Original Article
Hand-assisted laparoscopic living donor nephrectomy: initial Glasgow experience
Scottish Medical Journal 58(4) 237–240 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933013507873 scm.sagepub.com
F Hanif1 and MJ Clancy2
Abstract Aims: The study presents the early results of hand-assisted laparoscopic living donor nephrectomy (HALDN) carried out in West of Scotland from June 2009 to October 2010. Methods: The first 20 HALDN procedures carried out in our unit are presented. The outcomes reported are warm ischaemia time, operative time, delayed graft function, recipient renal function and one-month morbidity and mortality of donor and recipient. SPSS 15.0 was used for statistical analysis. Results: The mean age of the donors was 44 10 years, predominantly females (n ¼ 13), median operative time 135 33 min and warm ischaemia time 41 16 s. The length of the incision used was 65 mm in all cases. Duration of hospital stay was 5 1 days. Patient mortality was 0 and morbidity minimal with two donors developing minor wound infection and no other clinically significant postoperative morbidity. Among the recipients, 18/20 (90%) transplants worked primarily with two delayed graft functions, one due to early surgical complications in a small paediatric recipient and one due to recipient renal artery thrombosis. Conclusion: HALDN is safe and associated with minimal morbidity; further analysis aims to confirm excellent cosmetic results and quick return to activity compared with the standard open nephrectomy technique.
Keywords Living donor, laparoscopic living donor nephrectomy, renal transplant
Introduction The shortage of donor organs, especially in renal transplantation, continues to lead to a discrepancy between the number of end-stage renal disease patients on waiting lists and the number of available kidneys for transplantation. The major strategy to address this deficit has been the promotion of living kidney donation. The number of living donor kidney transplants is increasing year by year, 589 in 2005–2006 to 1037 in 2009–2010 and now represents more than one in three of all kidney transplants in the United Kingdom.1 One key disincentive to living donor kidney transplantation is the necessity for a painful operation to remove the donor kidney. Traditionally, this surgery has been performed using open donor nephrectomy (ODN) techniques with a relatively large incision sometimes including resection of a rib. With the advent of minimal access surgery, the procedure of retrieving a kidney from a living donor has also evolved with pure laparoscopic and hand-assisted laparoscopic donor nephrectomy (HALDN) gaining wide popularity.
It has been demonstrated that these methods have definite advantages over open surgery in terms of blood loss, analgesic requirements, duration of hospital stay and convalescence, but there was no difference in transplant function.2–5 The laparoscopic donor nephrectomy was introduced in 1995 and is now carried out through three different approaches: laparoscopic transperitoneal (LDN), laparoscopic hand-assisted transperitoneal (HALDN) and laparoscopic retroperitoneal donor nephrectomy (LRDN).6,7 There is some controversy regarding the possibility of relatively longer warm ischaemia and operative time and more bleeding with LDN.8 HALDN was introduced with an aim to reduce warm ischaemia time by using the hand port to extract 1 2
Specialty Registrar, Renal Transplant Unit, Western Infirmary, UK Consultant Surgeon, Renal Transplant Unit, Western Infirmary, UK
Corresponding author: Faisal Hanif, Renal Transplant Unit, Western Infirmary, Glasgow, UK. Email: [email protected]
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the kidney instantly after dividing the blood vessels.5,9–11 This technique is also associated with the potential advantage of tactile feedback, better manual control of bleeding points and relatively shorter learning curve. LRDN favours a retroperitoneal approach, thus avoiding possible morbidity related to transperitoneal dissection. At present, there is no strong evidence to support the use of one laparoscopic approach in preference to the other; however, there is some evidence suggesting that HALDN represents the most costeffective method of donor surgery achieving the equivalent clinical benefits of pure laparoscopic approaches with less operative time.12–14 In the West of Scotland, ODN was a routine until the introduction of HALDN in June 2009. This study aims to present the outcome of initial 20 HALDN procedures carried out in our unit serving the West of Scotland.
