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Laparoscopicdonor Nephrectomy Has Almost Replaced Open Donor Nephrectomy
Review Article
LAPAROSCOPIC DONOR NEPHRECTOMY HAS ALMOST REPLACED OPEN DONOR NEPHRECTOMY M V Ramesh Babu Senior Consultant Urologist, Apollo Speciality Hospitals, Lake View Road, K K Nagar, Madurai 625 020, India. Laparoscopic donor nephrectomy (LDN) has several advantages over the open procedure. Thus donor morbidity and pain are much less and the hospital stay is shorter. LDN has now almost replaced open donor nephrectomy. Key words : Laparoscopic donor nephrectomy
MAJORITY of our patients with ESRD undergo live donor renal transplantation because of short supply of cadaver organ. Although it has been established that the immediate and long term morbidity of nephrectomy is sufficiently low to make the risk acceptable for donor [1], we should realize that the renal donor undergoes a major surgery namely donor nephrectomy for nontherapeutic reasons to help a person suffering from ESRD. Hence the safety of donor is of paramount importance and the potential risks associated with the operation must be minimized. The development of laparoscopic donor nephrectomy has achieved this goal to a large extent [2]. ADVANTAGES OF LAPAROSCOPIC DONOR NEPHRECTOMY (LDN) Studies have shown that application of LDN resulted in less pain, decreased duration of hospital stay, smaller and cosmetically better scar and shorter convalescent period compared with the open flank approach [2] (Fig. 1-3). The development of this minimally invasive procedure of renal donation has led to an increase in the number of renal transplant procedures in the United States as more number of people volunteered to donate [2]. TECHNIQUE OF LAPAROSCOPIC DONOR NEPHRECTOMY LDN is a technically challenging procedure and generally requires more operative time than the open technique [2]. LDN can be performed through the retroperitoneal, transperitoneal approach or by the hand assisted laparoscopic technique. Transperitoneal route is commonly performed as it offers a larger working space and well defined anatomic landmarks [3]. The hand assisted approach provides tactile feedback and may be of use to surgeons who have limited advanced laparoscopic training. This technique has also been shown to reduce 133
operative time [2]. In donor nephrectomy the ureter is procured with its blood supply by conducting the dissection medial to the gonadal vein. As well adequate length of blood vessels should be procured so as to conduct the recipient vascular anatomosis without difficulty. These two are the essential steps to prevent ureteric and vascular complications respectively in the recipient. The right renal vein is short and the following modifications in technique can help to achieve maximum length of renal vein during right LDN. (i)
By applying the endoscopic GIA stapler (TA30) device parallel to the inferior vena cava staple the renal vein. Renal vein is cut flush with the staple. This can be achieved by introducing the stapler through the lower quadrant port.
(ii) Convert to open surgery to transect the renal vein and repair IVC on completion of the procedure. (iii) Hand assistance to secure the renal vein on completion of dissection laparoscopically. The relative hypoperfusion of donor kidney due to pneumoperitoneum and the slightly prolonged warm ischemia time associated with manipulations of the kidney into the Endocath bag before retrieval have been of concern. However it has been shown that the relative hypo perfusion of pneumoperitoneum can be ameliorated by fluid loading. Also the slightly prolonged warm ischemia time related to the use of Endocath bag is not clinically significant as the results of graft outcome of hand assisted and purely laparoscopic technique of kidney retrieval are the same [2]. Now-a-day most of the surgeons insert their hand to retrieve the graft and avoids using endobag. Hand technique is quick and complication free. Apollo Medicine, Vol. 6, No. 2, June 2009
Review Article
Fig.1. Laparoscopic (Retroperitoneoscopy) ports, 7cm upper abdominal incision to retrieve the graft.
Fig.2. Small incision of laparoscopic donor nephrectomy.
Fig.3. Incision of open donor nephrectomy.
