Increased transplantation of kidneys with multiple renal arteries in the laparoscopic live donor nephrectomy era: surgical technique and surgical and nonsurgical donor and recipient outcomes

BACKGROUND: For anatomical and technical reasons, many transplant centers restrict laparoscopic live donor nephrectomy (in contrast with open live donor nephrectomy) to left kidneys. HYPOTHESIS: This change in surgical practice increases procurement and transplantation rates of live donor kidneys with multiple renal arteries (RAs), without affecting donor and recipient outcomes. DESIGN AND SETTING: Retrospective review at an academic tertiary care referral center comparing laparoscopically procured single vs multiple-RA kidney grafts (April 1997 to October 2000). PATIENTS: Seventy-nine consecutive left laparoscopic live kidney donors and 78 transplant recipients. MAIN OUTCOME MEASURES: Donor and recipient complications and postoperative length of stay; cold and warm ischemia time; operating time; short-term and long-term graft function; and survival. RESULTS: We noted multiple RAs in 21 (27%) of all kidneys. The proportion of donors with 1 or more perioperative complications was 19% in the single-RA group vs 10% in the multiple-RA group (P was not significant). For the recipients, we noted no significant differences between groups with respect to surgical complications, quality of early and late graft function, rejection rates, graft losses (all immunologic), and graft survival. Cold and warm ischemia time and length of stay were similar for donors and recipients in both groups. Median operating times were significantly longer for the multiple-RA vs single-RA group (difference, 41 minutes for donors and 45 minutes for recipients; P<.02). CONCLUSIONS: While the introduction of laparoscopic live donor nephrectomy has significantly increased the number of grafts with multiple RAs (compared with historical open controls), this change in practice is safe for both donors and recipients from a patient outcome-based perspective. However, from an economic perspective, the longer operating time associated with multiple-RA grafts provides strong added rationale for optimization of surgical instruments and techniques to make right-sided laparoscopic nephrectomy a routine intervention.     

Laparoscopic live donor nephrectomy: the recipient

BACKGROUND: Laparoscopic live donor nephrectomy offers advantages to the donor in terms of decreased pain and shorter recuperation. Heretofore no detailed analysis of the recipient of laparoscopically procured kidneys has been performed. The purpose of this study was to determine whether laparoscopic donor nephrectomy had any deleterious effect on the recipient. METHODS: A retrospective review was conducted of all live donor renal transplantations performed from January 1995 through April 1998. The control group received kidneys procured via a standard flank approach (Open). Rejection was diagnosed histologically. Creatinine clearance was calculated using the Cockroft-Gault formula. RESULTS: A total of 110 patients received kidneys from laparoscopic (Lap) and 48 from open donors. One-year recipient (100% vs. 97.0%) and graft (93.5% vs. 91.1%) survival rates were similar for the Open and Lap groups, respectively. A similar incidence of vascular thrombosis (3.4% vs. 2.1%, P=NS) and ureteral complications (9.1% vs. 6.3%, P=NS) were seen in the Lap and Open groups, respectively. The incidence of acute rejection for the first month was 30.1% for the Lap group and 31.9% for the Open group (P=NS). The rate of decline of serum creatinine level in the early posttransplantation period was initially greater in the Open group, but by postoperative day 4 no significant difference existed. No difference was observed in allograft function long-term. The median length of hospital stay was 7.0 days for both groups. CONCLUSIONS: Laparoscopic live donor nephrectomy does not adversely effect recipient outcome. The previously demonstrated benefits to the donor, and the increased willingness of individuals to undergo live kidney donation, coupled with the acceptable outcomes experienced by recipients of laparoscopically procured kidneys justifies the continued development and adoption of this operation.     

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.     

