Surgical aspects of living donor nephrectomy | Actas Urológicas Españolas (English Edition)

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Rodríguez, A. Breda, S. Esquena, H. Villavicencio" "autores" => array:4 [ 0 => array:2 [ "nombre" => "O." "apellidos" => "Rodríguez" ] 1 => array:4 [ "nombre" => "A." "apellidos" => "Breda" "email" => array:1 [ 0 => "abreda@fundacio-puigvert.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Esquena" ] 3 => array:2 [ "nombre" => "H." "apellidos" => "Villavicencio" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Trasplante Renal, Servicio de Urología, Fundació Puigvert, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aspectos quirúrgicos actuales de la nefrectomía de donante vivo" ] ] "textoCompleto" => "IntroductionThe living donor kidney transplant (LDKT) is the treatment of choice for patients with terminal renal failure. Taking into account that it is an altruistic procedure in healthy people, it is essential that the intervention is a safe procedure and allows the individual to quickly regain normal activity.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> 40% of all kidney transplants performed in the U.S. and 20% of those carried out in Europe come from a living donor. In the case of countries where the rate of cadaveric donors is very low, up to 75% of transplants are from living donors.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The continuous increase in living donation is due, in large part, to the better short- and long-term results in relation to the cadaveric donor (93.9 and 86.2% survival at 1 and 3 years vs. 87.6 and 76.7%, respectively),<a class="elsevierStyleCrossRef" href="#bib0015">3</a> as well as less aggressive immunosuppressive regimens, better HLA matching, shorter cold ischemia times, and avoiding waiting lists, which in the case of Spain they can be of up to 2 years. They represent relative contraindications for donation, presence of a chronic active infection (TB, B/C hepatitis, or parasites), obesity, and some psychiatric disorders.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Absolute contraindications are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Surgical techniques have evolved from the classical lumbotomy and open-approach muscle-splitting miniincision to the current minimally invasive techniques including classical laparoscopy, hand-assisted one, hand-assisted retroperitoneoscopy, pure retroperitoneoscopy, NOTES (Natural Orifice Transluminal Endoscopic Surgery) or LESS (Laparoendoscopic Single SiteSurgery) and robotic nephrectomy. Thus, many of the disadvantages of living donation have improved, such as, faster postoperative recovery, less bleeding, and less need for analgesia.Other major surgical factors to consider are the proper selection of the kidney to be removed, specific considerations in obese patients, and the management of multiple pedicles. Although conventionally, and still at present, the trend in many centers is to choose the left kidney with simple pedicle, of young individuals with a suitable body mass index and ASA I, we increasingly tend to pick individuals with isolated alterations, such as HBP or obesity, if the renal function is correct.Donor assessmentGeneral aspectsThe evaluation of a potential living donor may be performed by an independent physician, followed by a nephrologist, psychiatrist, and surgical team of urologists. Initial studies should include: history and complete physical examination, HLA typing, blood tests (urea, creatinine, electrolytes, calcium, phosphorus, albumin), coagulation tests, serological test for HIV, cytomegalovirus, varicella virus, herpes virus, Epstein Barr virus, B/C hepatitis virus, RPR, FTA, and PPD (purified protein derivative), electrocardiogram, chest X-ray, and CT with urographic and vascular phase.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> In men, testicular exploration is included, and in those older than 50, PSA and DRE. In women, breast screening is also included, and in those over 40, mammography. Now, if there is a history of breast cancer in premenopausal age in first-degree relatives, the age for mammography should be below 35 years.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Choice of kidneyIt is mandatory that the living donor maintains the kidney with the best conditions. The renal anatomy has to be assessed by means of multidetector CT and angiography/urography with reconstructions.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> In the cases in which both kidneys have similar characteristics, it is chosen to remove the left kidney, which is the one with the longest renal vein and will facilitate implantation.The right nephrectomy has been attributed a greater number of complications such as venous thrombosis, greater delay in functional recovery, and, in general, greater number of implant loss due to technical difficulties during the vascular anastomosis; however, recent studies suggest that although there is a minimal increase in the risk of graft failure, it is considered as a perfectly acceptable option in donors in whom left nephrectomy is contraindicated<a class="elsevierStyleCrossRefs" href="#bib0030">6–8</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Multiple pediclesThe choice of kidneys with multiple pedicles has also been a controversial issue. We tried to avoid them, in order to minimize the vascular and ureteral complications. However, when the choice of the right kidney arises, many centers prefer to use the left kidney despite having a multiple pedicle. Abnormalities such as circumaortic veins, retroaortic veins, early bifurcation of the renal artery, multiple veins, or large lumbar veins, are not usually a problem for the donation. Although all the studies include a small number of patients with multiple pedicles, globally, it is considered to be feasible and safe. Only in 2 studies have they been associated to more ureteral complications in the receptor, especially with lower polar arteries<a class="elsevierStyleCrossRefs" href="#bib0045">9–14</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).ObesityRegarding obesity, several studies have shown that laparoscopic nephrectomy in selected patients is safe.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Besides instrumentation and special position needs, a higher incidence of anesthetic complications has been observed and postoperatively. Obese patients have an increased filtration fraction, which is an independent predictor of HBP, which can influence long-term renal function<a class="elsevierStyleCrossRef" href="#bib0075">15</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).Overall, patient assessment for living donor laparoscopically or robotically is similar to the open approach. The only relative contraindication for laparoscopic surgery, which does not exist in the open procedure, is a history of major upper abdominal surgery that might have led to dense adhesions so that the laparoscopic surgery may not be safe.Surgical options in living donor donationThere are several ways to get a living donor kidney. The method chosen will depend on the surgeon's experience and the best choice of intervention for each individual case.Open nephrectomyIt can be performed by classical transperitoneal approach, through an incision in the midline or left or right subcostal, under sub or supracostal left or right extraperitoneal, and dorsal lumbar below the 12th rib, with resection thereof, or above (extraperitoneal, extrapleural). Although some authors have preferred the transperitoneal approach to ensure better access to the vessels, the many advantages of the extraperitoneal surgery have eventually made it the standard technique.<a class="elsevierStyleCrossRefs" href="#bib0080">16,17</a>The objectives of nephrectomy include removal of the kidney with minimal anatomical and physiological damage, as well as minimal warm ischemia, avoiding trauma to the renal parenchyma and preserving an adequate length of the artery, vein, and ureter that allows us to perform a safe anastomosis without endothelial damage, and atraumatic ureteral reimplantation maintaining vascularization. The result of these premises should translate into an immediate graft function in the host with a low rate of vascular and ureteral complications.The literature review concludes that, overall, major complications have occurred in 3%<a class="elsevierStyleCrossRefs" href="#bib0005">1–7</a> of donors who underwent open surgery, most of which were resolved without permanent sequelae, and minor complications in 10%<a class="elsevierStyleCrossRefs" href="#bib0015">3–13</a> of patients.