Appendicitis following a live laparoscopic donor nephrectomy (LLDN) is rare complication and can present a diagnostic challenge. LLDN patients represent a unique group of patients for which there is limited research. Preventing a second operation and preserving residual kidney function are important considerations. Herein we present a case of appendicitis 9 days post hand assisted laparoscopic donor nephrectomy which presented as right sided abdominal pain and was con- firmed on computed tomography. It was successfully managed through a conservative approach of intravenous antibiotics and fluid. This case demonstrated successful conservative management of appendicitis post LLDN and is the first reported case of conservative management in LLDN pa- tients and only the second reported case of appendicitis post LLDN.

Background Transplant rejection is a major cause of graft loss and morbidity. Currently, no human models of antibody-mediated rejection (AMR) exist, limiting mechanistic investigation and organ-specific targeted therapy. Here, using 12 human kidneys and ex-vivo normothermic machine perfusion, we demonstrate phenotypes of AMR after addition of antibodies against either human HLA class I or blood group antigens (A, B), thus modelling clinical AMR that can follow HLA incompatible (HLAi) or blood group incompatible (ABOi) transplantation. Methods Discarded human kidneys with wide ranging demographics and cold ischaemia times (11-54 h) were perfused with red blood cells and fresh frozen plasma (FFP) as a source of complement/coagulation factors. For the HLAi model, 600 mu g of W6/32 anti-class 1 HLA antibody was added to the circuit (time '0'). For the ABOi model, high titre FFP of the relevant blood group antibody was added. Renal blood flow index (RBFi, mL/min/100 g), C3 desArg, prothrombin fragments 1 + 2 and histology were determined. Our endpoints included haemodynamic changes, thrombosis, and biopsy proven complement deposition. Findings Compared to control kidneys perfused without anti-donor antibodies, both models demonstrated haemodynamic collapse after antibody perfusion with only the HLAi model showing glomerular C4d deposition. Interpretation We show that a clinically relevant human kidney model of AMR is feasible, and anticipate that these models, with refinements, could provide a basis to test different strategies to prevent AMR. Copyright (c) 2022 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

BACKGROUND:Transplant rejection is a major cause of graft loss and morbidity. Currently, no human models of antibody-mediated rejection (AMR) exist, limiting mechanistic investigation and organ-specific targeted therapy. Here, using 12 human kidneys and ex-vivo normothermic machine perfusion, we demonstrate phenotypes of AMR after addition of antibodies against either human HLA class I or blood group antigens (A, B), thus modelling clinical AMR that can follow HLA incompatible (HLAi) or blood group incompatible (ABOi) transplantation.METHODS:Discarded human kidneys with wide ranging demographics and cold ischaemia times (11-54 h) were perfused with red blood cells and fresh frozen plasma (FFP) as a source of complement/coagulation factors. For the HLAi model, 600 μg of W6/32 anti-class 1 HLA antibody was added to the circuit (time '0'). For the ABOi model, high titre FFP of the relevant blood group antibody was added. Renal blood flow index (RBFi, mL/min/100 g), C3 desArg, prothrombin fragments 1 + 2 and histology were determined. Our endpoints included haemodynamic changes, thrombosis, and biopsy proven complement deposition.FINDINGS:Compared to control kidneys perfused without anti-donor antibodies, both models demonstrated haemodynamic collapse after antibody perfusion with only the HLAi model showing glomerular C4d deposition.INTERPRETATION:We show that a clinically relevant human kidney model of AMR is feasible, and anticipate that these models, with refinements, could provide a basis to test different strategies to prevent AMR.FUNDING:The Rosetrees and Stonygate Trust, The Royal College of Surgeons of England Fellowship Grant, NIHR Biomedical Research Centre/KCL Early Career Grant, Kidney Research U.K.

The incidence of incisional hernia after kidney transplantation varies between 1.1% and 3.8%. These are usually repaired electively using polypropylene mesh. We present here a case where a patient presented as an emergency, with a large painful incisional hernia over his kidney transplant, and evidence of local erythema and systemic inflammation. As this could have represented either infection or rejection, the patient was started on antibiotics and subsequently underwent graft nephrectomy and hernia repair using a biological (porcine-derived) acellular dermal matrix, Strattice™, with a satisfactory outcome. In addition, histology showed evidence of allograft rejection. This is the first reported case of an incisional hernia containing a rejecting kidney allograft, managed with nephrectomy and biological mesh repair.

