Laparoscopic Live Donor Nephrectomy: Single Center Experience N. Baldan, L. Furian, B. Ekser, L. Fabris, A. Broggiato, R. Cadrobbi, M. Costantini, G. Zaninotto, and P. Rigotti ABSTRACT Aims. The aim of this study was a retrospective assessment of the safety of laparoscopic live donor nephrectomy (LLDN) and the outcome of these renal transplantations. Methods. From November 2001 to October 2006, we performed 30 LLDN (all left nephrectomies) after excluding any renal vascular anomalies in the donor. All laparoscopic procedures were performed by a team consisting of an expert laparoscopic surgeon and a transplant surgeon. The donor mean age was 48.9 ⫾ 7.6 years (range 22 to 69), 33% of the donors were men and their mean Body Mass Index was 24.7 ⫾ 3.8 kg/m2. The recipients were a 32 ⫾ 14 years old (range 6 to 64), with 66% of them men, and their mean time on dialysis, 33 ⫾ 49 months (range 0 to 120). Results. After a mean follow-up of 39 ⫾ 14 months, all donors and recipients are alive. The mean operative time was 272 ⫾ 41 min (range 225–360) and the mean warm ischemia time, 161 ⫾ 35 seconds (range 107 to 240). Surgical complications in the donors were one incisional hernia and two cases of pneumonia. The donor’s mean hospital stay was 5.3 ⫾ 1.7 days (range 3 to 12) and their mean serum creatinine at discharge was 111 ⫾ 21 mol/L. There was one surgical complication-a hematoma-among the recipients, and all transplants functioned immediately except for one case. Conclusions. LLDN was confirmed to be safe and effective, with no negative impact on transplants success. Expertise in laparoscopic surgery is needed to minimize the side effects for the transplant donor and for the recipient.
M
ORE than 50 years since the first living related donor nephrectomy,1 many centers are currently performing this operation using various techniques. Open live donor nephrectomy (OLDN) has been the procedure of choice for many years. Laparoscopic live donor nephrectomy (LLDN) was introduced in 1995 in an attempt to reduce the morbidity associated with the open technique,2 but many centers embarking on a LLDN program observed that the advantages of LLDN had to be balanced against a learning curve with a high incidence of surgical complications. Over the last decade, developments in LLDN have drastically increased living donation rates in many countries, particularly The United States.3 The scenario is not the same in Europe, where only about 12% of transplanted kidneys originate from living donors.4 In Italy, the figures for living donation are below the European average. An Italian multi-center study showed that the national average in 2004 was 8.3% of all kidney transplantation procedures.5
These data suggested that efforts be made to increase kidneys from living donors. The purpose of this study was a retrospective review of the outcomes of LLDN, in terms of the donors and the recipients, analyzing how the rate of surgical complications might have been reduced in this initial phase of the program. PATIENTS AND METHODS We conducted a retrospective chart review of 30 living donors who underwent LLDN and their respective kidney transplant recipients from November 2001 (our first LLDN) to October 2006. All LLDN From the Dipartimento di Chirurgia Generale e Trapianti d’Organo, U.O. Trapianti Rene e Pancreas, Azienda Ospedaliera, Università di Padova, Padova, Italy. Address correspondence to Nicola Baldan, MD, PhD, Kidney and Pancreas Transplant Centre, Department of General Surgery and Organ Transplantation, Padua General Hospital, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy. E-mail:
[email protected]
© 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.07.021
Transplantation Proceedings, 39, 1787–1790 (2007)
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1788 procedures were performed by the same surgical team consisting of laparoscopic and a transplant surgeon. All patients were studied preoperatively by either angiogram, magnetic resonance angiography or computed tomographic angiography. LLDN was only performed in cases of left nephrectomy. Right open nephrectomy was indicated in cases of left multiple renal arteries or the right revealing reduced renal function, cysts, renal pelvic ectasia or smaller size, in which cases LLDN was not feasible. LLDN was performed as described by Ratner and Kavoussi.2 After kidney dissection, an Endocatch bag was inserted in the abdomen through a Pfannenstiel incision, preserving the integrity of the anterior parietal peritoneum and maintaining the pneumoperitoneum. The kidney was placed in the bag to enable wider exposure of the vessels. Two vascular EndoGIA were used to section the renal artery and vein as long as possible. The peritoneum of the Pfannenstiel was lacerated and the bag containing the kidney withdrawn. The harvested kidney perfused on the bench was preserved with cold Celsior solution.6
Donors The donor mean age was 48.9 ⫾ 7.6 years (range 22 to 69), and 33% were men (10/30); 24/30 were related (20 parents, 4 brothers or sisters), while 6 cases were unrelated (5 spouses, 1 sister-in-law). The mean Body Mass Index was 24.7 ⫾ 3.8; only 2 donors were obese (BMI ⫽ 31 and 37). Before donation, the donor mean serum creatinine was 81 ⫾ 11 mol/L, mean blood pressure 128/80 and 5 cases the donor was treated with an anti-hypertensive drug.
