Surgical Complications Following Renal Transplantation in a Large Institutional Cohort.

Background: Successful renal transplantation (RTx) relies on immunosuppression and an optimal surgical course with few surgical complications. Studies reporting the postoperative complications after RTx are heterogeneous and often lack systematic reporting of complications. This study aims to describe and identify postoperative short-term and long-term complications after RTx in a large institutional cohort and identify risk factors for a complicated surgical course. Methods: The study is a retrospective single-center cohort of 571 recipients who underwent living or deceased donor open RTx between 2014 and 2021. Data were collected on background information and perioperative and postoperative data. Complications were defined as short-term (<30 d) or long-term (>30 d) after transplantation and graded according to the Clavien-Dindo classification. Multivariable logistic regression was performed to evaluate risk factors for serious short-term complications and multivariable time-dependent Cox regression to evaluate risk factors for long-term complications. Results: A total of 351 patients received a graft from a deceased donor, and 144 of these grafts were on perfusion machine before transplantation. One or more short-term complications occurred in 345 (60%) patients. Previous RTx was associated with short-term Clavien-Dindo >2 complications in recipients (odds ratio = 2.08; 95% confidence interval [CI], 1.18-3.69; P = 0.01). Being underweight (body mass index <18.5) in combination with increasing age increased the odds of short-term Clavien-Dindo >2 and vascular complications. Increasing blood loss per 100 mL was associated with increased odds of short-term Clavien-Dindo >2 (odds ratio = 1.11; 95% CI, 1.01-1.21; P = 0.032). No associations were found for long-term complications after RTx. The 5-y cumulative incidence of graft loss was 12.6% (95% CI, 8.9-16.3). Conclusions: Short-term complications are common after RTx, and risk factors for severe short-term complications include previous RTx, increasing age, and low body mass index. No risk factors were identified for severe long-term complications. Further studies should explore whether new surgical techniques can reduce surgical complications in RTx.

Retrospective analysis of the perioperative outcome in living donor kidney transplantation with multiple renal arteries: does accessory vessel ligation affect the outcome?

PURPOSE: Accurate surgical reconstruction of arterial vascular supply is a crucial part of living kidney transplantation (LDKT). The presence of multiple renal arteries (MRA) in grafts can be challenging. In the present study, we investigated the impact of ligation versus anastomosis of small accessory graft arteries on the perioperative outcome. METHODS: Clinical and radiological outcomes of 51 patients with MRA out of a total of 308 patients who underwent LDKT with MRA between 2011 and 2020 were stratified in two groups and analyzed. In group 1 (20 patients), ligation of accessory arteries (ARAs) and group 2 (31 patients) anastomosis of ARAs was performed. RESULTS: Significant differences were observed in the anastomosis-, surgery-, and warm ischemia time (WIT) in favor of group 1. Students t-test showed comparable serum creatinine levels of 2.33 (± 1.75) to 1.68 (± 0.83) mg/dL in group 1 and 2.63 (± 2.47) to 1.50 (± 0.41) mg/dL in group 2, were seen from 1 week to 1 year after transplant. No increased rates of Delayed graft function (DGF), primary transplant dysfunction and transplant rejection were seen, but graft loss and revision rates were slightly higher when the ARAs were ligated. Analysis of Doppler sonography revealed that segmental perfusion deficits tend to regenerate during the clinical course. CONCLUSION: Ligation of smaller accessory renal arteries may not affect the outcome of living kidney transplantation, except for a minor increase in the reoperation rate. Segmental perfusion deficits of the graft seem to regenerate in most cases as seen in Doppler sonography.

Transplant nephrectomy: indication, surgical approach and complications-experiences from a single transplantation center.

