End-to-side versus end-to-end uretero-ureteral anastomosis in preemptive kidney transplantation from living donors: A monocentric experience.

PURPOSE: End-to-end (ETE) pyeloureterostomy is an alternative to ureteroneocystostomy for urinary anastomosis during kidney transplantation (KT). In preemptive KT from living donors (PKT-LD), end-to-side (ETS) uretero-ureteral anastomosis could have the benefits of pyeloureterostomy without ligation of the native kidney ureter. This study aimed to compare ETS to ETE uretero-ureteral anastomosis in PKT-LD. METHODS: A monocentric retrospective 8-year study included all consecutive cases of PKT-LD, excluding ureteroneocystomy anastomosis and homolateral nephrectomy. Two groups were compared: ETS and ETE. Perioperative data on graft function and urological complications were collected. RESULTS: One hundred and six patients were included: 48 patients in the ETS group and 58 patients in the ETE group. Median follow-up was 37.5 months [17.3; 57.5]. The estimated glomerular filtration rate at postoperative day ten and 3 months was similar in both groups. The overall complication rate was 16%, with no significant difference between the 2 groups. There was one ureteral stenosis in each group. None of the patients in the ETS group presented urinary fistula, whereas it occurred in one (1.7%) in the ETE group. Back pain due to native kidney obstruction occurred in 5 patients in the ETE group (8.6%), but not in the ETS group. CONCLUSION: In preemptive kidney transplantation from living donors, urinary anastomosis can safely be performed as an end-to-side uretero-ureteral anastomosis, with low urological complications. It could prevent symptoms and complications due to native kidney obstruction. LEVEL OF EVIDENCE: IV.

Robotic-assisted laparoscopy living donor nephrectomy: Technique and results of a monocentric retrospective series.

INTRODUCTION: Robot-assisted nephrectomy for living kidney donation (LKD) has been described in the literature as a safe and reproducible technique in high volume centers with extensive robotic surgery experience. Any surgical procedure in a healthy individual ought to be safe in regards to complications. The objective of this study was to evaluate the Robotic-assisted Living Donor Nephrectomy (RLDN) experience in a robotic surgery expert center. METHODS: This is a retrospective study from 11/2011 and 12/2019. In total, 118 consecutive Living Donor (LD) kidney transplants were performed at our institution. All the procedures were performed by robotic-assisted laparoscopic approach. Extraction was performed by iliac (IE), vaginal (VE) or umbilical extraction (UE). The left kidney was preferred even if the vascular anatomy was not modal. RESULTS: For donors: the median operative time was 120min with 50mL of blood loss. The median warm ischemia time was 4min, with a non-significant shorter duration with the UE (4min) in comparison with IE or VE (5min). Nine patients had postoperative complications including 1 grade II (blood transfusion) and 1 grade IIIb (vaginal bleeding after VE). None of our procedures were converted to open surgeries and no deaths were reported. For the recipients: 1.7% presented delayed graft function; their median GFR at 1 year was 61mL/min/1.73m2. CONCLUSION: RLDN in an expert center appears to be a safe technique. The advantages of the robot device in terms of ergonomy don't hamper the surgical outcomes. Donor, recipient and graft survivals seem comparable to the reported laparoscopic outcomes in the literature.

[Living-donor robotic-assisted kidney transplantation: French academic center experience]. / Transplantation rénale robot-assistée avec donneur vivant : expérience d'un centre universitaire français.

