1164

BETTER ENDOPYELOTOMY RESULTS WITH LARGER STENT SIZE! ARE THEY STABLE IN THE LONG TERM?

Tuesday, May 24, 2005

Hansjoerg Danuser*, Eduard Dobry, Sebastian Z'Brun, Agostino Mattei, Urs E Studer, Bern, Switzerland

INTRODUCTION AND OBJECTIVE: The impact of stent size in endopyelotomy is still controversial. Animal studies comparing 7 and 14 Fr. stents did not show any significant difference in outcome, but consisted of small numbers. However, we recently could show significantly better results over two years postoperatively using 27 Fr. instead of 14 Fr. stents. The aim of this study was to analyze long-term outcome in this series of patients with a minimal follow up of 5 years.

METHODS: One hundred and thirteen patients of the 196 patients with primary (n=98) and secondary (n=15) ureteropelvic junction obstruction (UPJO) treated by antegrade endopyelotomy had a follow -up of five or more years. Preoperative work-up included a urogram, diuretic renography and retrograde pyelography. Endopyelotomy was performed through an antegrade access using cold knife technique and was stented with a 14 Fr. or 27 Fr. catheter at the level of the endopyelotomy. Follow-up controls within the first two years were performed with a urogram and diuretic renography, thereafter with a questionnaire and ultrasound control every 2-3 years.

RESULTS: Seventy-two patients were stented with a 14 Fr. stent, 41 patients with a 27 Fr. stent. The success rate five years after endopyelotomy was 65% (47/72 patients) and 83% (34/41 patients) in those with 14 Fr. and those with 27 Fr. stenting respectively (p=0.04). One important risk factor, the pyelocaliceal volume with a median of 51 (10 - 339) ml in the 14 Fr. series vs. 61 (15 - 460) ml in the 27 Fr. series was not significantly different (p=0.15). Also the function of the treated kidney was comparable in both series with a median of 172 (12-379) ml/min. In the 14 Fr. series vs. 167 (43 - 357) ml/min in the 27 Fr. series (p=0.47). The patients with primary UPJO had a long-term success rate of 64%, 42 of 66 patients with 14 Fr. and 88%, 28 of 32 patients with 27 Fr. stents respectively (p=0.012). Risk factors were also not significantly different.

CONCLUSIONS: It seems that large caliber stenting in patients with UPJO treated by antegrade endopyelotomy results in better outcome, not only in the short term, but also in the long-term of five and more years.

1631

EVOLVED TECHNIQUES IN HAND ASSISTED LAPAROSCOPIC DONOR NEPHRECTOMY IMPROVE OUTCOMES IN KIDNEY TRANSPLANT RECIPIENTS

Wednesday, May 25, 2005

Peter C Fisher*, Jeffrey S Montgomery, Willam K Johnston, J Stuart Wolf, Ann Arbor, MI

INTRODUCTION AND OBJECTIVE: We reviewed our first consecutive 200 hand assisted laparoscopic donor nephrectomies (HALDN) performed by a single surgeon. We describe the evolution of our operative technique and show how changes in technique translated into improved outcomes among transplant recipients.

METHODS: Outcomes assessed include patient demographics, operative events, postoperative donor complications, recipient ureteral complications, and recipient graft function. Lasting changes in our operative technique include utilizing bipolar electrocautery on the tributaries of the renal vein, dissecting the ureter using a gonadal/ureteral packet, and dripping papaverine on the renal artery then desufflating to rest the kidney prior to removal.

RESULTS: Overall incidence of intraoperative donor complications was 1.5%. Incidence of major postoperative complications was 5.5%. Length of hospital stay for kidney donors averaged 1.9 days (range 1-8 days). Warm ischemia time decreased from an average 186 seconds to 143 seconds (p=0.01) when bipolar electrocautery rather than clips were used on renal vein tributaries. Ureteral complications in transplant recipients decreased from an incidence of 12.5% to 4.5% (p=0.08) when the gonadal vein and ureter were taken as a packet. The incidence of primary non-function in the donor kidney decreased from 6.7% to 0% (p=0.02) with the advent of dripping papaverine over the renal artery, desufflating, and allowing the kidney to rest prior to nephrectomy. Overall 5 year graft survival was 95% in donor kidneys with papaverine treatment prior to explantation.

CONCLUSIONS: This experience illustrates how fine adjustments to HALDN technique can improve outcomes in donors and recipients. Careful assessment of postoperative care in donors and recipients can lead to evolutionary changes in operative technique that result in fewer complications with hand assisted laparoscopic living donor nephrectomy and transplantation.

1633

LAPAROSCOPIC DONOR NEPHRECTOMY: IMPACT OF WARM ISCHEMIA ON ALLOGRAFT FUNCTION

Wednesday, May 25, 2005

Mahesh Goel*, David A Goldfarb, Inderbir S Gill, Clevelend, OH

INTRODUCTION AND OBJECTIVE: A critique of laparoscopic donor nephrectomy (LDN) has been its longer warm ischemia time (WIT). However, to our knowledge WIT has not been specifically correlated with allograft functional recovery. We evaluate the short and long-term effects of WIT on allograft function.

METHODS: Data were evaluated from 207 consecutive laparoscopic donor-recipient pairs. Patients were retrospectively divided into four groups based on duration of warm ischemia: group I: WIT <3 minutes (n=22), group II: WIT 3-4 min (n=55), group III: WIT 4-6 min (n=107), and group IV: WIT > 6 min. (n=23). Data regarding baseline and perioperative variables, as well as short-term and long-term allograft function was correlated with WIT. WIT was used both as categorical and continuous variable for this purpose.

RESULTS: Among the 207 donor-recipient pairs, mean donor age was 42.5±9.2 years, mean BMI was 26.7 ±4.0, and mean WIT was 4.15±1.4 minutes. Mean recipient age was 44.4±13 yrs and BMI was 26.2±4.7. Demographic data were comparable amongst the four groups. Recipient serum creatinine between the groups was similar at day 1 (P=0.56), day 5 (P=0.46), 1 month (P=0.68) and 6 months (P=0.07). WIT did not correlate with the incidence of delayed graft function (P=0.22), acute rejection (P=0.99) and allograft (P=0.6) or recipient survival (P=0.7). There was no correlation between WIT and short or long-term graft function. Graft survival was 98% and 95%, and patient survival was 97% and 95% at 1and 2 years respectively, which was not impacted upon by WIT.

CONCLUSIONS: Our data suggest that warm ischemia time, within the range studied herein, does not have a significant impact on recipient and allograft outcome. Although, every effort should be made to minimize warm ischemia, it should not be at the expense of deliberate hemostasis and retrieving an anatomically superior kidney with optimal vessel lengths.

Read Laparoscopy Selected Abstracts - Part 7

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