Int Urol Nephrol DOI 10.1007/s11255-015-1014-0
UROLOGY - ORIGINAL PAPER
Right versus left retroperitoneoscopic living‑donor nephrectomy Toshiaki Kashiwadate1,2 · Kazuaki Tokodai1,2 · Noritoshi Amada1 · Izumi Haga1 · Tetsuro Takayama1 · Atsushi Nakamura1 · Takuya Jimbo1 · Yasuyuki Hara2 · Naoki kawagishi2 · Noriaki Ohuchi2
Received: 2 April 2015 / Accepted: 13 May 2015 © Springer Science+Business Media Dordrecht 2015
Abstract Purpose To compare the safety and efficacy of rightside and left-side retroperitoneoscopic donor nephrectomy (RDN) using our hybrid technique. Methods We retrospectively reviewed the data obtained from 151 consecutive patients who underwent RDN between May 2005 and July 2013. Right and left nephrectomies were performed in 87 and 64 patients, respectively. We compared these two groups with respect to donors’ intraoperative parameters, postoperative outcomes, and recipients’ outcomes. Results There were no significant differences between the two groups regarding donor blood loss, warm ischemia time, donor postoperative creatinine levels, donor postoperative length of hospital stay, recipient creatinine levels at 1 year after transplantation, and 1-year graft survival rate after transplantation. The time required for graft extraction and overall operative time were significantly shorter in the right RDN group than in the left RDN group (152 vs. 168 min, P = 0.016; 175 vs. 195 min, P = 0.0059). Only one case in the right nephrectomy group required open conversion because of uncontrollable bleeding from the inferior vena cava.
This work was carried out at Department of Surgery of Japan Community Health Care Organization Sendai Hospital. * Kazuaki Tokodai [email protected] 1
Department of Surgery, Japan Community Health Care Organization Sendai Hospital, Sendai, Japan
2
Department of Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, 1‑1 Seiryo‑machi, Aoba‑ku, Sendai 980‑8574, Japan
Conclusion Although larger sample sizes would be required to evaluate postoperative complication rate, these results indicate that both the right and left RDN could be performed with similar donor and recipient outcomes. Keywords Donor selection · Graft survival · Kidney transplantation · Laparoscopic surgery · Living donors
Introduction Laparoscopic donor nephrectomy, initially reported by Ratner et al. [1], is an established technique worldwide [2–6]. However, right-sided laparoscopic donor nephrectomy has been associated with short renal vein and venous thrombosis [7]. Therefore, many surgeons tend to select only the left kidney even if multiple renal arteries are present on the left side [8]. Kohei et al. [9] reported that retroperitoneoscopic donor nephrectomy (RDN) is a safe technique and could be a surgical option for livingdonor kidney removal. RDN involves a direct and quick approach to retroperitoneal organs, without interference to the abdominal organs such as the liver [9, 10]. Left RDN is performed preferentially over right RDN, because the long renal vein facilitates implantation [9]. For this reason, most RDNs are performed on the left side. Recently, some researchers have reported that donor outcomes and graft function are similar in right and left RDN cases [10–12]. However, these reports include only a small number of right RDN cases, and no studies have examined a comparable number of right and left RDN cases. In this retrospective study, we examined a comparable number of right and left RDN cases and evaluated donor and recipient outcomes.
13
Int Urol Nephrol
Methods
Operative procedures
Donors
RDN was performed using the hybrid technique as we previously reported [14]. The patient was placed in the lateral decubitus position. A 12-mm laparoscopic port was inserted into the retroperitoneal space after balloon dilation using an air pump. An 8-cm transverse subcostal incision for the right RDN or an 8-cm vertical pararectal skin incision for the left RDN was made. Controlling and taping of the ureter were performed through the open incision. The GelPort (Applied Medical, CA, USA) was attached to the incision. The retroperitoneal space was maintained by insufflation of CO2 (pressure 8–10 mmHg). Two 12-mm ports were inserted through the GelPort. One minute after the intravenous administration of unfractionated heparin (70 U/kg), the renal arteries and veins were stapled with an Endo-TA stapler (COVIDIEN, Mansfield, MA, USA) and transected. Shortly thereafter, the GelPort was removed, and the kidney was extracted through the GelPort site.
