Laparoscopic live donor nephrectomy
Ben Challacombe and
Nizam Mamode
Department of Transplantation, Guy's Hospital, London, UK
Correspondence and offprint requests to: Mr Nizam Mamode, Clinical Transplantation, New Guy's House, Guy's Hospital, London SE1 9RT, UK. Email: Nizam.Mamode{at}gstt.sthames.nhs.uk
Keywords: laparoscopy; live donor nephrectomy
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Background
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Traditional open living donor nephrectomy (ODN) is a safe procedure with a mortality of 0.03% [1]. However, there is significant donor morbidity with acute and chronic wound pain, wound infection, prolonged hospital stay, late return to full activity and a risk of incisional herniae. Laparoscopic live donor nephrectomy (LLDN) was introduced <10 years ago in an attempt to minimize these complications, but concerns have been raised about the security of the technique for both donor and recipient, and whether it offers sufficient benefit over modern open techniques, including mini-incision nephrectomy. LLDN remains a technically difficult and complex operation, scoring 16 out of 21 for difficulty in the European Scoring System for Laparoscopic Operations [2].
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Techniques
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LLDN was first described at Johns Hopkins University by Ratner et al. in 1995 [3] on a 40-year-old man with good results. It may be performed using the hand-assisted method (HLDN) or the pure laparoscopic technique (PLDN). Furthermore, either a transperitoneal or retroperitoneal approach may be taken with either method. Usually, two 10 mm trocars are used, with a 78 cm midline incision for HDLN and a 67 cm Pfannenstiel incision for PLDN. Large blood vessels are either clipped or stapled; there are anecdotal reports of clips disengaging [4], while the use of stapling guns results in shorter vessel length on the kidney.
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Laparoscopic donor nephrectomy vs open surgery
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There have been two small randomized trials of LLDN vs ODN [5,6]. In the first, 23 HLDN and 27 ODN patients were compared. The operating (125 vs 206 min) and warm ischaemia times (96 vs 183 s) were significantly shorter for ODN. However, in the HLDN group, there was 47% less analgesic use, 35% shorter hospital stay, 33% rapid return to non-strenuous activity and 23% sooner return to work (Table 1). Post-operatively, mean pain scores were 0.6 (±0.8) for LLDN and 2.2 (±2.1) for ODN. More recently, 80 patients in Tehran were randomized to PLDN or ODN [6]. This study confirmed a longer operative and warm ischaemic time in PLDN but found no difference in length of stay, or in-hospital analgesia. There were more complications in the laparoscopic group, but a very high mean warm ischaemic time of 6.6 min raises questions about technique. Data regarding return to normal activities or work were not given.
There have been two systematic reviews comparing LLDN and ODN [7,8]. The most recent of these [7] found no statistically significant difference in complication rates between open and laparoscopic donor nephrectomy, but an increased operating time in the laparoscopic group in 9 out of 15 studies. Analgesic use was lower after LLDN (3688 mg morphine after LLDN vs 60265 mg after ODN P<0.001) and hospital stay was shorter (1.24.1 vs 2.67.5 days P<0.05). Similarly, return to work occurred at 1136 days after LLDN vs 3983 days (P<0.05). This confirms previous reports of significant differences in post-operative opiate requirement and longer term freedom from pain [9].
A study of 140 patients found that pain was lower and recovery quicker after PLDN, in comparison with mini-incision donor nephrectomy [10].
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Costs
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In-hospital costs are recognized to be higher for LLDN [11]. A Canadian group, using decision analysis modelling, found that LLDN cost Can$464 more than open surgery, but did not take into account the cost savings accrued by reducing the number of patients on dialysis [12]. Another study found that laparoscopic surgery cost an extra US$900 but that this difference was abolished when the shorter stay after LLDN was considered [13]. Costs may be reduced further when the loss of donor income due to longer recovery time after open surgery is taken into account.
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Complications of laparoscopic live donor nephrectomy
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Ureteric complications
A review of the first 5 years' experience with LLDN at Johns Hopkins and the University of Maryland found the initial incidence of ureteric complications of 9.1% to be unacceptable. By performing ureteral dissection medial to the gonadal vein, they have reduced their ureteral complication rate to 3% in a subsequent series of 100 cases [14]. A recent large series from Baltimore reports a 2% ureteral complication rate [15]. A retrospective analysis [16] of 122 LLDN vs 77 ODN recipients revealed a ureteric reconstruction rate, due to obstruction or urine leakage, of 4.1% (five patients) for LLDN compared with 6.5% (five patients) for ODN. This difference was not statistically significant and the authors concluded that LLDN was not associated with an increased incidence of ureteral complications.
Graft function
Data from UNOS (United Network for Organ Sharing) comparing 2734 LLLD procedures and 2576 ODNs showed no difference in short-term graft survival [17]. This study suggested that early function and the incidence of delayed function were similar for both groups; however, significantly more LLDNs (compared with ODNs) had discharge serum creatinines >1.4 mg/dl (49.2 vs 44.9%, P = 0.002) and 2.0 mg/dl (21.8 vs 19.5%, P = 0.04). Interestingly, later creatinines and graft function at 1 year showed no difference between the groups. This has been confirmed in a review of 738 consecutive LLDNs [15]. These data suggest slower early graft function in the LDN group which may be related to reduced renal perfusion as a side effect of the pneumoperitoneum.
