Outcomes and Cost Comparison of 3 Different Laparoscopic Approach for Living Donor Nephrectomy: A Retrospective, Single-Center, Inverse Probability of Treatment Weighting Analysis of 551 Cases.

BACKGROUND: At our institution, we switched from hand-assisted retroperitoneal laparoscopic donor nephrectomy (HRN) to hand-assisted transperitoneal laparoscopic donor nephrectomy (HTN); we later switched to standard retroperitoneal laparoscopic donor nephrectomy (SRN). This study was performed to evaluate outcomes and hospital costs among the 3 techniques. METHODS: This retrospective, observational, single-center, inverse probability of treatment weighting analysis study compared the outcomes among 551 cases of living donor kidney transplantation between 2014 and 2022. RESULTS: After the inverse probability of treatment weighting analysis, there were 114 cases in the HRN group, 204 cases in the HTN group, and 213 cases in the SRN group. Donor complication rates were lowest in the SRN group but did not differ between the HRN and HTN groups (1.1 vs 4.4 and 5.9%, P = .021). Donors in the SRN group had the lowest serum C-reactive protein concentrations on postoperative day 1 (4.3 vs 10.5 and 7.8 mg/dL, P < .001) and the shortest postoperative stay (4.3 vs 7.4 and 8.4 days, P < .001). Donors in the SRN group had the lowest total cost among the 3 groups (8868 vs 9709 and 10,592 USD, P < .0001). Donors in the SRN group also had the lowest costs in terms of "basic medical fees," "medication and injection fees," "Intraoperative drug and material costs," and "testing fees." Furthermore, the presence of complications was significantly correlated with higher total hospital costs (P < .001). CONCLUSION: SRN appeared to have the least invasive and complication, and a potential cost savings compared with the HRN and HTN.

Robotic liver resection: Hurdles and beyond.

Laparoscopy is currently considered the standard of care for certain procedures such as left-lateral sectionectomies and wedge resections of anterior segments. The role of robotic liver surgery is still under debate, especially with regards to oncological outcomes. The purpose of this review is to describe how the field of robotic liver surgery has expanded, and to identify current limitations and future perspectives of the technology. Available evidences suggest that oncologic results after robotic liver resection are comparable to open and laparoscopic approaches for hepatocellular carcinoma and colorectal liver metastases, with identifiable advantages for cirrhotic patients and patients undergoing repeat resections. Excellent outcomes and optimal patient safety can be only achieved with specific hepato-biliary and general minimally invasive training to overcome the learning curve.

Endoscopic Radial Artery Harvesting During Anesthesia Line Placement Reduces the Time and Cost of Multivessel Coronary Artery Bypass Grafting.

OBJECTIVE: Endoscopic radial artery (RA) harvesting performed concurrently with internal mammary artery (IMA) takedown and endoscopic saphenous vein (SV) harvesting creates a crowded and inefficient operating room environment. We assessed the effect of a presternotomy RA harvest strategy on surgery time and costs. METHODS: A total of 41 patients underwent elective, first-time, isolated multivessel on-pump coronary artery bypass grafting including an IMA, RA, and SV graft. The first 20 patients (Phase I) underwent endoscopic RA harvesting concurrently with IMA takedown and endoscopic SV harvesting after sternotomy, requiring two sets of endoscopic harvesting equipment per case, each used by a separate individual. The final 21 patients (Phase II) underwent endoscopic RA harvesting during anesthesia line placement, completing the procedure before sternotomy, thus requiring only one set of endoscopic harvesting equipment reused by a single individual. RESULTS: There were no differences in baseline patient characteristics, number of bypasses, duration of SV or RA harvest time, or duration of cardiopulmonary bypass or cross-clamp time between the two groups. Total surgery time was reduced by 32 minutes in Phase II (P = 0.044). Relative to a total hospital direct cost of 100.00 units, total surgery costs were reduced from 29.33 units in Phase I to 25.62 units in Phase II (P = 0.001). No anesthesia- or RA harvest-related complications occurred in either group. CONCLUSIONS: Endoscopic RA harvesting can be safely performed during anesthesia line placement prior to sternotomy. Our simple but innovative strategy improves intraoperative workflow, reduces the time and cost of surgery, and advances the delivery of high-quality patient care.