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Most of the studies reviewed share the fact that delayed graft function, thrombosis, and ureteral fistulas are rare events that appear in 1–2% of the cases.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a>Also, the overall hospital stay is 5–7 days.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a> In long-term follow-up, in a review of 524 donors with a follow-up of 15 years, only 4% were dissatisfied with the donation, and regretted having undergone surgery. Regarding the surgical wound pain, 84% reported no pain present, or medium intensity pain.In the long-term follow-up, in a review of 524 donors with a follow-up of 15 years, only 4% were dissatisfied with the donation and regretted having undergone surgery. Regarding the surgical wound pain, 84% reported no pain present, or medium-intensity pain.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>The advent of laparoscopic LDKT has stimulated the development of minimally invasive open surgery techniques. These techniques have shown excellent results in terms of recovery, cost-effectiveness, safety, and cosmetics. 10–12cm miophylactic mini-incision, with the patient in lateral decubitus and maximum flexion surgical table has been described. The incision is horizontal and anterior to the 11th rib to the umbilicus. The fascias of the external oblique muscles, internal and transverse abdominal are separated with scissors miophylactically without being cut.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> We can also make an anterior vertical mini-incision, in which, with the patient in supine position, an anterior vertical incision is made, 6–10cm lateral to the rectum below the costal arch. The abdominal muscles are separated into layers, and the peritoneum is separated medially to expose the kidney in a retroperitoneal position.<a class="elsevierStyleCrossRefs" href="#bib0105">21–23</a>Other miniinvasive techniques are finger-assisted living donor nephrectomy, which is performed with the patient in lateral decubitus and table at maximum deflection, using a 4-cm transverse incision and anterior to the tip of the 11th rib. All the muscle layers and the fascia of the lumbodorsal muscle are separated in line with the incision.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> In minimally invasive nephrectomy through a transverse incision, the patient is placed in a semilateral position, with 20° flexion, performing an 8–10cm transverse incision anterior to the 11th lateral rib on the edge of the rectum. The transversallis fascia is incised laterally, and the peritoneum is rejected medially using the Omnitract retractor.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>In microinvasive nephrectomy, the patient is placed in lateral decubitus and the incision is made 6–8cm from the tip of the 10th rib to the rectum, with the table flexed 30° and placed 20° in Trendelemburg.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> In the mini-nephrectomy through a posterior transcostal incision, the patient is placed in lateral decubitus, palpating the 12th rib. A 6–8cm incision is made along the rib starting 2–3cm anterior to the lateral edge of the sacrospinous muscle. The latissimus dorsi and the serratus posterior have to be sectioned, in order to expose the 12th rib.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> Finally, in video-assisted mini-laparotomy, a 5–7cm lateral incision is made and a 10-mm trocar is placed between the peritoneum. The 30° optics makes it possible to maximize the vision.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>Laparoscopic live donor nephrectomyGlobally, it has been shown that laparoscopic live donor nephrectomy (LLDN) has advantages over open surgery in terms of analgesic requirements, hospital stay, cosmetic result, and return to the work activity.<a class="elsevierStyleCrossRefs" href="#bib0145">29,30</a> We have not seen that the graft function is affected by the positive pressure of the pneumoperitoneum, being comparable to the open approach.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>The LLDN technique has evolved over time, and although it can be performed both transperitoneally and retroperitoneally, in most centers, it is performed transperitoneally due to the lower limitation of the surgical field and the possibility of removing the kidney through a midline or Pfannestiel incision.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> The technique is performed in modified lateral decubitus position, with the hips rotated back for easy access to the bottom of the midline and to remove the kidney. 3 5-mm laparoscopic accesses are performed, separated 4 fingers in supraumbilical pararectal position. The first of them, caudal to the 12th rib and using 30° optics. It is started by rejecting the peritoneum along the avascular Told's line. The dissection follows the existing plane between Gerota's fascia and the mesentery of the descending colon, until the left gonadal vein is identified.Dissection of the middle part of the gonadal vein should be limited to avoid devascularization of the ureter. En bloc elevation of the gonadal vein, the ureter, and the lower pole of the kidney is generally useful in anterolateral direction with regard to the psoas muscle to facilitate exposure of the pedicle. For the section of the pedicle, we use an Endo-GIA stapling device, with vascular load through access via 5-cm Pfannenstiel incision by which we will subsequently extract the kidney by endobag.<a class="elsevierStyleCrossRef" href="#bib0165">33</a>In the case of removing the right kidney, additional access in the lumbar fossa for anterior retraction of the liver lobe and increasing the length of the renal vein, which with the Endo-GIA causes the loss of 1–1.5cm, may be required. A 6-cm transverse incision could also be made above the confluence of the right renal vein and the inferior vena cava for the open section of the renal vasculature. Alternatively, reconstruction can be performed using saphenous vein graft of the receptor.<a class="elsevierStyleCrossRef" href="#bib0170">34</a>Hand-assisted laparoscopic nephrectomyBoth transperitoneal and retroperitoneal hand-assisted laparoscopic nephrectomy (HALN) has been described. The use of the hand can be performed throughout the procedure, or only at the time of the section of the pedicle and kidney extraction.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> The incisions can be periumbilical, supra- or infraumbilical in the midline, or Pfannenstiel.<a class="elsevierStyleCrossRefs" href="#bib0175">35,36</a> The advantages of hand-assisted laparoscopy compared to conventional laparoscopy are primarily the ability to digitally control a possible bleeding and allow for better exposure of the pedicle.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> This would make it possible to have shorter warm ischemia and surgical times.<a class="elsevierStyleCrossRefs" href="#bib0190">38–40</a> With the retroperitoneal approach, it is less likely to damage intra-abdominal organs.Comparison between techniquesLaparoscopic nephrectomy and hand-assisted laparoscopic nephrectomyMost studies conclude that the hand-assisted technique (transperitoneal) has shorter operative time, blood loss, warm ischemia, and hospital stay. The complications, analgesic requirements, and graft survival are similar in both.<a class="elsevierStyleCrossRefs" href="#bib0190">38–41</a> It should be borne in mind that these studies include a limited number of patients, with a low level of evidence, so the definitive role of the HALN is not yet fully defined (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Open nephrectomy and laparoscopic nephrectomyGlobally, several meta-analyses have concluded that although the operative time and the warm ischemia time are more favorable for the open approach, the LLDN has a shorter hospital stay, faster recovery, less pain, less blood loss, faster return to work, and better quality of life compared to the open approach. Most of these studies present the hand-assisted as an alternative rather than as the technique of choice.<a class="elsevierStyleCrossRefs" href="#bib0145">29,30,42–44</a>Via open surgery, it is easier to control intraoperative bleedings, and in the postoperative period; although the rate of reoperation for bleeding is similar in both groups (1.7 vs 0.7%), in a recent work by Friedman et al.<a class="elsevierStyleCrossRef" href="#bib0225">45</a> we saw that massive hemorrhages are associated to a greater extent to the use of surgical Hem-o-loks (more frequently in the laparoscopic approach) than with other methods of renal pedicle control.Although laparoscopy has a longer warm ischemia time, several studies have shown that this does not translate into increased graft dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0230">46,47</a> The incidence of complications remains lower in the laparoscopic group (14 vs 16%).