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Background: Minimally invasive liver surgery (MILS) has been progressively adopted on a nationwide scale. The aim of this study is to investigate MILS implementation in a high‐volume Dutch hepato‐pancreato‐biliary and transplant center, which is considered a moderate to low‐volume center from a European standpoint.Methods: All patients who underwent MILS at Erasmus Medical Center between April 2010 and December 2021 were retrospectively reviewed. Patients’ surgical outcomes were compared after stratification according to resections’ difficulty and liver cirrhosis.Results: A total of 212 cases were included. Major liver resections were performed in 24 patients (11%), while minor resections were performed in 188 patients (89%). Among those, 177 (94%) resections were classified as technically minor and 11 (6%) as technically major. Major morbidity was reported in 14/177 patients (8%) after technically minor resections and in 3/24 patients (13%) after major resections. Anatomically and technically major resections had higher intraoperative blood losses (425 (0–2100) vs. 240 (50–110) vs. 100 (0–2400) mL; p‐value < 0.001) and longer hospital stay (6 (3–25) vs. 5 (2–9) vs. 3 (1–44); p‐value < 0.001) when compared with the technically minor counterpart. Perioperative outcomes were similar when comparing cirrhotic MILS with the non‐cirrhotic cohort.Conclusion: MILS program implementation can lead to encouraging surgical outcomes even in low‐ to moderate‐volume centers. Although low procedural volume might be predictive of impaired outcomes, long‐standing experience in the HPB and liver transplant field could mitigate low‐case volume effects on surgical outcomes.

Objective: To determine the nationwide implementation and surgical outcome of minor and major robotic liver surgery (RLS) and assess the first phase of implementation of RLS during the learning curve. Background: RLS may be a valuable alternative to laparoscopic liver surgery. Nationwide population-based studies with data on implementation and outcome of RLS are lacking. Methods: Multicenter retrospective cohort study including consecutive patients who underwent RLS for all indications in 9 Dutch centers (August 2014–March 2021). Data on all liver resections were obtained from the mandatory nationwide Dutch Hepato Biliary Audit (DHBA) including data from all 27 centers for liver surgery in the Netherlands. Outcomes were stratified for minor, technically major, and anatomically major RLS. Learning curve effect was assessed using cumulative sum analysis for blood loss. Results: Of 9437 liver resections, 400 were RLS (4.2%) procedures including 207 minor (52.2%), 141 technically major (35.3%), and 52 anatomically major (13%). The nationwide use of RLS increased from 0.2% in 2014 to 11.9% in 2020. The proportion of RLS among all minimally invasive liver resections increased from 2% to 28%. Median blood loss was 150 mL (interquartile range 50–350 mL] and the conversion rate 6.3% (n=25). The rate of Clavien-Dindo grade ≥III complications was 7.0% (n=27), median length of hospital stay 4 days (interquartile range 2–5) and 30-day/in-hospital mortality 0.8% (n=3). The R0 resection rate was 83.2% (n=263). Cumulative sum analysis for blood loss found a learning curve of at least 33 major RLS procedures. Conclusions: The nationwide use of RLS in the Netherlands has increased rapidly with currently one-tenth of all liver resections and one-fourth of all minimally invasive liver resections being performed robotically. Although surgical outcomes of RLS in selected patient seem favorable, future prospective studies should determine its added value.

The role of ureteral stents in living donor kidney transplantation remains uncertain. In this randomized controlled trial (SPLINT), we compared urological complications in living donor kidney transplantations performed with or without stents. We included 200 consecutive patients that received living donor kidney transplantations at the Erasmus MC, University Medical Center Rotterdam. Patients (124 males, 76 females, mean age 54 ± 13) were randomized for suprapubic externalized single J stents (N=100) or no stent (N=100). The primary outcome was the probability of a percutaneous nephrostomy insertion (PCN) during a 12‐month follow‐up. To assess whether no stenting is non inferior to stenting, we allowed the probability of a PCN to increase by at most 5% (this is the non‐inferiority margin). Baseline characteristics were comparable between groups. In the no stent group, there were more PCN insertions 14% (95%CI 4.3‐ 23.7%), urinary leakages 12% (95%CI 5.4‐ 21.3%) and surgical re‐interventions due to urological complications 8% (95%CI 1.5‐ 14.5%). The stent group had more hematuria 26% (95%CI 13.1‐ 38.9%) and graft rejections 15% (95%CI 2.7‐ 27.3%). Patients in both groups had similar mean GFRs at several time points. Besides a better Euro‐Qol‐5D in the no stent group at 2 and 6 weeks postoperative, similar quality of life was reported based on SF‐36 and Euro‐Qol‐5D scores. In this trial, non‐inferiority has not been demonstrated for no stent placement in relation to the number urological complications.

