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ORIGINAL ARTICLE |
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| Year : 2002 | Volume
: 19
| Issue : 1 | Page : 29-37 |
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Laparoscopic live donor nephrectomy: An indian perspective
Nand Kishore Arvind, Anant Kumar
Department of Urology and Renal Transplantation, SGPGIMS, Lucknow, India
Correspondence Address:
Anant Kumar
Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rai Bareli Road, Lucknow - 226 014
India
 Source of Support: None, Conflict of Interest: None  | Check |
Keywords: Donor Nephrectomy; Laparoscopy
How to cite this article:
Arvind NK, Kumar A. Laparoscopic live donor nephrectomy: An indian perspective. Indian J Urol 2002;19:29-37 |
 Introduction | |  |
Renal transplantation remains the best option for end stage renal disease (ESRD). Living donor renal transplantation is associated with better graft and patient survival, shorter waiting time, optimization of medical health of the recipient and an overall reduced cost when compared with cadaveric transplantation according to United Network for Organ Sharing registry data. [1] Inspite of this, live donor nephrectomy accounts for 90%, 30% 25% and 25% of transplants performed in developing nations, western world, Scandinavian countries and Europe respectively. [2] This relates, in part, to the disincentives associated with donation. Factors such as prolonged hospitalization, postoperative pain, and extensive postoperative recovery associated with lost wages, and cosmetic results of major abdominal surgery, will deter individuals from live donor nephrectomy.
Laparoscopic live donor nephrectomy (LDN) was developed to decrease disincentives to live donations and overcome the organ shortage. In 1994, Gill and associates demonstrated the feasibility of performing LDN in porcine model. [3] Soon thereafter, Ratner and colleague reported the first successful human laparoscopic live donor nephrectomy. [4] Since then, several transplant centers have reported their experiences with LDN.
Open donor nephrectomy (ODN) is a very successful surgical procedure, and excellent results have been obtained with respect to patient morbidity and mot tality. [5],[6],[7] For LDN to be considered a successful procedure, it must equal or exceed the gold standard procedure - ODN - in 2 essential criteria: (1) outcome for the recipient and (2) outcome for the donor. A review of the outcome data comparing LDN to ODN reveals a paucity of randomized prospective studies. [8],[9],[10],[11],[12] Most reviews are retrospective, comparing results for ODN performed years earlier with results from more recently performed LDN. Such comparisons are invalid since, over the years, lengths of hospital stay have shortened for most procedures, including nephrectomy. In addition, because a shortage of organs has made living-related kidney transplants more universally accepted, transplant centers have gained experience with living donors, resulting in reduced hospital stays and improved outcome data.
In keeping with a general trend toward minimally invasive surgery, the operative approach to ODN has changed as well. The location and size of the incision and the extent of dissection have been altered to reduce postoperative morbidity. The length of stay for nephrectomy patients in general and for donor nephrectomy specifically has improved over the past 3 years. [13]
Is donor outcome better in LDN ?
The laparoscopic approach results in significant benefits to the donor. Various perioperative indices have been compared: blood loss, operative time, resumption of oral intake, parenteral narcotic use, and length of hospital stay. Various studies have shown that LDN results in less blood loss than ODN (122.3-266 mL and 393-408 mL, respectively). [14],[15] It has also been demonstrated that oral intake can resume quickly after LDN; approximately 2 days earlier than after ODN. [16] Parenteral narcotic use is lower for LDN compared with ODN, both in total dosage of morphine sulfate (LDN, 40 ± 33 mg; ODN 124 ± 88 mg; P<0.001) [17] and duration of use (LDN, 28.6 hours; ODN, 60.1 hours; P=0.0001). [10] The length of hospital stay is also shorter with LDN than with ODN (2.2-2.9 days and 4.5-5.5 days, respectively). [14],[15] While taking longer to perform than ODN, the operative time required for LDN is reasonable (LDN, 226.3 min; ODN. 212.8 min). [10] The increased operative time for the laparoscopic procedure adds to the total cost of operation without increasing morbidity. However operation room time is again not relevant to many hospitals in India. Although the intraop-erative blood loss is less in laparoscopic group, the transfusion rate was similar in both the groups. In the initial series, the conversion rate from laparoscopic to open approach ranged from 6% to 13%. With increasing experience, in the recent large series of the University of Maryland and the John Hopkins University, this had come down to 1.6% to 1.8%.[18],[19] The most common cause for conversion was excessive bleeding; however, this complication did not lead to a statistically significant increase in the transfusion rates in the laparoscopic donor nephrectomy group. The reoperative rate in the laparoscopic donor nephrectomy group ranged from 1 % to 8% for reasons like haemorrhage, small bowel obstruction, internal hernia, splenic injury, and for retrieval of a foreign body. Recent series of perioperative morbidity comparing the open approach with laparoscopic approach are shown in [Table - 1].
