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      Robotic assisted nephrectomy for living kidney donation (RANLD) with use of multiple locking clips or ligatures for renal vascular closure

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          Abstract

          Background

          Robotic assisted nephrectomy for living donation (RANLD) is a rapid emerging surgical technique competing for supremacy with totally laparoscopic and laparoscopic hand assisted techniques. Opinions about the safety of specific techniques of vascular closure in minimally invasive living kidney donation are heterogeneous and may be different for laparoscopic and robotic assisted surgical techniques.

          Methods

          We retrospectively analyzed perioperative and short-term outcomes of our first (n=40) RANLD performed with the da Vinci Si surgical platform. Vascular closure of renal vessels was performed by either double clipping or a combination of clips and non-transfixing suture ligatures.

          Results

          RANLD almost quintupled in our center for the observed time period. A total of n=21 (52.5%) left and n=19 (47.5%) right kidneys were procured. Renal vessel sealing with two locking clips was performed in 18 cases (45%) Both, clips and non-transfixing ligatures were used in 22 cases (55%). Mean donor age was 53.075±11.68 years (range, 28–70). The average total operative time was 150.75±27.30 min. Right donor nephrectomy (139±22 min) was performed significantly faster than left (160.95±27.93 min, P=0.01). Warm ischemia time was similar for both vascular sealing techniques and did not differ between left and right nephrectomies. No conversion was necessary. Clavien-Dindo Grade ≤IIIb complications occurred in (n=5) 12.5%. Grade IV and V complications did not develop. In particular no hemorrhage occurred using multiple locking clips or suture ligatures for renal vascular closure. Mortality was 0%. Thirteen kidneys (32.5%) were transplanted across the AB0 barrier.

          Conclusions

          RANLD is an emerging minimally invasive surgical technique which facilitates excellent perioperative and short-term outcomes also when using multiple locking clips or suture ligatures for renal vascular closure.

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          KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

          Krista Lentine, Bertram Kasiske, Andrew Levey … (2017)
          Abstract The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a “proof-in-concept” risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided. In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1–S109.
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            Solid organ transplantation in the 21st century

            Cara Black, Kareem Termanini, Oswaldo Aguirre … (2018)
            Solid organ transplantation (SOT) has emerged from an experimental approach in the 20 th century to now being an established and practical definitive treatment option for patients with end-organ dysfunction. The evolution of SOT has seen the field progress rapidly over the past few decades with incorporation of a variety of solid organs—liver, kidney, pancreas, heart, and lung—into the donor pool. New advancements in surgical technique have allowed for more efficient and refined multi-organ procurements with minimal complications and decreased ischemic injury events. Additionally, immunosuppression therapy has also seen advancements with the expansion of immunosuppressive protocols to dampen the host immune response and improve short and long-term graft survival. However, the field of SOT faces new barriers, most importantly the expanding demand for SOT that is outpacing the current supply. Allocation protocols have been developed in an attempt to address these concerns. Other avenues for SOT are also being explored to increase the donor pool, including split-liver donor transplants, islet cell implantation for pancreas transplants, and xenotransplantation. The future of SOT is bright with exciting new research being explored to overcome current obstacles.
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              Living-donor kidney transplantation: a review of the current practices for the live donor.

              Jennifer Davis, Francis Delmonico (2005)
              The first successful living-donor kidney transplant was performed 50 yr ago. Since then, in a relatively brief period of medical history, living kidney transplantation has become the preferred treatment for those with ESRD. Organ replacement from either a live or a deceased donor is preferable to dialysis therapy because transplantation provides a better quality of life and improved survival. The advantages of live versus deceased donor transplantation now are readily apparent as it affords earlier transplantation and the best long-term survival. Live kidney donation has also been fostered by the technical advance of laparoscopic nephrectomy and immunologic maneuvers that can overcome biologic obstacles such as HLA disparity and ABO or cross-match incompatibility. Congressional legislation has provided an important model to remove financial disincentives to being a live donor. Federal employees now are afforded paid leave and coverage for travel expenses. Candidates for renal transplantation are aware of these developments, and they have become less hesitant to ask family members, spouses, or friends to become live kidney donors. Living donation as practiced for the past 50 yr has been safe with minimal immediate and long-term risk for the donor. However, the future experience may not be the same as our society is becoming increasingly obese and developing associated health problems. In this environment, predicting medical futures is less precise than in the past. Even so, isolated abnormalities such as obesity and in some instances hypertension are no longer considered absolute contraindications to donation. These and other medical risks bring additional responsibility in such circumstances to track the unknown consequences of a live-donor nephrectomy.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Ann Transl Med
                Journal ID (iso-abbrev): Ann Transl Med
                Journal ID (publisher-id): ATM
                Title: Annals of Translational Medicine
                Publisher: AME Publishing Company
                ISSN (Print): 2305-5839
                ISSN (Electronic): 2305-5847
                Publication date (Print and electronic): March 2020
                Publication date (Print): March 2020
                Volume: 8
                Issue: 6
                Electronic Location Identifier: 305
                Affiliations
                [1 ]Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig , Leipzig, Germany;
                [2 ]Department of Gastroenterology, Division of Hepatology, University Hospital of Leipzig , Leipzig, Germany;
                [3 ]Department of Urology, University Hospital of Leipzig , Leipzig, Germany
                Author notes

                Contributions: (I) Conception and design: R Sucher, E Sucher, D Seehofer; (II) Administrative support: M Brunotte, J Weber; (III) Provision of study materials or patients: S Rademacher, J Weber; (IV) Collection and assembly of data: A Lederer, HM Hau; (V) Data analysis and interpretation: M Brunotte, J Weber; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

                [#]

                These authors contributed equally to this work.

                Correspondence to: PD Dr. Robert Sucher, MD. Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany. Email: robert.sucher@ 123456medizin.uni-leipzig.de .
                Article
                Publisher ID: atm-08-06-305
                DOI: 10.21037/atm.2020.02.97
                PMC ID: 7186662
                PubMed ID: 32355749
                SO-VID: d678d404-a1b3-4f41-b69f-c306afa6800f
                Copyright © 2020 Annals of Translational Medicine. All rights reserved.
                License:

                Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0.

                History
                Date received : 14 November 2019
                Date accepted : 27 December 2019
                Categories
                Subject: Original Article

                Keywords: kidney transplantation,robotic surgery,laparoscopic donor nephrectomy,renal allograft
                Data availability:
                Keywords: kidney transplantation, robotic surgery, laparoscopic donor nephrectomy, renal allograft

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