Skill and talent
Pioneer experience in Spain with LESS nephrectomy in living donor
Experiencia pionera en España con nefrectomía LESS de donante vivo
M. Musquera
, L. Peri, L. Izquierdo, P. Campillo, M.J. Ribal, A. Alcaraz
Corresponding author
Servicio de Urología, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Musquera, L. Peri, L. Izquierdo, P. Campillo, M.J. Ribal, A. Alcaraz" "autores" => array:6 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Musquera" "email" => array:1 [ 0 => "mmusquer@clinic.ub.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Peri" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Izquierdo" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Campillo" ] 4 => array:2 [ "nombre" => "M.J." "apellidos" => "Ribal" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Alcaraz" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Urología, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Experiencia pionera en España con nefrectomía LESS de donante vivo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 681 "Ancho" => 850 "Tamanyo" => 67529 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Abdominal incision for the insertion of the Quadport<span class="elsevierStyleSup">®</span>.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years, the rate of cadaveric donation has been reduced, especially at the expense of a reduction in the mortality of young people due to traffic accidents, elderly donors currently representing the principal percentage.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This fact has led to a very important shortage of organs, especially for young people. In an attempt to increase the pool of donors, several strategies are being carried out, such as using non-heart-beating donors, expanded criteria donors and, above all, enhancing live donation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">From the introduction of laparoscopy, there has been an exponential increase in this type of donation in recent years in live donor nephrectomy, reaching rates of 10% last year in Spain.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The emergence of new minimally invasive surgical techniques in urology, such as NOTES (Natural Orifice Transluminal Endoscopic Surgery) and LESS (Laparoendoscopic Single Site), can help in the increase of donation rates. Surgery using the LESS technique involves making a small incision through which several laparoscopic instruments are introduced to perform surgery, obtaining the same surgical results with a lower morbidity and better cosmetic results. All this makes it a very attractive technique to offer to kidney donors.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the first live donor nephrectomy using the LESS technique performed at our center in December 2010.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Casuistry</span><p id="par0025" class="elsevierStylePara elsevierViewall">We present the first two cases of live donor LESS nephrectomy performed at our center. In December 2010, we performed the first live donor nephrectomy to a 56-year-old candidate for kidney donor for his son. The donor does not refer to medical or surgical history of interest, and he has a body mass index (BMI) of 23.15<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>. The second case is a 42-year-old male candidate for kidney donation to his wife, equally without remarkable history, with a BMI of 21.47<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>. The vascular study by CT angiography showed kidneys of normal size and morphology and single bilateral renal vascular pedicle in both cases. Given the characteristics of the donors, we decided to perform a left nephrectomy using the LESS technique with the Quadport<span class="elsevierStyleSup">®</span> device (Advanced Surgical Concepts).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Surgical technique</span><p id="par0030" class="elsevierStylePara elsevierViewall">Under general anesthesia, the donor was placed in right lateral decubitus. A 4-cm-long incision was made at the paraumbilical level up to the aponeurosis. In order to obtain a better opening, without increasing the length of the incision, we performed a 1-cm perpendicular cut on the midline incision (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The incision at the level of the aponeurosis was extended to approximately 5<span class="elsevierStyleHsp" style=""></span>cm. Through this hole, we introduced the internal ring of the Quadport<span class="elsevierStyleSup">®</span> device, creating a firm traction of the plastic cylinder for good coaptation between the two cylinders, thus, achieving a good fixing to the abdominal wall thereof.