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Kuwait Experience in Laparoscopic Donor Nephrectomy: First 80 Cases
Kuwait Experience in Laparoscopic Donor Nephrectomy: First 80 Cases S. Buresley, M. Samhan, and M. Al-Mousawi ABSTRACT Introduction. Laparoscopic donor nephrectomy (LDN) has been adopted rapidly as it offers less postoperative pain, early recovery, and better cosmetic results compared with the open approach. This prospective study investigated the results of the first 80 LDN performed between May 2005 and May 2006, with regard to donor morbidity and effect on graft function. Patients and Methods. LDN was attempted in 80 donors by one surgical team. Donors included 68 men and 12 women, ages 22 to 53 years, with body mass indices of 17.9 to 42.4. According to computed tomographic angiography, left nephrectomy was planned in 75 donors and right nephrectomy in 5. Results. LDN was completed successfully in 74 (92.5%) and converted to open in 6 (7.5%) secondary to technical difficulties and operative bleeding. The mean operating time for LDN was 186.16 minutes (range, 95–260 minutes). Mean warm ischemia time (WIT) was 5.7 minutes (range 2–16 minutes). Mean hospital stay was 5.28 days (range, 3–14 days). Two donors (2.5%) were reexplored for postoperative bleeding. Renal function in all donors was satisfactory within 3 months of surgery. Immediate diuresis occurred in 76 (95%) recipients. Acute cellular rejection was diagnosed in 1 recipient. No association was observed between WIT, graft function, development of acute tubular necrosis (ATN), or rejection. Plasma creatinine normalization was clearly associated with donor age. Conclusions. LDN was found to be a safe procedure with low postoperative morbidity and short recovery time for donors. It can potentially increase the donor pool.
K
IDNEY TRANSPLANTATION is the treatment of choice for suitable patients with end-stage renal disease. The shortage of organs remains the most important factor limiting the success of kidney transplantation. To decrease the disparity between demand and supply of organs, and to reduce donor morbidity, minimally invasive surgical techniques and laparoscopic instrumentation have been applied to live donor nephrectomy (LDN), thereby reducing postoperative pain, shortening convalescence, and improving the cosmetic outcome of donor nephrectomy.3,5 LDN has, thus, shown the potential to increase the number of living kidney donors further by removing some of the disincentives inherent to donation itself. Some concerns still surround the application of this technique for renal donation.1 The procedure is technically demanding, involving a transperitoneal approach with attendant potential complications. The laparoscopic approach usually takes longer than the open operation, with a potential for an increased © 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 39, 813– 815 (2007)
incidence of respiratory and thromboembolic complications.2 LDN has become the primary source of living donor kidneys for transplantation. Herein we have reported our experience with the first 80 cases. PATIENTS AND METHODS This prospective study evaluated donor morbidity and graft outcomes of 80 LDN performed between May 10, 2005, and May 31, 2006. Patient data were obtained from a combination of a prospective longitudinal database, medical record review, and patient follow-up. Intra- and postoperative recorded data were also obtained. All donors underwent routine preoperative evaluation which included blood pressure measurement, 24-hour urine collecFrom the Hamed Al-Essa Organ Transplantation Centre, Safat, Kuwait. Address reprint requests to S. Buresley, P.O. Box 25427 Safat, Code 13115, State of Kuwait. E-mail: dr_salwa_buresley@ yahoo.com 0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.03.050 813
814
BURESLEY, SAMHAN, AND AL-MOUSAWI Table 1. Postdonation Change in Kidney Function Mean Calculated Creatinine Clearance [e.GPR (mL/min)] Postnephectomy
Donor Age (y)
Number
Before
3 Days
1 Month
3 Months
21–30 31–40 41–50 51–60
33 34 11 2
127.27 132.9 133.5 86.0
87.9 87.53 70.0 62.0
94.6 91.8 82.5 65.5
99.7 93.18 83.86 70.0