INTRODUCTION: The main objective was to report the intra-, post-operative and functional outcomes of living-donor robotic-assisted kidney transplantation (RAKT), performed by a surgeon skilled in robotic surgery. The secondary objective was to compare the results of RAKT, based on the surgeon's experience. METHODS: For this retrospective cohort study, we analyzed data from consecutive patients who underwent living-donor RAKT from July 2015 to March 2020 and compared the results of RAKT according to the surgeon's experience (group 1: 1-14th RAKT versus group 2: 15-29th RAKT). RESULTS: Twenty-nine living-donor RAKT were performed. The median age and BMI of the recipients were: 57.0 (44.0-66.0) years and 32.7 (23.5-39.6)kg/m2. The median overall operative time and median console time were: 140.0 (122.5-165.0) and 120.0 (107.5-137.5) minutes. The median rewarming time, arterial, venous and urinary anastomoses durations were: 35.0 (27.5-45.0), 15.0 (11.0-20.0), 12.0 (10.0-16.0), 20.0 (16.0-23.0) minutes. Two (6.9%) minor and 5 (17.2%) major (Clavien-Dindo≥III) postoperative complications occurred. At 2 years of follow-up, patient and transplant survival was 100% (n=29) and 93.1% (n=27). After the 14th RAKT, the rewarming time (P=0.01) and venous anastomosis duration (P=0.004) were statistically shorter. CONCLUSION: Living-donor robotic-assisted kidney transplantation, performed by a surgeon skilled robotic surgery, ensures good functional results in the medium term. LEVEL OF EVIDENCE: 3.

[Living donor nephrectomy: The French guidelines from CTAFU]. / Recommandations françaises du Comité de transplantation de l'Association française d'urologie (CTAFU) : néphrectomie pour don de rein.

OBJECTIVE: To propose surgical recommendations for living donor nephrectomy. METHOD: Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU regarding functional and anatomical assessment of kidney donors, including which side the kidney should be harvested from. Distinct surgical techniques and approaches were evaluated. References were considered with a predefined process to propose recommendations with the corresponding levels of evidence. RESULTS: The recommendations clarify the legal and regulatory framework for kidney donation in France. A rigorous assessment of the donor is one of the essential prerequisites for donor safety. The impact of nephrectomy on kidney function needs to be anticipated. In case of modal vascularization of both kidneys without a relative difference in function or urologic abnormality, removal of the left kidney is the preferred choice to favor a longer vein. Mini-invasive approaches for nephrectomy provide faster donor recovery, less donor pain and shorter hospital stay than open surgery. CONCLUSION: These French recommendations must contribute to improving surgical management of candidates for kidney donation.

[Renal transplantation, for whom, why and how ?] / La transplantation rénale, pourquoi, pour qui et comment ?

Chronic kidney disease is a gradual and irreversible decrease in the functioning of the kidneys, which no longer filter the body's blood properly. The main causes are diabetes and high blood pressure. With the aging of the population, it is a disease whose incidence is increasing. In the terminal stage of the disease, treatment of replacement of the renal function is necessary (by hemodialysis, peritoneal dialysis or renal transplantation). Currently, kidney transplantation is the best replacement treatment for kidney function, because it is more efficient than dialysis in terms of survival, quality of life and cost to the health system. But it requires the maintenance and monitoring of immunosuppressive therapy. In France, kidney transplants are mainly from deceased donors or from living donors. Kidney transplantation is a scheduled surgery when the transplant is from a living donor, and an emergency when the transplant is from a deceased donor. The surgical technique is standardized and consists of suturing the artery and vein of the transplant onto the recipient's iliac vessels and the ureter in the bladder, through an ilio-inguinal incision. The average survival time of a transplant is 10 years and some patients may receive 1, 2, 3 or more kidney transplants in succession during their lifetime.

[Robotic-assisted laparoscopic living donor nephrectomy: Study in donors and recipients from 155 cases]. / Néphrectomie laparoscopique assistée par robot dans le cadre du donneur-vivant : étude chez les donneurs et les receveurs à partir de 155 cas.

AIM: To evaluate morbidity and renal function of the donor and recipient during a robotic-assisted laparoscopic nephrectomy procedure. PATIENTS AND METHODS: It is a retrospective study of 155 consecutive patients by robot-assisted laparoscopy in the living donor. Mean operating time, warm ischemia time, blood loss, complications according to the Clavien classification and evolution of creatinine clearance were analyzed in the donors. Recovery of graft function, complications and changes in creatinine clearance were observed in recipients. RESULTS: The mean operating time was 176 (±23) minutes. The mean warm ischemia time was 4.8 (±0.6) minutes. Twenty seven complications were noted. The loss of renal function was 19% at 5 years in donors. Renal recovery was immediate for 153 recipients. Two were delayed due to sepsis. Two patients lost their graft at 15 and 18 months. Seventeen complications have been identified. The mean kidney function of the recipients is measured at 63ml/min at 5 years. CONCLUSION: Robotic-assisted laparoscopic nephrectomy procedure appears to provide the donor with low morbidity and a moderate decrease in creatinine clearance at 19% at 5 years. Morbidity is also low in recipients with very satisfactory 5-year mean renal function. The technique should promote donation. LEVEL OF EVIDENCE: 4.