Similar long-term outcomes for laparoscopic versus open live-donor nephrectomy kidney grafts: an OPTN database analysis of 5532 adult recipients

Prior studies that included both adult and pediatric recipients suggested slower early graft function for laparoscopically (vs. openly) procured live donor kidney grafts (LD-Ktxs). Any potential long-term impact, however, remains unknown. We compared long-term outcomes of 2685 (49%) laparoscopic vs. 2847 (51%) open LD-Ktxs reported to the Organ Procurement and Transplantation Network performed in adult (> or =18 yrs) recipients between November 1999 and December 2000, with follow-up to February 2006. Acute and chronic rejection accounted for 152 laparoscopic (51%) vs. 148 (46%) open graft losses (P=NS). At discharge and at 5 years, graft function was similar for both groups; graft survival at 5 years was 79% (laparoscopic) vs. 80% (open) (P=NS). We conclude that despite prior reports of slower early laparoscopic LD-Ktx function, both laparoscopic and open nephrectomy are equally effective for procurement of kidneys for adult recipients with regard to short- and long-term (>5 years) function and survival. Future studies must investigate whether these findings apply also to pediatric LD-Ktx recipients.     

Laparoscopic adult donor nephrectomy for pediatric renal transplantation

To evaluate retrospectively our laparoscopic adult donor nephrectomy experience for pediatric transplantation. Since February 1995, 7 adult donors have undergone laparoscopic donor nephrectomy for pediatric renal transplantation (recipients younger than 18 years and weighing less than 30 kg). The outcomes of these donors and pediatric recipients were evaluated. The 7 laparoscopic renal donors had a median operative time of 306 minutes, median allograft warm ischemia time of 275 seconds, median blood loss of 200 mL, median hospital stay of 3 days, and 14.2% overall complication rate. No graft loss or patient mortality occurred. The pediatric recipients of the laparoscopic live-donor allografts had a median creatinine clearance level of 52.1, 52.1, 44, and 41.1 mL/min at 3, 6, 12, and 18 months, respectively. The overall complication rate was 14.2%. The 1 and 2-year graft survival rates were 100%. No mortality occurred in the pediatric recipients. Laparoscopic donor nephrectomy is well tolerated by the adult donors and appears to provide acceptable recipient and allograft outcomes in the pediatric population.     

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.     

Laparoscopic live donor nephrectomy: Current practice and results of renal transplantation

Objective: In 2009, 1659 patients with end‐stage renal failure in Hong Kong were waiting for a renal transplant. The overall number of renal transplants carried out locally remains low, with an even lower number being live donor donations. Yet, live donor kidney transplantation yields results that are consistently superior to those of deceased donor kidney transplantation, and laparoscopic donor nephrectomy (LDN) is increasingly accepted worldwide as a safe and preferred surgical option. We aim to evaluate the outcome of LDN in our setting, and to compare with that of deceased donors in this retrospective review. Patients and Methods: A total of 12 patients received LDN over the study period of 2006–2009. Standard left transperitoneal LDN was carried out. Grafts including three with double vessels were prepared using the bench technique. The postoperative outcomes up to 1 year for both the donors and the recipients were studied. Contemporary results for the 47 deceased donor kidneys were studied and compared. Results: All donors had an eventful recovery. The operating time was 225.0 ± 67.4 min. The hospital stay was 5.6 ± 2.3 days. The recipient outcomes including hospital stay and creatinine levels at discharge and 1 year were 11 days, 121 umol/L and 116 umol/L, respectively. Specifically, no ureteric stricture or graft loss was noted at the 1‐year follow up. Recipient complications included haematoma (1 patient), renal artery stenosis (1 patient) and redo of vascular anastomosis (1 patient). In contrast, the deceased donor graft recipients had a hospital stay of 11 days, and creatinine levels of 205 umol/L on discharge and 205 umol/L at 1 year, respectively. The delayed graft function rates for the live donor and deceased donors group were 0% and 14.9%, whereas the 1‐year graft survival rates were 100% and 87.2% respectively. Conclusion: The results showed that the donor morbidity rate was low, as reflected by the short hospital stay. Also, the overall parameters of recipients were good. In particular, no ureteric stricture was noted, and graft survival was 100% at 1 year. Living donor kidney transplant program using the laparoscopic technique is a viable option to improve the pool of kidneys for transplantation.     

