|Year : 2000 | Volume
| Issue : 2 | Page : 88-91
Laparoscopic live donor nephrectomy in the context of the Indian subcontinent
Hari Siva T Gurunadha Rao, Sakti Das
Department of Urology, University of California Davis, School of Medicine, Sacramento, USA
Dept. of Urology, University of California Davis School of Medicine, 4860 Y Street, Suite 2100, Sacramento, CA 95817
Source of Support: None, Conflict of Interest: None
Keywords: Live Donor; Convalescence; Laparoscopic Nephrectomy; Allograft; Pneumo-Sleeve.
|How to cite this article:|
Gurunadha Rao HT, Das S. Laparoscopic live donor nephrectomy in the context of the Indian subcontinent. Indian J Urol 2000;16:88-91
Laparoscopic surgery has established its role as the preferred minimally invasive therapy for various urologic ailments. With its proven efficacy and safety in adrenalectomy, orchiopexy, ureterolithotomy and simple nephrectomy where it yields comparable outcome and less morbidity, laparoscopic techniques are being propagated for more advanced indications like radical nephrectomy, retroperitoneal lymph node dissection and live donor nephrectomy. Gill et al  first performed laparoscopic donor nephrectomy in a porcine model. This laid the groundwork for Ratner et al from Johns Hopkins University to perform the first laparoscopic live donor nephrectomy in 1995  .
Live donor renal transplantation is preferable to a cadaver allograft because of its many advantages to the recipient including improved patient and graft survival, rapid return of function, shorter hospital stay and lower morbidity.
The complication rates with open donor nephrectomy range from 8% to 47%. ,,,,,, D'Alessandro et al reported a 17% overall complication rate in a review of their 28-year experience with open live-related donor nephrectomy.  A review of reports from multiple medical centers with up to 28 years follow-up reveals a 16% overall complication rate in 3657 patients . ,,, In these series, mortality was 0.03%, estimated blood loss was 250 to 300 ml, mean operative time was approximately 4 hours and mean postoperative hospital stay was 5 days.
Postoperative complications of around 14% in the laparoscopic donor group are comparable to open series. ,, These complications include bowel injury secondary to trocar placement, devascularisation of the ureter, retroperitoneal hematoma and delayed epigastric arterial bleeding requiring open surgical repair. Most of these complications occurred in the early part of these series.
Minor complications such as wound infections and urinary tract infections have been rare in the laparoscopic and open groups. There have been no reported mortalities with laparoscopic live donor nephrectomy.
Intraoperative conversion to open nephrectomy occurred in 5.7%, 5.9% and 8.3% instances in various series during laparoscopic donor nephrectomy. ,, The incidence of open conversion is expected to decline with increased experience. By all parameters monitored, serum creatinine, urine output, postoperative acute tubular necrosis and need for hemodialysis and allograft rejection/survival, the kidneys procured laparoscopically appear to perform as well as those obtained via the open procedure. 
Several series have compared the laparoscopic approach with a similar open cohort. ,,, [15, The mean estimated blood loss in the laparoscopic group was 173 ml compared with 400 ml in the open group (p < 0.05).  The mean operating time (245 min vs. 215 min), warm ischemia time (4.1 min vs. 2.2 min) and time for diuresis after revascularization (48 min vs. 4.1 min) were longer in the laparoscopy group.  But none of the recipients required hemodialysis and the authors feel that vasodilating agents (PG El) may help to decrease the time for initial diuresis. Serum creatinine levels in the recipient at 1 week and 1 month after laparoscopic donor nephrectomy allograft was significantly higher than in the corresponding open donor nephrectomy group (2.8 vs. 1.8 mg/dl and 2.0 vs. 1.6 mg/ dl). But at 3 and 6 months after transplantation, the serum creatinine levels were similar in both the groups (1.7 vs. 1.5 mg/dl and 1.7 vs. 1.7 mg/dl, respectively). By 1-year post-transplant, the mean serum creatinine for laparoscopic nephrectomy was actually less than that for the open nephrectomy group (1.4 and 1.7 mg/dl, respectively).  It appears that higher serum creatinine levels in the immediate post-transplantation period raised the concern for possible rejection and significantly more patients in the laparoscopic nephrectomy group (25.2%) were prescribed tacrolimus within the first month than those in the open nephrectomy group (2.1 %).  The initial higher serum creatinine levels in the laparoscopy group did not impact on graft survival, which was equivalent in both groups.  There appears to be no difference in proven episodes of rejection when comparing similar groups. Although patients in the laparoscopic nephrectomy group compared to the open nephrectomy group were more likely to have delayed graft function (7.6 vs. 2.0%) and ureteral complications (4.5 vs. 1.0%), the rate of other complications, patient and graft survival rates were similar in the two groups, indicating that there is no significant difference in longer term graft function despite the slower initial renal recovery in the laparoscopy group.  There was an increased risk of venous thrombosis when using right-sided kidneys due to the shorter length of the right renal vein producing tension on the venous anastomosis, resulting in postoperative thrombosis. These initial problems of venous thrombosis of the graft kidney and increased ureteral complications are now prevented by restricting to the harvest of left kidney only and refinements in the operative technique avoiding skeletonizing the ureter.  In fact, in the last 50 patients reported by Fabrizio et al, the ureteral complication rate in the recipient has dropped below that of open donor nephrectomy.  The procedure can be performed safely even in the setting of multiple donor renal arteries without adverse effects on early allograft function.  With these modifications, laparoscopic nephrectomy appears to provide a donor kidney of equal efficacy as that obtained with open donation.
