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Laparoscopic Kidney Donation: Looking More Than Skin Deep
0022-5347/05/1746-2289/0 THE JOURNAL OF UROLOGY® Copyright © 2005 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 174, 2289 –2290, December 2005 Printed in U.S.A.
DOI: 10.1097/01.ju.0000187564.45385.22
Urological Survey RENAL TRANSPLANTATION AND RENOVASCULAR HYPERTENSION Laparoscopic Procurement of Kidneys With Multiple Renal Arteries is Associated With Increased Ureteral Complications in the Recipient J. T. CARTER, C. E. FREISE, R. A. MCTAGGART, H. D. MAHANTY, S.-M. KANG, S. H. CHAN, S. FENG, J. P. ROBERTS AND A. M. POSSELT, Division of Transplantation Surgery, University of California–San Francisco, San Francisco, California Am Transplant, 5: 1312–1318, 2005 This study investigates the effect of renal artery multiplicity on donor and recipient outcomes after laparoscopic donor nephrectomy. Three-hundred and sixty-one sequential procedures were performed over a 4-year period. Forty-nine involved accessory renal arteries; of these, 36 required revascularization and 13 were small polar vessels and ligated. The 312 remaining kidneys with single arteries served as controls. Study variables included operative times, blood loss, hospital stay, graft function and donor and recipient complications. Kidneys with multiple revascularized arteries had a longer mean warm ischemia time (35.3 vs. 29.2 min, p ⫽ 0.0003), and more ureteral complications (6/36 vs. 10/312, p ⫽ 0.0013) than single-artery controls. In contrast, ligation of a small superior accessory artery had no significant effect on donor operative time, blood loss, or complication rate while providing similar recipient graft function compared to single-artery controls. Renal artery number is important in selecting the appropriate kidney for laparoscopic procurement. Given the current excellent results with right-sided donor nephrectomy, kidneys with single arteries should be preferentially procured, irrespective of side. Editorial Comment: This is a retrospective, single center report that identifies multiple arteries requiring reconstruction as a risk factor for ureteral complications for laparoscopically procured kidneys. Of 49 cases with multiple arteries 36 required reconstruction. The others were small polar arteries that were ligated. After controlling for many other variables bivariate analyses demonstrated multiple renal arteries requiring reconstruction as a significant risk factor for a ureteral complication (17% vs 3% with single arteries). The 13 cases of small upper pole branches that were ligated did not yield increased complication rates. This is the first such observation published. Early in the development of laparoscopic donor nephrectomy there were high rates of ureteral complications reported. This outcome was likely due to dissection that devascularized the ureter. With wide dissection of the ureter, to include a healthy portion of periureteral tissues, ureteral complication rates have remained low (approximately 3%). Laparoscopic donation has been generally avoided on the right side because of difficulties in obtaining a cuff of inferior vena cava, resulting in a short renal vein, and reports showing higher rates of vascular thrombosis when using the right kidney. As a result, many transplant surgeons prefer to deal with multiple renal arteries from the left kidney rather than a short, fragile right renal vein. The principles of kidney selection have been transformed in the era since laparoscopic donation. This is the first known report showing an inferior outcome with the use of multiple vessels. However, many centers report good results with multiple artery kidneys retrieved laparoscopically. This report puts into question the preferential use of multiple artery left kidneys when simple anatomy is present on the right side. Moreover, it underscores the need to validate the donor technique at each center, ensuring high quality donor and recipient outcomes. David A. Goldfarb, M.D.
Laparoscopic Kidney Donation: Looking More Than Skin Deep A. D. KIRK AND P. A. PINTO, Transplantation Branch, National Institute of Diabetes and Digestive and Kidney Diseases, and Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland Am J Transplant, 5: 1177–1178, 2005 Permission to Publish Abstract Not Granted 2289
2290
RENAL TRANSPLANTATION AND RENOVASCULAR HYPERTENSION
Editorial Comment: This is a thought provoking editorial article addressing laparoscopic donor nephrectomy now that it has been in clinical use for 10 years. It acknowledges the importance of the laparoscopic donor technique but also indicates its limitations. Finally, it emphasizes the need to use individualized procurement techniques that are best suited to each patient to achieve a successful transplantation outcome. David A. Goldfarb, M.D.