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The pneumoperitoneum was achieved through one of the orifices of the Quadport<span class="elsevierStyleSup">®</span>. After the correct placement of the device, it is very important to make small incisions in the gel of the trocars to facilitate access to the abdominal cavity and maintain the sealing system. During the intervention, we used a 5-mm camera with flexible handle (Olympus), which makes it possible to work at two levels avoiding conflicts between the surgeon and the assistant. Nephrectomy was performed according to our usual technique, but with the use of a precurved clamp in the left hand and a straight instrument in the right hand. Following the release of the colon, the ureter was isolated and it was dissected to the junction of the iliac vessels. After its section to that level, we proceeded to the release and cranial dislocation of the lower renal pole, allowing us to gain access to the renal pedicle directly. After the careful dissection of the vascular pedicle and the release of the entire renal surface, a large collection bag (Endocatch<span class="elsevierStyleSup">®</span>, Covidien Surgical) was inserted through the 15-mm hole of the Quadport<span class="elsevierStyleSup">®</span>. Once the kidney was bagged, the metal ring was removed. After clipping through two Hem-o-loks<span class="elsevierStyleSup">®</span> (Teleflex Medical) in the artery and vein, the vessels are cut and then we pull the ring of the device for removal while the pre-bagged kidney is extracted. It was necessary to make a minimum extension of the aponeurotic incision that allowed us to extract the body quickly. The kidney was immediately perfused with Ringer's lactate, achieving a short warm ischemia time. We closed the abdominal wall with 1/0 vicryl sutures and the skin with absorbable subcutaneous suture. The final cut was 4<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">The total surgical time in both cases was 150<span class="elsevierStyleHsp" style=""></span>min, with an estimated 50 cc bleeding. The warm ischemia was 3.30″ and 2.47″, respectively. The transplant was performed without any incident, with good perfusion of the grafts and immediate diuresis. The postoperative course was correct in both cases, showing a prolonged paralytic intestinal ileus with spontaneous regression in the first donor. The patients were discharged at 6 and 3 days, respectively.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0045" class="elsevierStylePara elsevierViewall">Following the introduction of laparoscopic surgery in live donor nephrectomy, there has been a sharp increase in the rate of donation in the last 9 years.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This increase is directly related to the advantages of laparoscopic surgery over open surgery in terms of reduced morbidity for the donor and with the same functional outcome for the graft.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The emergence of new minimally invasive surgical techniques such as NOTES and LESS has revolutionized surgery, minimizing the incisions and morbidity, and improving the esthetic outcomes. In urology, these techniques have been widely accepted and have proven to be feasible and reproducible in experienced hands.</p><p id="par0055" class="elsevierStylePara elsevierViewall">LESS surgery is not a technique that can be seen as emerging, as there are series with more than 4000 cases of tubal ligation published in the late 1960s.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, in the field of urology, LESS surgery appears experimentally in 2004,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and in 2007 the first cases in humans are observed.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Since then, numerous groups have reported their experience in various surgical procedures, so now there is evidence that many of the intraabdominal surgical urological procedures can be carried out by LESS.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">LESS surgery is the concentration of the trocar incisions and removal of the organ in a single point, so with one small incision we must be able to perform a complete laparoscopic procedure. Due to its nature, it meets the essential requirements to be included within the so-called “scarless surgery” or minimal scar, given that the incisions are reduced as much as possible to obtain better esthetic results and minimize patient morbidity, allowing for a lower need for analgesia, a rapid recovery, and decreased postoperative complications related to the incision. In addition, using the navel as an entry point into the abdominal cavity makes this technique even more interesting, since it makes it possible to hide part of the incision through the navel when performing the skin suture.</p><p id="par0065" class="elsevierStylePara elsevierViewall">However, LESS surgery presents technical difficulties inherent to the procedure as disadvantages: loss of triangulation and sense of depth, collision of instruments, difficulty in organ retraction and need to cross the surgeon's hands. This makes that the introduction of this type of surgery in clinical practice should be progressive. According to the recent meeting of the European Society of Urotechnology NOTES and LESS Working Group, it is earnestly recommended that only surgeons experienced in conventional laparoscopic surgery start LESS surgery programs, and that patients tributary to this type of surgery are carefully selected, avoiding its performance in patients with a history of previous surgery and obese patients (BMI<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>30).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Kidney donation represents a special situation, as healthy people make it, so the surgical risk and morbidity of the individual must be reduced as much as possible. The application of the aforementioned surgical techniques in live donor nephrectomy is very promising, allowing for the performance of the surgery through a single incision, with the consequent reduction in morbidity and improved esthetic results. In the case of women, hybrid NOTES transvaginal surgery offers great advantages by avoiding abdominal incisions for the extraction of the organ.