EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Objectives: Our objective was to compare the outcomes of the different extraction sites between extended iliac port site incision and Pfannenstiel incision during laparoscopic donor nephrectomy.

Materials and Methods: We prospectively evaluated patients who underwent laparoscopic donor neph-rectomy from June 2014 to March 2015 at our institution. Perioperative parameters were included, with particular reference to warm ischemic time. The other parameters recorded included operative time, blood loss, hospital stay, analgesic requirement, and cosmetic results.

Results: We analyzed a total of 41 patients. Kidney retrieval site of each patient was made randomly. Extraction sites were done by using extended iliac port site incisions in 23 patients and by Pfannenstiel incision in 18 patients. Mean warm ischemic time was 4.09 minutes with extended iliac port site incision versus 4.94 minutes with Pfannenstiel incision (P = .04). Mean operative time, blood loss, hospital stay, and analgesic requirements were comparable between the 2 groups. Mean cosmetic score was 10.39 with extended iliac port site versus 12.06 with Pfannenstiel incision.

Conclusions: Extraction with extended iliac port site incision had significantly less warm ischemic time than Pfannenstiel incision in laparoscopic donor nephrec-tomy. It was also not inferior to Pfannenstiel incision regarding the other perioperative parameters that we measured.

Key words : Laparoscopy, Renal transplant

Kidney transplant is presently considered the best treatment option for patients with end-stage renal disease.¹ However, the rising incidence of end-stage renal disease together with static or reductions in the number of deceased donors has led to a shortage of organs. Reduced morbidity of donors from the use of minimally invasive surgery instead of open surgery may be one of the solutions to encourage the society or public to increase organ donations.

Laparoscopic donor nephrectomy (LDN) has now become the alternative standard to the open procedure for living-donor nephrectomy. The well-recognized benefits of laparoscopy over open surgery include less postoperative pain, shorter hospital stay, faster recovery, and improved cosmetic results. Moreover, this method provides graft survival function and overall surgical complication rates similar to the open surgery approach.^2-6

Laparoscopic surgical techniques have already become standard practice. However, current options for kidney retrieval are still without consensus. The various sites of extraction include Pfannenstiel incision, midline incision, and extended iliac port site (EP) incision, with use usually depending on surgeon preference.^7-9

Herein, we prospectively compared the outcomes of EP versus Pfannenstiel incision for kidney extraction in LDN.

Materials and Methods

This study was approved by the Ethics Committee on Human Experimentation of Ramathibodi Hospital. We prospectively randomized patients at our institution who underwent laparoscopic living-donor nephrectomy between June 2014 and March 2015 into 2 groups. Group 1 included 23 patients who had kidney extraction through the EP incision, and group 2 included 18 patients who had kidney extraction through Pfannenstiel incision. Exclusion criteria included previous abdominal surgery and right side kidney donation. All operative procedures were performed by a single surgical team with extensive experience in laparoscopic renal surgery.

Data collected included demographic data, American Society of Anesthesiologist physical status scores, perioperative blood loss, operative time, warm ischemic time, perioperative complications, postoperative analgesic requirement, length of hospital stay, and cosmetic outcomes. For the postsurgical cosmetic assessment, we used the Patient Scar Assessment Scale, which included 3 different dimensions: physical characteristics, cosmetic appearance, and patient’s symptoms.¹⁰ A higher score means a worse outcome. We evaluated the scar maturation at a period of at least 6 months after surgery.

Surgical techniques
All living donors were preoperatively screened by standard medical, surgical, and radiologic eval-uations. Computed tomography angiography was the modality of choice to visualize the renal vasculature. The surgical procedure was performed with standard laparoscopic renal surgery using two 10-mm and two 5-mm laparoscopic ports. At the beginning of the operation, 200 mL of 20% mannitol and a large volume of intravenous fluid were infused, and 2 g of ceftriaxone was given 1 hour before the procedure. Each patient was placed in a modified 45-degree left lateral position. After port placement and intra-abdominal insufflation, the colon was carefully mobilized. The ureter was identified and dissected within the gonadal vessel to confirm an adequate vascular supply to the ureter. The renal hilum was then dissected to achieve the maximum length of both artery and vein; the renal artery was dissected down to the level of the aorta, whereas the renal vein was dissected medially to the level of the adrenal vein. After dissection, the lateral attachment was released. The ureter was then clipped, and a 6- to 8-cm kidney extraction site was prepared using EP incision (group 1) or Pfannenstiel incision (group 2). However, the peritoneum was left intact to maintain the pneumoperitoneum. An iliac laparoscopic port was left in the patient (Figure 1). The renal artery and renal vein were clipped and cut using 10-mm and 15-mm double Hem-o-lok clips (Teleflex Medical, Research Triangle Park, NC, USA) for renal artery and renal vein.

