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Laparoscopic Living Donor Nephrectomy: A Single-Center Sequential Experience Comparing Hand-Assisted Versus Standard Technique
Adult Urology Laparoscopic Living Donor Nephrectomy: A Single-Center Sequential Experience Comparing Hand-Assisted Versus Standard Technique Burak Kocak, Talia B. Baker, Alan J. Koffron, and Joseph R. Leventhal OBJECTIVES
METHODS
RESULTS
CONCLUSIONS
To analyzed our institution’s 8-year experience (October 1997 through March 2006) with laparoscopic donor nephrectomy (LDN) and hand-assisted LDN (HALDN), comparing donor and recipient outcomes. A total of 482 LDNs were compared with 318 HALDNs with respect to donor sex, age, body mass index, hospital length of stay, donor and recipient serum creatinine levels, and incidence and type of complications. All HALDN were performed using hand-assist devices. Mean (⫾SD) ages were similar in both groups (41 ⫾ 10 years versus 39 ⫾ 10 years; P ⫽ NS). Mean body mass index was greater in the HALDN compared with the LDN group (29 ⫾ 5 kg/m2 versus 27 ⫾ 5 kg/m2; P ⬍0.01). Hospital length of stay was longer in the LDN group (1.6 ⫾ 0.7 days versus 1.2 ⫾ 0.6 days; P ⬍0.01). Graft function and donor’s 1-week serum creatinine levels were similar (1.9 ⫾ 1.6 mg/dL versus 1.2 ⫾ 0.4 mg/dL; P ⫽ NS). The intraoperative complication rate for LDN and HALDN was 3.3% and 2.2%, respectively (P ⫽ NS). Postoperative complications occurred in 3.3% of LDNs and 4.7% of HALDNs (P ⫽ NS). The conversion rate was 1.9% for LDN and 0.6% for HALDN (P ⬍0.01). Both LDN and HALDN are safe and effective. Hand-assisted LDN was not associated with an increased risk of incisional morbidity, postoperative ileus, or delayed graft function. The HALDN group experienced as uneventful and as rapid a recovery as the LDN group. UROLOGY 70: 1060 –1063, 2007. © 2007 Elsevier Inc.
L
aparoscopic donor nephrectomy (LDN) is now a well-established minimally invasive approach to living kidney donation. Laparoscopic donor nephrectomy is evolving as the new procedural “standard of care” for live donors. Many lessons have been learned from the initial experiences with standard LDN, which has resulted in the introduction of technical modifications of the original procedure (ie, hand-assisted laparoscopic donor nephrectomy [HALDN]). Hand-assisted LDN was first used to address certain disadvantages of LDN, including a steep learning curve for this advanced laparoscopic procedure, longer warm ischemia time, and an increased operative time.1–3 The use of the hand-assisted approach permits the surgical
From the Department of Urology, Ondokuzmayis University School of Medicine, Samsun, Turkey; and Division of Organ Transplantation, Department of Surgery, Northwestern University Medical School, Chicago, Illinois Reprint requests: Burak Kocak, M.D., Department of Urology, Ondokuzmayis University, School of Medicine, Kurupelit, 55139 Samsun, Turkey. E-mail: [email protected] Submitted: January 10, 2007; accepted (with revisions): July 3, 2007
1060
© 2007 Elsevier Inc. All Rights Reserved
team to use the necessary extraction incision to their advantage throughout the procedure. Potential advantages of hand-assisted donor nephrectomy include shorter operative time, a shorter learning curve related to the presence of robust tactile feedback, the ability to manually assist in dissection, prevention of torsion of the kidney after the lateral attachments have been dissected, and ease of obtaining hemostasis by manual compression of bleeding vessels.3–5 Despite the possible benefits of HALDN, concerns have been raised regarding increased incisional morbidity and the potential for an increased rate of postoperative ileus secondary to bowel handling. In November 2002 we altered the laparoscopic donor procedure at our institution to include the use of commercially available devices (LapDisc [Ethicon Endo-Surgery, Cincinnati, Ohio], GelPort [Applied Medical, Rancho Santa Margarita, Calif]) allowing for hand assistance. We have hypothesized that HALDN safely facilitates living donation without an increase in postoperative morbidity. We herein report our experience with HALDN and compare it with our results of LDN. 0090-4295/07/$32.00 doi:10.1016/j.urology.2007.07.018
Table 1. Donor demographics Variable Age (yr) Sex Male Female BMI (kg/m2) Kidney removed Right Left
LDN (n ⫽ 482)
HALDN (n ⫽ 318)
Total (n ⫽ 800)
P Value
39 ⫾ 10 (18–65)
41 ⫾ 10 (18–63)
39 ⫾ 10 (18–65)
NS
209 (26) 273 (34) 27 ⫾ 5
151 (19) 167 (21) 29 ⫾ 5
294 (45) 356 (55) 27 ⫾ 5
⬍0.01
4 (0.5) 478 (60)
3 (0.4) 315 (40)
7 (0.9) 793 (99.1)
LDN ⫽ laparoscopic donor nephrectomy; HALDN ⫽ hand-assisted LDN; BMI ⫽ body mass index. Values are mean ⫾ SD (range) or number (percentage of total study population).