Comparison of laparoscopic and open donor nephrectomy: UK experience

A comparison of laparoscopic and open donor nephrectomy is presented by authors from the UK. They found that the laparoscopic approach could safely be offered to patients treated in experienced units and after adequate training fo the surgeon, with no increase in complications or decrease in efficacy. OBJECTIVE: To compare our early experience of laparoscopic donor nephrectomy (LDN) with a contemporary cohort of conventional open donor nephrectomy (ODN). PATIENTS AND METHODS: Transperitoneal left-sided LDN was offered to carefully selected potential live kidney donors on the basis of vascular anatomy. The first 20 donors who underwent LDN were compared with a control group of 20 patients who had ODN. Donors and recipients were compared for demographics, intraoperative variables, postoperative complications and allograft function. RESULTS: There was no peri-operative mortality in either group. No laparoscopic procedure required open conversion. The operating time was comparable (165 vs 153 min); LDN was associated with significantly less intraoperative blood loss (200 vs 350 mL; Mann-Whitney U, P = 0.01) and hospital stay (3 vs 5 days; P < 0.001). The graft warm ischaemic time was significantly longer for LDN (5 vs 2 min; P < 0.001) but this did not appear to affect either the delayed graft function rate (5% vs 10%, not significant) or serum creatinine level at discharge (125 vs 126 micromol/L). CONCLUSIONS: UK centres with experience of advanced laparoscopy and ODN can safely offer LDN to potential live donors.     

Early postnephrectomy donor renal function: laparoscopic versus open procedure

Laparoscopic donor nephrectomy (LDN) is becoming the method of choice to procure kidneys from living donors. Despite the benefits to the donor, there have been concerns over the transient deterioration of renal function in the recipient of LDN compared with standard nephrectomy. We carried out a retrospective review of all living donors at our institution between January 2000 and December 2002. On the first postoperative day, the fall in renal function in laparoscopic donors is significantly greater than the fall seen in open donors. This difference could not be explained by relative hypotension, excessive blood loss, or inadequate fluid replacement in the laparoscopic group. Importantly, this difference is no longer evident by the third postoperative day. We speculate that this may be secondary to the pneumoperitoneum or the prolonged anesthesia on glomerular filtration rate. Furthermore, this finding could explain the slower recovery of graft function in recipients of laparoscopically procured kidney transplants.     

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.     

Laparoscopic live donor nephrectomy

BACKGROUND: The demand for renal transplants is greater than the available kidneys. Live donation is one way of increasing the supply. Laparoscopic removal of the donor kidney appears to reduce morbidity for the donors. Some who are hesitant because of the morbidity associated with open nephrectomy are willing to consider the laparoscopic donor nephrectomy. METHODS: Laparoscopic donor nephrectomy was offered to all but three donors since the commencement of the programme in 1997. Data were collected both prospectively and retrospectively for the first 120 donors. Venous and arterial anatomy was assessed preoperatively by computed tomographic angiography. RESULTS: All but four donor procedures were completed laparoscopically. Three of these were for bleeding that could not be safely controlled laparoscopically and the fourth was a planned conversion to deal with the renal vessels, in the first right nephrectomy. Two kidneys were lost due to arterial thrombosis and two underwent segmental infarction after the loss of one of two or three separately anastomosed vessels. Three recipients had delayed function and two of them required dialysis postoperatively. Other minor complications occurred but were uncommon. CONCLUSIONS: Laparoscopic live donor nephrectomy is safe for the donor and the transplant kidney. It offers the advantage of decreased morbidity for the donor, with a shorter hospital stay, earlier return to normal activity and, for some, early return to work.     

