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Background: Dual kidney transplantation (DKT) is a largely accepted strategy to enlarge the donor pool. Niguarda Hospital started this program in December 2010, and 38 DKT have been performed. In our series, we included recipients older than those in the other series published in literature. The aim of this study was to know if our recipient selection criteria for DKT are safe., Methods: We reviewed our data base of DKT and analyzed recipients' medical history, surgical technique, post-operative complications, graft survival, morbidity, and mortality. We then compared our results with the literature., Results: From December 2010 to April 2015, 38 DKT were performed in Niguarda Hospital. Delayed graft function was present in 21 recipients. Explantation of both kidneys was performed in 1 patient and explantation of 1 kidney in 6 patients. Post-operative complications were present in 8 patients. Five patients returned to hemodialysis after DKT. One recipient died of medical post-operative sepsis. The mean follow-up was 24 months. Graft survival and patient survival were 86.84% and 97.93%, respectively. Compared with the literature, our series had similar mortality and morbidity rates, even if recipients' age was higher than in other series., Conclusions: The strategy of DKT allocation in elderly recipients is safe. Further studies have to be performed to optimized selection of the recipients for DKT not to disadvantage younger patients in the transplant waiting list and to improve the technique of organ evaluation and preservation to refine graft allocation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Worldwide, organ shortage is a major limiting factor to transplantations. One possible way to face graft scarcity is splitting full livers into hemilivers; this procedure would allow transplantation in 2 adult recipients with the use of a single organ from a deceased donor., Objective: The goal of this study was to describe an adult-to-adult split liver operative protocol and share it between centers interested in exploring this procedure., Materials and Methods: A literature review was first conducted to elaborate on the present protocol; second, selection criteria for suitable deceased donors were identified. The technical aspects of performing the procurement were also analyzed; finally, the recipient selection criteria and the transplantation criteria were determined., Results: The donor characteristics should be consistent with the following: age≤55 years; weight≥70 kg; body mass index<28 kg/m2; intensive care unit stay<7 days; sodium level<160 mEq/L if the intensive care unit stay is >2 days; maximum transaminase value 3 times normal; hemodynamic stability; negative for hepatitis B surface antigen, hepatitis C virus, and human immunodeficiency virus; macrosteatosis<20%; macroscopic adequacy; and absence of anatomic anomalies requiring complex reconstruction. The procurement hospital should provide the preoperative computed tomography scan, liver dissector, and the intraoperative ultrasound. Indication for in situ or ex situ splitting depends on the hepatic vein outflow anatomy. Graft-to-recipient weight ratio should be ≥1%, and the graft-to-recipient spleen size ratio should be ≥0.6. United Network for Organ Sharing status 1 and 2A recipients are excluded, as are patients with transjugular intrahepatic portosystemic shunts. Hemiliver transplants are performed as in living-donor liver transplantation, and portal hyperflow is corrected by splenic artery ligation, splenectomy, and portal infusion of vasoactive drugs., Conclusions: The present protocol was proposed to test the validity of the full-left full-right split liver procedure. A retrospective analysis found that 130 transplantations were suitable for this procedure according to the present protocol in the period January 1, 2008, through December 31, 2011 (65 donors). We believe that these numbers could be greatly increased once this procedure is proven feasible and safe within the proposed criteria., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Robot-assisted surgery provide endowrist instruments and 3-dimensional visualization of the operative field that are improvements over traditional laparoscopy. The few research studies published so far have demonstrated that living-donor nephrectomy using the robot-assisted technique is safe and feasible, providing advantages for patients., Methods: Since November 2009, we performed 20 robot-assisted living-donor nephrectomies. Eight patients underwent hand-assisted robotic nephrectomy, whereas 20, totally robotic nephrectomy., Results: Median intraoperative bleeding was 174 mL (range, 10-750) but no patient needed intraoperative transfusion with blood cells. The median warm ischemia time was 3.16 minutes (range, 0.30-6.5). there was no case of conversion to an open procedure. The median operative time was 311 minutes (range, 85-530); the median console time was 160 minutes (range, 135-220)., Conclusion: Robot-assisted living-donor kidney recovery was a safe and effective procedure. The totally robotic recovery is an evolving technique. The prospect of robotic staplers, endowrist ligature, and robotic single port may further increase these advantages., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Donor safety must be considered to be a priority in live-donor liver transplantation (LDLT). The aim of this study was to evaluate these outcomes with special attention to surgical complications and their treatment., Methods: From March 2001 to March 2012, 80 live donors underwent right hepatectomy (5-8 segments). The middle hepatic vein was always left in the donor. Our retrospective study analyzed surgical outcomes and complications according to the Clavien classification modified for live donors., Results: With a median follow up of 63.2 ± 12.6 months, the mortality was 0%. Two donors experienced intraoperative complications, but all of them had complete recovery there after. Among the 22 complications in 17 donors (21.2%), 7 (8.7%) were major complications (Clavien grade 2b) but only 2 donors required surgical treatment., Conclusions: LDLT is a safe and feasible modality to alleviate the cadaveric donor shortage. The efficacy of this procedure is similar to that with deceased donors., (Copyright © 2013. Published by Elsevier Inc.)