tion analysis, blood sugar, renal and liver function blood investigations, ultrasound, and computed tomographic angiography. When both kidneys were equal, the left kidney was selected to take advantage of the longer left renal vein. However, if the left renal vascular anatomy was unfavorable compared with that of the right, the right kidney was selected. All donors received bowel preparation before surgery and prophylactic broad-spectrum antibiotics 1 hour before surgery. After insertion of a Foley catheter, patients were positioned in either the left or the right lateral decubitus positions, according to the kidney side for donation. Three operating ports were used for dissection: one 11 mm port at the umbilicus, one 12 mm port lateral to the rectus muscle, and one 5 mm port in the subcostal area. Care was taken to maintain adequate periureteral tissue to preserve vascularity, to maximize renal vessel length, and to minimize warm ischemia time (WIT). Prior to stapling, anticoagulation was done by injection of 5000 units of heparin intravenously which was reversed with 1 mg/kg protamine sulfate, also intravenously, after pedicle transection. The kidneys were removed using a hand extraction technique through a suprapubic transverse incision. After their removal, the kidneys were flushed with Euro-Collin’s solution and kept in an ice slush preparation. Operation time was defined as that from the initial skin incision to the wound closure, and WIT, as that from clipping of the renal artery to starting cold perfusion. All recipient surgeries were performed through a standard extraperitoneal Gibson incision. End-to-side anastomoses between the renal and external iliac vessels, as well as an extravesical ureteroneocystostomy with insertion of a DJ stent (removed cystoscopically after 4 – 6 weeks posttransplantation), were performed on all recipients.
RESULTS
From May 10, 2005, to May 31, 2006, LDN was attempted in 80 cases and completed successfully in 74 (92%). Mean donor age was 33.28 years (range, 22–53 years). Donors included 68 (85%) men and 12 (15%) women, with overall body mass indices of 17.9 to 42.4. Left nephrectomy was performed in 75 donors and right nephrectomy in 5 donors. Six donors (7.9%) required conversion to an open procedure; all were among the first 10 cases. Three (3.75%) were due to difficulty in identifying the ureter and to presence of multiple veins, while the remaining 3 were due to bleeding. The mean operating time was 186.16 minutes (range, 95–260 minutes). The mean WIT was 5.7 minutes (range, 2–16 minutes). Seven donors (8.75%) required blood transfusions with a total of 13 pints (range, 1– 6 Pints). However, none of the donors needed admission to the intensive care unit. Postoperative analgesia (Pethidine) requirement was
less when it was administered according to patient demand, rather than regular doses. The total dose ranged from 150 to 2350 mg (mean, 670 mg). The mean hospital stay of donors was 5.28 days (range, 3–14 days). Even though many of them could have been discharged earlier, they stayed longer for social reasons. One patient who stayed 14 days was reoperated and developed a chest infection. Most donors returned to work within 1 month after donation. Surgical complications were observed in 11 (13.75%) cases. Two cases (2.5%) were reoperated for bleeding: 1 from the suprarenal gland which was controlled laparoscopically, and 1 for evacuation of a subcutaneous hematoma. The most frequent complications following LDN were chest infection in 4 (5%) and atelectasis in 2 (2.5%) as most of the donors were heavy smokers. The rate of wound infection was low (2.5%), and urinary tract infection was reported in 1 donor (1.25%). All donors progressively recovered renal function, even though the recovery was incomplete within the 3-month follow-up (Table 1). Most transplant recipients were in the middle age group with a mean of 38.9 years (range, 3– 68 years); 54 (67.5%) were men and primary transplantation was performed in all except for 3 (3.75%). Immediate diuresis was observed in 76 (95%) cases. There were 6 (7.5%) cases with acute tubular necrosis (ATN). Three recipients required hemodialysis (HD) in the first week posttransplantation, 1 of whom recovered after 14 days, while the second did so after 120 days. The third needed antirejection treatment to recover. One recipient died suddenly of unknown cause at home 6 weeks posttransplantation with a functioning graft. There was clear association between plasma creatinine normalization and donor age (Table 2). Rejection which occurred in 8 cases (10%) was not related to the duration of WIT or the development of ATN. Eight (10%) recipients developed lymphoceles posttransplantation. DISCUSSION