Recipients The recipients were a mean of 32 ⫾ 14 years (range 6 to 64); 3 were pediatric cases (6, 9 and 15 years). Twenty were men (66%), and then overall mean weight was 62 ⫾ 15 kg (range 21 to 91). The mean HLA mismatch was 2.9 (range 0 to 5). In one case the transplant was preemptive, while the mean time on dialysis for the remainder was 33 ⫾ 49 months (range 0 to 120). All transplanted patients received a calcineurin inhibitor-based therapy. With basiliximab Monoclonal antibody induction in 4 cases.
Variables and Statistics All data are reported as mean values ⫾ standard deviations (SD). Statistical analyses were performed with Student’s t-test, Fisher’s exact test, or the Kruskal-Wallis or Mann-Whitney tests, as appropriate, to compare differences between quantitative and qualitative variables. Significance was set at a “P” value of ⬍ .05. KaplanMeier analysis was used to calculate graft and patient survival rates.
RESULTS
After a mean follow-up of 39 ⫾ 14 months, all recipient and but one donor is alive. One recipient died of myocardial infarction at 36 months after transplantation. Table 1 shows the results of LLDN in detail. The mean operating time was 272 ⫾ 41 min (range 225 to 360) and the mean warm ischemia time 161 ⫾ 35 seconds (range 107 to 240). Surgical complications in the donors included one incisional hernia at the port site. There were also two cases of postoperative pneumonia. The donor mean hospital stay was 5.3 ⫾ 1.7 days (range 3 to 12) and mean serum creatinine level at discharge was 111 ⫾ 21 mol/L. No donors started antihy-
BALDAN, FURIAN, EKSER ET AL Table 1. Results of LLDN Parameters
Mean
Range
Operating time (mins) Warm ischemia time (s) Complications pneumonia hernia at port site Analgesia (d) Return to oral nutrition (postop. day) Bowel movement (postop. day) Hospital stay (d) S-Cr at discharge (umol/L) Return to work (d) Mean follow-up (mo) S-Cr at last follow-up (umol/L) Blood pressure at follow-up (mm Hg)
272 ⫾ 41 161 ⫾ 35
225–360 107–240
2 1 1.6 ⫾ 1.4 2.4 ⫾ 0.5 2.9 ⫾ 0.7 5.3 ⫾ 1.7 113 ⫾ 21 21.8 ⫾ 7.7 39 ⫾ 14 111 ⫾ 21 123/78
0–5 2–3 2–4 3–12 87–166 10–30 1–60 76–160 90/70–150/80
pertensive therapy after nephrectomy. There were no surgical complications in the recipients; all transplants functioned immediately except for one case of PNF, where the recipient suffered anaphylactic shock due to basiliximab (anti-IL2R monoclonal antibody). The mean serum creatinine level measured at several time points after transplantation are shown in Table 2. Biopsy-proven acute rejection was documented in 9 recipients, all occurring in the first month after transplantation and resolved by steroid treatment, except for one case requiring thymoglobulin treatment. The recipient mean hospital stay was 18 ⫾ 9 days (range 11 to 49) and the mean serum creatinine at discharge was 112 ⫾ 28 mol/L (range 57 to 185).