[Living kidney donation]. / Le donneur vivant de rein.

OBJECTIVES: To review ethical, legal and technical aspects of living kidney donor surgery. MATERIAL AND METHODS: An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords: Donor nephrectomy; Kidney paired donation; Kidney transplantation; Laparoscopic nephrectomy; Living donor; Organs trafficking; Robotic assisted nephrectomy; Vaginal extraction. French legal documents have been reviewed using the government portal (http://www.legifrance.gouv.fr). Articles were selected according to methods, language of publication and relevance. A total of 6421 articles were identified; after careful selection, 161 publications were considered of interest and were eligible for our review. RESULTS: The ethical debate focuses on organ shortage, financial incentive, organ trafficking and the recent data suggesting a small but significant increase risk for late renal disease in donor population. Legal decisions aim to increase the number of kidneys available for donation, such as kidney-paired donation that faces several obstacles in France. Laparoscopic approach became widely used, while robotic-assisted donor nephrectomy failed to demonstrate improved outcome as compared with other minimal invasive techniques. CONCLUSION: Minimally invasive living donor nephrectomy aims to limit side effects in the donor without increasing the morbidity in this specific population of healthy persons; long term surveillance to prevent the onset of renal disease in mandatory.

[Ethics and kidney transplants with living donors]. / Éthique et transplantation rénale avec donneurs vivants.

The ethical debate surrounding transplant practices questions our societies. International recommendations set out numerous precautions which must be taken to ensure that donors act with their free will. While in most countries, including France, organ donation is a voluntary and non-commercial act, a black market exists in the world resulting in the trafficking of organs and tragic transplant tourism.

[Psychological specificities of living donor kidney transplantation]. / Spécificités psychiques de la greffe rénale avec donneur vivant.

For people with end-stage kidney disease, a transplant is the promise of a future without dialysis. Living donor kidney transplantation comprises many specificities and is distinct from cadaveric donor transplantation. Some psychological aspects explain these specificities. They may be subconscious and difficult to access, but it is essential to decipher them in order to adapt the support provided to these people.

[Towards the development of living donor kidney transplantation]. / Vers un développement des greffes de rein à partir de donneurs vivants.

Living donor kidney transplantation has been increasing since 2008. Living donors represent a significant potential for organ transplants, in a context where the needs outstrip the availability of organs from deceased donors. However, patients are still poorly informed regarding the conditions in which these transplants are possible.

[Robotic assisted laparoscopic living donor nephrectomy: preoperative assessment and results of 100 cases]. / Néphrectomie chez le donneur vivant par voie laparoscopique robot-assistée: évaluation préopératoire et résultats à partir de 100 cas.

AIM: To assess short term morbidity and renal function after robotic laparoscopic living donor nephrectomy. PATIENTS AND METHODS: We performed a retrospective analysis of 100 consecutives patients undergoing a robotic laparoscopic living donors nephrectomy. We analyzed isotopic measure of the renal function before and 4 months after surgery, the side, the number of arteries, the blood loss, the operative time and warm ischemia time. In the outcomes, we collected the complications, the length of stay, and for the receiver, the renal function recovery time, dialysis, survival and renal function at one year. RESULTS: Left kidney nephrectomy was performed in 85 patients and we observed 25 multiples renal arteries. Mean estimated blood loss was 0,8 g/dL. Mean operative time and warm ischemia time were respectively 174 ± 30 and 4.8 ± 1.7 minutes. Seven complications occured, with 2 major (Clavien-Dindo System). Mean length of stay was 5.1 ± 1.9 days. Mean glomerular filtration decrease was 26% and remains stable at one year after surgery. Grafts had an immediate renal function recovery for 99%, and were all functional after one year, with mean MDRD clearance of 57 ± 14mL/min. CONCLUSION: Robotic procedure in laparoscopic living donor nephrectomy seems to guarantee low morbidity and the stability of the renal function decrease of 26%.