Postoperative convalescence data from several series comparing laparoscopic nephrectomy with open donor nephrectomy are summarized in [Table - 2]. LDN patients also resume normal activities faster than ODN patients. Various indices such as resumption of normal housework, driving, work and exercise have been evaluated, and all such indices indicate an advantage for LDN donors. Normal household chores can be resumed 18 to 19 days earlier. [16] LDN patients resume driving 8.7 to 20.5 days earlier, and return to work 2 to 5 weeks earlier.[16],[17] Also, physically active people can resume exercise about 5 weeks earlier when LDN is performed compared with ODN.
Complication rates of LDN and ODN donors are comparable. In a study of ODNs with a 28-year follow-up, D'Alessandro and colleagues reported a complication rate of 17%. [5] The most common complications were pneumothorax and urinary tract infection. Johnson and associates reported a complication rate of 8.2% in 871 ODNs.[6] Major complications included wound infection (2.4%), pneumothorax (1.5%), femoral nerve compression (<1 %), and reoperation for retained sponge (<1%). In other studies laparoscopic cases had complication rates of 14% to 16%. [8],[10],[14],[17] In Nogueira and associates' series of 110 consecutive LDNs, the most common complications included transient thigh paresthesias (4.1%), blood transfusion (3.5%), and wound infection (2.9%). [14] The open conversion rate was 1.8%. Major complications of two largest series are shown in [Table - 3].
Unlike the factors described previously, cosmesis and body image are difficult to quantify objectively. Although no data exist from psychological studies comparing LDN and ODN with respect to body images, Hensman and colleagues reported that up to 25% of ODN patients complained of flank "diastasis" after surgery. [20] Laparoscopic donor nephrectomy gives better cosmesis as scar is small and is often located in the lower flank or suprapubic region. It is a major incentive to females.
Ultimately, a significant benefit of laparoscopic surgery is to remove the disincentives to renal donation. While it may be argued that donors are altruistic and motivated individuals who will donate regardless of surgical approach, it is clear that institutions employing laparoscopic techniques experience dramatic increases (85% to >100%) in live donor nephrectomies. [16],[17] In a postoperative survey of donors, 20% of LDN patients stated that they would not have donated if LDN had not been offered.[21]
Cost
The hospital stay was significantly shorter for the laparoscopic group; however, the cost savings generated by a decrease in hospital stay were negated by a significantly greater operative cost in the laparoscopic group. [22] The net result was that, the total cost of hospitalization was similar in the two groups. The financial loss of the laparoscopic donor was 30% of the loss incurred by the open donor nephrectomy patients due to absence from work.
However, this does not hold true in Indian setup, where disposables are expensive (Endocatch US $ 105, pneumosleeve US $ 490, vascular staplers US $ 300), whereas hospital bed charges are only US $6 to US $8 per day. Moreover, the operation charges are fixed, and patients are not charged according to the duration of the procedure. The consumables are charged as and when used. High cost was the major cause of reluctance of our patients regarding laparoscopic donor nephrectomy when the program was started in 2000, which forced us to develop a modified technique as described above, that avoided use of costly disposables. This modified technique is significantly cheaper in comparison to the standard and hand assisted donor nephrectomy [Table - 4].[23]
Recipient Outcome
In a recently conducted survey to determine the current practices, attitudes and plans regarding laparoscopic donor nephrectomy in high-volume renal transplantation centers at USA (representing 43% of all kidney transplantation done nationally), the most common disincentive for laparoscopic nephrectomy was concern for graft survival .[24]
Because the therapeutic goal of donor nephrectomy is to restore renal function to the recipient, paramount importance is placed on achieving excellent allograft function and survival. Additionally, given the time-tested safety of ODN, LDN recipient morbidity should be minimal.