DISCUSSION
It is now widely accepted that kidney transplantation not only improves the quality of life but also prolongs survival. Unfortunately, the shortage of organs makes it impossible to face the increasing need. In this situation, living donation is one potential way to increase organ availability. The first successful living donor renal transplantation was performed in 1954 by Murray in Boston.1 Over the next 40 years, living donor nephrectomy was performed via a lombotomy or laparotomy access. In 1995, Ratner and colleagues were the first to perform LLDN in an effort to reduce surgical trauma and improve the postoperative course after nephrectomy.2 Ever since these early experiences, advantages of LLDN have been clearly evident,7–9 -in terms of less postoperative pain, a shorter hospital stay and a quicker return to work, although the operating time was longer. All these aspects were confirmed in our own experience. One of the main disadvantages of LLDN, observed particularly in the initial experiences, was a learning curve with high incidences of ureteral complications and early graft function loss.10 In his first 175 cases, Ratner recorded ureteral complications in 9.1% of patients.11 This high complication rate was not observed at our center. To
LAPARASCOPIC LIVE DONOR NEPHRECTOMY
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Table 2. Mean Recipient Serum Creatinine Levels in the Recipients (mol/L) at Various Time Points
Serum creatinine
Day 0
Day 3
Day 7
Discharge
1 mo
6 mo
12 mo
650 ⫾ 228
190 ⫾ 245
160 ⫾ 106
112 ⫾ 28
118 ⫾ 32
126 ⫾ 19
125 ⫾ 30
minimize the effect of the learning curve, our LLDN have been performed by the same team. Bleeding is another frequent intra-operative complication in LLDN which is responsible for most conversions to open surgery, which occur in 1.8 –13% of cases.12, 13 There have been no conversions so far at our center. Finally, the donated kidney may be damaged by a lengthy warm ischemia time and the high intra- abdominal pressure induced by the pneumoperitoneum. Many authors have suggested a possible association between LLDN and prolonged warm ischemia time due to the laparoscopic renal vessel section and kidney extraction. These factors can affect the recovery of renal function. In our experience, the warm ischemia time was sufficiently short because the kidney was placed in the bag just before clamping the renal vessels. Pneumoperitoneum may hinder renal outflow and consequently damage the kidney.14,15 At our center, all donors were over-hydrated the night before and during the LLDN to cope with risk of damage due to high intraperitoneal pressure. This preparatory measure also made the donor polyuric. The suitability of these methods was confirmed by the absence of any cases of delayed graft function in our series. The only case of primary nonfunction was attributed to an anaphylactic reaction to monoclonal antibody which was unrelated to the LLDN technique. Some groups have developed alternative mini-invasive techniques. In 1998, Wolf performed the first hand-assisted LLDN (H-ALLDN) showing that this enabled better control of the renal vessels and avoided bleeding and vascular pedicle torsion.16,17 H-ALLDN also facilitated the atraumatic mobilization of the colon for ureteral dissection, avoiding microvascular lesions and the risk of ureteral necrosis, as well as allowed retraction of the kidney to better expose the renal vessels in the final stages of the organ harvest. This technique reduced the learning curve and thus minimized the incidence of surgical complications.12 Accurate donor selection is crucial to reduce surgical complications, particularly at centers with limited LLDN experience. Previous abdominal surgery, right kidney nephrectomy, obesity and multiple arteries are the most frequent reasons for excluding LLDN. The first renal vessel anatomy evaluations at our center were performed using angiography. Later, we used magnetic resonance angiography or computed tomographic angiography, as suggested by several authors.18,19 Due to our failure to identify an inferior polar artery using magnetic resonance angiography in 2 cases, in the latest 10 donors we have opted for computed tomographic angiography.