MATERIAL AND METHODS
RESULTS
Patient Selection
Demographics Donor characteristics are listed in Table 1. Mean patient age was not different between the two groups. The two groups were not different in terms of sex distribution. Mean BMI was higher in the HALDN group.
A total of 800 LDNs were performed from October 1997 through March 2006 at our center. This study is a sequential study comparing 318 HALDNs with 482 standard LDNs. Patient data were obtained from a combination of medical record review and doctor–patient interaction. The data collected included donor sex, age, weight, height, body mass index (BMI), transfusion requirement, length of postoperative hospital stay, donor serum creatinine levels before and 1 week after the surgery, donor hemoglobin levels before, immediately after, and 1 week after the surgery, intraoperative complications, postoperative recovery, and complications. Complications were defined as untoward events within the perioperative period that altered patient recovery, prolonged hospital stay, or represented technical deviations during the surgical procedure. Renal allograft function was also evaluated. Delayed graft function was defined as the need for dialysis in the postoperative period. Evaluation of potential donors for LDN and absolute contraindications to live renal donation were defined earlier.2 The presence of two functional kidneys and an assessment of vascular anatomy were determined by high-resolution computed tomographic angiography or by magnetic resonance angiography. When each kidney was equal in appearance, the left kidney was selected to take surgical advantage of the longer left renal vein for recipient surgical implantation. The right kidney was selected only if there was a potential benefit to the donor to retain the left kidney.
Operative Technique The operative technique for LDN (three to four laparoscopic ports, left/right lower quadrant or periumbilical extraction incision) was described earlier.2 In 318 cases, a pneumatic sleeve (LapDisc or GelPort) was used to allow for hand-assisted nephrectomy; port placement was essentially the same in these cases except that the posterior axillary line port was omitted. In most of the cases the surgery was performed through only two ports.
Statistics Statistical analyses were performed on a computer using commercially available software. Data are expressed as the mean plus or minus standard deviation. All of the numeric data were compared using Student’s t test after normality tests. The chisquare test and Fisher correction were used for comparing the rates between groups. A P value of ⬍0.05 was accepted as statistically significant. UROLOGY 70 (6), 2007
Intraoperative and Postoperative Data The average length of stay was 1.6 ⫾ 0.7 days and 1.2 ⫾ 0.6 days in the LDN and HALDN groups, respectively (P ⬍0.01). Tables 2 and 3 list intraoperative and postoperative complications, respectively. There were 11 open conversions, of which 6 were in the first 100 cases. The conversion rate was 1.9% (n ⫽ 9) and 0.6% (n ⫽ 2) in the LDN and HALDN groups, respectively (P ⬍0.01). The overall open conversion rate was 1.4%. Four conversions were elective and related to surgical technical difficulties, which included lack of exposure, donor obesity, and need for open management of multiple vessels. The remaining seven open conversions were due to renovascular injuries, which included aortic injury, renal arterial injury, lumbar vein injury, and adrenal vein injury. There were nine major renovascular complications (1.1%); all except two required open conversion. The intraoperative complication rate was 3.3% and 2.2% in the LDN and HALDN groups, respectively (P ⫽ NS). The overall rate of intraoperative complications was 2.9%. Intraoperative complications other than the renovascular injuries included splenic capsular tear, a diaphragmatic injury repaired laparoscopically, adrenal hematoma, serosal bowel injury repaired laparoscopically, transient carbon dioxide pneumomediastinum, and ureteral injury. The postoperative complication rate was 3.3% and 4.7% in the LDN and HALDN groups, respectively (P ⫽ NS). The prolonged ileus rate was not different in the HALDN group compared with LDN. One case of intestinal obstruction secondary to internal hernia occurred with both the LDN and the HALDN approach. The overall rate of postoperative complications was 3.9%. The two cases of intestinal obstruction secondary to internal hernia were managed by laparoscopic exploration and repair. There has been one additional case of prolonged ileus requiring laparoscopic re-exploration in 1061
Table 2. Intraoperative complications Complication
LDN (n ⫽ 482)
HALDN (n ⫽ 318)
Total (n ⫽ 800)
Splenic capsular tear Diaphragmatic tear Adrenal hematoma Serosal bowel injury Transient CO2 pneumoperitoneum Aortic injury Renal arterial injury Lumbar vein injury Renal vein injury Adrenal vein injury Partial failure of the renal vein staple line Ureteral injury Total
3 1 1 3 2 1 3 2 0 0 0 0 16 (3.3)
1 0 2 0 0 0 0 0 1 1 1 1 7 (2.2)
4 1 3 3 2 1 3 2 1 1 1 1 23 (2.9)
P Value Laparoscopic control Laparoscopic repair Laparoscopic repair Conversion Conversion Conversion Laparoscopic control Conversion Laparoscopic suture repair NS
Abbreviations as in Table 1. Values are number (percentage of group total).