In the EP group, the kidney was grasped with a locked endoscopic grasper at perinephric fat tissue through the iliac port. The kidney was then gently pulled out and monitored with laparoscopic visualization. Once the kidney reached the incision, we opened the peritoneal, and the endoscopic grasper was exchanged with open sponge grasper to grasp the kidney. The kidney was then removed for placement in the recipient. In the Pfannenstiel group, after the pedicle had been controlled, the peritoneum was opened at the Pfannenstiel incision. The pneumoperitoneum was aborted. The kidney was grasped and removed blindly by the surgeon or assistant hand through the Pfannenstiel incision.

Statistical analyses
Categorical data were displayed as number (percent). Continuous data were displayed as mean ± standard deviation. Categorical variables were compared with the chi-square test. Continuous variables were compared with the t test or Mann-Whitney U test. Statistical analyses were performed with SPSS software (SPSS: An IBM Company, version 18, IBM Corporation, Armonk, NY, USA). P values < .05 (2-sided) were considered statistically significant.

Forty-one patients were included in the study: 23 received EP incision and 18 received Pfannenstiel incision. There were no significant differences in terms of demographic data, body mass index, and American Society of Anesthesiologist physical status scores in both groups (Table 1). The perioperative outcomes, including operative time, blood loss, analgesic requirement, and hospital stay, were also similar with both approaches (Table 2).

However, mean warm ischemic time was significantly different, at 4.09 minutes in the EP group versus 4.94 minutes in the Pfannenstiel group (P = .04). Cosmetic results were also better in the EP group, although not statistically significant. There were no complications and no delayed graft function or graft loss in our study.

Individuals who donate their kidney take the risk of a major operation without getting any direct benefit to themselves. Therefore, we should provide them with an exceptional operation with zero margins of error. We believe that donor nephrectomy is one of the most stressful urologic surgical procedures. The choice of how to retrieve the graft is a crucial step of this operation. Mistakes in this critical step can lead to major complications for the donor, such as internal organ injury, kidney graft defect, or even kidney graft loss. Donors should be offered procedures with the least morbidity.

Almost all laparoscopic techniques for kidney donations have been standardized. However, there is a lack of standardization regarding kidney graft extraction site; this fact is cause for concern and requires a consensus. The various techniques, including Pfannenstiel, EP, midline incision, and vaginal extraction, have their own advantages and disadvantages.^7-9,11 Some authors have used hand-assisted devices, specimen retrieval bags, or simply manual extraction.^8,12 In general, the choice of organ extraction is dependent on surgeon experience and preference. Saito and associates¹³ have demonstrated that subcostal flank incision is the most popular, followed by Pfannenstiel among healthcare providers. Adiyat and associates¹² have recently found that Pfannenstiel extraction provides the shortest warm ischemia time compared with EP or midline incisions. However, this group used a hand-assisted device to facilitate extraction in their Pfannenstiel group and used their hands in the EP group. This created a disparity and could have led to bias of shorter warm ischemic time. The authors also mentioned that there is a possibility of misplacing the kidney inside the abdomen when using Pfannenstiel extraction. In a recent meta-analysis that compared Pfannenstiel and expanded port site specimen extraction in LDN, Pfannenstiel incision provided greater benefits in terms of pain reduction and cosmetic outcomes.¹⁴ In the Pfannenstiel group, the authors used a hand port device for organ retrieval, which could have reduced the warm ischemia time. However, this study was limited by the small number of generally low-quality studies available for analyses. The authors recommended that further randomized controlled trials are needed to confirm the results.

Simforoosh and associates^11,15 demonstrated the benefits of Pfannenstiel incision in their large series of mini-LDN and standard LDN. At Pfannenstiel incision, they used suprapubic trocar for insertion of a vascular clipping device in mini-LDN. This method takes advantage of vascular clipping in a nearly perpendicular direction, thus providing longer vessels for anastomosis. They also demonstrated better outcomes in terms of cosmetic results with Pfannenstiel incision in their series because the wound would be covered by hair growth. Pfannenstiel incisions may also be associated with lower rates of incisional hernias. Gill and colleagues¹⁶ performed donor nephrectomy by a laparoscopic single-site surgery technique using an umbilical R-port and extracted the kidney through the umbilical incision. However, laparoscopic single-site surgery has been associated with higher cost, a more challenging technique, and longer warm ischemia time.