Vol. 174, 2289 –2290, December 2005 Printed in U.S.A.
DOI: 10.1097/01.ju.0000187564.45385.22
Urological Survey RENAL TRANSPLANTATION AND RENOVASCULAR HYPERTENSION Laparoscopic Procurement of Kidneys With Multiple Renal Arteries is Associated With Increased Ureteral Complications in the Recipient J. T. CARTER, C. E. FREISE, R. A. MCTAGGART, H. D. MAHANTY, S.-M. KANG, S. H. CHAN, S. FENG, J. P. ROBERTS AND A. M. POSSELT, Division of Transplantation Surgery, University of California–San Francisco, San Francisco, California Am Transplant, 5: 1312–1318, 2005 This study investigates the effect of renal artery multiplicity on donor and recipient outcomes after laparoscopic donor nephrectomy. Three-hundred and sixty-one sequential procedures were performed over a 4-year period. Forty-nine involved accessory renal arteries; of these, 36 required revascularization and 13 were small polar vessels and ligated. The 312 remaining kidneys with single arteries served as controls. Study variables included operative times, blood loss, hospital stay, graft function and donor and recipient complications. Kidneys with multiple revascularized arteries had a longer mean warm ischemia time (35.3 vs. 29.2 min, p ⫽ 0.0003), and more ureteral complications (6/36 vs. 10/312, p ⫽ 0.0013) than single-artery controls. In contrast, ligation of a small superior accessory artery had no significant effect on donor operative time, blood loss, or complication rate while providing similar recipient graft function compared to single-artery controls. Renal artery number is important in selecting the appropriate kidney for laparoscopic procurement. Given the current excellent results with right-sided donor nephrectomy, kidneys with single arteries should be preferentially procured, irrespective of side. Editorial Comment: This is a retrospective, single center report that identifies multiple arteries requiring reconstruction as a risk factor for ureteral complications for laparoscopically procured kidneys. Of 49 cases with multiple arteries 36 required reconstruction. The others were small polar arteries that were ligated. After controlling for many other variables bivariate analyses demonstrated multiple renal arteries requiring reconstruction as a significant risk factor for a ureteral complication (17% vs 3% with single arteries). The 13 cases of small upper pole branches that were ligated did not yield increased complication rates. This is the first such observation published. Early in the development of laparoscopic donor nephrectomy there were high rates of ureteral complications reported. This outcome was likely due to dissection that devascularized the ureter. With wide dissection of the ureter, to include a healthy portion of periureteral tissues, ureteral complication rates have remained low (approximately 3%). Laparoscopic donation has been generally avoided on the right side because of difficulties in obtaining a cuff of inferior vena cava, resulting in a short renal vein, and reports showing higher rates of vascular thrombosis when using the right kidney. As a result, many transplant surgeons prefer to deal with multiple renal arteries from the left kidney rather than a short, fragile right renal vein. The principles of kidney selection have been transformed in the era since laparoscopic donation. This is the first known report showing an inferior outcome with the use of multiple vessels. However, many centers report good results with multiple artery kidneys retrieved laparoscopically. This report puts into question the preferential use of multiple artery left kidneys when simple anatomy is present on the right side. Moreover, it underscores the need to validate the donor technique at each center, ensuring high quality donor and recipient outcomes. David A. Goldfarb, M.D.
Laparoscopic Kidney Donation: Looking More Than Skin Deep A. D. KIRK AND P. A. PINTO, Transplantation Branch, National Institute of Diabetes and Digestive and Kidney Diseases, and Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland Am J Transplant, 5: 1177–1178, 2005 Permission to Publish Abstract Not Granted 2289
2290
RENAL TRANSPLANTATION AND RENOVASCULAR HYPERTENSION
Editorial Comment: This is a thought provoking editorial article addressing laparoscopic donor nephrectomy now that it has been in clinical use for 10 years. It acknowledges the importance of the laparoscopic donor technique but also indicates its limitations. Finally, it emphasizes the need to use individualized procurement techniques that are best suited to each patient to achieve a successful transplantation outcome. David A. Goldfarb, M.D.