<a class="elsevierStyleCrossRef" href="#bib0230">46</a> Apart from the pain of surgical wound, which is longer in the open surgery group, there are no differences in other major or minor specific complications.In the case of specifically comparing the transperitoneal approach and retroperitoneoscopy within laparoscopy, we have seen that the transperitoneal approach presents fewer lung lesions, hernias, and surgical wound pain than the retroperitoneal approach.<a class="elsevierStyleCrossRefs" href="#bib0240">48,49</a>Doubts regarding follow-up, complications, and safety of the donor and receptor have been solved over time. LLDN is currently the standard technique in most centers with experience in laparoscopy.<a class="elsevierStyleCrossRef" href="#bib0250">50</a>Laparoscopic nephrectomy and mini-incisional open nephrectomyThe existing randomized studies have concluded that the LLDN presents better quality of life compared to the mini-incision with equal functionality to the graft.<a class="elsevierStyleCrossRef" href="#bib0255">51</a> Overall, compared to the mini-incision, the LLDN has a longer surgical time and less blood loss, without differences in terms of complications. The LLDN has fewer analgesic requirements and a shorter hospital stay.<a class="elsevierStyleCrossRefs" href="#bib0255">51,52</a> Now, the LLDN is technically more demanding with a longer learning curve. Because of this, many smaller centers have opted for mini-incisional approaches.Lewis et al.<a class="elsevierStyleCrossRef" href="#bib0255">51</a> conducted a study comparing the open approach, laparoscopy, and mini-incision. The operative time and warm ischemia were longer for the mini-incision and laparoscopy. Blood loss, hospital stay, and recovery of normal activity were significantly lower in laparoscopy. The analgesic requirements were similar (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).Follow-up of the receptorGlobally, no significant differences were seen in overall or graft survival, need for dialysis, incidence of technical complications (ureteral or vascular), incidence, time or severity of graft rejection, and immediate or long-term function between the receptors made by open or laparoscopic approach.<a class="elsevierStyleCrossRef" href="#bib0265">53</a>Theoretically, the pneumoperitoneum required for laparoscopic surgery would reduce the blood supply to the kidney, causing a decrease in its function; however, hyperhydration significantly helps maintain the rhythm of diuresis. The patients must be hydrated with 5–7 l of crystalloids during surgery, and 25mg of mannitol administered to encourage diuresis. After the transplant, the decrease in creatinine levels in the laparoscopic group indicates an immediate recovery of the renal function.<a class="elsevierStyleCrossRef" href="#bib0270">54</a>Although the creatinine nadir is reached earlier in the open surgery group (third vs. fourth postoperative day), clinical significance has not been appreciated. The average hospital stay is around 7 days for both groups, and there are no significant differences in terms of ureteral complications.<a class="elsevierStyleCrossRef" href="#bib0275">55</a> Survival after one year of the laparoscopic and open (100 vs. 97%) and graft group (93.5 vs 91.1%) were similar in both groups.<a class="elsevierStyleCrossRefs" href="#bib0270">54,55</a>Developing surgical techniquesThe literature in this field is limited, although the theoretical advantages of the robot would be the scanned image in combination with the advances in microsurgery.<a class="elsevierStyleCrossRef" href="#bib0280">56</a> There is a study comparing the robot to the open approach, in which the operative time and warm ischemia are greater in the robot, with equivalent graft function, similar complications, and shorter hospital stay for the robot.<a class="elsevierStyleCrossRef" href="#bib0285">57</a> Similarly, new minimally invasive surgical techniques such as robotic-assisted nephrectomy and NOTES or LESS, whose results so far are preliminary, are recently being introduced.<a class="elsevierStyleCrossRefs" href="#bib0290">58,66</a>ConclusionsCurrently, there is sufficient evidence to consider the LLDN as the technique of choice, although the role of the hand-assisted technique and retroperitoneoscopy are still not entirely clarified. The techniques of mini-incisional open surgery techniques represent an acceptable alternative for the centers that have not yet implemented laparoscopic surgery. The right kidney nephrectomy, multiple pedicles, and in obese patients is justified in selected cases.Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres227331" "titulo" => array:5 [ 0 => "Abstract" 1 => "Context" 2 => "Objective" 3 => "Evidence acquisition" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec212218" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres227330" "titulo" => array:5 [ 0 => "Resumen" 1 => "Contexto" 2 => "Objetivo" 3 => "Adquisición de la evidencia" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec212217" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Donor assessment" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "General aspects" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Choice of kidney" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Multiple pedicles" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Obesity" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Surgical options in living donor donation" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Open nephrectomy" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Laparoscopic live donor nephrectomy" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Hand-assisted laparoscopic nephrectomy" ] 3 => array:3 [ "identificador" => "sec0055" "titulo" => "Comparison between techniques" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Open nephrectomy and laparoscopic nephrectomy" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Laparoscopic nephrectomy and mini-incisional open nephrectomy" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Follow-up of the receptor" ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Developing surgical techniques" ] 9 => array:2 [ "identificador" => "sec0080" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-05-03" "fechaAceptado" => "2012-05-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec212218" "palabras" => array:3 [ 0 => "Living donor nephrectomy" 1 => "Laparoscopy" 2 => "Results" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec212217" "palabras" => array:3 [ 0 => "Nefrectomía de donante vivo" 1 => "Laparoscopia" 2 => "Resultados" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ContextLiving donor renal transplant surgery has evolved from the classical nephrectomy by lumbotomy to less invasive surgery, the laparoscopic and robotic nephrectomy currently being the most important. It is important to know the available evidence on whether nephrectomy in patients with multiple arteries, right kidney and in obese patients can be performed safely when there is a correct indication. ObjectiveTo perform a review of the different surgical techniques in living donor nephrectomy, adapted to the current surgical evidence and other aspects related to the indication. Evidence acquisitionA systematic review was made in PubMed (1997–2011). This included previous reviews randomized controlled clinical studies, cohort studies, and meta-analyses of these surgical aspects of living donor nephrectomy. ConclusionsCurrently, there is sufficient evidence to consider living donor laparoscopic nephrectomy (LDLN) as the technique of choice, although the role of hand-assisted retroperitoneoscopic technique is still not totally clear. Open surgery techniques using mini-incision are an acceptable alternative for the sites that have not yet implemented laparoscopic surgery. Right kidney nephrectomy, of those cases that present multiple pedicles and in obese donors, is justified in selected cases." