Comparison of laparoendoscopic single site (LESS) and conventional laparoscopic donor nephrectomy at a single institution.

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Most transplant centres harvest living donor kidneys via a conventional laparoscopic surgical approach. Laparoendoscopic single-site donor nephrectomy (LESS-DN) is a relatively novel minimally invasive approach that allows the surgery to be performed via a single incision. This technique may be advantageous in decreasing surgical morbidity and improving cosmetic outcomes, thus plausibly reducing the barriers to kidney donation. The study demonstrates the safety and feasibility of LESS-DN in a large consecutive series of kidney donors. Comparative analysis between LDN and LESS-DN showed that there was a significant decrease in intra-operative blood loss and allograft warm ischaemia time in the LESS-DN group, but also a significant increase in operating time. Other peri-operative outcomes were similar between the two approaches. Evaluation of the LESS-DN cases alone revealed that, the operating times did not significantly change through the course of the series. Using this outcome as a surrogate for technical difficulty suggests a relatively shallow learning curve for LESS-DN. To present a comparative analysis of peri-operative outcomes for >200 cases of conventional laparoscopic donor nephrectomy (LDN) and laparoendoscopic single site donor nephrectomy (LESS-DN). From 2006 to 2011, 213 donor nephrectomies were performed by two surgeons (R.E.L and W.A.M.) at a tertiary transplant centre. The approach changed from conventional LDN to LESS-DN over the course of the series. The two approaches were compared retrospectively and evaluated for differences in peri-operative outcomes. Statistical significance was assessed using Student's t-test and chi-squared analysis. A total of 111 patients underwent LDN and 102 patients underwent LESS-DN. Total operating time was significantly longer in the LESS-DN group (206.1 vs 181.9 min, P < 0.001), but LESS-DN resulted in less intra-operative blood loss (61.5 mL vs 85.9 mL, P < 0.001) and shorter warm ischaemia times (4.4 vs 5.0 min, P = 0.01). There were no significant differences in analgesic requirements, subjective pain scores, length of hospital stay, postoperative graft function, or donor's postoperative glomerular filtration rate between the two approaches. Complication rates were low regardless of the approach, and there were no major complications (>grade II) in the LESS-DN group. In experienced hands, LESS-DN results in peri-operative outcomes similar to those of conventional LDN without compromising donor safety, while providing a desirable cosmetic result. For surgeons familiar with LDN, transitioning to the LESS approach using this technique appears to have a relatively short learning curve.

Stamatakis L ，Mercado MA ，Choi JM ，Sanchez EJ ，Gaber AO ，Knight RJ ，Mayer WA ，Link RE ... -  《-》

Comparison of laparoendoscopic single-site donor nephrectomy and conventional laparoscopic donor nephrectomy: donor and recipient outcomes.

To present a comparison of perioperative donor outcomes and recipient graft function in a series of patients undergoing laparoendoscopic single-site donor nephrectomy (LESS-DN) versus conventional laparoscopic donor nephrectomy (LDN). Data were collected for 50 consecutive LESS-DN patients and a matched cohort of 50 LDN patients. The donor outcomes analyzed included operative time, estimated blood loss, complications, visual analog pain scores, and recovery time. The recipient outcomes analyzed included serum creatinine at discharge and follow-up and the incidence of delayed graft function. The mean total operative time was shorter in the LDN group than in the LESS-DN group (P < .0001). Linear regression analysis of the LESS-DN operative times relative to case number showed a significant decrease in the operative time with increasing case number (r(2) = 0.19, P = .002). No statistically significant differences were found in estimated blood loss, warm ischemia time, length of stay, or visual analog pain scores between the 2 groups. However, the surgical incision was significantly smaller in the LESS-DN group (P < .0001). After discharge, the patient-reported time to complete recovery was faster in the LESS-DN group (P = .01). The incidence of complications was similar in both groups; however, major complications only occurred in the LDN group. No differences were found in the recipient serum creatinine values or the incidence of delayed graft function. Our initial experience with LESS-DN is encouraging. This retrospective matched-pair comparison between LESS-DN and LDN suggests that the single-port approach might be associated with quicker convalescence. Longer operative times in the LESS-DN group could simply represent the learning curve of a novel procedure.