Does renal function suffer in patients with kidneys obtained by LDN ? It has been shown that the pneumoperitoneum used for laparoscopy results in transient oliguria. [25] Concern over this physiologic phenomenon has led to the use of aggressive intraoperative hydration and administration of an osmotic diuretic (mannitol) to encourage diuresis. However, as animal experiments have proven, no chronic ischemic renal histologic changes are evident after prolonged pneumoperitoneum.[26] Other concerns regarding longer warm ischemia times, trauma to the allograft during laparoscopic dissection, and trauma during allograft extraction have been expressed. [27]
With respect to short-term allograft function, conflicting results have been obtained. Nogueira and colleagues, in a comparison of 132 LDN and 99 ODN cases, observed higher serum creatinine levels in LDN recipients compared with ODN recipients from 1 week (2.8 ± 0.3 mg/dL versus 1.8 ± 0.2 mg/dL, P=0.005) to 1 month (2.0 ± 0.1 mg/ dL versus 1.6 ± 0.1 mg/dL, P=0.05) after transplant.' Ratner and associates, in their series of 110 laparoscopic and 48 open cases, observed no significant differences in serum creatinine during the 4-day period following surgery. [15] However, it did take 1 day longer for nadir serum creatinine to be reached in LDN allografts - 4 days as opposed to 3. London and colleagues, in a smaller series (21 ODN, 12 LDN) also observed no significant differences in serum creatinine at 1, 3 and 30 days following transplantation. [12]
Although short-term renal function is important, attaining durable long-term renal function that enables independence from dialysis is the ultimate objective. In the 2 largest institutional series to date, the long-term renal function of LDN and ODN allografts was equivalent. [18],[19] Ratner and associates noted that, at 24 months, creatinine clearance was no significantly different between the 2 groups. [15] Interestingly, the University of Maryland series shows that LDN allografts had a slightly lower mean serum creatinine (LDN, 1.4 ± 0.1 mg/dL; ODN, 1.7 ± 0.1 mg/dL, P=0.03) at 1 year following transplantation.[14]
Allograft survival rates of LDN and ODN cases were also comparable. Nogueira and colleagues reported that combined patient and graft survival rates were statistically equivalent. [14] The incidence of early acute rejection was similar in the 2 groups (ODN, 3.0%, LDN, 2.3%). Ratner and associates also observed no difference in patient survival, graft survival, or rejection rates. [15]
Recipient complication rates were comparable as well. Major complications that were more common among LDN than ODN recipients included ureteral complications (4.5%-9.1%), delayed graft function (7.6%), and graft vascular thrombosis (2.7%). [14],[15] It is important to note that these complications were more frequent among the initial cases but decreased in frequency with increasing surgical experience.
Evolving Techniques
Ratner et al first described the technique of laparoscopic donor nephrectomy through transperitoneal approach. Since then, there has been tremendous modification in technique, approach and cost reductive innovation, which has led to the emergence of more than I technique of laparoscopic donor nephrectomy.
In standard laparoscopic donor nephrectomy three laparoscopic ports are placed under direct vision - one latera] to the rectus muscle halfway between the umbilicus and iliac crest, the other at the umbilicus, and third in the midline midway between xiphoid and umbilicus. The camera is positioned at the umbilicus port, and the operation is performed through the two ports.[28] A fourth port is often necessary for the purpose of retraction and is placed in t.'e anterior axillary line at the level of the umbilicus. The ipsilateral colon is mobilized medially by reflecting the lateral peritoneal reflection. The ligamentous attachments between the colon, diaphragm, and kidney are divided, exposing Gerota's fascia. The upper pole of the kidney is dissected within Gerota's fascia, leaving the lateral, posterior, and inferior attachment to the kidney intact. Once the upper pole is completely free, the hilar vessels are exposed. The gonadal, lumbar and adrenal veins are identified, doubly clipped, and divided. Renal vein is retracted upwards to expose the renal artery. The renal artery is now identified and freed to provide maximum vascular exposure to its proximal origin at the aorta. Attention is focused next on the ureteral dissection. The gonadal vessels are identified at the level of the renal hilum and dissected inferiorly to where the ureter crosses the iliac vessel. The gonadal vessels are once again identified, clipped, and divided at the level of renal pelvis. The ureter is then dissected inferiorly down to the level of iliac artery and vein, where it is clipped and divided. The remaining attachment to the kidney is then divided with sharp and blunt dissection. Just before division of the vascular pedicle, a periumbilical incision is created that is large enough to remove the kidney easily, and an Endocatch device is introduced with purse string suture in the peritoneum around the device to preserve the pneumoperitoneum. The laparoscope is moved to the epigastric port and the renal artery and the vein are sequentially divided with the aid of the endovascular gastrointestinal stapler. The kidney is placed in the Endocatch bag. Once secured. the peritoneum is opened, and the kidney is removed through the incision and the fascia is closed with No.1 absorbable suture. Pneumoperitoneum is re-established to inspect the renal bed and trocar sites for bleeding and hemostasis is done. The fascia at trocar site 10 mm and larger are closed with 2-0 absorbable sutures, and the skin is closed with 4-0 absorbable sutures.
