Objectives: Laparoscopic donor nephrectomy has become the criterion standard for kidney retrieval from living donors. There is no information on the experience and outcomes of laparoscopic donor nephrectomy in Pakistan. The objective of the study was to identify benefits and harms of using laparoscopic compared with open nephrectomy techniques for renal allograft retrieval.

Materials and Methods: In this a retrospective study, patient files from May 2014 to September 2015 were analyzed. Patients were divided into 2 groups: those with open donor nephrectomy and those with laparoscopic donor nephrectomy. Donor case files and operative notes were analyzed for age, sex, laterality, body mass index, warm ischemia time, perioperative and postoperative complications, surgery time, and length of hospital stay. Finally, serum creatinine patterns of both donors and recipients were analyzed. Data were analyzed using SPSS version 10 (SPSS: An IBM Company, IBM Corporation, Armonk, NY, USA).

Results: Of 388 total donors, 190 (49%) had open donor nephrectomy and 198 (51%) had laparoscopic donor nephrectomy. For both groups, most donors were older than 25 years with male preponderance. Left-to-right kidney donation ratio was markedly higher in the laparoscopic group than in the open donor nephrectomy group, with 6 cases of double renal artery also included in this study. There were no significant differences in surgery times between the 2 groups, whereas the laparoscopic donor nephrectomy group had shorter hospital stay. Analgesic requirements were markedly shorter in the laparoscopic donor nephrectomy group. The 1-year graft function was not significantly different between the 2 groups.

Conclusions: The results for laparoscopic donor nephrectomy were comparable to those for open donor nephrectomy, and its acceptability was high. Laparoscopic donor nephrectomy should be the preferred approach for procuring the kidney graft.

Key words : Graft, Kidney transplant, Laparoscopic

Introduction

Living kidney donation is the major organ source for patients with end-stage renal disease and for those on wait lists for renal transplant. The first laparoscopic donor nephrectomy (LDN) was performed by Ratner and colleagues in 1995.¹ Since then, LDN has actually replaced conventional open donor nephrectomy (ODN). Laparoscopic donor nephrectomy is a unique surgical operation as it is performed on a healthy individual, and every measure of safety should be taken because of this.

Laparoscopic donor nephrectomy also affects society as it has decreased disincentives for kidney donation, as reported by different authors.^2-5 Advantages of LDN have been well established in terms of short convalescence and hospital stay; because of these advantages, donors can start their daily activities and resume work much earlier than donors who have had ODN.⁶ Nevertheless, outcomes as far as graft function and patient survival are of concern as they are the same for LDN versus ODN.^7,8

The objectives of the study were to identify the benefits and harms of using LDN versus ODN techniques for renal allograft retrieval.

Materials and Methods

In this retrospective analysis, donors seen between May 2014 and September 2015 were divided into 2 groups: those who had ODN and those who had LDN. Donor case files and operative notes were analyzed for age, sex, laterality, and body mass index (BMI). Warm ischemia time (WIT) in both groups was also analyzed. In both groups, perioperative and postoperative complications, surgery time, and length of hospital stay were also analyzed. Finally, serum creatinine patterns of both donors and recipients were analyzed. Data were analyzed using SPSS version 10 (SPSS: An IBM Company, IBM Corporation, Armonk, NY, USA).

Results

Kidney transplant activity at Sindh Institute of Urology and Transplantation over the years is shown in Figure 1. Of 388 total donors, 190 (49%) had ODN and 198 (51%) had LDN. Most donors in both groups were older than 25 years with male preponderance (Figure 2). Left-to-right kidney donation ratio was markedly higher in the LDN group than in the ODN group, with 6 cases of double renal artery also included in this study (Figure 3). Mean BMI and WIT values are shown in Table 1. Perioperative, postoperative, and recipient complications are shown in Table 2. There were no significant differences in surgery time between the 2 groups, whereas the LDN group had shorter length of hospital stay (Table 1). Analgesic requirements were markedly shorter in the LDN group (Figure 4). Biopsy findings in both groups are shown in Figure 5. One-year graft function was not different between groups, as shown in Figure 6.

Discussion

Laparoscopic donor nephrectomy is a challenging surgery, and the learning curve is somewhat high. Teams experienced with general laparoscopic procedures have a shorter learning curve than less experienced teams.⁹ Surgeons who have experience with ODN are also at an advantage for performing LDN. For our team, we had a somewhat short learning curve as our practice is in a high-volume center, dealing with more than 300 renal transplants/year and performing ODN in more than 4500 cases before switching to LDN (Figure 1).

