Is minimally invasive donor nephrectomy the future?
Article Outline
The advent of laparoscopic donor nephrectomy has resulted in most transplant units critically reevaluating the services that they offer to living donors. The flank approach to donor nephrectomy has stood the test of time. The operation is safe and provides a good-quality organ. However, it is associated with significant morbidity in terms of loin pain, structural disability, and cosmesis, which may occur in 7% to 9% of patients. Moreover, donors are worried about the large flank incision.1 However, with increased surgical expertise, there is little doubt that the original approach to donor nephrectomy is far from ideal and needs modification.
Laparoscopic donor nephrectomy has been propagated as an alternative. It is important to remember that the donor nephrectomy has two vital components: the safety of the donor and optimal condition of the harvested organ. In a recent study regarding laparoscopic donor complications the incidence of complications after this approach was 17%.2 Moreover, the pneumoperitoneum that is created during laparoscopic donor nephrectomy has a detrimental effect on both pulmonary function and vascular perfusion. The increased intra-abdominal pressure results in decreased renal vein blood flow with reduced cortical and medullary perfusion, which may explain the increased incidence of delayed function observed among laparoscopically harvested kidneys.3 Rigorous overhydration may correct this. In India, where most living-related donors are old, the laparoscopic approach may have a detrimental effect on donor cardiac function. There is also some evidence that early parenchymal insults may produce longer-term deleterious effects, which may not be evident during the first year.4 Laparoscopic donor nephrectomy may thus compromise the two vital components of the operation—the safety of the donor and the condition of the harvested organ. Most living donor programs follow fundamental principles with regard to the harvested kidney. The larger kidney and the most normal kidney is usually left behind, so as to not compromise the renal donor’s reserve.
In most open donor nephrectomy programs the incidence of a right donor nephrectomy is approximately 22% to 35%. Surprisingly in laparoscopic donor nephrectomy the right kidney is harvested in only 2% to 5% of patients.5 Are we leaving the best kidney behind in laparoscopic donor nephrectomy? Laparoscopic donor nephrectomy may thus compromise the most fundamental principle of a live donor program. The right kidney is usually more difficult to harvest laparoscopically. It usually results in a shorter renal vein making implantation technically more demanding. Earlier efforts used reconstruction with the saphenous vein of the recipient, but recent modifications have been proposed to use a transverse skin incision after laparoscopicic mobilization of the kidney and application of a vascular clamp on the inferior vena cava to secure an adequate length of the renal vein.6
Open donor nephrectomy has stood the test of time. In a study by Shaffer et al.7 of surgical complications among 201 consecutive patients who underwent donor nephrectomy, bleeding was encountered in one patient, pneumothorax in two, wound infection in two, and pneumonia in two. Only one patient developed an incisional hernia. However, laparoscopic donor complications were far more serious in the study by Montgomery et al. of 200 laparoscopic donor nephrectomies.2 Retroperitoneal hematoma was encountered in four patients, splenic injury in two patients, bowel injury in three patients, and renal vein tear in one patient. Six patients required blood transfusions. The incidence of complications has declined with increasing experience. The living donor is sacred to the program, his only interest is in helping a fellow human being. Donor complications should not be taken lightly and the learning curve needs to be as steep as possible. One serious complication in a living donor may push your program back by a decade. Laparoscopically retrieved kidneys create problems in the recipient as well. There is a documented higher incidence of renal vein thrombosis and urologic complications.
Urologic complications in recipients of kidneys harvested laparoscopically have been reported to be 10.8%, a figure that has that has declined with experience to approximately 3.0%. In most centers, the incidence is about 1%.5
Added to this are the economic considerations including the cost of disposables required for laparoscopic donor nephrectomy, which is approximately $2251 compared to $812 for an open nephrectomy. The big advantage is that the laparoscopic donor goes home earlier than the open donor, thus saving the hospital money in terms of bed occupancy. He is also able to return to work earlier. In this part of the world in-patient hospital stay is fairly cheap in government hospitals and the family has sold every piece of property for the recurring cost of immunosuppressants. The saving in terms of disposables can be considerable.
At our center we have explored the mini-donor nephrectomy as an option to the classical or the laparoscopic donor nephrectomy. The procedure consists of a non-rib resecting flank incision usually above the eleventh rib, which is extended depending on the position of the kidney. The ureter is mobilized with the gonadal vein and the renal vein and artery are dissected. Two narrow-based deaver retractors are used and the artery and vein are ligated and then divided. The incision is closed in layers with 4-0 monocryl applied to the skin. We currently have performed 78 operations in donors with a mean age of 40.98 years and a mean weight of 63.66 kg. Our mean length of the incision is 9.2 cm and the time to harvest (incision time to time the kidney is in ice) is 45.15 minutes. The mean postoperative stay is 2.26 days; the verbal pain score on day one was 2.4, and on the day of discharge 1.4. We have not lost any kidney due to problems with the harvests; all kidneys have displayed a brisk diuresis on day 1. No urologic complications have been encountered in any patient. We routinely stent all ureters. The mini-donor nephrectomy appears to be a viable alternative that may be appropriate for the developing world where the donors are thin and where no extra cost for disposables is incurred by the hospital for this procedure.8
References
PII: S0041-1345(02)03906-4
doi:10.1016/S0041-1345(02)03906-4
© 2003 Elsevier Science Inc. All rights reserved.