Recent modification in standard laparoscopic technique places the unopened Endocatch bag through a Pfannenstiel incision at the beginning of the procedure. It helps in the retraction of the colon medially. The bag is opened once kidney is free from the posterior aspect. Kidney is manipulated into the bag before cutting the vessels. This maneuver decreases the warm ischemia time as no time is wasted in entrapping the kidney into the bag.
Another modification is to give a 7 cm muscle-splitting incision in the left iliac fossa over the port. The hand is pushed into the peritoneal cavity to retrieve the kidney. This helps in cutting down the cost by avoiding use of Endocatch.
The main disadvantages of this approach is that, it takes considerable skill to remove a kidney that remains suitable for renal transplantation. Several laparoscopic assisted techniques have been described to overcome the steep learning curve associated with laparoscopic donor nephrectomy. These techniques exploit the mandatory 6-8 cm extraction incision of classical laparoscopic approach throughout the procedure and are basically a hybrid of conventional open and laparoscopic approach. These techniques include transperitoneal donor nephrectomy and laparoscopic assisted extraperitoneal donor nephrectomy. [23],[29],[30]
The first successful hand assisted laparoscopic donor nephrectomy using pneumosleeve device (Dexterity, Blue Bell, PA) was reported in 1998 by Wolf and co-workers. [29] The hand device is placed in the periumbilical or infraumbilical position. Two 12 mm trocars are introduced. One trocar placed in the midclavicular line just below the umbilicus is used for the surgeon's working instruments. The other trocar is placed in the anterior axillary line above the iliac crest. A 10 mm 30 degree laparoscope is introduced through this port. The rest of the operation is performed similar to a standard laparoscopic approach and the graft is extracted through hand port device incision.
Yang and co-workers reported their experience with laparoscopic assisted extraperitoneal donor nephrectomy in 1995.[30] In this technique, the kidney is exposed through either a small pararectus or small median incision, and the procedure is performed under laparoscopic and direct visualization using combination of laparoscopic and conventional instruments. The operative space is maintained in a gasless field by means of special abdominal wall retractors and lifters, which facilitates the renal dissection. Again renal pedicles are transected using gastrointestinal staplers and the kidney is brought out with the help of an endobag.
Recently the author (A.K.) has developed a cost saving technique of laparoscopic assisted donor nephrectomy.[23] Patient is placed in the flank position and pneumoperitoneum is established using veress needle, and an 11-mm. port is placed through a subumbilical incision or at the lateral border of the rectus muscle at the same level. This port is used as camera port throughout the dissection. The second port (5-12 mm) is placed in the centre of line connecting the umbilicus with the left anterior superior iliac spine. A third port (5 mm) is placed at the level of the midclavicular line 2 fingerbreadth below the costal margin (MCL). The colon is mobilized from the bifurcation of common iliac artery till the upper pole of the kidney. The upper pole of the kidney is dissected first. Splenocolic ligament is cut which helps in dropping the spleen from the superior part of the kidney. Splenic retraction is provided by a fan retractor placed through a 5 mm port, which is sited along the anterior axillary line (AAL) 6 to 7 cm from the MCL port. Gonadal vein is traced proximally to identify the renal vein. The gonadal, adrenal and lumbar veins are divided between clips. The renal artery and vein are dissected and freed from lymphatic tissues. The adrenal gland is dissected away from the upper pole of the kidney. The ureter is transected in the pelvis and the distal end clipped. It is freed from the retroperitoneum and mobilized up along with gonadal vein to ensure good vascularity. The lateral attachment of the kidney is divided. The gas supply is turned off, and all ports are removed. The MCL and AAL port sites are connected by 6-8 cm incision, where the skin and fascia are cut and the underlying muscles split sufficiently to allow entry of the surgeon's hand. In a muscular patient, some muscle fibers are cut at both the angles of the wound to facilitate exposure. The hand is inserted into the peritoneal cavity to confirm complete mobilization of the kidney. Long Dever's retractors are inserted to provide direct access to hilar vessels. Any residual retroperitoneal attachments can be divided at this stage. Two 2-0 vicryl sutures are thrown around the renal vein and the knot is pushed closed to renal vein but not tightened. Finally, the renal artery is clipped three to four times with the 30-mm metal clips (Ethicon) and cut. The vein is tied with 2-0 vicryl suture by pushing the prethrown knot with a long right angle dissector. The vein is cut distal to the knot and the kidney removed. In our experience, the left upper quadrant incision connecting the MCL and AAL port is particularly useful, as it provides excellent access to the renal hilum. In case of any inadvertent vascular injury, conversion to open procedure can be done rapidly through same incision. As no disposables are used, (cf. hand-assisted - Pneumosleeve and vascular staples and standard laparoscopic techniques - Enrlocatch, vascular staple) the cost is comparable to the open counterpart, which is an important consideration in developing countries.
