweight female donors does not lead to increased operation times, morbidity or technical complications. In contrast, the outcome in obese males seems to be less advantageous, indicating that total LDN in overweight women can be advocated as a routine procedure but in obese men reluctance seems justified.     

Glomerular hyperfiltration after unilateral nephrectomy in living kidney donors

Glomerular hyperfiltration, which is expected to occur after uninephrectomy, could potentially damage the non-transplanted donor kidney in living donor transplantation. We therefore prospectively measured renal function (inulin and PAH clearance), albumin excretion and blood pressure in the donors of 30 consecutive living donor kidney transplants before uninephrectomy (n = 29) and 1 week (n = 27) and 1 year (n = 16) after. Hyperfiltration was defined as: (post-nephrectomy inulin clearance)/(0.5 x pre-nephrectomy inulin clearance); hyper-perfusion was defined in an analogous way for PAH clearance. Hyperfiltration averaged 128 ± 5% [SEM] and hyperperfusion 133 ± 6% 1 week after uninephrectomy. Hyperfiltration was nearly unchanged (126 ± 7%) 1 year after nephrectomy, whereas hyperperfusion had significantly decreased to 118 ± 8% (P < 0.02). There was no significant change in blood pressure after nephrectomy, and no new cases of hypertension were observed during the 1-year follow-up. The degree of hyperfiltration did not correlate with donor age. Microalbuminuria > 30 mg/24 h was found in two donors 1 week after nephrectomy (one of which normalized at 1 year) and in one additional donor 1 year after nephrectomy. The degree of hyperfiltration did not correlate with albumin excretion rate. In conclusion, no adverse consequences of hyperfiltration were demonstrable during the 1-year observation period, but the prognostic role of occasional microalbuminuria should be further investigated.     

A randomized clinical trial of living donor nephrectomy: a plea for a differentiated appraisal of mini-open muscle splitting incision and hand-assisted laparoscopic donor nephrectomy

A randomized controlled trial was designed to compare various outcome variables of the retroperitoneal mini‐open muscle splitting incision (MSI) technique and the transperitoneal hand‐assisted laparoscopic technique (HAL) in performing living donor nephrectomies. Fifty living kidney donors were randomized to MSI or HAL. Primary endpoint was pain experience scored on a visual analogue scale (VAS). After MSI living donors indicated lower median (range) VAS scores at rest than HAL living donors on postoperative day 2.5 [10 (0–44) vs. 15 (0–70), P = 0.043] and day 3 [7 (0–28) vs. 10 (0–91), P = 0.023] and lower VAS scores while coughing on postoperative day 3 [20 (0–73) vs. 42 (6–86), P = 0.001], day 7 [8 (0–66) vs. 33 (3–76), P < 0.001] and day 14 [2 (0–17) vs. 12 (0–51), P = 0.009]. The MSI technique also resulted in reduced morphine requirement, better scores on three domains of the RAND‐36, reduced costs and reduced CRP and IL‐6 levels. The HAL technique was superior in operating time and postoperative decrease of hemoglobin level. The MSI technique is superior to the HAL technique in performing living donor nephrectomies with regard to postoperative pain experience. This study reopens the discussion of the way to go in performing the living donor nephrectomy.     

Comparison of hand-assisted laparoscopic and open donor nephrectomy in living donors

Objectives:   Although the advent of (hand-assisted) laparoscopic donor nephrectomy has had a positive effect on the donor pool, there is still some concern about the increased morbidity and safety of the laparoscopic donor nephrectomy. The aim of this study was to compare the results of hand-assisted laparoscopic donor nephrectomy (HALD) with open donor nephrectomy (ODN).
Methods:   A single-center non-randomized analysis of 202 living donor kidney transplantations (44 ODN, 158 HALD) between January 1995 and April 2006 was conducted.
Results:   The left kidney was harvested in 75% in the ODN group and 53% in the HALD group ( P  = 0.009). There was no conversion in the HALD group. Mean donor operative time for HALD (174 min) was longer than for ODN (124 min, P  < 0.001). The mean donor hospital stay (4.9 days vs 9.6 days, P  < 0.001) was significantly less for HALD. HALD had lower mean creatinine values at day 7 and 1 month ( P  = 0.001 and P  = 0.002) and lower urological complication rates ( P  = 0.02) compared with ODN. The 1-year graft survival rates of the ODN and the HALD group were 84% and 95% ( P  = 0.006), respectively.
Conclusion:   hand-assisted laparoscopic donor nephrectomy is a safe procedure for a donor nephrectomy with potential benefits compared with ODN.     

