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 1.01.5 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 1). 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 1
. 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 2
). 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.
|
|
|
|
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 810 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 4). The decline in serum creatinine post-transplant was brisk in both cohorts (Figure 2
). 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.
|
|
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