PURPOSE: Management of a failed kidney allograft, and the question whether it should be removed is a challenging task for clinicians. The reported risks for transplant nephrectomy (TN) vary, and there is no clear recommendation on indications or surgical approach that should be used. This study gives an overview of indications, compares surgical techniques, and identifies risk factors for higher morbidity. METHODS: Retrospective analysis was conducted on all transplant nephrectomies performed between 2005 and 2020 at Charité Hospital Berlin, Department of Urology. Patient demographics, laboratory parameters, graft survival data, indication for TN, and surgical complications were extracted from medical reports. RESULTS: A total of 195 TN were performed, with graft intolerance syndrome being the most common indication in 52 patients (26.7%), acute rejection in 36 (18.5%), acute infection in 30 (15.4%), and other reasons to stop immunosuppression in 26 patients (13.3%). Rare indications were vascular complications in 16 (8.2%) and malignancies in the allograft in six (3.1%) cases. Extracapsular surgical approach was significantly more often used in cases of vascular complications and earlier allograft removal, but there was no difference in complication rates between extra- and intracapsular approach. Acute infection was identified as an independent risk factor for a complication grade IIIb or higher according to Clavien-Dindo classification, with a HR of 12.3 (CI 2.2-67.7; p = 0.004). CONCLUSION: Transplant nephrectomy should only be performed when there is a good indication, and non-elective surgery should be avoided, when possible, as it increases morbidity.

How experienced robotic nurses adapt to the Hugo™ RAS system.

No studies have reported on the impact at team level of the Medtronic Hugo™ RAS system. We described the work patterns and learning curves of an experienced robotic nurse team adapting to the new robotic system. We prospectively recorded the robotic nurse team's preoperative, perioperative, and postoperative tasks on the first 30 robotic procedures performed. The data were descriptively analyzed, and Gantt Charts were created for a timeline overview of the work patterns. We compared the operative times between the Medtronic Hugo™ RAS and the Davinci® system. The preoperative phase seemed to improve with a median time of 94 min (IQR 81-107). After 20 surgeries, the work pattern became more consistent where the scrub and circulating nurses worked simultaneously. There was no noticeable improvement for the perioperative and postoperative phases with a stable median time of 170 min (IQR 135-189) and 26 min (IQR 22-31). We found that the work pattern seemed to stabilize after 20 surgeries but with a continued decrease in preoperative time without a learning curve plateau. The robotic nurse team suffered from few breaks and long working hours because only a few nurses at our facility were trained in the Hugo™ system.

Skills transfer from the DaVinci® system to the Hugo™ RAS system.

PURPOSE: Recently, the robotic surgical system, Hugo™ was approved for clinical use. The transfer of skills is important for understanding the implementation of surgical innovation. We explored the transfer of skills from the DaVinci® to the Hugo™ by studying the learning curve and short-term patient outcomes during radical prostatectomy (RARP). METHODS: We examined the transfer of skills from one surgeon performing RARP from the first case with the Hugo™ system in April 2022. The surgeon had previously performed > 1000 RARPs using DaVinci®. Perioperative and clinical outcomes were collected for procedures on both Hugo™ and DaVinci®. Patient follow-up time was 3 months. RESULTS: Nineteen Hugo™ cases and 11 DaVinci® cases were recorded. No clinically relevant difference in procedure time was found when transferring to Hugo™. Patients operated using Hugo™ had more contacts postoperatively compared to the DaVinci®, all Clavien-Dindo (CD) grade 1 (53% vs 18%). Three patients from the Hugo™ group were re-admitted within 30 days with catheter malfunction (CD grade 1), infection without a focus (CD grade 2), and ileus due to a hernia in the port hole (CD grade 3b). The 3-month follow-up showed similar results in prostate-specific antigen levels (PSA) and erectile dysfunction between the two robotic systems, but a higher incidence of incontinence was found for the Hugo™. CONCLUSION: We observed that the skills of an experienced robotic surgeon are transferable from DaVinci® to Hugo™ when performing RARP. No obvious benefits were found for using Hugo™ compared to DaVinci® for RARP although this needs confirmatory studies.

Incidence of and Risk Factors for Recurrent Urinary Tract Infections in Renal Transplant Recipients.