Table 3. Postoperative complications Complication
LDN (n ⫽ 482)
HALDN (n ⫽ 318)
Total (n ⫽ 800)
P Value
Urinary retention Wound infection Chylous ascites Temporary lateral thigh numbness Port site granuloma with nerve entrapment Prolonged ileus Blood loss ⬎2 g/dL Scrotal swelling Intestinal obstruction Total
5 4 2 1 1 2 0 0 1 16 (3.3)
3 3 1 0 0 4 1 2 1 15 (4.7)
8 7 3 1 1 6 1 2 2 31 (3.9)
NS
Abbreviations as in Table 1. Values are number (percentage of group total).
the HALDN group. The postoperative day-7 serum creatinine values of the donors in the LDN and HALDN groups were 1.3 ⫾ 0.3 mg/dL and 1.4 ⫾ 0.3 mg/dL, respectively (P ⫽ NS). Graft Function Graft function and 1-week creatinine levels were similar (1.9 ⫾ 1.6 versus 1.2 ⫾ 0.4 g/dL; P ⫽ NS). There were no cases of primary nonfunction of transplanted kidneys in either group. There has been only one short- or long-term allograft urologic complication in this series. All kidneys removed laparoscopically functioned immediately with one exception: one recipient of LDN kidneys experienced delayed graft function with ATN requiring dialysis. The same patient presented with a lower ureteral stricture 3 months after the transplantation, which required nonoperative radiologic intervention. This was a kidney procured with standard technique. There were three vascular thromboses in the LDN group and three vascular thromboses in the HALDN group.
COMMENT Donor nephrectomy is unique among major surgical procedures because it exposes an otherwise healthy person to 1062
the risks of major surgery entirely for the benefit of another person. There is no excuse for anything less than a safe operation in a well patient. Although LDN is now a well-established minimally invasive procedure, the operation is not without any concerns. Many lessons have been learned from the initial experiences with LDN, which has resulted in the introduction of technical modifications of the original procedure (ie, HALDN) with the sole purpose of making the procedure safer. Hand-assisted LDN was first used to minimize the diasadvantages of LDN, including a steep learning curve of this advanced laparoscopic procedure, longer warm ischemia time, and an increased operative time.1–3 A shorter learning curve seems to arise from the return of tactile feedback. To date, no head-to-head prospective randomized comparative series of hand-assisted versus purely laparoscopic LDNs have been published, and it seems unrealistic to expect one in the near future, given that most groups comparing the two procedures started the program with either one of the techniques and later altered the procedure to include the other. On the other hand, the steep learning curve for LDN has been clearly demonstrated by our group.1 Some investigators have made the experience-based recommendation to adopt the HALDN techUROLOGY 70 (6), 2007
nique for a newly established laparoscopic donor program because of a perceived greater ease of mastery.3,6 The initial description of LDN by the Johns Hopkins University group described an 8-cm extraction incision.7 With experience this was quickly minimized to a 5- or 6-cm extraction incision.8 The idea of taking advantage of a large incision, which is required for intact kidney removal throughout the entire laparoscopic procedure rather than just at its conclusion, is a potential advantage of the HALDN technique. The incision required for hand-assisted laparoscopic nephrectomy differs from 6 to 8 cm.6,9 However, the greater degree of incisional manipulation raises the possibility of increased morbidity of the procedure compared with a purely laparoscopic approach. There was no difference between the two groups in terms of incisional morbidity in our study. There were no extraction port hernias in our series. Cosmetic differences between the two incisions seem negligible but might be important to some patients. For patients desiring a more cosmetic incision, the conventional laparoscopic approach with a Pfannenstiel incision remains an acceptable alternative. Hand-assisted laparoscopic surgery has the potential for increased rates of postoperative ileus, owing to an increase in bowel manipulation. We did not observe a statistically significant difference between LDN and HALDN in either postoperative ileus or intestinal obstruction in our study. The HALDN donors were more obese than the LDN group in our study. The purely laparoscopic approach