Introduction: Chronic viral hepatitis is considered to be the most significant risk factor for development of hepatocellular carcinoma (HCC). Nevertheless, about 5%-15% of HCC occur in noncirrhotic or virus-unrelated cirrhotic patients. The natural history of HCC in terms of incidence, clinical features, and tumor progression differs according to the underlying cancerogenic factors and differences in hepatocarcinogenetic pathways. Little is know about the relationship between HCC outcomes after liver transplantation (OLT) and the primary liver disease. We retrospectively analyzed the outcomes of patients transplanted due to HCC in settings of either virus-related or virus-unrelated cirrhosis., Patients and Methods: From January 2000 to December 2007, 179 patients underwent OLT due to HCC: 157 (87.8%) affected by virus-related (group A) and 22 (12.2%) virus-unrelated cirrhosis (group B). We analyzed patient characteristics including demographics, tumor features, downstaging treatments, and recurrences., Results: At a mean follow-up of 41.2 months, the 3- and 5-year overall long-term survivals between group A versus group B were 81% versus 75% and 85% versus 78.4% respectively (P = NS). The 3- and 5-year disease-free survivals between group A versus group B were 90.8% versus 89.6% and 85.6% versus 85.6%, respectively (P = NS). After OLT, HCC recurrences occurred in 14 group A (14/157, 8.9%) and 4 patients (4/22, 18.1%) group B subjects., Discussion: Our data demonstrated that after OLT, HCC outcomes were not different between patients with virus-related or -unrelated cirrhosis. The direct oncogenetic role played by hepatitis B and C appear to not be associated with a greater risk to develop HCC recurrence., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Liver adenomatosis (LA) is a rare benign disease of the liver with unclear pathogenesis, which is characterized by multiple hepatic adenomas. The management of LA remains controversial. Herein we have reported a case of LA treated by living donor liver transplantation (LDLT). A 48-year-old woman developed multiple liver adenomas. In view of the sizes and localizations of the lesions, the patient underwent right hepatic resection and segment II nodulectomy. Thirty-four months later, she developed recurrence of multiple hepatic adenomas and 2 nodules were highly suspect for hepatocellular carcinoma. Re-resection was not indicated due to the whole liver being involved with adenomas. The patient underwent LDLT. At 45 months thereafter she is alive and disease-free. In conclusion, LDLT is indicated in cases of nonresectability; it may offer optimal results in view of the absence of portal hypertension and the elimination of waiting list time.

