Results in Laparoscopic Living Donor Nephrectomy: A Multicentric Experience M. Ferrario, E. Buckel, C. Astorga, J. Godoy, J. Aguiló, G. González, J. Ormazábal, Á. Cámbara, C. Derosas, C. Herzog, and L. Calabrán ABSTRACT Objective. Renal transplantation is the most successful therapy to improve survival and quality of life for patients with end-stage renal disease. Living donors have been used as an alternative to reduce the stay on the waiting list. Laparoscopic living donor nephrectomy has become the standard procedure for renal transplantation. Minimally invasive surgery involves less postoperative pain with less analgesic requirements allowing shorter hospital stay for the donor. Material and Methods. We retrospectively analyzed demographic and intraoperative data and surgical complications for 46 patients who underwent laparoscopic living donor nephrectomy between March 2001 and March 2011. Results. Mean donor age was 41 years. Mean operative time was 170 45 minutes. The average cold ischemic time was 40 minutes and warm ischemic time was 26 minutes. Twentyone patients were donors for pediatric receptors. Fourty patients underwent left laparoscopic nephrectomy, the other 6 patients underwent right laparoscopic nephrectomy due to vascular anatomic variant. Right laparoscopic nephrectomy was converted in 1 case (2.2%) due to renal vein laceration without donor morbidity and without compromise of graft function. Renal function at the second day post donor nephrectomy was measured using serum creatinine averaged 1.2 mg/dL with a mean increase of 0.4 mg/dL from baseline, with normalization after 30 days. No patient required blood transfusion, and there were no immediate surgical complications, infections, or mortality. One patient developed an incisional hernia in relation to the site of kidney removal. The mean hospital stay was 5 1 days. Conclusions. Laparoscopic nephrectomy in our experience is a safe technique without postoperative morbidity or mortality. It is associated with low levels of pain, early discharge and early return to physical activity and work, good sense of aesthetic results, and longterm graft function comparable to traditional nephrectomy and cadaveric grafts.
R
ENAL transplantation is the most successful therapy to improve survival and quality of life for end-stage renal disease. Living donors have been used as an alternative to reduce the stay on the waiting list. Laparoscopic living donor nephrectomy (LLDN) has become the standard procedure for renal transplantation. It was introduced in 1995 to reduce the morbidity associated with the open technique.1,2 Minimally invasive surgery involves less postoperative pain with less analgesic requirements allowing shorter hospital stay for the donor. The aim of this study was a retrospective assessment of the safety and outcomes of LLDN.
MATERIALS AND METHODS We retrospectively analyzed the demographic and intraoperative data and surgical complications for 46 patients who underwent LLDN between March 2001 and March 2011 in Clínica Las Condes
From the Unit of Transplantation, Clínica las Condes, Santiago, Chile. Address reprint requests to Mario Ferrario, MD, Lo Fontecilla 441, Las Condes, Santiago, Chile, +56227591046. E-mail: [email protected]
0041-1345/13/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.08.089
ª 2013 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
3716
Transplantation Proceedings, 45, 3716e3718 (2013)
LAPAROSCOPIC LIVING DONOR NEPHRECTOMY
3717 Table 2. Results of Living Donor Nephrectomy (n [ 46)
Table 1. Patients (n [ 46) Donor
N
Parameters
Female Male Left kidney Right kidney Mean Age (y)
33 13 41 5 41
Operating time (min) Cold ischemic time (min) Hospital stay (d) Donor’s serum creatinine at 2 d post nephrectomy (mg/dL) Donor’s serum creatinine at 30 d follow-up (mg/dL)
and Luis Calvo Mackenna Hospital. All nephrectomies were performed completely by laparoscopic transperitoneal technique. The donor kidney vascular anatomy was evaluated using high-resolution computed tomographic angiograms with three-dimensional reconstructions. The surgical technique was as follows. The patient was positioned in a flexed, lateral decubitus. Once a pneumoperitoneum was established, the first 12-mm port was placed lateral to the rectus muscle at the level of the umbilicus using a visual obturator to allow entry into the abdomen under direct vision. Once in the peritoneal cavity, the visual trocar was removed and the abdomen was then inspected for any injury due to insufflation and to identify adhesions in areas where the secondary ports will be placed. Remaining trocars were placed under direct vision. A second 12-mm trocar was placed under xiphoid process and a third 12-mm trocar between the 2 previous ports. A 3-trocar technique was usually used to complete the dissection. Then, the ureter was dissected to minimize disruption of its blood supply; it was then divided at the level of the iliac vessels. The entire dissection was completed without hand assistance. After complete mobilization of the kidney, the renal artery and vein were divided using a vascular Endo-GIA (Covidien LLC, Mansfield, MA) stapler separately. The kidney was extracted manually via the oblique paramedian lower quadrant incision.
