Single-Site Laparoscopic Living Donor Nephrectomy Offers Comparable Perioperative Outcomes to Conventional Laparoscopic Living Donor Nephrectomy at a Higher Cost

With equivalent outcomes to open nephrectomy, laparoscopic donor nephrectomy (multiple-site [conventional] laparoscopic donor nephrectomy [MS-LDN]) has become standard for living kidney donation. Benefits of laparoscopic nephrectomy include shorter hospital stay, decreased analgesia, and shorter convalescence (1, 2). Multiple studies have demonstrated comparable recipient outcomes despite slightly increased warm ischemia and operative times with laparoscopy (1–4). Several centers have reported single-site laparoscopic nephrectomy with excellent results in small series (5–10). Because of limited available data, however, the question of whether single-site laparoscopy offers advantage over conventional laparoscopy remains. To evaluate this, retrospective analysis of all initial, consecutive, single-site laparoscopic donor nephrectomies (SS-LDNs) was performed with comparison to MS-LDN. Donors underwent standard screening protocols. Contraindications to donation included diabetes, hypertension, renal dysfunction, or cancer. For SS-LDN, left kidney donors with single renal artery and vein were selectively chosen. A GelPort (Applied Medical, Rancho Santa Margarita, CA) was inserted through a 5-cm periumbilical incision. Three ports were triangulated through the device. For standard MS-LDN, the abdomen was entered using the Veress technique. Four ports were placed under direct visualization. Reusable laparoscopic instruments were used in both groups. Briefly, the left colon, spleen, and pancreatic tail were mobilized. Lumbar and gonadal veins were divided. The kidney was mobilized, and adrenal gland was freed. The ureter, artery, and vein were divided, and the kidney was bagged, removed, flushed, and placed on ice. Postoperatively, donors received intermittent ketorolac and opioids as needed. Surgeries were performed at Duke University by three experienced laparoscopic surgeons from 2005 to 2009. The results of 10 SS-LDNs were compared with twenty age-, sex-, and anatomically-matched MS-LDN. No cases required conversion. Among demographics, age, sex, and prior surgery were not significantly different; however, body mass index (BMI) was less for SS-LDN (Table 1). Operative times and blood loss were also equivalent. After surgery, donors had similar length of stay, analgesic usage, and creatinine; however, variable direct cost was 10% greater for SS-LDN (Table 1). Four MS-LDN recipients had complications. Two donors exhibited wound infections. One donor developed hernia after 4 months. One donor developed pulmonary edema and pneumothorax. No SS-LDN recipients exhibited complications.TABLE 1: Comparison of single-site with multiple-site laparoscopic donor nephrectomyRecently, endosurgery has trended toward increasingly minimally invasive approaches to minimize pain and improve cosmesis (11, 12). Because of limited published reports, the ultimate benefit over conventional laparoscopy is undetermined. Most notably, SS-LDN was associated with greater cost than MS-LDN, primarily due to equipment costs. Only one other recent study evaluated costs. They similarly found single-site nephrectomy to be more expensive (9). Cosmetic improvements are one potential benefit to SS-LDN. A small study evaluating subjective outcomes did note improved patient satisfaction with cosmesis; however, both MS-LDN and SS-LDN recipients were equally willing to recommend donation (5). One could argue that increased donor enthusiasm would annul increased cost, but based on the limited data, no definitive statement can be made as to potential increases in donor availability. This was a small retrospective analysis of immediate perioperative outcomes and was, thus, limited; however, no definitive advantages were observed. Surprisingly, operative times were slightly shorter for SS-LDN. This was likely due to proficiency bias, as three surgeons performed MS-LDN. In contrast, SS-LDNs were performed by a single surgeon, whose operative times tended to be shorter. When only this surgeon was evaluated, differences were negated (OR time MS-LDN 176.5 hr, range 126–220 hr, P=0.49). Postoperative analgesia was also slightly less after SS-LDN. The increase after MS-LDN was primarily due to an outlier who developed pulmonary edema, requiring intubation and continuous opioid infusion. Removal of this outlier nearly negates the advantage (22.5 mg, range 0–82.5 mg, P=0.36). Increased infection rates after MS-LDN likely represent selection bias. Both patients with infection had BMI more than 30 kg/m2, whereas all SS-LDN recipients had BMI less than 30 kg/m2. Thus, SS-LDN offers comparable results with MS-LDN. Only one published study comparatively evaluates SS-LDN with MS-LDN. A matched-pair comparison of 18 SS-LDN recipients demonstrates equivalent patient satisfaction, slightly shorter convalescence, and improved cosmesis; however, warm ischemia was increased compared with conventional MS-LDN. In addition, overall satisfaction for either procedure was similar (5). Several small series have evaluated single-site simple nephrectomy (8, 9). Similar to our series, one demonstrated no improvement in operative time or analgesia (8). Another small prospective study did note decreased analgesia and shorter convalescence after single-site nephrectomy; however, patients accrued $1200 greater intraoperative charges (9). Overall, these studies combined with the present data do not profoundly advocate SS-LDN, unless higher procedure costs can be justified by actual increased donor participation. Unlike advantages of laparoscopic over open nephrectomy, advances afforded by SS-LDN are marginal at best. Cosmesis may be improved, but large-scale prospective randomized trials are necessary before definitive conclusions can be reached. Keri E. Lunsford Matthew T. Harris Kimberly N. Nicoll Bradley H. Collins Debra L. Sudan Paul C. Kuo Deepak Vikraman Department of Surgery Duke University Medical Center Durham, NC