John Hopkins transplant surgeons remove healthy kidney through donors vagina

Minimally invasive organ removal could increase donations, surgeons say

In what is believed to be a first-ever procedure of its kind, surgeons at Johns Hopkins have successfully removed a healthy donor kidney through a small incision in the back of the donor’s vagina.

“The kidney was successfully removed and transplanted into the donor’s niece, and both patients are doing fine,” says Robert Montgomery, M.D., Ph.D., chief of the transplant division at Johns Hopkins University School of Medicine who led the team that performed the historic operation.

The transvaginal donor kidney extraction, performed Jan. 29 on a 48-year-old woman from Lexington Park, Md., eliminated the need for a 5-to-6-inch abdominal incision and left only three pea-size scars on her abdomen, one of which is hidden in her navel.

Transvaginal kidney removals have been done previously to remove cancerous or non-functioning kidneys that endanger a patient’s health, but not for healthy kidney donation. "Because transplant donor nephrectomies are the most common kidney removal surgery — 6,000 a year just in the United States — this approach could have a tremendous impact on people’s willingness to donate by offering more surgical options,” says Montgomery.

“Since the first laparoscopic donor nephrectomy was performed at Johns Hopkins in 1995, surgeons have been troubled by the need to make a relatively large incision in the patient’s abdomen after completing the nephrectomy to extract the donor kidney. “That incision is thought to significantly add to the patient’s pain, hospitalization and convalescence,” says Montgomery. “Removing the kidney through a natural opening should hasten the patient’s recovery and provide a better cosmetic result.”

Both laparoscopies and transvaginal operations are enabled by wandlike cameras and tools inserted through small incisions. In the transvaginal nephrectomy, two wandlike tools pass through small incisions in the abdomen and a third flexible tool housing a camera is placed in the navel.

Video images displayed on monitors guide surgeons’ movements. Once the kidney is cut from its attachments to the abdominal wall and arteries and veins are stapled shut, surgeons place the kidney in a plastic bag inserted through an incision in the vaginal wall and pull it out through the vaginal opening with a string attached to the bag.

Montgomery says the surgery took about three and a half hours, roughly the same as a traditional laparoscopic procedure.

The Jan. 29 operation is one of a family of new surgical procedures called natural orifice translumenal endoscopic surgeries (NOTES) that use a natural body opening to remove organs and tissue, according to Anthony Kalloo, M.D., the director of the Division of Gastroenterology at Johns Hopkins University School of Medicine and the pioneer of NOTES. The most common openings used are the mouth, anus and vagina.

Since 2004, successful NOTES in humans have removed diseased gallbladders and appendixes through the mouth, and gallbladders, kidneys and appendixes through the vagina.

Recently, Kalloo says, some medical experts have called for more studies to compare the safety and effectiveness of NOTES against traditional laparoscopies, which also leave very small scars, have been in use for many years, and are proven to be safer and less painful for patients than older “open” abdominal procedures. He supports more studies.

But, he adds, “natural orifice translumenal endoscopic surgery is the final frontier to explore in making surgery scarless, less painful and for obese patients, much safer.” An organ donor, in particular, is most deserving of a scar-free, minimally invasive and pain-free procedure.”

Additional surgeons from Johns Hopkins University School of Medicine who participated in the procedure were Mohamad E. Allaf, M.D., assistant professor in the departments of Urology and Biomedical Engineering and director of minimally invasive and robotic surgery; Andy Singer, M.D., Ph.D., assistant professor in the Division of Transplant Surgery; and Wen Shen, M.D., M.P.H., assistant professor in the Department of Gynecology and Obstetrics.

Fewer clogged arteries may need stent treatment

A new study gives fresh evidence that many people with clogged heart arteries are being overtreated with stents, and that a simple blood-flow test might help prevent unnecessary care.

Fewer deaths, heart attacks and repeat procedures occurred when doctors implanted fewer of these tiny artery props, using the blood-flow test to decide when they were truly needed, the study found.

Results were published in Thursday's New England Journal of Medicine.

Several reports in recent years have suggested that stents and artery-opening angioplasty procedures were being overused in non-emergency cases, often without giving medicine alone a chance to work.

Concern about stent complications also has made doctors more cautious about elective angioplasty.

"It's really raised a lot of question about when is it appropriate," said Dr. Robert Harrington, director of the Duke Clinical Research Institute, who had no role in the new study.

The finding that blood-flow testing may help guide these decisions "adds another parameter for us to consider," he said.

Non-emergency cases

The test has been around for some years but is used in only about 10 per cent of angioplasties now, several heart specialists said.

More than one million angioplasties are done in the United States each year, and about half are the type in this study — non-emergency cases involving people with narrowings in two or more major heart arteries.

