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Abstrak :
Pendahuluan dan tujuan: Pendekatan yang digunakan sebelumnya dari nephrectomy donor laparoskopi di pusat kami adalah transperitoneal. Belakangan ini pendekatan retroperitoneal secara rutin digunakan dalam nefrektomi donor. Namun, tidak ada kesimpulan pasti tentang perbedaan objektif antara kedua pendekatan yang telah dicapai hingga saat ini. Penelitian ini bertujuan untuk membandingkan hasil pembedahan antara pendekatan retroperitoneal dan transperitoneal pada nefrektomi donor. Metode: Penelitian ini merupakan penelitian prospektif observasional single center, yang mencakup total 813 subjek yang menjalani nefrektomi donor di Rumah Sakit Umum Pusat Nasional Dr. Cipto Mangunkusumo. Perbandingan warm ischemic time 1, time to clip, skin to skin, intraoperative blood loss dan komplikasi dilakukan dengan menggunakan Uji Man Whitney di IBM SPPS Statistik 25. Hasil: Sebanyak 687 subjek yang mendapatkan pendekatan transperitoneal dan 126 subjek dengan pendekatan retroperitoneal. Waktu iskemik hangat 1, waktu untuk klip dan kulit ke kulit, pendekatan retroperitoneal memiliki waktu yang jauh lebih lama. Namun, dalam hal kehilangan darah dan komplikasi, pendekatan retroperitoneal memiliki hasil yang lebih baik dengan rata-rata kehilangan darah adalah 50 cc, dibandingkan dengan transperitoneal 100 cc (p<0,001). Tingkat komplikasi serupa pada pendekatan transperitoneal (31 kasus, 4,6%) dibandingkan retroperitoneal (6 kasus 4,7%) Namun, cedera terkait usus dan kandung kemih hanya ditemukan pada pendekatan transperitoneal yang memerlukan pembedahan lebih lanjut. Kesimpulan: LLDN retroperitoneoscopic memberikan beberapa keuntungan termasuk komplikasi peri operasi yang lebih rendah, mengurangi kemungkinan cedera usus dan kandung kemih, dan mengurangi risiko kehilangan darah intraoperatif ......ntroduction and Objectives: The previous used approach of laparoscopic donor nephrectomy in our center was transperitoneal. In recent time retroperitoneal approach is routinely use in donor nephrectomy. However, there is no definitive conclusion on the objective differences between the two approaches that have been reached to date. This study aims to compare the surgical outcome between retroperitoneal and transperitoneal approach in donor nephrectomy. Method: This is a prospective observational single center study, which covered a total of 813 subject underwent donor nephrectomy in Cipto Mangunkusumo General Hospital. Comparison of warm ischemic time 1, time to clip, skin to skin, intraoperative blood loss and complication was carried out using Man Whitney Test in IBM SPPS Statistic 25. Results: A Total of 687 subject that received transperitoneal approach and 126 subject with retroperitoneal approach. The warm ischemic time 1, time to clip and skin to skin, retroperitoneal approach has significantly longer time. However, in term of blood loss and complication, retroperitoneal approach has better result with average blood loss is 50 cc, compare to transperitoneal 100 cc (p< 0.001). Complication rate was similar in transperitoneal approach (31 cases, 4,6%) than retroperitoneal (6 cases 4,7%) However, bowel and bladder related injury were only found in transperitoneal approach which need further surgery. Conclusion: Retroperitoneoscopic LLDN provides several advantages including lower peri operative complications, reduced possibility of bowel and bladder related injury, and reduced the risk of intraoperative blood loss.

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Though kidney transplantation is considered a routine procedure, there are still significant challenges in post-transplant management. Core Concepts in Renal Transplantation is a clinically focused authoritative guide to the management of kidney transplantation. This comprehensive, state-of-the-art reference summarizes the recent changes in the field of transplantation, offering the complete range of up-to-date information on all the various aspects of basic immunobiology and the medical care of the transplant recipient.

