Indian Journal of Urology Users online:1017  
IJU
Home Current Issue Ahead of print Editorial Board Archives Symposia Guidelines Subscriptions Login 
Print this page  Email this page Small font sizeDefault font sizeIncrease font size


 
ORIGINAL ARTICLE
Year : 2002  |  Volume : 19  |  Issue : 1  |  Page : 29-37
 

Laparoscopic live donor nephrectomy: An indian perspective


Department of Urology and Renal Transplantation, SGPGIMS, Lucknow, India

Correspondence Address:
Anant Kumar
Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rai Bareli Road, Lucknow - 226 014
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions

 

Keywords: Donor Nephrectomy; Laparoscopy


How to cite this article:
Arvind NK, Kumar A. Laparoscopic live donor nephrectomy: An indian perspective. Indian J Urol 2002;19:29-37

How to cite this URL:
Arvind NK, Kumar A. Laparoscopic live donor nephrectomy: An indian perspective. Indian J Urol [serial online] 2002 [cited 2019 Jul 16];19:29-37. Available from: http://www.indianjurol.com/text.asp?2002/19/1/29/20288



   Introduction Top


Renal transplantation remains the best option for end stage renal disease (ESRD). Living donor renal transplan­tation is associated with better graft and patient survival, shorter waiting time, optimization of medical health of the recipient and an overall reduced cost when compared with cadaveric transplantation according to United Net­work for Organ Sharing registry data. [1] Inspite of this, live donor nephrectomy accounts for 90%, 30% 25% and 25% of transplants performed in developing nations, western world, Scandinavian countries and Europe respectively. [2] ­ This relates, in part, to the disincentives associated with donation. Factors such as prolonged hospitalization, post­operative pain, and extensive postoperative recovery as­sociated with lost wages, and cosmetic results of major abdominal surgery, will deter individuals from live donor nephrectomy.

Laparoscopic live donor nephrectomy (LDN) was de­veloped to decrease disincentives to live donations and overcome the organ shortage. In 1994, Gill and associates demonstrated the feasibility of performing LDN in por­cine model. [3] Soon thereafter, Ratner and colleague reported the first successful human laparoscopic live donor nephrec­tomy. [4] Since then, several transplant centers have reported their experiences with LDN.

Open donor nephrectomy (ODN) is a very successful surgical procedure, and excellent results have been obtained with respect to patient morbidity and mot tality. [5],[6],[7] For LDN to be considered a successful procedure, it must equal or exceed the gold standard procedure - ODN - in 2 essential criteria: (1) outcome for the recipient and (2) outcome for the donor. A review of the outcome data comparing LDN to ODN reveals a paucity of randomized prospective stud­ies. [8],[9],[10],[11],[12] Most reviews are retrospective, comparing results for ODN performed years earlier with results from more recently performed LDN. Such comparisons are invalid since, over the years, lengths of hospital stay have short­ened for most procedures, including nephrectomy. In ad­dition, because a shortage of organs has made living-related kidney transplants more universally accepted, transplant centers have gained experience with living donors, result­ing in reduced hospital stays and improved outcome data.

In keeping with a general trend toward minimally inva­sive surgery, the operative approach to ODN has changed as well. The location and size of the incision and the ex­tent of dissection have been altered to reduce postopera­tive morbidity. The length of stay for nephrectomy patients in general and for donor nephrectomy specifically has improved over the past 3 years. [13]

Is donor outcome better in LDN ?

The laparoscopic approach results in significant ben­efits to the donor. Various perioperative indices have been compared: blood loss, operative time, resumption of oral intake, parenteral narcotic use, and length of hospital stay. Various studies have shown that LDN results in less blood loss than ODN (122.3-266 mL and 393-408 mL, respec­tively). [14],[15] It has also been demonstrated that oral intake can resume quickly after LDN; approximately 2 days ear­lier than after ODN. [16] Parenteral narcotic use is lower for LDN compared with ODN, both in total dosage of mor­phine sulfate (LDN, 40 ± 33 mg; ODN 124 ± 88 mg; P<0.001) [17] and duration of use (LDN, 28.6 hours; ODN, 60.1 hours; P=0.0001). [10] The length of hospital stay is also shorter with LDN than with ODN (2.2-2.9 days and 4.5-5.5 days, respectively). [14],[15] While taking longer to perform than ODN, the operative time required for LDN is reasonable (LDN, 226.3 min; ODN. 212.8 min). [10] The increased operative time for the laparoscopic procedure adds to the total cost of operation without increasing mor­bidity. However operation room time is again not relevant to many hospitals in India. Although the intraop-erative blood loss is less in laparoscopic group, the transfusion rate was similar in both the groups. In the initial series, the conversion rate from laparoscopic to open approach ranged from 6% to 13%. With increasing experience, in the recent large series of the University of Maryland and the John Hopkins University, this had come down to 1.6% to 1.8%.[18],[19] The most common cause for conversion was excessive bleeding; however, this complication did not lead to a statistically significant increase in the transfusion rates in the laparoscopic donor nephrectomy group. The reoperative rate in the laparoscopic donor nephrectomy group ranged from 1 % to 8% for reasons like haemorrhage, small bowel obstruction, internal hernia, splenic injury, and for retrieval of a foreign body. Recent series of perioperative morbidity comparing the open approach with laparoscopic approach are shown in [Table - 1].

