Faculty Bibliography

PURPOSE: Inadvertent injuries during trocar and Veress needle placement are a rare but potentially serious complication of laparoscopic surgery. An access alternative is an optical trocar under direct vision. Limited data are available regarding the safety of this technique. We reviewed complications related to optical access trocars during standard transperitoneal urological laparoscopic procedures performed at a single institution. MATERIALS AND METHODS: From 1995 to 2001 the optical access trocar was used as the initial trocar in 1,283 urological laparoscopic procedures. The procedures included simple and radical nephrectomy in 309 cases, donor nephrectomy in 386, partial nephrectomy in 79, pyeloplasty in 173 and various other procedures in 336. Intra-abdominal complications caused by optical access trocar were assessed. RESULTS: The optical trocar was inserted at the umbilicus in 88 patients (7.4%), in the right upper quadrant in 445 (34.7%) and in the left upper quadrant in 750 (58.5%). There were 4 injuries (0.31%) associated with the optical access trocar. Complications occurred on the left side in 3 cases and on the right side in 1, including 1 injury to bowel, 1 mesenteric injury resulting in a retroperitoneal hematoma and 2 injuries to epigastric vessels. Three cases were recognized and repaired immediately but in a case of epigastric vessel injury the expanding abdominal wall hematoma required postoperative repair. CONCLUSIONS: Optical access trocars provide a safe and rapid technique for initial trocar placement. Results of this large series support the finding that few trocar related complications are associated with the optical access trocar

BACKGROUND: Pulsatile perfusion (PP) is used by some centers to provide information that may aid in the selection of cadaveric renal allografts for transplantation. However, basing organ acceptance on PP parameters alone may lead to the discarding of kidneys from otherwise suitable donors. In this case series, we report the reevaluation and transplantation of kidneys refused by other centers after evaluation with PP. METHODS: Retrospective review of 14 cadaveric kidneys imported for repeat PP at our center after initially poor PP parameters from an outside organ procurement organization resulted in refusal by multiple centers. RESULTS: Median age of donors was 46 (range 21-64), and mean terminal serum creatinine was 1.3+/-0.6 mg/dL. Despite favorable donor characteristics, each kidney was refused by an average of 9.3 centers. Poor PP parameters and concerns about donor quality were the reasons for refusal in the majority of cases. Pulsatile-perfusion parameters at the outside center were poor: mean flow of 103 mL/min/100 g and mean resistance of 0.321 mm Hg/(mL/min/100 g). Repeat PP parameters at our center after importation were markedly improved (flow=167 mL/min/100 g and resistance=0.195 mm Hg/[mL/min/100 g]). Eleven of 14 kidneys were transplanted and currently have acceptable graft function (mean serum creatinine=1.6 mg/dL at a median follow-up of 12 months). CONCLUSIONS: This series describes the successful transplantation of 11 kidneys from acceptable donors that were initially discarded by multiple centers after poor PP parameters were obtained. The good allograft function in these organs emphasizes the importance of considering all donor factors when making allocation decisions.

OBJECTIVE: The purpose of this study was to determine the accuracy of multidetector CT (MDCT) angiography as the primary imaging technique in the evaluation of living kidney donors. SUBJECTS AND METHODS: Seventy-four consecutive living kidney donors (30 men, 44 women; mean age, 41.7 years) who underwent MDCT were evaluated. CT examination was performed with 120 mL of IV contrast material at an injection rate of 3 mL/sec and a pitch of 6. In every case, arterial and venous phase volumetric data sets were acquired at 25 and 55 sec, respectively. Scans were reconstructed at 1-mm intervals for three-dimensional (3D) imaging using a volume-rendering technique. Axial CT images and 3D CT angiography were evaluated prospectively by one reviewer and retrospectively by two reviewers who had no knowledge of surgical results. Surgical correlation for the location of primary and accessory renal arteries, early branching of the renal arteries, and renal vein anomalies was made. RESULTS: Seventy-two subjects underwent left nephrectomy, and two subjects underwent right nephrectomy because supernumerary left renal arteries were detected on preoperative CT angiography. Eighteen supernumerary renal arteries (two arteries to 16 kidneys and three arteries to one kidney) to 74 kidneys underwent nephrectomy. CT and surgical findings agreed in 93% of subjects (the average of three reviewers; range, 89-97%). Two small accessory renal arteries were missed by all three reviewers. Those arteries were diminutive and were thought to be insignificant by the surgeons. Early branching of the renal arteries was shown in 14 arteries, and CT and surgical findings agreed in 96% (the average of three reviewers; range, 93-97%). Renal vein anomalies were present in eight subjects, and CT and surgical findings agreed in 99% of the cases (range, 96-100%). CONCLUSION: MDCT angiography is highly accurate for detecting vascular anomalies and providing anatomic information for laparoscopic living donor nephrectomy.