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ContextoLa cirugía del trasplante renal de donante vivo, ha evolucionado desde la clásica nefrectomía por lumbotomia a una cirugía menos invasiva, imponiéndose en la actualidad la nefrectomía laparoscópica y robótica. Resulta importante conocer la evidencia disponible acerca de si la nefrectomía en pacientes con múltiples arterias, riñón derecho y en pacientes obesos puede realizarse de manera segura ante una indicación correcta. ObjetivoRealizar una revisión de las diferentes técnicas quirúrgicas en nefrectomía de donante vivo, adaptada a la evidencia científica actual, y de otros aspectos que rodean la indicación. Adquisición de la evidenciaSe realizó una revisión sistemática en PubMed (1997–2011), que incluye revisiones previas, estudios clínicos aleatorizados controlados, estudios de cohortes, y metanálisis de los aspectos quirúrgicos de la nefrectomía de donante vivo. ConclusionesActualmente existe suficiente evidencia para considerar la nefrectomía laparoscópica de donante vivo (NLDV) como técnica de elección, aunque el papel de la técnica mano-asistida y la retroperitoneoscopia todavía no están del todo claros. Las técnicas de cirugía abierta por mini-incisión representan una alternativa aceptable para los centros que no hayan implementado todavía la cirugía laparoscópica. La nefrectomía de riñón derecho, de aquellos casos que presentan pedículos múltiples y en los donantes obesos esta justificada en casos seleccionados." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rodríguez O, et al. Aspectos quirúrgicos actuales de la nefrectomía de donante vivo. Actas Urol Esp. 2013;37:181–7." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age <18 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Uncontrolled HBP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Proteinuria >300mg/24h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abnormal glomerular filtration for age \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Microscopic hematuria \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High risk of thromboembolism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe disease (chronic pulmonary disease, recent malignancy, heart disease) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">History of bilateral renal calculi \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HIV infection \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab338915.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Absolute contraindications for living donor kidney transplant." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Level of evidence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type of evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left vs right</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1b</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Randomized clinical trials<a class="elsevierStyleCrossRef" href="#bib0040">8</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prospective studies<a class="elsevierStyleCrossRef" href="#bib0030">6</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0025">5,7</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multiple pedicles</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prospective studies<a class="elsevierStyleCrossRef" href="#bib0060">12</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0045">9–11</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obese vs non obese \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRef" href="#bib0075">15</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab338916.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Level and type of evidence as to the choice of kidney, multiple pedicles, and obesity in live donor nephrectomy." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Level of evidence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type of evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Open vs mini-incision</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prospective studies<a class="elsevierStyleCrossRefs" href="#bib0105">21,51</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0100">20,22</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mini-incision vs LLDN</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Randomized clinical trials<a class="elsevierStyleCrossRef" href="#bib0295">59</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prospective studies<a class="elsevierStyleCrossRef" href="#bib0255">51</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metaanalysis<a class="elsevierStyleCrossRef" href="#bib0300">60</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LLDN vs HALN</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">II</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Randomized clinical trials<a class="elsevierStyleCrossRef" href="#bib0305">61</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prospective studies<a class="elsevierStyleCrossRefs" href="#bib0310">62,63</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0320">64,65</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Robotic vs open \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRef" href="#bib0285">57</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab338917.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Levels and types of evidence in the comparison of different techniques in live donor nephrectomy." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:66 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Medical progress: procurement and allocation of solid organs for transplantation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" 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Surgical aspects of living donor nephrectomy

Aspectos quirúrgicos actuales de la nefrectomía de donante vivo

O. Rodríguez, A. Breda

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abreda@fundacio-puigvert.es

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, S. Esquena, H. Villavicencio

Unidad de Trasplante Renal, Servicio de Urología, Fundació Puigvert, Barcelona, Spain

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in large part&#44; to the better short- and long-term results in relation to the cadaveric donor &#40;93&#46;9 and 86&#46;2&#37; survival at 1 and 3 years vs&#46; 87&#46;6 and 76&#46;7&#37;&#44; respectively&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> as well as less aggressive immunosuppressive regimens&#44; better HLA matching&#44; shorter cold ischemia times&#44; and avoiding waiting lists&#44; which in the case of Spain they can be of up to 2 years&#46; They represent relative contraindications for donation&#44; presence of a chronic active infection &#40;TB&#44; B&#47;C hepatitis&#44; or parasites&#41;&#44; obesity&#44; and some psychiatric disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Absolute contraindications are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Surgical techniques have evolved from the classical lumbotomy and open-approach muscle-splitting miniincision to the current minimally invasive techniques including classical laparoscopy&#44; hand-assisted one&#44; hand-assisted retroperitoneoscopy&#44; pure retroperitoneoscopy&#44; NOTES &#40;Natural Orifice Transluminal Endoscopic Surgery&#41; or LESS &#40;Laparoendoscopic Single SiteSurgery&#41; and robotic nephrectomy&#46; Thus&#44; many of the disadvantages of living donation have improved&#44; such as&#44; faster postoperative recovery&#44; less bleeding&#44; and less need for analgesia&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Other major surgical factors to consider are the proper selection of the kidney to be removed&#44; specific considerations in obese patients&#44; and the management of multiple pedicles&#46; Although conventionally&#44; and still at present&#44; the trend in many centers is to choose the left kidney with simple pedicle&#44; of young individuals with a suitable body mass index and ASA I&#44; we increasingly tend to pick individuals with isolated alterations&#44; such as HBP or obesity&#44; if the renal function is correct&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Donor assessment</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">General aspects</span><p id="par0025" class="elsevierStylePara elsevierViewall">The evaluation of a potential living donor may be performed by an independent physician&#44; followed by a nephrologist&#44; psychiatrist&#44; and surgical team of urologists&#46; Initial studies should include&#58; history and complete physical examination&#44; HLA typing&#44; blood tests &#40;urea&#44; creatinine&#44; electrolytes&#44; calcium&#44; phosphorus&#44; albumin&#41;&#44; coagulation tests&#44; serological test for HIV&#44; cytomegalovirus&#44; varicella virus&#44; herpes virus&#44; Epstein Barr virus&#44; B&#47;C hepatitis virus&#44; RPR&#44; FTA&#44; and PPD &#40;purified protein derivative&#41;&#44; electrocardiogram&#44; chest X-ray&#44; and CT with urographic and vascular phase&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In men&#44; testicular exploration is included&#44; and in those older than 