Methods After a successful application to the new interventional procedures process, permission from NHS Greater Glasgow and Clyde clinical governance department for a HALDN programme was obtained. In view of start-up cost implications, a successful business case was made to justify logistical and funding support. The first 20 HALDN procedures carried out in our unit from June 2009 to October 2010 are presented. All HALDN procedures were carried out by the same surgeon (MJC) who has been formally trained to do this operation. The recipient operations were carried out by one of the other four surgeons in the team and not by the donor surgeon. The prospective assessment of living donor was based on Renal Society/British Transplantation Society guidelines.15 It involved ABO typing and HLA matching, evaluation of general fitness to coupe with the surgical procedure, assessment of the renal function and suitability of the kidney for donation from anatomical and immunological view point and exclusion of transmissible disease risk. The renal anatomy was visualised by magnetic resonance angiography and function was assessed by measuring glomerular filtration rate (GFR) with a radio isotope diethylene triamine pentaacetic acid (DTPA) scan.15 Dimercaptosuccinic acid scan was only used in selective donors when GFR was equivocal on DTPA scan. For the first eight cases, only donors with uncomplicated vascular arrangement and normal range body mass index were selected for HALDN. Subsequent cases were not differentially selected for laparoscopic versus open surgery based on renal vessel anatomy or body mass index. Our preferred side to retrieve a kidney was the left side because of the long left renal vein which facilitates ease of recipient surgery; however, the right
side was used where complex left-sided vascular anatomy was present. Informed consent was obtained after providing detailed printed and verbal information. All cases received formal approval and a licence to transplant from the Human Tissue Authority after being reviewed by an independent non-clinical assessor. Renal protection was provided by fluid pre-loading with normal saline on the night before surgery and the intraoperative use of FLOWTRON compression boots to minimise intraoperative haemodynamic changes due to position and pneumoperitoneum. All procedures were carried out under general anaesthesia in a lateral position with truncal flexion as previously described.16 For left-sided procedures, an upper midline 65 mm abdominal incision was made to allow the introduction of surgeon’s hand via a GelPortÕ (Applied Medical, CA, USA). For right-sided procedures, a Pfannenstiel incision was used. The inserted hand can supplement the procedure by manoeuvring the organ to facilitate dissection, apply pressure on any bleeding points and permit rapid, atraumatic and quicker retrieval of the kidney.16,17 Pneumoperitoneum was created after the placement of GelPortÕ . Two 10 mm incisions were used. For left-sided procedures, an infraumbilical port was used for the camera and left iliac fossa, mid clavicular line site for the working port. For right-sided procedures, an upper midline operating port was used along with a port at McBurney’s point for the camera. Dissection was carried out as previously described, mobilising the descending colon medially with Hormonic ACEÕ (Ethicon Endo-Surgery, OH, USA), incision of Gerota’s fascia and exposure of renal vessels16 The adrenal lumbar and gonadal veins were divided on the left side, renal vein and artery dissected to free them to obtain maximum length. The ureter was dissected to the level of pelvic brim. After the full mobilisation of the kidney within Gerota’s fascia, the ureter was divided at the level of pelvic brim and distal stump was secured with Ligaclips (Ligaclips Ethicon Inc., Somerville, NJ, USA). The renal artery followed by renal vein ^were then divided with an endovascular stapler (Ethicon Endo-surgery) ensuring maximum length and the kidney was retrieved through the GelPortÕ and handed over to the recipient surgeon for reperfusion and preparation. Haemostasis was secured and no drain routinely used. The donor was kept well hydrated after the procedure to ensure optimum urine output. The study end point was one-month follow-up for both donors and recipients. The outcomes reported are warm ischaemia time, operative time, delayed graft function, recipient renal function and one-month morbidity and mortality of donor and recipient. Mean values are given with standard deviation (SD). SPSS 15.0 was used for statistical analysis. Warm ischaemia time was the time taken from
Downloaded from scm.sagepub.com at UQ Library on March 13, 2015
Hanif and Clancy
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removal of kidney from donor to placement in ice, whereas it has already been completely disconnected from donor. ‘Delayed graft function’ was defined as a need for dialysis in first week after renal transplant due to a poorly performing transplanted kidney and when it was not for management of hyperkalaemia or pulmonary oedema due to fluid overload. A ‘graft’ means a kidney for transplantation or already transplanted.