RESULTS
Laparoscopic transperitoneal nephrectomy was successfully completed in 45 of 46 cases, with 1 conversion to open surgery (2.2%) due to renal vein laceration without donor morbidity and without compromise of graft function. Twenty-one patients were donors for pediatric receptors. Fourty patients underwent left laparoscopic nephrectomy, the other 6 patients underwent right laparoscopic nephrectomy due to vascular anatomic variant (Table 1). Mean operative time was 170 46 minutes. Cold ischemic time was 40 5 minutes. Hospital stay was 5 1 days (Table 2). There were no major donor complications; one patient developed an incisional hernia in relation to the site of kidney removal. The mean hospital stay was 5 1 days. The mean cold ischemic time was 40 5 minutes and warm ischemic time was 26 minutes. Recipient survival was 96% and 88% (1 and 5 years) and graft survival 96% and 84% (1 and 5 years). DISCUSSION
Renal transplantation is the most successful therapy to improve survival and quality of life for patients with end-stage renal disease. Living donor nephrectomy has a proven low surgical risk with high quality grafts. LLDN was introduced in
Mean SD
Range
120e250 32e46 4e11 0.83e1.6
170 40 5 1.2
46.0 5 1 0.4
0.8 0.3
0.70e1.1
Abbreviation: SD, standard deviation.
19952 and has been used since as a safe technique with mortality rates about 0.02% due in most cases to arterial bleeding. Pulmonary embolism is another cause of death related to this procedure.3,4 Bleeding during the surgery is the most frequent reason to convert to open surgery, described in the literature as ranging between 1.8% and 13%.5,6 The use of vascular stapler devices is now widely accepted as a safe procedure during the surgery and allows reduction in the bleeding rates.7 Although laparoscopic procedures in different areas are now commonplace in many health centers in our country there is little evidence published on the subject of LLDN. A previous experience by Rocca et al comparing open nephrectomy with hand-assisted laparoscopic nephrectomy (HALN) showed a complication rate of 7.4% due to bleeding, which required a second surgical intervention.8 Castillo et al published a series of 319 laparoscopic nephrectomies, 23 of which were LLDN, with a complication rate for the whole series of 5.64%.9 Our study contributes to show how LLDN performed in private and public health centers in Chile can achieve results that are comparable to specialized centers in developed countries. We believe that this technique should be the standard of care for kidney living donors whenever possible. In conclusion, LLDN in our experience is a safe technique without morbidity or mortality. It is associated with low levels of pain, early discharge and early return to physical activity and work, good sense of aesthetic results, and long-term graft function comparable with traditional nephrectomy and cadaveric grafts. REFERENCES 1. Abecassis M, Adams M, Adams P. Live organ donor consensus group: consensus statement on the live organ donor. JAMA. 2000;284:2919. 2. Ratner LE, Ciseck LJ, Moore RG, et al. Laparoscopic live donor nephrectomy. Transplantation. 1995;60:1047. 3. Matas AJ, Bartlett ST, Leichtman AB, et al. Morbidity and mortality after living kidney donation, 1999e2001: survey of United States transplant center. Am J Transplant. 2003;3:830. 4. Ahearn A, Posselt A, Kang S, et al. Experience with laparoscopic donor nephrectomy among more than 1000 cases, low complication rates, despite more challenging cases. Arch Surg. 2011;146:859. 5. Johnson EM, Remucal MJ, et al. Complications and risks of living donor nephrectomy. Transplantation. 1997;64:1124. 6. Novotny MJ. Laparoscopic live donor nephrectomy. Urol Clin North Am. 2001;28:127.