Right kidney LLDN is avoided at most centers, because the right vein is shorter.20 Using a vascular stapler further shortens the vein, thus increasing the risk of thrombosis. Although many authors with ample LLDN experience continue to perform right LLDN only occasionally, if at all.21,22 Kok recently presented better results with right LLDN than with left LLDN, in terms of the duration of the procedure, blood loss, conversion to open surgery and postoperative complications.23 Obesity (BMI⬎30) has been considered another reason to exclude LLDN,24 but in an analysis of 110 obese donors, Leventhal found no disadvantage in terms of blood loss, intraoperative complications, conversions or hospital stay.19 In our series, all but two donors had a BMI ⬍ 30; the two obese donors had no surgical or postoperative complications and were discharged no later than the other donors. The presence of multiple arteries can make it more difficult to dissect the vascular pedicle, thus increasing the incidence of complications after transplantation. Kuo nonetheless recorded similar operating times, surgical complications and conversions for kidneys with single and multiple arteries. Only the warm ischemia time was longer for kidneys with multiple arteries, but this did not affect the recovery of renal function.19,25 We share this point of view but, at the beginning of our experience, we preferred to perform LLDN only in patients with a single renal artery and no contraindications to left kidney donation. In conclusion, Living donation is one method to deal with the organ shortage. LLDN was confirmed as being safe and effective, without any negative impact on transplantation outcomes. Expertise in laparoscopic surgery is essential to minimize the complications both of the laparoscopic procedure and for the transplant recipient. REFERENCES 1. Harrison JH, Merrill JP, Murray JE: Renal homotransplantations in identical twins. Surg Forum 6:432, 1956 2. Ratner LE, Ciseck LJ, Moore RG, et al: Laparoscopic live door nephrectomy. Transplantation 60:1047, 1995 3. Troppmann C, Ormond DB, Perez RV: Laparoscopic (vs oper) live donor nephrectomy: a UNOS database analysis of early graft function and survival. Am J Transplant 3:1295, 2003 4. Groth CG: Presidential address 2002: Organ transplantation as a patient service worldwide. Transplantation 75:1098, 2003 5. Pietrabissa A, Boggi U, Vistoli F, et al: Laparoscopic Living Donor Nephrectomy in Italy: A national profile. Transplant Proc 36:460, 2004 6. Pedotti P, Cardillo M, Rigotti P, et al: A comparative prospective study of two available solutions for kidney and liver preservation. Transplantation 77:1540, 2004 7. Cadeddu JA, Ono Y, Clayman RV, et al: Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience. Urology 53:773, 1998
1790 8. Ono Y, Kinukawa T, Hattori R, et al: Laparoscopic radical nephrectomy for renal cell carcinoma: a five-year experience. Urology 53:280, 1999 9. Jeschke K, Wakonig J, Pitzler C, et al: Laparoscopic radical nephrectomy: a single-center experience of 51 cases. Tech Urol 6:9, 2000 10. Nogueira JM, Cangro CB, Fink JC, et al: A comparison of recipient renal outcomes with laparoscopic versus open donor nephrectomy. Transplantation 67:722, 1999 11. Ratner LE, Montgomery RA, Maley WR, et al: Laparoscopic live donor nephrectomy: the recipient. Transplantation 69:2319, 2000 12. Novotny MJ: Laparoscopic live donor nephrectomy. Urol Clin North Am 28:127, 2001 13. Ratner LE, Kavoussi LR, Schulam PG, et al: Comparison of laparoscopic live donor nephrectomy versus the standard open approach. Transplant Proc 29:138, 1997 14. Kirsch AJ, Hensle TW, Chang DT, et al: Renal effects of CO2 insufflation: oliguria and acute renal dysfunction in a rat pneumoperitoneum model. Urology 43:453, 1994 15. Richard WO, Scovill W, Shin B, et al: Acute renal failure associated with increased intra-abdominal pressure. Ann Surg 197:183, 1983 16. Wolf JS, Tchetgen M, Merion RM: Hand-assisted laparoscopic live donor nephrectomy. Urology 52:885, 1998 17. Slakey DP, Wood JC, Hender D, et al: Laparoscopic living donor nephrectomy. Transplantation 68:581, 1999
BALDAN, FURIAN, EKSER ET AL 18. Ratner LE, Montgomery RA, Kavoussi LR: Laparoscopic live donor nephrectomy: the four-year Johns Hopkins University experience. Nephrol Dial Transplant 14:2090, 1999 19. Leventhal JR, Kocak B, Salvalaggio PR, et al: Laparoscopic donor nephrectomy 1997 to 2003: lessons learned with 500 cases at a single institution. Surgery 136:881, 2004 20. Melcher ML, Carter JT, Posselt A, et al: More than 500 consecutive laparoscopic donor nephrectomies without conversion or repeated surgery. Arch Surg 140:835, 2005 21. Kok NFM, Alwayn IPJ, Tran KTC, et al: Reluctance towards right-side laparoscopic donor nephrectomy does not make sense. Am J Transplant 6(Suppl 2): 806, 2006 22. Bay WH, Herbert LA: The living donor in kidney transplantation. Ann Intern Med 106(5): 719, 1987 23. Kuo PC, Cho ES, Flowers JL, et al: Laparoscopic living donor nephrectomy and multiple renal arteries. Am J Surg 176:559, 1998 24. Rydberg J, Kopecky KK, Tann M, et al: Evaluation of prospective living renal donors for laparoscopic nephrectomy with multisection CT: the marriage of minimally invasive imaging with minimally invasive surgery. Radiografics 2001 Oct; 21 Spec No: S223–236 25. Giessing M, Kroencke TJ, Taupitz M, et al: Gadoliniumenhanced three-dimensional magnetic resonance angiografhy versus conventional digital subtraction angiography: which modality is superior in evaluating living kidney donors? Transplantation 76: 1000, 2003