Objective: Living donor liver transplantation (LDLT) may represent a valid therapeutic option allowing several advantages for patients affected by hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT). However, some reports in the literature have demonstrated worse long-term and disease-free survivals among patients treated by LDLT than deceased donor liver transplantation (DDLT) for HCC. Herein we have reported our long-term results comparing LDLT with DDLT for HCC., Patients and Methods: Among 179 patients who underwent OLT from January 2000 to December 2007, 25 (13.9%) received LDLT with HCC 154 (86.1%) received DDLT. Patients were selected based on the Milan criteria. Transarterial chemoembolization, radiofrequency ablation, percutaneous alcoholization, or liver resection was applied as a downstaging procedure while on the waiting list. Patients with stage II HCC were proposed for LDLT., Results: The overall 3- and 5-year survival rates were 77.3% and 68.7% versus 82.8% and 76.7% for LDLT and DDLT recipients, respectively, with no significant difference by the log-rank test. Moreover, the 3- and 5-year recurrence-free survival rates were 95.5% and 95.5% (LDLT) versus 90.5% and 89.4% (DDLT; P = NS)., Conclusions: LDLT guarantees the same long-term results as DDLT where there are analogous selection criteria for candidates. The Milan criteria remain a valid tool to select candidates for LDLT to achieve optimal long-term results.

Living donation in the field of renal transplantation has increased over time as well as the use of laparoscopic nephrectomy. We present a 15-year experience on 162 living donors (105 women, 57 men; mean age, 46.7 years; range, 31-74 years) who underwent nephrectomy using different surgical approaches as open lombotomic nephrectomy (OLN), open transperitoneal nephrectomy (OTN), and laparoscopic hand-assisted nephrectomy (LHAN). We collected data on residual donor and recipient renal function, as well as early versus late medical and surgical complications. With a mean follow-up of about 8 years, we observed normal residual renal function in all donors and similar results of early and late graft function independent of the surgical procedure. Long-term incidence of hypertension and noninsulin-dependent diabetes in living donors was similar to the general population. OLN and OTN donors showed higher incidences of early and late complications, readmissions, and reoperations than LHAN donors. Our results confirmed that living donor nephrectomy is a safe procedure without serious side effects in terms of renal function and long-term quality of life. LHAN should be the preferred technique because of a lower incidence of early and late complications.

We examined surgical complications among a group of diabetic type 1 patients (IDDM) with end-stage renal disease (ESRD) who had undergone pancreas-kidney transplantations (PK). Between October 1993 and August 2004, 70 SPK were performed using bladder (n = 14) or enteric (n = 56) drainage. Donors were selected according to standard criteria (mean age, 27.6 years; range, 17-49). All patients received cyclosporine-based immunosuppression. All pancreata functioned immediately, whereas 2 patients needed postoperative dialysis. Four patients (5.7%) lost their pancreatic graft due to vascular thrombosis; both patients underwent urgent allograft pancreaectomy and pancreas retransplantation (re-PT). One of them (1.4%) experienced a venous thrombosis and died due to a pulmonary embolism at 12 hours after re-PT. The other 3 patients had uneventful postoperative courses and were discharged with good pancreatic and renal function. Three patients in the bladder group (21.4%) had an anastomotic leak, which resolved with a bladder catheter. Four patients in the enteric group (7.1%) who experienced an anastomotic leak needed a second surgical procedure but in 3 of them allograft pancreatectomy was necessary. Relaparotomy was required in the other 3 patients due to hemorrhage (1 patient) or occlusion (2 patients). Acute rejection episodes, which occurred in 16 patients (22.8%), were treated with steroid boluses. With a mean follow-up of 72 months (range, 3-129), 2 patients have died at 8 and at 36 months, respectively, after SPK due to acute myocardial infarction (2.9%). Chronic rejection was the leading cause of pancreatic failure in 5 patients (7.1%) and of renal failure in 2 patients (2.8%). Patient, kidney, and pancreas survival rates were 95.8%, 92.9%, and 81.5%, respectively. Surgical complications were the leading cause of pancreatic allograft loss in IDDM and ESRD patients submitted to SPK.