Postoperative convalescence data from several series comparing laparoscopic nephrectomy with open donor nephrectomy are summarized in [Table - 2]. LDN patients also resume normal activities faster than ODN patients. Various indices such as resumption of normal housework, driving, work and exercise have been evaluated, and all such indices indicate an advantage for LDN donors. Nor­mal household chores can be resumed 18 to 19 days earlier. [16] LDN patients resume driving 8.7 to 20.5 days ear­lier, and return to work 2 to 5 weeks earlier.[16],[17] Also, physi­cally active people can resume exercise about 5 weeks earlier when LDN is performed compared with ODN.

Complication rates of LDN and ODN donors are com­parable. In a study of ODNs with a 28-year follow-up, D'Alessandro and colleagues reported a complication rate of 17%. [5] The most common complications were pneumot­horax and urinary tract infection. Johnson and associates reported a complication rate of 8.2% in 871 ODNs.[6] Ma­jor complications included wound infection (2.4%), pneu­mothorax (1.5%), femoral nerve compression (<1 %), and reoperation for retained sponge (<1%). In other studies laparoscopic cases had complication rates of 14% to 16%. [8],[10],[14],[17] In Nogueira and associates' series of 110 consecutive LDNs, the most common complications included transient thigh paresthesias (4.1%), blood transfusion (3.5%), and wound infection (2.9%). [14] The open conver­sion rate was 1.8%. Major complications of two largest series are shown in [Table - 3].

Unlike the factors described previously, cosmesis and body image are difficult to quantify objectively. Although no data exist from psychological studies comparing LDN and ODN with respect to body images, Hensman and col­leagues reported that up to 25% of ODN patients com­plained of flank "diastasis" after surgery. [20] Laparoscopic donor nephrectomy gives better cosmesis as scar is small and is often located in the lower flank or suprapubic re­gion. It is a major incentive to females.

Ultimately, a significant benefit of laparoscopic surgery is to remove the disincentives to renal donation. While it may be argued that donors are altruistic and motivated individuals who will donate regardless of surgical ap­proach, it is clear that institutions employing laparoscopic techniques experience dramatic increases (85% to >100%) in live donor nephrectomies. [16],[17] In a postoperative survey of donors, 20% of LDN patients stated that they would not have donated if LDN had not been offered.[21]

Cost

The hospital stay was significantly shorter for the laparo­scopic group; however, the cost savings generated by a decrease in hospital stay were negated by a significantly greater operative cost in the laparoscopic group. [22] The net result was that, the total cost of hospitalization was simi­lar in the two groups. The financial loss of the laparoscopic donor was 30% of the loss incurred by the open donor nephrectomy patients due to absence from work.

However, this does not hold true in Indian setup, where disposables are expensive (Endocatch US $ 105, pne­umosleeve US $ 490, vascular staplers US $ 300), whereas hospital bed charges are only US $6 to US $8 per day. Moreover, the operation charges are fixed, and patients are not charged according to the duration of the proce­dure. The consumables are charged as and when used. High cost was the major cause of reluctance of our patients re­garding laparoscopic donor nephrectomy when the pro­gram was started in 2000, which forced us to develop a modified technique as described above, that avoided use of costly disposables. This modified technique is signifi­cantly cheaper in comparison to the standard and hand assisted donor nephrectomy [Table - 4].[23]

Recipient Outcome

In a recently conducted survey to determine the current practices, attitudes and plans regarding laparoscopic do­nor nephrectomy in high-volume renal transplantation centers at USA (representing 43% of all kidney transplan­tation done nationally), the most common disincentive for laparoscopic nephrectomy was concern for graft survival .[24]

Because the therapeutic goal of donor nephrectomy is to restore renal function to the recipient, paramount im­portance is placed on achieving excellent allograft func­tion and survival. Additionally, given the time-tested safety of ODN, LDN recipient morbidity should be minimal.