50&#44; PSA and DRE&#46; In women&#44; breast screening is also included&#44; and in those over 40&#44; mammography&#46; Now&#44; if there is a history of breast cancer in premenopausal age in first-degree relatives&#44; the age for mammography should be below 35 years&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Choice of kidney</span><p id="par0030" class="elsevierStylePara elsevierViewall">It is mandatory that the living donor maintains the kidney with the best conditions&#46; The renal anatomy has to be assessed by means of multidetector CT and angiography&#47;urography with reconstructions&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the cases in which both kidneys have similar characteristics&#44; it is chosen to remove the left kidney&#44; which is the one with the longest renal vein and will facilitate implantation&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The right nephrectomy has been attributed a greater number of complications such as venous thrombosis&#44; greater delay in functional recovery&#44; and&#44; in general&#44; greater number of implant loss due to technical difficulties during the vascular anastomosis&#59; however&#44; recent studies suggest that although there is a minimal increase in the risk of graft failure&#44; it is considered as a perfectly acceptable option in donors in whom left nephrectomy is contraindicated<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Multiple pedicles</span><p id="par0040" class="elsevierStylePara elsevierViewall">The choice of kidneys with multiple pedicles has also been a controversial issue&#46; We tried to avoid them&#44; in order to minimize the vascular and ureteral complications&#46; However&#44; when the choice of the right kidney arises&#44; many centers prefer to use the left kidney despite having a multiple pedicle&#46; Abnormalities such as circumaortic veins&#44; retroaortic veins&#44; early bifurcation of the renal artery&#44; multiple veins&#44; or large lumbar veins&#44; are not usually a problem for the donation&#46; Although all the studies include a small number of patients with multiple pedicles&#44; globally&#44; it is considered to be feasible and safe&#46; Only in 2 studies have they been associated to more ureteral complications in the receptor&#44; especially with lower polar arteries<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;14</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Obesity</span><p id="par0045" class="elsevierStylePara elsevierViewall">Regarding obesity&#44; several studies have shown that laparoscopic nephrectomy in selected patients is safe&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Besides instrumentation and special position needs&#44; a higher incidence of anesthetic complications has been observed and postoperatively&#46; Obese patients have an increased filtration fraction&#44; which is an independent predictor of HBP&#44; which can influence long-term renal function<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Overall&#44; patient assessment for living donor laparoscopically or robotically is similar to the open approach&#46; The only relative contraindication for laparoscopic surgery&#44; which does not exist in the open procedure&#44; is a history of major upper abdominal surgery that might have led to dense adhesions so that the laparoscopic surgery may not be safe&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Surgical options in living donor donation</span><p id="par0055" class="elsevierStylePara elsevierViewall">There are several ways to get a living donor kidney&#46; The method chosen will depend on the surgeon&#39;s experience and the best choice of intervention for each individual case&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Open nephrectomy</span><p id="par0060" class="elsevierStylePara elsevierViewall">It can be performed by classical transperitoneal approach&#44; through an incision in the midline or left or right subcostal&#44; under sub or supracostal left or right extraperitoneal&#44; and dorsal lumbar below the 12th rib&#44; with resection thereof&#44; or above &#40;extraperitoneal&#44; extrapleural&#41;&#46; Although some authors have preferred the transperitoneal approach to ensure better access to the vessels&#44; the many advantages of the extraperitoneal surgery have eventually made it the standard technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The objectives of nephrectomy include removal of the kidney with minimal anatomical and physiological damage&#44; as well as minimal warm ischemia&#44; avoiding trauma to the renal parenchyma and preserving an adequate length of the artery&#44; vein&#44; and ureter that allows us to perform a safe anastomosis without endothelial damage&#44; and atraumatic ureteral reimplantation maintaining vascularization&#46; The result of these premises should translate into an immediate graft function in the host with a low rate of vascular and ureteral complications&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The literature review concludes that&#44; overall&#44; major complications have occurred in 3&#37;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;7</span></a> of donors who underwent open surgery&#44; most of which were resolved without permanent sequelae&#44; and minor complications in 10&#37;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;13</span></a> of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Most of the studies reviewed share the fact that delayed graft function&#44; thrombosis&#44; and ureteral fistulas are rare events that appear in 1&#8211;2&#37; of the cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Also&#44; the overall hospital stay is 5&#8211;7 days&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> In long-term follow-up&#44; in a review of 524 donors with a follow-up of 15 years&#44; only 4&#37; were dissatisfied with the donation&#44; and regretted having undergone surgery&#46; Regarding the surgical wound pain&#44; 84&#37; reported no pain present&#44; or medium intensity pain&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In the long-term follow-up&#44; in a review of 524 donors with a follow-up of 15 years&#44; only 4&#37; were dissatisfied with the donation and regretted having undergone surgery&#46; Regarding the surgical wound pain&#44; 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the patient is placed in a semilateral position&#44; with 20&#176; flexion&#44; performing an 8&#8211;10<span class="elsevierStyleHsp" style=""></span>cm transverse incision anterior to the 11th lateral rib on the edge of the rectum&#46; The transversallis fascia is incised laterally&#44; and the peritoneum is rejected medially using the Omnitract retractor&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In microinvasive nephrectomy&#44; the patient is placed in lateral decubitus and the incision is made 6&#8211;8<span class="elsevierStyleHsp" style=""></span>cm from the tip of the 10th rib to the rectum&#44; with the table flexed 30&#176; and placed 20&#176; in Trendelemburg&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> In the mini-nephrectomy through a posterior transcostal incision&#44; the patient is placed in lateral decubitus&#44; palpating the 12th rib&#46; A 6&#8211;8<span class="elsevierStyleHsp" style=""></span>cm incision is made along the rib starting 2&#8211;3<span class="elsevierStyleHsp" style=""></span>cm anterior to the lateral edge of the sacrospinous muscle&#46; The latissimus dorsi and the serratus posterior have to be sectioned&#44; in order to expose the 12th rib&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Finally&#44; in video-assisted mini-laparotomy&#44; a 5&#8211;7<span class="elsevierStyleHsp" style=""></span>cm lateral incision is made and a 10-mm trocar is placed between the peritoneum&#46; The 30&#176; optics makes it possible to maximize the vision&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Laparoscopic live donor nephrectomy</span><p id="par0100" class="elsevierStylePara elsevierViewall">Globally&#44; it has been shown that laparoscopic live donor nephrectomy &#40;LLDN&#41; has advantages over open surgery in terms of analgesic requirements&#44; hospital stay&#44; cosmetic result&#44; and return to the work activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> We have not seen that the graft function is affected by the positive pressure of the pneumoperitoneum&#44; being comparable to the open approach&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The LLDN technique has evolved over time&#44; and although it can be performed both transperitoneally and retroperitoneally&#44; in most centers&#44; it is performed