It is easier to start a left-sided donor nephrectomy with single artery and single renal vein. Right-sided LDN is a more difficult procedure because of handling of the liver and inferior vena cava. Nevertheless, indications for right-sided LDN include multiple left renal arteries, small right kidney, and right renal cyst.¹⁰ Despite early reports of venous thrombosis in right-sided LDN recipients,¹¹ with better under­standing of laparoscopic surgery, right-sided LDN is no longer a contraindication.¹⁰ In our study, we performed 23 cases of right-sided LDNs without any complications.

Body mass index is regarded as a tool to measure whether the individual is underweight, overweight, or obese. Contrary to the belief that high BMI may cause problems in open surgery, transperitoneal laparoscopic surgery is easy because of the larger working space. In our donor cohort, BMI caused no problems in LDN, despite 38% of donors having BMI greater than 25 kg/m² (thus either overweight or obese). This has also been substantiated previously.^12-14

Warm ischemia time represents the ischemia under normothermic conditions. There is a theoretical risk of delayed graft function in cases of increased WIT, and every effort should be made to keep WIT as low as possible in renal transplant. The optimum WIT is between 2 and 3 minutes,^15,16 which was also observed in our study. Nevertheless, mean WIT of more than 8 minutes with primary functioning graft was reported by Simforoosh and associates.⁷

Vascular injury remains the most important concern during LDN.¹⁷ Lumbar vein dissection remains the most difficult part of vascular dissection. Without division of lumbar vein, renal arterial access is impossible. This is why we thought that the lumbar vein is a gateway to the renal artery. Our conversion rate was 3%, with most occurring because of vascular injury and all occurring in the first 100 cases.

Surgery time remains an issue in the early part of the learning curve for LDN. Several authors have reported more hours of surgery with LDN than with ODN.^4,6,7 In our study, we found that the first few cases took more than 4 hours; however, with gained experience, surgery time dropped and became almost comparable with our ODN group and comparable to the published literature.⁸

Referred pain at shoulder tip because of residual pneumoperitoneum was the major postoperative complication that we observed in our LDN group, which persisted for more than 1 week and required oral analgesics. This complication has also been reported by Mathuram and associates.¹⁸

There is always a theoretical risk of having hyper­filtration injury for patients who had hemin­ephrectomy in bilateral normal kidneys, as in cases of donors. In our study, both groups of donors showed a transient rise in serum creatinine, with this rise becoming normal after some time without intervention. This finding has also been previously reported.^5,16

In this study, we found no significant post­operative surgical complications in recipients of both procedure groups. The most common complications in both groups were lymphocele and ureteric leakage. Troppmann and associates reported 9% rate of ureteric leakage in the LDN group and no leakage in the ODN group and vice versa for lymphocele.⁴ However, the causes of lymphocele and ureteric leakage are multifactorial and should not be considered only as a surgical complication. Thus, these complications should not preclude LDN as a surgical procedure.

Because of less pain and shorter convalescence with LDN, a short hospital stay is expected. In our study, the LDN donors had a significantly shorter hospital stay than the ODN donors, which has also been reported in several publications.^4,15 A short hospital stay has a positive effect on hospital admin­istration as it provides more space to accommodate patients who require hospital admissions.

Graft biopsy is an integral part of transplant follow-up, either in a protocol setting or for diagnosis. In our study, rejection episodes were not significantly different for acute rejection, as also reported by Power and associates.⁸ There is always a theoretical risk of acute tubular injury of the kidney in laparoscopic procedures because of pressures of pneumoperitoneum, as shown previously.^19,20 In contrast, in our study, the incidence of acute tubular injury was more in the ODN group than in the LDN group. This is because, with ODN, there is direct handling of the kidney, which may give rise to vascular spasms. With LDN, there is no direct handling of the kidney; rather, the kidney is handled by a grasper through Gerota fascia. If the pneumoperitoneum is kept under 15 mm Hg and gentle handling of the kidney is done, there is less chance of vascular spasm and of acute tubular injury in LDN, which may be depicted on graft biopsy.

One of the reasons for the popularity of LDN and the preference over ODN worldwide is the comparable graft outcome. In our study, 1-year follow-up results were comparable between LDN and ODN. Without any doubt, this comparable graft outcome, as similarly reported in a number of studies, makes this procedure standard of care in renal transplant.^4,5,7,8,15

Conclusions

Because of advancements in surgical skills and better understanding of laparoscopic anatomy and physiology, LDN has become a popular surgical technique for graft procurement. Even kidneys with multiple arteries and veins and right-sided kidneys can be harvested safely. Donor satisfaction, less morbidity, and an early return to daily activities and work are other advantages. Of final importance, graft outcomes for both groups are comparable, making LDN the criterion standard approach in renal transplant programs.

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