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Severe gingival enlargement (GE) is one of the most commonly observed adverse effects in patients who have undergone renal transplants due to the use of cyclosporine A. Objectives: We aimed to gain more insight into the prevalence of GE in patients with renal transplants. Methods: We searched the PubMed and Web of Science databases for relevant studies from January 1990 to January 2018. Using random effects models, we calculated summary incidence rates and 95% confidence intervals (CIs). Results: A total of 595 patients from 10 studies were included. Patients using cyclosporine A with or without any other drugs had a 62.6% (95% CI, 41.9% until 79.5%) incidence of GE. Subgroup analysis according to diagnostic criteria showed that the incidence of GE was lower when using well defined diagnostic criteria or scoring system. The incidence of GE was 88.2% (95% CI, 80.9% until 93.0%) in patients using cyclosporine A with nifedipine. Cyclosporine A without nifedipine was associated with a significantly decreased risk of GE incidence when compared with the combination of cyclosporine A and nifedipine (odds ratio: 0.198, 95% CI, 0.083 until 0.473, P < 0.001). Conclusions: It is important for all clinicians to know the effects of the aforementioned drugs and the treatment options.

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Pendahuluan dan tujuan: Pembedahan laparoskopi telah diakui dapat mengurangi tingkat morbiditas sehingga meningkatkan keselamatan pasien. Saat tindakan LLDN, komplikasi yang paling sering adalah cedera pembuluh darah ginjal, yang sering membutuhkan transfusi darah. Selain perlunya transfusi darah, pendarahan berat yang disebabkan oleh cedera pembuluh ginjal membutuhkan konversi dan perbaikan terbuka. Dengan demikian, penelitian ini ingin mendeskripsikan dan menganalisis kebutuhan transfusi darah dalam operasi laparoscopic living donor nephrectomy di pusat kami. Bahan dan metode:  Studi kohort retrospektif ini dilakukan di Departemen Urologi di Rumah Sakit Nasional Cipto Mangunkusumo. Rekam medis semua pasien donor ginjal yang menjalani prosedur LLDN di institusi kami dari November 2011 hingga Oktober 2017 ditinjau. Data termasuk usia donor, kadar hemoglobin sebelum operasi, kadar hemoglobin pasca operasi, jumlah pendarahan intraoperatif, jumlah arteri renalis, jumlah vena renalis, sisi donor, konversi ke operasi terbuka, durasi operasi, dan BMI donor dikumpulkan dan dianalisis. Data-data ini selanjutnya dikorelasikan dengan tingkat transfusi. Hasil: Terdapat 500 pasien yang menjalani tindakan laparoscopic living donor nephrectomy di institusi kami. Semua pasien menjalani prosedur LLDN dengan pendekatan transperitoneal. Perbedaan proporsi tingkat transfusi darah antara pasien pria 0,9% dibandingkan dengan 0,6% pada pasien wanita tidaklah signifikan (p=0,782). Tidak ada perbedaan yang signifikan dalam proporsi tingkat transfusi darah dengan sisi ginjal (p=0,494), jumlah arteri (p=0,362), usia (p=0,978), BMI (p=0,569), dan kadar hemoglobin sebelum operasi (p=0,766). Median perkiraan jumlah pendarahan pada pasien yang menerima transfusi darah intraoperatif secara signifikan lebih besar daripada pasien yang tidak menerima transfusi darah (p <0,001). Kesimpulan: Berdasarkan penelitian ini, kami menyarankan bahwa di institusi kami, penggunaan produk darah pra operasi tidak selalu diperlukan. Kurva pembelajaran dan teknik ahli bedah memiliki peran penting dalam mencegah komplikasi intraoperatif dan kehilangan darah.

