Robotic versus laparoscopic versus open nephrectomy for live kidney donors.

BACKGROUND: Waiting lists for kidney transplantation continue to grow. Live kidney donation significantly reduces waiting times and improves long-term outcomes for recipients. Major disincentives to potential kidney donors are the pain and morbidity associated with surgery. This is an update of a review published in 2011. OBJECTIVES: To assess the benefits and harms of open donor nephrectomy (ODN), laparoscopic donor nephrectomy (LDN), hand-assisted LDN (HALDN) and robotic donor nephrectomy (RDN) as appropriate surgical techniques for live kidney donors. SEARCH METHODS: We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing LDN with ODN, HALDN, or RDN were included. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: Thirteen studies randomising 1280 live kidney donors to ODN, LDN, HALDN, or RDN were included. All studies were assessed as having a low or unclear risk of bias for selection bias. Five studies had a high risk of bias for blinding. Seven studies randomised 815 live kidney donors to LDN or ODN. LDN was associated with reduced analgesia use (high certainty evidence) and shorter hospital stay, a longer procedure and longer warm ischaemia time (moderate certainty evidence). There were no overall differences in blood loss, perioperative complications, or need for operations (low or very low certainty evidence). Three studies randomised 270 live kidney donors to LDN or HALDN. There were no differences between HALDN and LDN for analgesia requirement, hospital stay (high certainty evidence), duration of procedure (moderate certainty evidence), blood loss, perioperative complications, or reoperations (low certainty evidence). The evidence for warm ischaemia time was very uncertain due to high heterogeneity. One study randomised 50 live kidney donors to retroperitoneal ODN or HALDN and reported less pain and analgesia requirements with ODN. It found decreased blood loss and duration of the procedure with HALDN. No differences were found in perioperative complications, reoperations, hospital stay, or primary warm ischaemia time. One study randomised 45 live kidney donors to LDN or RDN and reported a longer warm ischaemia time with RDN but no differences in analgesia requirement, duration of procedure, blood loss, perioperative complications, reoperations, or hospital stay. One study randomised 100 live kidney donors to two variations of LDN and reported no differences in hospital stay, duration of procedure, conversion rates, primary warm ischaemia times, or complications (not meta-analysed). The conversion rates to ODN were 6/587 (1.02%) in LDN, 1/160 (0.63%) in HALDN, and 0/15 in RDN. Graft outcomes were rarely or selectively reported across the studies. There were no differences between LDN and ODN for early graft loss, delayed graft function, acute rejection, ureteric complications, kidney function or one-year graft loss. In a meta-regression analysis between LDN and ODN, moderate certainty evidence on procedure duration changed significantly in favour of LDN over time (yearly reduction = 7.12 min, 95% CI 2.56 to 11.67; P = 0.0022). Differences in very low certainty evidence on perioperative complications also changed significantly in favour of LDN over time (yearly change in LnRR = 0.107, 95% CI 0.022 to 0.192; P = 0.014). Various different combinations of techniques were used in each study, resulting in heterogeneity among the results. AUTHORS' CONCLUSIONS: LDN is associated with less pain compared to ODN and has comparable pain to HALDN and RDN. HALDN is comparable to LDN in all outcomes except warm ischaemia time, which may be associated with a reduction. One study reported kidneys obtained during RDN had greater warm ischaemia times. Complications and occurrences of perioperative events needing further intervention were equivalent between all methods.

Routine intraoperative ureteric stenting for kidney transplant recipients.

