Learning curves of minimally invasive donor nephrectomy in a high-volume center: A cohort study of 1895 consecutive living donors

Background Few studies have investigated the learning curves of minimally invasive donor nephrectomy (MIDN) using the cumulative sum (CUSUM) analysis. In addition, no study has compared the learning curves of the different surgical MIDN techniques in one cohort study using the CUSUM analysis. This study aims to evaluate and compare learning curves for several MIDN using the CUSUM analysis. Methods A retrospective review of consecutive donors, who underwent MIDN between 1997 and 2019, was conducted. Three laparoscopic-assisted techniques were applied in our institution and included for analysis: laparoscopic (LDN), hand-assisted retroperitoneoscopic (HARP), and robot-assisted laparoscopic (RADN) donor nephrectomy. The outcomes were compared based on surgeon volume to develop learning curves for the operative time per surgeon. Results Out of 1895 MIDN, 1365 (72.0%) were LDN, 427 (22.5%) were HARP, and 103 (5.4%) were RADN. The median operative time and median blood loss were 179 (IQR, 139–230) minutes and 100 (IQR, 40–200) mL, respectively. The incidence of major complication was 1.2% with no mortality, and the median hospital stay was three (IQR, 3–4) days. The CUSUM analysis resulted in learning curves, defined by decreased operative time, of 23 cases in LDN, 45 cases in HARP, and 26 cases in RADN. Conclusions Our study shows different learning curves in three MIDN techniques with equal post-operative complications. The LDN and RADN learning curves are shorter than that of the hand-assisted donor nephrectomy. Our observations can be helpful for informing the development of teaching requirements for fellows to be trained in MIDN

Obese living kidney donors: a comparison of hand-assisted retroperitoneoscopic versus laparoscopic living donor nephrectomy

Background: The aim of this study was to examine the difference in outcome between hand-assisted retroperitoneoscopic and laparoscopic living donor nephrectomy in obese donors, and the impact of donor body mass index on outcome. Methods: Out of 1108 living donors who underwent hand-assisted retroperitoneoscopic or laparoscopic donor nephrectomy between 2010 and 2018, 205 were identified having body mass index ≥ 30. These donors were included in this retrospective study, analyzing postoperative outcomes and remnant renal function. Results: Out of 205 donors, 137 (66.8%) underwent hand-assisted retroperitoneoscopic donor nephrectomy and 68 donors (33.2%) underwent laparoscopic donor nephrectomy. Postoperative outcome did not show any significant differences between the hand-assisted retroperitoneoscopic donor nephrectomy group and the laparoscopic donor nephrectomy group in terms of major c

Learning curve of kidney transplantation in a high-volume center: A Cohort study of 1466 consecutive recipients

Background The purpose of this study was to evaluate surgical outcomes of kidney transplantation (KTX) based on surgeon volume and surgeon experience, and to develop the learning curve model for KTX using the cumulative sum (CUSUM) analysis. Methods A retrospective review of 1466 consecutive recipients who underwent KTX between 2010 and 2017 was conducted. In total, 51 surgeons, including certified transplant surgeons, transplant fellows and surgical residents were involved in these procedures using a standardized protocol. Outcomes were compared based on surgeon volume (low [1–30] versus high [31≥] volume) and surgeon's type (consultant surgeons, fellows or residents). Results Operative time (129 versus 135 min, P Conclusions Surgical training in KTX using a standardize protocol can be accomplished with a steep learning curve without compromising perioperative outcomes under the careful selection of surgeons and procedures

The prognosis of kidney transplant recipients with aorto-iliac calcification: a systematic review and meta-analysis

The prognosis of kidney transplant recipients (KTR) with vascular calcification (VC) in the aorto-iliac arteries is unclear. We performed a systematic review and meta-analysis to investigate their survival outcomes. Studies from January 1st, 2000 until March 5th, 2019 were included. Outcomes for meta-analysis were patient survival, (death-censored) graft survival and delayed graft function (DGF). Twenty-one studies were identified, eight provided data for meta-analysis. KTR with VC had a significantly increased mortality risk [1-year: risk ratio (RR) 2.19 (1.39–3.44), 5-year: RR 2.28 (1.86–2.79)]. The risk of 1-year graft loss was three times higher in recipients with VC [RR 3.15 (1.30–7.64)]. The risk of graft loss censored for death [1-year: RR 2.26 (0.58–2.73), 3-year: RR 2.19 (0.49–9.82)] and the risk of DGF (RR 1.24, 95% CI 0.98–1.58) were not statistically different. The quality of the evidence was rated as very low. To conclude, the presence of VC was associated with an increased mortality risk and risk of graft loss. In this small sample size, no statistical significant association between VC and DGF or risk of death-censored graft loss could be demonstrated. For interpretation of the outcomes, the quality and sample size of the evidence should be taken into consideration