Results HALDN was carried out between June 2009 and December 2010 in 20 donors. Mean donor age was 44 10 years, predominantly females (n ¼ 13). The mean isotope GFR was 85 10. There were 15/20 left and the rest were right kidneys with a single artery each. The length of the hand port incision used was 65 mm in all cases. Mean operative time was 135 33 min with a warm ischaemia time 41 16 s (time taken for transfer from donor to ice). The mean length of renal arteries and veins retrieved was 28 5 and 27 5 mm, respectively. There was no intraoperative vascular or ureteric injury during organ retrieval. None of the donor required any blood transfusion. Mean duration of hospital stay for the donors was 5 1 days. Median followup was eight months. Two donors had minor wound infection with no other clinically significant postoperative morbidity. Among the recipients, 18/20 (90%) transplant worked primarily with two delayed graft function, one due to early postoperative renal vein thrombosis requiring successful revascularisation and the other due to recipient size mismatch and hypotension in a complex paediatric patient but both of them worked eventually. There were no other vascular or ureteric complications in the recipients.
Discussion HALDN has become the procedure of choice in many centres and our initial experience as others have shown that it is a safe, acceptable and popular approach for living donation. In our series, the standard incision size was only 6.5 cm. We managed to achieve adequate length of the artery and vein for transplantation (renal arteries and veins length 28 5 and 27 5 mm, respectively). The warm ischaemia time at retrieval has been criticised to be prolonged in minimally invasive procedures as compared to ODN, but in this study, the mean warm ischaemia time was 41 16 s as compared to Chiong et al.16 (2.16 min 0.72 s^). Mean duration of hospital stay was 5 1 days which is 1 day less than historical controls in our unit undergoing ODN. The mean hospital stay in other studies has been reported between three and six days.17,18 Critics of minimally invasive
surgery also point out gastrointestinal injuries which have been reported related to this procedure, but we report no gastrointestinal, vascular or ureteric injury in our series.19 The study is limited because of small number of patients, but it gives an encouragement to the centres like us which adopt or are planning to adopt minimal access techniques as a standard procedure for their patients. After the initial encouraging results, we are now offering HALDN to almost all donors and currently more than 90% live donor nephrectomies are carried out with this technique in Glasgow.
Conclusion HALDN is a safe procedure, associated with a small incision, minimal complications and quick return to normal activity. It should be offered as a first line of procedure to almost all potential live kidney donors. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of conflicting interests None declared.
References 1. NHS blood and transplant, http://www.uktransplant.org.uk/ ukt/statistics/transplant_activity_report/transplant_activity_report.jsp (2011, accessed 26 September 2013). 2. Greco F, Hoda MR, Alcaraz A, et al. Laparoscopic livingdonor nephrectomy: analysis of the existing literature. Eur Urol 2010; 58: 498–509. 3. Kok NF, Lind MY, Hansson BM, et al. Comparison of laparoscopic and mini incision open donor nephrectomy: single blind, randomised controlled clinical trial. BMJ 2006; 333: 221. 4. Nicholson ML, Elwell R, Kaushik M, et al. Health-related quality of life after living donor nephrectomy: a randomized controlled trial of laparoscopic versus open nephrectomy. Transplantation 2011; 91: 457–461. 5. Dolce CJ, Keller JE, Walters KC, et al. Laparoscopic versus open live donor nephrectomy: outcomes analysis of 266 consecutive patients. Surg Endosc 2009; 23: 1564–1568. 6. Ratner LE, Ciseck LJ, Moore RG, et al. Laparoscopic live donor nephrectomy. Transplantation 1995; 15: 1047–1049. 7. Kohei N, Kazuya O, Hirai T, et al. Retroperitoneoscopic living donor nephrectomy: experience of 425 cases at a single center. J Endourol 2010; 24: 1783–1787. 8. Kokkinos C, Nanidis T, Antcliffe D, et al. Comparison of laparoscopic versus hand-assisted live donor nephrectomy. Transplantation 2007; 83: 41–47. 9. Wolf JS Jr, Tchetgen MB and Merion RM. Hand-assisted laparoscopic living donor nephrectomy. Urology 1998; 52: 885–887.