3718 7. Sundaram C, Bargman V, Bernie J. Methods of vascular control during laparoscopic donor nephrectomy. J Endourol. 2006;20:467. 8. Rocca X, Espinoza O, Hidalgo F, Gonzalez F. Laparoscopic nephrectomy: safe and comfortable surgical alternative for living
FERRARIO, BUCKEL, ASTORGA ET AL donors and for good results of graft function. Transplant Proc. 2005;37:3349. 9. Castillo O, Bejarano C, Cortés O, Pinto I, Hoyos J, Vitagliano G. Complications in laparoscopic nephrectomy. Actas Urol Esp. 2006;30:812.
R
ENAL transplantation is the most successful therapy to improve survival and quality of life for end-stage renal disease. Living donors have been used as an alternative to reduce the stay on the waiting list. Laparoscopic living donor nephrectomy (LLDN) has become the standard procedure for renal transplantation. It was introduced in 1995 to reduce the morbidity associated with the open technique.1,2 Minimally invasive surgery involves less postoperative pain with less analgesic requirements allowing shorter hospital stay for the donor. The aim of this study was a retrospective assessment of the safety and outcomes of LLDN.
MATERIALS AND METHODS We retrospectively analyzed the demographic and intraoperative data and surgical complications for 46 patients who underwent LLDN between March 2001 and March 2011 in Clínica Las Condes
From the Unit of Transplantation, Clínica las Condes, Santiago, Chile. Address reprint requests to Mario Ferrario, MD, Lo Fontecilla 441, Las Condes, Santiago, Chile, +56227591046. E-mail: [email protected]
0041-1345/13/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.08.089
ª 2013 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
3716
Transplantation Proceedings, 45, 3716e3718 (2013)
LAPAROSCOPIC LIVING DONOR NEPHRECTOMY
3717 Table 2. Results of Living Donor Nephrectomy (n [ 46)
Table 1. Patients (n [ 46) Donor
N
Parameters
Female Male Left kidney Right kidney Mean Age (y)
33 13 41 5 41
Operating time (min) Cold ischemic time (min) Hospital stay (d) Donor’s serum creatinine at 2 d post nephrectomy (mg/dL) Donor’s serum creatinine at 30 d follow-up (mg/dL)
and Luis Calvo Mackenna Hospital. All nephrectomies were performed completely by laparoscopic transperitoneal technique. The donor kidney vascular anatomy was evaluated using high-resolution computed tomographic angiograms with three-dimensional reconstructions. The surgical technique was as follows. The patient was positioned in a flexed, lateral decubitus. Once a pneumoperitoneum was established, the first 12-mm port was placed lateral to the rectus muscle at the level of the umbilicus using a visual obturator to allow entry into the abdomen under direct vision. Once in the peritoneal cavity, the visual trocar was removed and the abdomen was then inspected for any injury due to insufflation and to identify adhesions in areas where the secondary ports will be placed. Remaining trocars were placed under direct vision. A second 12-mm trocar was placed under xiphoid process and a third 12-mm trocar between the 2 previous ports. A 3-trocar technique was usually used to complete the dissection. Then, the ureter was dissected to minimize disruption of its blood supply; it was then divided at the level of the iliac vessels. The entire dissection was completed without hand assistance. After complete mobilization of the kidney, the renal artery and vein were divided using a vascular Endo-GIA (Covidien LLC, Mansfield, MA) stapler separately. The kidney was extracted manually via the oblique paramedian lower quadrant incision.