Afaneh C ，Aull MJ ，Gimenez E ，Wang G ，Charlton M ，Leeser DB ，Kapur S ，Del Pizzo JJ ... -  《-》

Pfannenstiel laparoendoscopic single-site (LESS) vs conventional multiport laparoscopic live donor nephrectomy: a prospective randomized controlled trial.

To present outcomes of a randomized, patient-blinded controlled trial on Pfannenstiel laparoendoscopic single-site (LESS) vs conventional multiport laparoscopic live donor nephrectomy. Patients presenting as left kidney donors between January 2009 and November 2011 were randomized to LESS donor nephrectomy (LESS-DN: n = 15) or conventional laparoscopic donor nephrectomy (LDN: n = 14). Patients were blinded to the surgical approach preoperatively and attempts to continue patient blinding postoperatively were made by applying dressings consistent with multiple conventional laparoscopic incisions for all patients. De-identified data related to the operation, peri-operative course and postoperative follow-up were prospectively collected and compared between the two groups with an intention-to-treat analysis. There were no significant differences between the groups when comparing operating time, estimated blood loss (EBL), i.v. fluid administration, renal allograft warm ischaemia time (WIT), length of hospital stay (LOS) and total inpatient analgesic requirements. Quantitative pain assessment was not significantly different on postoperative day (POD) #0, however, it was significantly lower in the LESS-DN group, beginning on POD #1 (P < 0.05). The changes in haematocrit and serum creatinine in the two groups were not significantly different, and there were no blood transfusions in either group, nor was there a decline in estimated glomerular filtration rate to <60 mL/min per 1.73 m² of body surface area in any patients. Two patients in the LESS-DN group were converted to conventional LDN, both because of failure to progress effectively. All allografts were functional at the time of transplantation and revascularization, with no cases of hyperacute rejection. Peri-operative variables including EBL, WIT and LOS were equivalent when comparing Pfannenstiel LESS-DN with conventional LDN. Patient-reported visual analogue pain scale scores were significantly lower in the LESS-DN group beginning on the first postoperative day.

Richstone L ，Rais-Bahrami S ，Waingankar N ，Hillelsohn JH ，Andonian S ，Schwartz MJ ，Kavoussi LR ... -  《-》

Comparison of complications of laparoscopic versus laparoendoscopic single site donor nephrectomy using the modified Clavien grading system.

We compared postoperative complications of laparoendoscopic single site and standard laparoscopic living donor nephrectomy using a standardized complication reporting system. We retrospectively analyzed the records of consecutive patients who underwent a total of 663 laparoscopic living donor nephrectomies and 101 laparoendoscopic single site donor nephrectomies. All data were recorded retrospectively. The 30-day complication rate was compiled and graded using the modified Clavien complication scale. Multivariate binary logistic regression was used to determine independent predictors of complications. Baseline demographics were comparable between the groups. Compared to those with laparoscopic living donor nephrectomy patients who underwent laparoendoscopic single site donor nephrectomy had a shorter hospital stay and less estimated blood loss but longer operative time (p <0.05) as well as higher oral but lower intravenous in hospital analgesic requirements (p <0.05). Mean warm ischemia time was marginally lower in the laparoendoscopic single site donor nephrectomy group (3.9 vs 4 minutes, p = 0.03). At 30 days there was no difference in the overall complication rate between the laparoscopic living and laparoendoscopic single site donor nephrectomy groups (7.1% vs 7.9%, p >0.05). There were 8 major complications (grade 3 to 5) in the laparoscopic living donor nephrectomy group but only 1 in the laparoendoscopic single site group. Multivariate binary logistic regression analysis revealed that estimated blood loss was a predictor of fewer complications at 30 days. With appropriate patient selection and operative experience laparoendoscopic single site donor nephrectomy may be a safe procedure associated with postoperative outcomes similar to those of laparoscopic living donor nephrectomy as well as low morbidity. Using a standardized complication system can aid in counseling potential donors in the future.

Ramasamy R ，Afaneh C ，Katz M ，Chen X ，Aull MJ ，Leeser DB ，Kapur S ，Del Pizzo JJ ... -  《-》

Laparo-endoscopic single site (LESS) versus standard laparoscopic left donor nephrectomy: matched-pair comparison.

Canes D ，Berger A ，Aron M ，Brandina R ，Goldfarb DA ，Shoskes D ，Desai MM ，Gill IS ... -  《-》