Cost-effectiveness of four living-donor nephrectomy techniques from a hospital perspective.

BACKGROUND: In Europe, transplantation centres use different nephrectomy techniques: open surgery, and standard, hand-assisted and robot-assisted laparoscopies. Few studies have analysed the disparity in costs and clinical outcomes between techniques. Since donors are healthy patients expecting minimum pain and fast recovery, this study aimed to compare the cost-effectiveness of four nephrectomy techniques focusing on early surgical outcomes, an essential in the donation act. METHODS: A micro-costing approach was used to estimate the cost of implementation from a hospital perspective. Estimates took into account sterilization costs for multiple-use equipment, costs for purchasing single-use equipment, staff and analgesics. The study recruited donors in 20 centres in France. Quality of life by EuroQol-5D was assessed preoperatively, and 4 and 90 days post-operatively. Two effectiveness indicators were built: quality-of-life recovery and post-operative pain days averted (PPDA). The study was registered at ClinicalTrials.gov NCT02830568, on 10 June 2010. RESULTS: A total of 264 donors were included; they underwent open surgery (n = 65), and standard (n = 65), hand-assisted (n = 65) and robot-assisted laparoscopies (n = 69). Use of the nephrectomy techniques differed greatly in cost of implementation and immediate post-operative outcomes but not in clinical outcomes at 90 days. At 4 days, hand-assisted laparoscopy provided the lowest cost per quality-of-life recovery unit of effectiveness (%) and PPDA (days) (€2056/40.1%/2.3 days, respectively). Robot-assisted laparoscopy was associated with the best post-operative outcomes but with the highest cost (€3430/59.1%/2.6 days). CONCLUSION: Hand-assisted, standard and robot-assisted laparoscopies are cost-effective techniques compared with open surgery. Hand-assisted surgery is the most cost-effective procedure. Robot-assisted surgery requires more healthcare resource use but enables the best clinical outcome.

Incorporating ex-vivo lung perfusion into the UK adult lung transplant service: an economic evaluation and decision analytic model.

BACKGROUND: An estimated 20-30% of end-stage lung disease patients awaiting lung transplant die whilst on the waiting list due to a shortage of suitable donor lungs. Ex-Vivo Lung Perfusion is a technique that reconditions donor lungs initially not deemed usable in order to make them suitable for transplantation, thereby increasing the donor pool. In this study, an economic evaluation was conducted as part of DEVELOP-UK, a multi-centre study assessing the clinical and cost-effectiveness of the Ex-Vivo Lung Perfusion technique in the United Kingdom. METHODS: We estimated the cost-effectiveness of a UK adult lung transplant service combining both standard and Ex-Vivo Lung Perfusion transplants compared to a service including only standard lung transplants. A Markov model was developed and populated with a combination of DEVELOP-UK, published and clinical routine data, and extrapolated to a lifetime horizon. Probabilistic sensitivity and scenario analyses were used to explore uncertainty in the final outcomes. RESULTS: Base-case model results estimated life years gained of 0.040, quality-adjusted life-years (QALYs) gained of 0.045 and an incremental cost per QALY of £90,000 for Ex-Vivo Lung Perfusion. Scenario analyses carried out suggest that an improved rate of converting unusable donor lungs using Ex-Vivo Lung Perfusion, similar resource use post-transplant for both standard and EVLP lung transplant and applying increased waiting list costs would reduce ICERs to approximately £30,000 or below. CONCLUSION: DEVELOP-UK base-case results suggest that incorporating Ex-Vivo Lung Perfusion into the UK adult lung transplant service is more effective, increasing the number of donor lungs available for transplant, but would not currently be considered cost-effective in the UK using the present NICE threshold. However, results were sensitive to change in some model parameters and in several plausible scenario analyses results indicate that a service incorporating Ex-vivo lung perfusion would be considered cost-effective . TRIAL REGISTRATION: ISRCTN registry number: ISRCTN44922411 . Date of registration: 06/02/2012. Retrospectively registered.

