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ARTERIAL ANASTOMOSIS WITHOUT SUTURES USING RING-PIN STAPLER IN RENAL TRANSPLANTATION: A COMPARISON BETWEEN RING-PIN STAPLER AND SUTURE ANASTOMOSES

Ye G., Mo H.G., Yin-Fu Z., Zhi-Lin Y.

Xinqiao Hospital, The Third Military Medical University, Department of Urology, Chongqing, China

INTRODUCTION & OBJECTIVES: Vascular anastomosis using ring-pin staplers was reported in several animal and clinical studies. The description of the ease of application and absence of foreign material in the vascular lumen with a near-perfect coaptation of the intimal surface in the line of anastomosis let us to evaluate the mechanical ‘nonsuture’ technology in renal transplantation.

MATERIAL & METHODS: During 1991 and 2002 the renal artery anastomosis to the internal iliac artery in an end-to-end fashion were performed with ring-pin staplers in 36 transplant recipients (non-suture group, N-group). At other times the arterial anastomoses were sutured by one of the skilful surgeons with interrupted 5 or 6/0 cardiovascular suture in 39 patients (Suture group, S-group). There was no statistically significant difference between the groups with respect to sex distribution or to age (male/female ratio 2:1 and 3:2 in N-group and S-group, respectively; mean age 38.9 and 43.3, N- and S-group respectively; p>0.05).

The mean diameter of the donor renal artery was 5.5 mm in N-group and 5.6 mm in Sgroup (p>0.1), and that of the internal iliac artery was 5.3 mm and 5.5 mm respectively (p>0.1). An ex vivo double-barrel anastomosis of the donor renal arteries was carried out in 3 donor kidneys in N-group and in 4 in the other group. The 5-mm ring was applied in all but 3 cases, in which the 6-mm ring was used. The donor renal vein was anastomosed to the external iliac vein in end-to-side fashion using 5 or 6/0 cardiovascular sutures. Reestablishment of the urinary tract was carried out by extravesical ureteroneocystostomy.

RESULTS: The operations with ring-pin stapler were successfully completed in all 36 patients. The arterial anastomoses took 5.5-9 min (average: 7 min) in N-group and 10-20 min (means: 16 min) in S-group (p<0.01) to complete. A small suture line leak was encountered in each group, and it was temporary and self-stopping. There was no arterial thrombosis. In non-suture group, two donor kidneys have a lower polar artery that was successfully anastomosed to the epigastric artery with ring-pin stapler (using 3-mm ring). All the patients had an uneventful recovery except one in S-group (2.6 per cent), who died postoperatively of sepsis. Sixty-five patients (34 in N-group and 32 in S-group) were followed up for 9-24 months. Based on the findings of echo-Doppler techniques, renal artery stenosis was observed in no cases in N-group but 2 patients in S-group (5.1 per cent) that caused poorly controlled hypertension on 3 or more antihypertensive medications.

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LIVING- UNRELATED KIDNEY TRANSPLANTATION UNDER CURRENT IMMUNOSUPPRESSIVE PROTOCOLS: COMPARISON OF RESULTS WITH LIVING RELATED AND CADAVERIC TRANSPLANTS

Chkhotua A.¹, Yussim A.², Bar-Nathan N.², Shaharabani E.², Lustig S.2, Shapira Z.2, Mor E.²

¹National Centre of Urology, National Centre of Urology, Tbilisi, Georgia, ²Rabin Medican Centre, Transplantation, Petach-Tiqva, Israel

INTRODUCTION & OBJECTIVES: Widespread acceptance of living-unrelated kidney transplantation (Tx) is till an ethically controversial issue. Despite several publications, not all its benefits and drawbacks are clear. We analyse our 3-year, single centre experience with 302 kidney Tx. comparing the outcomes of living-unrelated with living-related and cadaver transplants.

MATERIAL & METHODS: Between 9/97 and 1/00, 129 patients underwent living kidney Tx. from related (L.R.D.; n=80) and unrelated (L.U.R.; n=49) donors and another 173 received a cadaver graft (C.G.). Of 49 unrelated donors 25 were spouses, 18 - friends, cross-over Tx. was done between spouses of 2 couples and another 2 were altruistic donations. Immunosuppressive protocols consisted of MMF with Cs.A.-neoral (41%) or tacrolimus (59%), plus steroids. Patient and graft survival data, rejection rate, graft functional parameters and post-Tx complications have been compared between the groups.