Perioperative donor morbidity, a barrier to living organ donation, may be mitigated by the laparoscopic approach. From September 2002 to September 2004, 15 living donors, of ages ranging from 36 to 59 years, underwent laparoscopic nephrectomy. We used a hand-assisted device to increase the safety of the procedure. The average operating time was 200 minutes. The average blood loss was about 100 mL. The patients resumed oral intake and started walking within 1 day. The average postoperative hospital stay was 6 days. Although laparoscopic operating times were longer than those for traditional surgery, we showed benefits to the laparoscopic donor to be less postoperative pain, better cosmesis, shorter recovery time, and faster return to normal activities. We therefore consider laparoscopic nephrectomy a good alternative to traditional surgery for selected patients. Despite a lack of strong evidence, such as large prospective randomized studies, laparoscopic donor nephrectomy is likely to become the gold standard for donor nephrectomy in the near future.

We retrospectively studied the incidence of urological complications in a consecutive series of 590 patients (group B) who received a kidney transplant (KT) with a ureteral stent from January 1994 to December 2002. The ureteral stent was sewn to the bladder catheter during the surgical procedure and left in situ for a mean time of 10 days (range 8 to 12 days). The results were compared to a consecutive series of 414 patients who received a KT from March 1986 to December 1993 without a ureteral stent (group A). The two groups were comparable in terms of donor and recipient gender, ischemia time, delayed graft function, and chronic rejection incidence, but differed in mean donor age (44.1 vs 36.0 years), mean recipient age (45.4 vs 39.1 years), living/cadaveric donor rate (19.8% vs 11.9%), arterial lesions and bench reconstruction rate (11.1 vs 3.5%), as well as acute rejection episodes (11.7% vs 29.2%). Complications were seen in nine patients in group B (1.5%) and 17 patients in group A (4.1%) (P < .0001). Urinary leaks presented in two patients in group B (0.3%) and 11 patients in Group A (2.6%; P < .0001), while stenosis was present in six patients in group B (1.5%) and 7 in group A (1.2%) (P = NS). Urological complications such as urinary tract infection and macroscopic hematuria were similar in both groups. Time to presentation of a leak was within 2 weeks from KT in 10 patients (92.3%), while stenosis presented early in four patients (one in group B and four in group A). Of the stenoses, 69.3% presented late (beyond 12 weeks) in five patients in group B and three in Group A. In conclusion, our data suggest that routine use of double pigtail ureteral stent significantly decreased the incidence of leaks and early stenoses, but it did not modify late stenosis incidence. In the last decade, risk factors for urological complications have been increasing over time, namely, older donors and older recipients, living donation, length of dialysis, and the use of grafts with arterial lesions. Therefore we believe that a ureteral stent should be routinely considered to afford the advantage to protect the urinary anastomosis in the early postoperative period when the incidence of complications is highest, without the need of cystoscopy for its removal.

Unlabelled: Although right hemiliver transplant from living donors (LD) is gaining acceptance as a way to overcome the critical organ shortage, splitting a liver for two adults from cadaveric donor (CD) is still controversial., Methods: From May 1999 to August 2004 we performed nine right hemiliver transplants using segments 5-6-7-8 from CD and 18 from LD., Results: We compared the two procedures to evaluate both the technical aspects and the patients' outcomes. In the CD group, three recipients died (33%), two of whom were UNOS Status 2A. Patient and graft survivals were 67% (median follow-up: 23 months). Among the LD group, three recipients died (17%) and two were retransplanted; one because of arterial thrombosis and the other as a consequence of small-for-size syndrome. Patient and graft survivals were 83% and 72%, respectively (median follow-up: 8 months). There were five early complications in the CD group (55%) and five (27%) in the LD group. Two patients in the LD group experienced a late stenosis of the biliary anastomosis., Discussion: Data from our early experience show that better results are achieved by right hemiliver transplants from LD; the morbidity and mortality are higher among the CD group. We believe that this finding is probably a consequence of better preoperative donor evaluation, shorter ischemia time, better logistics, and learning curve. Recipient selection is crucial; this kind of graft is at high risk of poor function, technical complications, and infections. Further experience will help to clarify the reliability of right hemiliver transplants from CD.