Donor Safety Systematic review of the literature comparing the laparoscopic and open donor nephrectomy techniques suggest that the laparoscopic procedure has a complication rate that is similar to the open procedure [46]. The two donor deaths (one from pulmonary embolus and one from unreported cause in the hand assisted group) and one patient in a persistent vegetative state following complications caused by intra-operative bleeding in the laparoscopic group identified by Matas and colleagues are of serious concern [7]. The undertaking of LDN cannot be taken lightly. The operation theatre should be adequately equipped and the surgical team well trained before undertaking LDN. The complications rates of LDN vary widely depending on the study design and case definitions. Most studies show that the LDN is a safe procedure and comparable to the traditional open donor nephrectomy in terms of complications. RECIPIENT OUTCOME Grafts procured by the laparoscopic approach function Apollo Medicine, Vol. 6, No. 2, June 2009
promptly after surgery. Delayed graft function occurs in approximately 5 to 10% of recipients. Despite slightly longer warm ischemia with LDN there has been no increase in the rate of delayed graft function in recipients of laparoscopically procured kidneys. The rate of recovery of renal functions, as measured by a decline in the serum creatitine level, has been shown to be comparable for grafts procured using laparoscopic and open techniques. As well laparoscopically procured kidneys have durable function that is comparable to grafts that are procured using an open approach [2]. CONCLUSION LDN is a minimally invasive surgery with less morbidity compared to open donor nephrectomy. With this technique it is possible to procure a graft with adequate length of artery, vein and ureter that can be safely transplanted into the recipient. The complications rate in the donor and graft outcome in the recipient are comparable in the laparoscopic and open techniques of graft procurement. LDN is a technically demanding
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Review Article
surgery and it is likely to replace the open donor nephrectomy as more and more centers perform this technically difficult procedure. It appear that open donor nephrectomy may only be comtemplated when kidney is very abnormal in anatomy and vessels position. Such situation will be infrequent. REFERENCES
3. Gill IS, Retroperitoneal Laparoscopic Nephrectomy Urol Clin North Am 1998; 25: 343. 4. Handschin AE, Weber M, Demartines N, et al. Laparoscopic donor nephrectomy. Br J Surg 2003; 90: 1323. 5. Merlin TL, Scott DF, Rao MM, et al. The safety and efficacy of laparoscopic live donor nephrectomy: a systematic review. Transplantation 2000; 70:1659.
1. Benedict Cosimi A, Dicken SCK. Kidney Transplantation: principles and practice, 6e: Donor Nephrectomy, Open Nephrectomy 2009; 111-117.
6. Tooher RL, Rao MM, Scott DF, et al. A systematic review of laparoscopic live-donor nephrectomy. Transplantation 2004; 78: 404.
2. Christopher E Sunpkins, Robert A. Mont Jomeny: Kidney Transplantation: Principles and practice, 6e: Laparoscopic Live Donor Nephrectomy 2009; 117-125.
7. Matas AJ, Barlett ST, Leichtinan AB, et al. Morbidity and mortality after living kidney donation, 1999-2001: survey of United States transplant centers. Am J Transplant 2003; 3: 830.
135
Apollo Medicine, Vol. 6, No. 2, June 2009
LAPAROSCOPIC DONOR NEPHRECTOMY HAS ALMOST REPLACED OPEN DONOR NEPHRECTOMY M V Ramesh Babu Senior Consultant Urologist, Apollo Speciality Hospitals, Lake View Road, K K Nagar, Madurai 625 020, India. Laparoscopic donor nephrectomy (LDN) has several advantages over the open procedure. Thus donor morbidity and pain are much less and the hospital stay is shorter. LDN has now almost replaced open donor nephrectomy. Key words : Laparoscopic donor nephrectomy
MAJORITY of our patients with ESRD undergo live donor renal transplantation because of short supply of cadaver organ. Although it has been established that the immediate and long term morbidity of nephrectomy is sufficiently low to make the risk acceptable for donor [1], we should realize that the renal donor undergoes a major surgery namely donor nephrectomy for nontherapeutic reasons to help a person suffering from ESRD. Hence the safety of donor is of paramount importance and the potential risks associated with the operation must be minimized. The development of laparoscopic donor nephrectomy has achieved this goal to a large extent [2]. ADVANTAGES OF LAPAROSCOPIC DONOR NEPHRECTOMY (LDN) Studies have shown that application of LDN resulted in less pain, decreased duration of hospital stay, smaller and cosmetically better scar and shorter convalescent period compared with the open flank approach [2] (Fig. 1-3). The development of this minimally invasive procedure of renal donation has led to an increase in the number of renal transplant procedures in the United States as more number of people volunteered to donate [2]. TECHNIQUE OF LAPAROSCOPIC DONOR NEPHRECTOMY LDN is a technically challenging procedure and generally requires more operative time than the open technique [2]. LDN can be performed through the retroperitoneal, transperitoneal approach or by the hand assisted laparoscopic technique. Transperitoneal route is commonly performed as it offers a larger working space and well defined anatomic landmarks [3]. The hand assisted approach provides tactile feedback and may be of use to surgeons who have limited advanced laparoscopic training. This technique has also been shown to reduce 133
operative time [2]. In donor nephrectomy the ureter is procured with its blood supply by conducting the dissection medial to the gonadal vein. As well adequate length of blood vessels should be procured so as to conduct the recipient vascular anatomosis without difficulty. These two are the essential steps to prevent ureteric and vascular complications respectively in the recipient. The right renal vein is short and the following modifications in technique can help to achieve maximum length of renal vein during right LDN. (i)
By applying the endoscopic GIA stapler (TA30) device parallel to the inferior vena cava staple the renal vein. Renal vein is cut flush with the staple. This can be achieved by introducing the stapler through the lower quadrant port.