Addressing the Problems
In the largest clinical series performed to date, ureteral injury has occurred at a disturbingly high rate (4.5% - 9.1%). [14],[27] However, the technique of ureteral harvesting has evolved to address this issue. At John Hopkins, the technique has been modified to preserve lower pole renal adipose tissue and the "golden triangle" of periureteral tissue between the kidney, gonadal vein, and renal hilum. Philosophe and associates noted dramatic improvement in ureteral complication rates after adopting the use of the endoscopic gastrointestinal stapling device to divide the ureter. [31] For the first 130 LDN patients, 20(15%) ureteral complications were reported, whereas in the most recent 63 patients, only 1 (0.01 %) ureteral complication occurred .[31]
Another purported shortcoming of LDN is the steep learning curve associated with the procedure. Currently, LDN is confined to major transplant centers with extensive laparoscopic expertise. Various methods are being investigated to ameliorate this situation. Hand-assisted LDN using the Pneumosleeve (Dexterity, Roswell, Ga) device has been successful, lowering operative and warm ischemia times. [29],[32] Another strategy to overcome the learning curve and disseminate technique over long distances is to have experienced surgeons telementor less experienced laparoscopists. Telementoring experiments between John Hopkins and counterparts in Italy have been successfully conducted for laparoscopic nephrectomy. Technological advances in instrumentation and robotics may also facilitate mastery of LDN in the future. [33]
Right Donor Nephrectomy
Left nephrectomy has been preferred because of the longer renal vein and overall greater technical ease. In right side, the liver has to be retracted and it is technically difficult to duplicate clamping the vena cava with Satinsky clamp. Straight division of the renal vein at vena cava with vascular staplers results in loss of approximately l to 1.5 cm of vein as compared with open approach. [34] The resulting short and thin vein can make anastomosis more difficult and may some times result in vascular complication and/or graft loss. [35] The technical challenge of this procedure has necessitated the propensity for the left kidney retrieval (97.5% to 100%) compared to that for open donor nephrectomy (70% to 80%), which violates the principle of leaving the better kidney with the donor.
Various modifications have been proposed to facilitate safe harvesting of right kidney through laparoscopic approach. Gill et al reported right donor nephrectomy done via the retroperitoneal approach.[39] After dividing the renal vessels with an endoscopic gastrointestinal stapler, they performed additional bench surgery to mobilize the vein into hilum, thereby adding length for the recipient anastomosis. Lee et al described a laparoscopic assisted technique. [40] After laparoscopic dissection of the kidneys an 8-cm right upper quadrant transverse incision was made, through which a Satinsky clamp was passed across the vena cava. Vessel division, kidney removal and cavotomy repair were performed through this incision. Recently Turk et al [41] have used a modified Satinsky atraumatic vascular clamp, developed for thoracoscopic procedure for right nephrectomies. To clamp the inferior vena cava and divide the vessel a small incision is made to the right anterior superior iliac spine. Modified clamp which is longer than the standard clamp is inserted without trocar into the peritoneum and is used for clamping the inferior vena cava. The renal vein is transected close to vena cava with scissors. The cavotomy is closed with a laparoscopic running 3-0 polydioxane suture and the clamp is removed. In Scandinavian countries, to circumvent difficult anastomosis of short renal vein, internal iliac vein is divided from the external iliac vein. This brings the external iliac vein higher up in the wound and expedites the anastomosis.
Recent retrospective multi-institutional review of 97 right donor nephrectomies was done by Buell et al which were performed for varying reasons, like multiple vessels on left side, smaller right kidneys or cystic mass on right side. [42] Mean surgical time was 235+/- 66.7 minutes, and mean blood loss of 139+/- 165.9 ml. Conversion was required in three patients secondary to bleeding or anatomical anomalies. Mean warm ischemia time was limited to 238 +/- 17 seconds. Two grafts were lost during the early experience of these centers due to renal vein thrombosis. Both surgical and postoperative complications were limited, with few long-term adverse effects. Mean serum creatinine levels were higher than open and left laparoscopic donor nephrectomy on postoperative day 1, but at all remaining intervals the right laparoscopic donors had equivalent serum creatinine values.