LDN has been performed by the open surgical approach for several decades. In contrast, LDN is being adopted rapidly by transplant centers around the world as it offers less postoperative pain, more rapid convalescence, and better cosmetic result compared with the open approach.5 However, there are concerns that the laparoscopic technique results in increased costs, due to the requirement for expensive disposable equipment, such as trocars, hand ports, and vessel staplers. The operation time was shortened with more cases from 4 hours in the 1st case to an Table 2. Effect of Donor Age on Recipient’s Renal Function Recipient Mean S. Creat (mL/L) Postnephrectomy Donor Age (y)
Number
Before
3d
1 mo
3 mo
21–30 31–40 41–50 51–60
33 34 11 2
127.27 132.9 133.5 86
87.9 87.53 70.0 62.0
94.6 91.8 82.5 65.5
99.7 93.18 83.36 70.0
LAPAROSCOPIC DONOR NEPHRECTOMY IN KUWAIT
average of 1.5 hours after the 15th case. Also, there was a noticeable decrease in WIT with progress of the learning curve. Most donors were found to exhibit a raised serum creatinine on the first postoperative day, ranging from one and a half to double that of the preoperative level. This observation could be due to the effect of the pneumoperitoneum compressing the renal vein leading to diminished renal plasma flow and oligouria resulting in ATN,4,6 but there was a noticeable recovery of creatinine in the follow-up period. Postoperative complications were usually due to individual factors such as obesity and smoking. Also, it was clear that the time to achieve good renal function depended on donor age, as the creatinine fell much faster using kidneys from younger donors. In conclusion, this study demonstrated that LDN was a safe procedure with low postoperative morbidity for the donor and short recovery time. There is, without a doubt, a learning curve to master this technique. These findings
815
addressed some of the concerns surrounding LDN and supported its potential to reduce disincentives of living donors. REFERENCES 1. Alston C, Spalivieno M, Gill IS: Laparoscopic donor nephrectomy. Urology 65:833, 2005 2. Derweesh I, Goldfarb D, Abreu S, et al: Laparoscopic live donor nephrectomy and open donor nephrectomy— early and late renal function outcomes. Urology 65:862, 2005 3. Sudhindran S, Sanjeevan KV, Saheed CSM, et al: Initial experience with laparoscopic donor nephrectomies. Transplant Proc 36:1901, 2004 4. Basiri A, Ziaee SA, Hosseini Moghaddam SMM, et al: Laparoscopic living donor nephrectomy in a center with limited laparoscopic experience. Transplant Proc 2549, 2003 5. Odeland MD, Ney AL, Jacobs DM, et al: Initial experience with laparoscopic donor nephrectomy. Surgery 126:603, 1999 6. Floweres JL, Jacobs S, Cho E, et al: Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 226:348, 1997
K
IDNEY TRANSPLANTATION is the treatment of choice for suitable patients with end-stage renal disease. The shortage of organs remains the most important factor limiting the success of kidney transplantation. To decrease the disparity between demand and supply of organs, and to reduce donor morbidity, minimally invasive surgical techniques and laparoscopic instrumentation have been applied to live donor nephrectomy (LDN), thereby reducing postoperative pain, shortening convalescence, and improving the cosmetic outcome of donor nephrectomy.3,5 LDN has, thus, shown the potential to increase the number of living kidney donors further by removing some of the disincentives inherent to donation itself. Some concerns still surround the application of this technique for renal donation.1 The procedure is technically demanding, involving a transperitoneal approach with attendant potential complications. The laparoscopic approach usually takes longer than the open operation, with a potential for an increased © 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 39, 813– 815 (2007)