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Introduction and objectives: Laparoscopic surgery has been acknowledged to reduce the morbidity rate thus improving patient safety. During the LLDN, the most frequent complication is renal vessels injuries, which often requires a blood transfusion. Besides the need for a blood transfusion, major bleeding caused by renal vessels injuries require open conversion and repair. Thus, this study would like to descript and analyze the need for blood transfusion in laparoscopic living donor nephrectomy surgery in our center. Materials and methods: We performed a retrospective cohort study in the Department of Urology at Cipto Mangunkusumo National Hospital. The records of all kidney transplantation donor patients who underwent LLDN procedures carried out at our institution from November 2011 to October 2017 were reviewed. Data including donor age, preoperative hemoglobin level, postoperative hemoglobin level, intraoperative bleeding, number of artery(ies), number of vein(s), donor side, conversion to open surgery, surgery duration, and donor BMI were collected and analyzed. These data were further correlated with transfusion rate. Results: There were 500 patients underwent laparoscopic living donor nephrectomy procedure at our institution. All of the patients had LLDN with a transperitoneal approach. The difference in blood transfusion rate proportion between male patients with 0.9% compared to 0.6% in female patients was not significant (p=0.782). There are no significant difference in blood transfusion rate proportion regarding to renal side (p=0.494), number of artery (p=0.362), age (p=0.978), BMI (p=0.569), and preoperative hemoglobin (p=0.766). Median estimated blood loss in patients who received intraoperative blood transfusion was significantly much greater than in patients who did not receive a blood transfusion (p<0.001). Conclusion: Based on this study, we suggest that in our institution, preoperative blood products are not necessarily needed. The surgeon's learning curve and technique play a significant role in preventing intraoperative complications and blood loss.

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Tujuan: Penelitian ini bertujuan untuk menganalisis variabel yang berhubungan dengan kondisi intra-operatif dan pasca-operasi selama proses pembelajaran dan melakukan evaluasi hasil dari metode berbasis mentor-initiated pada LDN di Rumah Sakit Cipto Mangunkusumo (RSCM), Jakarta, Indonesia. Material dan Metode: Penelitian retrospektif ini menggambarkan pengalaman pada 140 prosedur LDN yang dilakukan di RSCM sejak November 2011 sampai Agustus 2014. Sebanyak 66 kasus LDN pertama, dilakukan oleh seorang ahli bedah laparoskopi sebagai operator utama (mentor) dan secara bersamaan, membimbing operator kedua (trainee). Setelah itu, operasi dilakukan secara bergantian oleh kedua ahli bedah. Dilakukan analisis pada variabel yang berhubungan dengan kondisi intra-operatif dan pasca operasi pada 66 kasus LDN pertama, serta analisa perbandingan antara prosedur operasi yang dikerjakan oleh masing-masing ahli bedah. Hasil: Rerata usia pendonor adalah 32.97 tahun dengan rasio jenis kelamin 6:4 (laki-laki:perempuan). Sebanyak 64% pendonor tidak memiliki hubungan keluarga dengan resipien. Donor ginjal kiri dilakukan pada 82.1% (n=112) prosedur, dan kanan sebanyak 17.9% (n=28). Tidak ada perbedaan signifikan pada waktu operasi (p=0.36), Warm Ischemia Time (WIT) 1 (p=0.66), jumlah perdarahan intra-operatif (p=0.46) antara kedua operator. Hanya satu variable (time to clip) yang ditemukan secara statistik bermakna, p = 0.024. Perbandingan antara grup pertama (1-50 LDN) dan grup terakhir (100-140 LDN) hanya variable WIT 1 dan time to clip; p = 0.029, p = 0.029 yang ditemukan signifikan secara statistik. Kesimpulan: LDN merupakan suatu prosedur yang cukup menjanjikan dan aman untuk meningkatkan jumlah pendonor ginjal. Kesulitan untuk mencapai suatu learning curve menjadi permasalahan utama yang harus dihadapi oleh setiap ahli bedah laparoskopik, terutama karena dampak yang potensial terhadap keberhasilan suatu transplantasi ginjal. Pengalaman yang cukup pada operasi laparoskopi saluran kemih bagian atas sangat diperlukan sebelum melakukan LDN. Pendekatan berbasis mentor-initiated akan membantu peserta latihan untuk mengenali dan melakukan keseluruhan operasi dengan baik tanpa membahayakan patient safety.

