Key words : Donor outcomes, Kidney transplantation

Introduction

Living donor kidney transplant techniques have rapidly evolved from the original open surgery method to the hand-assisted laparoscopic donor nephrectomy (HALDN) method, then to the purely laparoscopic donor nephrectomy (LDN) method, and finally to robotic surgery. Organs from living donors comprise 28% of all transplants,¹ but the best approach for procurement of donor kidneys has yet to be defined. Cypriot history follows a similar trend, with open surgery as the only technique in use between the period from 1986 to 2010, after which the HALDN technique was adopted from 2010 until 2021. From 2021 until the present day, the LDN technique has become the new standard.

In this study, we compared outcomes of HALDN versus pure LDN at our center and provided suggestions for a smooth transition from one technique to the other, with an aim to increase the number of kidney transplants from living donors.

Materials and Methods

Our data were retrospectively retrieved from a prospective database and involved 48 surgeries performed at the Nicosia General Hospital, the only National Transplant Centre in Cyprus, between 2018 and 2022, by 2 surgeons. These data include the historically first 16 standard LDN performed by 1 surgeon and the historically last 32 HALDN performed by another surgeon. All donations were made by living donors, and all donors were first-degree or second-degree relatives of the recipients. Altruistic living organ donations are not permitted in Cyprus, and all organ donations from relatives above second degree must be examined on a case-by-case basis by the transplant committee. The data analyses were performed with SPSS software (version 25). Continuous variables were compared through an independent t test, and nominal or ordinal values were compared with Pearson chi-square test or the Fisher exact test if entries for a category were below 5. Any continuous data that did not fit a normal distribution were analyzed with Mann-Whitney rank sum test.

Operative technique
The LDN was performed according to the standard technique, as follows. A Veress needle is inserted into the Palmer point, and the intra-abdominal pressure is set to 12 mm Hg. A 10-mm port is inserted into the paraumbilical area, and another 2 ports are placed under vision. A 5-mm trocar is placed in the subcostal area, and a 12-mm trocar is placed in the left iliac fossa. The left colon, spleen, and tail of the pancreas are mobilized using ultrasonic scissors. The anterior renal fascia (Gerota’s fascia) is exposed, and the gonadal vein and ureter are identified with subsequent ligation of the gonadal vein. The ureter and periuteral fat are mobilized. The adrenal and lumbar veins are dissected, separated, and consequently ligated and divided. The kidney is freed and remains held only by the renal artery, vein, and ureter. A 1.5-L specimen retrieval bag is inserted via a Pfannenstiel incision to rapidly extract the kidney, after the clipping of the renal vessels and ureter. The ports are removed under vision after washout and hemostasis and sutured in a standard fashion.

The HALDN procedure was performed according to the standard technique, as described by Slakey and colleagues,2 as follows. The HALDN port is placed via a midline incision using a hand-access laparoscopic system (GelPort; Applied Medical). The mobilization of the colon and the dissection of the kidney hilum are performed via retraction and manipulation of the tissues by hand.

Outcome measures
We used 6 factors to establish a valid comparison, those being operative time, length of hospital stay, donor creatine (before hospital discharge and at the 1-month follow-up), conversions to open surgery, and complications.

Results

Donor characteristics
Demographic details in the 2 groups of patients were similar. Both groups were composed of 31% male patients and 69% female patients, with a mean age of 52 to 53 years. The average body mass index was 25 to 26. There was a higher incidence of cardiovascular comorbidities in the LDN group, a higher incidence of dyslipidemia in the HALDN group, and twice as many patients with 2 renal arteries in the LDN group; however, these differences in the 3 factors were not significant. A significant number of patients in the LDN group demonstrated other comorbidities, such as thyroid diseases. In addition, most participants in the LDN group had a left donor nephrectomy (P = .022; Table 1).

Donor outcomes
We first compared the 32 HALDN cases with the 16 LDN cases (Table 2). Given the difference in the levels of experience between the 2 surgeons with their respective operations (11 years for HALDN vs 1 year for LDN), we also chose to compare the first 8 and last 8 LDN cases in an attempt to account for the learning curve of the LDN method (Table 3).

Operative time was shorter for the HALDN group (P = .005). However, as shown by further analysis of the data from the LDN group, we were able to ascertain that after the first 8 cases, the operative time decreased significantly, and the operative times of the last LDN cases (cases 9-16) were found to be comparable to the operative times of the HALDN group (P = .008). We can thus likely attribute the longer operative time for LDN to the surgeon’s learning curve of the new approach. Furthermore, a statistically significant majority of LDN cases involved the removal of the left kidney (P = .022), an arguably lengthier procedure given the requirement for identification and ligation of the gonadal vein.

Donor creatinine levels at discharge and at the 1-month postoperative check-up were found to be similar (P = .418 and P = .843, respectively). There was also no improvement between the first half (cases 1-8) and second half (cases 9-16) of the LDN group (Table 3).

There was 1 case of conversion to open surgery from LDN, which was a result of substantial bleeding from the renal artery stump. Early conversion was performed safely with immediate control of the bleeding site. Both donor and graft recovered well. The difference in conversion to open surgery was not significant (P = .153; Table 2).

