M. Giessing

Laparoscopic live donor right nephrectomy: A new technique with preservation of vascular length

Purpose: We report our initial experience with right laparoscopic live donor nephrectomy using a modified vascular clamp for achieving maximal length of the renal vein. Materials and Methods: Since 1999, 34 patients have undergone laparoscopic live donor nephrectomy at ChariteHospital in Berlin, including 30 on the left and 4 on the right side. The right technique involves a 4-port transperitoneal laparoscopic approach with a muscle splitting lumbar incision for kidney extraction. To duplicate completely the comparable open operation a modified Satinsky atraumatic vascular clamp (Aesculap, Inc., Center Valley, Pennsylvania) was introduced throug ha1c m.lateral incision and placed across the vena cava, enabling harvest of the full length of the renal vein flush with the vena cava. The vena cavotomy is closed with a running suture placed in intracorporeal fashion. Results: All procedures were successfully accomplished without technical or surgical compli- cations. Mean operative time was 170 minutes. Mean renal warm ischemia time from endoscopic cross clamping of the renal vessels to cold perfusion on the bench was 2.1 minutes. In all 4 kidneys it was possible to harvest the whole length of the renal vein, so that the recipient operation was performed under optimal vascular conditions. All 4 kidneys were transplanted successfully in the recipients and showed immediate function. Conclusions: Right laparoscopic live donor nephrectomy is technically feasible, safe and a viable option for minimally invasive organ donation when left kidney donation is not desired. The Satinsky atraumatic vascular clamp enabled harvest of the whole right renal vein. We believe that this laparoscopic technique effectively duplicates the open operation with less morbidity.

Laparoscopy for living donor nephrectomy – particularities of the currently applied techniques

Today, laparoscopic donor nephrectomy (LDN) in many centers features the standard approach for kidney retrieval in living donors. More than 60% of the centers in the USA currently perform LDN and numbers are rising in Europe as well. Todays variety of laparoscopic approaches reflects the evolution in the field of LDN. Multiple modifications have been made for the laparoscopic approach, with consequences for intraoperative handling of the kidney, operating and ischemic times and with impact on donor, organ, and recipient. We reviewed the literature from 1995 to 2004 and critically evaluated the different technical modifications, their specific advantages and disadvantages and their impact for the operation. The article aims to help the surgeon choose the technique he feels most safe with for performing laparoscopic kidney retrieval safely and with good results for donor and recipient.

Orthotopic neobladder after kidney transplantation in a male patient with recurring urothelial carcinoma and renal cancer

Patients with analgesic nephropathy are at high risk for transitional cell carcinoma. Immunosuppression after renal transplantation increases the risk of de novo and recurrent malignancies up to 15%. 2 Reports on orthotopic bladder replacement after kidney transplantation are rare. We describe a male patient with recurring urothelial carcinoma and detection of renal carcinoma after renal transplantation. To our knowledge we report the first case of an orthotopic neobladder in a male patient with 2 occurrences of urological carcinomas after kidney transplantation.

Impact of surgeon experience on complication rates and functional outcomes of 484 deceased donor renal transplants: a single-centre retrospective study

Study Type – Therapy (outcomes)

Steroid- and calcineurin inhibitor free immunosuppression in kidney transplantation: state of the art and future developments

Owing to the increasing disparity of organ demand and organ supply the search for optimal immunosuppressive strategies has become a central issue in kidney transplantation (KTX). In the focus today are modifications of the use of calcineurin-inhibitors (CNIs, Cyclosporine A/Tacrolimus) and steroids, as they are nephrotoxic and promote cardiovascular risk factors like arterial hypertension, hyperlipidemia and diabetes mellitus. These modifications can either be withdrawal or avoidance of these substances in combination with new and/or established immunosuppressants. Because about half of all KTXs are performed by or with the help of urologists’ knowledge of modern immunosuppressive regimens is crucial also for urologists. We performed a literature research (PubMed, DIMDI, medline) for CNI- and steroid-sparing protocols and studies to elucidate their influence on graft-function and graft- and patient-survival. New substances and actual studies were also evaluated. Several published reports on CNI- and steroid-sparing protocols after KTX exist, including withdrawal, reduction or avoidance. The time of reduction seems to be crucial: an initially increased immune response should be counterbalanced by an initially intensified immunosuppression. Therefore, late steroid withdrawal seems to be safer than early withdrawal especially in Cyclosporine-based immunosuppression. Steroid avoidance also seems feasible on a CNI based regimen, especially in context with induction therapy. Withdrawal or avoidance of CNIs seems feasible with mycophenolate acid and/or induction therapy with IL 2-receptor antibodies as co-immunosuppressants. This is of interest in grafts with deteriorating function or from donors with extended criteria. Also, CNI- and steroid-free immunosuppression can be successfully performed with new immunosuppressants but results are yet premature. CNI- and/or steroid reduction, withdrawal or even avoidance is feasible. As long-term graft function is the goal of KTX and as more kidneys from donors with extended criteria are transplanted “tailored immunosuppression” will replace standards in the future.