*These authors contributed equally to this work Introduction: Robotic surgery has been increasingly used in fashioning various surgical anastomoses. Our aim was to collect and analyze outcomes related to anastomoses performed using a robotic approach and compare them with those done using laparoscopic or open approaches through meta-analysis. Methods: A systematic review was conducted for articles comparing robotic with laparoscopic and/or open operations (colectomy, low anterior resection, gastrectomy, Roux-en-Y gastric bypass (RYGB), pancreaticoduodenectomy, radical cystectomy, pyeloplasty, radical prostatectomy, renal transplant) published up to June 2019 searching Medline, Scopus, Google Scholar, Clinical Trials and the Cochrane Central Register of Controlled Trials. Studies containing information about outcomes related to hand-sewn anastomoses were included for meta-analysis. Studies with stapled anastomoses or without relevant information about the anastomotic technique were excluded. We also excluded studies in which the anastomoses were performed extracorporeally in laparoscopic or robotic operations. Results: We included 83 studies referring to the aforementioned operations (4 randomized controlled and 79 non-randomized, 10 prospective and 69 retrospective) apart from colectomy and low anterior resection. Anastomoses done using robotic instruments provided similar results to those done using laparoscopic or open approach in regards to anastomotic leak or stricture. However, there were lower rates of stenosis in robotic than in laparoscopic RYGB (p=0.01) and in robotic than in open radical prostatectomy (p<0.00001).Moreover, all anastomoses neededmore time to be performed using the robotic rather than the open approach in renal transplant (p≤0.001). Conclusion: Robotic anastomoses provide equal outcomes with laparoscopic and open ones in most operations, with a few notable exceptions.

INTRODUCTION:Robotic surgery has been increasingly used in fashioning various surgical anastomoses. Our aim was to collect and analyze outcomes related to anastomoses performed using a robotic approach and compare them with those done using laparoscopic or open approaches through meta-analysis.METHODS:A systematic review was conducted for articles comparing robotic with laparoscopic and/or open operations (colectomy, low anterior resection, gastrectomy, Roux-en-Y gastric bypass (RYGB), pancreaticoduodenectomy, radical cystectomy, pyeloplasty, radical prostatectomy, renal transplant) published up to June 2019 searching Medline, Scopus, Google Scholar, Clinical Trials and the Cochrane Central Register of Controlled Trials. Studies containing information about outcomes related to hand-sewn anastomoses were included for meta-analysis. Studies with stapled anastomoses or without relevant information about the anastomotic technique were excluded. We also excluded studies in which the anastomoses were performed extracorporeally in laparoscopic or robotic operations.RESULTS:We included 83 studies referring to the aforementioned operations (4 randomized controlled and 79 non-randomized, 10 prospective and 69 retrospective) apart from colectomy and low anterior resection. Anastomoses done using robotic instruments provided similar results to those done using laparoscopic or open approach in regards to anastomotic leak or stricture. However, there were lower rates of stenosis in robotic than in laparoscopic RYGB (p=0.01) and in robotic than in open radical prostatectomy (p<0.00001). Moreover, all anastomoses needed more time to be performed using the robotic rather than the open approach in renal transplant (p≤0.001).CONCLUSION:Robotic anastomoses provide equal outcomes with laparoscopic and open ones in most operations, with a few notable exceptions.

Background: Postoperative infection after hand-assisted laparoscopic donor nephrectomy (HALDN) confers significant morbidity to a healthy patient group. Current UK guidelines cite a lack of evidence for routine antibiotic prophylaxis. This trial assessed if a single preoperative antibiotic dose could reduce post HALDN infections. Methods: Eligible donors were randomly and blindly allocated to preoperative single-dose intravenous co-amoxiclav or saline. The primary composite endpoint was clinical evidence of any postoperative infection at 30 days, including surgical site infection (SSI), urinary tract infection (UTI), and lower respiratory tract infection (LRTI). Findings: In all, 293 participants underwent HALDN (148 antibiotic arm and 145 placebo arm). Among them, 99% (291/293) completed follow-up. The total infection rate was 40.7% (59/145) in the placebo group and 23% (34 of 148) in the antibiotic group (P= 0.001). Superficial SSIs were 20.7% (30/145 patients) in the placebo group versus 10.1% (15/148 patients) in the antibiotic group (P= 0.012). LRTIs were 9% (13/145) in the placebo group and 3.4% (5/148) in the antibiotic group (P= 0.046). UTIs were 4.1% (6/145) in the placebo group and 3.4% (5/148) in the antibiotic group (P= 0.72). Antibiotic prophylaxis conferred a 17.7% (95% confidence interval 7.2%-28.1%), absolute risk reduction in developing postoperative infection, with 6 donors requiring treatment to prevent 1 infection. Interpretation: Single-dose preoperative antibiotic prophylaxis dramatically reduces post-HALDN infection rates, mainly impacting SSIs and LRTIs.