Antibody-mediated rejection (AbAR) is increasingly recognized in the renal allograft population, and successful therapeutic regimens have been developed to prevent and treat AbAR, enabling excellent outcomes even in patients highly sensitized to the donor prior to transplant. It has become critical to develop standardized criteria for the pathological diagnosis of AbAR. This article presents international consensus criteria for and classification of AbAR developed based on discussions held at the Sixth Banff Conference on Allograft Pathology in 2001. This classification represents a working formulation, to be revisited as additional data accumulate in this important area of renal transplantation.

There is a significant shortage of donor kidneys. As a result, kidney transplant candidates wait for prolonged periods of time for an organ, and over eight die every day while awaiting a kidney transplant. To improve this situation, the transplant community has actively sought creative solutions to the organ shortage. Many patients have willing live donors who are excluded from donation due to a positive crossmatch or blood group incompatibility. Plasmapheresis and intravenous immunoglobulin in combination can efficiently remove antibodies against donor tissue and blood group antigens and prevent these antibodies from returning after transplantation. Both strategies are complex but have good success rates and provide an opportunity for transplantation to those who might wait years for an organ or die waiting on the list Knowledge of these novel protocols is essential for the nephrology nurse who is often the first health care provider to discuss transplantation with end stage renal disease (ESRD) patients.

Routine live donor evaluations reveal unexpected silent pathologies. Herein, we describe our experience treating such pathologies at the time of laparoscopic donor nephrectomy. We have not encountered any previous reports of such an approach. We prospectively collected data on 321 donors. Concomitant surgeries at the time of procurement included two laparoscopic adrenalectomies, one colposuspension, one laparoscopic cholecystectomy, and one liver biopsy. Mean operative time was 321 min (range 230-380), with a mean blood loss of 280 mL (range 150-500). No blood transfusions were required. The left kidney was procured in four cases. The right kidney was obtained on one occasion. Mean hospital stay was 3 days (median 3, range 2-4). No short- or long-term complications have been identified. Mean follow-up time was 2.63 years (median 2.76, range 2.23-2.99). Four of the five kidney recipients were first-time transplants who had not yet started dialysis. Simultaneous surgical interventions at the time of laparoscopic live kidney donation are safe and can be undertaken in selected cases. This practice is beneficial to both the donor and the recipient, and is likely to become more commonplace with changing practice patterns involving donor evaluation and management

BACKGROUND/AIMS: Noting the contribution to renal transplantation by the introduction of the laparoscopic approach to donor nephrectomy, we investigated the possibility of performing a laparoscopic hepatic lobe procurement with the goal of performing a live donor liver transplantation. We describe our technique and determine its feasibility for such a goal. METHODS: The surgical technique was developed over a series of 12 adult female pigs and adapted in two human cadavers. The technique included pneumoperitoneum with CO2, mobilization of the liver, and transection of the parenchyma into right and left lobes with a laparoscopic cavitron ultrasonic aspirator. The vascular inflow and outflow structures (hepatic artery, portal vein, hepatic veins) of the anatomical specimen being procured were preserved undisturbed during the hepatic transection. No temporary vascular occlusion techniques were utilized. The vascular structures were stapled and sectioned just prior to removal of the specimen. RESULTS: Hepatic lobectomies were successfully performed laparoscopically. Vascular and biliary structures were preserved to allow for subsequent transplantation. Operative time from establishment of pneumoperitoneum to lobe procurement was under 4 h. CONCLUSIONS: This study demonstrates the feasibility of laparoscopic living donor procurement for liver transplantation, from both a technical and a physiological perspective

