Laparoscopic live donor nephrectomy: the four year Johns Hopkins University experience

Lloyd E. Ratner, Robert A. Montgomery and Louis R. Kavoussi

Departments of Surgery and Urology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA

Correspondence and offprint requests to: Lloyd E. Ratner, MD, Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St./Harvey 611, Baltimore, MD 21287-8611, USA.

Introduction and rationale

Laparoscopic live donor nephrectomy is an operation that was designed specifically in an attempt to alleviate the profound shortage of kidneys for transplantation [1]. In the US, there is a growing disparity between the organ supply and demand. This has resulted in prolonged waiting times on the cadaveric renal transplant waiting list [2]. Commensurate with the increased waiting times has been an increase in the number of deaths of patients awaiting transplantation. Live kidney donors have remained an under-utilized source of transplantable organs.

Live donor renal transplantation offers several advantages over cadaveric transplantation. First, the long waiting times are eliminated. Second, there is a lower incidence of delayed function. Third, both patient and graft survival rates are significantly better with live donor transplantation [3]. Thus, not only are more organs made available, the need for repeat transplantation is reduced. Also, live donor renal transplantation is more cost effective than cadaveric donor transplantation [4]. However, despite these advantages, there exist significant disincentives to live kidney donation.

The long hospitalization and recuperation time associated with open nephrectomy via a flank approach can pose significant financial and logistical problems in terms of time out of work, lost income, job security and inability to care for dependant children. Also, a number of individuals express concerns about fear of pain and the cosmetic results of major abdominal surgery. Thus, by reducing these disincentives, we hypothesized that more individuals would be willing to donate. Clayman et al. [5] had demonstrated that laparoscopic nephrectomy for disease could significantly reduce post-operative pain, length of hospitalization and recuperation times. Therefore, modification of the laparoscopic nephrectomy operation to produce a viable organ for transplantation promised similar advantages.

Technical considerations

The advantages of the laparoscopic live donor operation arise from the ability to utilize small incisions and to place them at sites remote from the location of the kidney, therefore avoiding a debilitating large flank incision. Thus, a 5 cm lower midline or Pfannenstiel incision suffices to deliver the kidney. The operation can be performed by either a transperitoneal or retroperitoneal approach. We prefer the transperitoneal approach because it affords more laparoscopic working space. It also allows the kidney to be removed easily from the abdomen through a relatively low pain, midline incision. A pneumoperitoneum of 15 mmHg is created using CO2. Other centres have reported using abdominal wall lifters. Dissection of vascular structures is facilitated by the magnification achieved via the laparoscope. The renal vasculature is divided using an endo-GIA stapler. This device lays down two rows of staples and cuts between them simultaneously. On the right side, use of this stapler results in loss of 1.0–1.5 cm of vein, leaving the recipient surgeon with a short thin vein to contend with. Therefore, the donor operation is modified slightly for right kidneys. However, because of technical considerations, we prefer to utilize the left kidney, even if multiple left renal arteries are present. The exception to this is if there is a clear advantage to the donor by leaving the left kidney in situ.

Donor results

The laparoscopic donor operation has resulted in less pain, shorter hospitalization and shorter recuperation time when compared with the standard open operation. We first reviewed our experience of 70 laparoscopic live donor nephrectomies, and compared them with 20 open donor nephrectomies performed prior to the introduction of our laparoscopic donor programme (Table 1Go). A subsequent series compared 25 laparoscopic live donor nephrectomies with 35 contemporaneous live donor nephrectomies. In this review, post-discharge analgesic requirements were studied [6]. The duration of analgesic requirements post-discharge for both narcotic analgesics and over the counter preparations are shown in Figure 1Go. Overall analgesic requirements for the laparoscopic operation were ~7 days while that for the open operation was of the order of 1 month. Patients in the laparoscopic cohort also had a shorter hospitalization, returned to work earlier and were able to resume driving, caring for dependent individuals and carrying out household chores significantly sooner (Table 2Go). Those patients that had physically demanding jobs (often those individuals in a lower socioeconomic strata with the greatest financial disincentives to donation) were also able to return to work significantly sooner than those in the open cohort (3.8±2.7 vs 8.0±4.0 weeks, respectively, P=0.019). Hence, the laparoscopic donor operation successfully reduces potential disincentives to donation as had been hypothesized.


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Table 1. Donor results—historic control
 


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Fig. 1. Analgesic requirements after discharge.

 

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Table 2. Donor results—contemporaneous series
 
Donor morbidity has been acceptable with the laparoscopic donor operation. Morbidity in the overall Johns Hopkins' experience is shown in Table 3Go. It is of note that complications that are not uncommon with the open donor operation, such as pneumothorax, incisional hernia and chronic wound pain or discomfort, are virtually non-existent with the laparoscopic operation. Also, we have not seen any subsequent small bowel obstructions despite utilizing the transperitoneal approach for the laparoscopic operation.


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Table 3. Donor morbidity
 
Theoretical considerations

By necessity, the laparoscopic donor operation requires a pneumoperitoneum to be maintained during surgery. Theoretically, the elevated intra-abdominal pressure could be deleterious to the function of the kidney in the recipient. Elevated intra-abdominal pressure has been shown to decrease renal blood flow and urine output in experimental models [7]. Conceivably, renal ischaemia and acute tubular necrosis could result in this situation. Renal ischaemia can induce MHC class II expression, possibly rendering the organ more allogenic. However, London et al. have demonstrated that these effects can be overcome with volume loading [7]. It is not uncommon for donors to receive 8–10 litres of crystalloid intra-operatively to promote a brisk diuresis.