We retrospectively reviewed 151 consecutive patients who underwent RDN at our hospital between May 2005 and July 2013 including 87 right RDN and 64 left RDN cases. The local institutional internal review board approved this study. All patients underwent preoperative examinations which included three-dimensional computed tomography and Tc-99m dimercaptosuccinic acid renal scanning. The three-dimensional computed tomography was performed to evaluate the renal vasculature. The dimercaptosuccinic acid renal scanning was performed to measure the difference in function between the right and left kidneys. The kidney graft selection in our hospital was based on the principle that the better kidney should remain for the donor. In the cases of equivalent estimated functions, the graft selection was dependent on the number of renal vessels. The two groups were compared regarding intraoperative and postoperative parameters including the time required for graft extraction, overall operative time, warm ischemia time, total ischemia time, donor blood loss, donor postoperative creatinine levels, and donor length of postoperative hospital stay. The time required for graft extraction was defined as the time from skin incision to graft extraction. Warm ischemia time was defined as the time from closure of the renal artery to flushing of the kidney with cold solution. Total ischemia time was defined as the time from closure of the renal artery to reperfusion of the kidney with systemic blood flow, and the bench preparation and the vascular anastomosis were performed during that time. Recipients Recipients received immunosuppressive treatment consisting of prednisolone, calcineurin inhibitor, mycophenolate mofetil or mizoribine (Asahi Kasei Pharma, Tokyo, Japan), and anti-IL-2 receptor antibodies. This immunosuppressive regimen has been reported previously [13]. Additionally, ABO-incompatible recipients received anti-CD20 monoclonal antibody (rituximab) and three or four sessions of double-filtration plasmapheresis before transplantation as we previously reported [14]. The right and left RDN groups were compared regarding recipient outcomes including recipient overall operative time, blood loss, serum creatinine levels, slow graft function (serum creatinine level more than 3.0 mg/dL at 4 days after transplantation), delayed graft function (recipients required hemodialysis after transplantation because of acute tubular necrosis), acute rejection rate, and graft survival rate.
13
Statistical analyses All the calculations were performed with the JMP Pro 11 software package (SAS Institute Inc., Cary, NC, USA). Data are expressed as mean ± SD or median (range) where appropriate. The statistical significance of normally distributed, skewed, and dichotomous data was determined using Student’s t test, Wilcoxon signed-rank test, and Fisher’s exact test, respectively. Overall graft survival after transplantation was calculated using Kaplan–Meier curves, and univariate analysis was performed using the log-rank test. A P value
UROLOGY - ORIGINAL PAPER
Right versus left retroperitoneoscopic living‑donor nephrectomy Toshiaki Kashiwadate1,2 · Kazuaki Tokodai1,2 · Noritoshi Amada1 · Izumi Haga1 · Tetsuro Takayama1 · Atsushi Nakamura1 · Takuya Jimbo1 · Yasuyuki Hara2 · Naoki kawagishi2 · Noriaki Ohuchi2
Received: 2 April 2015 / Accepted: 13 May 2015 © Springer Science+Business Media Dordrecht 2015
Abstract Purpose To compare the safety and efficacy of rightside and left-side retroperitoneoscopic donor nephrectomy (RDN) using our hybrid technique. Methods We retrospectively reviewed the data obtained from 151 consecutive patients who underwent RDN between May 2005 and July 2013. Right and left nephrectomies were performed in 87 and 64 patients, respectively. We compared these two groups with respect to donors’ intraoperative parameters, postoperative outcomes, and recipients’ outcomes. Results There were no significant differences between the two groups regarding donor blood loss, warm ischemia time, donor postoperative creatinine levels, donor postoperative length of hospital stay, recipient creatinine levels at 1 year after transplantation, and 1-year graft survival rate after transplantation. The time required for graft extraction and overall operative time were significantly shorter in the right RDN group than in the left RDN group (152 vs. 168 min, P = 0.016; 175 vs. 195 min, P = 0.0059). Only one case in the right nephrectomy group required open conversion because of uncontrollable bleeding from the inferior vena cava.