BACKGROUND: Major urological complications (MUCs) after kidney transplantation contribute to patient morbidity and compromise graft function. The majority arise from the vesicoureteric anastomosis and present early after transplantation. Ureteric stents have been successfully used to treat such complications. A number of centres have adopted a policy of universal prophylactic stenting, at the time of graft implantation, to reduce the incidence of urine leaks and ureteric stenosis. Stents are associated with specific complications and some centres advocate a policy of only stenting selected anastomoses. OBJECTIVES: To examine the benefits and harms of routine ureteric stenting to prevent urological complications in kidney transplant recipients. SEARCH METHODS: We searched the Cochrane Renal Group's Specialised Register (up to 8 January 2013) through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA: All RCTs and quasi-RCTs were included in our meta-analysis. DATA COLLECTION AND ANALYSIS: Four reviewers assessed the studies for quality against four criteria (allocation concealment, blinding, intention-to-treat and completeness of follow-up). The primary outcome was the incidence of MUCs. Further outcomes of interest were graft and patient survival and the incidence of adverse events (urinary tract infection (UTI), haematuria, irritative symptoms, pain and stent migration). Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) with 95% confidence intervals (CI). MAIN RESULTS: Seven RCTs (1154 patients) of low or moderate quality were identified. The incidence of MUCs was significantly reduced (RR 0.24, 95% CI 0.07 to 0.77, P = 0.02, NNT 13) by universal prophylactic stenting. This was dependent on whether the same surgeon performed, or was in attendance, during the operations. Two patients lost their grafts to infective urinary tract complications in the stented group. UTIs, in general, were more common in stented patients (RR 1.49, 95% CI 1.04 to 2.15) unless the patients were prescribed cotrimoxazole 480 mg/d: in which case the incidence was equivalent (RR 0.97, 95% CI 0.71 to 1.33). Stents appeared generally well tolerated, although studies using longer stents (≥ 20 cm) for longer periods (> 6 weeks) had more problems with encrustation and migration. AUTHORS' CONCLUSIONS: Routine prophylactic stenting reduces the incidence of MUCs. Studies comparing selective stenting and universal prophylactic stenting, whilst difficult to design and analyse, would address the unresolved quality of life and economic issues.

Laparoscopic versus open nephrectomy for live kidney donors.

BACKGROUND: Waiting lists for kidney transplantation continue to grow and live organ donation has become more important as the number of brain stem dead cadaveric organ donors continues to fall. The major disincentive to potential kidney donors is the pain and morbidity associated with open surgery. OBJECTIVES: To identify the benefits and harms of using laparoscopic compared to open nephrectomy techniques to recover kidneys from live organ donors. SEARCH METHODS: We searched the online databases CENTRAL (in The Cochrane Library 2010, Issue 2), MEDLINE (January 1966 to January 2010) and EMBASE (January 1980 to January 2010) and handsearched textbooks and reference lists. SELECTION CRITERIA: Randomised controlled trials comparing laparoscopic donor nephrectomy (LDN) with open donor nephrectomy (ODN). DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. MAIN RESULTS: Six studies were identified that randomised 596 live kidney donors to either LDN or ODN arms. All studies were assessed as having low or unclear risk of bias for selection bias, allocation bias, incomplete outcome data and selective reporting bias. Four of six studies had high risk of bias for blinding. Various different combinations of techniques were used in each study, resulting in heterogeneity in the results. The conversion rate from LDN to ODN ranged from 1% to 1.8%. LDN was generally found to be associated with reduced analgesia use, shorter hospital stay, and faster return to normal physical functioning. The extracted kidney was exposed to longer warm ischaemia periods (2 to 17 minutes) with no associated short-term consequences. ODN was associated with shorter duration of procedure. For those outcomes that could be meta-analysed there were no significant differences between LDN or ODN for perioperative complications (RR 0.87, 95% CI 0.47 to 4.59), reoperations (RR 0.57, 95% CI 0.09 to 3.64), early graft loss (RR 0.31, 95% CI 0.06 to 1.48), delayed graft function (RR 1.09, 95% CI 0.52 to 2.30), acute rejection (RR 1.41, 95 % CI 0.87 to 2.27), ureteric complications (RR 1.51, 95% CI 0.69 to 3.31), kidney function at one year (SMD 0.15, 95% CI -0.11 to 0.41) or graft loss at one year (RR 0.76, 95% CI 0.15 to 3.85). AUTHORS' CONCLUSIONS: LDN is associated with less pain compared with open surgery; however, there are equivalent numbers of complications and occurrences of perioperative events that require further intervention. Kidneys obtained using LDN procedures were exposed to longer warm ischaemia periods than ODN-acquired grafts, although this has not been reported as being associated with short-term consequences.