is quite challenging in obese patients, a group who could benefit from the laparoscopic approach because wound complications are reduced, pulmonary restriction due to pain is lessened, and early ambulation is improved. We do not have an upper BMI limit for the donor procedure, and we have performed this operation in patients with a BMI as high as 48 kg/m2. There were no technical modifications in the obese donor group. We have found it easier to manage obese donors with the HALDN technique. Hand-assisted LDN allows for safe and effective donor nephrectomy.10 There was no difference in the incidence of intraoperative and postoperative complications between LDN and HALDN. Conversion rates were higher in the LDN group compared with HALDN. We attribute this to two main factors. First, we started to perform HALDN after we passed our learning curve for this specific operation. We performed the first HALDN after performing 258 cases with the LDN technique. We mostly performed HALDN in the second half of our series. Second, the hand-assisted approach holds the advantage over the LDN technique that bleeding can be controlled manually if a vascular injury occurs, thus avoiding possible conversion. Thus, we were able to complete a HALDN case with renal vein injury, avoiding conversion in our series. We have selected the HALDN approach as our procedure of choice because we believe that it holds a number of
UROLOGY 70 (6), 2007
advantages over the LDN technique, many of which are difficult to validate in a scientific clinical study. First of all, the use of the hand-assisted approach permits us to use the necessary extraction incision to our advantage throughout the procedure. Ureteral dissection and final mobilization of the kidney is much easier, especially in obese patients. In addition, if a vascular injury occurs, rapid control of bleeding can be achieved with hand assistance, final dissection of the renal artery and vein can be completed, and the kidney can be quickly extracted and therefore conversion possibly avoided. Adoption of HALDN was associated with reduction in the number of laparoscopic ports used (two versus four ports) as well as a reduction in operating room time (more than 50% of HALDN completed in less than 100 minutes). Interestingly, hospital stay was shorter for patients undergoing HALDN. We attribute this to a more refined algorithm for patient management, which evolved during our early experience with LDN and was fully mature for all HALDN patients. Importantly, the HALDN group experienced as uneventful and as rapid a recovery as the LDN group.
CONCLUSIONS Hand-assisted LDN has proven in this series to be as safe and effective as traditional LDN while preserving the benefits of minimally invasive surgery. Each technique offers some advantages over the other. Individual surgeons will need to determine which technique suits their skills and operative styles.
References 1. Leventhal JR, Kocak B, Salvalaggio PRO, et al: Laparoscopic donor nephrectomy 1997-2003: lessons learned with 500 cases at a single institution. Surgery 136: 881– 890, 2004. 2. Leventhal JR, Deeik RK, Joehl RJ, et al: Laparoscopic live donor nephrectomy—is it safe? Transplantation 70: 602– 606, 2000. 3. Slakey DP, Wood JC, Hender D, et al: Laparoscopic living donor nephrectomy: advantages of the hand-assisted method. Transplantation 68: 581–583, 1999. 4. Ruiz-Deya G, Cheng S, Palmer E, et al: Open donor, laparoscopic donor and hand assisted laparoscopic donor nephrectomy: a comparison of outcomes. J Urol 166: 1270 –1274, 2001. 5. Gershbein AB, and Fuchs GJ: Hand-assisted and conventional laparoscopic live donor nephrectomy: a comparison of two contemporary techniques. J Endourol 16: 509 –513, 2002. 6. Buell JF, Hanaway MJ, Potter SR, et al: Hand-assisted laparoscopic living-donor nephrectomy as an alternative to traditional laparoscopic living-donor nephrectomy. Am J Transp 2: 983–988, 2002. 7. Ratner LE, Ciseck LJ, Moore RG, et al: Laparoscopic live donor nephrectomy. Transplantation 60: 1047–1049, 1995. 8. Flowers JL, Jacobs S, Cho E, et al: Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 226: 483– 489, 1997. 9. Wolf JS, Tchetgen MB, and Merion RM: Hand-assisted laparoscopic live donor nephrectomy. Urology 52: 885– 887, 1998. 10. Chow GK, Prieto M, Bohorquez HE, et al: Hand-assisted laparoscopic donor nephrectomy for morbidly obese patients. Transplant Proc 34: 728, 2002.