Why LDN should be done in India ?
In India, despite the enactment of Human Organ Transplantation Bill and Brain Death Legislation by parliament and its subsequent adoption by most of the states, cadaveric organ donation is still non-existent, and only 450 cadaveric transplants have been performed till now. [43] Therefore, vast majorities of renal transplant are still performed in India using live donor kidneys. Although LDN is being performed increasingly worldwide, very few centers in India have active laparoscopic live donation programmes. [23],[44] Steep learning curve and operative costs are the major hindrances responsible for slow progress in this field. Hospital beds are not expensive in majority of the centers and patients are also not keen to get early discharge or join work early. They even insist on staying in the hospital for longer period and usually ask for longer leave; however, nobody wants pain and morbidity. LDN is definitely associated with less pain and better cosmesis. Young females prefer it to the open counterpart. Costreductive innovation in technique of LDN and its propagation is required to meet the demand of the huge population of ESRD awaiting transplantation.
How LDN can be done in India ?
Because the learning curve for laparoscopic donor nephrectomy is long, each institution and surgical team will have to make a judgment as to the best approach to be used at their respective centers. To begin with, the concerned surgeon should have experience of assisting or doing 25 laparoscopic simple nephrectomies under the guidance of experienced laparoscopic surgeon or urologist. He should embark upon LDN with the support of laparoscopic surgeon and experienced transplant surgeon. In initial 50 cases learning curve has to be taken in account and threshold for conversion should be low. Handassisted laparoscopic technique can be helpful during this period. With increasing experience the complication and conversion rate would decrease and it would become a safe procedure. Donor and graft safety should be the prime concern. Presently it is more expensive; but our modified approach is a feasible option in a developing country. [23]
Donor Nephrectomy at SGPGI: Changing Trends
We are one of the largest centers engaged in live related renal transplantation and 1050 transplants have been done till date. From 1988 to 1999 the kidneys were harvested through standard rib cutting ODN. In Jan 2000 we started LDN and have modified our ODN technique in which the rib is spared and subcostal 8-10 cm incision is used. The randomized trial comparing the result of standard ODN, mini incision ODN and LDN has been reported elsewhere.
We started laparoscopies donor program in Jan 2000, and have performed 98 laparoscopic donor nephrectomies till now. Of these, two were performed by hand-assisted technique, 17 by the standard technique and 79 by our modified lap assisted cost saving approach. The advantage of our technique and its result were reported elsewhere. [8]
Of the 79 cases done by modified technique, the male to female ratio has been 21:58; donor weight has ranged from 46 to 64 kg with mean age being 31 years (range 2964 years). All donors except one had left kidney retrieval and 11 patients had multiple vessels. One right donor nephrectomy was done by same approach. The intraoperative data and postoperative results are shown in [Table - 2],[Table - 3],[Table - 4]. Conversion to open was done in 7 cases due to excessive bleeding or mechanical failures of instruments during early period of the program. There were two major complications: one because of secondary haemorrhage and other due to enoxaprim-induced idiosyncratic platelets dysfunction leading to postoperative hemorrhage. The most common minor complication was wound infection, which substantially decreased after introduction of metal autoclavable laparoscopic instruments. None of our laparoscopic patients had any vascular or ureteral complications. The mean serum creatinine at follow-up ranging from 1 month to 27 months has been 1.37 mg/dl.
We have also done 130 mini incision donor nephrectomy with comparable results. This is another viable alternative to LDN. Here incision is 8 to 12 cm depending on patient's body mass index. It requires long instruments, thin and long retractors and head light. Surgeon experience is also mandatory to remove donor kidney from a small incision. Morbidity is same and hospital stay is 3-4 days.
| Conclusions | | |
Laparoscopic option is a safe and effective alternative to open surgery. LDN has evolved as a means to make renal donation more attractive for potential donors. The goals of donor nephrectomy are twofold - to provide the recipient with the highest-quality kidney, donor should have minimal morbidity and absolute safety.
Are LDN allografts quality kidneys? Yes! It has been demonstrated LDN recipients have good allograft function and survival equal to that obtained with ODN. Furthermore, refinement of laparoscopic technique has addressed only problems with ureteral complications and graft venous thromboses and these complications are very low in recent series.
Is LDN safe for the donor? While the types of complication may vary between ODN and LDN, the overall complication rates are similar. No mortalities have been reported among LDN donors. Complication rates have also decreased with increased surgeon experience and improvement in technique.