Background: Recurrent urinary tract infections (rUTIs) are common after renal transplantation (RTx), and the impact on graft and patient survival remains controversial. Objective: In this study, we investigate the incidence and risk factors for rUTIs in a cohort of RTx recipients and evaluate the effect on graft and patient survival. Design setting and participants: A retrospective cohort of adult patients who underwent RTx at Rigshospitalet, Denmark, between 2014 and 2021 was evaluated in this study. Outcome measurements and statistical analysis: Risk factors for rUTIs were explored with a multivariable cause-specific Cox proportional hazard analysis. The Kaplan-Meier estimate was used to assess overall survival. Results and limitations: A total of 571 RTx recipients were included. The median age was 52 yr (interquartile range: 42-62 yr). Of the cases, 62% were deceased donor RTx. A total of 103 recipients experienced rUTIs. We found increasing age (hazard ratio [HR]: 1.02 per year increase, 95% confidence interval [95% CI]: 1.00-1.04, p = 0.02), female gender (HR: 2.1, 95% CI: 1.4-3.3, p < 0.001), history of lower urinary tract symptoms (HR: 2.3, 95% CI: 1.4-3.5, p = 0.001), and a UTI within 30 d of surgery (HR: 3.5, 95% CI: 2.1-5.9, p < 0.001) were associated with rUTIs. No influence of rUTIs on overall or graft survival was observed. Conclusions: One in six patients experience rUTIs after RTx. Pre- and postoperative variables affect the risk of rUTIs, but none are easily modifiable. In this cohort, rUTIs did not affect the graft function or survival. The etiology of rUTIs remains poorly understood, and there is a continuous need to study how rUTIs can be reduced and treated optimally. Patient summary: In this study, we looked at the risk factors for recurrent urinary tract infections in patients after kidney transplantation. We conclude that 21.5% of patients experience recurrent urinary tract infections 5 years after kidney transplantation. Multiple risk factors were found and should be taken into consideration by clinicians.

Surgical Approaches and Outcomes in Living Donor Nephrectomy: A Systematic Review and Meta-analysis.

CONTEXT: The use of living kidney donors is increasing and there are several surgical approaches for donor nephrectomy but it remains unknown which procedure is optimal for the patient and the graft. OBJECTIVE: To review different surgical techniques for living donor nephrectomy and compare complication rates, warm ischemia time, and delayed graft function. EVIDENCE ACQUISITION: A systematic review of prospective studies involving surgical complications following living donor nephrectomy was conducted in the MEDLINE/PubMed and EMBASE databases according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Baseline data, perioperative and postoperative parameters, and postoperative complications are reported. Overall complication rates between surgical techniques were compared via analysis of variance with post hoc analysis. We included 35 studies involving 6398 patients and representing six different surgical procedures for living donor nephrectomy. EVIDENCE SYNTHESIS: Hand-assisted laparoscopic donor nephrectomy had a significantly higher overall complication rate compared to open, laparoscopic, retroperitoneoscopic, and laparoendoscopic single-site techniques (p < 0.005). The complication rates were low and no mortality was observed. The main limitation was varying reporting of complications, with only one-third of the studies using the Clavien-Dindo classification. CONCLUSIONS: No specific surgical approach seems superior in terms of complications, which were generally low. Different factors such as warm ischemia time, blood loss, and surgeon expertise define which surgical approach should be chosen. PATIENT SUMMARY: We looked at the different surgical methods for removing the kidney from a living kidney donor. Overall, the different surgical techniques were similar in terms of complications and no donors died in the studies we reviewed. The choice of procedure depends on multiple factors such as the expertise of the surgeon and the surgical center.

Virtual reality simulator metrics cannot be used to assess competence in ureteronephroscopy and stone removal - a validation study.

