Laparoscopic right living donor nephrectomy

INTRODUCTION: Left laparoscopic donor nephrectomy (LDN) is preferred over right LDN due to technical ease. The purpose of this study was to compare results between right and left LDN and thereby determine whether substantial experience with right LDN can provide results equivalent to left LDN. METHODS: All LDN from 2000 to 2004 were reviewed, and right LDN data compared to left LDN data. Statistical analyses included chi-square and Student t tests. RESULTS: Two hundred thirteen left LDN (84%) were compared to 40 right LDN (16%). Donor age, gender, race, and body mass index, and multiple arteries were similar in right and left LDN groups. Operative and cold ischemia times were similar, but warm ischemia was longer for right LDN (3:55 +/- 1:22 minutes) than left LDN (3.18 +/- 1:06 minutes; P = .004). Despite this, renal allograft function was similar on postoperative day 7 (creatinine 1.77 +/- 1.21 for right LDN, 1.7 +/- 1.5 for left LDN) and at 1 year (right LDN 1.5 +/- 0.4, left LDN 1.23 +/- 0.28). Graft survival rate in the right LDN at 1 year was 97.5%. CONCLUSIONS: This large experience with right LDN indicates that results comparable to left LDN can be obtained. This observation increases the options for LDN in patients with multiple left renal arteries, or with right renal cysts, or with right kidneys that are smaller in size compared to the contralateral left kidney.     

Right-sided laparoscopic live-donor nephrectomy: is reluctance still justified?

BACKGROUND: Laparoscopic donor nephrectomy (LDN) of the right kidney is performed with great reluctance because of the shorter renal vein and possible increased incidence of venous thrombosis. METHODS: In this retrospective, clinical study, right LDN and left LDN were compared. Between December 1997 and May 2001, 101 LDN were performed. Seventy-three (72%) right LDN were compared with 28 (28%) left LDN for clinical characteristics, operative data, and graft function. RESULTS: There were no significant differences between the two groups regarding conversion rate, complications, hospital stay, thrombosis, graft function, and graft survival. Operating time was significantly shorter in the right LDN group (218 vs. 280 min). CONCLUSION: In this study, right LDN was not associated with a higher number of complications, conversions, or incidence of venous thrombosis compared with the left LDN. Thus, reluctance toward right LDN is not justified, and therefore, right LDN should not be avoided.     

腹腔镜活体供肾切取手术操作培训课程体系的构建

目的:探讨构建腹腔镜活体供肾切取术(laparoscopic live donor nephrectomy,LDN)操作培训课程体系的可行性。方法:通过对LDN技能培训课程不同阶段的标准化设计,制定相关训练科目和考核标准,在完成训练后进行考核和评估。结果:成功构建LDN的标准化培训课程体系,根据此体系能对外科医师进行LDN培训。结论:LDN培训课程体系能有效提高外科医师的LDN操作技能,并能达到规范手术步骤和过程的要求。     

10 Jahre laparoskopische Lebendnierenspende

Ten years ago the first laparoscopic living donor nephrectomy (LDN) was performed. Today, LDN is a routine operation in many US-American transplantation centers and an increasing number of centers in Europe are practicing LDN. In this article the different aspects of LDN for donor, kidney, recipient and operating surgeon are evaluated.We performed a literature research concerning LDN and the different aspects. Our own experience, as the largest LDN center in Germany, is part of the evaluation. Laparoscopic extraction of a kidney from a living donor is as safe for the donor as the open approach. At the same time, LDN offers multiple advantages like reduced pain and shorter convalescence. For the donated kidney and the recipient no disadvantages occur from the laparoscopic technique, as long as special intra- and perioperative demands are met. For the operating surgeon multiple developments have expanded the technical armentarium. LDN is safe for donor, recipient and kidney. Central issue of an optimal LDN is sufficient experience with laparoscopic urological techniques.     