Socioeconomic Status in Non-directed and Voucher-based Living Kidney Donation.

BACKGROUND: Little has been reported about the socioeconomic status (SES) and demographics of non-directed (altruistic) and voucher-based donation. OBJECTIVE: To analyze common characteristics amongst altruistic donors in order to promote non-directed and voucher-based donation. DESIGN, SETTING, AND PARTICIPANTS: Information regarding altruistic donations from 2008 to 2015 and voucher-based donors was obtained from the National Kidney Registry. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: An SES index, created and validated by the Agency for Healthcare Research and Quality (AHRQ), was created by geocoding the donor's zip code and linking it to seven publicly available SES variables found in the 2010 United States Census data. RESULTS AND LIMITATIONS: In total, 267 non-directed and 3 voucher-based donations were identified. Non-directed donors were predominantly female (58%), with an average age of 45.6 yr (range, 21-72). The mean SES index score was 55.6 (SD=3.2), which corresponds to the 77th percentile of 1.5 million MediCare beneficiaries as reported by the AHRQ in 2008. Voucher-based donors were Caucasian males of high SES. The study was limited by the number of voucher-based donations. CONCLUSIONS: Non-directed and voucher-based donors are in the upper end of the economic spectrum. The voucher-based program has built within it the inherent capacity to remove disincentives to donation, which currently limit altruistic donation. PATIENT SUMMARY: We wanted to determine what types of people donated their kidneys altruistically, so that we could understand how to motivate more people to donate their kidneys. The voucher-based program was recently started and is a promising tool to motivate many people to donate kidneys by removing major disincentives to donation.

Organ recovery cost assessment in the French healthcare system from 2007 to 2014.

Background: Organ recovery costs should be assessed to allow efficient and sustainable integration of these costs into national healthcare budgets and policies. These costs are of considerable interest to health economists, hospitals, financial managers and policy makers in most developed countries. This study assessed organ recovery costs from 2007 to 2014 in the French healthcare system based on the national hospital discharge database and a national cost study. The secondary objective was to describe the variability in the population of deceased organ donors during this period. Methods: All stays for organ recovery in French hospitals between January 2007 and December 2014 were quantified from discharge abstracts and valued using a national cost study. Five cost evaluations were conducted to explore all aspects of organ recovery activities. A sensitivity analysis was conducted to test the methodological choice. Trends regarding organ recovery practices were assessed by monitoring indicators. Results: The analysis included 12 629 brain death donors, with 28 482 organs recovered. The mean cost of a hospital stay was €7469 (SD = €10, 894). The mean costs of separate kidney, liver, pancreas, intestine, heart, lung and heart-lung block recovery regardless of the organs recovered were €1432 (SD = €1342), €502 (SD = €782), €354 (SD = €475), €362 (SD = €1559), €542 (SD = €955), €977 (SD = €1196) and €737 (SD = €637), respectively. Despite a marginal increase in donors, the number of organs recovered increased primarily due to improved practices. Conclusion: Although cost management is the main challenge for successful organ recovery, other aspects such as organization modalities should be considered to improve organ availability.

Cold ischemia time is an important risk factor for post-liver transplant prolonged length of stay.