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> This technique achieves excellent esthetic results and probably a lower morbidity for the individual, being, therefore, a very promising technique. As for men, the LESS technique can be a very attractive alternative to transvaginal surgery because the surgery is performed with a single incision through which the organ will be extracted.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The first LESS live donor nephrectomy performed through the navel was described by Gill et al. in 2008.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In this first surgery, a 2-mm accessory clamp was used to perform it. The same group has recently published the results of a retrospective comparison between LESS live donor nephrectomy and the conventional laparoscopic one. In this study, a donor for LESS had to be converted to laparoscopic surgery. No differences were found regarding the need for postoperative analgesia and length of hospitalization, although it should be pointed out that the LESS group donors had a shorter period of convalescence and return to work, showing better satisfaction with regard to esthetic results. The warm ischemia time was significantly higher in LESS surgery, but without any impact on the graft function.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The second live donor LESS nephrectomy was described two years later by the group of Andonian et al. In this case, the nephrectomy was performed through a Pfannenstiel incision, through which three 5-mm ports were placed positioned in a triangular shape without using any device, getting very good esthetic results.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> From our point of view, LESS surgery makes sense when the incision is made above the navel, given that the incision can be reduced and hidden in the umbilical fold itself, allowing for better esthetic results.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the last year, several American groups have published their initial experience with live donor LESS nephrectomies using different devices, such as the GelPOINT placed at the navel,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> the Quadport, or the Triport,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> confirming the reproducibility of the surgical technique and good esthetic results.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In an attempt to compare this technique with laparoscopic surgery, considered the technique of choice together with open surgery,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> we found several studies that intend to retrospectively compare both surgical techniques. The only advantage found of this technique over laparoscopy has been the esthetic result.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,15</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The findings from the only prospective and randomized study, although small numbers, have been published recently, comparing LESS nephrectomy with standard laparoscopy. The LESS technique, although with a longer warm ischemia time, has a lower incision, shorter hospital stay and less pain at 48<span class="elsevierStyleHsp" style=""></span>h compared to laparoscopic surgery.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In the latest edition of the congress of the European Urological Association, held in Vienna in 2011, the first series of LESS live donor nephrectomy were performed in Europe, with good results and short ischemia time.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The LESS technique is feasible and reproducible for kidney surgery. It should be considered an option for male donors, as it reduces morbidity and provides better cosmetic results, and it can, thus, increase the rate of donation.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres99980" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec87146" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres99981" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec87145" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Casuistry" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Comment" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-04-15" "fechaAceptado" => "2011-04-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec87146" "palabras" => array:3 [ 0 => "LESS" 1 => "Living donor nephrectomy" 2 => "Surgical technique" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec87145" "palabras" => array:3 [ 0 => "LESS" 1 => "Nefrectomía donante vivo" 2 => "Técnica quirúrgica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">LESS surgery (<span class="elsevierStyleItalic">Laparoendoscopic single site surgery</span>) is a surgical technique that aims to perform intraabdominal surgery using a single site entry, allowing for reduction in the number and size of the incisions, achieving better esthetic results with at least the same functional outcomes as with the conventional laparoscopic surgery.</p> <span class="elsevierStyleSectionTitle">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present the first experience of LESS living donor nephrectomy carried out by a totally European team. To perform it, a Quadport<span class="elsevierStyleSup">®</span> device was placed through a 4-cm long paraumbilical incision.