Downloaded from scm.sagepub.com at UQ Library on March 13, 2015
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10. Shokeir AA. Open versus laparoscopic live donor nephrectomy: a focus on the safety of donors and the need for a donor registry. J Urol 2007; 178: 1860. 11. Delmonico FL, Sheehy E, Marks WH, et al. Organ donation and utilization in the United States. Am J Transplant 2005; 5: 862. 12. Halgrimson WR, Jeffrey C, Susan MM, et al. Donor complications following laparoscopic compared to hand-assisted living donor nephrectomy: an analysis of the literature. J Transplant 2010; 10: 825. 13. Lindstro¨m P, Haggman M and Wadstrom J. Handassisted laparoscopic surgery (HALS) for live donor nephrectomy is more time- and cost-effective than standard laparoscopic nephrectomy. Surg Endosc 2002; 16: 422–425. 14. Monti J. Live donor nephrectomy: least expensive approach yields best outcomes. Society of American Gastrointestinal and Endoscopic Surgeons 12th world congress of endoscopic surgery, http://www.medscape.com/viewarticle/720661 (accessed 2 March 2011).
15. BTS, http://www.bts.org.uk/Documents/Guidelines/Active/ UK%20Guidelines%20for%20Living%20Donor%20 Kidney%20July%202011.pdf (2011, accessed 12 October 2013). 16. Chiong E, Yip SK, Cheng WS, et al. Hand assisted laparoscopic living donor nephrectomy. Ann Acad Med Singapore 2004; 33: 294–297. 17. Chandak P, Kessaris N, Challacombe B, et al. How safe is hand-assisted laparoscopic donor nephrectomy?—Results of 200 live donor nephrectomies by two different techniques. Nephrol Dial Transplant 2009; 24: 293–297. 18. Lai IR, Yang CY, Yeh CC, et al. Hand-assisted versus total laparoscopic live donor nephrectomy: comparison and technique evolution at a single center in Taiwan. Clin Transplant 2010; 24: E182. 19. Øyen O, Andersen M, Mathisen L, et al. Laparoscopic versus open living-donor nephrectomy: experiences from a prospective, randomised, single-center study focusing on donor safety. Transplantation 2005; 79: 1236–1240.
Downloaded from scm.sagepub.com at UQ Library on March 13, 2015
Hand-assisted laparoscopic living donor nephrectomy: initial Glasgow experience
Scottish Medical Journal 58(4) 237–240 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933013507873 scm.sagepub.com
F Hanif1 and MJ Clancy2
Abstract Aims: The study presents the early results of hand-assisted laparoscopic living donor nephrectomy (HALDN) carried out in West of Scotland from June 2009 to October 2010. Methods: The first 20 HALDN procedures carried out in our unit are presented. The outcomes reported are warm ischaemia time, operative time, delayed graft function, recipient renal function and one-month morbidity and mortality of donor and recipient. SPSS 15.0 was used for statistical analysis. Results: The mean age of the donors was 44 10 years, predominantly females (n ¼ 13), median operative time 135 33 min and warm ischaemia time 41 16 s. The length of the incision used was 65 mm in all cases. Duration of hospital stay was 5 1 days. Patient mortality was 0 and morbidity minimal with two donors developing minor wound infection and no other clinically significant postoperative morbidity. Among the recipients, 18/20 (90%) transplants worked primarily with two delayed graft functions, one due to early surgical complications in a small paediatric recipient and one due to recipient renal artery thrombosis. Conclusion: HALDN is safe and associated with minimal morbidity; further analysis aims to confirm excellent cosmetic results and quick return to activity compared with the standard open nephrectomy technique.
Keywords Living donor, laparoscopic living donor nephrectomy, renal transplant
Introduction The shortage of donor organs, especially in renal transplantation, continues to lead to a discrepancy between the number of end-stage renal disease patients on waiting lists and the number of available kidneys for transplantation. The major strategy to address this deficit has been the promotion of living kidney donation. The number of living donor kidney transplants is increasing year by year, 589 in 2005–2006 to 1037 in 2009–2010 and now represents more than one in three of all kidney transplants in the United Kingdom.1 One key disincentive to living donor kidney transplantation is the necessity for a painful operation to remove the donor kidney. Traditionally, this surgery has been performed using open donor nephrectomy (ODN) techniques with a relatively large incision sometimes including resection of a rib. With the advent of minimal access surgery, the procedure of retrieving a kidney from a living donor has also evolved with pure laparoscopic and hand-assisted laparoscopic donor nephrectomy (HALDN) gaining wide popularity.