Risk analysis of cold ischemia time (CIT) in liver transplantation has largely focused on patient and graft survival. Posttransplant length of stay is a sensitive marker of morbidity and cost. We hypothesize that CIT is a risk factor for posttransplant prolonged length of stay (PLOS) and aim to conduct an hour-by-hour analysis of CIT and PLOS. We retrospectively reviewed all adult, first-time liver transplants between March 2002 and September 2016 in the United Network for Organ Sharing database. The 67,426 recipients were categorized by hourly CIT increments. Multivariate logistic regression of PLOS (defined as >30 days), CIT groups, and an extensive list of confounding variables was performed. Linear regression between length of stay and CIT as continuous variables was also performed. CIT 1-6 hours was protective against PLOS, whereas CIT >7 hours was associated with increased odds for PLOS. The lowest odds for PLOS were observed with 1-2 hours (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.45-0.92) and 2-3 hours (OR, 0.65; 95% CI, 0.55-0.78) of CIT. OR for PLOS steadily increased with increasing CIT, reaching the greatest odds for PLOS with 13-14 hours (OR, 2.05; 95% CI, 1.57-2.67) and 15-16 hours (OR, 2.06; 95% CI, 1.27-3.33) of CIT. Linear regression revealed a positive correlation between length of stay and CIT with a correlation coefficient of +0.35 (P < 0.001). In conclusion, post-liver transplant length of stay is sensitive to CIT, with a substantial increase in the odds of PLOS observed with nearly every additional hour of cold ischemia. We conclude that CIT should be minimized to protect against the morbidity and cost associated with posttransplant PLOS. Liver Transplantation 24 762-768 2018 AASLD.

Factors associated with perceived donation-related financial burden among living kidney donors.

The perception of living kidney donation-related financial burden affects willingness to donate and the experience of donation, yet no existing tools identify donors who are at higher risk of perceived financial burden. We sought to identify characteristics that predicted higher risk of perceived financial burden. We surveyed 51 living kidney donors (LKDs) who donated from 01/2015 to 3/2016 about socioeconomic characteristics, predonation cost concerns, and perceived financial burden. We tested associations between both self-reported and ZIP code-level characteristics and perceived burden using Fisher's exact test and bivariate modified Poisson regression. Donors who perceived donation-related financial burden were less likely to have an income above their ZIP code median (14% vs. 72%, P = .006); however, they were more likely than donors who did not perceive burden to rent their home (57% vs. 16%, P = .03), have an income <$60 000 (86% vs. 20%, P = .002), or have had predonation cost concerns (43% vs. 7%, P = .03). Perceived financial burden was 3.6-fold as likely among those with predonation cost concerns and 10.6-fold as likely for those with incomes <$60 000. Collecting socioeconomic characteristics and asking about donation-related cost concerns prior to donation might allow transplant centers to target financial support interventions toward potential donors at higher risk of perceiving donation-related financial burden.

Choice, pressure and markets in kidneys.

We do not always benefit from the expansion of our choice sets. This is because some options change the context in which we must make decisions in ways that render us worse off than we would have been otherwise. One promising argument against paid living kidney donation holds that having the option of selling a 'spare' kidney would impact people facing financial pressures in precisely this way. I defend this argument from two related criticisms: first, that having the option to sell one's kidney would only be harmful if one is pressured or coerced to take this specific course of action; and second, that such forms of pressure are unlikely to feature in a legal market.

Extended applications of the reamer-irrigator-aspirator (RIA) system.

While the RIA system was initially designed for reaming and clearing the femoral canal contents in preparation for femoral nailing, it has since been used in various other applications in the field of orthopaedic surgery. The RIA is an ideal device for accessing large quantities of autogenous bone graft, to be used in the treatment of nonunions, segmental bone loss, or arthrodesis. The RIA has also been used for treatment of intramedullary infections and osteomyelitis, as well as intramedullary nailing of long bones with metastatic lesions, as it allows for clearing the canal of infectious/tumour burden, and lowers the risk of dissemination into the soft tissues and systemic circulation. There is also some limited evidence that the RIA may be used for clearing the femoral/tibial canal of cement debris. Despite multiple applications, the use of RIA has a risk of eccentric reaming and iatrogenic fractures. RIA is also a costly procedure, and its routine use may not be advantageous in the setting of limited health care resources.