1063
METHODS
RESULTS
CONCLUSIONS
To analyzed our institution’s 8-year experience (October 1997 through March 2006) with laparoscopic donor nephrectomy (LDN) and hand-assisted LDN (HALDN), comparing donor and recipient outcomes. A total of 482 LDNs were compared with 318 HALDNs with respect to donor sex, age, body mass index, hospital length of stay, donor and recipient serum creatinine levels, and incidence and type of complications. All HALDN were performed using hand-assist devices. Mean (⫾SD) ages were similar in both groups (41 ⫾ 10 years versus 39 ⫾ 10 years; P ⫽ NS). Mean body mass index was greater in the HALDN compared with the LDN group (29 ⫾ 5 kg/m2 versus 27 ⫾ 5 kg/m2; P ⬍0.01). Hospital length of stay was longer in the LDN group (1.6 ⫾ 0.7 days versus 1.2 ⫾ 0.6 days; P ⬍0.01). Graft function and donor’s 1-week serum creatinine levels were similar (1.9 ⫾ 1.6 mg/dL versus 1.2 ⫾ 0.4 mg/dL; P ⫽ NS). The intraoperative complication rate for LDN and HALDN was 3.3% and 2.2%, respectively (P ⫽ NS). Postoperative complications occurred in 3.3% of LDNs and 4.7% of HALDNs (P ⫽ NS). The conversion rate was 1.9% for LDN and 0.6% for HALDN (P ⬍0.01). Both LDN and HALDN are safe and effective. Hand-assisted LDN was not associated with an increased risk of incisional morbidity, postoperative ileus, or delayed graft function. The HALDN group experienced as uneventful and as rapid a recovery as the LDN group. UROLOGY 70: 1060 –1063, 2007. © 2007 Elsevier Inc.
L
aparoscopic donor nephrectomy (LDN) is now a well-established minimally invasive approach to living kidney donation. Laparoscopic donor nephrectomy is evolving as the new procedural “standard of care” for live donors. Many lessons have been learned from the initial experiences with standard LDN, which has resulted in the introduction of technical modifications of the original procedure (ie, hand-assisted laparoscopic donor nephrectomy [HALDN]). Hand-assisted LDN was first used to address certain disadvantages of LDN, including a steep learning curve for this advanced laparoscopic procedure, longer warm ischemia time, and an increased operative time.1–3 The use of the hand-assisted approach permits the surgical
From the Department of Urology, Ondokuzmayis University School of Medicine, Samsun, Turkey; and Division of Organ Transplantation, Department of Surgery, Northwestern University Medical School, Chicago, Illinois Reprint requests: Burak Kocak, M.D., Department of Urology, Ondokuzmayis University, School of Medicine, Kurupelit, 55139 Samsun, Turkey. E-mail: [email protected] Submitted: January 10, 2007; accepted (with revisions): July 3, 2007
1060
© 2007 Elsevier Inc. All Rights Reserved
team to use the necessary extraction incision to their advantage throughout the procedure. Potential advantages of hand-assisted donor nephrectomy include shorter operative time, a shorter learning curve related to the presence of robust tactile feedback, the ability to manually assist in dissection, prevention of torsion of the kidney after the lateral attachments have been dissected, and ease of obtaining hemostasis by manual compression of bleeding vessels.3–5 Despite the possible benefits of HALDN, concerns have been raised regarding increased incisional morbidity and the potential for an increased rate of postoperative ileus secondary to bowel handling. In November 2002 we altered the laparoscopic donor procedure at our institution to include the use of commercially available devices (LapDisc [Ethicon Endo-Surgery, Cincinnati, Ohio], GelPort [Applied Medical, Rancho Santa Margarita, Calif]) allowing for hand assistance. We have hypothesized that HALDN safely facilitates living donation without an increase in postoperative morbidity. We herein report our experience with HALDN and compare it with our results of LDN. 0090-4295/07/$32.00 doi:10.1016/j.urology.2007.07.018
Table 1. Donor demographics Variable Age (yr) Sex Male Female BMI (kg/m2) Kidney removed Right Left
LDN (n ⫽ 482)
HALDN (n ⫽ 318)
Total (n ⫽ 800)
P Value
39 ⫾ 10 (18–65)
41 ⫾ 10 (18–63)
39 ⫾ 10 (18–65)
NS
209 (26) 273 (34) 27 ⫾ 5
151 (19) 167 (21) 29 ⫾ 5
294 (45) 356 (55) 27 ⫾ 5
⬍0.01
4 (0.5) 478 (60)
3 (0.4) 315 (40)
7 (0.9) 793 (99.1)
LDN ⫽ laparoscopic donor nephrectomy; HALDN ⫽ hand-assisted LDN; BMI ⫽ body mass index. Values are mean ⫾ SD (range) or number (percentage of total study population).