Data from the Cleveland Clinic [18] have shown that prolonged pneumoperitoneum, warm ischaemia time, renal artery length or use of right kidney did not adversely affect functional outcome. In addition, LLDN using either 10 or 15 mmHg IAP gives equally good post-operative graft function at 30 days [19]. Furthermore, in rats, it has been shown that 1 year after transplantation, there are no differences in renal function or histomorphology between kidney grafts exposed to either pneumoperitoneum or a gasless procedure [20].
The warm ischaemia times for HLDN are shorter than for PLDN and marginally longer than for ODN, although not statistically significant. Comparison of HLDN, PLDN and ODN indicates that although slow graft function may initially be greater in PLDN due to longer warm ischaemia, at 3, 6 and 12 months there is no difference among the three groups [21].
In summary, kidneys procured laparoscopically may have slower initial function, but this does not seem to affect later function; the cause remains uncertain.
Other complications
It remains difficult to compare overall complication rates for laparoscopic and open surgery due to the paucity of data. The most recent systematic review found no significant difference in total complication rates, but these rates varied from 0 to 3035% for both groups [7]. Mean complication rates were 9% for laparoscopic surgery and 8% for open surgery, and included pneumonia, wound infection, haemorrhage, incisional hernia and chronic wound pain. However, the two randomized studies have been too small to make any categoric statements about respective complication rates [5,6].
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Right-sided donor nephrectomy
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In both ODN and LLDN, the left kidney is usually preferred due to the longer renal vein. However, when the left kidney is unsuitable for donation, there has been a reluctance to harvest right-sided kidneys due to reports from the Johns Hopkins group of an increase in renal vein thrombosis [22]. It has been suggested that the use of laparoscopic stapling devices results in an unacceptably short vein with right-sided nephrectomy. Recently, however, Boorjian et al. [23] have shown that the right kidney can be used safely. They looked retrospectively at 40 right-sided LLDNs in whom the indications for the right-sided donor nephrectomy included a difference in split renal function of >10%, multiple left renal vessels and right renal cysts. They found no difference in morbidity or graft function using the right side. Other Dutch groups recently have also shown no difference in outcome parameters between right and left HLDN in moderate sized series [24,25].
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Multiple arteries
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Kavoussi's group showed that anomalous left renal vasculature is not a contraindication to laparoscopic left donor nephrectomy [26]. They successfully transplanted 76 left renal allografts that had multiple arteries without vascular complications and found no difference in warm ischaemic times, graft survival, surgical complications or length of stay between multiple or single renal artery grafts. Similar results have also been shown in other centres, reinforcing the view that kidneys with multiple renal arteries, although time-consuming to dissect and graft, can be used safely [27,28].
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Hand-assisted vs pure laparoscopic nephrectomy
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There have been no randomized comparisons of the two procedures. Safety has been a major concern in the development of LLDN, and there are anecdotal reports of serious intra-operative bleeding. The hand-assisted technique allows immediate control of bleeding at the cost of an incision that is 1 cm longer than in PLDN and placed in the midline rather than suprapubically. Non-randomized comparisons have shown that HDLN is easier to learn, quicker and results in less blood loss than PLDN and has a shorter warm ischaemic time (Table 1) [29,30].
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Training
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Little organized training exists for LLDN, and many transplant surgeons may have difficulty acquiring the necessary skills, as they may have little or no experience of laparoscopy. Clearly, formal training programmes and certification are required. In our institution, we have used telementoring to obtain real-time transatlantic supervision by a highly experienced surgeon via dedicated ISDN lines at low cost. Telementoring is ideally suited to laparoscopy and may aid in the development of new LLDN programmes. We have now performed a total of 24 HLDNs, of which four were telementored, with no conversions to open surgery, a mean warm ischaemic time of 198 s and a mean recipient creatinine of 120 µmol/l on day 7. All grafts have had primary function. The only complications have been one chest infection and late incisional hernia (same patient) and one episode of epididymitis. Return to normal activities has ranged from 4 days to 6 weeks.
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Conclusions
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LLDN has been shown to be a safe procedure in experienced hands. It allows a quicker recovery, with
23 days less in hospital, return to work at
3 weeks (compared with 9 weeks for open surgery) and less post-operative pain. As yet there is no clear evidence of fewer complications after LLDN. In general, HLDN is safer, reduces the learning curve and results in a shorter operating time and shorter warm ischaemic time.
Early concerns about ureteric complications after laparoscopic donor nephrectomy have not been borne out by recent studies. There is some evidence for slower initial graft function but this does not appear to have any clinical impact; the cause is unclear and more research is required to investigate both the mechanism and whether there are any long-term sequelae. To this end, a laparoscopic donor registry would be invaluable.
Both right-sided kidneys and those with multiple arteries can be safely procured laparoscopically.
At present, there are only two randomized controlled trials of LLDN, and more level 1 data are required. In addition, many centres are starting to offer live donor nephrectomy through a mini-incision and this novel technique needs to be compared with LLDN and HLDN.
Future developments may include the use of surgical robots in LLDN, with an initial report of 12 cases using the da Vinci robot showing less blood loss but a longer operative time [31].
Conflict of interest statement. None declared.
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References
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