Ex vivo normothermic perfusion (EVNP) technology is a promising means of organ preservation, assessment, and preconditioning prior to kidney transplantation, which has been pioneered by a single group. We describe the challenges of setting up clinical EVNP programs in 2 new centers, as well as early patient outcomes. Governance, training, and logistical pathways are described. In order to demonstrate safety and proficiency in this new technique, early patient outcomes are also described. Patient outcomes included the incidence of primary nonfunction, delayed graft function, graft and patient survival at 1 year. Contralateral kidneys undergoing static cold storage alone were used as a comparator group. Between March 2016 and July 2017, EVNP was performed on 14 kidneys from 12 donors (11 kidneys in center 1, 3 kidneys in center 2). Of the 14 kidneys that underwent EVNP, 12 organs were implanted into 10 recipients. Two pairs of kidneys were implanted as dual grafts and 1 kidney was implanted simultaneously with a pancreas. The remaining 7 kidneys were transplanted as single allografts. Seven pairs of kidneys were available for paired analysis comparing EVNP versus static cold storage. Graft and patient outcomes were comparable between the 2 preservation techniques. The introduction of a clinical EVNP service requires a careful multimodal approach, drawing on the expertise of specialists in transplantation, hematology, and microbiology. Both new clinical EVNP programs demonstrated proficiency and safety when a structured dissemination process was followed.

Ex vivo normothermic perfusion (EVNP) of deceased donor kidneys is being used in a growing number of UK centers,1 because there is emerging evidence for its use in organ resuscitation,2 viability assessment,3 and reduction of delayed graft function.4 Although no infectious complications attributable to EVNP have been reported thus far,4 it is possible that the warm perfusate may enhance microbial growth. We sought to determine whether organs become microbiologically contaminated during EVNP. To the best of our knowledge, this is the first report to address contamination during normothermic organ perfusion. Deceased donor kidneys undergoing EVNP between July 2016 and June 2017 at our unit were included. The perfusion technique has been described previously4 and is performed using strict sterile technique. No antibiotics were given during EVNP. After the kidney had undergone EVNP for 40 minutes, 20 mL of warm perfusate was sampled under aseptic technique and placed in aerobic and anaerobic blood culture bottles containing soybean-casein digest broth 3%. Cold preservation fluid from the organ transport bag was also cultured before kidney EVNP. All recipients received a single dose of intravenous amikacin of 7 mg/kg at induction of anesthesia. Posttransplant infections were prospectively recorded. All positive warm and cold fluid cultures were discussed with microbiology colleagues (C.H., C.v.N.t.P.) and were treated if advised. Twelve kidneys underwent EVNP and were transplanted into 10 recipients (2 dual transplants). Warm perfusate cultures were not taken from 3 kidneys. Five of the 9 EVNP perfusate cultures (56%) had positive bacterial growth (Table 1). In 4 cases, the organisms were coagulase-negative Staphylococcus species and were not treated. Methicillin-sensitive Staphylococcus aureus was cultured once, and the asymptomatic recipient was treated with intravenous flucloxacillin for 7 days from day 1 postoperatively. Two cold transport fluid cultures had positive growth, but with no consistency with the organisms grown from the EVNP perfusates. None of the EVNP perfusate-cultured organisms were implicated in episodes of recipient infection during the early posttransplant period (Table 1). All 10 patients remain well, with no incidences of infected perinephric collections or early sepsis at follow-up (6-15 months post-EVNP).TABLE 1: Donor and recipient demographic data, culture results, and posttransplant infective episodesThese results suggest that there is a high rate of contamination with skin commensals during warm organ perfusion, though this does not appear to be the case in hypothermic machine perfusion.5 The source of these organisms remains largely unknown. Discrepant warm and cold fluid culture results suggest that these organisms do not originate from the retrieval process, but that the organisms are introduced either during EVNP or the culture-taking process. We acknowledge that the study size is small, making it difficult to be certain of the clinical relevance of skin commensals grown from EVNP cultures. However, the absence of infections with these organisms in recipients during the follow-up period (and in those patients where EVNP cultures were not taken4) is reassuring. This lack of skin commensal-related infection in our recipients may be due to the routine use of antibiotics at the time of organ retrieval and implantation, and the relatively high rate of antibiotic use for other infections posttransplant. The use of antibiotics during EVNP would be an attractive option; however, the pharmacology of antibiotics on EVNP is currently unknown, and this therefore raises the risk of nephrotoxicity. Centers should consider the abovementioned when deciding whether to use antibiotics during EVNP or not. At present, UK centers do not give antibiotics to the kidney during warm perfusion. An ongoing randomized controlled trial of EVNP will provide further safety information on this approach.1 Given the issues raised above, the microbiological safety of other warm organ perfusion techniques should also be investigated. This is particularly important if the duration of warm perfusion is prolonged, because microbial growth may be enhanced.6