Laparoscopic live donor nephrectomy: trends in donor and recipient morbidity following 381 consecutive cases

OBJECTIVE: To review a single-institution 6-year experience with laparoscopic live donor nephrectomy detailing the technical modifications, clinical results, as well as the trends in donor and recipient morbidity. SUMMARY BACKGROUND DATA: Since 1995, laparoscopic donor nephrectomy has had a significant impact on the field of renal transplantation, resulting in decreased donor morbidity, without jeopardizing procurement of a high-quality renal allograft. This technique has become the preferred method of allograft procurement for many transplantation centers worldwide but still remains technically challenging with a steep learning curve. METHODS: Records from 381 consecutive laparoscopic donor nephrectomies were reviewed with evaluation of both donor and recipient outcomes. Trends in donor and recipient complications were assessed over time by comparing the outcomes between four equally divided groups. RESULTS: All 381 kidneys were procured and transplanted successfully with only 8 (2.1%) open conversions. Mean operative time was 252.9 +/- 55.7 minutes, estimated blood loss 344.2 +/- 690.3 mL, warm ischemia time 4.9 +/- 3.4 minutes, and donor length of stay was 3.3 +/- 4.5 days. There was a significant decline in total donor complications, allograft loss, and rate of vascular thrombosis with experience. The rate of ureteral complications declined significantly when comparing our early (Group A) versus later (Groups B-D) experience. CONCLUSION: Laparoscopic donor nephrectomy has remained a safe, less invasive, and effective technique for renal allograft procurement. Over our 6-year experience and with specific refinements in surgical technique, we have observed a decline in both donor and recipient morbidity following laparoscopic live donor nephrectomy.     

Laparoscopic v open donor nephrectomy for pediatric kidney recipients: preliminary report of a randomized controlled trial

BACKGROUND AND PURPOSE: Laparoscopic surgery is widely accepted for nephrectomy in adult renal transplantation. The success of this technique has not been compared with open donor nephrectomy (ODN) in children. PATIENTS AND METHODS: In this randomized clinical trial, 40 adult kidney donors were randomly divided into two groups: 20 cases of laparoscopic donor nephrectomy (LDN) and 20 of ODN. Recipients had an age of <15 years. Our exclusion criteria were previous renal transplantation, hemolytic uremic syndrome, focal segmental glomerulosclerosis, oxalosis in the recipients, and multiple renal arteries bilaterally in donors. RESULTS: All donor nephrectomies were completed as scheduled, and no patients undergoing LDN required conversion to open nephrectomy. No patients in either the ODN or the LDN group required reoperation. Acute rejection was diagnosed in six patients receiving kidneys procured by ODN (30%) and 4 patients (20%) receiving kidneys obtained by LDN (P = 0.3). No recipients or donors died. At 1 year, the graft survival times in the ODN and LDN groups were 310.8 +/- 28.8 and 302.7 +/- 28.2 days, respectively (P = 0.8). CONCLUSION: At our medical center, pediatric LDN recipients had graft outcomes similar to those of ODN recipients. We recommend LDN for harvest of kidneys for pediatric recipients at experienced centers.     

Laparoscopic live donor nephrectomy in the presence of circumaortic or retroaortic left renal vein

PURPOSE: Laparoscopic live donor nephrectomy is now an accepted alternative to open surgery in donors with normal renal vasculature. However, the suitability of laparoscopy for donors with anomalous vasculature is less well known. We compared the donor and recipient outcome data of 16 patients with circumaortic or retroaortic left renal vein to 20 recent patients with normal left renal venous anatomy undergoing laparoscopic donor left nephrectomy. MATERIALS AND METHODS: Of 170 patients undergoing laparoscopic donor nephrectomy at our institution from October 1997 to October 2002, 18 (10.6%) had either a circumaortic or retroaortic left renal vein (group 1). Demographic and perioperative parameters of these donors and their recipients were retrospectively compared to a contemporary cohort of 20 recent patients with a normal single left renal vein (group 2). RESULTS: All laparoscopic procedures were completed successfully without open conversion. Groups 1 and 2 were similar in regard to operative time (199 vs 226 minutes, p = 0.90), blood loss (125 vs 100 cc, p = 0.45), warm ischemia time (3.4 vs 3.9 minutes, p = 0.14) and hospital stay (2.9 vs 3.2 days, p = 0.45). Length of allograft renal artery and vein was similar between groups. Cold ischemia and revascularization times were also comparable between groups. Recipient serum creatinine was comparable at 5 days (1.7 vs 1.6 mg/dl), 3 months (1.5 vs 1.4 mg/dl) and 1 year (1.5 vs 1.5 mg/dl). CONCLUSIONS: Presence of a circumaortic or retroaortic renal vein is not a contraindication to laparoscopic live donor left nephrectomy. A left kidney with vasculature anatomically adequate for transplantation can be achieved with excellent donor and recipient outcomes.     