This work was carried out at Department of Surgery of Japan Community Health Care Organization Sendai Hospital. * Kazuaki Tokodai [email protected] 1
Department of Surgery, Japan Community Health Care Organization Sendai Hospital, Sendai, Japan
2
Department of Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, 1‑1 Seiryo‑machi, Aoba‑ku, Sendai 980‑8574, Japan
Conclusion Although larger sample sizes would be required to evaluate postoperative complication rate, these results indicate that both the right and left RDN could be performed with similar donor and recipient outcomes. Keywords Donor selection · Graft survival · Kidney transplantation · Laparoscopic surgery · Living donors
Introduction Laparoscopic donor nephrectomy, initially reported by Ratner et al. [1], is an established technique worldwide [2–6]. However, right-sided laparoscopic donor nephrectomy has been associated with short renal vein and venous thrombosis [7]. Therefore, many surgeons tend to select only the left kidney even if multiple renal arteries are present on the left side [8]. Kohei et al. [9] reported that retroperitoneoscopic donor nephrectomy (RDN) is a safe technique and could be a surgical option for livingdonor kidney removal. RDN involves a direct and quick approach to retroperitoneal organs, without interference to the abdominal organs such as the liver [9, 10]. Left RDN is performed preferentially over right RDN, because the long renal vein facilitates implantation [9]. For this reason, most RDNs are performed on the left side. Recently, some researchers have reported that donor outcomes and graft function are similar in right and left RDN cases [10–12]. However, these reports include only a small number of right RDN cases, and no studies have examined a comparable number of right and left RDN cases. In this retrospective study, we examined a comparable number of right and left RDN cases and evaluated donor and recipient outcomes.
13
Int Urol Nephrol
Methods
Operative procedures
Donors
RDN was performed using the hybrid technique as we previously reported [14]. The patient was placed in the lateral decubitus position. A 12-mm laparoscopic port was inserted into the retroperitoneal space after balloon dilation using an air pump. An 8-cm transverse subcostal incision for the right RDN or an 8-cm vertical pararectal skin incision for the left RDN was made. Controlling and taping of the ureter were performed through the open incision. The GelPort (Applied Medical, CA, USA) was attached to the incision. The retroperitoneal space was maintained by insufflation of CO2 (pressure 8–10 mmHg). Two 12-mm ports were inserted through the GelPort. One minute after the intravenous administration of unfractionated heparin (70 U/kg), the renal arteries and veins were stapled with an Endo-TA stapler (COVIDIEN, Mansfield, MA, USA) and transected. Shortly thereafter, the GelPort was removed, and the kidney was extracted through the GelPort site.
We retrospectively reviewed 151 consecutive patients who underwent RDN at our hospital between May 2005 and July 2013 including 87 right RDN and 64 left RDN cases. The local institutional internal review board approved this study. All patients underwent preoperative examinations which included three-dimensional computed tomography and Tc-99m dimercaptosuccinic acid renal scanning. The three-dimensional computed tomography was performed to evaluate the renal vasculature. The dimercaptosuccinic acid renal scanning was performed to measure the difference in function between the right and left kidneys. The kidney graft selection in our hospital was based on the principle that the better kidney should remain for the donor. In the cases of equivalent estimated functions, the graft selection was dependent on the number of renal vessels. The two groups were compared regarding intraoperative and postoperative parameters including the time required for graft extraction, overall operative time, warm ischemia time, total ischemia time, donor blood loss, donor postoperative creatinine levels, and donor length of postoperative hospital stay. The time required for graft extraction was defined as the time from skin incision to graft extraction. Warm ischemia time was defined as the time from closure of the renal artery to flushing of the kidney with cold solution. Total ischemia time was defined as the time from closure of the renal artery to reperfusion of the kidney with systemic blood flow, and the bench preparation and the vascular anastomosis were performed during that time. Recipients Recipients received immunosuppressive treatment consisting of prednisolone, calcineurin inhibitor, mycophenolate mofetil or mizoribine (Asahi Kasei Pharma, Tokyo, Japan), and anti-IL-2 receptor antibodies. This immunosuppressive regimen has been reported previously [13]. Additionally, ABO-incompatible recipients received anti-CD20 monoclonal antibody (rituximab) and three or four sessions of double-filtration plasmapheresis before transplantation as we previously reported [14]. The right and left RDN groups were compared regarding recipient outcomes including recipient overall operative time, blood loss, serum creatinine levels, slow graft function (serum creatinine level more than 3.0 mg/dL at 4 days after transplantation), delayed graft function (recipients required hemodialysis after transplantation because of acute tubular necrosis), acute rejection rate, and graft survival rate.
13
Statistical analyses All the calculations were performed with the JMP Pro 11 software package (SAS Institute Inc., Cary, NC, USA). Data are expressed as mean ± SD or median (range) where appropriate. The statistical significance of normally distributed, skewed, and dichotomous data was determined using Student’s t test, Wilcoxon signed-rank test, and Fisher’s exact test, respectively. Overall graft survival after transplantation was calculated using Kaplan–Meier curves, and univariate analysis was performed using the log-rank test. A P value