Does renal function suffer in patients with kidneys ob­tained by LDN ? It has been shown that the pneumoperi­toneum used for laparoscopy results in transient oliguria. [25] Concern over this physiologic phenomenon has led to the use of aggressive intraoperative hydration and adminis­tration of an osmotic diuretic (mannitol) to encourage diu­resis. However, as animal experiments have proven, no chronic ischemic renal histologic changes are evident af­ter prolonged pneumoperitoneum.[26] Other concerns re­garding longer warm ischemia times, trauma to the allograft during laparoscopic dissection, and trauma during allograft extraction have been expressed. [27]

With respect to short-term allograft function, conflict­ing results have been obtained. Nogueira and colleagues, in a comparison of 132 LDN and 99 ODN cases, observed higher serum creatinine levels in LDN recipients compared with ODN recipients from 1 week (2.8 ± 0.3 mg/dL ver­sus 1.8 ± 0.2 mg/dL, P=0.005) to 1 month (2.0 ± 0.1 mg/ dL versus 1.6 ± 0.1 mg/dL, P=0.05) after transplant.' Ratner and associates, in their series of 110 laparoscopic and 48 open cases, observed no significant differences in serum creatinine during the 4-day period following sur­gery. [15] However, it did take 1 day longer for nadir serum creatinine to be reached in LDN allografts - 4 days as opposed to 3. London and colleagues, in a smaller series (21 ODN, 12 LDN) also observed no significant differ­ences in serum creatinine at 1, 3 and 30 days following transplantation. [12]

Although short-term renal function is important, attain­ing durable long-term renal function that enables inde­pendence from dialysis is the ultimate objective. In the 2 largest institutional series to date, the long-term renal func­tion of LDN and ODN allografts was equivalent. [18],[19] Ratner and associates noted that, at 24 months, creatinine clear­ance was no significantly different between the 2 groups. [15] Interestingly, the University of Maryland series shows that LDN allografts had a slightly lower mean serum creati­nine (LDN, 1.4 ± 0.1 mg/dL; ODN, 1.7 ± 0.1 mg/dL, P=0.03) at 1 year following transplantation.[14]

Allograft survival rates of LDN and ODN cases were also comparable. Nogueira and colleagues reported that combined patient and graft survival rates were statistically equivalent. [14] The incidence of early acute rejection was similar in the 2 groups (ODN, 3.0%, LDN, 2.3%). Ratner and associates also observed no difference in patient sur­vival, graft survival, or rejection rates. [15]

Recipient complication rates were comparable as well. Major complications that were more common among LDN than ODN recipients included ureteral complications (4.5%-9.1%), delayed graft function (7.6%), and graft vascular thrombosis (2.7%). [14],[15] It is important to note that these complications were more frequent among the initial cases but decreased in frequency with increasing surgical experience.

Evolving Techniques

Ratner et al first described the technique of laparoscopic donor nephrectomy through transperitoneal approach. Since then, there has been tremendous modification in technique, approach and cost reductive innovation, which has led to the emergence of more than I technique of laparoscopic donor nephrectomy.

In standard laparoscopic donor nephrectomy three lapa­roscopic ports are placed under direct vision - one latera] to the rectus muscle halfway between the umbilicus and iliac crest, the other at the umbilicus, and third in the midline midway between xiphoid and umbilicus. The cam­era is positioned at the umbilicus port, and the operation is performed through the two ports.[28] A fourth port is often necessary for the purpose of retraction and is placed in t.'e anterior axillary line at the level of the umbilicus. The ipsilateral colon is mobilized medially by reflecting the lateral peritoneal reflection. The ligamentous attach­ments between the colon, diaphragm, and kidney are di­vided, exposing Gerota's fascia. The upper pole of the kidney is dissected within Gerota's fascia, leaving the lat­eral, posterior, and inferior attachment to the kidney in­tact. Once the upper pole is completely free, the hilar vessels are exposed. The gonadal, lumbar and adrenal veins are identified, doubly clipped, and divided. Renal vein is retracted upwards to expose the renal artery. The renal artery is now identified and freed to provide maximum vascular exposure to its proximal origin at the aorta. At­tention is focused next on the ureteral dissection. The go­nadal vessels are identified at the level of the renal hilum and dissected inferiorly to where the ureter crosses the iliac vessel. The gonadal vessels are once again identi­fied, clipped, and divided at the level of renal pelvis. The ureter is then dissected inferiorly down to the level of iliac artery and vein, where it is clipped and divided. The re­maining attachment to the kidney is then divided with sharp and blunt dissection. Just before division of the vascular pedicle, a periumbilical incision is created that is large enough to remove the kidney easily, and an Endocatch device is introduced with purse string suture in the perito­neum around the device to preserve the pneumoperito­neum. The laparoscope is moved to the epigastric port and the renal artery and the vein are sequentially divided with the aid of the endovascular gastrointestinal stapler. The kidney is placed in the Endocatch bag. Once secured. the peritoneum is opened, and the kidney is removed through the incision and the fascia is closed with No.1 absorbable suture. Pneumoperitoneum is re-established to inspect the renal bed and trocar sites for bleeding and hemostasis is done. The fascia at trocar site 10 mm and larger are closed with 2-0 absorbable sutures, and the skin is closed with 4-0 absorbable sutures.

Recent modification in standard laparoscopic technique places the unopened Endocatch bag through a Pfannenstiel incision at the beginning of the procedure. It helps in the retraction of the colon medially. The bag is opened once kidney is free from the posterior aspect. Kidney is ma­nipulated into the bag before cutting the vessels. This maneuver decreases the warm ischemia time as no time is wasted in entrapping the kidney into the bag.