The management of bilateral ureteric injury following radical hysterectomy.

Iatrogenic ureteric injury is a well-recognised complication of radical hysterectomy. Bilateral ureteric injuries are rare, but do pose a considerable reconstructive challenge. We searched a prospectively acquired departmental database of ureteric injuries to identify patients with bilateral ureteric injury following radical hysterectomy. Five patients suffered bilateral ureteric injury over a 6-year period. Initial placement of ureteric stents was attempted in all patients. Stents were placed retrogradely into 6 ureters and antegradely into 2 ureters. In 1 patient ureteric stents could not be placed and they underwent primary ureteric reimplantation. In the 4 patients in which stents were placed, 2 were managed with stents alone, 1 required ureteric reimplantation for a persistent ureterovaginal fistula, and 1 developed a recurrent stricture. No patient managed by ureteric stenting suffered deterioration in serum creatinine. We feel that ureteric stenting, when possible, offers a safe primary management of bilateral ureteric injury at radical hysterectomy.

Routine intraoperative stenting for renal transplant recipients.

BACKGROUND: Major urological complications (MUCs) after kidney transplantation contribute to patient morbidity and compromise graft function. Ureteric stents have been successfully used to treat such complications and a number of centers have adopted a policy of universal prophylactic stenting, at the time of graft implantation, to reduce the incidence of urine leaks and ureteric stenosis. METHODS: In conjunction with the Cochrane Renal Group we searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of articles, books and abstracts and contacted companies, authors and experts to identify randomized controlled trials examining the use of stents in renal transplantation. The primary outcome was the incidence of MUCs and data on this statistic was pooled and analyzed using a random effects model. RESULTS: Seven randomized controlled trials (1154 patients) of low or moderate quality were identified. The incidence of MUCs was significantly reduced (relative risk [RR] 0.24; 95% CI: 0.07 - 0.77; P=0.02; number needed to treat = 13) by prophylactic ureteric stenting. Urinary tract infections were more common in stented patients (RR 1.49), unless the patients were prescribed 480 mg cotrimoxazole once daily. With this antibiotic regime the incidence of infection was equivalent between the two groups (RR 0.97). Stents appeared generally well tolerated, although trials using longer stents (> or = 20 cm) for longer periods of time (>6 weeks) reported more problems with encrustation and migration. CONCLUSIONS: Universal prophylactic stenting reduces the incidence of MUCs and should be recommended on the basis of currently available randomized controlled trials.

Prospective study comparing three-dimensional computed tomography and magnetic resonance imaging for evaluating the renal vascular anatomy in potential living renal donors.

OBJECTIVE: To prospectively compare the accuracy of multislice spiral computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) in evaluating the renal vascular anatomy in potential living renal donors. SUBJECTS AND METHODS: Thirty-one donors underwent multislice spiral CTA and gadolinium-enhanced MRA. In addition to axial images, multiplanar reconstruction and maximum intensity projections were used to display the renal vascular anatomy. Twenty-four donors had a left laparoscopic donor nephrectomy (LDN), whereas seven had right open donor nephrectomy (ODN); LDN was only considered if the renal vascular anatomy was favourable on the left. CTA and MRA images were analysed by two radiologists independently. The radiological and surgical findings were correlated after the surgery. RESULTS: CTA showed 33 arteries and 32 veins (100% sensitivity) whereas MRA showed 32 arteries and 31 veins (97% sensitivity). CTA detected all five accessory renal arteries whereas MRA only detected one. CTA also identified all three accessory renal veins whereas MRA identified two. CTA had a sensitivity of 97% and 47% for left lumbar and left gonadal veins, whereas MRA had a sensitivity of 74% and 46%, respectively. CONCLUSION: Multislice spiral CTA with three-dimensional reconstruction was more accurate than MRA for both renal arterial and venous anatomy.

Comparison of laparoscopic and open donor nephrectomy: UK experience.

UNLABELLED: 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.