Objectives: The aim of this study was to investigate the effects of antegrade balloon dilatation on ureteral strictures that developed after kidney transplant. Materials and Methods: The hospital databases of the Erasmus Medical Center (Rotterdam, The Netherlands) and the Academic Medical Center (Amsterdam, The Netherlands) were retrospectively screened for patients who underwent balloon dilatation after kidney transplant. Balloon dilatation was technically successful whenever it was able to pass the strictured segment with the guidewire followed by balloon inflation; the procedure was clinically successful if no further interventions (for example, surgical revision of the ureteroneocystostomy or prolonged double J placement) were necessary. Results: Fifty patients (2.4%) of 2075 kidney transplant recipients underwent antegrade balloon dilatation because of urinary outflow obstruction. Median time between transplant and balloon dilatation was 3 months (range, 0-139 mo). In 43 patients (86%), balloon dilatation was technically successful. In the remaining 7 patients (14%), it was impossible to pass the strictured segment with the guidewire. In 20 of 43 patients (47%) having a technically successful procedure, the procedure was also clinically successful, with median follow-up after balloon dilatation of 35.5 months (range, 0-102 mo). We did not identify any patient or stricture characteristic that influenced the outcome of treatment. Conclusions: Balloon dilatation is a good option for ureter stricture treatment after kidney transplant as it is minimal invasive and can prevent surgical exploration in almost 50% of cases.

BACKGROUND The aim of this study was to evaluate the number of urinary tract infections (UTI) that occur after kidney transplantation (KT) and to identify possible risk factors for development of a UTI. MATERIAL AND METHODS We retrospectively analyzed all KTs performed between January 2012 and December 2013 in the Erasmus University Medical Center, Rotterdam. UTI was scored if: (1) a patient had a urine culture with no more than 2 species of microorganisms, (2) at least 1 of which was a bacterium of ≥10^5 CFU/mL, (3) which was treated with antibiotics, and (4) which occurred within 3 months after KT. RESULTS A total of 417 patients were transplanted from January 2012 until December 2013. A UTI developed in 115 (28%), after a median of 13 days from transplantation (range: 3-82 days). The most common causative agent was Escherichia coli, followed by Enterococcus faecalis, Enterococcus faecium, and Klebsiella pneumoniae. The variables that were independently related to a UTI were female gender (OR 3.58, 95%CI 2.16-5.91), recipients age >60 y (OR 2.12, 95%CI 1.28-3.48), percutaneous nephrostomy placements (OR 6.29, 95%CI 3.35-11.85), and surgical re-interventions (OR 2.12, 95%CI 1.04-4.32). Mean glomerular filtration rate was significantly lower in the group of patients with a UTI at 3, 6, 9, and 12 months postoperatively compared to those patients who did not have a UTI. CONCLUSIONS We conclude that a UTI after KT is a common problem. We identified independent risk factors for the development of a UTI. UTI is associated with a GFR decrease postoperatively.

The aim of this study was to evaluate the role of ureteral length on urological complications. Data were retrospective collected from the INEX‐trial database, a RCT to compare the intravesical to the extravesical ureteroneocystostomy. Ureteral length was measured in 198 recipients and used to divide recipients into three categories based on interquartile ranges: short (≤8.5 cm), medium (8.6–10.9 cm) and long ureters (≥11 cm). Urological complications were defined as the number of percutaneous nephrostomy placements (PCN). Fifty recipients fell into the short, 98 into the medium and 50 recipients into the long ureter category. Median follow‐up was 26 (range 2–45) months. There was no significant difference in number of PCN placements between the categories. There were 9 (18%) PCN placements in the short ureter category, 21 (20%) in medium ureter category and 10 (21%) in the long ureter category, P = 0.886. Risk factor analysis for gender, arterial multiplicity and type of ureteroneocystostomy showed no differences in PCN placements between the three ureteral length categories. We conclude that ureteral length alone does not seem to influence the number of urological complications.

Urological complications after kidney transplantation are mostly related to the ureteroneocystostomy, often requiring interventions with additional costs, morbidity and mortality. Our aim was to assess risk factors for urological complications in deceased donor kidney transplantation. Between January 2000 and December 2011, 566 kidney transplantations were performed with deceased donor kidneys. Recipients were divided in a group with, and a group without urological complications, defined as the need for a percutaneous nephrostomy catheter or surgical revision of the ureteroneocystostomy. Univariate and multivariate analyses were performed. Univariate analysis showed increased number of male donors (p = 0.041), male recipients (p = 0.002), pre-emptively transplanted recipients (p = 0.007), and arterial reconstructions (p = 0.004) in the group with urological complications. Less urological complications occurred in recipients on hemodialysis (p = 0.005). More overall surgical interventions (p<0.001), surgical site infections (p = 0.042), urinary tract infections (p<0.001) and lymphoceles (p<0.001) occurred in the group with urological complications. Multivariate analysis showed that male recipients (p = 0.010) and arterial reconstructions (p = 0.019) were independent risk factors. No difference was found between both groups in patient or graft survival. In conclusion, recipient male gender and arterial reconstruction are independent risk factors for urological complications after deceased donor kidney transplantation. Nevertheless, graft and recipient survival is not different between both groups.