The hospital stay was reduced by 50% in the laparoscopic donors and patients returned to work sooner (3.9 vs. 6.4 weeks). , Laparoscopic approach results in less postoperative pain and quicker convalescence compared with open donation [Table 1]. 
The learning curve for laparoscopic nephrectomy is steep. But recently various ancillary methods like handassisted laparoscopic approach,  gasless laparoscopy-assisted method  have been developed which will be helpful in decreasing the slope of this learning curve. Gasless laparoscopy can avoid deterioration of renal hemodynamics and resultant oliguria induced by carbon dioxide insufflation. Slakey et al showed that hand-assisted live donor nephrectomy achieved an adequate length of artery, vein and ureter and a decrease in the mean operating time and most importantly a significantly shorter warm ischemia time when compared to the classical laparoscopic donor nephrectomy.  Drehmer et al have shown in a prospective study that retroperitoneoscopic hand-assisted live donor nephrectomy compared favorably with open live donor nephrectomy with regard to perioperative morbidity, cosmesis and graft outcome .  There was no conversion to the open method in their series. Formal training courses, apprenticeships and the use of various assisted devices and techniques mentioned above can shorten the learning curve of laparoscopy.
Laparoscopic live donor nephrectomy is expected to increase the number of willing donors. At Johns Hopkins University Medical Center, the number of living donors increased by greater than 100% after laparoscopic donor nephrectomy was started  and this has been seen at other centers performing the procedure.  Approximately 20% of patients insist they would not have donated if laparoscopic donor nephrectomy was not available.  Potential donors may be more willing to undergo laparoscopic nephrectomy than open nephrectomy, thus increasing the organ supply.
Despite the enactment of the Human Organ Transplantation and Brain Death Legislation by the Indian Parliament and its subsequent adoption by most of the states of Indian Union, cadaveric organ donation does not seem to be well accepted yet by Indian populace. Therefore, majority of renal transplantation procedures performed in India encompass a live-related donor for transplantation. There are very few centres in the country promoting cadaver renal allograft transplantation. Even in these centers, the live-related renal allografts far outnumber the cadaver renal allografts. This fact has got an important bearing to lead us to further seriously consider incorporation of laparoscopic live donor nephrectomy in the Indian scenario.
In view of the great magnitude of patients with end stage renal disease on the waiting lists of most transplant programs in India, expansion of donor pool by accepting elderly donors (> 60 years age) and marginal donors needs to be explored. Laparoscopic nephrectomy by virtue of its minimally invasive nature and less morbidity would be suitable for these relatively higher risk donors. Laparoscopic live donor nephrectomy can be performed without compromise to the allograft. It has been shown to result in less postoperative discomfort, improved cosmetic outcome and rapid recovery for the donor. The apparent increase in cost of therapy related to technology, equipment costs and increased operating room time would be offset by shorter hospitalisation, earlier return to vocation and gain of working hours. The complication rates appear equivalent to comparable open donor nephrectomy series. Laparoscopic live donor nephrectomy may ultimately increase the total number of live-related kidney transplants.
Laparoscopic donor nephrectomy is especially suited to a country like India where cadaveric renal transplantation is still marginally endorsed and most transplant programs predominantly utilize live renal allografts. It is imperative for us to initiate learning programs through workshops, training courses and apprenticeships so that increasing number of urologists can offer the minimally invasive choice of laparoscopic live donor nephrectomy to our countrymen.
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