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Volume: 14 Issue: 2 April 2016

FULL TEXT

ARTICLE
Hand-assisted Laparoscopic Nephrectomy in Living-donor Kidneys With Multiple Arteries: Experience of a Transplant Center

Objectives: Hand-assisted laparoscopic nephrectomy is a relatively new procedure in our country. This article reports on one of the largest number of this procedure in kidneys with multiple vessels.

Materials and Methods: We reviewed all cases of hand-assisted laparoscopic nephrectomy from July 2002 to February 2009. Results were then descriptive, with statistical analyses performed with SPSS software (SPSS: An IBM Company, version 10.0, IBM Corpora­tion, Armonk, NY, USA).

Results: From July 2002 to February 2009, 165 patients had hand-assisted laparoscopic nephrectomy, with 96.9% being the left kidney. We found a prevalence of 18.7% (n = 31) of kidneys with multiple arteries, with 8 of these having multiple principal arteries, 9 with superior polar artery, and 14 with inferior polar artery. Twenty-nine donors (17.57%) presented with more than 1 principal vein. Warm ischemia was longer in kidneys with multiple arteries (4.16 vs 3.96 min); recipient renal function (evaluated by creatinine levels at day 5 after transplant) was 1.63 mg/dL in kidneys with single artery versus 1.27 mg/dL in kidneys with multiple arteries. There were no significant differences for time of surgery, bleeding, and discharge of the donor.

Conclusions: We found no differences in kidney function between single and multiple artery kidneys, resulting in the conclusion that hand-assisted laparoscopic nephrectomy offers an effective option for kidney donors, including those with multiple arteries.


Key words : Hand-assisted laparoscopic nephrectomy, Kidney transplant, Multiple arteries

Introduction

Kidneys are organs that develop from the metanephros at the commencement of the fifth week of gestation, which at the beginning are intrapelvic organs proximal between them. As the fetus grows, kidneys ascend to their final location in the abdomen. As they move, the irrigation changes. At the beginning, kidneys have branches from the iliac arteries, which subsequently are from the inferior aorta and finally from the descending aorta. As they ascend, the inferior vessels disappear. In some cases, the vessels do not disappear, leaving a kidney with multiple principal arteries or polar arteries defined as a vessel or branch of the aorta, which arrives to the superior or inferior pole of the kidney. The venous drainage shows the same manner.1

The kidneys are located in the retroperitoneal space in the upper part of the posterior abdomen next to the spine, with the right one a little lower than the left. In 75% of the organs, kidneys have irrigation from a single artery.2

One study analyzed 288 nephrectomies, with 154 kidneys (54%) being the right one. The study found 72% of the kidneys had single artery and vein, 15% had 2 arteries, 3% had 2 arteries and 2 veins, and 4% had more than 2 arteries. The study also found that nephrectomy of multiple vessel kidneys was related to longer surgery time and warm ischemia but without affecting the outcome of the function. This study also noted that the inferior polar artery was related with more ureteral complications.3

A review of 240 cases of laparoscopic donor nephrectomy found that 15% of kidneys had multiple arteries. Of these, 9 (25%) were right kidneys and 28 (75%) were left kidneys. Cold ischemia was longer in kidneys with multiple arteries (46 ± 24 min vs 35 ± 13 min) as was warm ischemia time (260 ± 125 min vs 197 ± 47 min). Renal function evaluated with the use of creatinine levels on day 7 and at 1 year was similar in both groups. The investigators also commented on the importance of preserving the inferior polar artery.4

Several other studies have reported a prevalence of kidneys with multiple arteries that ranged from 6.06% to 27%. All of these studies reported similar warm and cold ischemia times and similar kidney function; therefore, these do not contraindicate the transplant of kidneys with multiple arteries. Only 1 study reported more ureteral complications, and all of these studies emphasized the importance of preserving the inferior polar artery.5-10

In a retrospective study of 140 transplants of kidneys with multiple arteries, only 40% were functional at the fifth year. This was found to be related to having more than 2 arteries and pedicle restorations, with more vascular complications and loss of the kidney graft.11

Arteriography is the best method for detection of multiple renal arteries, having greater specificity and ability to detect than magnetic resonance imaging for polar arteries. However, arteriography also leads to a bigger risk of nephropathy or contrast allergy and results in radiation for the donor.12,13

Materials and Methods

We reviewed all hand-assisted laparoscopic neph­rectomies performed by our team from July 2002 to February 2008. Sex, age, surgery time, bleeding, warm ischemia time, and kidney function on day 5 after transplant were evaluated. Both groups (with and without multiple arteries) were evaluated, with results statistically analyzed with SPSS software (SPSS: An IBM Company, version 10.0, IBM Corporation, Armonk, NY, USA). Most procedures involved the left kidney because the longer renal vein facilitates anastomosis during the implant phase. During the hand-assisted laparoscopic nephrectomy, arteries and veins were ligated using 10-mm Hem-o-lok (Weck; TELEFLEX MEDICAL, Research Triangle Park, NC, USA). To prepare for possible multiple arteries, the reconstruction was made at the bench at implant phase and was performed by an experienced surgeon who made anastomosis in most cases to iliac vessels. Limitation of our study included the many times the same team performed the nephrectomy and the implant lengthening surgical times.