It has been demonstrated that these methods have definite advantages over open surgery in terms of blood loss, analgesic requirements, duration of hospital stay and convalescence, but there was no difference in transplant function.2–5 The laparoscopic donor nephrectomy was introduced in 1995 and is now carried out through three different approaches: laparoscopic transperitoneal (LDN), laparoscopic hand-assisted transperitoneal (HALDN) and laparoscopic retroperitoneal donor nephrectomy (LRDN).6,7 There is some controversy regarding the possibility of relatively longer warm ischaemia and operative time and more bleeding with LDN.8 HALDN was introduced with an aim to reduce warm ischaemia time by using the hand port to extract 1 2
Specialty Registrar, Renal Transplant Unit, Western Infirmary, UK Consultant Surgeon, Renal Transplant Unit, Western Infirmary, UK
Corresponding author: Faisal Hanif, Renal Transplant Unit, Western Infirmary, Glasgow, UK. Email: [email protected]
Downloaded from scm.sagepub.com at UQ Library on March 13, 2015
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the kidney instantly after dividing the blood vessels.5,9–11 This technique is also associated with the potential advantage of tactile feedback, better manual control of bleeding points and relatively shorter learning curve. LRDN favours a retroperitoneal approach, thus avoiding possible morbidity related to transperitoneal dissection. At present, there is no strong evidence to support the use of one laparoscopic approach in preference to the other; however, there is some evidence suggesting that HALDN represents the most costeffective method of donor surgery achieving the equivalent clinical benefits of pure laparoscopic approaches with less operative time.12–14 In the West of Scotland, ODN was a routine until the introduction of HALDN in June 2009. This study aims to present the outcome of initial 20 HALDN procedures carried out in our unit serving the West of Scotland.
Methods After a successful application to the new interventional procedures process, permission from NHS Greater Glasgow and Clyde clinical governance department for a HALDN programme was obtained. In view of start-up cost implications, a successful business case was made to justify logistical and funding support. The first 20 HALDN procedures carried out in our unit from June 2009 to October 2010 are presented. All HALDN procedures were carried out by the same surgeon (MJC) who has been formally trained to do this operation. The recipient operations were carried out by one of the other four surgeons in the team and not by the donor surgeon. The prospective assessment of living donor was based on Renal Society/British Transplantation Society guidelines.15 It involved ABO typing and HLA matching, evaluation of general fitness to coupe with the surgical procedure, assessment of the renal function and suitability of the kidney for donation from anatomical and immunological view point and exclusion of transmissible disease risk. The renal anatomy was visualised by magnetic resonance angiography and function was assessed by measuring glomerular filtration rate (GFR) with a radio isotope diethylene triamine pentaacetic acid (DTPA) scan.15 Dimercaptosuccinic acid scan was only used in selective donors when GFR was equivocal on DTPA scan. For the first eight cases, only donors with uncomplicated vascular arrangement and normal range body mass index were selected for HALDN. Subsequent cases were not differentially selected for laparoscopic versus open surgery based on renal vessel anatomy or body mass index. Our preferred side to retrieve a kidney was the left side because of the long left renal vein which facilitates ease of recipient surgery; however, the right
side was used where complex left-sided vascular anatomy was present. Informed consent was obtained after providing detailed printed and verbal information. All cases received formal approval and a licence to transplant from the Human Tissue Authority after being reviewed by an independent non-clinical assessor. Renal protection was provided by fluid pre-loading with normal saline on the night before surgery and the intraoperative use of FLOWTRON compression boots to minimise intraoperative haemodynamic changes due to position and pneumoperitoneum. All procedures were carried out under general anaesthesia in a lateral position with truncal flexion as previously described.16 For left-sided procedures, an upper midline 65 mm abdominal incision was made to allow the introduction of surgeon’s hand via a GelPortÕ (Applied Medical, CA, USA). For right-sided procedures, a Pfannenstiel incision was used. The inserted hand can supplement the procedure by manoeuvring the organ to facilitate dissection, apply pressure on any bleeding points and permit rapid, atraumatic and quicker retrieval of the kidney.16,17 Pneumoperitoneum was created after