Comparison of laparoscopic and open donor nephrectomy: a randomized controlled trial

Authors from Iran compare various outcomes between laparoscopic and open donor nephrectomy in kidney transplantation; they carried out a large comparative trial, and found that laparoscopic donor nephrectomy gave better donor satisfaction and morbidity, with equivalent graft outcome. OBJECTIVE: To compare the graft survival, donor and recipient outcome, donor satisfaction, and complications of laparoscopic (LDN) and open donor nephrectomy (ODN) in kidney transplantation. PATIENTS AND METHODS: In a randomized controlled trial, 100 cases each of LDN and ODN were compared. We modified the standard LDN procedure to make it less expensive. RESULTS: The mean (sd) operative duration was 152.2 (33.9) min for ODN and 270.8 (58.5) min for LDN, and the mean duration of kidney warm ischaemia was 1.87 min for ODN and 8.7 min for LDN. Only one LDN required conversion to ODN because of bleeding. The mean follow-up in the LDN and ODN groups was not significantly different (406.1 vs 403.8 days). The mean (sd) score for donor satisfaction was 17.3 (3.5) for ODN and 19.6 (1.0) for LDN. The rate of ureteric complications was 2% for ODN and none for LDN. As determined by serum creatinine levels at 3, 21-30, 90, 180 and 365 days after surgery, graft function was not significantly different between ODN and LDN. Long-term graft survival was 93.8% for LDN and 92.7% for ODN. CONCLUSIONS: Compared to ODN, LDN was associated with greater donor satisfaction, less morbidity and equivalent graft outcome.     

Laparoscopic live donor nephrectomy--is it safe?

BACKGROUND: Laparoscopic live donor nephrectomy (LDN) is a less invasive alternative to open nephrectomy (ODN) for living kidney donation. Concerns have been raised regarding the safety of LDN, the short and long term function of kidneys removed by LDN, and a potential higher incidence of urologic complications in LDN transplant recipients. METHODS: Between October 1997 and May 1999, 80 LDNs were performed at our center. All patients were followed longitudinally with office visits and telephone interviews. These LDNs were compared with 50 ODN performed from January 1996 to October 1997. RESULTS: LDN procedures took significantly longer than ODN (4.6 vs. 3.1 hr). However, LDN was associated with significant reduction in i.v. narcotic use, a rapid return to diet, and shorter hospital stay. Of the 80 LDN procedures, a total of 75 (94%) were completed laparoscopically. Five patients were converted to laparotomy: three for hemorrhage and two for complex vascular anatomy. ODN conversion was associated with large donor body habitus and/or obesity. Seven LDN patients had minor complications and 4 had major complications. All major complications consisted of vascular injuries (2 lumbar vein injuries, 1 renal artery, and 1 aortic injury). All patients made complete recoveries. All LDN kidneys functioned immediately posttransplant. We have observed 100% patient and 97% 1-year actuarial graft survival in LDN transplant recipients. There have been no short-or long-term urologic complications in this series. CONCLUSION: With increasing experience and standardization of technique, LDN is a safe and effective procedure. Patients undergoing LDN demonstrate clinically significant, more rapid postoperative recoveries and shorter hospital stays than ODN patients. Excellent initial graft function and long-term graft survival have been observed with LDN kidneys. Urologic complications can be avoided. LDN has become the preferred surgical approach for living kidney donation at our center.     

Laparoscopic right donor nephrectomy

BACKGROUND: Laparoscopic donor nephrectomy (LDN) preferentially involves the left kidney to optimize vessel length, but occasionally, right nephrectomy is preferred. Right LDN differs markedly in anatomic relations and the need for a fourth port. This retrospective study compares donor outcomes and graft function of right and left LDN and describes the technique. METHODS: Consecutive patients undergoing right LDN from March 26, 1996 to December 31, 2000 were compared with those undergoing left LDN. Age, height, weight, body mass index, creatinine, creatinine clearance, operative time, warm ischemia time, analgesic requirements, serial postoperative creatinine, time to diet resumption, and hospital stay were compared. A second cohort matched for age, gender, race, and temporal left LDN also were compared with the group undergoing right LDN. RESULTS: No significant differences were found for any of the parameters measured. CONCLUSION: This study demonstrates that despite substantial differences in the procedures, donor outcome and graft survival are similar for right and left LDN.     