Clip or staple in laparoscopic live donor nephrectomy? A systematic literature review.

INTRODUCTION: Ligation of the renal pedicle is a crucial step in laparoscopic renal harvesting. Currently, two devices are widely used: Hem-o-Lok® clips and staplers. Each has its advantages and disadvantages. METHODS: A systematic literature review was conducted following the PRISMA methodology on PubMed, EMBASE, and Cochrane databases with no time restrictions. Registered in the PROSPERO database (CRD42023460585), the study's primary outcome measures include the failure rate of the ligation tool, conversion to open surgery, rate of severe bleeding, and device-related death. Other secondary variables are also explored. An assessment of the quality of included comparative studies was performed using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. RESULTS: Out of 393 articles identified using our keywords, 32 were included. Overall, clips have a lower failure rate during application, elongate graft vessel length, and are more cost-effective. Staples are associated with a shorter warm ischemia time and lower blood loss. There is no significant difference between the two devices in terms of conversion, severe bleeding, death, and blood transfusion. CONCLUSION: There is no perfect modality for renal pedicle control during laparoscopic harvesting, as each instrument has its pros and cons. Hem-o-Lok® clips are a safe and cost-effective option, particularly suitable for right-sided harvesting or in cases of vascular variations. However, they are still associated with a risk of secondary displacement with potentially serious consequences. Certain technical tricks can mitigate this risk.

[Organ donation is not a gift]. / Le don d'organes n'est pas un don.

If the obligation to donate as defined by French law ("we are all donors") remains in the wake of sociologist Marcel Mauss's Essai sur le don (Essay on donation), there the similarity ends. How do you make a counter-donation to a deceased person? In the case of inter vivos organ donation, the act is more akin to mutualization than donation.

[Perspectives for future development of the kidney paired donation programme in France]. / Perspectives pour une évolution du programme de don croisé de reins en France.

Almost one third of kidney donation candidates are incompatible (HLA and/or ABO) with their directed recipient. Kidney paired donation allows potential donors to be exchanged and gives access to a compatible kidney transplant. The Bioethics Law of 2011 authorised kidney paired donation in France with reciprocity between 2 incompatible "donor-recipient" pairs. A limited number of transplants have been performed due to a too restricted authorization compared to other European practices. This study presents the perspectives of the new Bioethics Law, enacted in 2021, which increases the authorised practices for kidney paired donation in France. The two simulated evolutions are the increase of the number of pairs involved in a kidney paired donation to 6 (against 2 currently) and the use of a deceased donor as a substitution to one of living donor. Different scenarios are simulated using data from the Agence de la Biomedecine; incompatible pairs registered in the kidney paired donation programme in France between December 2013 and February 2018 (78 incompatible pairs), incompatible transplants performed during the same period (476 incompatible pairs) and characteristics of deceased donors as well as proposals made over this period. Increasing the number of pairs has a limited effect on the number of transplants, which increases from 18 (23% of recipients) in the current system to 25 (32% of recipients) when 6 pairs can be involved. The use of a deceased donor significantly increases the number of transplants to 41 (52% of recipients). This study makes it possible to evaluate the increase in possibilities of kidney transplants by kidney paired donation following the new bioethics law. A working group and an information campaign for professionals and patients will be necessary for its implementation.

[End stage kidney disease in Maghreb and Africa: Overview of transplant programs in Maghreb and Africa]. / Insuffisance rénale terminale au Maghreb et en Afrique : panorama des programmes de transplantation au Maghreb et en Afrique.

Kidney transplantation is the best treatment for the patient with end stage kidney disease in term of increasing the survival rate, reducing complications, improving quality of live and its lower cost compared to peritoneal dialysis or hemodialysis. However, the number of patients waiting for kidney transplantation is growing day by day and the gap between demand and supply is still huge. This situation is even more complicated in developing countries where the lack of legislation, infrastructure and government involvement is common. Some national transplantation programs have been implemented, with the support of the International Society for Transplantation and the International Society of Nephrology, in order to increase the transplantation activity of these countries in accordance with the Istanbul Declaration on organ trafficking and transplant tourism.