the placement of GelPortÕ . Two 10 mm incisions were used. For left-sided procedures, an infraumbilical port was used for the camera and left iliac fossa, mid clavicular line site for the working port. For right-sided procedures, an upper midline operating port was used along with a port at McBurney’s point for the camera. Dissection was carried out as previously described, mobilising the descending colon medially with Hormonic ACEÕ (Ethicon Endo-Surgery, OH, USA), incision of Gerota’s fascia and exposure of renal vessels16 The adrenal lumbar and gonadal veins were divided on the left side, renal vein and artery dissected to free them to obtain maximum length. The ureter was dissected to the level of pelvic brim. After the full mobilisation of the kidney within Gerota’s fascia, the ureter was divided at the level of pelvic brim and distal stump was secured with Ligaclips (Ligaclips Ethicon Inc., Somerville, NJ, USA). The renal artery followed by renal vein ^were then divided with an endovascular stapler (Ethicon Endo-surgery) ensuring maximum length and the kidney was retrieved through the GelPortÕ and handed over to the recipient surgeon for reperfusion and preparation. Haemostasis was secured and no drain routinely used. The donor was kept well hydrated after the procedure to ensure optimum urine output. The study end point was one-month follow-up for both donors and recipients. The outcomes reported are warm ischaemia time, operative time, delayed graft function, recipient renal function and one-month morbidity and mortality of donor and recipient. Mean values are given with standard deviation (SD). SPSS 15.0 was used for statistical analysis. Warm ischaemia time was the time taken from
Downloaded from scm.sagepub.com at UQ Library on March 13, 2015
Hanif and Clancy
239
removal of kidney from donor to placement in ice, whereas it has already been completely disconnected from donor. ‘Delayed graft function’ was defined as a need for dialysis in first week after renal transplant due to a poorly performing transplanted kidney and when it was not for management of hyperkalaemia or pulmonary oedema due to fluid overload. A ‘graft’ means a kidney for transplantation or already transplanted.
Results HALDN was carried out between June 2009 and December 2010 in 20 donors. Mean donor age was 44 10 years, predominantly females (n ¼ 13). The mean isotope GFR was 85 10. There were 15/20 left and the rest were right kidneys with a single artery each. The length of the hand port incision used was 65 mm in all cases. Mean operative time was 135 33 min with a warm ischaemia time 41 16 s (time taken for transfer from donor to ice). The mean length of renal arteries and veins retrieved was 28 5 and 27 5 mm, respectively. There was no intraoperative vascular or ureteric injury during organ retrieval. None of the donor required any blood transfusion. Mean duration of hospital stay for the donors was 5 1 days. Median followup was eight months. Two donors had minor wound infection with no other clinically significant postoperative morbidity. Among the recipients, 18/20 (90%) transplant worked primarily with two delayed graft function, one due to early postoperative renal vein thrombosis requiring successful revascularisation and the other due to recipient size mismatch and hypotension in a complex paediatric patient but both of them worked eventually. There were no other vascular or ureteric complications in the recipients.
Discussion HALDN has become the procedure of choice in many centres and our initial experience as others have shown that it is a safe, acceptable and popular approach for living donation. In our series, the standard incision size was only 6.5 cm. We managed to achieve adequate length of the artery and vein for transplantation (renal arteries and veins length 28 5 and 27 5 mm, respectively). The warm ischaemia time at retrieval has been criticised to be prolonged in minimally invasive procedures as compared to ODN, but in this study, the mean warm ischaemia time was 41 16 s as compared to Chiong et al.16 (2.16 min 0.72 s^). Mean duration of hospital stay was 5 1 days which is 1 day less than historical controls in our unit undergoing ODN. The mean hospital stay in other studies has been reported between three and six days.17,18 Critics of minimally invasive
surgery also point out gastrointestinal injuries which have been reported related to this procedure, but we report no gastrointestinal, vascular or ureteric injury in our series.19 The study is limited because of small number of patients, but it gives an encouragement to the centres like us which adopt or are planning to adopt minimal access techniques as a standard procedure for their patients. After the initial encouraging results, we are now offering HALDN to almost all donors and currently more than 90% live donor nephrectomies are carried out with this technique in Glasgow.