Experience with 247 living related donor nephrectomy cases at a single institution in Japan

There is currently much concern over the morbidity and mortality of donors undergoing nephrectomy for living related renal transplants. Between April, 1970 and July, 1986, 247 cases of living related renal transplants were performed at the Second Department of Surgery, Kyoto Prefectural University of Medicine. The average age of the donors was 50.3±9.7 years, 81 per cent of the donors being parents of the recipients. Minor abnormalities which did not affect the donors suitability were found in 71 cases. Nephrectomies were performed extraperitoneally in all cases. Peri-operative complications, including wound complications in 13 cases, urinary infection in 12 cases and pulmonary complications and arrythmia in 4 cases, were considered to be minor in nature. A variety of renal function tests, carried out two weeks after nephrectomy revealed normal levels, although they had become slightly worse than those estimated pre-operatively. Long-term sequalae in the follow-up period from 18 months to 16 years and 2 months, was studied on 124 donors who answered questionnaires. Currently, there are 5 late deaths, none of which are directly related to the nephrectomy. Of the 124 donors, 85.5 per cent stated that there had been no change in their physical states following surgery. Pain or a feeling of discomfort at the wound site was reported by 10 donors (8.1 per cent) and hypertension was observed only in 3 (2.4 per cent). No major complication directly related to the donor nephrectomy was found, except for one case of incisional hernia. The donor nephrectomy operation thus appeared to be quite safe, and successful long-term sequelae can be obtained if the donor is selected carefully, according to the strict prospective evaluation of medical state and renal functions.     

Subjective and objective comparison of critical care pathways for open donor nephrectomy

PURPOSE: In the era of minimally invasive techniques and cost containment, care pathways after donor nephrectomy are important. While open donor nephrectomy remains the established procedure, questions regarding the surgical approach, postoperative care and patient morbidity/dissatisfaction have surfaced. We compared results of standard and fast-track care pathways after donor nephrectomy. MATERIALS AND METHODS: Between January 1998 and August 1999, 60 patients underwent open donor nephrectomy. By surgeon preference, patients received either ketorolac only (31), ketorolac plus morphine spinal (17) or patient controlled anesthesia (12). Data related to surgery, hospital course and cost were reviewed. Patients were surveyed regarding return to daily activities and groups were statistically analyzed. RESULTS: The mean dose per patient was 183 (ketorolac only), 180 (ketorolac plus morphine spinal) and 69 (patient controlled analgesia) mg. Median hospital stay was 2 days for the fast-track pathways (ketorolac only, ketorolac plus morphine spinal) compared to 3 days for the patient controlled analgesia group (p <0.001). Delayed oral intake was seen in 6% of patients on ketorolac only and 3% for those on ketorolac plus morphine spinal compared to 83% of the patient controlled analgesia group (p <0.001). Return to exercise (median weeks, p <0.79) was 2 for the ketorolac only group, 3.5 for ketorolac plus morphine spinal and 3.5 for patient controlled analgesia. Mean global cost was $9,394 for the ketorolac only group, $9,238 for ketorolac plus morphine spinal and $11,601 for patient controlled analgesia (p <0.02). CONCLUSIONS: Fast-track pathways significantly shortened hospital stay and quickened oral intake. Cost was significantly contained using new pathways. Resumption of daily activities was comparable among the groups. Comparisons of critical care pathways are required to optimize patient care after kidney donation. Prospective trials are needed to verify our results.     

后腹腔镜下亲属活体右侧供肾切取术经验总结

目的探讨后腹腔镜下亲属活体右侧供肾切取术的安全性,并总结相关临床经验。 方法回顾性分析2010年2月至2019年6月解放军总医院第八医学中心实施的14例亲属活体右侧供肾切取术临床资料,其中8例为后腹腔镜下供肾切取(腹腔镜组),6例为经腰部开放供肾切取(开放手术组)。腹腔镜组供者常规采取左侧卧位,腰部采用三套管法穿刺。采用成组t检验比较两组供者手术时间、腔静脉切口缝合时间、供肾动脉长度、供肾静脉长度、供肾热缺血时间、手术出血量和术后住院时间。P<0.05为差异有统计学意义。 结果14例亲属活体右侧供肾切取术均成功,两组供者术中均未输血,腹腔镜组供肾切取术中均未中转开腹。腹腔镜组与开放手术组供肾静脉长度分别为(2.2±0.4)和(1.2±0.3)cm,术中出血量分别为(45±12)和(80±10)mL,差异均有统计学意义(t＝1.042和5.781,P均<0.05)。两种术式手术时间、腔静脉切口缝合时间、供肾动脉长度、供肾热缺血时间及术后住院时间差异均无统计学意义(P均>0.05)。截至2019年8月,开放手术组和腹腔镜组供者中位随访时间分别为6个月(3～18个月)和8个月(3～24个月),均健康。受者术前及术后应用巴利昔单抗行免疫诱导治疗,术后免疫抑制方案为CNI＋抗代谢类药物＋糖皮质激素。移植肾功能均于术后2周内恢复,术后均顺利摆脱透析。截至2019年8月,14例受者随访时间3～12个月,期间受者及移植肾功能均正常。 结论亲属活体右侧供肾获取过程中采用腹腔镜联合Satinsky钳技术安全、可行,可较大限度地延长供肾静脉,且术中出血量更少。     