Opting out: a single-centre pilot study assessing the reasons for and the psychosocial impact of withdrawing from living kidney donor evaluation.

Understanding why individuals opt out of living donation is crucial to enhancing protections for all living donors and to identify modifiable barriers to donation. We developed an ethical approach to conducting research on individuals who opted out of living kidney donation and applied it in a small-scale qualitative study at one US transplant centre. The seven study participants (64% response rate) had varied reasons for opting out, the most prominent of which was concern about the financial burden from lost wages during the postoperative period. Several reported feeling alone during their decision-making process. Although no participants used an alibi, a centre-provided statement of non-eligibility to donate, all believed that centres should offer alibis to help preserve donor autonomy. Given the complexity of participants' decisions and the emotions they experienced before and after deciding not to donate, we suggest approaches for independent living donor advocates to support this population. This study demonstrates that research on individuals who opt out of donation is feasible and yields valuable insight into methods to improve the evaluation experience for potential living donors.

The CelluTome epidermal graft-harvesting system: a patient-reported outcome measure and cost evaluation study.

Conventional split skin grafts (SSG) require anaesthesia, specialist equipment and can have high donor site (DS) morbidity. The CelluTome epidermal graft-harvesting device is a novel alternative, providing pain-free epidermal skin grafts (ESG) in the outpatient setting, with projected minimal DS trauma and improved patient satisfaction. This study aimed to compare ESG with SSG by evaluating patient-related outcome measures (PROMs) and the cost implications of both. Twenty patients answered a graft satisfaction questionnaire that evaluated: donor/graft site noticeability, aesthetic concerns, adverse problems and patient satisfaction. Cost/patient was calculated based on total operative expenses and five clinic follow-ups. In 100% of the ESG cases, there were no DS noticeability or adverse problems compared to 25% in the SSG group. Complete satisfaction with DS appearance was observed in 100% of the ESG cases (50% SSG). Noticeability, adverse problems and overall satisfaction were significantly better in ESG cases (P < 0.05). Graft site parameters were comparable with similar healing outcomes. The cost per patient for ESG was £431 and £1489 for SSG, with an annual saving of £126 960 based on 10 grafts/month. For the right patient, CelluTome provides comparable wound healing, with reduced DS morbidity and higher patient satisfaction.

A Comparison of Two Fat Grafting Methods on Operating Room Efficiency and Costs.

BACKGROUND: Centrifugation (Cf) is a common method of fat processing but may be time consuming, especially when processing large volumes. OBJECTIVES: To determine the effects on fat grafting time, volume efficiency, reoperations, and complication rates of Cf vs an autologous fat processing system (Rv) that incorporates fat harvesting and processing in a single unit. METHODS: We performed a retrospective cohort study of consecutive patients who underwent autologous fat grafting during reconstructive breast surgery with Rv or Cf. Endpoints measured were volume of fat harvested (lipoaspirate) and volume injected after processing, time to complete processing, reoperations, and complications. A budget impact model was used to estimate cost of Rv vs Cf. RESULTS: Ninety-eight patients underwent fat grafting with Rv, and 96 patients received Cf. Mean volumes of lipoaspirate (506.0 vs 126.1 mL) and fat injected (177.3 vs 79.2 mL) were significantly higher (P < .0001) in the Rv vs Cf group, respectively. Mean time to complete fat grafting was significantly shorter in the Rv vs Cf group (34.6 vs 90.1 minutes, respectively; P < .0001). Proportions of patients with nodule and cyst formation and/or who received reoperations were significantly less in the Rv vs Cf group. Based on these outcomes and an assumed per minute operating room cost, an average per patient cost savings of $2,870.08 was estimated with Rv vs Cf. CONCLUSIONS: Compared to Cf, the Rv fat processing system allowed for a larger volume of fat to be processed for injection and decreased operative time in these patients, potentially translating to cost savings. LEVEL OF EVIDENCE 3.

