Impact of surgeon experience on complication

rates and functional outcomes of 484

BJUI BJU INTERNATIONAL
deceased donor renal transplants: a single-
centre retrospective study
Hannes Cash*, Torsten Slowinski‡, Anette Buechler*, Annaeva Grimm*,
Frank Friedersdorff*, Danilo Schmidt‡, Kurt Miller*, Markus Giessing†
and T. Florian Fuller*
Department of *Urology and †Nephrology, Charité University Medicine Berlin, Campus Mitte, Berlin, and
‡
Department of Urology, Heinrich Heine University Hospital, Duesseldorf, Germany
Accepted for publication 10 November 2011

Study Type – Therapy (outcomes) What’s known on the subject? and What does the study add?
Level of Evidence 2c Although renal transplantation represents a well established surgical procedure, the
learning curve for this procedure has not been studied so far. The published data on
surgical complications do not discriminate between surgeons and their stage of
OBJECTIVE expertise.
• To determine how postoperative and The present study highlights the importance of a structurized programme in urological
functional outcomes after deceased donor sub-speciality training. Renal transplanation represents a standardized procedure with
renal transplantation (DDRT) are related to a low learning-curve for uncompliciated cases. When comparing experienced urological
surgeon experience. transplant surgeons with inexperienced surgeons, the postoperative complications and
functional outcome were similar. One exception is seen in ureteroneocystostomy, which
PATIENTS AND METHODS should be considered in clinical practice.

• The outcomes of 484 adult DDRT

performed by 13 urological surgeons were
retrospectively reviewed.
• After completion of a staged renal
transplant training programme under
supervision of an attending urological
transplant surgeon, the 13 surgeons
were either assigned to the inexperienced
group (n = 8) or the experienced group
(n = 5).
• Surgeons in the experienced group had
performed more than 30 unsupervised
DDRT in a standard fashion with routine
ureteric stenting.
• Between 1988 and 2005, inexperienced
surgeons performed 152 DDRT, whereas
experienced surgeons performed 332 DDRT.
RESULTS
• Patient and graft survival at 2 hyears
were 98% and 94.7%, respectively.
• Early graft loss in five recipients was
unrelated to surgeon experience.
• Delayed graft function occurred in 29%
of cases and median 1-year serum-
creatinine was 1.48 mg/dL, with no
difference between surgeon groups.
• Postoperative bleeding and lymphocele
formation were the most frequent surgical
complications, with an equal distribution
between groups.
• Ureteric complications had a
significantly higher incidence among
inexperienced surgeons (6.6% versus 2.7%;
P = 0.04).
CONCLUSION
• We conclude that DDRT as performed by
inexperienced urological renal transplant
surgeons has both acceptable short- and
long-term outcomes.
KEYWORDS
kidney transplantation, surgeon experience,
urological complications

INTRODUCTION
Renal transplantation is the treatment of
choice for patients with end-stage renal
disease [1]. Compared to haemodialysis,
deceased donor renal transplantation (DDRT)
offers a superior quality of life and a
prolonged overall survival [2]. The best
results in patient and graft outcomes
are achieved by living donor renal
transplantation [3].
As with most operative procedures, centre
volume is considered to have a major
influence on complication rates and
graft function after DDRT [4]. Surgical
complications still represent a major source
of postoperative morbidity in recipients of
deceased donor renal transplants. Surgeon-
associated risk factors have a major impact
on surgical complications [5,6]. However,

© 2012 THE AUTHORS

E368 BJU INTERNATIONAL © 2 0 1 2 B J U I N T E R N A T I O N A L | 11 0 , E 3 6 8 – E 3 7 3 | doi:10.1111/j.1464-410X.2012.11024.x
 IMPACT OF SURGEON EXPERIENCE ON RENAL TRANSPLANTATION

FIG. 1. A were classified as ‘experienced’. Although

(A) Number of deceased donor 60 the inexperienced group consisted mostly
renal transplantations (DDRT) (tx) of board certified urological specialists
performed per annum during the at the beginning of their 2-year sub-
40

tx per year
study period. An increased DDRT
volume is seen after the year
2000; a trend which remains
ongoing today (data from 2005
to 2010 not shown). (B) Number
of DDRTs per surgeon group per
speciality training, the experienced group
consisted of attending surgeons and
20 of specialists in their final stage of
urological sub-specialization. The
distribution of renal transplantation per
0
annum is shown in Fig. 1A. The main
19 9
19 0
19 1
92

19 3
19 4
19 5
19 6
97

19 8
99

20 0
20 1
02

20 3
20 4
05
9

0
8
9

9
9
9
9

0
0
annum. After 2000, a gradual surgical volume of the inexperienced
19

19

19

20

20
increase of surgeon volume is year transplant surgeons was seen in the years
seen in the inexperienced group. 2000–2005, parallel to an increase of centre
B
50
volume (Fig. 1B). All of the surgeons
inexperienced
experienced
included in the present study participated
40 in the Eurotransplant organ retrieval
tx per year

30 programme.