incidence of respiratory and thromboembolic complications.2 LDN has become the primary source of living donor kidneys for transplantation. Herein we have reported our experience with the first 80 cases. PATIENTS AND METHODS This prospective study evaluated donor morbidity and graft outcomes of 80 LDN performed between May 10, 2005, and May 31, 2006. Patient data were obtained from a combination of a prospective longitudinal database, medical record review, and patient follow-up. Intra- and postoperative recorded data were also obtained. All donors underwent routine preoperative evaluation which included blood pressure measurement, 24-hour urine collecFrom the Hamed Al-Essa Organ Transplantation Centre, Safat, Kuwait. Address reprint requests to S. Buresley, P.O. Box 25427 Safat, Code 13115, State of Kuwait. E-mail: dr_salwa_buresley@ yahoo.com 0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.03.050 813
814
BURESLEY, SAMHAN, AND AL-MOUSAWI Table 1. Postdonation Change in Kidney Function Mean Calculated Creatinine Clearance [e.GPR (mL/min)] Postnephectomy
Donor Age (y)
Number
Before
3 Days
1 Month
3 Months
21–30 31–40 41–50 51–60
33 34 11 2
127.27 132.9 133.5 86.0
87.9 87.53 70.0 62.0
94.6 91.8 82.5 65.5
99.7 93.18 83.86 70.0
tion analysis, blood sugar, renal and liver function blood investigations, ultrasound, and computed tomographic angiography. When both kidneys were equal, the left kidney was selected to take advantage of the longer left renal vein. However, if the left renal vascular anatomy was unfavorable compared with that of the right, the right kidney was selected. All donors received bowel preparation before surgery and prophylactic broad-spectrum antibiotics 1 hour before surgery. After insertion of a Foley catheter, patients were positioned in either the left or the right lateral decubitus positions, according to the kidney side for donation. Three operating ports were used for dissection: one 11 mm port at the umbilicus, one 12 mm port lateral to the rectus muscle, and one 5 mm port in the subcostal area. Care was taken to maintain adequate periureteral tissue to preserve vascularity, to maximize renal vessel length, and to minimize warm ischemia time (WIT). Prior to stapling, anticoagulation was done by injection of 5000 units of heparin intravenously which was reversed with 1 mg/kg protamine sulfate, also intravenously, after pedicle transection. The kidneys were removed using a hand extraction technique through a suprapubic transverse incision. After their removal, the kidneys were flushed with Euro-Collin’s solution and kept in an ice slush preparation. Operation time was defined as that from the initial skin incision to the wound closure, and WIT, as that from clipping of the renal artery to starting cold perfusion. All recipient surgeries were performed through a standard extraperitoneal Gibson incision. End-to-side anastomoses between the renal and external iliac vessels, as well as an extravesical ureteroneocystostomy with insertion of a DJ stent (removed cystoscopically after 4 – 6 weeks posttransplantation), were performed on all recipients.
RESULTS
From May 10, 2005, to May 31, 2006, LDN was attempted in 80 cases and completed successfully in 74 (92%). Mean donor age was 33.28 years (range, 22–53 years). Donors included 68 (85%) men and 12 (15%) women, with overall body mass indices of 17.9 to 42.4. Left nephrectomy was performed in 75 donors and right nephrectomy in 5 donors. Six donors (7.9%) required conversion to an open procedure; all were among the first 10 cases. Three (3.75%) were due to difficulty in identifying the ureter and to presence of multiple veins, while the remaining 3 were due to bleeding. The mean operating time was 186.16 minutes (range, 95–260 minutes). The mean WIT was 5.7 minutes (range, 2–16 minutes). Seven donors (8.75%) required blood transfusions with a total of 13 pints (range, 1– 6 Pints). However, none of the donors needed admission to the intensive care unit. Postoperative analgesia (Pethidine) requirement was