Donor insemination: Israel as a representative case of a competitive market examining the possibility of policy reform.

AIM: To measure the private and social benefits of donor insemination (DI). METHODS: An empirical model investigates the general public and DI clients' willingness to pay (WTP) for DI, and the willingness of potential donors to become altruistic or paid sperm donors. RESULTS: The general public and DI clients value DI and have a positive WTP for it, whereas willingness to donate, altruistically or for payment, is either low or very low. CONCLUSION: The general public's and DI clients' WTP for DI is in average above actual cost, so the government should consider funding or subsidizing DI. The government should encourage altruistic gamete donation through information and education of all parties involved directly and indirectly in the process of donation whose ultimate goal is the birth of a child.

Providing Coverage for the Unique Lifelong Health Care Needs of Living Kidney Donors Within the Framework of Financial Neutrality.

Organ donation should neither enrich donors nor impose financial burdens on them. We described the scope of health care required for all living kidney donors, reflecting contemporary understanding of long-term donor health outcomes; proposed an approach to identify donor health conditions that should be covered within the framework of financial neutrality; and proposed strategies to pay for this care. Despite the Affordable Care Act in the United States, donors continue to have inadequate coverage for important health conditions that are donation related or that may compromise postdonation kidney function. Amendment of Medicare regulations is needed to clarify that surveillance and treatment of conditions that may compromise postdonation kidney function following donor nephrectomy will be covered without expense to the donor. In other countries lacking health insurance for all residents, sufficient data exist to allow the creation of a compensation fund or donor insurance policies to ensure appropriate care. Providing coverage for donation-related sequelae as well as care to preserve postdonation kidney function ensures protection against the financial burdens of health care encountered by donors throughout their lives. Providing coverage for this care should thus be cost-effective, even without considering the health care cost savings that occur for living donor transplant recipients.

An observational study of Donor Ex Vivo Lung Perfusion in UK lung transplantation: DEVELOP-UK.

BACKGROUND: Many patients awaiting lung transplantation die before a donor organ becomes available. Ex vivo lung perfusion (EVLP) allows initially unusable donor lungs to be assessed and reconditioned for clinical use. OBJECTIVE: The objective of the Donor Ex Vivo Lung Perfusion in UK lung transplantation study was to evaluate the clinical effectiveness and cost-effectiveness of EVLP in increasing UK lung transplant activity. DESIGN: A multicentre, unblinded, non-randomised, non-inferiority observational study to compare transplant outcomes between EVLP-assessed and standard donor lungs. SETTING: Multicentre study involving all five UK officially designated NHS adult lung transplant centres. PARTICIPANTS: Patients aged ≥ 18 years with advanced lung disease accepted onto the lung transplant waiting list. INTERVENTION: The study intervention was EVLP assessment of donor lungs before determining suitability for transplantation. MAIN OUTCOME MEASURES: The primary outcome measure was survival during the first 12 months following lung transplantation. Secondary outcome measures were patient-centred outcomes that are influenced by the effectiveness of lung transplantation and that contribute to the health-care costs. RESULTS: Lungs from 53 donors unsuitable for standard transplant were assessed with EVLP, of which 18 (34%) were subsequently transplanted. A total of 184 participants received standard donor lungs. Owing to the early closure of the study, a non-inferiority analysis was not conducted. The Kaplan-Meier estimate of survival at 12 months was 0.67 [95% confidence interval (CI) 0.40 to 0.83] for the EVLP arm and 0.80 (95% CI 0.74 to 0.85) for the standard arm. The hazard ratio for overall 12-month survival in the EVLP arm relative to the standard arm was 1.96 (95% CI 0.83 to 4.67). Patients in the EVLP arm required ventilation for a longer period and stayed longer in an intensive therapy unit (ITU) than patients in the standard arm, but duration of overall hospital stay was similar in both groups. There was a higher rate of very early grade 3 primary graft dysfunction (PGD) in the EVLP arm, but rates of PGD did not differ between groups after 72 hours. The requirement for extracorporeal membrane oxygenation (ECMO) support was higher in the EVLP arm (7/18, 38.8%) than in the standard arm (6/184, 3.2%). There were no major differences in rates of chest radiograph abnormalities, infection, lung function or rejection by 12 months. The cost of EVLP transplants is approximately £35,000 higher than the cost of standard transplants, as a result of the cost of the EVLP procedure, and the increased ECMO use and ITU stay. Predictors of cost were quality of life on joining the waiting list, type of transplant and number of lungs transplanted. An exploratory model comparing a NHS lung transplant service that includes EVLP and standard lung transplants with one including only standard lung transplants resulted in an incremental cost-effectiveness ratio of £73,000. Interviews showed that patients had a good understanding of the need for, and the processes of, EVLP. If EVLP can increase the number of usable donor lungs and reduce waiting, it is likely to be acceptable to those waiting for lung transplantation. Study limitations include small numbers in the EVLP arm, limiting analysis to descriptive statistics and the EVLP protocol change during the study. CONCLUSIONS: Overall, one-third of donor lungs subjected to EVLP were deemed suitable for transplant. Estimated survival over 12 months was lower than in the standard group, but the data were also consistent with no difference in survival between groups. Patients receiving these additional transplants experience a higher rate of early graft injury and need for unplanned ECMO support, at increased cost. The small number of participants in the EVLP arm because of early study termination limits the robustness of these conclusions. The reason for the increased PGD rates, high ECMO requirement and possible differences in lung injury between EVLP protocols needs evaluation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN44922411. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 85. See the NIHR Journals Library website for further project information.