20 All donor kidneys were flushed with

10 histidine–tryptophan–ketoglutarate solution.
Renal transplantation was performed via a
0 Gibson incision using the standard
19 0
19 1
92

19 3
19 4
19 5
19 6
19 7
19 8
20 9
20 0
20 1
02

20 3
20 4
05
19 9

0
9

9
9
9
9
9
9
9
0

0
0
extraperitoneal technique with placement
8

19

20
19

year of the graft in the iliac fossa and end-to-

several studies have shown that, with
adequate supervision, surgeon expertise is
not a determinant of postoperative
outcomes [7,8].
In Germany, ≈30% of renal transplants are
performed by urologists. In most German
urological transplant centres, renal
transplantation is exclusively carried out by
experienced surgeons. As a high-volume
renal transplant centre with currently more
than 100 renal transplants per year, we
aimed to expand the pool of urological
transplant surgeons by implementing a
staged training programme for board-
certified urological specialists with no
experience in renal transplantation.
In the present single-centre retrospective
study, we compared the outcomes of 484
adult DDRT performed by either experienced
or inexperienced transplant urologists. All 13
urological surgeons who participated in the
present study were assigned to either
category based on the number of
unsupervised DDRT (less than 30 versus
more than 30) performed after finishing our
staged renal transplant training programme.
The present study aimed to evaluate the
impact of surgeon experience on graft
outcomes and complication rates after
DDRT.
PATIENTS AND METHODS
Between January 1988 and December 2005,
691 adult recipients underwent DDRT at
Charité University Hospital, Campus Mitte.
Screening of our electronic database and of
the clinical charts yielded complete data sets
on 484 DDRT recipients. Patient inclusion
criteria were a follow-up of at least 1 year
and recipient age >18 years. DDRT were
performed by 13 urological transplant
surgeons, all of whom had participated in a
staged renal transplant training programme.
Regarding the structure of the training
programme, during the first 10 renal
transplants, the trainee performed parts of
the vascular and vesico-ureteric anastomosis
under the guidance of an attending
urological transplant surgeon. The next 10
transplants were performed entirely by the
trainee himself under close supervision of
an attending urological transplant surgeon.
After completing the training programme,
all 13 surgeons were allowed to perform
unsupervised DDRT. To stratify the 13
surgeons into two expertise categories
(inexperienced versus experienced), a
threshold of 30 unsupervised DDRT was
chosen. According to this criterion, eight
surgeons who performed less than 30
unsupervised DDRT were retrospectively
classified as ‘inexperienced’, whereas five
side anastomosis between the renal vessels
and the external iliac vessels of the
recipient. Vesico-ureteric anastomosis
was accomplished using the Politano–
Leadbetter technique with routine ureteric
stenting.
IMMUNOSUPPRESSION
Triple immunosuppression was started on
the day of transplantation and consisted of
prednisone, mycophenolatemofetil and a
calcineurin inhibitor. Oral prednisone was
tapered to a dose of 10 mg per patient
during the first 6 months. Target trough
serum levels for cyclosporine and tacrolimus
were between 150–250 ng/mL and
10–12 ng/mL, respectively.
Patients with a high immunological risk
(pre-transplanted patients, panel-reactive
antibodies positive or living unrelated donor)
received induction therapy with anti-
interleukin-2 receptor antibodies (20 mg of
basiliximab pre-transplantation and at day 4
post-transplantation).
STATISTICAL ANALYSIS
Statistical analysis was performed using
PASW, version 18 for Windows (SPSS Inc.,
Chicago, IL, USA). Values are reported as the
median (SEM), unless indicated otherwise. For

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BJU INTERNATIONAL © 2012 BJU INTERNATIONAL E369
CASH ET AL.