transperitoneally due to the lower limitation of the surgical field and the possibility of removing the kidney through a midline or Pfannestiel incision&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> The technique is performed in modified lateral decubitus position&#44; with the hips rotated back for easy access to the bottom of the midline and to remove the kidney&#46; 3 5-mm laparoscopic accesses are performed&#44; separated 4 fingers in supraumbilical pararectal position&#46; The first of them&#44; caudal to the 12th rib and using 30&#176; optics&#46; It is started by rejecting the peritoneum along the avascular Told&#39;s line&#46; The dissection follows the existing plane between Gerota&#39;s fascia and the mesentery of the descending colon&#44; until the left gonadal vein is identified&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Dissection of the middle part of the gonadal vein should be limited to avoid devascularization of the ureter&#46; En bloc elevation of the gonadal vein&#44; the ureter&#44; and the lower pole of the kidney is generally useful in anterolateral direction with regard to the psoas muscle to facilitate exposure of the pedicle&#46; For the section of the pedicle&#44; we use an Endo-GIA stapling device&#44; with vascular load through access via 5-cm Pfannenstiel incision by which we will subsequently extract the kidney by endobag&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In the case of removing the right kidney&#44; additional access in the lumbar fossa for anterior retraction of the liver lobe and increasing the length of the renal vein&#44; which with the Endo-GIA causes the loss of 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#44; may be required&#46; A 6-cm transverse incision could also be made above the confluence of the right renal vein and the inferior vena cava for the open section of the renal vasculature&#46; Alternatively&#44; reconstruction can be performed using saphenous vein graft of the receptor&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Hand-assisted laparoscopic nephrectomy</span><p id="par0120" class="elsevierStylePara elsevierViewall">Both transperitoneal and retroperitoneal hand-assisted laparoscopic nephrectomy &#40;HALN&#41; has been described&#46; The use of the hand can be performed throughout the procedure&#44; or only at the time of the section of the pedicle and kidney extraction&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> The incisions can be periumbilical&#44; supra- or infraumbilical in the midline&#44; or Pfannenstiel&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;36</span></a> The advantages of hand-assisted laparoscopy compared to conventional laparoscopy are primarily the ability to digitally control a possible bleeding and allow for better exposure of the pedicle&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> This would make it possible to have shorter warm ischemia and surgical times&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#8211;40</span></a> With the retroperitoneal approach&#44; it is less likely to damage intra-abdominal organs&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Comparison between techniques</span><p id="par0125" class="elsevierStylePara elsevierViewall">Laparoscopic nephrectomy and hand-assisted laparoscopic nephrectomy</p><p id="par0130" class="elsevierStylePara elsevierViewall">Most studies conclude that the hand-assisted technique &#40;transperitoneal&#41; has shorter operative time&#44; blood loss&#44; warm ischemia&#44; and hospital stay&#46; The complications&#44; analgesic requirements&#44; and graft survival are similar in both&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#8211;41</span></a> It should be borne in mind that these studies include a limited number of patients&#44; with a low level of evidence&#44; so the definitive role of the HALN is not yet fully defined &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Open nephrectomy and laparoscopic nephrectomy</span><p id="par0135" class="elsevierStylePara elsevierViewall">Globally&#44; several meta-analyses have concluded that although the operative time and the warm ischemia time are more favorable for the open approach&#44; the LLDN has a shorter hospital stay&#44; faster recovery&#44; less pain&#44; less blood loss&#44; faster return to work&#44; and better quality of life compared to the open approach&#46; Most of these studies present the hand-assisted as an alternative rather than as the technique of choice&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30&#44;42&#8211;44</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Via open surgery&#44; it is easier to control intraoperative bleedings&#44; and in the postoperative period&#59; although the rate of reoperation for bleeding is similar in both groups &#40;1&#46;7 vs 0&#46;7&#37;&#41;&#44; in a recent work by Friedman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> we saw that massive hemorrhages are associated to a greater extent to the use of surgical Hem-o-loks &#40;more frequently in the laparoscopic approach&#41; than with other methods of renal pedicle control&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Although laparoscopy has a longer warm ischemia time&#44; several studies have shown that this does not translate into increased graft dysfunction&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;47</span></a> The incidence of complications remains lower in the laparoscopic group &#40;14 vs 16&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Apart from the pain of surgical wound&#44; which is longer in the open surgery group&#44; there are no differences in other major or minor specific complications&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In the case of specifically comparing the transperitoneal approach and retroperitoneoscopy within laparoscopy&#44; we have seen that the transperitoneal approach presents fewer lung lesions&#44; hernias&#44; and surgical wound pain than the retroperitoneal approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;49</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Doubts regarding follow-up&#44; complications&#44; and safety of the donor and receptor have been solved over time&#46; LLDN is currently the standard technique in most centers with experience in laparoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Laparoscopic nephrectomy and mini-incisional open nephrectomy</span><p id="par0160" class="elsevierStylePara elsevierViewall">The existing randomized studies have concluded that the LLDN presents better quality of life compared to the mini-incision with equal functionality to the graft&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Overall&#44; compared to the mini-incision&#44; the LLDN has a longer surgical time and less blood loss&#44; without differences in terms of complications&#46; The LLDN has fewer analgesic requirements and a shorter hospital stay&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#44;52</span></a> Now&#44; the LLDN is technically more demanding with a longer learning curve&#46; Because of this&#44; many smaller centers have opted for mini-incisional approaches&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Lewis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> conducted a study comparing the open approach&#44; laparoscopy&#44; and mini-incision&#46; The operative time and warm ischemia were longer for the mini-incision and laparoscopy&#46; Blood loss&#44; hospital stay&#44; and recovery of normal activity were significantly lower in laparoscopy&#46; The analgesic requirements were similar &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p></span></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Follow-up of the receptor</span><p id="par0170" class="elsevierStylePara elsevierViewall">Globally&#44; no significant differences were seen in overall or graft survival&#44; need for dialysis&#44; incidence of technical complications &#40;ureteral or vascular&#41;&#44; incidence&#44; time or severity of graft rejection&#44; and immediate or long-term function between the receptors made by open or laparoscopic approach&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Theoretically&#44; the pneumoperitoneum required for laparoscopic surgery would reduce the blood supply to the kidney&#44; causing a decrease in its function&#59; however&#44; hyperhydration significantly helps maintain the rhythm of diuresis&#46; The patients must be hydrated with 5&#8211;7 l of crystalloids during surgery&#44; and 25<span class="elsevierStyleHsp" style=""></span>mg of mannitol administered to encourage diuresis&#46; After the transplant&#44; the decrease in