RESULTS: L.R.D. recipients were younger than L.U.R.D. and C.G. patients (p<0.001), with the less number of re-transplants than in L.U.R. group (p<0.05). H.L.A. matching was higher in L.R.D. than in L.U.R. recipients (p<0.001). Acute rejection developed in 28.6% of L.U.R. vs. 27.5% of L.R.D. and 29.7% of C.G. recipients (p=N.S.). There was no statistical difference in severity of rejections between the groups. The incidence of delayed graft function was significantly higher in C.G. recipients (22.1%) than in L.U.R. (6.2%) and L.R.D. patients (3.9%. p<0.001). The mean diuresis 48 hours post-Tx. was significantly lower in CG recipients than in L.R.D. and L.U.R.D. patients (p<0.05). The mean creatinine levels at 1 week, 1 and 6 months, 1, 2 and 3 years post-Tx were similar for all three groups. Early and late post-operative complications did not differ between the groups. There was no difference in patient survival. One-, 2- and 3-year graft survival rates were significantly better in patients of L.U.R. (92.7%, 88.3%, 88.3%) and LRD transplants (91.9%, 91.9%, 87.1%) than in cadaver kidney recipients (80.3%, 78.6%, 76.2%) (p<0.01). In the Cox hazards regression model increasing recipient age and retransplantation were associated with patient death (odds ratios 1.1 and 9.7; p=0.0012 and 0.0073, respectively) and graft loss (odds ratios 1.04 and 9.6; p=0.0035 and 0.0019, respectively).

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TRANSPLANTING CADAVERIC KIDNEYS FROM OLD DONORS INTO OLD RECIPIENTS - GOOD RESULTS WITH A LOT OF COMPLICATIONS

Giessing M.¹, Conrad S.², Neumayer H.H.³, Stahl R.A.K.⁴, Huland H.², Loening S.A.¹

¹Humboldt University of Berlin, Charité, Campus Mitte, Department of Urology, Berlin, Germany, ²Universitätsklinikum Hamburg Eppendorf, Department of Urology, Hamburg, Germany, ³Humboldt University of Berlin, Charité, Campus Mitte, Department of Nephrology, Berlin, Germany, ⁴Universitätsklinikum Hamburg Eppendorf, Department of Nephrology, Hamburg, Germany

INTRODUCTION & OBJECTIVES: Cadaveric kidneys from old donors have a significantly worse prognosis than kidneys from donors of younger age groups when transplanted with cold ischemia times (CIT) around 20 hours. However, there is evidence that the functional potential of these kidneys can be preserved by very short CIT. To enlarge the potential donor pool, Euro transplant started in 1999 a separate allocation program for kidneys of donors over 64 years. These kidneys are allocated to local or regional recipients older than 64 years - without HLA-matching, since they are thought to have a less reactive immune system - to ensure short CIT. We have analyzed the outcome of patients and kidneys transplanted in our centres within the European Senior Program (ESP).

MATERIAL & METHODS: Patients were evaluated retrospectively for demographic data, initial and subsequent kidney function, perioperative and late complications, and graft and patient survival were noted. Immunosuppression was performed with Cyclosporin A, steroids and Azathioprin or MMF in the majority of cases.

RESULTS: From January 1999 to June 2003, 60 ESP-transplants were performed (median: donor age 69.8 years, recipient age 67.3 years, 4 HLA-mismatches). Due to a median CIT of 8 hours, 51 of 60 kidneys (80%) showed primary function. There was one perioperative death due to cardiac decompensation and 3 other patients developed pulmonary oedema. Surgical complications included ureteral leaks or stenoses in 3 (5%) and lymphoceles in 7 (12%). Infectious complications were frequent (23 of 60 patients, 38%) and included septicimia (7%), fatal encephalitis (2%), liver abscess (2%), perforating diverticulitis (2%), wound infections (5%), pneumonia (7%) CMV reactivation (7%), and symptomatic UTI (12%). On the other hand, biopsy proven rejections were noted in as much as 32 of 60 kidneys (53%). After a median follow-up of 25 months, 8 patients have died mainly due to cardiac reasons (all with functioning graft) and 4 grafts were lost. The remaining kidneys maintained adequate function: median serum creatinine was 1.7 mg/dl at 1 month and 1.9 mg/dl at 3 years. The 3-year graft survival censored for death with functioning graft is 76%.

CONCLUSIONS: These data demonstrate that cadaveric kidneys from old donors can achieve acceptable long-term functions in old recipients if short CIT are provided.

