The mini–donor nephrectomy: a viable option
Article Outline
The classic open donor nephrectomy is a time-tested and safe operation. It provides good quality organs for transplantation but it is associated with significant morbidity in terms of loin pain, disability, and cosmesis. In India, although brain death is recognized, cadaveric transplantation is still in its infancy and the vast majority of renal transplantation is carried out using grafts from living donors. The advent of the laparoscopic donor nephrectomy has made us critically re-evaluate the service we offer our renal donors. We at the All India Institute of Medical Sciences have evolved the mini–donor nephrectomy as an option to the classic donor nephrectomy. Sixty consecutive donors, in whom nephrectomy was completed using a small rib-sparing incision, were evaluated. The length of incision, time to harvest, warm ischemia time, quality of organ harvested, day of discharge, verbal pain score, and day of return to normal activity were evaluated. The mini–donor nephrectomy appears to be a viable alternative to the classic donor nephrectomy.
Materials and methods
The mini–donor nephrectomy was performed as the surgical procedure of choice for 60 consecutive live related renal transplantations done over a 14-month period. All renal donors were evaluated with a detailed medical history, physical examination, blood group, blood sugar, renal function tests, liver function tests, serology for hepatitis B, hepatitis C, and human immunodeficiency virus, intravenous urogram, a diethylene triamine penta acetic acid–glomerular filtration rate (DTPA-GFR), and digital subtraction angiography. Perioperative antibiotic prophylaxis was carried out using cefatoxime. The surgery was performed under general anaesthesia. Following intubation, the patient was catheterized and placed in the standard kidney position. An anterior incision was made approximately measuring 6 cm above the rib lying over the renal pelvis as demonstrated by the intravenous urogram. The retroperitoneal space was entered and the ureter was slinged with an adequate amount of periureteric fat. The incision was then extended to facilitate dissection of the renal hilum. The renal vein was then dissected and the gonadal and suprarenal vein was ligated. A plane was then developed between the kidney and the peritoneum and the ureter with the gonadal vein was then dissected till the level of bifurcation of the common iliac artery. Mannitol was then given intravenously. The artery was then dissected till the aorta on the left side and for a good distance behind the inferior vena cava on the right side. Once the dissection was complete, the ureter was divided after ligation of the distal end. Following this, the renal artery and then the renal vein were doubly ligated and cut. The kidney was then removed and placed in ice slush for perfusion. Haemostasis was secured and the wound was closed by interrupted sutures using 1-0 vicryl. The skin was closed with monocryl. No drains were used. Postoperatively all patients were given intermittent intramuscular opioid analgesics for 24 hours and subsequently oral anaelgesics for 3 days. The urinary catheter was removed and intravenous fluids were stopped on the first postoperative day following which the donor was started on clear fluids and ambulated.
The length of the incision, weight of the patient, warm ischemia insult, day of discharge, time to harvest the kidney, postoperative complications, and graft function in the recipient were evaluated. The verbal pain score was evaluated on the first postoperative day, the day of discharge, and at 7 days following surgery. The incision length was measured from one end of the incision to the other. The time to harvest was defined as the duration from the skin incision to the kidney being in ice. Postoperative pain was assessed by means of the verbal rating score in which 1 is no pain, 2 is mild pain, 3 is moderate pain, and 4 is severe pain. The day of discharge was the postoperative day on which the donor was discharged.
Results
Sixty live mini–donor nephrectomies were performed. Thirty-six of the donors were females and 24 were males. The mean age of the donors was 40.98 years (range: 22 to 68 years). Fifty-eight donors were related to the recipient, whereas 2 were altruistic renal donations authorized by the hospital authorization committee. The mean weight of our donors was 65.5 kg (range: 45 to 95 kg). The average length of the incision was 9.8 cm (range: 7.6 to 14.8 cm). The mean time to harvest the kidney was 46.11 minutes and the longest was 78.90 minutes. The warm ischemia time was 2.12 minutes (range: 1.8 to 3.6 minutes). All kidneys had good primary function. There was no intraoperative complication in any of the donors.
Of all donors in our study, 51.66% had mild pain when assessed by the verbal pain rating score, 36.6% had moderate pain on the same regimen, and 11.66% had severe pain on the same drugs. Also, 73.33% of our patients were discharged on the second postoperative day, 20% on the third postoperative day, and 6.6% on the fourth postoperative day. At discharge, 56.6% of our donors had no pain on oral analgesics, 36.6% had mild pain, and 6.6% had moderate pain. At 7 days of follow-up, 76.66% had no pain, 20% had mild pain, and 3.3% had moderate pain. All patients returned to near normal activity by the 15th postoperative day. Also, 18.33% of our donors had postoperative fever, which was due to thrombophlebitis in 36.36% and urinary tract infection (UTI) in 33%. In 36.6% no cause could be found and the fever responded to a discontinuation of the intravenous fluids.
Discussion
The introduction of the laparoscopic donor nephrectomy has resulted in significant controversy regarding its application and its exact role in renal allograft procurement.1, 2 Laparoscopic donor nephrectomy is a technically difficult operation. Considerable care and laparoscopic experience are needed to ensure the safety of the donor and the recipient. Expensive and special equipment is required to perform this procedure. Peritoneal insufflation causes a reflex decrease in urine output probably due to a decrease in renal perfusion as a result of renal venous outflow compression. Increased renal arterial traction leading to vasospasm and compression on the renal parenchyma during extraction are the other factors that are likely to interfere with the renal perfusion and hence are likely to compromise graft function in the recipient.3 Excessive skeletonization of the ureter with increased incidence of ureteric complications also has been reported.4, 5 Donor complications have included prolonged duration of surgery and injury to aorta, IVC, bowel, spleen, and others. The incision size has progressively decreased with increasing experience. It has not been possible however, to decrease it to less than 7 cm without potentially damaging the renal parenchyma.6
In comparison, mini–donor nephrectomy has certain advantages. The procedure does not require special equipment. There is no or minimal learning curve. The problems of pneumoperitoneum are obviated. The average incision size of approximately 10 cm is comparable to the 7 cm incision used in laparoscopy. The warm ischemia time averaged just more than 2 minutes (range: 1 to 4 minutes). The harvesting time was on an average 46 minutes. The corresponding values for the laparoscopic procedure are 148 seconds and 215 minutes, respectively.3
In our study, there were no intraoperative complications. The average duration of hospital stay for the donors was 58.32 hours. This is less than the average duration of stay of 66.7 hours for laparoscopic donor nephrectomy patients.
To conclude, donor nephrectomy through a mini incision is an attractive alternative. The procedure is safe, does not require expensive equipment or special training, and leads to an early discharge from the hospital. The rib is not excised, thus obviating the associated problems. As compared with the laparoscopic procedure, although the incision size is slightly larger, other parameters, such as hospital stay, pain, and time to return to normal activity, are comparable. Its low cost and safety along with good immediate graft function argues for its use in the developing world. Obviously, a randomized controlled trial is needed to assess this procedure with respect to laparoscopic donor nephrectomy.
References
PII: S0041-1345(02)03786-7
doi:10.1016/S0041-1345(02)03786-7
© 2003 Elsevier Science Inc. All rights reserved.