[Human resources allocated to kidney transplantation in 2016 in France: A national survey]. / Les moyens de la transplantation rénale en France sont-ils en adéquation avec le Plan greffe 2021 ? État des lieux réalisé par la Commission transplantation de la SFNDT.

Following the publication of the ministerial action plan setting goals for the next five years, we performed a survey regarding the human resources and work organizations in the French renal transplant centers (n=33) on behalf of French speaking society of nephrology dialysis and transplantation (SFNDT). While the renal transplantation activity has been raising last years, we describe that the most active centers frequently resorted to an on-site nephrology guard and a surgeon dedicated to the transplantation activity, whereas only eight centers have a non restricted access to an operating room. Since 2002, the number of transplantations and follow-up visits performed by one nephrologist (full-time equivalent) have increased by 20 and 11%, respectively, while patient monitoring after transplantation is claimed to be shared with partner health centers in 94% of the transplant centers. Thus, the number of patients per nephrologist has increased when the active list exceeds 1150 patients in a center, e.g., 45% of centers in 2016 and 70% of centers in 2021 if the objectives are achieved. This survey also showed the stagnation of the specialized paramedical staff. Finally, the survey shows that the two main hurdles to the development of living donor transplantation are the availability of operating rooms and the lack of paramedical employees. In conclusion, this survey shows that an increase in the number of medical, surgical and paramedical staff will be necessary to achieve departmental objectives.

[Outcome of living kidney donors for transplantation]. / Devenir des donneurs vivants de rein pour la transplantation.

Nowadays, several treatments exist to treat terminal chronic renal failure. Best results for the recipients are obtained with kidney transplantation concerning mortality and quality of life. Transplantation is also the cheaper option for society. Living kidney donation raises the issue of the becoming of the donor, an absolutely healthy subject who gets to a surgical procedure. The becoming of living kidney donors has been compared with the one of controls subjects in several studies. The evaluations focused on the complications of nephrectomy in the short and long-term: kidney failure, hypertension, proteinuria, possibility of pregnancy, quality of life, and mortality. The first results did not show any risk linked to kidney donation, compared to general population. However, since 2013, kidney donors were found at higher risk for kidney failure and even for mortality, compared with controls selected like donor candidates. The risk of kidney donation is nevertheless acceptable and minimal, on the condition of rigorous selection of candidates and regular follow-up.

[New scores in renal transplantation: How can we use them?] / Nouveaux scores en transplantation rénale : comment peut-on les utiliser ?

In renal transplant medicine, several scores have been recently developed in order to help decision-making in clinical practice. The aim of this update is to focus on these new scores that allow to better estimate the quality of the renal transplant, to refine the allocation policy, to help registration of old recipients on the waiting list, or to evaluate the risk to develop end-stage renal failure after living donation.

[Cost of a renal transplant: medico-economic analysis of the amount reimbursed by the French national health program to finance renal transplantation]. / Coût d'un greffon rénal: calcul médico-économique des montants remboursés par l'Assurance maladie pour financer les étapes préalables et périphériques à la transplantation rénale.

Successful organ transplantation relies on several ancillary activities such as the identification of a compatible donor, organ allocation and procurement and the coordination of the transplant process. No existing study of the overall costs, in France, of these additional transplantation activities could be identified. This study determines the total additional costs of ancillary transplantation activities by comparing the costs of kidney transplantations with living donors against those using deceased donors. The data used are drawn from the 2013 public healthcare tariff calculations, PMSI recorded activity and transplant activity in 2012 as assessed and reported by the Agence de la biomédecine. The results show that, in 2012, additional transplant costs varied from 13835.44 € to 20050.67 € for a deceased donor and were 13601.66 € for a living donor. In conclusion, this study demonstrates that all the costs covered by National Health Insurance need to be taken into account in the economic impact evaluation of renal transplantation and during the development of this national priority activity.