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LAPAROSCOPIC VS. OPEN DONOR NEPHRECTOMY - IMPACT ON QUALITY OF LIFE AND WILLINGNESS TO DONATE

Giessing M.¹, Reuter S.¹, Schönberger B.¹, Deger S.¹, Hirte I.¹, Budde K.², Fritsche L.², Neumayer H.H.², Loening S.¹

¹Charité University Hospital, Department of Urology, Berlin, Germany, ² Charité University Hospital, Department of Nephrology, Berlin, Germany

INTRODUCTION & OBJECTIVES: Living kidney donation now features more than 50% of all renal transplantations performed in the US and numbers are rising in Europe as well. Despite donors’ altruistic motivation, obstacles against kidney donation include the fear of the operation, including associated pain and time away from home and work. With implementation of the less traumatic laparoscopic organ retrieval by Ratner in 1995, this technique has been reported to support donors’ willingness to step forward. Nevertheless, no study has been performed yet to compare the classic open donor nephrectomy with the laparoscopic approach with regard to the impact of the surgical technique on donors’ quality of life (QoL). We therefore performed a retrospective study on QoL of all donors who donated a kidney at our hospital from 1983 to 2001.

MATERIAL & METHODS: Three questionnaires were sent to all living kidney donors of our department. Answers of the validated and standardized international SF-36 questionnaire and the validated and standardized German GBB-24 questionnaire were compared with age- and gender matched national references. A third questionnaire included specific questions on the impact of the organ retrieval technique.

RESULTS: Two of the 120 donors had died due to risks unrelated to organ donation, further 12 were lost to follow-up. All of the 106 contactable donors answered, reflecting the highest response rate reported in comparison to other studies. Therefore, a bias - as possible reason for favourable results - could be excluded. Of the donors 58% had an open and 42% a laparoscopic organ retrieval, complication rates and complaints after organ donation did not differ between the groups. The SF-36 questionnaire revealed a better QoL for laparoscopic organ retrieval in 7 of 8 items, even though differences were significant only for the item "mental health". No difference between the laparoscopic and open was seen in the German GBB-24 questionnaire. Specific questions revealed that 89% (lap) vs. 94% (open) would be willing to donate again if possible (p=ns). For 45% of the donors the technique applied would be an important issue and of these 80% would prefer the laparoscopic approach.

CONCLUSIONS: Laparoscopic organ retrieval is followed by a better quality of life than open donation. Nevertheless, surgical technique in our study is important only for less than half of the donors, underlining the strong altruistic motivation of the donors. Whether a rising number of donors due to the retrieval technique is a centre-effect has to be further determined.

335

LAPAROSCOPIC TRANSPERITONEAL PYELOPLASTY USING A REMOTECONTROLLED ROBOTIC SURGICAL SYSTEM (DA VINCI®). 37 CASES

Hubert J., Feuillu B., Mourey E., Ferchaud J., Prevot L., Mangin P.

CHU Nancy - Brabois, Department of Urology, Nancy, France

INTRODUCTION & OBJECTIVES: Dismembered pyeloplasty is the gold standard treatment for uretero-pelvic junction (UPJ) syndrome. Laparoscopic dismembered pyeloplasty has been developed for few years but is a challenging procedure. Recent developments in robotic assisted remote laparoscopy offer the surgeon a real benefit in this type of surgery. Objective: To evaluate the feasibility and results of laparoscopic robotic pyeloplasty.

MATERIAL & METHODS: From November 2001 to September 2003 we performed 37 transperitoneal laparoscopic pyeloplasties for UPJ obstruction with a remotecontrolled robotic surgical system (Da Vinci®). 4 ports were used: 3 for the robotic arms and 1 for the assistant. Suture was completed with 6/0 running sutures and a ureteral JJ stent was introduced preoperatively and left indwelling for 4 weeks. Mean patient age: 37 years (17-81), sex ratio: 12 men and 25 women. Control IVU was performed 3 months after surgery.

RESULTS: 36 pyeloplasties (12 left, 24 right) were completed laparoscopically with the robot. There was 1 open conversion related to difficulties of uretero-pelvic dissection on a large inflammatory left kidney. An inferior polar pedicle had to be uncrossed in 22 cases. Mean operative time was 135 min (80-210). Mean suturing time was 38 min (18- 60), including JJ stent placement. Mean hospital stay was 6.5 days (5-11). Bladder catheter was removed at day 3 (2-9). There were 3 post-operative urinary infections which resolved with antibiotic treatment. At 3 months follow-up, all the patients were clinically improved. Of the 24 available IVU’s there was a good ureteral excretion at 10 minutes in 23 patients (one patient was slightly improved).

CONCLUSIONS: Robotics offers many undeniable advantages: 3-dimensional vision, image magnification, precision of movements, ergonomic surgeon position. It allows the open surgeon to transfer his surgical skill to the laparoscopic approach. Laparoscopic robotic pyeloplasty is performed with anatomical results comparable to those obtained in open surgery with magnification glasses, and with a now equivalent operative time. Robotic surgery will probably have an outstanding impact in the treatment of UPJ syndrome.