A stagnant supply of transplantable organs in the face of a relentless burgeoning of transplant waiting lists has created a crisis. Necessity continues to be the mother of invention and as the crisis has deepened it has served as a crucible for the development of new ways to think about perennial problems. Our program has taken a 2-pronged approach to increasing the organ supply for our patients. First, through innovations like the laparoscopic donor nephrectomy, ABO-incompatible and positive-crossmatch transplantation protocols, unconventional paired kidney exchanges, and the use of altruistic donors we have more than doubled our utilization of live donor organs. At the same time, we have developed algorithms and interrogative techniques to enhance the intelligent use of kidneys from expanded criteria donors for patients who do not have an available live donor. The laparoscopic nephrectomy has proven to be a safe and effective way of removing a significant barrier to live donation. Our results from 100 ABOi, (+)XM, and PKE transplants are similar to national statistics for compatible live donor transplants, suggesting that existing paradigms of compatibility can be safely expanded. These encouraging early outcomes and the savings they transmit to the health care system have allowed us to obtain insurance coverage for the InKTP programs, setting the stage for further expansion of these opportunities to broaden the options for patients with end-stage renal disease.

BACKGROUND: Deposition of C4d in peritubular capillaries (PTCs) has been shown to be a sensitive marker for antibody-mediated (humoral) rejection in renal transplant biopsies. Some studies also suggest that C4d in PTCs is specific for humoral rejection or, at least, for the presence of donor-specific antibodies. However, in other studies, PTC C4d deposits were noted in more than 40% of renal transplant biopsies performed for graft dysfunction and capillary C4d deposition in heart transplants may result from ischemic injury. METHODS: To test the specificity of C4d staining as a marker for acute humoral rejection ACR in renal allografts, indirect immunofluorescence using a monoclonal anti-C4d antibody and a fluorescein-isothiocyanate-conjugated secondary antibody was performed on cryostat sections of 90 renal transplant biopsies, including 35 pairs of preimplantation and 1-hr postreperfusion biopsies of the same graft, postreperfusion biopsies of 12 additional grafts, and 8 positive controls (biopsies with known C4d-positive AHR). Eighteen grafts were cadaveric, 17 grafts were liviing-related, and 12 grafts were living-unrelated (excluding controls). Included in these grafts were 13 grafts that developed AHR 3 to 34 days posttransplantation. RESULTS: Only 2 of 82 perioperative biopsies showed C4d staining in PTCs. Both perioperative biopsies were postreperfusion biopsies of grafts diagnosed with AHR 5 and 34 days posttransplantation, respectively, and, in each case, the recipient had been treated with plasmapheresis before transplantation because of a positive crossmatch (cytotoxic and flow cytometric) and continued to have a weakly positive flow crossmatch at the time of transplantation. In one biopsy, C4d staining was focal, and in the other biopsy, it was diffuse; in both biopsies, C4d staining was relatively mild (1+ on a 0-4+ scale). No C4d staining was noted on preimplantation biopsies of each graft. All biopsies that contained glomeruli showed linear capillary loop or blotchy mesangial staining, or both, which was similar in prereperfusion and postreperfusion biopsies. All positive controls showed diffuse C4d staining in PTCs. CONCLUSIONS: C4d staining in PTCs may be seen as early as 1 hr posttransplantation in some recipients with low levels of antidonor antibodies. However, this was not observed as a feature of ischemic or ischemia-reperfusion injury in perioperative renal transplant biopsies, including those of cadaveric grafts with cold ischemia times of as long as 41 hr.