The study was done in the United States and Europe, and involved 1,005 people who were having chest pain because of reduced blood flow to the heart or were recovering from a mild heart attack. All were scheduled to have angioplasty based on the usual test — an X-ray called an angiogram, in which a dye is injected so doctors can see artery narrowings.

Half of the study participants had their narrowed areas treated with angioplasty and stents, as indicated by angiograms alone.

The rest were given a blood-flow test. Doctors place a wire in the artery and measure pressure in front of and beyond the narrowing. This tells whether the narrowing is keeping a big amount of blood from getting through to the heart.

More accurate stent placements

In this group, only narrowings that significantly impeded blood flow were treated with angioplasties and stents.

Results: people given the blood-flow test received, on average, roughly two stents versus roughly three for the others.

A year later, only 13 per cent of them had died, suffered a heart attack or needed further artery treatment, versus 18 per cent of those treated on the basis of angiograms alone. Rates of chest pain at one year were similar.

With the blood-flow test, "we were able to more accurately or more judiciously place stents," and decide which arteries to skip, said Dr. William Fearon, a Stanford University cardiologist who helped lead the study.

Between five and 10 per cent of those given the blood-flow test were able to skip angioplasty and stents altogether, and were prescribed medicines instead, he said.

The study was mostly paid for by Radi Medical Systems Inc., a Swedish company that makes the wire used in the blood-flow test and was recently acquired by St. Jude Medical of St. Paul, Minn.

Several study leaders have consulted or been paid speakers for Radi or various stent makers.

The Radi wire, with a sensor that does the pressure measurement, costs about $750 US versus $100 US for an ordinary angioplasty wire. But it likely saves money by avoiding pricier stents, which cost $2,000 US and up, and possibly some cardiac stress tests, which cost $1,000 US or more, Fearon and other heart specialists said.

A second study should quickly be done to see if the benefit can be confirmed, justifying routine use of the blood-flow test, said Dr. Stephen Ellis, a Cleveland Clinic cardiologist who wrote an editorial accompanying the study.

"If validated, the results really should improve medical care," he said.

A second company — Volcano Corp. in Rancho Cordova, Calif. — also makes a blood-flow testing wire.

Cleveland Clinic announces near-total face transplant

Science fiction moved took a leap closer to science fact today as the nation’s first near-total face transplant has been done on a woman at the Cleveland Clinic, the hospital announced.

Reconstructive surgeon Dr. Maria Siemionow replaced nearly all of the woman’s face — an amazing 80 percent — with that of a deceased female donor in an operation a couple weeks ago.

The patient’s name and age were not released. The hospital plans to hold a news conference Wednesday to give further details.


The world’s first partial face transplant occurred in France three years ago on a woman who had been mauled by her dog. Two others have been announced since then — a Chinese farmer attacked by a bear and a European man disfigured by a genetic condition.

The nature of the injuries or disfigurement that prompted the Cleveland case are not yet known. Such transplants are controversial, because they are aimed at improving a patient’s quality of life rather than saving it, and require recipients to take immune-suppressing drugs for the rest of their life.

“It is very important what kind of recipient they selected,” and how great the need was, said Dr. Bohdan Pomahac, a surgeon at Harvard-affiliated Brigham and Women’s Hospital in Boston, which plans to offer face transplants too.

“There are patients who can benefit tremendously from this,” he said. “It’s great that it happened. It is a major move forward. Hopefully it will open the door both to the public and to other centers” wanting to offer such transplants, Pomahac said.

There are considerable issues confronting face transplant procedures, experts say.

Burn and severe trauma patients have long needed better options, but “the ethics are really controversial,” said Dr. Jeffrey Guy, director of the Burn Center at Vanderbilt University.

Medical teams and patients need to be prepared for the possibility of tissue rejection and the complex psychological factors unique to face transplants, noted bioethicist Arthur Caplan, Ph.D.

"It raises issues both for the donor family and the recipient's family and friends," said Caplan, director of the Center for Bioethics at the University of Pennsylvania. "Our personal identity is tied up in the face in a way that isn't true about the liver or kidney."

The risk now is balancing two medical risks: the need to give strong immune suppression drugs to prevent rejection, and managing the risk of infection increased by taking such medicines.

Rejection is a possibility whenever someone receives an organ or cells from someone else because the body regards this as foreign tissue. Two types of problems can result.

The first is graft-versus-host disease, which happens when the new marrow attacks the body of the recipient (the host). The second is when the host’s body attacks the marrow or the transplanted face, causing inflammation and other problems at the site of the new tissue.

Either of these can be life-threatening. They can come on suddenly, within days or weeks of the operation, a situation called acute rejection. Or chronic, low-level rejection can set in and slowly undermine the recipient’s health.