Laparoscopic right donor nephrectomy: a large single-center experience

BACKGROUND: Laparoscopic procurement of right donor kidneys is frequently avoided or performed using hand-assist devices because of concerns regarding donor safety, adequate exposure, and vessel length. The present study describes the authors' large series of right donor nephrectomies performed laparoscopically without the use of hand ports or other manual assist devices. METHODS: The authors retrospectively analyzed all right laparoscopic donor nephrectomies performed at their center from November 1, 1999, to February 20, 2004. Study variables included operative times, blood loss, hospital stay, graft function, and donor and recipient complications. Left donor nephrectomies performed during the same period served as controls. RESULTS: Of 387 laparoscopic kidney procurements, 54 (14 %) were right nephrectomies. Blood loss, extraction times, length of stay, and overall complication rates were similar between right and left donor groups. The mean operative time in the right nephrectomy group was significantly shorter than in the left nephrectomy group (169 +/- 25 and 186 +/- 29 min, respectively; P = 0.003). Graft function 1 month after transplantation and the incidence of delayed graft function were similar in both groups. There was one graft loss caused by thrombosis in the left nephrectomy group; other graft-related complications in the recipients were similar in both groups. CONCLUSIONS: This large single-center experience demonstrates that laparoscopic right donor nephrectomy performed without hand-assist devices is safe and yields kidneys with excellent function. The authors conclude that selection of the appropriate kidney for donation using this approach can be based on the same criteria that have traditionally governed open donor nephrectomy.     

Comparison of open,laparoscopic, and hand-assisted approaches to live-donor nephrectomy

BACKGROUND: Minimally invasive donor nephrectomy has become a favored procedure for the procurement of kidneys from live donors. The optimal minimally invasive surgical approach has not been determined. In the current work, we compared the outcome of kidneys procured using the traditional open approach with two minimally invasive techniques: the standard laparoscopic procedure and a hand-assist procedure. METHODS: The function of live-donor kidneys procured by open versus minimally invasive procedures was compared (procedures compared were the traditional open donor nephrectomy [ODN], the standard laparoscopic [LAP] approach, and the hand-assisted [HA] laparoscopic technique). The length of donor operation, donor length of stay in the hospital, surgical complications, and cost of hospitalization for three groups of patients were assessed in a series of 150 live-donor nephrectomies. RESULTS: We found that both minimally invasive procedures yielded kidney allografts with excellent early function and a minimum of complications in the donor. The open procedure was associated with a reduced operative time but increased donor length of stay in the hospital. Resource utilization analysis revealed that both minimally invasive techniques were associated with a slight increase in costs compared with the open procedure, despite a shorter hospital stay. CONCLUSIONS: Minimally invasive donor nephrectomy is safe and effective for procuring normally functioning organs for live-donor transplantation. Of the two minimally invasive approaches examined, the hand-assisted technique was found to afford a number of important advantages, including facilitating teaching of residents and students, that it is more readily mastered by transplant surgeons, and that it may provide an additional margin of safety for the donor.     

Laparoscopic right nephrectomy for live kidney donation: functional results

Laparoscopic live-donor nephrectomy has gained wide acceptance. However, the vast majority of surgeons perform left nephrectomies only, which may not always be in the best interest of the donor. Of 17 consecutive laparoscopic donor nephrectomies, 13 were done on the right side. The function of these grafts was compared with that of 17 kidneys previously procured by an open technique and with that of the four left laparoscopic grafts. Ischaemic damage was evaluated by post-operative nuclear scanning and urinary lysozyme, and graft function by creatinine and creatinine clearance. Results show that operating time was longer in the laparoscopic donors, but identical in right and left laparoscopic procurements. Ischaemic damage and function were similar, regardless of the side or the surgical technique. We can conclude that right laparoscopic donor nephrectomy is feasible and results in good graft function. Systematic harvesting from the left side may, therefore, not be justified.     