Another modification is to give a 7 cm muscle-splitting incision in the left iliac fossa over the port. The hand is pushed into the peritoneal cavity to retrieve the kidney. This helps in cutting down the cost by avoiding use of Endocatch.

The main disadvantages of this approach is that, it takes considerable skill to remove a kidney that remains suit­able for renal transplantation. Several laparoscopic assisted techniques have been described to overcome the steep learning curve associated with laparoscopic donor nephrec­tomy. These techniques exploit the mandatory 6-8 cm ex­traction incision of classical laparoscopic approach throughout the procedure and are basically a hybrid of conventional open and laparoscopic approach. These tech­niques include transperitoneal donor nephrectomy and laparoscopic assisted extraperitoneal donor nephrectomy. [23],[29],[30]

The first successful hand assisted laparoscopic donor nephrectomy using pneumosleeve device (Dexterity, Blue Bell, PA) was reported in 1998 by Wolf and co-workers. [29] The hand device is placed in the periumbilical or infraumbilical position. Two 12 mm trocars are introduced. One trocar placed in the midclavicular line just below the umbilicus is used for the surgeon's working instruments. The other trocar is placed in the anterior axillary line above the iliac crest. A 10 mm 30 degree laparoscope is intro­duced through this port. The rest of the operation is per­formed similar to a standard laparoscopic approach and the graft is extracted through hand port device incision.

Yang and co-workers reported their experience with laparoscopic assisted extraperitoneal donor nephrectomy in 1995.[30] In this technique, the kidney is exposed through either a small pararectus or small median incision, and the procedure is performed under laparoscopic and direct visu­alization using combination of laparoscopic and conven­tional instruments. The operative space is maintained in a gasless field by means of special abdominal wall retrac­tors and lifters, which facilitates the renal dissection. Again renal pedicles are transected using gastrointestinal staplers and the kidney is brought out with the help of an endobag.

Recently the author (A.K.) has developed a cost saving technique of laparoscopic assisted donor nephrectomy.[23] Patient is placed in the flank position and pneumoperito­neum is established using veress needle, and an 11-mm. port is placed through a subumbilical incision or at the lateral border of the rectus muscle at the same level. This port is used as camera port throughout the dissection. The second port (5-12 mm) is placed in the centre of line con­necting the umbilicus with the left anterior superior iliac spine. A third port (5 mm) is placed at the level of the midclavicular line 2 fingerbreadth below the costal mar­gin (MCL). The colon is mobilized from the bifurcation of common iliac artery till the upper pole of the kidney. The upper pole of the kidney is dissected first. Splenocolic ligament is cut which helps in dropping the spleen from the superior part of the kidney. Splenic retraction is pro­vided by a fan retractor placed through a 5 mm port, which is sited along the anterior axillary line (AAL) 6 to 7 cm from the MCL port. Gonadal vein is traced proximally to identify the renal vein. The gonadal, adrenal and lumbar veins are divided between clips. The renal artery and vein are dissected and freed from lymphatic tissues. The adre­nal gland is dissected away from the upper pole of the kidney. The ureter is transected in the pelvis and the distal end clipped. It is freed from the retroperitoneum and mo­bilized up along with gonadal vein to ensure good vascularity. The lateral attachment of the kidney is divided. The gas supply is turned off, and all ports are removed. The MCL and AAL port sites are connected by 6-8 cm incision, where the skin and fascia are cut and the under­lying muscles split sufficiently to allow entry of the sur­geon's hand. In a muscular patient, some muscle fibers are cut at both the angles of the wound to facilitate expo­sure. The hand is inserted into the peritoneal cavity to con­firm complete mobilization of the kidney. Long Dever's retractors are inserted to provide direct access to hilar ves­sels. Any residual retroperitoneal attachments can be di­vided at this stage. Two 2-0 vicryl sutures are thrown around the renal vein and the knot is pushed closed to renal vein but not tightened. Finally, the renal artery is clipped three to four times with the 30-mm metal clips (Ethicon) and cut. The vein is tied with 2-0 vicryl suture by pushing the prethrown knot with a long right angle dissector. The vein is cut distal to the knot and the kidney removed. In our experience, the left upper quadrant inci­sion connecting the MCL and AAL port is particularly useful, as it provides excellent access to the renal hilum. In case of any inadvertent vascular injury, conversion to open procedure can be done rapidly through same inci­sion. As no disposables are used, (cf. hand-assisted - Pneumosleeve and vascular staples and standard laparo­scopic techniques - Enrlocatch, vascular staple) the cost is comparable to the open counterpart, which is an impor­tant consideration in developing countries.

