Int Urol Nephrol DOI 10.1007/s11255-015-1007-z
UROLOGY - ORIGINAL PAPER
Endourological management of live donors with urolithiasis at the time of donor nephrectomy: a single center experience Praveen Pushkar1 · Anshuman Agarwal1 · Surjeet Kumar1 · Sandeep Guleria1
Received: 11 April 2015 / Accepted: 7 May 2015 © Springer Science+Business Media Dordrecht 2015
Abstract Purpose Live related renal donors with urolithiasis are made suitable for renal transplantation in two-stage procedure in most of the centers: first making the donor kidney stone free surgically or by ESWL and then proceeding to renal transplantation. To reduce the cost and morbidity of two surgical procedures in donors, we did a pilot study of removing subcentimeter renal calculi in live donors, after explanting the kidney, during bench surgery. Materials and methods We included all prospective renal donors with subcentimeter (4–10 mm) calculi in one kidney in our study (n = 14). All these patients underwent standard donor evaluation and metabolic work up. After the donor nephrectomy, bench retrograde intra-renal surgery (RIRS) with or without pyelotomy was done for stone clearance followed by renal transplantation. Results Stone clearance was achieved in 13 out of 14 donors. Donors and recipients were followed for 6–24 months. No stone recurrence or graft dysfunction was seen in the follow-up period. Conclusion We concluded that bench RIRS is an excellent modality in the management of small renal calculi in prospective renal donors who are not having metabolically active disease. This reduced the cost and morbidity to the donor and minimized waiting time for transplant. Keywords Bench ureteroscopy · Renal transplantation · Ex vivo ureteroscopy
* Praveen Pushkar [email protected] 1
New Delhi, Delhi, India
Introduction Renal transplantation is the preferred method of therapy for patients with end-stage renal disease (ESRD) since it is more cost-effective and associated with a better quality of life. Moreover, survival after transplantation is far superior to those on hemodialysis. The number of patients listed for kidney transplantation is increasing disproportionately to the number of kidney transplantations performed annually. An ideal kidney donor is the one who has no renal disease, no active infection, and no transmissible malignancy. Due to shortage of living donors, centers have started using expanded criteria for donors (ECD), of which one is to use kidneys with renal stones. If the stone is very small (1-cm renal calculi were found. One had bilateral stone, and two had recurrent nephrolithiasis.
Int Urol Nephrol Table 1 Stone size and location with techniques used in our study
Patient no. Age/sex Stone size (mm) Stone location Technique
Result
1 2 3 4 5 6 7 8 9
42/F 34/F 45/M 58/F 64/M 30/F 51/F 63/M 39/M
4, 4 7 6 9 7 6.5 10 9.5 5, 4
Left UC, MC Left LC Left UC Left MC Right MC Left UC Left UC Pelvis Right LC, UC
Bench URS + laser + basket Success Bench flexible URS + pyelotomy Success Bench URS + pneumatic + forceps Success Bench URS + pyelotomy Success Bench URS + pyelotomy Success Bench URS + pneumatic + forceps Success Bench URS + pyelotomy Success Bench URS + pyelotomy Success Bench flexible URS + laser + basket Success
10 11 12 13
42/F 44/F 27/F 54/M
5 6, 4, 3 9 10
Right LC Left UC, MC Left MC Left UC
Donor gifted stone Bench URS + laser + basket Bench URS + pyelotomy Bench URS + pyelotomy
Failed Success Success Success
14
35/F
4.5
Right LC
Bench flexible URS + basket
Success
UC upper calyx, MC middle calyx, LC lower calyx, URS ureterorenoscopy
Donor age-group ranged from 27 to 64 years (mean 44.8 years). Stone sizes encountered ranged from 4 to 10 mm (mean 6.3 mm). Three patients had multiple stones. Stone clearance was achieved in 13 out of 14 patients on the bench, which was confirmed on ureteroscopy (Table 1). Time taken for the procedure ranged from 22 to 49 min (mean 28 min). Flexible scope was used in three cases. There was no change in cold ischemia time as we did transplant in sequential manner, and our procedure was completed before the donor was shifted out of the operating room. In one patient, stone removal failed as the infundibulum was very narrow, which allowed only guidewire to pass through it, so it was left in situ as there was no danger of stone dislodgement. In two patients, where pneumatic lithoclast was used, mucosal injury was seen on the posterior wall. Stone was retrieved via pyelotomy in seven patients and via ureter in six. Two recipients developed mild graft dysfunction on second postoperative day, which recovered later. All the patients were discharged before seventh postoperative day. Baseline S. creatinine at the time of discharge was 1.2 ± 0.3 mg/dL. None of our patients had recurrence of stones during the follow-up. Donors were followed for 12 months (6–18 months), and recipients were followed for 16 months (12–24 months). No stone recurrence was seen in any recipients in the follow-up period. Single recipient with stone in the allograft in which bench ureteroscopy failed was also asymptomatic at 12-month follow-up.