(ii) Convert to open surgery to transect the renal vein and repair IVC on completion of the procedure. (iii) Hand assistance to secure the renal vein on completion of dissection laparoscopically. The relative hypoperfusion of donor kidney due to pneumoperitoneum and the slightly prolonged warm ischemia time associated with manipulations of the kidney into the Endocath bag before retrieval have been of concern. However it has been shown that the relative hypo perfusion of pneumoperitoneum can be ameliorated by fluid loading. Also the slightly prolonged warm ischemia time related to the use of Endocath bag is not clinically significant as the results of graft outcome of hand assisted and purely laparoscopic technique of kidney retrieval are the same [2]. Now-a-day most of the surgeons insert their hand to retrieve the graft and avoids using endobag. Hand technique is quick and complication free. Apollo Medicine, Vol. 6, No. 2, June 2009
Review Article
Fig.1. Laparoscopic (Retroperitoneoscopy) ports, 7cm upper abdominal incision to retrieve the graft.
Fig.2. Small incision of laparoscopic donor nephrectomy.
Fig.3. Incision of open donor nephrectomy.
Donor Safety Systematic review of the literature comparing the laparoscopic and open donor nephrectomy techniques suggest that the laparoscopic procedure has a complication rate that is similar to the open procedure [46]. The two donor deaths (one from pulmonary embolus and one from unreported cause in the hand assisted group) and one patient in a persistent vegetative state following complications caused by intra-operative bleeding in the laparoscopic group identified by Matas and colleagues are of serious concern [7]. The undertaking of LDN cannot be taken lightly. The operation theatre should be adequately equipped and the surgical team well trained before undertaking LDN. The complications rates of LDN vary widely depending on the study design and case definitions. Most studies show that the LDN is a safe procedure and comparable to the traditional open donor nephrectomy in terms of complications. RECIPIENT OUTCOME Grafts procured by the laparoscopic approach function Apollo Medicine, Vol. 6, No. 2, June 2009
promptly after surgery. Delayed graft function occurs in approximately 5 to 10% of recipients. Despite slightly longer warm ischemia with LDN there has been no increase in the rate of delayed graft function in recipients of laparoscopically procured kidneys. The rate of recovery of renal functions, as measured by a decline in the serum creatitine level, has been shown to be comparable for grafts procured using laparoscopic and open techniques. As well laparoscopically procured kidneys have durable function that is comparable to grafts that are procured using an open approach [2]. CONCLUSION LDN is a minimally invasive surgery with less morbidity compared to open donor nephrectomy. With this technique it is possible to procure a graft with adequate length of artery, vein and ureter that can be safely transplanted into the recipient. The complications rate in the donor and graft outcome in the recipient are comparable in the laparoscopic and open techniques of graft procurement. LDN is a technically demanding
134
Review Article
surgery and it is likely to replace the open donor nephrectomy as more and more centers perform this technically difficult procedure. It appear that open donor nephrectomy may only be comtemplated when kidney is very abnormal in anatomy and vessels position. Such situation will be infrequent. REFERENCES
3. Gill IS, Retroperitoneal Laparoscopic Nephrectomy Urol Clin North Am 1998; 25: 343. 4. Handschin AE, Weber M, Demartines N, et al. Laparoscopic donor nephrectomy. Br J Surg 2003; 90: 1323. 5. Merlin TL, Scott DF, Rao MM, et al. The safety and efficacy of laparoscopic live donor nephrectomy: a systematic review. Transplantation 2000; 70:1659.
1. Benedict Cosimi A, Dicken SCK. Kidney Transplantation: principles and practice, 6e: Donor Nephrectomy, Open Nephrectomy 2009; 111-117.
6. Tooher RL, Rao MM, Scott DF, et al. A systematic review of laparoscopic live-donor nephrectomy. Transplantation 2004; 78: 404.
2. Christopher E Sunpkins, Robert A. Mont Jomeny: Kidney Transplantation: Principles and practice, 6e: Laparoscopic Live Donor Nephrectomy 2009; 117-125.
7. Matas AJ, Barlett ST, Leichtinan AB, et al. Morbidity and mortality after living kidney donation, 1999-2001: survey of United States transplant centers. Am J Transplant 2003; 3: 830.
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Apollo Medicine, Vol. 6, No. 2, June 2009