Addressing the Problems

In the largest clinical series performed to date, ureteral injury has occurred at a disturbingly high rate (4.5% - 9.1%). [14],[27] However, the technique of ureteral harvesting has evolved to address this issue. At John Hopkins, the technique has been modified to preserve lower pole renal adipose tissue and the "golden triangle" of periureteral tissue between the kidney, gonadal vein, and renal hilum. Philosophe and associates noted dramatic improvement in ureteral complication rates after adopting the use of the endo­scopic gastrointestinal stapling device to divide the ureter. [31] For the first 130 LDN patients, 20(15%) ureteral compli­cations were reported, whereas in the most recent 63 patients, only 1 (0.01 %) ureteral complication occurred .[31]

Another purported shortcoming of LDN is the steep learning curve associated with the procedure. Currently, LDN is confined to major transplant centers with exten­sive laparoscopic expertise. Various methods are being investigated to ameliorate this situation. Hand-assisted LDN using the Pneumosleeve (Dexterity, Roswell, Ga) device has been successful, lowering operative and warm ischemia times. [29],[32] Another strategy to overcome the learn­ing curve and disseminate technique over long distances is to have experienced surgeons telementor less experi­enced laparoscopists. Telementoring experiments between John Hopkins and counterparts in Italy have been suc­cessfully conducted for laparoscopic nephrectomy. Tech­nological advances in instrumentation and robotics may also facilitate mastery of LDN in the future. [33]

Right Donor Nephrectomy

Left nephrectomy has been preferred because of the longer renal vein and overall greater technical ease. In right side, the liver has to be retracted and it is technically diffi­cult to duplicate clamping the vena cava with Satinsky clamp. Straight division of the renal vein at vena cava with vascular staplers results in loss of approximately l to 1.5 cm of vein as compared with open approach. [34] The result­ing short and thin vein can make anastomosis more diffi­cult and may some times result in vascular complication and/or graft loss. [35] The technical challenge of this proce­dure has necessitated the propensity for the left kidney retrieval (97.5% to 100%) compared to that for open do­nor nephrectomy (70% to 80%), which violates the prin­ciple of leaving the better kidney with the donor.

Various modifications have been proposed to facilitate safe harvesting of right kidney through laparoscopic ap­proach. Gill et al reported right donor nephrectomy done via the retroperitoneal approach.[39] After dividing the re­nal vessels with an endoscopic gastrointestinal stapler, they performed additional bench surgery to mobilize the vein into hilum, thereby adding length for the recipient anasto­mosis. Lee et al described a laparoscopic assisted tech­nique. [40] After laparoscopic dissection of the kidneys an 8-cm right upper quadrant transverse incision was made, through which a Satinsky clamp was passed across the vena cava. Vessel division, kidney removal and cavotomy repair were performed through this incision. Recently Turk et al [41] have used a modified Satinsky atraumatic vascular clamp, developed for thoracoscopic procedure for right nephrectomies. To clamp the inferior vena cava and di­vide the vessel a small incision is made to the right ante­rior superior iliac spine. Modified clamp which is longer than the standard clamp is inserted without trocar into the peritoneum and is used for clamping the inferior vena cava. The renal vein is transected close to vena cava with scissors. The cavotomy is closed with a laparoscopic running 3-0 polydioxane suture and the clamp is removed. In Scandinavian countries, to circumvent difficult anastomo­sis of short renal vein, internal iliac vein is divided from the external iliac vein. This brings the external iliac vein higher up in the wound and expedites the anastomosis.

Recent retrospective multi-institutional review of 97 right donor nephrectomies was done by Buell et al which were performed for varying reasons, like multiple vessels on left side, smaller right kidneys or cystic mass on right side. [42] Mean surgical time was 235+/- 66.7 minutes, and mean blood loss of 139+/- 165.9 ml. Conversion was re­quired in three patients secondary to bleeding or anatomi­cal anomalies. Mean warm ischemia time was limited to 238 +/- 17 seconds. Two grafts were lost during the early experience of these centers due to renal vein thrombosis. Both surgical and postoperative complications were lim­ited, with few long-term adverse effects. Mean serum cre­atinine levels were higher than open and left laparoscopic donor nephrectomy on postoperative day 1, but at all re­maining intervals the right laparoscopic donors had equiva­lent serum creatinine values.

Why LDN should be done in India ?

In India, despite the enactment of Human Organ Trans­plantation Bill and Brain Death Legislation by parliament and its subsequent adoption by most of the states, cadav­eric organ donation is still non-existent, and only 450 ca­daveric transplants have been performed till now. [43] Therefore, vast majorities of renal transplant are still per­formed in India using live donor kidneys. Although LDN is being performed increasingly worldwide, very few centers in India have active laparoscopic live donation programmes. [23],[44] Steep learning curve and operative costs are the major hindrances responsible for slow progress in this field. Hospital beds are not expensive in majority of the centers and patients are also not keen to get early dis­charge or join work early. They even insist on staying in the hospital for longer period and usually ask for longer leave; however, nobody wants pain and morbidity. LDN is definitely associated with less pain and better cosmesis. Young females prefer it to the open counterpart. Cost­reductive innovation in technique of LDN and its propa­gation is required to meet the demand of the huge popula­tion of ESRD awaiting transplantation.