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ABSTRACT
Objective: variables related to both surgical and postoperative outcome during the learning curve and evaluate the result of mentor-initiated approach of laparoscopic donor nephrectomies at Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Materials and Methods: This retrospective study describes our experiences on 140 laparoscopic nephrectomies in living donors performed in Cipto Mangunkusumo Hospital from November 2011 to August 2014. First sixty-six LDN was performed by one experienced laparoscopic surgeon as the main operator while mentoring the second operator. Afterward the surgery was performed alternately between the two surgeons. Variables related to both the surgical and postoperative outcome during the initial phase and comparisons of the procedures performed by each surgeon were analyzed. Results: Donors’ average age was 32.97 years with male female ratio 6 : 4. About 64% patients were not family related. The left kidney procedures was performed 112 times (82.1%), whereas the right kidney 28 procedures (17.9%). No significant difference in operating time done by both operators (p= 0.36), WIT 1 (p=0.66), and intraoperative blood loss (p=0.46) with only time to clip as single statistically significant variable with p=0.024. Comparison between 1-50 LDN group and the 100-140 LDN group on WIT 1 and time to clip were found statistically significant with p = 0.029, p = 0.029. Conclusion: Laparoscopic donor nephrectomy (LDN) is a fairly safe and a promising procedure to increase the kidney donation pool. A steep learning curve is still the main problem that every surgeon had to deal with, mainly due to the concern of its potential impact on graft survival. Experience in laparoscopic upper urinary tract surgery is recommended to start with LDN. A mentor-initiated approach allows the introduction of this procedure to trainees with good results on the overall surgery without compromising patient safety.

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Latar Belakang. Optimalisasi hemodinamik perioperatif berkorelasi dengan peningkatan hasil terapi pascaoperasi. Alat pantau pulse contour analysis telah digunakan rutin pada operasi transplantasi ginjal di RSCM. Teknologi ini mahal dan harus dilakukan pemasangan akses kateter arteri. Terdapat alat ukur lain dengan kelebihan tidak invasif.Tujuan. Mengetahui kesesuaian hasil pengukuran hemodinamik antara teknik bio-impedance analysis dan pulse contour analysis pada pasien resipien transplantasi ginjal.Metode. Penelitian observasional statistik potong lintang terhadap 35 pasien resipien transplantasi ginjal di RSCM dan RSCM Kencana Jakarta periode Oktober 2017-Febuari 2018. Parameter hemodinamik pasien diukur menggunakan kedua alat uji yaitu ICONTM dan EV1000TM, pencatatan dilakukan pascainduksi, pascainsisi dan pascapelepasan klem arteri renalis. Analisis data menggunakan uji kesesuaian Bland-Altman dan korelasi.Hasil. Rerata perbedaan nilai indeks curah jantung dan indeks isi sekuncup antara kedua alat adalah 1,3 l/mnt/m2 dan 22,1 ml/denyut/m2 lebih tinggi pada EV1000TM. Rerata perbedaan hasil indeks tahanan vaskular sistemik dan stroke volume variation antara kedua alat adalah 973,3 dynes-detik-m2/cm5 dan 4,8 lebih rendah pada EV1000TM.Simpulan. Tidak terdapat kesesuaian hasil pengukuran curah jantung, tahanan vaskular sistemik dan stroke volume variation antara teknik bio-impedance analysis dengan teknik pulse contour analysis pada pasien resipien transplantasi ginjal. Background. Hemodynamic optimization perioperative has strong correlation with improvement of post-operative outcome. Pulse contour analysis uses regularly for monitoring in renal transplantation surgery at RSCM hospital. This technology is expensive and need access to artery vascular. There is other monitoring device with excess non-invasive use. Purpose. Comparing hemodynamic measurement results between bio-impedance analysis and pulse contour analysis in renal transplant recipients.Method. Cross sectional observasional study to 35 renal transplantation recipient patients at RSCM and RSCM Kirana hospitals Jakarta during October 2017-February 2018. Each patient was measured with both devices ICONTM and EV1000TM. Data collected after induction, after incision and after renal artery release. All the data analyzed with Bland-Altmant agreement and corellation.Result. Mean difference of cardiac output index and stroke volume index are 1,3 l/mnt/m2 and 22,1 ml/denyut/m2 higher in EV1000TM. Mean difference of systemic vascular resistance index and stroke volume variation are 973,3 dynes-detik-m2/cm5 and 4,8 lower in EV1000TM. Conclusion. There is no agreement in measurement of cardiac output, systemic vascular resistance and stroke volume variation between bio-impedance analysis and pulse contour analysis in renal transplantation recipient patients.