Kidney transplantation into urinary conduits with ureteroureterostomy between transplant and native ureter: single-center experience.

OBJECTIVES To evaluate the functional outcomes and complications after allogeneic kidney transplantation into recipients with a urinary conduit using ureteroureterostomy between the transplant and native ureter. METHODS We performed a retrospective study of 6 patients with a pre-existing urinary conduit undergoing kidney transplantation at a single tertiary academic center from May 1982 to February 2007. RESULTS The study included 1 female and 5 males aged 16 to 65 years. Two patients received a living donor transplant. The indications for pretransplant conduit formation were neurogenic bladder in 3 and bladder contraction with vesicoureteral reflux in 3. One patient received a colon conduit. All patients underwent kidney transplantation into a urinary conduit using ureteroureterostomy between the transplant ureter and the ipsilateral native ureter. The average interval between conduit formation and kidney transplantation was 83.5 months and the average time of requiring hemodialysis was 56.3 months. The mean follow-up was 5.3 years. The patient and graft survival rate was 100% and 83.3%, respectively. The 3-year serum creatinine averaged 1.4 mg/dL. One graft was lost because of chronic rejection. Transplant ureter obstruction occurred in 2 patients and required endoscopy or open revision. Four patients underwent post-transplant native nephrectomy for recurrent pyelonephritis. Three patients were hospitalized for treatment of graft pyelonephritis. CONCLUSIONS In our experience, ureteroureterostomy between the transplant and native ureter is technically feasible and provides good functional results despite a high incidence of urinary tract infection. We recommend this approach in renal transplant recipients with a short contracted conduit or in those in whom the donor ureter is too short to warrant a tension-free ureteroileal anastomosis.

Kidney transplantation in childhood and adolescence

ZusammenfassungDie Ursachen der terminalen Niereninsuffizienz im Kindesalter unterscheiden sich deutlich von denen des Erwachsenenalters. Die Therapie der Wahl besteht in der Nierentransplantation. In Deutschland wurden im Jahre 2003 117 Kinder und Jugendliche nierentransplantiert. Spezifische Probleme bestehen in der Immunsuppression und den daraus resultierenden Komorbiditäten im Kindesalter. Der vorliegende Beitrag gibt eine Übersicht über die Möglichkeiten und Probleme der Vorbereitung, der Transplantation und des weiteren Verlaufs von Nierentransplantationen im Kindesalter.AbstractThe reasons for end-stage renal disease in pediatric patients differ from adults. The therapy of choice is renal transplantation. A total of 117 children and adolescents were treated with renal transplantation in 2003 in Germany. Immunosuppressive therapy and related comorbidities are the main problems in pediatric patients. The following article provides a summary of transplantation in children, preparation, and follow-up.

Nierentransplantation im Kindes- und Jugendalter

ZusammenfassungDie Ursachen der terminalen Niereninsuffizienz im Kindesalter unterscheiden sich deutlich von denen des Erwachsenenalters. Die Therapie der Wahl besteht in der Nierentransplantation. In Deutschland wurden im Jahre 2003 117 Kinder und Jugendliche nierentransplantiert. Spezifische Probleme bestehen in der Immunsuppression und den daraus resultierenden Komorbiditäten im Kindesalter. Der vorliegende Beitrag gibt eine Übersicht über die Möglichkeiten und Probleme der Vorbereitung, der Transplantation und des weiteren Verlaufs von Nierentransplantationen im Kindesalter.AbstractThe reasons for end-stage renal disease in pediatric patients differ from adults. The therapy of choice is renal transplantation. A total of 117 children and adolescents were treated with renal transplantation in 2003 in Germany. Immunosuppressive therapy and related comorbidities are the main problems in pediatric patients. The following article provides a summary of transplantation in children, preparation, and follow-up.

