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Introducing hand-assisted retroperitoneoscopic live donor nephrectomy: Learning curves and development based on 413 consecutive cases in four centers
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Transplantation Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Transplantation Surgery.
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2011 (English)In: Transplantation, ISSN 0041-1337, E-ISSN 1534-6080, Vol. 91, no 4, 462-469 p.Article in journal (Refereed) Published
Abstract [en]

Background: Hand-assisted and retroperitoneoscopic techniques reduce the risk of bleeding and intra-abdominal complications in live donor nephrectomy (LDN). This study reports on our four-centre experience, development and learning curves from the first 413 LDN using a hand-assisted retroperitoneoscopic technique (HARS).

Methods: The first 413 consecutive donors operated on using HARS were included in the study. Donor demographics, peri- and postoperative data, complications, and recipient outcomes have been compiled. The data was analysed as a whole and separately for each centre, looking at centre differences and learning curves over time.

Results: Significant differences were found in donor demographics between centres for the variables: age, BMI, number of arteries, and side of operation. Mean operating time was 170.2 minutes, with significant differences between centres. Operating time was also significantly influenced by learning curves, Sex/BMI, and side of operation. Warm ischemia time differed significantly between centres and was influenced by centre-wise learning and number of arteries. Overall conversion rate was 2.4% and differed significantly between centres. There was no mortality and no intra-abdominal complications. Apart from the conversions and one pulmonary embolism, there were no major intra- or postoperative complications. Overall 3-month graft survival was 99%, with 96% immediate onset of function and 1% ureteral complications.

Conclusions: The HARS technique reduces the risk of intra-abdominal complications. It can be implemented with excellent donor and recipient outcomes despite different population demographics and centre/surgeon-related tradition and experience. Based on our experience, we recommend the technique in order to increase the safety margin of LDN.

Place, publisher, year, edition, pages
2011. Vol. 91, no 4, 462-469 p.
Keyword [en]
Hand assistance, Hand-assisted retroperitoneoscopic nephrectomy, Learning curve, Live donor nephrectomy, Living donors, Morbidity, Multicenter, Review, Safety
National Category
Surgery
Research subject
Medicine
Identifiers
URN: urn:nbn:se:uu:diva-134509DOI: 10.1097/TP.0b013e3182052bafISI: 000287127600017PubMedID: 21169880OAI: oai:DiVA.org:uu-134509DiVA: diva2:372755
Available from: 2010-11-27 Created: 2010-11-27 Last updated: 2017-12-12Bibliographically approved
In thesis
1. Minimizing Risks and Morbidity in Live Kidney Donors
Open this publication in new window or tab >>Minimizing Risks and Morbidity in Live Kidney Donors
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Live kidney donors are healthy volunteers who are exposed to major surgical procedure and physical harms with no direct therapeutic benefits. Efforts to minimize their risks and morbidity are therefore of utmost importance. The current thesis describes studies on donor evaluation, surgical procedure and postoperative management of live kidney donors. The overall purpose is to evaluate and possibly improve routines and treatments in order to reduce risks and the overall morbidity of live kidney donors.

In Study I, we evaluated the assessment of kidney function during donor evaluation and found that the accuracy of iohexol glomerular filtration rate (GFR) is compromised by large variations in repeated measurements in presumably healthy donors. We proposed that there is a need for improvement of GFR measurements and that the assessment of predonation kidney function should be more comprehensive, involving GFR, laboratory investigations, functional and morphological examinations and sound clinical judgment. In Study II, we addressed the risk of perioperative venous thromboembolism (VTE) and concluded that expanding the standard screening protocol for VTE to include perioperative venous duplex can potentially decrease the VTE-related morbidity. In studies III and IV, we investigated the impact of hand-assisted retroperitoneoscopic (HARS) nephrectomy on donor safety and perioperative morbidity. The HARS nephrectomy uses the hand-assisted approach, which enables immediate manual compression for hemostasis in case of sudden and severe bleeding. Additionally, the pure retroperitoneal access further increases the safety margin of laparoscopic donor nephrectomy by 1) minimizing the risk of intestinal injury, and 2) exposure of the retroperitoneal nerves, making HARS suitable for continuous infusion of local anesthetics (CILA). CILA effectively reduces the need for opioid consumption and has the potential to totally obviate opiate analgesics postoperatively. Consequently, CILA in combination with HARS reduces morphine-related morbidity and promotes postoperative recovery.

In accordance with these data, we recommend improvement and modification of the donor evaluation process as well as a broad introduction of HARS nephrectomy in combination with CILA to increase the safety margin for live kidney donors.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2010. 63 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 632
Keyword
live donors, morbidity, GFR, donor nephrectomy, postoperative pain treatment, venous thromboembolism, HARS
National Category
Surgery
Research subject
Medicine
Identifiers
urn:nbn:se:uu:diva-134511 (URN)978-91-554-7972-5 (ISBN)
Public defence
2011-01-26, Robergsalen, ingång 40, Akademiska Sjukhuset, 75185 Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2011-01-05 Created: 2010-11-27 Last updated: 2011-03-07Bibliographically approved

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