How LDN can be done in India ?

Because the learning curve for laparoscopic donor ne­phrectomy is long, each institution and surgical team will have to make a judgment as to the best approach to be used at their respective centers. To begin with, the con­cerned surgeon should have experience of assisting or doing 25 laparoscopic simple nephrectomies under the guidance of experienced laparoscopic surgeon or urolo­gist. He should embark upon LDN with the support of laparoscopic surgeon and experienced transplant surgeon. In initial 50 cases learning curve has to be taken in ac­count and threshold for conversion should be low. Hand­assisted laparoscopic technique can be helpful during this period. With increasing experience the complication and conversion rate would decrease and it would become a safe procedure. Donor and graft safety should be the prime concern. Presently it is more expensive; but our modified approach is a feasible option in a developing country. [23]

Donor Nephrectomy at SGPGI: Changing Trends

We are one of the largest centers engaged in live related renal transplantation and 1050 transplants have been done till date. From 1988 to 1999 the kidneys were harvested through standard rib cutting ODN. In Jan 2000 we started LDN and have modified our ODN technique in which the rib is spared and subcostal 8-10 cm incision is used. The randomized trial comparing the result of standard ODN, mini incision ODN and LDN has been reported elsewhere.

We started laparoscopies donor program in Jan 2000, and have performed 98 laparoscopic donor nephrectomies till now. Of these, two were performed by hand-assisted technique, 17 by the standard technique and 79 by our modified lap assisted cost saving approach. The advan­tage of our technique and its result were reported else­where. [8]

Of the 79 cases done by modified technique, the male to female ratio has been 21:58; donor weight has ranged from 46 to 64 kg with mean age being 31 years (range 29­64 years). All donors except one had left kidney retrieval and 11 patients had multiple vessels. One right donor ne­phrectomy was done by same approach. The intraoperative data and postoperative results are shown in [Table - 2],[Table - 3],[Table - 4]. Conversion to open was done in 7 cases due to exces­sive bleeding or mechanical failures of instruments dur­ing early period of the program. There were two major complications: one because of secondary haemorrhage and other due to enoxaprim-induced idiosyncratic platelets dysfunction leading to postoperative hemorrhage. The most common minor complication was wound infection, which substantially decreased after introduction of metal autoclavable laparoscopic instruments. None of our laparoscopic patients had any vascular or ureteral compli­cations. The mean serum creatinine at follow-up ranging from 1 month to 27 months has been 1.37 mg/dl.

We have also done 130 mini incision donor nephrec­tomy with comparable results. This is another viable al­ternative to LDN. Here incision is 8 to 12 cm depending on patient's body mass index. It requires long instruments, thin and long retractors and head light. Surgeon experi­ence is also mandatory to remove donor kidney from a small incision. Morbidity is same and hospital stay is 3-4 days.


   Conclusions Top


Laparoscopic option is a safe and effective alternative to open surgery. LDN has evolved as a means to make renal donation more attractive for potential donors. The goals of donor nephrectomy are twofold - to provide the recipient with the highest-quality kidney, donor should have minimal morbidity and absolute safety.

Are LDN allografts quality kidneys? Yes! It has been demonstrated LDN recipients have good allograft func­tion and survival equal to that obtained with ODN. Fur­thermore, refinement of laparoscopic technique has addressed only problems with ureteral complications and graft venous thromboses and these complications are very low in recent series.

Is LDN safe for the donor? While the types of compli­cation may vary between ODN and LDN, the overall com­plication rates are similar. No mortalities have been reported among LDN donors. Complication rates have also decreased with increased surgeon experience and improve­ment in technique.

With the issues of safety and efficacy addressed, LDN offers additional benefits to the donor with respect to com­fort, cosmesis, and postoperative recovery. These benefits should attract more individuals to come forward and help their relatives with ESRD.

It remains to be seen whether LDN will replace ODN as the primary means of live donor nephrectomy. Due to the challenge represented by LDN, other alternative open approaches are being explored such as a dorsal approach, mini incision and an anterior retroperitoneal approach. [14] At the very least, LDN has sparked interest in a stagnant field; ODN has not changed much in the last half century but rapid changes are occurring in last 2-3 years. We be­lieve, however, that LDN is an attractive challenge and is a procedure that will enhance the pool of potential renal donors in future.