less when it was administered according to patient demand, rather than regular doses. The total dose ranged from 150 to 2350 mg (mean, 670 mg). The mean hospital stay of donors was 5.28 days (range, 3–14 days). Even though many of them could have been discharged earlier, they stayed longer for social reasons. One patient who stayed 14 days was reoperated and developed a chest infection. Most donors returned to work within 1 month after donation. Surgical complications were observed in 11 (13.75%) cases. Two cases (2.5%) were reoperated for bleeding: 1 from the suprarenal gland which was controlled laparoscopically, and 1 for evacuation of a subcutaneous hematoma. The most frequent complications following LDN were chest infection in 4 (5%) and atelectasis in 2 (2.5%) as most of the donors were heavy smokers. The rate of wound infection was low (2.5%), and urinary tract infection was reported in 1 donor (1.25%). All donors progressively recovered renal function, even though the recovery was incomplete within the 3-month follow-up (Table 1). Most transplant recipients were in the middle age group with a mean of 38.9 years (range, 3– 68 years); 54 (67.5%) were men and primary transplantation was performed in all except for 3 (3.75%). Immediate diuresis was observed in 76 (95%) cases. There were 6 (7.5%) cases with acute tubular necrosis (ATN). Three recipients required hemodialysis (HD) in the first week posttransplantation, 1 of whom recovered after 14 days, while the second did so after 120 days. The third needed antirejection treatment to recover. One recipient died suddenly of unknown cause at home 6 weeks posttransplantation with a functioning graft. There was clear association between plasma creatinine normalization and donor age (Table 2). Rejection which occurred in 8 cases (10%) was not related to the duration of WIT or the development of ATN. Eight (10%) recipients developed lymphoceles posttransplantation. DISCUSSION
LDN has been performed by the open surgical approach for several decades. In contrast, LDN is being adopted rapidly by transplant centers around the world as it offers less postoperative pain, more rapid convalescence, and better cosmetic result compared with the open approach.5 However, there are concerns that the laparoscopic technique results in increased costs, due to the requirement for expensive disposable equipment, such as trocars, hand ports, and vessel staplers. The operation time was shortened with more cases from 4 hours in the 1st case to an Table 2. Effect of Donor Age on Recipient’s Renal Function Recipient Mean S. Creat (mL/L) Postnephrectomy Donor Age (y)
Number
Before
3d
1 mo
3 mo
21–30 31–40 41–50 51–60
33 34 11 2
127.27 132.9 133.5 86
87.9 87.53 70.0 62.0
94.6 91.8 82.5 65.5
99.7 93.18 83.36 70.0
LAPAROSCOPIC DONOR NEPHRECTOMY IN KUWAIT
average of 1.5 hours after the 15th case. Also, there was a noticeable decrease in WIT with progress of the learning curve. Most donors were found to exhibit a raised serum creatinine on the first postoperative day, ranging from one and a half to double that of the preoperative level. This observation could be due to the effect of the pneumoperitoneum compressing the renal vein leading to diminished renal plasma flow and oligouria resulting in ATN,4,6 but there was a noticeable recovery of creatinine in the follow-up period. Postoperative complications were usually due to individual factors such as obesity and smoking. Also, it was clear that the time to achieve good renal function depended on donor age, as the creatinine fell much faster using kidneys from younger donors. In conclusion, this study demonstrated that LDN was a safe procedure with low postoperative morbidity for the donor and short recovery time. There is, without a doubt, a learning curve to master this technique. These findings
815
addressed some of the concerns surrounding LDN and supported its potential to reduce disincentives of living donors. REFERENCES 1. Alston C, Spalivieno M, Gill IS: Laparoscopic donor nephrectomy. Urology 65:833, 2005 2. Derweesh I, Goldfarb D, Abreu S, et al: Laparoscopic live donor nephrectomy and open donor nephrectomy— early and late renal function outcomes. Urology 65:862, 2005 3. Sudhindran S, Sanjeevan KV, Saheed CSM, et al: Initial experience with laparoscopic donor nephrectomies. Transplant Proc 36:1901, 2004 4. Basiri A, Ziaee SA, Hosseini Moghaddam SMM, et al: Laparoscopic living donor nephrectomy in a center with limited laparoscopic experience. Transplant Proc 2549, 2003 5. Odeland MD, Ney AL, Jacobs DM, et al: Initial experience with laparoscopic donor nephrectomy. Surgery 126:603, 1999 6. Floweres JL, Jacobs S, Cho E, et al: Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 226:348, 1997