MATERIAL AND METHODS
RESULTS
Patient Selection
Demographics Donor characteristics are listed in Table 1. Mean patient age was not different between the two groups. The two groups were not different in terms of sex distribution. Mean BMI was higher in the HALDN group.
A total of 800 LDNs were performed from October 1997 through March 2006 at our center. This study is a sequential study comparing 318 HALDNs with 482 standard LDNs. Patient data were obtained from a combination of medical record review and doctor–patient interaction. The data collected included donor sex, age, weight, height, body mass index (BMI), transfusion requirement, length of postoperative hospital stay, donor serum creatinine levels before and 1 week after the surgery, donor hemoglobin levels before, immediately after, and 1 week after the surgery, intraoperative complications, postoperative recovery, and complications. Complications were defined as untoward events within the perioperative period that altered patient recovery, prolonged hospital stay, or represented technical deviations during the surgical procedure. Renal allograft function was also evaluated. Delayed graft function was defined as the need for dialysis in the postoperative period. Evaluation of potential donors for LDN and absolute contraindications to live renal donation were defined earlier.2 The presence of two functional kidneys and an assessment of vascular anatomy were determined by high-resolution computed tomographic angiography or by magnetic resonance angiography. When each kidney was equal in appearance, the left kidney was selected to take surgical advantage of the longer left renal vein for recipient surgical implantation. The right kidney was selected only if there was a potential benefit to the donor to retain the left kidney.
Operative Technique The operative technique for LDN (three to four laparoscopic ports, left/right lower quadrant or periumbilical extraction incision) was described earlier.2 In 318 cases, a pneumatic sleeve (LapDisc or GelPort) was used to allow for hand-assisted nephrectomy; port placement was essentially the same in these cases except that the posterior axillary line port was omitted. In most of the cases the surgery was performed through only two ports.
Statistics Statistical analyses were performed on a computer using commercially available software. Data are expressed as the mean plus or minus standard deviation. All of the numeric data were compared using Student’s t test after normality tests. The chisquare test and Fisher correction were used for comparing the rates between groups. A P value of ⬍0.05 was accepted as statistically significant. UROLOGY 70 (6), 2007
Intraoperative and Postoperative Data The average length of stay was 1.6 ⫾ 0.7 days and 1.2 ⫾ 0.6 days in the LDN and HALDN groups, respectively (P ⬍0.01). Tables 2 and 3 list intraoperative and postoperative complications, respectively. There were 11 open conversions, of which 6 were in the first 100 cases. The conversion rate was 1.9% (n ⫽ 9) and 0.6% (n ⫽ 2) in the LDN and HALDN groups, respectively (P ⬍0.01). The overall open conversion rate was 1.4%. Four conversions were elective and related to surgical technical difficulties, which included lack of exposure, donor obesity, and need for open management of multiple vessels. The remaining seven open conversions were due to renovascular injuries, which included aortic injury, renal arterial injury, lumbar vein injury, and adrenal vein injury. There were nine major renovascular complications (1.1%); all except two required open conversion. The intraoperative complication rate was 3.3% and 2.2% in the LDN and HALDN groups, respectively (P ⫽ NS). The overall rate of intraoperative complications was 2.9%. Intraoperative complications other than the renovascular injuries included splenic capsular tear, a diaphragmatic injury repaired laparoscopically, adrenal hematoma, serosal bowel injury repaired laparoscopically, transient carbon dioxide pneumomediastinum, and ureteral injury. The postoperative complication rate was 3.3% and 4.7% in the LDN and HALDN groups, respectively (P ⫽ NS). The prolonged ileus rate was not different in the HALDN group compared with LDN. One case of intestinal obstruction secondary to internal hernia occurred with both the LDN and the HALDN approach. The overall rate of postoperative complications was 3.9%. The two cases of intestinal obstruction secondary to internal hernia were managed by laparoscopic exploration and repair. There has been one additional case of prolonged ileus requiring laparoscopic re-exploration in 1061
Table 2. Intraoperative complications Complication
LDN (n ⫽ 482)
HALDN (n ⫽ 318)
Total (n ⫽ 800)
Splenic capsular tear Diaphragmatic tear Adrenal hematoma Serosal bowel injury Transient CO2 pneumoperitoneum Aortic injury Renal arterial injury Lumbar vein injury Renal vein injury Adrenal vein injury Partial failure of the renal vein staple line Ureteral injury Total
3 1 1 3 2 1 3 2 0 0 0 0 16 (3.3)
1 0 2 0 0 0 0 0 1 1 1 1 7 (2.2)
4 1 3 3 2 1 3 2 1 1 1 1 23 (2.9)
P Value Laparoscopic control Laparoscopic repair Laparoscopic repair Conversion Conversion Conversion Laparoscopic control Conversion Laparoscopic suture repair NS
Abbreviations as in Table 1. Values are number (percentage of group total).