FIG. 2. (A) Kaplan–Meier curve for 2-year patient

TABLE 1 Donor and recipient demographics in 484 deceased donor renal transplantations
survival for inexpierenced (<30 deceased donor
renal transplantations [DDRT]) and experienced
Experienced Inexperienced
(>30 DDRT) surgeons. (B) Kaplan–Meier curve for
Variable surgeons (n = 5) surgeons (n = 8)
2-year graft survival for inexpierenced (<30 DDRT)
Renal transplants, n 332 152
and experienced (>30 DDRT) surgeons. The number
Donor age (years), mean (SEM) 49 (17) 48 (18)
at risk at 2 years was 143 in the inexperienced
Recipient age (years), mean (SEM) 48 (15) 47 (14)
group (n = 152) and 307 in the experienced group
Male/female recipients (%) 60.5/39.5 62.5/37.5
(n = 332).
Recipients with second transplant (%) 20.8 15.8
Recipient mean body mass index (kg/m2) 27 27 A Patient Survival
Renal artery multiplicity (%) 26 27 100 <30 DDRT
>30 DDRT
Cold ischaemia time (h) 14.6 (6.3) 14 (6.5) 80
Recipient disease (%) P = 0.43
Glomerulonephritis 34.3 40.8 60

%
Pyelonephritis 17.8 13.8 40
Polycystic kidney disease 9.3 10.5
20
Analgesic nephropathy 5.7 3.9
Hereditary nephropathy 5.1 3.9 0
Hypertensive nephropathy 3.3 7.2 Days 0 200 400 600 800
Unknown/other 2.4 2.6
B Graft Survival
100 <30 DDRT
>30 DDRT
80
P = 0.26
60

%
TABLE 2 Postoperative outcome 40
20
Experienced Inexperienced
Variable surgeons (n = 5) surgeons (n = 8) 0
Renal transplants, n 332 152 Days 0 200 400 600 800
Follow-up (months), mean (SEM) 96 (54) 72 (70)
Warm ischaemia time (min), mean (SEM) 48 (15.2) 48 (14.4)
1-year serum-creatinine (mg/dL), mean (SEM) 1.52 (1.07) 1.43 (1.02)
parameters among the two groups of
Delayed graft function (%) 28 30
surgeons is outlined in Table 2. No
1-year rejection rate (%) 35 35
significant differences were seen between
Postoperative complications (%) 17.7 18.6
the two groups.

SURGEON EXPERTISE AND POSTOPERATIVE

evaluation of differences between medians,
the Mann–Whitney U-test was used. Group
means were compared using ANOVA. Survival
analysis was calculated by the Kaplan–Meier
method using the log-rank test to compare
groups. P < 0.05 was considered statistically
significant.
RESULTS
DONOR AND RECIPIENT DEMOGRAPHICS
The group of experienced surgeons (n = 5)
carried out 332 renal transplants, whereas
the group of inexperienced surgeons
(n = 8) carried out 152 renal transplants.
Demographic data did not differ
significantly between the two groups of
surgeons (Table 1).
PERI-OPERATIVE DATA AND POSTOPERATIVE
OUTCOME
Mean cold and warm ischaemia times were
14 h and 48 min, respectively. Overall 2-year
patient and graft survival were 98% and
94.7%, respectively. Sub-analysis of the
surgeon groups showed a 2-year patient
survival of 99.7% in the inexperienced group
and 97.6% in the experienced group (P =
0.43; Fig. 2A). The 2-year graft survival was
96.7% for the inexperienced surgeons and
94.3% for the experienced surgeons (P =
0.26; Fig. 2B). Median 1-year serum
creatinine was 1.48 (1.05) mg/dL. The overall
incidence of delayed graft function (DGF),
defined as the need for at least one
haemodialysis within the first week, was
29%. The 1-year rejection rate was 35%. The
differential distribution of postoperative
COMPLICATIONS
Differential analysis of surgical
complications is shown in Table 3. The
incidence of postoperative bleeding and
vascular complications, as well as the
frequency of lymphocele drainage, were
equally distributed between groups. Early
graft loss as a result of vascular thrombosis
occurred in five recipients. In the
experienced group, three grafts were lost as
a result of arterial or venous thrombosis
within the first few days after
transplantation. In the inexperienced group,
two grafts were lost within the first week as
a result of venous thrombosis. No technical
difficulties were encountered during
engraftment. Revision surgery was
performed by an experienced surgeon and
involved in situ flushing of the renal vein