As shown here, our technique of organ retrieval is unique. We did not use any hand port devices or any specimen bags for kidney retrieval. We believe that the simplicity of an operation usually leads to superior surgical outcomes, and thus we have tried to minimize our use of equipment. We extracted the kidney by using an endoscopic grasper, gently grasping the perinephric fat around the kidney. The benefit of this technique is not only its cost reduction but also avoids putting the kidney into a specimen bag before clipping the renal pedicles. Moreover, there is no bag to obscure the renal pedicle during pedicle clipping, which can possibly lead to serious graft vessel injury. However, in our Pfannenstiel group, we could not use endoscopic graspers to grasp the kidney as we did in our EP group. An endoscopic grasper would mean maintaining the pneumoperitoneum to keep endoscopic visual-ization, and for this we would have to place another laparoscopic port or hand port device at the Pfannenstiel incision. This is not worthwhile enough to use an expensive device at the end of this procedure. Therefore, we blindly retrieved the kidney using our hand in the Pfannenstiel group. However, this maneuver is not simple and needs an experienced surgical team to perform this maneuver when the pneumoperitoneum is not maintained. Moreover, in emergency situations, we may not be able to tackle the problem until the abdominal incision is closed to bring back the pneumo-peritoneum. In our series without any hand-assisted devices or specimen retrieval bags, EP incision showed benefits in term of the warm ischemic time compared with Pfannenstiel incision.

Our data are different from earlier studies.^12,14The blinded maneuver was related to some difficulties when we retrieved the kidney without any device regarding the far distance between the kidney and position of Pfannenstiel incision. This might be the reason to explain why EP incision provided better results in terms of warm ischemia in our series. The difference in warm ischemic time between the 2 groups was less than 1 minute, which might not have any effect on graft function. However, we still believe that the ultimate goal of this operation is to reduce warm ischemic time to as short as possible. We exclusively performed the procedure only on the left side, but there were a few patients in both groups who had double renal arteries. Therefore, this issue might not affect the warm ischemic time outcome.

Previously, we reported the comparative out-comes between hand-assisted and standard LDN.¹⁷ We found that the hand-assisted technique provided a statistically significant difference but not clinically significant difference in terms of shorter warm ischemic time compared with standard laparoscopy. However, some difficulties encountered included having less working space and the surgeon’s hand obscuring the surgical field during the procedure compared with a full laparoscopic approach. Our patient population is usually small in stature, which may compound this difficulty. Thus, our population may not be perfectly suitable for the hand-assisted technique. Therefore, we now perform the operation using the full laparoscopic approach. In addition, it seems not to make any sense and be not necessary to use an expensive hand-assisted device just for the facilitation of organ retrieval but not for the full procedure.

We have demonstrated that the other measured outcomes, including operative time, bleeding, pain, and cosmetic results, were similar between Pfan-nenstiel and EP incisions. The size of the incision was comparable between both techniques. However, the incision size in our series may be somewhat large compared with other series.^8,12 This is because we prefer to have a large incision at the beginning, thus avoiding having the kidney obstructed during the extraction. However, with more experience, the size of the incision has now been reduced to 5 to 6 cm.

Regarding cosmetic outcomes evaluated by Patient Scar Assessment Scale,¹⁰ the score was com-parable in both groups. The scar of Pfannenstiel incision may not be seen in the future because it can be hidden by pubic hair. However, in the EP group, we extended the iliac port incision to the extraction site to reduce the scar score. Therefore, the Pfannenstiel group had a higher scar score. Because of this, we found the cosmetic results to be coun-terbalanced between these 2 groups.

An alternative option of kidney extraction site is the transvaginal route. The single significant benefit of this approach is the desirable cosmetic result.¹⁸ However, several concerns and limitations should be considered. It can be performed specifically in women who have previously had vaginal delivery and elastic vagina. To prevent infection, the vaginal route needs to be cleaned, usually for about 10 minutes. A sufficient-length colpotomy should be performed, and a specimen extraction bag is required to prevent or overcome kidney and vaginal disparities. These limitations and disadvantages should be balanced versus the cosmetic benefit.

Our study has some limitation because of the small number of patients. However, this study has less bias compared with earlier reports. Although it is still difficult to provide a consensus by using our data, we can at least narrow and provide some clues for future randomized research with larger numbers of LDN patients. In conclusion, based on our results, we prefer to use EP incision for extraction because of its benefits of shorter warm ischemia time, although the proper extraction site usually depends on surgeon preference. Both EP and Pfannenstiel incisions have advantages and disadvantages. Our data suggest that further research is needed to find the consensus. The answer to this issue can help surgeons reach a higher level of treatment for this stressful operation.

Volume: 15 Issue: 2 April 2017

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