Laparoscopic versus open donor nephrectomy: comparing ureteral complications in the recipients and improving the laparoscopic technique.

BACKGROUND: Laparoscopic live donor nephrectomy (LDN) is a recently developed procedure, the performance of which needs to be studied. Given the reported advantages in the donors, this study looks at graft outcome and ureteral complications in recipients of kidneys procured by open donor nephrectomy (ODN) versus LDN. METHODS: The LDN recipients consisted of 193 patients since 3/27/96. A total of 168 ODN recipients from 1991 to 1998 served as controls. Immunosuppression protocols were similar for both groups. RESULTS: Two-year graft survival for LDN and ODN was 98% and 96%, respectively. Two-year patient survival for LDN and ODN was 98% and 97%, respectively. The incidence of delayed graft function and mean serum creatinine at 3 and 12 months was similar in both groups. However, the number of ureteral complications that required operative repair was significantly higher for LDN recipients compared to ODN recipients, 7.7% (n=15) vs. 0.6% (n=1) respectively (P=0.03). Ureteral stenting was required in an additional 3.1% (n=6) of LDN and 2.4% (n=4) of ODN (P=NS). There was, however, a learning curve with time. For the first 130 LDN patients, a total of 20 ureteral complications were recorded, whereas only one occurred in the more recent 63 patients (P=0.03). CONCLUSIONS: The higher ureteral complication rate in LDN recipients has improved over time as technical causes have been identified. We have noted significant improvement in ureteral viability by using the endogastrointestinal anastomosis instrument on the ureter and peri-ureteral tissue. LDN is therefore an excellent alternative to ODN. Identification of hazards unique to this technique is critical before its broader application.     

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.     

Cost effectiveness of laparoscopic versus mini-incision open donor nephrectomy: a randomized study

BACKGROUND: Cost-effectiveness remains an issue surrounding the introduction of laparoscopic donor nephrectomy (LDN). METHODS: In a randomized controlled trial the cost-effectiveness of LDN versus mini-incision open donor nephrectomy (ODN) was determined. Fifty donors were included in each group. All in-hospital costs were documented. Postoperatively, case record forms were sent to the donors during 1-year follow-up to record return-to-work and societal costs. To offset costs against quality of life, the Euroqol-5D questionnaire was administered preoperatively and 3, 7, 14, 28, 90, 180, and 365 days postoperatively. RESULTS: Mean total costs were euro6,090 (US$7,308) after LDN and euro4,818 ($5,782) after ODN (P<0.001). Disposables influenced the cost difference most. Mean productivity loss was 68 and 75 days after LDN and ODN respectively, corresponding to euro783 ($940) gained per donor after LDN. The main gain in quality of life in the LDN group was realized within 4 weeks postoperatively. LDN resulted in a mean gain of 0.03 quality-adjusted life years at mean costs of euro1,271 ($1,525) and euro488 ($586) from a healthcare perspective and a societal perspective, respectively. This implies that one additional Quality-Adjusted Life Year after LDN costs about euro16,000 ($19,200) from a societal point of view and about euro41,000 ($49,200) from a health-care perspective. Activities other than work were resumed significantly earlier after LDN (66 vs. 91 days, P=0.01). CONCLUSION: In addition to a clinically relevant donor-experienced benefit from LDN, this technique appeared, given a societal perspective, a cost-efficient procedure mainly due to less productivity losses.     

Laparoscopic Live Donor Nephrectomy: Rationale, Techniques, and Implications

Laparoscopic live donor nephrectomy (LDN) was conceived as a means for decreasing donor nephrectomy morbidity and reducing disincentives for kidney donation. Since LDN was first reported in 1995, explosive growth has led to its performance at more than 100 centers worldwide. Despite initial skepticism in some segments of the transplant community, the results of LDN have improved progressively so that it is emerging as a new standard of care for live kidney donation. We review the development and refinement of LDN and its current rationale and applications.     

A survey: the prevalence of laparoscopic donor nephrectomy at large U.S. transplant centers.