Recipient results

It is imperative that with any change in the donor operation the recipient outcome be at least comparable. We have compared 110 recipients of laparoscopically procured live donor transplants with 48 patients receiving kidneys from open donors [8]. No significant differences were observed in patient or graft survival, need for dialysis, incidence of technical complications (ureteral or vascular), incidence, timing or severity of rejection episodes, or long-term creatinine clearance (Table 4Go). The decline in serum creatinine post-transplant was brisk in both cohorts (Figure 2Go). However, the open group reached a nadir in serum creatinine on the third post-operative day, while the laparoscopic patients achieved minimal creatinine values on the fourth post-operative day. This was not of clinical significance. The median length of hospitalization was seven days for both groups.


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Table 4. Recipient morbidity, length of stay and late function
 


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Fig. 2. Recipient early renal function laparoscopic vs open donor.

 
Recipient ureteral and vascular complications generally occurred early in our series and appear to be a function of the learning curve. The evolution of the operative technique and patient (and kidney) selection seem to have eliminated these problems. Thus, we believe that the operation itself is over the learning curve; however, there will be a learning curve for each individual surgeon.

Implications and spin-offs

As had been hypothesized, the laparoscopic donor operation has successfully removed some of the disincentives to live kidney donation. Since the initiation of our laparoscopic live donor programme, we have seen a >100% increase in live donor transplants at our institution. Live donor transplants account for ~60% of renal transplants at Johns Hopkins Hospital compared with one-third of those performed in the US as a whole. Roughly 20% of patients report that they would not have donated if the open operation were their only option; 66% of our patients state that the availability of the laparoscopic operation profoundly influenced their decision to donate.

The decreased operative morbidity of the laparoscopic operation has also resulted in an overall shift in the risk/benefit ratio. Therefore, we have been able successfully to perform live donor transplants on high risk recipients where previously both donors and surgeons would have been reluctant to proceed. Included among these are several patients that had a positive donor-specific cross-match abrogated by pre-transplant plasmapheresis. Also, several altruistic individuals have come forward to donate into the system to the most suitable recipient. Finally, the laparoscopic donor operation has been the impetus to re-evaluate critically what had been a relatively stagnant area [9]. A number of groups currently are looking at alternative open techniques such as the anterior retroperitoneal approach or a dorsal approach to decrease post-operative pain and shorten recuperation, without the necessity of developing laparoscopic skills.

Conclusions

Laparoscopic live donor nephrectomy can be performed safely. It offers donors the advantages of decreased pain, shorter hospitalization and quicker recuperation. This has been achieved without any deleterious effect upon recipient outcome. The laparoscopic operation has been effective in increasing individuals' willingness to donate. Thus, it demonstrates that by removing disincentives to live donation, we can increase the organ supply. We propose additional strategies be entertained and examined to address any remaining disincentives to live kidney donation [10].

Laparoscopic live donor nephrectomy has evolved as an operation over the last 4 years. Dissemination of the procedure is occurring quite rapidly. It is likely that in the future it will be the procedure of choice for live kidney donation.

References

  1. Ratner LE, Ciseck LJ, Moore RG, Cigarroa FG, Kaufman HS, Kavoussi LR. Laparoscopic live donor nephrectomy. Transplantation 1995; 60: 1047–1049[ISI][Medline]
  2. 1997 Annual Report of the U.S. Scientific Registry for Transplant Recipients and the Organ Procurement and Transplantation Network—Transplant Data: 1988–1996. UNOS, Richmond, VA, and the Division of Transplantation, Office of Special Programs, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, MD
  3. Cecka JM. The UNOS scientific renal transplant registry—ten years of kidney transplants. In: Cecka JM, Terasaki PI, eds. Clinical Transplants 1997. UCLA Tissue Typing Laboratory, Los Angeles; 1998; 1
  4. Eggers P. Comparison of treatment costs between dialysis and transplantation. Semin Nephrol 1992; 12: 284–289[ISI][Medline]
  5. Clayman RV, Soper NJ, Dierks SM et al. Laparoscopic nephrectomy (letter). N Engl J Med 1991; 325: 1110[ISI][Medline]
  6. Ratner LE, Hiller J, Sroka M et al. Laparoscopic live donor nephrectomy removes disincentives to live donation. Transplant Proc 1997; 29: 3402–3403[ISI][Medline]
  7. London E, Neuhaus A, Ho H, Wolfe B, Rudich S, Perez R. Beneficial effect of volume expansion on the altered renal hemodynamics of prolonged pneumoperitoneum. Presented at the 24th Annual Scientific Meeting of the American Society of Transplant Surgeons, May 1998, Chicago, IL
  8. Ratner LE, Montgomery RA, Cohen C et al. Laparoscopic live donor nephrectomy: the recipient. Transplantation 1998; 85:S109
  9. Shaffer D, Sahyoun AI, Madras PN, Monaco AP. Two hundred one consecutive living-donor nephrectomies. Arch Surg 1998; 133: 426–431[Abstract/Free Full Text]
  10. Ratner LE, Montgomery RA, Kavoussi LR. Living-donor nephrectomies: laparoscopy and open techniques (letter). Arch Surg 1998; 133: 1253[Free Full Text]