Conclusion HALDN is a safe procedure, associated with a small incision, minimal complications and quick return to normal activity. It should be offered as a first line of procedure to almost all potential live kidney donors. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of conflicting interests None declared.
References 1. NHS blood and transplant, http://www.uktransplant.org.uk/ ukt/statistics/transplant_activity_report/transplant_activity_report.jsp (2011, accessed 26 September 2013). 2. Greco F, Hoda MR, Alcaraz A, et al. Laparoscopic livingdonor nephrectomy: analysis of the existing literature. Eur Urol 2010; 58: 498–509. 3. Kok NF, Lind MY, Hansson BM, et al. Comparison of laparoscopic and mini incision open donor nephrectomy: single blind, randomised controlled clinical trial. BMJ 2006; 333: 221. 4. Nicholson ML, Elwell R, Kaushik M, et al. Health-related quality of life after living donor nephrectomy: a randomized controlled trial of laparoscopic versus open nephrectomy. Transplantation 2011; 91: 457–461. 5. Dolce CJ, Keller JE, Walters KC, et al. Laparoscopic versus open live donor nephrectomy: outcomes analysis of 266 consecutive patients. Surg Endosc 2009; 23: 1564–1568. 6. Ratner LE, Ciseck LJ, Moore RG, et al. Laparoscopic live donor nephrectomy. Transplantation 1995; 15: 1047–1049. 7. Kohei N, Kazuya O, Hirai T, et al. Retroperitoneoscopic living donor nephrectomy: experience of 425 cases at a single center. J Endourol 2010; 24: 1783–1787. 8. Kokkinos C, Nanidis T, Antcliffe D, et al. Comparison of laparoscopic versus hand-assisted live donor nephrectomy. Transplantation 2007; 83: 41–47. 9. Wolf JS Jr, Tchetgen MB and Merion RM. Hand-assisted laparoscopic living donor nephrectomy. Urology 1998; 52: 885–887.
Downloaded from scm.sagepub.com at UQ Library on March 13, 2015
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10. Shokeir AA. Open versus laparoscopic live donor nephrectomy: a focus on the safety of donors and the need for a donor registry. J Urol 2007; 178: 1860. 11. Delmonico FL, Sheehy E, Marks WH, et al. Organ donation and utilization in the United States. Am J Transplant 2005; 5: 862. 12. Halgrimson WR, Jeffrey C, Susan MM, et al. Donor complications following laparoscopic compared to hand-assisted living donor nephrectomy: an analysis of the literature. J Transplant 2010; 10: 825. 13. Lindstro¨m P, Haggman M and Wadstrom J. Handassisted laparoscopic surgery (HALS) for live donor nephrectomy is more time- and cost-effective than standard laparoscopic nephrectomy. Surg Endosc 2002; 16: 422–425. 14. Monti J. Live donor nephrectomy: least expensive approach yields best outcomes. Society of American Gastrointestinal and Endoscopic Surgeons 12th world congress of endoscopic surgery, http://www.medscape.com/viewarticle/720661 (accessed 2 March 2011).
15. BTS, http://www.bts.org.uk/Documents/Guidelines/Active/ UK%20Guidelines%20for%20Living%20Donor%20 Kidney%20July%202011.pdf (2011, accessed 12 October 2013). 16. Chiong E, Yip SK, Cheng WS, et al. Hand assisted laparoscopic living donor nephrectomy. Ann Acad Med Singapore 2004; 33: 294–297. 17. Chandak P, Kessaris N, Challacombe B, et al. How safe is hand-assisted laparoscopic donor nephrectomy?—Results of 200 live donor nephrectomies by two different techniques. Nephrol Dial Transplant 2009; 24: 293–297. 18. Lai IR, Yang CY, Yeh CC, et al. Hand-assisted versus total laparoscopic live donor nephrectomy: comparison and technique evolution at a single center in Taiwan. Clin Transplant 2010; 24: E182. 19. Øyen O, Andersen M, Mathisen L, et al. Laparoscopic versus open living-donor nephrectomy: experiences from a prospective, randomised, single-center study focusing on donor safety. Transplantation 2005; 79: 1236–1240.
Downloaded from scm.sagepub.com at UQ Library on March 13, 2015