BACKGROUND: There is controversy whether laparoscopic donor nephrectomy (LDN) is the procedure of choice for live kidney donors. The purpose of this survey therefore was to determine the current practices, attitudes, and plans regarding LDN in high-volume renal transplant centers. METHODS: Medical directors of the 31 highest volume kidney transplant centers were surveyed via telephone. Kidney transplant data for 1998 and 1999 were collected. RESULTS: The surveyed centers performed 5213 transplantations in 1998, representing 43% of all kidney transplantations done nationally. Twelve (39%) of the 31 centers performed LDN in 1998, increasing to 20 (65%) of 31 in 1999. Of 1174 live donor operations performed by the 20 centers in 1999, 365 (31%) were LDNs. Among the surveyed centers, four had no plans to begin an LDN program. The most commonly cited incentive for LDN was "shorter recovery time," whereas the most common disincentive was "concern about graft quality." A combination of observation and animate laboratory was the most commonly reported method of learning the LDN procedure. Six-month follow-up interviews found that 26 (84%) of 31 centers had performed LDN; only 1 of the 31 centers had no plans to perform LDNs. CONCLUSIONS: LDN may be the de facto procedure of choice for live donors within the next year. Efforts should now focus on improving techniques for performing and teaching this procedure.     

Terminal hand-assist for laparoscopic donor nephrectomy

BACKGROUND: Laparoscopic donor nephrectomy (LDN) has become widely popular in developed countries but not so in developing countries. One explanation for this maybe the difficulty in getting access devices due to the prohibitive cost. We report our method of terminal hand-assisted LDN in which successful donor nephrectomy is feasible without expensive access devices. METHOD: The patient is placed in the corresponding classic renal surgery position. Three ports are placed for left-sided and four for right-sided LDN. After complete mobilization of the kidney laparoscopically, the assistant's right hand is introduced for left-sided LDN through a 7-cm left lower quadrant transverse muscle-splitting incision. For right-sided LDN, the surgeon's right hand is inserted through a corresponding ipsilateral incision (for right-handed surgeons). A simple method to prevent the leakage of pneumoperitoneum is described. The hand inside the abdomen aids in the final steps and completes the extraction of the kidney swiftly. Manual mopping, lavage, and hemostasis are also possible. RESULTS: Five cases of LDN at our centre were done in this fashion, four on the left side and one on the right. The mean kidney retrieval time after clamping the renal artery was 3:18 +/- 0:46 minutes (range 2:30 to 4:30). Postoperative stay was 4 to 5 days. Recipient serum creatinine normalized within 3 to 4 days. CONCLUSIONS: Short duration terminal hand-assist for LDN without any special access device is possible without the fear of excessive gas leakage. It is helpful to reduce prolonged warm ischemia and to relieve the surgeon's apprehension, at least in the initial learning phase of LDN.     

Open versus laparoscopic donor nephrectomy in live related renal transplantation

BACKGROUND: This analysis sought to evaluate the efficiency and safety of laparoscopic nephrectomy (LDN) for the donor, the recipient, and the graft. LDN seems to have advantages over the open donor nephrectomy (ODN) in length of hospital stay, postoperative comfort, and pain control. METHODS: The results of 40 patients who underwent LDN between October 2000 and September 2003 were compared to those of 40 ODN patients just preceding the LDN patients. Eight laparoscopy patients required conversion to an open procedure due to bleeding (4; two major and two minor), technical problems with the instrument (n = 1) and difficulty in the dissection (n = 3). RESULTS: The demographic data, percentages of right and left nephrectomy, number of vessels, rates of acute rejection episodes, as well as the rates of urologic and vascular complications were similar between the two groups. The time of hospital stay was shorter, and the duration of the operation and of the warm ischemia time were significantly longer for the LDN group. The postoperative decline in serum creatinine levels were similar for the two groups. Graft survival rates were 91.7% at both the first and third years in the LDN group; 92.5% and 87.0% for the ODN group, a difference that was not statistically significant. CONCLUSION: LDN is as efficient and safe as ODN for donors, recipients, and grafts.     