Results

In 165 cases analyzed, 68 donors (41.2%) were males, with mean age of 38.6 years (range, 20-63 y). We found that 160 nephrectomies were left kidneys, 4 were right, and 1 case involved a horseshoe kidney. In all kidneys included in our analyses, 31 (18.7%) had multiple arteries, with 1 case having 3 arteries (Table 1 and Figure 1).

Of the examined kidneys, 29 (17.57%) had more than 1 vein (2 had 3 veins). The average surgical time was 131.4 minutes (range, 50-260 min). The mean surgical time was 128.8 minutes in the single artery group compared with 142.9 minutes in the multiple artery group. There was a tendency for the surgery to last more than 3 hours if the kidney had more than 1 artery, although this was not statistically significant (P = .065). From the total number of nephrectomies, the average amount of surgical bleeding was 82.12 mL (range, 30-1200 mL). The large maximum bleeding was because of a bad collocation of the Hem-o-lok in an artery with inadequate dissection in the 11th case that caused conversion of the surgery to open laparotomy. There was also a case with 1000 mL of bleeding because of a laceration of the spleen (repaired laparoscopically). However, when we compared surgical bleeding, there was no difference in both groups (86.18 mL for kidneys with single artery and 67.0 mL for kidneys with multiple arteries). There was also no difference when we compared warm ischemia time in the groups (3.96 min for single artery vs 4.16 min for multiple arteries), although we found that when warm ischemia lasted longer it correlated with longer surgical time (P = .002). The function of the graft was evaluated by the creatinine level at the fifth day, showing an average of 1.56 mg/dL (range, 0.6-9 mg/dL), with values for the single artery group of 1.61 mg/dL and values for multiple artery group of 1.27 mg/dL without statistical difference. There was no statistical difference when we compared the single artery group versus the multiple artery group regarding surgical bleeding (P = .57), duration of the surgery (P = .11), and creatinine levels on day 5 (P = .21).

Discussion

In our study group, 18.2% of the hand-assisted laparoscopic nephrectomies were from kidneys with multiple arteries, and there was a tendency for surgery to last more than 3 hours for these cases. However, we found no differences when we compared both groups regarding creatinine level at day 5 posttransplant. Although hand-assisted laparoscopic nephrectomy is a challenging procedure that requires proper equipment and requires more ability from the surgeon, according to our results, we recommend the retrieval of organs with multiple arteries when the surgeon is capable of doing a proper anastomosis in the recipient, including adequate bench surgery. As reported in the literature, we recommend the preservation of the inferior polar artery because in many cases the irrigation of the ureter depends on this vessel and the incorrect collocation of it can lead to ureter necrosis. In addition, we always tried to dissect vessels proximal to the aorta to have longer vessels that make the implant phase easier.

A recent report showed that there were no significant differences in operative time, warm ischemia, estimated blood loss, transfusion rate, analgesic requirement, or hospital stay when a matched cohort of patients who underwent hand-assisted laparoscopic nephrectomy was compared with patients who underwent pure laparoscopic nephrectomy.14 Our present results and the literature both attest that the learning curve is less with hand-assisted laparoscopic nephrectomy. We used a hand port devise located in the midline at the umbilical scar level; this location facilitated retrieval of the kidney. As mentioned in other reviews, the benefit of pure laparoscopic nephrectomy is that the kidney can be extracted by a Pfannenstiel incision or using a previous scar.14

Since the introduction of the LDN in 1995 by Ratner, it has been preferred to retrieve the left kidney because of its longer vein, which facilitates the transplant in the recipient. The current approach is to use whichever side is better for the donor followed by the side that is better for the recipient.15 A recent meta-analysis showed no differences in kidney function and thrombosis when they compared the right versus the left kidney.16 We decided to use the right kidney in 3 cases, 2 because the left kidney had 4 arteries and the other case because the donor had underwent previous surgery for diverticular disease in the sigmoid colon, so we suspected adhesions at that level.

The implant of a right kidney may be more difficult because of the shorter vein. Some recommendations that we have learned include use of Hem-o-lok for retrieval, which allows us to leave a longer vein than with a stapler. Another recommendation is to make a complete dissection up to the vena cava. At transplant, make a good dissection of the iliac vessels and analyze whether your patient requires transplant of the right kidney. Our recipients were thin patients; in 1 case, we ligated the internal iliac vein so the external vein becomes superficial.


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Volume : 14
Issue : 2
Pages : 153 - 156
DOI : 10.6002/ect.2015.0201


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From the Hospital Central “Ignacio Morones Prieto,” Centro Estatal de Trasplantes San Luis Potosí, San Luis Potosí, México
Acknowledgements: The authors declare no conflicts of interest, and no funding was received during the duration of this project.
Corresponding author: Alfonso Ricardo Bandín Musa, Circuito Roble No. 52 Col: Residencial del Parque, San Luis Potosí, San Luis Potosí 78294, México
Phone: +52 44 4840 2313
Fax: +52 44 4834 2700
E-mail: alfonsobandin@hotmail.com