Table 3. Postoperative complications Complication
LDN (n ⫽ 482)
HALDN (n ⫽ 318)
Total (n ⫽ 800)
P Value
Urinary retention Wound infection Chylous ascites Temporary lateral thigh numbness Port site granuloma with nerve entrapment Prolonged ileus Blood loss ⬎2 g/dL Scrotal swelling Intestinal obstruction Total
5 4 2 1 1 2 0 0 1 16 (3.3)
3 3 1 0 0 4 1 2 1 15 (4.7)
8 7 3 1 1 6 1 2 2 31 (3.9)
NS
Abbreviations as in Table 1. Values are number (percentage of group total).
the HALDN group. The postoperative day-7 serum creatinine values of the donors in the LDN and HALDN groups were 1.3 ⫾ 0.3 mg/dL and 1.4 ⫾ 0.3 mg/dL, respectively (P ⫽ NS). Graft Function Graft function and 1-week creatinine levels were similar (1.9 ⫾ 1.6 versus 1.2 ⫾ 0.4 g/dL; P ⫽ NS). There were no cases of primary nonfunction of transplanted kidneys in either group. There has been only one short- or long-term allograft urologic complication in this series. All kidneys removed laparoscopically functioned immediately with one exception: one recipient of LDN kidneys experienced delayed graft function with ATN requiring dialysis. The same patient presented with a lower ureteral stricture 3 months after the transplantation, which required nonoperative radiologic intervention. This was a kidney procured with standard technique. There were three vascular thromboses in the LDN group and three vascular thromboses in the HALDN group.
COMMENT Donor nephrectomy is unique among major surgical procedures because it exposes an otherwise healthy person to 1062
the risks of major surgery entirely for the benefit of another person. There is no excuse for anything less than a safe operation in a well patient. Although LDN is now a well-established minimally invasive procedure, the operation is not without any concerns. Many lessons have been learned from the initial experiences with LDN, which has resulted in the introduction of technical modifications of the original procedure (ie, HALDN) with the sole purpose of making the procedure safer. Hand-assisted LDN was first used to minimize the diasadvantages of LDN, including a steep learning curve of this advanced laparoscopic procedure, longer warm ischemia time, and an increased operative time.1–3 A shorter learning curve seems to arise from the return of tactile feedback. To date, no head-to-head prospective randomized comparative series of hand-assisted versus purely laparoscopic LDNs have been published, and it seems unrealistic to expect one in the near future, given that most groups comparing the two procedures started the program with either one of the techniques and later altered the procedure to include the other. On the other hand, the steep learning curve for LDN has been clearly demonstrated by our group.1 Some investigators have made the experience-based recommendation to adopt the HALDN techUROLOGY 70 (6), 2007
nique for a newly established laparoscopic donor program because of a perceived greater ease of mastery.3,6 The initial description of LDN by the Johns Hopkins University group described an 8-cm extraction incision.7 With experience this was quickly minimized to a 5- or 6-cm extraction incision.8 The idea of taking advantage of a large incision, which is required for intact kidney removal throughout the entire laparoscopic procedure rather than just at its conclusion, is a potential advantage of the HALDN technique. The incision required for hand-assisted laparoscopic nephrectomy differs from 6 to 8 cm.6,9 However, the greater degree of incisional manipulation raises the possibility of increased morbidity of the procedure compared with a purely laparoscopic approach. There was no difference between the two groups in terms of incisional morbidity in our study. There were no extraction port hernias in our series. Cosmetic differences between the two incisions seem negligible but might be important to some patients. For patients desiring a more cosmetic incision, the conventional laparoscopic approach with a Pfannenstiel incision remains an acceptable alternative. Hand-assisted laparoscopic surgery has the potential for increased rates of postoperative ileus, owing to an increase in bowel manipulation. We did not observe a statistically significant difference between LDN and HALDN in either postoperative ileus or intestinal obstruction in our study. The HALDN donors were more obese than the LDN group in our study. The purely laparoscopic approach is quite challenging in