With the issues of safety and efficacy addressed, LDN offers additional benefits to the donor with respect to comfort, cosmesis, and postoperative recovery. These benefits should attract more individuals to come forward and help their relatives with ESRD.
It remains to be seen whether LDN will replace ODN as the primary means of live donor nephrectomy. Due to the challenge represented by LDN, other alternative open approaches are being explored such as a dorsal approach, mini incision and an anterior retroperitoneal approach. [14] At the very least, LDN has sparked interest in a stagnant field; ODN has not changed much in the last half century but rapid changes are occurring in last 2-3 years. We believe, however, that LDN is an attractive challenge and is a procedure that will enhance the pool of potential renal donors in future.
| References | | |
| 1. | US Renal Data System (USRDS): 1994 Annual Data Report. The National Institute of Health, National Institute of Diabetes and Diabetes and Kidney Disease, Betheseda, MD. June 1994.  |
| 2. | 1997 Annual Report of the U.S. Scientific Registry of Transplant Recipients and the Organ Procurement and Transplantation Network. Transplant data : 1988-1996. UNOS, Richmond, VA and the Division of Transplantation, Bureau of Health Resources and Services Administration. US Department of Health and Human services, Rockville, MD. |
| 3. | Gill IS, Carbone JM, Claymen RV et al. Laparoscopic live donor nephrectomy. J Endourol 1994; 8: 143. |
| 4. | Ratner LE, Ceseck LJ, Moore RG et al. Laparoscopic live donor nephrectomy. Transplantation 1995; 60: 1047. |
| 5. | D'Alessandro AM, Sollinger HW, Knechtle SJ et al. Living related and unrelated donors for kidney transplantation. A 28-year experience. Ann Surg 1995: 222(3): 353-364. |
| 6. | Johnson EM, Remucal MJ, Gillingham KJ et al. Complications and risks of living donor nephrectomy. Transplantation 1997; 64(8): 1124-1128. |
| 7. | Dunn JF, Nylander WA, Richie RE et al. Living related kidney donors. A 14-year experience. Ann Surg 1996: 203(6): 637-643. |
| 8. | Jacobs SC, Cho E, Dunkin BJ. Laparoscopic donor nephrectomy current role in renal allograft procurement. Urology 2000; 55(6): 807-811. |
| 9. | Wolf JS, Marcovich R, Merion RM et al. Prospective, case matched comparison of hand assisted laparoscopic and open surgical live donor nephrectomy. J Urol 2000; 163(6): 1650-1653. |
| 10. | Flowers JL, Jacobs S, Cho E et al. Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 1997:226(4): 483-490. |
| 11. | Ratner LE, Kavoussi LR, Sroka M et al. Laparoscopic assisted live donor nephrectomy - a comparison with the open approach. Transplantation 1997; 63(2): 229-233. |
| 12. | London E, Rudich S. McVicar J et al. Equivalent renal allograft function with laparoscopic versus open live donor nephrectomies. Transplant Proc 1999: 31(1-2): 258-260. |
| 13. | Ayvazian M and Khauli RB. Open vs. laparoscopic donor nephrectomy. Contemp Urol 2001; 5. |
| 14. | Nogueira JM, Cangro CB, Fink JC et al. A comparison of recipient renal outcomes with laparoscopic versus open live donor nephrectomy. Transplantation 1999; 67(5): 722-728. |
| 15. | Ratner LE, Montgomery RA, Kavoussi LR. Laparoscopic live donor nephrectomy: the four-year John Hopkins University experience. Nephrol Dial Transplant 1999: 14(9): 2090-2093. |
| 16. | Ratner LE, Hiller J, Sroka M et al. Laparoscopic live donor nephrectomy removes disincentives to live donation. Transplant Proc 1997; 29(8): 3402-3403. |
| 17. | Ratner LE, Kavoussi LR, Schulam PG et al. Comparison of laparoscopic live donor nephrectomy versus the standard open approach. Transplant Proc 1997; 29(1-2): 138-139. |
| 18. | Jacobs SC, Cho E, Dunkin BJ et al. Laparoscopic live donor nephrectomy : The University of Maryland 3-year experience. J Urol 2001; 164:1494. |
| 19. | Ratner LE, Bisshoff JT, Montogmery RA et al. Laparoscopic live donor nephrectomy: long-term results. J Urol Suppl 1998; 159: 182. |