Laparoscopic Versus Open Renal Procurement for Pediatric Recipients of Living Donor Renal Transplantation

Despite reports demonstrating the safety of laparoscopic donor nephrectomy (LDN) for pediatric recipients of renal transplants, recent evidence has challenged using LDN for recipients 5 years of age or younger. We retrospectively reviewed the records of all pediatric recipients of living donor renal transplants from September 2000 through August 2004. We compared those who received allografts recovered by LDN (n = 34) with those recovered by open donor nephrectomy (ODN, n = 26). Outcomes of interest included operative complications, postoperative renal function, the incidence of delayed graft function or episodes of acute rejection and long-term graft function. Donor and recipient demographic data were similar for the LDN and ODN groups. Serum creatinine and calculated creatinine clearance were not significantly different between groups both in the early postoperative period and at long-term follow-up (p > 0.142). Rates of delayed graft function and acute rejection did not differ between groups. Among recipients aged 5 years old or younger stratified by donor technique (9 LDN, 5 ODN recipients), no difference was noted in graft outcomes both early and long-term (p > 0.079). At our center, pediatric LDN recipients have graft outcomes comparable to those of ODN recipients. At experienced centers, we recommend continued use of LDN for pediatric recipients of all ages.     

University of Kentucky experience with laparoscopic live donor nephrectomy using two different techniques

Laparoscopic live donor nephrectomy (LDN) is becoming increasingly popular for its minimum donor morbidity and accelerated return to work. Hand-assisted laparoscopic donor nephrectomy (HALDN) may be more acceptable if the modified technique would offer easier performance. We compared our experience with HALDN and conventional LDN. From November 1998 to June 2004, two groups of patients underwent conventional LDN (n = 71) or HALDN (n = 12). Operative and extraction times, complications, and immediate graft function were compared. Mean operative and extraction times are significantly shorter in the HALDN group (206.7 versus 143.4 minutes and 225 versus 141 seconds). Two in the LDN group required open conversion (3%). Three in the LDN group showed delayed graft function (4%). Three in the LDN group developed graft renal artery thrombosis (4%). There was no ureteral complication in both groups. HALDN provides shorter operative and extraction times and better recipient surgeon satisfaction without increasing donor morbidity.     

Maximizing renal artery length in right laparoscopic donor nephrectomy by retrocaval exposure of the aortorenal junction

Laparoscopic donor nephrectomy (LDN) has become the standard of care at increasing numbers of renal transplant programs worldwide. As in open donor nephrectomy, the left kidney has remained the preferred organ for LDN because of the greater renal vessel lengths. Currently, the overwhelming majority of donor operations are performed on the left kidney. This disparity may be due to an unfamiliarity with the technique of right LDN and technical difficulties encountered in obtaining adequate arterial and venous vessel lengths. Modifications in the laparoscopic technique have increased the length of the renal vein obtained from either side; however, further techniques are needed to maximize the length of the right renal artery in LDN. Herein the authors present a technique to provide exposure of the right aortorenal junction that provides maximal length of the right renal artery. This technique has currently been used in 20 consecutive right LDN operations without vascular complications or technical graft losses.     

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.     

Outcomes of laparoscopic donor nephrectomy in obese patients

The applicability of laparoscopic donor nephrectomy (LDN) has not been assessed in the obese donor. We hypothesized that obesity is not a technical contraindication to LDN. From May 1998 to February 1999, 40 patients underwent LDN at the Georgetown Transplant Institute with the transperitoneal technique. Prophylaxis against deep venous thrombosis consisted of venous compression stockings, low-molecular weight heparin in obese patients, and early ambulation. The following variables were examined: donor sex, age, weight, height, related versus nonrelated donation, body mass index (BMI; wt/ht2), operating room time, estimated blood loss, length of stay, time out of work, and complications. BMI>31 indicates morbid obesity, BMI>27 indicates >20% over ideal body weight, and normal BMI is 25. The patients were divided into nonobese (BMI< or =31) and obese groups (BMI>31). The two groups do not differ in outcome after LDN. Our data indicate that obesity is not associated with increased morbidity or mortality after LDN.