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The nephrectomy was performed using the standards of conventional laparoscopic surgery, with the use of a precurved instrument in the left hand and straight instruments in the right. After bagging the kidney, the artery and vein were sectioned after clipping, allowing for rapid extraction of the organ through the same incision, with warm ischemia of 3.30″ and 2.47″, respectively.</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Living donor nephrectomy using the LESS technique is feasible and can be considered a good option for obtaining live donor kidney grafts in males. The application of said surgical in living kidney donor can increase the rate of donation, by reducing morbidity and improving the esthetic results with the same outcome for the donor as for the recipient.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La cirugía LESS (<span class="elsevierStyleItalic">Laparoendoscopic single site surgery</span>) es una técnica quirúrgica que pretende realizar la cirugía intraabdominal mediante un único puerto de entrada, permitiendo una reducción del número y tamaño de las incisiones, consiguiendo mejores resultados estéticos con, al menos, los mismos resultados funcionales que la cirugía laparoscópica convencional.</p> <span class="elsevierStyleSectionTitle">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Presentamos la primera experiencia de nefrectomía LESS de donante vivo realizada por un equipo íntegramente europeo. Para su realización se colocó un dispositivo Quadport<span class="elsevierStyleSup">®</span> a través de una incisión paraumbilical de 4 centímetros de longitud.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La nefrectomía se realizó siguiendo los estándares de la cirugía laparoscópica convencional, con el uso de un instrumento precurvado en la mano izquierda e instrumentos rectos en la derecha. Tras el embolsado del riñón se seccionaron la arteria y la vena previo clipaje, permitiendo una extracción rápida del órgano a través de la misma incisión, con una isquemia caliente de 3,30″ y 2,47″ respectivamente.</p> <span class="elsevierStyleSectionTitle">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La nefrectomía de donante vivo mediante la técnica LESS es factible, y puede ser considerada una buena opción para la obtención de injertos renales de vivo en varones. La aplicación de dicha técnica quirúrgica en la donación renal de vivo puede incrementar la tasa de donación, al reducir la morbilidad y mejorar los resultados estéticos, con los mismos resultados tanto para el donante como para el receptor.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Musquera M, et al. Experiencia pionera en España con nefectomía LESS de donante vivo. Actas Urol Esp.2011;35:559–62.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 681 "Ancho" => 850 "Tamanyo" => 67529 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Abdominal incision for the insertion of the Quadport<span class="elsevierStyleSup">®</span>.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 852 "Ancho" => 850 "Tamanyo" => 117511 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Final esthetic result two months after the intervention.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Recomendaciones de la Sociedad Española de Nefrología (SEN) y de la Organización Nacional de Trasplante (ONT) sobre trasplante renal de donante vivo" ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3265/Nefrologia.pre2011.Feb.10860" "Revista" => array:4 [ "tituloSerie" => "Nefrología" "fecha" => "2010" "volumen" => "30" "numero" => "Suppl. 2" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laparoscopic sterilization. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2018 February | 6 | 1 | 7 |
| 2018 January | 5 | 0 | 5 |
| 2017 December | 9 | 0 | 9 |
| 2017 November | 4 | 0 | 4 |
| 2017 October | 14 | 2 | 16 |
| 2017 September | 9 | 1 | 10 |
| 2017 August | 17 | 1 | 18 |
| 2017 July | 15 | 3 | 18 |
| 2017 June | 16 | 2 | 18 |
| 2017 May | 20 | 4 | 24 |
| 2017 April | 16 | 6 | 22 |
| 2017 March | 15 | 1 | 16 |
| 2017 February | 18 | 2 | 20 |
| 2017 January | 14 | 1 | 15 |
| 2016 December | 24 | 6 | 30 |
| 2016 November | 25 | 3 | 28 |
| 2016 October | 28 | 7 | 35 |
| 2016 September | 25 | 2 | 27 |
| 2016 August | 31 | 4 | 35 |
| 2016 July | 13 | 1 | 14 |
| 2016 June | 10 | 3 | 13 |
| 2016 May | 21 | 7 | 28 |
| 2016 April | 18 | 5 | 23 |
| 2016 March | 28 | 8 | 36 |
| 2016 February | 33 | 10 | 43 |
| 2016 January | 24 | 11 | 35 |
| 2015 December | 21 | 5 | 26 |
| 2015 November | 16 | 6 | 22 |
| 2015 October | 22 | 5 | 27 |
| 2015 September | 14 | 1 | 15 |
| 2015 August | 44 | 3 | 47 |
| 2015 July | 37 | 4 | 41 |
| 2015 June | 21 | 1 | 22 |
| 2015 May | 19 | 2 | 21 |
| 2015 April | 28 | 10 | 38 |
| 2015 March | 32 | 5 | 37 |
| 2015 February | 10 | 1 | 11 |
| 2015 January | 25 | 2 | 27 |
| 2014 December | 42 | 10 | 52 |
| 2014 November | 21 | 4 | 25 |
| 2014 October | 47 | 11 | 58 |
| 2014 September | 34 | 7 | 41 |
| 2014 August | 31 | 8 | 39 |
| 2014 July | 36 | 3 | 39 |
| 2014 June | 12 | 3 | 15 |
| 2014 May | 10 | 4 | 14 |
| 2014 April | 8 | 2 | 10 |
| 2014 March | 14 | 4 | 18 |
| 2014 February | 9 | 2 | 11 |
| 2014 January | 10 | 1 | 11 |
| 2013 December | 10 | 1 | 11 |
| 2013 November | 19 | 1 | 20 |
| 2013 October | 23 | 4 | 27 |
| 2013 September | 4 | 0 | 4 |
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