creatinine levels in the laparoscopic group indicates an immediate recovery of the renal function&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Although the creatinine nadir is reached earlier in the open surgery group &#40;third vs&#46; fourth postoperative day&#41;&#44; clinical significance has not been appreciated&#46; The average hospital stay is around 7 days for both groups&#44; and there are no significant differences in terms of ureteral complications&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Survival after one year of the laparoscopic and open &#40;100 vs&#46; 97&#37;&#41; and graft group &#40;93&#46;5 vs 91&#46;1&#37;&#41; were similar in both groups&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;55</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Developing surgical techniques</span><p id="par0185" class="elsevierStylePara elsevierViewall">The literature in this field is limited&#44; although the theoretical advantages of the robot would be the scanned image in combination with the advances in microsurgery&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> There is a study comparing the robot to the open approach&#44; in which the operative time and warm ischemia are greater in the robot&#44; with equivalent graft function&#44; similar complications&#44; and shorter hospital stay for the robot&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> Similarly&#44; new minimally invasive surgical techniques such as robotic-assisted nephrectomy and NOTES or LESS&#44; whose results so far are preliminary&#44; are recently being introduced&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">58&#44;66</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0190" class="elsevierStylePara elsevierViewall">Currently&#44; there is sufficient evidence to consider the LLDN as the technique of choice&#44; although the role of the hand-assisted technique and retroperitoneoscopy are still not entirely clarified&#46; The techniques of mini-incisional open surgery techniques represent an acceptable alternative for the centers that have not yet implemented laparoscopic surgery&#46; The right kidney nephrectomy&#44; multiple pedicles&#44; and in obese patients is justified in selected cases&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflict of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "identificador" => "xres227331"
          "titulo" => array:5 [
            0 => "Abstract"
            1 => "Context"
            2 => "Objective"
            3 => "Evidence acquisition"
            4 => "Conclusions"
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        ]
        1 => array:2 [
          "identificador" => "xpalclavsec212218"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres227330"
          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Contexto"
            2 => "Objetivo"
            3 => "Adquisici&#243;n de la evidencia"
            4 => "Conclusiones"
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec212217"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Donor assessment"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "General aspects"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Choice of kidney"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Multiple pedicles"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Obesity"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0035"
          "titulo" => "Surgical options in living donor donation"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Open nephrectomy"
            ]
            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Laparoscopic live donor nephrectomy"
            ]
            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Hand-assisted laparoscopic nephrectomy"
            ]
            3 => array:3 [
              "identificador" => "sec0055"
              "titulo" => "Comparison between techniques"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "Open nephrectomy and laparoscopic nephrectomy"
                ]
                1 => array:2 [
                  "identificador" => "sec0065"
                  "titulo" => "Laparoscopic nephrectomy and mini-incisional open nephrectomy"
                ]
              ]
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Follow-up of the receptor"
        ]
        8 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Developing surgical techniques"
        ]
        9 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Conclusions"
        ]
        10 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Conflict of interest"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2012-05-03"
    "fechaAceptado" => "2012-05-11"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec212218"
          "palabras" => array:3 [
            0 => "Living donor nephrectomy"
            1 => "Laparoscopy"
            2 => "Results"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec212217"
          "palabras" => array:3 [
            0 => "Nefrectom&#237;a de donante vivo"
            1 => "Laparoscopia"
            2 => "Resultados"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Context</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Living donor renal transplant surgery has evolved from the classical nephrectomy by lumbotomy to less invasive surgery&#44; the laparoscopic and robotic nephrectomy currently being the most important&#46; It is important to know the available evidence on whether nephrectomy in patients with multiple arteries&#44; right kidney and in obese patients can be performed safely when there is a correct indication&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To perform a review of the different surgical techniques in living donor nephrectomy&#44; adapted to the current surgical evidence and other aspects related to the indication&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Evidence acquisition</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A systematic review was made in PubMed &#40;1997&#8211;2011&#41;&#46; This included previous reviews randomized controlled clinical studies&#44; cohort studies&#44; and meta-analyses of these surgical aspects of living donor nephrectomy&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Currently&#44; there is sufficient evidence to consider living donor laparoscopic nephrectomy &#40;LDLN&#41; as the technique of choice&#44; although the role of hand-assisted retroperitoneoscopic technique is still not totally clear&#46; Open surgery techniques using mini-incision are an acceptable alternative for the sites that have not yet implemented laparoscopic surgery&#46; Right kidney nephrectomy&#44; of those cases that present multiple pedicles and in obese donors&#44; is justified in selected cases&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Contexto</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a del trasplante renal de donante vivo&#44; ha evolucionado desde la cl&#225;sica nefrectom&#237;a por lumbotomia a una cirug&#237;a menos invasiva&#44; imponi&#233;ndose en la actualidad la nefrectom&#237;a laparosc&#243;pica y rob&#243;tica&#46; Resulta importante conocer la evidencia disponible acerca de si la nefrectom&#237;a en pacientes con m&#250;ltiples arterias&#44; ri&#241;&#243;n derecho y en pacientes obesos puede realizarse de manera segura ante una indicaci&#243;n correcta&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Realizar una revisi&#243;n de las diferentes t&#233;cnicas quir&#250;rgicas en nefrectom&#237;a de donante vivo&#44; adaptada a la evidencia cient&#237;fica actual&#44; y de otros aspectos que rodean la indicaci&#243;n&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Adquisici&#243;n de la evidencia</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; una revisi&#243;n sistem&#225;tica en PubMed &#40;1997&#8211;2011&#41;&#44; que incluye revisiones previas&#44; estudios cl&#237;nicos aleatorizados controlados&#44; estudios de cohortes&#44; y metan&#225;lisis de los aspectos quir&#250;rgicos de la nefrectom&#237;a de donante vivo&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Actualmente existe suficiente evidencia para considerar la nefrectom&#237;a laparosc&#243;pica de donante vivo &#40;NLDV&#41; como t&#233;cnica de elecci&#243;n&#44; aunque el papel de la t&#233;cnica mano-asistida y la retroperitoneoscopia todav&#237;a no est&#225;n del todo claros&#46; Las t&#233;cnicas de cirug&#237;a abierta por mini-incisi&#243;n representan una alternativa aceptable para los centros que no hayan implementado todav&#237;a la cirug&#237;a laparosc&#243;pica&#46; La nefrectom&#237;a de ri&#241;&#243;n derecho&#44; de aquellos casos que presentan ped&#237;culos m&#250;ltiples y en los donantes obesos esta justificada en casos seleccionados&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez O&#44; et al&#46; Aspectos quir&#250;rgicos actuales de la nefrectom&#237;a de donante vivo&#46; Actas Urol Esp&#46; 2013&#59;37&#58;181&#8211;7&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#60;18 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Uncontrolled HBP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Proteinuria &#62;300<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abnormal glomerular filtration for age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Microscopic hematuria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">High risk of thromboembolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe disease &#40;chronic pulmonary disease&#44; recent malignancy&#44; heart disease&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">History of bilateral renal calculi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HIV infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab338915.