obese patients, a group who could benefit from the laparoscopic approach because wound complications are reduced, pulmonary restriction due to pain is lessened, and early ambulation is improved. We do not have an upper BMI limit for the donor procedure, and we have performed this operation in patients with a BMI as high as 48 kg/m2. There were no technical modifications in the obese donor group. We have found it easier to manage obese donors with the HALDN technique. Hand-assisted LDN allows for safe and effective donor nephrectomy.10 There was no difference in the incidence of intraoperative and postoperative complications between LDN and HALDN. Conversion rates were higher in the LDN group compared with HALDN. We attribute this to two main factors. First, we started to perform HALDN after we passed our learning curve for this specific operation. We performed the first HALDN after performing 258 cases with the LDN technique. We mostly performed HALDN in the second half of our series. Second, the hand-assisted approach holds the advantage over the LDN technique that bleeding can be controlled manually if a vascular injury occurs, thus avoiding possible conversion. Thus, we were able to complete a HALDN case with renal vein injury, avoiding conversion in our series. We have selected the HALDN approach as our procedure of choice because we believe that it holds a number of
UROLOGY 70 (6), 2007
advantages over the LDN technique, many of which are difficult to validate in a scientific clinical study. First of all, the use of the hand-assisted approach permits us to use the necessary extraction incision to our advantage throughout the procedure. Ureteral dissection and final mobilization of the kidney is much easier, especially in obese patients. In addition, if a vascular injury occurs, rapid control of bleeding can be achieved with hand assistance, final dissection of the renal artery and vein can be completed, and the kidney can be quickly extracted and therefore conversion possibly avoided. Adoption of HALDN was associated with reduction in the number of laparoscopic ports used (two versus four ports) as well as a reduction in operating room time (more than 50% of HALDN completed in less than 100 minutes). Interestingly, hospital stay was shorter for patients undergoing HALDN. We attribute this to a more refined algorithm for patient management, which evolved during our early experience with LDN and was fully mature for all HALDN patients. Importantly, the HALDN group experienced as uneventful and as rapid a recovery as the LDN group.
CONCLUSIONS Hand-assisted LDN has proven in this series to be as safe and effective as traditional LDN while preserving the benefits of minimally invasive surgery. Each technique offers some advantages over the other. Individual surgeons will need to determine which technique suits their skills and operative styles.
References 1. Leventhal JR, Kocak B, Salvalaggio PRO, et al: Laparoscopic donor nephrectomy 1997-2003: lessons learned with 500 cases at a single institution. Surgery 136: 881– 890, 2004. 2. Leventhal JR, Deeik RK, Joehl RJ, et al: Laparoscopic live donor nephrectomy—is it safe? Transplantation 70: 602– 606, 2000. 3. Slakey DP, Wood JC, Hender D, et al: Laparoscopic living donor nephrectomy: advantages of the hand-assisted method. Transplantation 68: 581–583, 1999. 4. Ruiz-Deya G, Cheng S, Palmer E, et al: Open donor, laparoscopic donor and hand assisted laparoscopic donor nephrectomy: a comparison of outcomes. J Urol 166: 1270 –1274, 2001. 5. Gershbein AB, and Fuchs GJ: Hand-assisted and conventional laparoscopic live donor nephrectomy: a comparison of two contemporary techniques. J Endourol 16: 509 –513, 2002. 6. Buell JF, Hanaway MJ, Potter SR, et al: Hand-assisted laparoscopic living-donor nephrectomy as an alternative to traditional laparoscopic living-donor nephrectomy. Am J Transp 2: 983–988, 2002. 7. Ratner LE, Ciseck LJ, Moore RG, et al: Laparoscopic live donor nephrectomy. Transplantation 60: 1047–1049, 1995. 8. Flowers JL, Jacobs S, Cho E, et al: Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 226: 483– 489, 1997. 9. Wolf JS, Tchetgen MB, and Merion RM: Hand-assisted laparoscopic live donor nephrectomy. Urology 52: 885– 887, 1998. 10. Chow GK, Prieto M, Bohorquez HE, et al: Hand-assisted laparoscopic donor nephrectomy for morbidly obese patients. Transplant Proc 34: 728, 2002.
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