Deep neuromuscular block reduces the incidence of intra-operative complications during laparoscopic donor nephrectomy: a pooled analysis of randomized controlled trials

Study objective To assess whether different intensities of intra-abdominal pressure and deep neuromuscular blockade influence the risk of intra-operative surgical complications during laparoscopic donor nephrectomy. Design A pooled analysis of ten previously performed prospective randomized controlled trials. Setting Laparoscopic donor nephrectomy performed in four academic hospitals in the Netherlands: Radboudumc, Leiden UMC, Erasmus MC Rotterdam, and Amsterdam UMC. Patients Five hundred fifty-six patients undergoing a transperitoneal, fully laparoscopic donor nephrectomy enrolled in ten prospective, randomized controlled trials conducted in the Netherlands from 2001 to 2017. Interventions Moderate (tetanic count of four > 1) versus deep (post-tetanic count 1–5) neuromuscular blockade and standard (≥10 mmHg) versus low (<10 mmHg) intra-abdominal pressure. Measurements The primary endpoint is the number of intra-operative surgical complications defined as any deviation from the ideal intra-operative course occurring between skin incision and closure with five severity grades, according to ClassIntra. Multiple logistic regression analyses were used to identify predictors of intra- and postoperative complications. Main results In 53/556 (9.5%) patients, an intra-operative complication with ClassIntra grade ≥ 2 occurred. Multiple logistic regression analyses showed standard intra-abdominal pressure (OR 0.318, 95% CI 0.118–0.862; p = 0.024) as a predictor of less intra-operative complications and moderate neuromuscular blockade (OR 3.518, 95% CI 1.244–9.948; p = 0.018) as a predictor of more intra-operative complications. Postoperative complications occurred in 31/556 (6.8%), without significant predictors in multiple logistic regression analyses. Conclusions Our data indicate that the use of deep neuromuscular blockade could increase safety during laparoscopic donor nephrectomy. Future randomized clinical trials should be performed to confirm this and to pursue whether it also applies to other types of laparoscopic surgery. Trial registration Clinicaltrials.gov LEOPARD-2 (NCT02146417), LEOPARD-3 trial (NCT02602964), and RELAX-1 study (NCT02838134), Klop et al. (NTR 3096), Dols et al. 2014 (NTR1433).

Laparoscopic donor nephrectomy: technique and outcome, a single-center experience

Background Laparoscopic donor nephrectomy (LDN) has been established as a surgical standard for living kidney donation. The aim of this work is to report our own experience with LDN regarding outcome and technique. Methods We prospectively identified 110 LDN cases between May 2017 and April 2020. Donor case files and operative notes were analyzed for age, sex, laterality, body mass index, warm ischemia time (WIT), intraoperative and postoperative complications, operative time, and length of hospital stay (LOS). Data were analyzed using SPSS version 10 (SPSS: An IBM Company, IBM Corporation, Armonk, NY, the USA). Results The mean age was 38 years, and 77% were males. Three cases (2.72%) required conversion to conventional open donor nephrectomy (ODN). Nevertheless, none of cases required intraoperative blood transfusion. The mean WIT was 2.6 min. Two cases (1.8%) developed major vascular injury (Clavien grade IIIb) and required conversion to ODN. Postoperatively, one patient (0.9%) needed transfusion of one unit of packed RBCs (Clavien grade II). The mean LOS was 2 days. Most common early postoperative complication was ileus (Clavien grade II) that developed in 4 (3.6%) cases. Incisional hernia (Clavien grade IIIb) was encountered in two (1.8%) cases. Two (1.8%) cases developed wound infection at the incision site and treated conservatively (Clavien grade I). Conclusions LDN is a safe technique with accepted intraoperative and postoperative morbidity. It offers short hospital stay, better cosmesis and early convalescence. In experienced hands, it can effectively deal with various vascular and ureteral anomalies without compromising early graft function.

Does the Side Matter? A Retrospective Cohort Study Comparing Left and Right Pure Laparoscopic Donor Nephrectomies

<b><i>Objectives:</i></b> Right laparoscopic donor nephrectomy (RLDN) is no longer regarded inferior to left LDN (LLDN). However, this knowledge is based on many studies suffering from inherent learning curves, center-specific imbalances, and different laparoscopic techniques. <b><i>Methods:</i></b> Pure LDNs at a high-volume referral center from 2011 to 2016 were retrospectively analyzed. Patient, graft characteristics, outcomes of LDNs, and corresponding open kidney transplantations were compared between LLDN and RLDN including a follow-up. <b><i>Results:</i></b> 160 (78.4%) LLDNs and 44 (21.6%) RLDNs only differed regarding graft characteristics, as more right grafts had multiple veins (34.1 vs. 6.9%, <i>p</i> &#x3c; 0.001) and worse scintigraphic function (44 vs. 51%, <i>p</i> &#x3c; 0.001). RLDNs were shorter (201 vs. 220 min, <i>p</i> = 0.032) with longer warm ischemia time (165 vs. 140 s, <i>p</i> &#x3c; 0.001), but left grafts were transplanted faster (160 vs. 171 min, <i>p</i> = 0.048). Recipients of right kidneys had more postoperative complications (grade 3: 25.6 vs. 11.3%, <i>p</i> = 0.020). At a follow-up of 45 (range 6–79) months, neither the kidney function, nor death-censored graft (5-year: LLDN 89 vs. 92%, <i>p</i> = 0.969) and patient survival (5-year: LLDN 95 vs. 98%, <i>p</i> = 0.747) differed. <b><i>Conclusions:</i></b> Pure LLDN and RLDN can have different outcomes at high-volume centers, especially higher complications for recipients of right grafts. However, long-term function and graft survival are the same irrespective of the chosen side.

Chylous ascites after laparoscopic donor nephrectomy: First case report in Turkey

Living-donor kidney transplantation is one of the treatment options of end-stage renal failure. In many transplant centers, laparoscopic live-donor transplantation is recognised as the standard pro- cedure. Chylous ascites (CA) is a very rare complication after laparoscopic donor nephrectomy (LDN). We aimed to present the management of the first case report in Turkey. 62-year-old male patient underwent laparoscopic transperitoneal left donor nephrectomy. One month after discharge, he was admitted with abdominal distention and imaging revealed diffuse free fluid in the abdomen. After diagnosis, milky colored chylous fluid was collected by inserting a percutenous drainage cathe- ter. The patient was treated with combination of percutaneous drainage, somatostatin analogue and total parenteral nutrition. Keywords: chylous ascites; laparoscopic donor nephrectomy; complication