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E370 BJU INTERNATIONAL © 2012 BJU INTERNATIONAL
 IMPACT OF SURGEON EXPERIENCE ON RENAL TRANSPLANTATION

after DDRT. In the present retrospective

TABLE 3 Surgical complications
study, we found that urological surgeons
who were inexperienced in renal
Experienced Inexperienced
transplantation, and who completed a
Variable surgeons (n = 5) surgeons (n = 8) P
staged training programme under the
Renal transplants, n 332 152
guidance of an attending renal transplant
Postoperative bleeding with intervention, n (%) 14 (4.2) 6 (3.9) 0.63
urologist, can safely perform this procedure
Lymphocele drainage, n (%) 25 (7.5) 9 (5.9) 0.79
with outcomes comparable to those of
Ureteric complications, n (%) 9 (2.7) 10 (6.6) 0.04
experienced urological renal transplant
Ureteric stenosis, n (%) 5 (1.5) 6 (3.9) 0.09
surgeons.
Vascular thrombosis, n (%) 11 (3.3) 4 (2.6) 0.74
Graft loss as a result of vascular thrombosis, n (%) 3 (0.9) 2 (1.3) 0.5
Donor and recipient demographics, as well
as peri-operative parameters, including cold
and warm ischaemia times, did not differ
between the two patient cohorts assigned to
Number of Complications, TABLE 4 either the experienced or the inexperienced
Variable transplantations, n n (%) Surgeon-related group of transplant surgeons. A 1-year
Experienced surgeons complications serum creatinine level <1.5 mg/dL has been
Surgeon 1 30 4 (13.3)
shown to predict excellent long-term graft
survival [8]. In the present study, an overall
Surgeon 2 42 9 (21.4)
1-year serum creatinine level of 1.48 mg/dL
Surgeon 3 72 16 (22.2)
translated into a favourable 2-year graft
Surgeon 4 87 18 (20.7)
survival rate of 94.7%. Surgeon experience
Surgeon 5 101 11 (10.9)
had no significant impact on 1-year serum
Mean rate (%) 17.7
creatinine levels, with the inexperienced
Inexperienced surgeons
group showing a slightly lower value
Surgeon 1 6 1 (16.7)
(Table 2). Delayed graft function is a
Surgeon 2 11 3 (27.3)
surrogate marker of donor organ quality and
Surgeon 3 14 2 (14.3)
non-immunological injury to the graft
Surgeon 4 22 4 (18.2)
resulting from cold ischaemia and surgical
Surgeon 5 23 3 (13)
trauma. Donor age is the dominant factor
Surgeon 6 23 6 (26)
determining DGF and graft survival in
Surgeon 7 26 2 (7.6)
deceased donor renal transplants [9]. A
Surgeon 8 27 7 (25.9)
median donor age of 48 years in the present
Mean rate (%) 18.6
study cohort resulted in a DGF rate of
29% with no difference between groups.
In their recent retrospective study on 113
adult renal transplant recipients, Hokema
with heparinized saline. Eventually, both SURGEON-RELATED COMPLICATIONS et al. [10] reported similar values: donor
renal grafts had to be removed as a result age of 51 years and a DGF rate of 31%.
of irreversible ischaemic damage. The complication rate of each individual In a previous study from our institution,
surgeon is outlined in Table 4. The number the incidence of DGF among deceased
The incidence of ureteric complications was of transplantations performed by an donor renal transplant recipients reached
significantly higher in the inexperienced experienced surgeon was in the range 40% with a median donor age of 58.5
group (6.6% versus 2.7%; P = 0.04). Ureteric 30–101. The complication rate in this group years [11].
stenosis represented the most frequent was 17.7%. The number of transplantations
ureteric complication in both goups of carried out by an inexperienced surgeon was To assess the quality of the renal transplant
surgeons. Although the rate of ureteric in the range 6–27. The complication rate in procedure itself, we compared intra-
stenosis was higher in the inexperienced this group was 18.6%. There was no inverse operative and postoperative complications
group, this was not statistically significant correlation between surgeon expertise and between experienced and inexperienced
(P = 0.09). In six out of 11 patients with a complication frequency. urological transplant surgeons. Relevant
ureteric stenosis, open reanastomosis of the surgical complications included
transplant ureter was necessary. The haemorrhage, vascular thrombosis, urinary
remaining five patients were treated with DISCUSSION leakage, ureteric stricture and lymphocele
ureteric stenting for at least 3 months. formation requiring surgery. Postoperative
Ureteric leakage resolved in three out of To our knowledge, the present study is the haemorrhage and lymphocele formation
eight DDRT recipients after conservative first reported investigation of the impact of requiring surgery occurred in 4% and 6.7%
treatment. Surgical treatment for ureteric surgeon experience on postoperative of cases, respectively. In the literature, the
leakage was required in five recipients. complications and early functional outcomes incidence of lymphoceles after renal