Laparoscopic live donor nephrectomy: a comparison with the conventional open approach

PURPOSE: Laparoscopic live donor nephrectomy is an emerging technique that has not yet gained widespread acceptance in the transplant community due to perceived technical difficulties. However, the potential advantages of decreasing donor morbidity, decreasing hospital stay and improving convalescence while producing a functional kidney for the recipient may prove to enhance living related renal transplantation. We report our early experience with laparoscopic live donor nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 50 consecutive laparoscopic nephrectomies performed from October 1998 to May 2000 and compared them with 50 consecutive open donor nephrectomies, which served as historical controls. RESULTS: Donor age, donor sex and number of HLA mismatches did not differ statistically in the 2 groups. In the laparoscopic and open nephrectomy groups mean followup was 109 and 331 days (p = 0.0001), mean operative time was 234 and 208 minutes (p = 0.0068), mean estimated blood loss was 114 and 193 ml (p = 0.0001), and mean hospital stay was 3.5 and 4.7 days (p = 0.0001), respectively. Average renal warm ischemia time was 2.8 minutes in the laparoscopic nephrectomy group. Serum creatinine did not differ statistically in the 2 groups preoperatively or postoperatively at days 1 and 5, and 1 month. The rate of recipient ureteral complications in the laparoscopic and open nephrectomy groups was 2% (1 of 50 cases) and 6% (3 of 50), respectively (not significant). CONCLUSIONS: Laparoscopic live donor nephrectomy is an attractive alternative to open donor nephrectomy. Laparoscopic nephrectomy results in less postoperative discomfort, an improved cosmetic result and more rapid recovery for the donor with equivalent functional results and complications.     

Kidney transplantation from related and unrelated living donors in a single German centre.

BACKGROUND: Organ transplantation began in 1954 with living related donation (LRD). Because of organ shortage from cadavers, unrelated kidney donation (LURD) has been proposed and shown to have good results despite complete HLA mismatching. This study aims to look at differences and similarities comparing LRD and LURD performed in our centre since the implementation of the German transplant law in 1997. METHODS: Between January 1997 and July 2001, 62 out of 112 potential living donors and their recipients were accepted. Immunosuppression consisted of triple therapy (steroids, cyclosporin, mycophenolate) in patients with three or fewer mismatches, or quadruple therapy including mono- or polyclonal antibody treatment in patients with four or more mismatches or cytotoxic antibodies. LRD and LURD groups were compared for number and type of rejections, complications and kidney function at the end of observation (median 15.5 months, range 1-50 months). RESULTS: Out of 112 pairs presenting, transplantation was performed in only 62 cases (55.4%). Reasons to deny transplantation were medical problems of the potential donors in 19, psychological problems in 13, recipient problems in seven and other reasons in 11 pairs. In 38 cases LRD transplantation and in 24 cases LURD transplantation was carried out. Recipient age was significantly lower in the LRD group (37.7+/-12.1 years) compared with the LURD group (53.6+/-7.8 years). Mean donor age was 49.7+/-9.2 years in the LRD group and 50.3+/-9.1 years in the LURD group (ns). The number of mismatches was lower in LRD (2.1+/-1) than in LURD (4.4+/-0.9) (P=0.001) transplantation. The acute rejection rate was similar in both groups (52.2 vs 54.2%). OKT3 and tacrolimus rescue therapy for more severe rejections was more often applied in the LRD group but the difference did not reach the level of significance. There were more infectious complications in LURD transplantation (66.7 vs 36.4%, P=0.036) and a trend towards more surgical complications in LRD transplantation (28.9 vs 8.3%, P=0.062). One graft was lost due to transplant artery thrombosis and one recipient died 4 months after transplantation subsequent to cerebral ischaemia. Both patients belonged to the LRD group. Creatinine values at the end of observation time were 1.76+/-0.6 mg/dl in the LRD group and 1.62+/-0.5 mg/dl in the LURD group (ns). CONCLUSION: Although kidney transplantation from unrelated donors was performed with a lower HLA match and although the recipients were older, the results are equivalent to living related transplantation. Therefore, kidney transplantation from emotionally related living donors represents a valuable option for patients with end-stage renal disease. Careful selection of donors and recipients is a prerequisite of success.     

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.