Comparison of Upper Midline Incision With and Without Laparoscopic Assistance for Living-Donor Right Hepatectomy.

BACKGROUND: Since minimally invasive procedures for living-donor right hepatectomy (LDRH) became popular in recent years, several studies comparing the outcomes of donors undergoing an upper midline incision (UMI) under laparoscopic assistance for LDRH with those undergoing the traditional open LDRH have been published. However, there are very few comparative studies of outcomes for a UMI for LDRH with and without laparoscopic-assistance. We designed the present study to compare the benefits and shortcomings of a UMI for LDRH with and without laparoscopic assistance. METHODS: Forty-eight patients in our center were included in the study: group hybrid (n = 28) versus group UMI (n = 20). Their surgical outcomes, postoperative course, and cosmetic outcomes were studied from medical records. RESULTS: No differences existed between the 2 groups regarding their baseline characteristics except that group Hybrid had more donors with positive hepatitis B core antibody. No difference was observed in operative time, graft weight, warm ischemia time, blood loss, incision length, liver and coagulation function test results, postoperative complications, or cosmetic parameters. No deaths occurred in both groups. The length of postoperative hospital stay was similar for both groups, but the hospital cost was significantly lower for group UMI than for group hybrid (6,906.7 ± 777.4 USD vs 7,643.3 ± 918.6 USD; P = .005). CONCLUSIONS: An UMI without laparoscopic assistance can be considered as the first-line incision of choice for LDRH.

[Analysis of contractual incentives for kidney transplants in Brazil using the principal-agent model]. / Análise dos incentivos contratuais de transplantes de rins no Brasil pelo modelo agente-principal.

The aim of this article was to analyze contractual incentives for kidney transplants in Brazil based on the principal-agent model. The approach assumes that the Brazilian Ministry of Health is the principal and the public hospitals accredited by the National Transplant System are the agent. The Ministry of Health's welfare depends on measures taken by hospitals in kidney uptake. Hospitals allocate administrative, financial, and management efforts to conduct measures in kidney donation, removal, uptake, and transplantation. Hospitals may choose the levels of effort that are consistent with the payments and incentives received in relation to transplantation costs. The solution to this type of problem lies in structuring an optimal incentives contract, which requires aligning the interests of both parties involved in the transplantation system.