手助腹腔镜活体供肾摘取术在肾移植中的应用

目的 为减轻对话体供者的损伤，探讨腹腔镜在供肾切取中的应用。方法 对3名亲属活体供肾者采用腹腔镜切取肾脏，术前行磁共振、静脉尿路造影和数字减影血管造影检查，以了解供者双侧肾脏的血管情况，取肾术在全身麻醉下进行，先行腹腔穿刺，注入CO2气体，以形成气腹，供肾通过脐上腹中线切口取出。结果 2例取左肾，l例取右肾，3例取肾手术均获成功，手术历时5、4和3．5h，失血100～400ml，供肾热缺血时间分别为8、5、5min，血管吻合完毕开放血流后，移植肾均在1min内泌尿，移植肾功能良好。结论 活体供者采用腹腔镜取肾可减轻供者的手术创伤，术后伤口疼痛轻，住院时间短，身体恢复快。     

Urologic complications in renal transplant recipients by donor type

BACKGROUND AND PURPOSE: Reduced donor morbidity has been established after laparoscopic donor nephrectomy compared with open harvest, but differences in recipient outcomes remain less obvious. We compared the urologic complications in patients receiving kidneys procured by cadaveric, open, and laparoscopic harvest. PATIENTS AND METHODS: A retrospective study of all the kidney transplantations performed between January 1998 and December 2003 was undertaken to extract 100 consecutive patients in each group. All urologic complications were obtained and grouped by the type of donor procurement. RESULTS: Overall, 48 of the 276 transplant patients (17%) had urologic complications: 14% of the cadaveric-donor recipients, 20% of the open-donor recipients, and 18% of the laparoscopic-donor recipients. There were no ureteral complications in the laparoscopic group. CONCLUSIONS: Laparoscopically procured donor kidneys were associated with significantly fewer recipient ureteral complications than open cadaver or live-donor procurement.     

Long-term impact of pneumoperitoneum used for laparoscopic donor nephrectomy on renal function and histomorphology in donor and recipient rats

OBJECTIVE: To investigate the long-term impact of pneumoperitoneum used for laparoscopic donor nephrectomy on renal function and histomorphology in donor and recipient. SUMMARY BACKGROUND DATA: Laparoscopic donor nephrectomy has the potential to increase the number of living kidney donations by reducing donor morbidity. However, function of laparoscopically procured kidneys might be at risk due to ischemia as a consequence of elevated intra-abdominal pressure during laparoscopy. METHODS: In experiment 1, 30 Brown Norway rats were randomized to three procedures: 2 hours of CO2 insufflation, 2 hours of helium insufflation, and 2 hours of gasless laparoscopy. After this, a unilateral nephrectomy was performed in all animals. Another six rats were used as controls. In experiment 2, 36 donor Brown Norway rats were subjected to a similar insufflation protocol, but after nephrectomy a syngeneic renal transplantation was performed. All rats had a follow-up period of 12 months. Urine and blood samples were collected each month for determination of renal function. After 1 year, donor and recipient kidneys were removed for histomorphologic and immunohistochemical analysis. RESULTS: In donors as well as in recipients, no significant changes in serum creatinine, proteinuria, or glomerular filtration rate were detected between the CO2, the helium, and the gasless control group after 1 year. No histologic abnormalities due to abdominal gas insufflation were found. Immunohistochemical analysis did not show significant differences in the number of infiltrating cells (CD4, CD8, ED1, OX62, and OX6) and adhesion molecule expression (ICAM-1) between the three groups. CONCLUSIONS: Abdominal gas insufflation does not impair renal function in the donor 1 year after LDN. One year after transplantation, no differences in renal function or histomorphology were detected between kidney grafts exposed to either pneumoperitoneum or a gasless procedure.