Discussion The presence of kidney stones has been a relative contraindication for living donation. The lifetime risk of recurrence kidney stones is an important consideration in evaluating suitability for kidney donation. With the use of CT angiography as part of routine living donor workup, renal calculi are more frequently detected and their clinical significance in this setting is largely unknown. There are few data on the lifetime risk specific to the kidney donor population. There are reports where judicious use of allografts with small stones in donors with normal metabolic studies has been successfully done without much postoperative complications [6]. Transplantation of small (
UROLOGY - ORIGINAL PAPER
Endourological management of live donors with urolithiasis at the time of donor nephrectomy: a single center experience Praveen Pushkar1 · Anshuman Agarwal1 · Surjeet Kumar1 · Sandeep Guleria1
Received: 11 April 2015 / Accepted: 7 May 2015 © Springer Science+Business Media Dordrecht 2015
Abstract Purpose Live related renal donors with urolithiasis are made suitable for renal transplantation in two-stage procedure in most of the centers: first making the donor kidney stone free surgically or by ESWL and then proceeding to renal transplantation. To reduce the cost and morbidity of two surgical procedures in donors, we did a pilot study of removing subcentimeter renal calculi in live donors, after explanting the kidney, during bench surgery. Materials and methods We included all prospective renal donors with subcentimeter (4–10 mm) calculi in one kidney in our study (n = 14). All these patients underwent standard donor evaluation and metabolic work up. After the donor nephrectomy, bench retrograde intra-renal surgery (RIRS) with or without pyelotomy was done for stone clearance followed by renal transplantation. Results Stone clearance was achieved in 13 out of 14 donors. Donors and recipients were followed for 6–24 months. No stone recurrence or graft dysfunction was seen in the follow-up period. Conclusion We concluded that bench RIRS is an excellent modality in the management of small renal calculi in prospective renal donors who are not having metabolically active disease. This reduced the cost and morbidity to the donor and minimized waiting time for transplant. Keywords Bench ureteroscopy · Renal transplantation · Ex vivo ureteroscopy
* Praveen Pushkar [email protected] 1
New Delhi, Delhi, India
Introduction Renal transplantation is the preferred method of therapy for patients with end-stage renal disease (ESRD) since it is more cost-effective and associated with a better quality of life. Moreover, survival after transplantation is far superior to those on hemodialysis. The number of patients listed for kidney transplantation is increasing disproportionately to the number of kidney transplantations performed annually. An ideal kidney donor is the one who has no renal disease, no active infection, and no transmissible malignancy. Due to shortage of living donors, centers have started using expanded criteria for donors (ECD), of which one is to use kidneys with renal stones. If the stone is very small (1-cm renal calculi were found. One had bilateral stone, and two had recurrent nephrolithiasis.
Int Urol Nephrol Table 1 Stone size and location with techniques used in our study
Patient no. Age/sex Stone size (mm) Stone location Technique
Result
1 2 3 4 5 6 7 8 9
42/F 34/F 45/M 58/F 64/M 30/F 51/F 63/M 39/M
4, 4 7 6 9 7 6.5 10 9.5 5, 4
Left UC, MC Left LC Left UC Left MC Right MC Left UC Left UC Pelvis Right LC, UC
Bench URS + laser + basket Success Bench flexible URS + pyelotomy Success Bench URS + pneumatic + forceps Success Bench URS + pyelotomy Success Bench URS + pyelotomy Success Bench URS + pneumatic + forceps Success Bench URS + pyelotomy Success Bench URS + pyelotomy Success Bench flexible URS + laser + basket Success
10 11 12 13
42/F 44/F 27/F 54/M
5 6, 4, 3 9 10
Right LC Left UC, MC Left MC Left UC
Donor gifted stone Bench URS + laser + basket Bench URS + pyelotomy Bench URS + pyelotomy
Failed Success Success Success
14
35/F
4.5
Right LC
Bench flexible URS + basket
Success
UC upper calyx, MC middle calyx, LC lower calyx, URS ureterorenoscopy
Donor age-group ranged from 27 to 64 years (mean 44.8 years). Stone sizes encountered ranged from 4 to 10 mm (mean 6.3 mm). Three patients had multiple stones. Stone clearance was achieved in 13 out of 14 patients on the bench, which was confirmed on ureteroscopy (Table 1). Time taken for the procedure ranged from 22 to 49 min (mean 28 min). Flexible scope was used in three cases. There was no change in cold ischemia time as we did transplant in sequential manner, and our procedure was completed before the donor was shifted out of the operating room. In one patient, stone removal failed as the infundibulum was very narrow, which allowed only guidewire to pass through it, so it was left in situ as there was no danger of stone dislodgement. In two patients, where pneumatic lithoclast was used, mucosal injury was seen on the posterior wall. Stone was retrieved via pyelotomy in seven patients and via ureter in six. Two recipients developed mild graft dysfunction on second postoperative day, which recovered later. All the patients were discharged before seventh postoperative day. Baseline S. creatinine at the time of discharge was 1.2 ± 0.3 mg/dL. None of our patients had recurrence of stones during the follow-up. Donors were followed for 12 months (6–18 months), and recipients were followed for 16 months (12–24 months). No stone recurrence was seen in any recipients in the follow-up period. Single recipient with stone in the allograft in which bench ureteroscopy failed was also asymptomatic at 12-month follow-up.
Discussion The presence of kidney stones has been a relative contraindication for living donation. The lifetime risk of recurrence kidney stones is an important consideration in evaluating suitability for kidney donation. With the use of CT angiography as part of routine living donor workup, renal calculi are more frequently detected and their clinical significance in this setting is largely unknown. There are few data on the lifetime risk specific to the kidney donor population. There are reports where judicious use of allografts with small stones in donors with normal metabolic studies has been successfully done without much postoperative complications [6]. Transplantation of small (