336

ROBOTIC-ASSISTED LAPAROSCOPIC PYELOPLASTY: CLINICAL RESULTS

Peschel R.¹, Neururer R.¹, Bartsch G.¹, Chow G.², Gettman M.²

¹University Hospital Innsbruck, Department of Urology, Innsbruck, Austria, ²Mayo Clinic, Department of Urology, Rochester, United States

INTRODUCTION & OBJECTIVES: The Da Vinci robotic system has been introduced with a goal of simplifying complex laparoscopic tasks like intracorporeal suturing. Laparoscopic pyeloplasty is an effective treatment modality for ureteropelvic junction obstruction, but intracorporeal suturing may limit clinical applicability. We reviewed our clinical results with Da Vinci-assisted laparoscopic pyeloplasty. MATERIAL & METHODS: From June, 2001 through August, 2003, 45 patients with symptomatic ureteropelvic junction obstruction (UPJO) underwent Da Vinci-assisted laparoscopic pyeloplasty using a 4-port transperitoneal approach. Anderson-Hynes and non-dismembered pyeloplasty were performed in 35 and 10 patients, respectively. All steps of laparoscopic pyeloplasty were performed by the surgeon from a remote control unit and a scrubbed assistant surgeon. Perioperative results and radiographic follow-up data were retrospectively reviewed. RESULTS: All steps of robotic-assisted Anderson-Hynes and non-dismembered pyeloplasties were successfully performed. Optimal robotic function required careful positioning and alignment taking into account individual variations at the UPJO. The scrubbed assistant surgeon was also critical to the success of the robotic-assisted procedure. The mean operative times for Anderson-Hynes and non-dismembered pyeloplasty were 142 minutes (range 90-270 minutes) and 105 minutes (range 70-200 minutes), respectively. The mean lengths of stay for Anderson-Hynes and nondismembered pyeloplasty were 4.5 days (range 3-7) and 4.2 days (range 3-6), respectively. Estimated blood loss was < 50 cc in all cases. No intraoperative complications were observed related to the robotic device. In one case stent placement was not possible, therefore conversion was performed. One access-related bowel injury in the non-dismembered cohort required open conversion and repair. Postoperatively, open exploration was required in one patient in the Anderson-Hynes cohort to repair a defect in the renal pelvis. At a mean follow-up of 18 months (range 3 - 27 months), the overall objective success rate was 100%. CONCLUSIONS: A coordinated approach by the surgeon and scrubbed assistant is required for optimal function of the robotic device. The initial clinical results for roboticassisted Anderson-Hynes and non-dismembered pyeloplasty appear encouraging but long-term follow-up is yet missing.

LB12

KIDNEY TRANSPLANTATION IN CHILDREN. LONG TERM SINGLE CENTRE EXPERIENCE

Hamdi M., Mohan P., Little D.M., Hickey D.P.

Royal College of Surgeons, Urology and Transplantation Department, Beaumont Hospital, Dublin, Ireland

INTRODUCTION & OBJECTIVES: Kidney transplantation in children represents both technical and immunological challenge to the transplantation team. We report our long term experience in the field.

MATERIAL & METHODS: From January 1986 till the end of December 2001, 158 kidney transplants were performed in 130 recipients. (70 males and 60 females). Mean Age at transplantation was 12.73 years (range 2-18 years). Causes of ESRD were pyelonephritis in 57 (36%) patients, glomerulonephritis in 46 (29%), congenital malformation and hereditary disorders each in 16 (10%) and unknown aetiology in 23 (15%). Standard surgical techniques were adopted with intraperitoneal placement of the graft in children less than 20 kg in weight. Postoperative immunosuppression protocols can be classified into 3 eras. Era1 (1986-1990), Cyclosporine, Immuran, and Steroids. Era 2 (1991-1996) Antithymocyte- globulin (ATG), Neoral, Immuran and Steroids. Era 3 (1997-2001), Tacrolimus, Mycophenolate mophetil (MMF), and Steroids.

RESULTS: The overall patient survival is 94%. Causes of death were hyperkalaemia in 3, cardiac arrest in 2, sepsis in 2, subarachnoid haemorrhage in 1, cerebrovascular accident in 1 and post bone marrow transplantation in 1. Median graft survival is 7.37 years. Causes of graft failure were rejection in 44 patients, renal vein thrombosis in 8, recurrence of the original disease in 8, death with a functioning graft in 5 and haemolytic uraemic syndrome in 1. Changing our immunosuppression protocols dramatically affected our results. The 1, 3 and 5 years graft survival were for era1, 56%, 46%, 42%, era2, 79%,72%,64%, era3, 88% 77% 73% respectively.

CONCLUSIONS: For successful kidney transplantation in a child, meticulous surgical as well medical care is needed. Aggressive immunotherapy is a key element of success but should be balanced against the potential harmful impact of these drugs on growth and development.

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