Incarcerated hernia after laparoscopic drainage of a lymphocele

Laparoscopic lymphocele drainage is considered the gold standard for the treatment of lymphoceles after kidney transplantation. We report on a female patient who developed a symptomatic posttransplant lymphocele. After laparoscopic lymphocele drainage the patient presented with acute pain in the left lower abdomen. A CT scan showed a hernia into the peritoneal window. This is a rare but potentially severe complication after intraperitoneal lymphocele drainage. CT imaging and swift reoperation with enlargement of the peritoneal window are critical to avoid serious complications. To avoid bowel incarceration, the peritoneal window should be as large as possible.ZusammenfassungDie laparoskopische Lymphozelenfensterung stellt eine Standardtherapie bei symptomatischen Lymphozelen nach Nierentransplantation dar. Wir berichten über eine Patientin, die nach erfolgter Nierentransplantation eine symptomatische Lymphozele entwickelte. Nach laparoskopischer Lymphozelenfensterung kam es einige Wochen später zu einer Ileussymptomatik. Eine computertomographische (CT-)Untersuchung zeigte eine inkarzerierte Dünndarmhernie in das zu kleine iatrogene Peritonealfenster. Es handelt sich um eine seltene Komplikation nach Lymphozelenfensterung. Durch CT-gestützte Bildgebung und zügige operative Revision mit Erweiterung des peritonealen Fensters lassen sich schwerwiegende Komplikationen vermeiden.AbstractLaparoscopic lymphocele drainage is considered the gold standard for the treatment of lymphoceles after kidney transplantation. We report on a female patient who developed a symptomatic posttransplant lymphocele. After laparoscopic lymphocele drainage the patient presented with acute pain in the left lower abdomen. A CT scan showed a hernia into the peritoneal window. This is a rare but potentially severe complication after intraperitoneal lymphocele drainage. CT imaging and swift reoperation with enlargement of the peritoneal window are critical to avoid serious complications. To avoid bowel incarceration, the peritoneal window should be as large as possible.

Inkarzerierte Hernie nach laparoskopischer Lymphozelenfensterung@@@Incarcerated hernia after laparoscopic drainage of a lymphocele

Laparoscopic lymphocele drainage is considered the gold standard for the treatment of lymphoceles after kidney transplantation. We report on a female patient who developed a symptomatic posttransplant lymphocele. After laparoscopic lymphocele drainage the patient presented with acute pain in the left lower abdomen. A CT scan showed a hernia into the peritoneal window. This is a rare but potentially severe complication after intraperitoneal lymphocele drainage. CT imaging and swift reoperation with enlargement of the peritoneal window are critical to avoid serious complications. To avoid bowel incarceration, the peritoneal window should be as large as possible.ZusammenfassungDie laparoskopische Lymphozelenfensterung stellt eine Standardtherapie bei symptomatischen Lymphozelen nach Nierentransplantation dar. Wir berichten über eine Patientin, die nach erfolgter Nierentransplantation eine symptomatische Lymphozele entwickelte. Nach laparoskopischer Lymphozelenfensterung kam es einige Wochen später zu einer Ileussymptomatik. Eine computertomographische (CT-)Untersuchung zeigte eine inkarzerierte Dünndarmhernie in das zu kleine iatrogene Peritonealfenster. Es handelt sich um eine seltene Komplikation nach Lymphozelenfensterung. Durch CT-gestützte Bildgebung und zügige operative Revision mit Erweiterung des peritonealen Fensters lassen sich schwerwiegende Komplikationen vermeiden.AbstractLaparoscopic lymphocele drainage is considered the gold standard for the treatment of lymphoceles after kidney transplantation. We report on a female patient who developed a symptomatic posttransplant lymphocele. After laparoscopic lymphocele drainage the patient presented with acute pain in the left lower abdomen. A CT scan showed a hernia into the peritoneal window. This is a rare but potentially severe complication after intraperitoneal lymphocele drainage. CT imaging and swift reoperation with enlargement of the peritoneal window are critical to avoid serious complications. To avoid bowel incarceration, the peritoneal window should be as large as possible.