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Absolute contraindications for living donor kidney transplant&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Level of evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Type of evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left vs right</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1b</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Randomized clinical trials<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prospective studies<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multiple pedicles</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prospective studies<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obese vs non obese&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab338916.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Level and type of evidence as to the choice of kidney&#44; multiple pedicles&#44; and obesity in live donor nephrectomy&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Level of evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Type of evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Open vs mini-incision</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prospective studies<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;51</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mini-incision vs LLDN</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Randomized clinical trials<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prospective studies<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaanalysis<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LLDN vs HALN</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Randomized clinical trials<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prospective studies<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">62&#44;63</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">64&#44;65</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Robotic vs open&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retrospective studies<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Levels and types of evidence in the comparison of different techniques in live donor nephrectomy&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:66 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Medical progress&#58; procurement and allocation of solid organs for transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46;J&#46; Hauptman"
                            1 => "K&#46;J&#46; O&#8217;Connor"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199702063360607"
                      "Revista" => array:6 [
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                        "fecha" => "1997"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9010150"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "EUA Guidelines Renal Transplantation 2011&#46; Available from&#58; <a id="intr0005" class="elsevierStyleInterRef" href="http://www.uroweb.org/guidelines">www&#46;uroweb&#46;org&#47;guidelines</a>&#46;"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Laparoscopic live donor nephrectomy&#58; trends in donor and recipient morbidity following 381 consecutive cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46;M&#46; Su"
                            1 => "L&#46;E&#46; Ratner"
                            2 => "R&#46;A&#46; Montgomery"
                            3 => "T&#46;W&#46; Jarrett"
                            4 => "B&#46;J&#46; Trock"
                            5 => "V&#46; Sinkov"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Surg"
                        "fecha" => "2004"
                        "volumen" => "240"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15273562"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Protocolo Trasplante renal donante vivo&#46; Fundaci&#243; Puigvert&#46; Available from&#58; <a id="intr0010" class="elsevierStyleInterRef" href="http://www.fundacio-puigvert.es/">www&#46;fundacio-puigvert&#46;es</a>&#46;"
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluaci&#243;n anat&#243;mica del donante vivo de ri&#241;&#243;n&#58; &#191;tomograf&#237;a axial computarizada o resonancia nuclear magn&#233;tica&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;L&#46; Ruiz-Cerd&#225;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Urol Esp"
                        "fecha" => "2010"
                        "volumen" => "34"
                        "paginaInicial" => "493"
                        "paginaFinal" => "494"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20510110"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Laparoscopic donor nephrectomy&#58; a plea for the right-sided approach"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "L&#46;F&#46; Dols"
                            1 => "N&#46;F&#46; Kok"
                            2 => "I&#46;P&#46; Alwayn"
                            3 => "T&#46;C&#46; Tran"
                            4 => "W&#46; Weimar"
                            5 => "J&#46;N&#46; Ijzermans"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/TP.0b013e318198a3a6"
                      "Revista" => array:6 [
                        "tituloSerie" => "Transplantation"
                        "fecha" => "2009"
                        "volumen" => "87"
                        "paginaInicial" => "745"
                        "paginaFinal" => "750"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19295321"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Right-sided laparoscopic live-donor nephrectomy&#58; is reluctance still justified&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;Y&#46; Lind"
                            1 => "E&#46;J&#46; Hazebroek"
                            2 => "W&#46;C&#46; Hop"
                            3 => "W&#46; Weimar"
                            4 => "H&#46; Jaap Bonjer"
                            5 => "J&#46;N&#46; IJzermans"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Transplantation"
                        "fecha" => "2002"
                        "volumen" => "74"
                        "paginaInicial" => "1045"
                        "paginaFinal" => "1048"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12394852"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Left or right kidney in hand-assisted donor nephrectomy&#63; A randomized controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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Article information

ISSN: 21735786
Original language: English

DOI:10.1016/j.acuroe.2012.05.018

The statistics are updated each day

Year/Month	Html	Pdf	Total

2023 March	0	0	0
2018 February	9	0	9
2018 January	14	3	17
2017 December	7	2	9
2017 November	20	0	20
2017 October	18	3	21
2017 September	17	2	19
2017 August	25	1	26
2017 July	26	3	29
2017 June	16	12	28
2017 May	16	2	18
2017 April	19	10	29
2017 March	17	42	59
2017 February	14	2	16
2017 January	25	0	25
2016 December	25	5	30
2016 November	29	4	33
2016 October	37	5	42
2016 September	15	3	18
2016 August	21	2	23
2016 July	13	1	14
2016 June	14	5	19
2016 May	19	11	30
2016 April	11	11	22
2016 March	29	14	43
2016 February	24	19	43
2016 January	21	14	35
2015 December	13	11	24
2015 November	16	13	29
2015 October	12	12	24
2015 September	15	6	21
2015 August	16	6	22
2015 July	11	5	16
2015 June	6	1	7
2015 May	11	0	11
2015 April	13	9	22
2015 March	28	8	36
2014 June	2	0	2
2014 May	1	1	2
2014 January	4	2	6
2013 December	9	2	11
2013 November	16	3	19
2013 October	9	5	14
2013 September	10	5	15

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