 
   References Top

1.US Renal Data System (USRDS): 1994 Annual Data Report. The National Institute of Health, National Institute of Diabetes and Dia­betes and Kidney Disease, Betheseda, MD. June 1994.  Back to cited text no. 1    
2.1997 Annual Report of the U.S. Scientific Registry of Transplant Recipients and the Organ Procurement and Transplantation Net­work. Transplant data : 1988-1996. UNOS, Richmond, VA and the Division of Transplantation, Bureau of Health Resources and Serv­ices Administration. US Department of Health and Human serv­ices, Rockville, MD.  Back to cited text no. 2    
3.Gill IS, Carbone JM, Claymen RV et al. Laparoscopic live donor nephrectomy. J Endourol 1994; 8: 143.  Back to cited text no. 3    
4.Ratner LE, Ceseck LJ, Moore RG et al. Laparoscopic live donor nephrectomy. Transplantation 1995; 60: 1047.  Back to cited text no. 4    
5.D'Alessandro AM, Sollinger HW, Knechtle SJ et al. Living related and unrelated donors for kidney transplantation. A 28-year experi­ence. Ann Surg 1995: 222(3): 353-364.  Back to cited text no. 5    
6.Johnson EM, Remucal MJ, Gillingham KJ et al. Complications and risks of living donor nephrectomy. Transplantation 1997; 64(8): 1124-1128.  Back to cited text no. 6    
7.Dunn JF, Nylander WA, Richie RE et al. Living related kidney donors. A 14-year experience. Ann Surg 1996: 203(6): 637-643.  Back to cited text no. 7    
8.Jacobs SC, Cho E, Dunkin BJ. Laparoscopic donor nephrectomy current role in renal allograft procurement. Urology 2000; 55(6): 807-811.  Back to cited text no. 8    
9.Wolf JS, Marcovich R, Merion RM et al. Prospective, case matched comparison of hand assisted laparoscopic and open surgical live donor nephrectomy. J Urol 2000; 163(6): 1650-1653.  Back to cited text no. 9    
10.Flowers JL, Jacobs S, Cho E et al. Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 1997:226(4): 483-­490.  Back to cited text no. 10    
11.Ratner LE, Kavoussi LR, Sroka M et al. Laparoscopic assisted live donor nephrectomy - a comparison with the open approach. Trans­plantation 1997; 63(2): 229-233.  Back to cited text no. 11    
12.London E, Rudich S. McVicar J et al. Equivalent renal allograft function with laparoscopic versus open live donor nephrectomies. Transplant Proc 1999: 31(1-2): 258-260.  Back to cited text no. 12    
13.Ayvazian M and Khauli RB. Open vs. laparoscopic donor nephrec­tomy. Contemp Urol 2001; 5.  Back to cited text no. 13    
14.Nogueira JM, Cangro CB, Fink JC et al. A comparison of recipient renal outcomes with laparoscopic versus open live donor nephrec­tomy. Transplantation 1999; 67(5): 722-728.  Back to cited text no. 14    
15.Ratner LE, Montgomery RA, Kavoussi LR. Laparoscopic live do­nor nephrectomy: the four-year John Hopkins University experi­ence. Nephrol Dial Transplant 1999: 14(9): 2090-2093.  Back to cited text no. 15    
16.Ratner LE, Hiller J, Sroka M et al. Laparoscopic live donor ne­phrectomy removes disincentives to live donation. Transplant Proc 1997; 29(8): 3402-3403.  Back to cited text no. 16    
17.Ratner LE, Kavoussi LR, Schulam PG et al. Comparison of laparoscopic live donor nephrectomy versus the standard open ap­proach. Transplant Proc 1997; 29(1-2): 138-139.  Back to cited text no. 17    
18.Jacobs SC, Cho E, Dunkin BJ et al. Laparoscopic live donor ne­phrectomy : The University of Maryland 3-year experience. J Urol 2001; 164:1494.  Back to cited text no. 18    
19.Ratner LE, Bisshoff JT, Montogmery RA et al. Laparoscopic live donor nephrectomy: long-term results. J Urol Suppl 1998; 159: 182.  Back to cited text no. 19    
20.Hensman C, Lionel G, Hewett P, et al. Laparoscopic live donor nephrectomy: the preliminary experience. Aust NZJ Surg 1999; 69(5): 365-368.  Back to cited text no. 20    
21.Hiller J, Sroka M, Holochek MJ et al. Functional advantages of laparoscopic live-donor nephrectomy compared with conventional open-donor nephrectomy. J Transpl Coord 1997: 7(3): 134-140.  Back to cited text no. 21    
22.Odland MD, Ney AL, Jacobs DM et al. Initial experience with laparoscopic live donor nephrectomy. Surg 1999: 126: 603.  Back to cited text no. 22    
23.Kumar A, Dubey D, Arvind NK et al. Laparoscopy-Assisted Live Donor Nephrectomy: A Modified Cost-Effective Approach for Developing Countries. J Endo 2002; 16(3): 155.  Back to cited text no. 23    
24.Finelli FC, Gongora E, Sasaki TM et al. A survey : the prevalence of laparoscopic donor nephrectomy at large U.S. transplant centers. Transplantation 2001: 71: 1862.  Back to cited text no. 24    