A significantly shorter length of hospital stay was observed for the LDN procedure (P = .031). Our analysis included the 1 LDN patient who underwent conversion to open surgery despite their greatly increased hospital stay, given our initial intention was to treat them using the LDN method. It also showed further improvement between the first 8 and last 8 cases (P = .007).

Finally, there was a trend toward fewer postoperative complications in the LDN group that did not reach significance (P = .355; Table 2). The complications of the HALDN operation included 2 incisional hernias and 3 superficial wound infections, of which 1 infection required a relaparotomy for evacuation of a superficial abscess, whereas the LDN series included 1 respiratory complication.

Discussion

The European Renal Association registry shows that Cyprus has the highest unadjusted incidence of kidney replacement therapy for end-stage kidney disease among all 34 sampled countries as of 2020 (273 cases per million population).¹ However, Cyprus ranks consistently among the lowest in rates of kidney transplant from deceased donors and just above the middle in rates of kidney transplant from living donors.^1,3 It is crucial to offer donors a minimally invasive surgery that will provide them with the fastest possible recovery and return to daily life. In addition, the standardized techniques should aim for the best aesthetic outcomes and the least amount of pain to reduce the fear and anxiety associated with undergoing an operation. This has been thought to increase the number of potential living donors and eventually increase transplants, as stated in various studies.^2,4,5 It is also important to still ensure the success of the transplant for the recipient and the safety of both parties.

Since the inception of the HALDN technique, there has been debate in the transplant community regarding its safety and efficacy versus LDN. This debate has yet to result in quantifiable evidence of the superiority of one technique over the other.⁶ Many studies suggest that LDN holds some advantages in donor recovery over HALDN, although those results have not been reproduced in all studies. These advantages include less lengthy hospital stays, lower use of analgesia, and improved cosmesis.^2,4,6,7

The advantages of the HALDN method include increased tactile sensation and spatial orientation, which help with blunt dissection and mobilization of the kidney. These details have been associated with shorter operative times and better hemostasis.^8-10 Incisional hernias and wound infections were more common in the HALDN group versus the LDN group, which may be due to the larger incision for the HALDN procedure. This is supported by some studies that report lower incisional morbidity for LDN.⁷

Our results reflect those seen in many other studies, showing that the LDN method is not inferior to the HALDN method.^4,6-8 We have seen a shorter length of stay and a trend toward fewer comp-lications for the LDN technique. This is likely attributed to the less traumatic nature of the operation itself and the lack of drains, which would require postoperative removal. These findings exist despite the confounding comparison of the historically last cases of an established technique in our unit versus the first cases of the new approach.

It is important to note that the difference in experience between the 2 surgeons with regard to each technique may have produced less accurate data for LDN, given the learning curve associated with performing a new operation. Such a learning curve has been widely reported in previous studies.^5,7-9 This could explain the higher percentage of conversion to open surgery for the LDN group, given its occurrence in the third case performed historically. The reduction in operating time from the first LDN group (cases 1-8) to the second LDN group (cases 9-16) suggests further improvement with increased surgeon experience, as noted in a similar study that reported a significant decrease in operative time with a higher caseload.¹¹

There are a few limitations in our study that should be considered. Our study was retrospective in nature and included a small number of patients. We have not included data on pain scores or assessments of patient-reported quality of life after kidney donation.

Our experience with the transition period bet-ween HALDN and LDN allowed us to offer some suggestions to centers whose teams may pursue a similar transition to LDN. Careful selection of patients is crucial for successful implementation of a new surgical technique. Ideally, donors with no anatomic variations for left donor nephrectomy should be preferred, because most transplant surgeons are more familiar with left nephrectomy, and hence it would be easier for them to apply the new technique. Furthermore, donors should have favorable characteristics, such as a lower body mass index score and single vessels, to reduce the technical difficulty of the operation. This choice is reflected in our data for the LDN operation.

With regard to the operation itself, the Pfannenstiel incision can be utilized from the beginning of the operation, and a hand-access laparoscopic system can be placed as a safety measure. This will allow for rapid conversion to the HALDN technique in case of emergency and thereby improve safety for the patient and increase comfort for the surgeon. Use of abdominal drains and catheters should be gradually addressed to avoid immediate changes in initial cases.

The transition process should continue outside the operating room. There should be a stepwise change in practice with regard to postoperative patient treatment by the ward staff. Finally, after the new technique is established, there should be a slow decrease in the use of opiates, as well as earlier mobilization of the patient to decrease the length of hospital stay. The aim is to eventually implement enhanced recovery protocols in all donors with regard to both intraoperative and postoperative treatment.¹²

In conclusion, the transition from HADN to LDN is safe and could be implemented in transplant centers that are still using the first technique. Transition between the 2 procedures in a way that does not produce inferior results is feasible but requires careful selection of patients and slow, stepwise adjustment of intraoperative and posto-perative patient treatment. The LDN method is a safe procedure for the donor, which may include a less lengthy hospital stay and a more appealing cosmetic result that could increase willingness to donate among the population. This is specifically important for developing countries that seek to establish or further increase living donor kidney transplants.

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