© 2012 THE AUTHORS

BJU INTERNATIONAL © 2012 BJU INTERNATIONAL E 3 71
CASH ET AL.
transplantation varies between 0.6% and
26% [12–16].
The incidence of surgical complications does
not appear to decrease with growing
surgical expertise, suggesting that factors
such as donor and recipient morbidity may
influence the type and frequency of
post-transplant surgical complications
(Table 4). However, in-depth analysis of the
source of post-transplant surgical
complications is beyond the scope of the
present study given the relatively small
patient numbers.
We found a significantly higher incidence of
ureteric complications in the inexperienced
group compared to the experienced group.
For ureteroneocystostomy, all surgeons used
the antirefluxive Politano–Leadbetter
technique. With this technique, the
transplant ureter is anchored within the
bladder using a submucosal tunnel. Previous
studies have shown that this intravesical
implantation approach is more susceptible
to complications compared to other
techniques [17,18]. Although a higher
stenosis rate was found in the inexperienced
group of surgeons in the present study, the
overall ureteric complication rate is
comparable to that reported in the literature
[17,19]. The learning curve associated with
the technically demanding Politano–
Leadbetter technique could have accounted
for the higher rate of ureteric complications
among inexperienced surgeons compared to
the experienced group. We found that two
surgeons in the inexperienced group were
responsible for six out of 10 (60%) ureteric
complications. In the present study, ureteric
complications did not affect graft outcomes,
which is in agreement with previously
reported results [20,21]. In the literature, the
extravesical Lich-Gregoir technique is
favoured among transplant surgeons [22].
The overall ureteric complication rate is
consistent with previously published data,
even with those studies using the Lich-
Gregoir technique [16,23,24]. As a
consequence of the findings of the present
study, we recently switched from the
intravesical ureteric implantation technique
to the extravesical Lich-Gregoir technique.
In times of limited human resources as a
result of economic constraints, high-volume
surgical or urological centres with a busy
renal transplant programme are forced to
steadily increase the number of surgeons
E372
performing DDRT. Working time regulations
may limit the availability of attending
surgeons for scheduled daytime procedures
if they have performed renal transplantation
the night before [25]. The question arises as
to whether or not there is a minimal volume
of renal transplants that a board certified
urological specialist has to perform under
the guidance of an attending surgeon before
embarking on unsupervised ‘out-of-hours’
renal transplantations. Our staged renal
transplant training programme, including 20
guided procedures, proved to be appropriate
to enable urological surgeons with no
previous experience in renal transplantation
to safely perform unsupervised DDRT.
Certification by the American Society of
Transplant Surgeons requires a transplant
fellow to perform 30 renal transplants over
the duration of the fellowship (http://www.
asts.org/fellowshiptraining/accreditation.
aspx). Choosing a threahold surgeon volume
of 30 unsupervised renal transplants, with
the aim of discriminating between
experienced and inexperienced urological
transplant surgeons, we found no significant
difference between the two groups in terms
of postoperative complications and early
graft outcomes. It may be argued that the
threshold volume for an experienced
transplant surgeon could have been lowered
to 10 or 15 procedures, given the apparent
success of our training programme.
Nevertheless, in the present study,
experienced surgeons had a significantly
lower ureteric complication rate compared
to inexperienced ones. Whether
or not the extravesical Lich-Gregoir
ureteroneocystostomy yields better results
among inexperienced transplant surgeons
than the more complex intravesical
Politano–Leadbetter technique is a matter to
be resolved in future investigations. The
limitations of our present study include its
retrospective character and the relatively
large number of surgeons involved.
We conclude that DDRT can be a technically
challenging surgical procedure and, given
the extreme shortage of organs from
deceased donors, renal transplant surgeons
have a high responsibility for the future
well-being of their patients. However,
because of economic constraints with
respect to limited human resources among
healthcare providers, increasing the pool of
renal transplant surgeons is indispensable,
especially in high-volume transplant centres.
We have shown that urological surgeons
BJU INTERNATIONAL
who are inexperienced in renal
transplantation are capable of safely
performing DDRT after participating in a
staged training programme under the
supervision of an experienced renal
transplant urologist. The higher incidence of
ureteric complications among inexperienced
surgeons using the intravesical Politano–
Leadbetter ureteroneocystostomy technique
had no impact on long-term graft survival
and may decrease with the use of the more
robust Lich-Gregoir technique.
CONFLICT OF INTEREST
The authors declare that there are no
conflicts of interest.
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Correspondence: Florian Fuller, Department
Berlin, Charitéplatz 1, 10117 Berlin, Germany.
e-mail: florian.fuller@charite.de
Abbreviations: DDRT, deceased donor renal
transplantation; DGF, delayed graft function.
E373
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