RESULTS
Laparoscopic transperitoneal nephrectomy was successfully completed in 45 of 46 cases, with 1 conversion to open surgery (2.2%) due to renal vein laceration without donor morbidity and without compromise of graft function. Twenty-one patients were donors for pediatric receptors. Fourty patients underwent left laparoscopic nephrectomy, the other 6 patients underwent right laparoscopic nephrectomy due to vascular anatomic variant (Table 1). Mean operative time was 170 46 minutes. Cold ischemic time was 40 5 minutes. Hospital stay was 5 1 days (Table 2). There were no major donor complications; one patient developed an incisional hernia in relation to the site of kidney removal. The mean hospital stay was 5 1 days. The mean cold ischemic time was 40 5 minutes and warm ischemic time was 26 minutes. Recipient survival was 96% and 88% (1 and 5 years) and graft survival 96% and 84% (1 and 5 years). DISCUSSION
Renal transplantation is the most successful therapy to improve survival and quality of life for patients with end-stage renal disease. Living donor nephrectomy has a proven low surgical risk with high quality grafts. LLDN was introduced in
Mean SD
Range
120e250 32e46 4e11 0.83e1.6
170 40 5 1.2
46.0 5 1 0.4
0.8 0.3
0.70e1.1
Abbreviation: SD, standard deviation.
19952 and has been used since as a safe technique with mortality rates about 0.02% due in most cases to arterial bleeding. Pulmonary embolism is another cause of death related to this procedure.3,4 Bleeding during the surgery is the most frequent reason to convert to open surgery, described in the literature as ranging between 1.8% and 13%.5,6 The use of vascular stapler devices is now widely accepted as a safe procedure during the surgery and allows reduction in the bleeding rates.7 Although laparoscopic procedures in different areas are now commonplace in many health centers in our country there is little evidence published on the subject of LLDN. A previous experience by Rocca et al comparing open nephrectomy with hand-assisted laparoscopic nephrectomy (HALN) showed a complication rate of 7.4% due to bleeding, which required a second surgical intervention.8 Castillo et al published a series of 319 laparoscopic nephrectomies, 23 of which were LLDN, with a complication rate for the whole series of 5.64%.9 Our study contributes to show how LLDN performed in private and public health centers in Chile can achieve results that are comparable to specialized centers in developed countries. We believe that this technique should be the standard of care for kidney living donors whenever possible. In conclusion, LLDN in our experience is a safe technique without morbidity or mortality. It is associated with low levels of pain, early discharge and early return to physical activity and work, good sense of aesthetic results, and long-term graft function comparable with traditional nephrectomy and cadaveric grafts. REFERENCES 1. Abecassis M, Adams M, Adams P. Live organ donor consensus group: consensus statement on the live organ donor. JAMA. 2000;284:2919. 2. Ratner LE, Ciseck LJ, Moore RG, et al. Laparoscopic live donor nephrectomy. Transplantation. 1995;60:1047. 3. Matas AJ, Bartlett ST, Leichtman AB, et al. Morbidity and mortality after living kidney donation, 1999e2001: survey of United States transplant center. Am J Transplant. 2003;3:830. 4. Ahearn A, Posselt A, Kang S, et al. Experience with laparoscopic donor nephrectomy among more than 1000 cases, low complication rates, despite more challenging cases. Arch Surg. 2011;146:859. 5. Johnson EM, Remucal MJ, et al. Complications and risks of living donor nephrectomy. Transplantation. 1997;64:1124. 6. Novotny MJ. Laparoscopic live donor nephrectomy. Urol Clin North Am. 2001;28:127.
3718 7. Sundaram C, Bargman V, Bernie J. Methods of vascular control during laparoscopic donor nephrectomy. J Endourol. 2006;20:467. 8. Rocca X, Espinoza O, Hidalgo F, Gonzalez F. Laparoscopic nephrectomy: safe and comfortable surgical alternative for living
FERRARIO, BUCKEL, ASTORGA ET AL donors and for good results of graft function. Transplant Proc. 2005;37:3349. 9. Castillo O, Bejarano C, Cortés O, Pinto I, Hoyos J, Vitagliano G. Complications in laparoscopic nephrectomy. Actas Urol Esp. 2006;30:812.