25.McDougall EM, Monk TG, Wolf JS et al. The effect of prolonged pneumoperitoneum on renal function in an animal model. J Am Coll Surg 1996: 182(4): 317-328.  Back to cited text no. 25    
26.Lee BR, Cadeddu JA, Molnar-Nadasdy G et al. Chronic effect of pneumoperitoneum on renal histology. JEndourol 1999; 13(4): 279-­282.  Back to cited text no. 26    
27.Novick AC. Laparoscopic live donor nephrectomy. Con Urology 1999; 53(4): 668-670.  Back to cited text no. 27    
28.Fabrio MD, Ratner LE, Montogomery RA, et al. Laparoscopic live donor nephrectomy. Urol Clin North Am 2000; 26: 247.  Back to cited text no. 28    
29.Wolf JS Jr, Tcheten MB, Merion RM. Hand-assisted laparoscopic live donor nephrectomy. Urology 1998; 52: 885.  Back to cited text no. 29    
30.Yang SC. Park DS, Lee DH et al. Retroperitoneal endoscopic live donor nephrectomy : Report of three cases. J TJrol 1995: 153: 1884.  Back to cited text no. 30    
31.Philosophe B. Kuo PC, Schweitzer EJ et al. Laparoscopic versus open donor nephrectomy : comparing ureteral complications in the recipients and improving the laparoscopic technique. Transplanta­tion. 1999; 68(4): 497-502.  Back to cited text no. 31    
32.Slakey DP. Wood JC, Hender D et al. Laparoscopic living donor nephrectomy : advantages of the hand-assisted method. Transplan­tation 1999; 68(4): 581-583.  Back to cited text no. 32    
33.Kavoussi L. Chow G, Ratner L. Open vs. laparoscopic donor nephrectomy. Contemporary Urology 2001; 5.  Back to cited text no. 33    
34.Ratner LE, Kavoussi LR, Chavin KD et al. Laparoscopic live donor nephrectomy: technical consideration and allograft vascular length (letter to editor). Transplantation 1998; 65: 1657.  Back to cited text no. 34    
35.Kim F, Ratner LE, Kavoussi LR. Renal transplantation: Laparoscopic live donor nephrectomy. Urol Clin North Am 2000; 27: 777.   Back to cited text no. 35    
36.Scott LB. Thomas RB, Mathew CR et al. Laparoscopic live donor nephrectomy : A comparison with conventional approach (Editorial comment by McDougall EM). J Urol 2001; 165: 766.  Back to cited text no. 36    
37.Shaffer D, Sahyon Al, Madras PN et al. Two-hundred-one con­secutive living donor nephrectomies. Arch Surg 1998: 133: 426.  Back to cited text no. 37    
38.Barry JM. Editorial comment. J Urol 2000; 164: 1499.  Back to cited text no. 38    
39.Gill IS, Uzoo RG, Hobart MG et al. Laparoscopic retroperitoneal live donor right nephrectomy for purpose of allotransplantation and autotransplantation. J Urol 2000: 164: 1500.  Back to cited text no. 39    
40.Lee RB, Chow GK, Ratner LE et al. Laparoscopic live donor ne­phrectomy : outcomes equivalent to open surgery. J Endourol 2000; 14: 811.  Back to cited text no. 40    
41.Turk IA. Serdar D, Davis JW et al. Laparoscopic live donor right nephrectomy : A new technique with preservation of vascular length. J Urol 2002: 167: 630.  Back to cited text no. 41    
42.Buell JF, Edye M, Johnson M et al. Are concerns over right laparoscopic donor nephrectomy unwarranted ? Ann Surg 2001; 233: 645.  Back to cited text no. 42    
43.Kumar A, Arvind NK. Laparoscopic live donor nephrectomy. In: AK Hemal. Contemporary trends in Laparoscopic Urologic Sur­gery. B I Churchill Livingstone. 2002; 229-239.  Back to cited text no. 43    
44.Soin AS, Rajasekar MR, Rajakumari V et al. Experience with laparoscopic donor nephrectomy in India : is the open approach justified any longer ? Transplant Proc 2000; 32: 1585.  Back to cited text no. 44    



 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4]

This article has been cited by
1 A comparative study of laparoscopic with conventional open donor nephrectomy in renal transplantation
Sinha, T., Varma, P.P., Srivastava, A., Karan, S.C., Sandhu, A.S., Sethi, G.S., Khanna, R., (...), Narang, V.
Medical Journal Armed Forces India. 2006; 62(3): 236-238
[Pubmed]
2 Laparoscopic live-donor nephrectomy: Modifications for developing nations
Kumar, A., Chaudhary, H., Srivastava, A., Raghavendran, M.
BJU International. 2004; 93(9): 1291-1295
[Pubmed]



 

Top
Print this article  Email this article
Previous article Next article

    

 
   Search
 
   Next article
   Previous article 
   Table of Contents
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    [PDF Not available] *
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Introduction
    Conclusions
    References
    Article Tables

 Article Access Statistics
    Viewed4392    
    Printed71    
    Emailed0    
    PDF Downloaded0    
    Comments [Add]    
    Cited by others 2    

Recommend this journal

HEALTHWARE INDIA