A novel difficulty grading system for laparoscopic living donor nephrectomy

Background Several difficulty grading systems have been developed as a useful tool for selecting patients and training surgeons in laparoscopic procedures. However, there is little information on predicting the difficulty of laparoscopic donor nephrectomy (LDN). The aim of this study was to develop a grading system to predict the difficulty of LDN. Methods Data of 1741 living donors, who underwent pure or hand-assisted LDN between 1994 and 2018 were analyzed. Multivariable analyses were performed to identify factors associated with prolonged operative time, defined as a difficulty index with 0 to 8. The difficulty of LDN was classified into three levels based on the difficulty index. Results Multivariable analyses identified that male (odds ratio [OR] 1.69, 95% CI 1.37–2.09, P  28 (OR 1.36, 95% CI 1.08–1.72, P = 0.009), pure LDN (OR 1.99, 95% CI 1.53–2.60, P  Conclusion We developed a novel grading system with simple preoperative donor factors to predict the difficulty of LDN. This grading system may help surgeons in patient selection to advance their experiences and/or teach fellows from simple to difficult LDN

Learning curves of minimally invasive donor nephrectomy in a high-volume center: A cohort study of 1895 consecutive living donors

Background: Few studies have investigated the learning curves of minimally invasive donor nephrectomy (MIDN) using the cumulative sum (CUSUM) analysis. In addition, no study has compared the learning curves of the different surgical MIDN techniques in one cohort study using the CUSU

Learning curve of kidney transplantation in a high-volume center: A Cohort study of 1466 consecutive recipients

Background: The purpose of this study was to evaluate surgical outcomes of kidney transplantation (KTX) based on surgeon volume and surgeon experience, and to develop the learning curve model for KTX using the cumulative sum (CUSUM) analysis. Methods: A retrospective review of 1466 consecutive recipients who underwent KTX between 2010 and 2017 was conducted. In total, 51 surgeons, including certified transplant surgeons, transplant fellows and surgical residents were involved in these procedures using a standardized protocol. Outcomes were compared based on surgeon volume (low [1–30] versus high [31≥] volume) and surgeon's type (consultant surgeons, fellows or residents). Results: Operative time (129 versus 135 min, P < 0.001) and warm ischemia time (20.9 versus 24.2 min, P < 0.001) were significantly shorter in the high-volume group, however postoperative outcomes were equal in both groups. The CUSUM analysis revealed that approximately 30 procedures were necessary to improve surgical skills. In addition, no effect of surgeon's type including consultant surgeons, fellows and residents on postoperative outcomes was found. Conclusions: Surgical training in KTX using a standardize protocol can be accomplished with a steep learning curve without compromising perioperative outcomes under the careful selection of surgeons and procedures

Vascular multiplicity should not be a contra-Indication for live kidney donation and transplantation

Background: Whether vascular multiplicity should be considered as contraindication and therefore 'extended donor criterion' is still under debate. Methods: Data from all live kidney donors from 2006-2013 (n=951) was retrospectively reviewed. Vascular anatomy as imaged by MRA, CTA or other modalities was compared with intraoperative findings. Furthermore, the influence of vascular multiplicity on outcome of donors and recipients was studied. Results: In 237 out of 951 donors (25%), vascular multiplicity was present. CTA had the highest accuracy levels regarding vascular anatomy assessment. Regarding outcome of donors with vascular multiplicity

Clinical outcome of kidney transplantation after bariatric surgery: A single-center, retrospective cohort study

Patients with class II and III obesity and end-stage renal disease are often ineligible for kidney transplantation (KTx) due to increased postoperative complications and technically challenging surgery. Bariatric surgery (BS) can be an effective solution for KTx candidates who are considered inoperable. The aim of this study is to evaluate outcomes of KTx after BS and to compare the outcomes to obese recipients (BMI ≥ 35 kg/m2) without BS. This retrospective, single-center study included patients who received KTx after BS between January 1994 and December 2018. The primary outcome was postoperative complications. The secondary outcomes were graft and patient survival. In total, 156 patients were included, of whom 23 underwent BS prior to KTx. There were no significant differences in postoperative complications. After a median follow-up of 5.1 years, death-censored graft survival, uncensored graft survival, and patient survival were similar to controls (log rank test p =.845,.659, and.704, respectively). Dialysis pre-transplantation (Hazard Ratio (HR) 2.55; 95%CI 1.03–6.34, p =.043) and diabetes (HR 2.41; 95%CI 1.11–5.22, p =.027) were independent risk factors for all-cause mortality. A kidney from a deceased donor was an independent risk factor for death-censored graft loss (HR 1.98; 95%CI 1.04–3.79, p =.038). Patients who received a KTx after BS have similar outcomes as obese transplant recipients