Laparoscopic donor nephrectomy is the future

Khauli, R.B.

doi:10.1016/S0041-1345(02)04039-3

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Volume 35, Issue 1 , Pages 41-42, February 2003

Laparoscopic donor nephrectomy is the future

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The spectrum of issues facing transplantation in the third millennium are multiple and diverse. However, the most serious single issue that stands out is the ever-growing number of patients on chronic dialysis awaiting transplantation. As of March 2002, there were more than 51,363 patients waiting for kidney transplants on the UNOS national patient waiting list. Nevertheless, only 13,372 transplants were performed in 2000, of which 5293 were from living donors.¹ The widening disparity between the number of patients awaiting transplantation versus those actually receiving them can only be solved by increasing the live donor kidney pool because other exhaustive measures, including the use of suboptimal cadaveric donors, have failed to increase the number of transplants. A powerful solution to the problem may have emerged in the past several years with the advent of laparoscopic donor nephrectomy (Lap Nx). By virtue of the minimally invasive surgical properties of Lap Nx and its application to healthy volunteers who do not have any inherent direct gain from surgical intervention and hospitalization, it represents a unique solution that is able to diminish the disincentive to donors and therefore increase the actual number of kidney donations. It is now well established that Lap Nx offers equivalent safety outcomes as open nephrectomy (Open Nx) to the donor but with a significant benefit of no disfigurement, diminished hospital stay, faster recovery, and shorter time to resumption of normal work and preoperative activities.², ³, ⁴ Following the introduction of Lap Nx programs at established transplant centers, there has been a documented 40% to 60% increase in the number of donations in two series.⁵, ⁶ With these substantial advantages, why is it then that Lap Nx has not been accepted universally as the standard procedure in most centers?

Several explanations could be given that may have obviated Lap Nx from being labled as “the standard” that it deserves: (1) The learning curve is very steep and demands a multidisplinary approach to surgery that has been classically performed by a single specialty (transplantation surgery or urology). (2) Any graft insult as a result of Lap Nx is difficult to tolerate because the open approach has been well established over the past four decades with almost no, or perhaps minimal, graft compromise. (3) Classically, transplant surgeons may have focused on recipient and graft outcome more than that of the donor, whose outcome has been excellent, with minimal morbidity or mortality using the open approach. Thus, the issue of diminished donor morbidity and reducing pain to the minimum has been almost totally ignored. (4) Cost issues seem to show a higher expense for Lap Nx compared with the open approach.

Several pioneering centers have addressed the issue of the difficult learning curve.², ³, ⁴, ⁵, ⁶ The initial results of Lap Nx point to an increase in graft warm ischemia time that may impact the rate of ATN and the 1-month serum creatinine value after transplantation.², ³ However, if one looks closer at this issue, one may appreciate that short-term renal function may not necessarily have a durable long-term functional impact on the recipient’s course. The long-term outcomes of Lap Nx seems to be equivalent to Open Nx in two large series and in recent reports.⁴, ⁶ Allograft survival was no different in two large series showing equivalent survival rates of organs obtained by Lap Nx versus Open Nx; the acute rejection rates were similar. Early urological complications, particularly urinary leak and ureteral necrosis, were reported to be higher for Lap Nx versus Open Nx in the initial series. Recipient ureteral complications were initially reported to be 9.1% at Johns’ Hopkins⁷ and 10.8% at the University of Maryland.⁸ These incidences are appreciably higher than those reported among recipients of grafts performed by the traditional Open Nx approach in these two series (6.3% and 3%, respectively). The high rate of ureteral complications has decreased to 3% in later series that incorporate a wide ureteral dissection, including ureteral periadvential tissue and vasculature.⁶ The high occurrence of ureteral complications in the early Lap Nx series raises important questions regarding the approach that was used to mobilize the ureter in the earlier series. Perhaps the procedures in the earlier series violated the precept to avoid overskeletonization of the ureter. Similarly, some workers claim that Lap Nx is associated with a higher rate of complications of vascular insult and of ATN-DGF. Perhaps the risks of vascular spasm, thrombi, or serious mishaps may be overcome by judicious sharp and blunt dissection for vascular mobilization, application of low-pressure pneumoperitoneum (8 mm Hg), and aggressive plasma expansion intraoperatively. These principles have resulted in almost universal diuresis of grafts obtained by Lap Nx. Consequently, our group has emphasized the need for full collaboration between the urologic surgeon, the laparoscopic surgeon, and the transplant surgeon in both the donor and recipient surgeries.⁹ This collaboration has resulted in superior recipient and graft outcomes, with minimal morbidity despite the difficult early learning curve.

In conclusion, we believe that Lap Nx is now the “standard” of care and the procedure of the future. Lap Nx shall replace Open Nx as the standard approach for kidney retrieval in most institutions. It has been shown to result in at least a two-fold increase in the number of donations, which is the rate-limiting step for improving the utility and wide application of renal transplantation. The learning curve need not be a stumbling block, as it may be negotiated without appreciable risk to the graft or recipient.

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