sulfamethoxazole daily. Pancreas-kidney recipients received 100 mg of fluconazole daily for 5 days, 500 mg thrice daily of metronidazole and 1 g thrice daily of amoxicillin for 4 days. All positive cultures were communicated to the nephrologist on duty, who then assessed whether the standard antimicrobial prophylaxis was sufficient, or based on sensitivities, whether an additional antimicrobial was necessary. Overall, 96 patients from 286 kidney and pancreas-kidney recipients (33.6%) had a wound infection or collection that cultured 1 or more distinct organisms. This consisted of 77 (80%) superficial wound infections (wound/skin infections) and 19 (19.7%) deep infections (intra-abdominal perigraft collections). Wound infections were typically treated with a combination of antimicrobial therapy and debridement, whereas deeper collections required aspiration for targeted antimicrobial therapy. An increased rate of enteric flora contamination in simultaneous pancreas and kidney transplants (26%) relative to kidney alone (9%, P = 0.03) may drive the increased risk of wound infection in this group, (odds ratio [OR], 44.37; 95% confidence interval [CI], 5.02-391.93; P = 0.001). Importantly, we found that when BACTEC was utilized in both kidney and kidney-pancreas recipients to identify the type of microbiological growth, the risk of recipient wound infection at the surgical site was significantly reduced (adjusted OR, 0.24; 95% CI, 0.07-0.86; P = 0.029). When standard culture was used, the odds of infection were higher (adjustedOR, 4.02; 95%CI, 1.09-14.84; P = 0.037), and authors speculate that this association is likely due to the poorer identification of potential infection. A systematic review and meta-analysis of culture-positive

Robotic-assisted kidney transplantation (RAKT) offers key benefits for patients that have been demonstrated in several studies. A barrier to the wider uptake of RAKT is surgical skill acquisition. This is exacerbated by the challenges of modern surgery with reduced surgical training time, patient safety concerns and financial pressures. Simulation is a well-established method of developing surgical skill in a safe and controlled environment away from the patient. We have developed a 3D printed simulation model for the key step of the kidney transplant operation which is the vascular anastomosis. The model is anatomically accurate, based on the CT scans of patients and it incorporates deceased donor vascular tissue. Crucially, it was developed to be used in the robotic operating theatre with the operating robot to enhance its fidelity. It is portable and relatively inexpensive when compared with other forms of simulation such as virtual reality or animal lab training. It thus has the potential of being more accessible as a training tool for the safe acquisition of RAKT specific skills. We demonstrate this model here.

Donor nephrectomy operative complexity and postoperative outcomes remain subject to large degrees of unexplained heterogeneity. This study assess the clinical correlation of CT based intrabdominal and perinephric fat content using 3 different fat calculation methods (1. % visceral fat at the umbilicus, 2. 3D visceral fat content of the whole abdomen and donated kidney and 3. perinephric fat in anterior, posterior, medial and lateral planes at the level of the renal vein) producing 15 separate data points for each donor. The study was performed in a single centre in 500 patients undergoing hand assisted laparoscopic donor nephrectomy between 2005 - 2014 who had CT angiography performed as part of their routine preoperative work up. Analysis of each fat measure was carried out with spearman correlations, test and ANOVA. Multivariate regression models of the predictors of a low post donation clearance state at one year (GFR <45mls/min) and operating time (as a marker of operative complexity) were also developed. The mean age of the cohort was 44.1 yrs, 17% were obese and 51% female. Abdominal visceral fat content (r2=0.12 coefficient 0.36 p=0.001) and perinephric fat content (r2=0.14, coefficient 0.07 p<0.001) were strong independent predictors of operating time when adjusted for operating surgeon, arterial multiplicity. Total abdominal visceral fat measures were also greater in those developing postoperative infection (1692cm2 v 1489cm2 p=0.04). Greater perinephric fat content was associated with incisional hernia development (235cm2 v 163cm2 p=0.04). The mean reduction in glomerular filtration rate (GFR) post renal donation at one year was 30.5mls/min (SD 9.6). Spearman rank correlation statistics demonstrated significant positive associations between GFR reduction at one year post donation and visceral fat content at the umbilicus (spearman rho=0.14, p=0.03) and total abdominal visceral fat content (spearman rho 0.13, p=0.04). There was no association with BMI (spearman rho 0.02, p=0.69). Similarly subcutaneous and perinephric fat measures demonstrated no relationship. 7% of the kidney donors studied had a one year post donation "low" GFR clearance state (<45mls/min). A logistic regression model adjusted for preoperative GFR and age demonstrated abdominal visceral fat content measured at the umbilicus to be an independent predictor of a low GFR state at one year (OR 1.1 p=0.001, LR chi2 = 68, p=0.001 r2 = 0.48). |In this the largest CT based anthropometric study of kidney donors to date; visceral and perinephric CT based fat measurements appear to be superior predictors of short and long term outcomes (when compared to BMI). In marginal cases of donation particulary where there is concern over residual renal function post donation, these measures may facilitate perioperative decision making.

Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: This review aims to look at the benefits and harms of MIS in kidney transplant recipients.