| 20. | Hensman C, Lionel G, Hewett P, et al. Laparoscopic live donor nephrectomy: the preliminary experience. Aust NZJ Surg 1999; 69(5): 365-368. |
| 21. | Hiller J, Sroka M, Holochek MJ et al. Functional advantages of laparoscopic live-donor nephrectomy compared with conventional open-donor nephrectomy. J Transpl Coord 1997: 7(3): 134-140. |
| 22. | Odland MD, Ney AL, Jacobs DM et al. Initial experience with laparoscopic live donor nephrectomy. Surg 1999: 126: 603. |
| 23. | Kumar A, Dubey D, Arvind NK et al. Laparoscopy-Assisted Live Donor Nephrectomy: A Modified Cost-Effective Approach for Developing Countries. J Endo 2002; 16(3): 155. |
| 24. | Finelli FC, Gongora E, Sasaki TM et al. A survey : the prevalence of laparoscopic donor nephrectomy at large U.S. transplant centers. Transplantation 2001: 71: 1862. |
| 25. | McDougall EM, Monk TG, Wolf JS et al. The effect of prolonged pneumoperitoneum on renal function in an animal model. J Am Coll Surg 1996: 182(4): 317-328. |
| 26. | Lee BR, Cadeddu JA, Molnar-Nadasdy G et al. Chronic effect of pneumoperitoneum on renal histology. JEndourol 1999; 13(4): 279-282. |
| 27. | Novick AC. Laparoscopic live donor nephrectomy. Con Urology 1999; 53(4): 668-670. |
| 28. | Fabrio MD, Ratner LE, Montogomery RA, et al. Laparoscopic live donor nephrectomy. Urol Clin North Am 2000; 26: 247. |
| 29. | Wolf JS Jr, Tcheten MB, Merion RM. Hand-assisted laparoscopic live donor nephrectomy. Urology 1998; 52: 885. |
| 30. | Yang SC. Park DS, Lee DH et al. Retroperitoneal endoscopic live donor nephrectomy : Report of three cases. J TJrol 1995: 153: 1884. |
| 31. | Philosophe B. Kuo PC, Schweitzer EJ et al. Laparoscopic versus open donor nephrectomy : comparing ureteral complications in the recipients and improving the laparoscopic technique. Transplantation. 1999; 68(4): 497-502. |
| 32. | Slakey DP. Wood JC, Hender D et al. Laparoscopic living donor nephrectomy : advantages of the hand-assisted method. Transplantation 1999; 68(4): 581-583. |
| 33. | Kavoussi L. Chow G, Ratner L. Open vs. laparoscopic donor nephrectomy. Contemporary Urology 2001; 5. |
| 34. | Ratner LE, Kavoussi LR, Chavin KD et al. Laparoscopic live donor nephrectomy: technical consideration and allograft vascular length (letter to editor). Transplantation 1998; 65: 1657. |
| 35. | Kim F, Ratner LE, Kavoussi LR. Renal transplantation: Laparoscopic live donor nephrectomy. Urol Clin North Am 2000; 27: 777. |
| 36. | Scott LB. Thomas RB, Mathew CR et al. Laparoscopic live donor nephrectomy : A comparison with conventional approach (Editorial comment by McDougall EM). J Urol 2001; 165: 766. |
| 37. | Shaffer D, Sahyon Al, Madras PN et al. Two-hundred-one consecutive living donor nephrectomies. Arch Surg 1998: 133: 426. |
| 38. | Barry JM. Editorial comment. J Urol 2000; 164: 1499. |
| 39. | Gill IS, Uzoo RG, Hobart MG et al. Laparoscopic retroperitoneal live donor right nephrectomy for purpose of allotransplantation and autotransplantation. J Urol 2000: 164: 1500. |
| 40. | Lee RB, Chow GK, Ratner LE et al. Laparoscopic live donor nephrectomy : outcomes equivalent to open surgery. J Endourol 2000; 14: 811. |
| 41. | Turk IA. Serdar D, Davis JW et al. Laparoscopic live donor right nephrectomy : A new technique with preservation of vascular length. J Urol 2002: 167: 630. |
| 42. | Buell JF, Edye M, Johnson M et al. Are concerns over right laparoscopic donor nephrectomy unwarranted ? Ann Surg 2001; 233: 645. |
| 43. | Kumar A, Arvind NK. Laparoscopic live donor nephrectomy. In: AK Hemal. Contemporary trends in Laparoscopic Urologic Surgery. B I Churchill Livingstone. 2002; 229-239. |
| 44. | Soin AS, Rajasekar MR, Rajakumari V et al. Experience with laparoscopic donor nephrectomy in India : is the open approach justified any longer ? Transplant Proc 2000; 32: 1585. |
[Table - 1], [Table - 2], [Table - 3], [Table - 4]
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