OBJECTIVE: The growing use of simulation-based training makes it necessary to develop efficient training programs in order to ensure optimal use of time and resources. Our aim was to develop and gather validity evidence for a simulation-based test in ureteronephroscopy and set a pass/fail standard for the test that will allow future mastery learning. DESIGN: This study is a validation study. A test in ureteronephroscopy and stone removal on the URO Mentor™ virtual reality simulator (3D Systems, USA) was developed by two experienced urologists in order to ensure content. Participants with different experience completed three standardized tasks on the simulator and simulator-generated metrics were used as outcome parameters to minimize bias and ensure a fair response process. RESULTS: Twenty novices, 15 intermediates, and 8 experienced urologists were included in the study. Validity evidence for internal structure and relationship to other variables was questionable with weak and mostly insignificant correlations across all four metrics (Cronbach's alpha = 0.14, p = 0.15) and across the three modules (Cronbach's alpha = 0.41 (p = 0.02), 0.35 (p = 0.06), 0.10 (p = 0.35), and 0.30 (p = 0.09) for each metric, respectively). It was not possible to establish a pass/fail score for the simulation test with meaningful consequences. CONCLUSION: Our study showed that automatically generated simulator metrics cannot be used as a valid way of assessing competence in ureteronephroscopy. Virtual-reality simulator training could still be a valuable and patient-safe way to practice these skills, but an experienced supervisor is needed to determine when the trainee is ready to continue to supervised practice on patients.

Simulation-based training for flexible cystoscopy - A randomized trial comparing two approaches.

BACKGROUND: Simulation-based training allows trainees to experiment during training and end-of-training tests could increase motivation and retention. The aim of this trial was to determine if a simulation-based training program including directed self-regulated learning and post-testing improved clinical outcomes compared to a traditional simulation-based training program. METHODS: A randomized trial was conducted involving 32 participants without prior experience in endoscopic procedures. The intervention group practiced independently in a simulation centre and got a post-test whereas the control group received traditional instructions and demonstrations before being allowed to practice. Three weeks after the intervention the participants performed cystoscopies on two consecutive patients. Clinical performance was assessed using a global rating scale (GRS) with established evidence of validity. Independent samples t-test, Cronbach's α, Pearson's r, and paired samples t-test were used for statistical analysis. RESULTS: Twenty-five participants performed two cystoscopies on patients. There was no significant difference between the two study groups with respect to mean GRS of performance (p = 0.63, 95 % CI; -2.4-3.9). The internal consistency of the global rating scale was high, Cronbach's α = 0.91. Participants from both study groups demonstrated significant improvement between the first and second clinical procedures (p = 0.004, 95 % CI, 0.8-3.5). Eight (32%) and 15 (60%) participants demonstrated adequate clinical skills in their first and second procedure, respectively. CONCLUSIONS: No significant differences were found on the clinical transfer when comparing the two programs. Neither of our training programs was able to ensure consistent, competent performance on patients and this finding could serve as an important argument for simulation-based mastery learning where all training continues until a pre-defined level of proficiency is met. TRIAL REGISTRATIONS: The trial was submitted before enrolment of participants to the Regional Scientific Ethics Committee of the Capital Region which established that ethical approval was not necessary (H-4-2014-122). The trial was registered at Clinicaltrials.gov (NCT02411747).

Direct Observation vs. Video-Based Assessment in Flexible Cystoscopy.

OBJECTIVE: Direct observation in assessment of clinical skills is prone to bias, demands the observer to be present at a certain location at a specific time, and is time-consuming. Video-based assessment could remove the risk of bias, increase flexibility, and reduce the time spent on assessment. This study investigated if video-based assessment was a reliable tool for cystoscopy and if direct observers were prone to bias compared with video-raters. DESIGN: This study was a blinded observational trial. Twenty medical students and 9 urologists were recorded during 2 cystoscopies and rated by a direct observer and subsequently by 2 blinded video-raters on a global rating scale (GRS) for cystoscopy. Both intrarater and interrater reliability were explored. Furthermore, direct observer bias was explored by a paired samples t-test. RESULTS: Intrarater reliability calculated by Pearson's r was 0.86. Interrater reliability was 0.74 for single measure and 0.85 for average measures. A hawk-dove effect was seen between the 2 raters. Direct observer bias was detected when comparing direct observer scores to the assessment by an independent video-rater (p < 0.001). CONCLUSION: This study found that video-based assessment was a reliable tool for cystoscopy with 2 video-raters. There was a significant bias when comparing direct observation with blinded video-based assessment.