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Latar Belakang: Disfungsi ereksi (DE) adalah salah satu penyakit sering ditemukan pada mereka yang menderita penyakit ginjal stadium akhir (ESRD). Meskipun transplantasi ginjal memperbaiki masalah ini pada beberapa pasien, sebanyak 20 hingga 50% penerimanya terus menderita DE. Sampai saat ini, literatur mengenai efek transplantasi ginjal terhadap DE masih kontroversial. Mayoritas penelitian menunjukkan bahwa pasien mendapatkan kembali fungsi ereksi setelah transplantasi ginjal, sedangkan penelitian lain menunjukkan efek minimal transplantasi terhadap status DE. Kami melakukan tinjauan sistematis untuk merangkum efek transplantasi ginjal terhadap status DE. Metode: Pencarian literatur sistematis di PubMed, Cochrane, dan Scopus, dilakukan pada bulan April 2020 dengan menggunakan kata bebas dan istilah MeSH. Kami memasukkan semua penelitian prospektif yang menyelidiki skor IIEF sebelum dan sesudah transplantasi pada penerima transplantasi ginjal dengan DE. Hasil: Pencarian database awal di PubMed dan Google Scholar menghasilkan 4.052 makalah. 42 makalah dipertimbangkan untuk analisis teks lengkap. Dari 42 teks lengkap yang dicari, empat diantaranya dimasukkan dalam tinjauan sistematis. Sebanyak 152 dari 230 subjek menunjukkan peningkatan fungsi ereksi melalui skor IIEF-5 setelah transplantasi ginjal. Meta-analisis yang dilakukan terhadap skor IIEF dan kadar Testosteron menunjukkan perbedaan yang signifikan sebelum dan sesudah transplantasi. Kesimpulan: Temuan kami telah mengkonfirmasi bahwa transplantasi ginjal meningkatkan fungsi ereksi. Dengan demikian, peningkatan signifikan dalam skor testosteron dan IIEF pasca transplantasi terbukti secara statistik dalam penelitian ini. Namun, karena jumlah penelitian yang ada terbatas, bukti yang ada pun terbatas. Penelitian lebih lanjut dengan metodologi yang lebih baik dan ukuran sampel yang lebih besar diperlukan untuk menyelidiki pengaruh transplantasi ginjal pada fungsi ereksi. ......Introduction: Erectile dysfunction (ED) is a major health burden worldwide frequently found in those with end-stage renal disease (ESRD) Although renal transplant improves the problem in some patients, as many as 20 to 50% of recipients continue to suffer ED. To this date, literature regarding the effect of kidney transplantation on ED has been contradictory. Majority of studies have shown that patients regain erectile function following renal transplant, whereas other studies showed minimal effect of transplantation on the status of ED.1,2 We did a systematic review to summarize the effects of kidney transplantation on the status of ED. Methods: A systematic literature search on PubMed, Cochrane, and Scopus, were carried out in April 2020 by using both free words and MeSH terms. We included all prospective studies investigating the pre- and post-transplant IIEF scores of renal transplant recipients with ED. Results: The initial database search on PubMed and Google Scholar produced 4,052 papers. 42 papers were considered for full-text analysis. Out of 42 full texts sought, four were included in the systematic review. A total of 152 out of 230 subjects showed improvement of erectile function by means of IIEF-5 score after renal transplantation. Meta-analysis performed on IIEF score and Testosterone level show significant differences pre and post-transplantation. Conclusion: Our findings have confirmed that renal transplantation improves erectile function. Thus, significant improvement in testosterone and IIEF score post- transplantation were proven statistically in this study. However, as there were only a limited number of studies, the evidence is limited. Further studies with better methodology and larger sample size are needed to investigate the effect of renal transplantation on erectile function.