Laparoscopic Donor Nephrectomy: Pro

At the time of its introduction laparoscopic live donor nephrectomy (LDN) was considered a radical development. Despite this perception, LDN represented a logical next step in a conceptual and technical evolution. Currently, LDN is being performed at over 100 centers worldwide. Its adoption is progressing rapidly, fueled largely by patient demand and the related economic necessity felt by many transplant centers. We present data that we believe demonstrates that LDN is not only safe for both the donor and recipient, but the preferred method of live organ procurement, because of its inherent benefits. Renal transplantation is the optimal treatment for end-stage renal disease. However, its therapeutic application is limited by the organ supply. Despite numerous attempts to increase cadaveric donation, only a minimal increase in cadaveric organ donors has been realized compared to the exponential growth in the renal transplant waiting list. This has resulted in prolonged waiting times with a concomitant increase in the number of people dying while awaiting renal transplantation. Strategies to increase the organ supply include the following: 1) educating both the general public and medical professionals about organ donation; 2) passing legislation for presumed consent or required request; 3) using expanded criteria donor organs; 4) using non-heart beating donors; 5) reducing the rate of retransplantation; 6) xenotransplantation; and 7) increasing the use of live donors. Increasing live donor rates is the most immediately applicable strategy and also should decrease the rate of retransplantation. We hypothesized that many individuals who might wish to donate are prohibited by both financial and logistical disincentives to donation (2). If potential donors faced shorter recuperative times, less pain, and better cosmetic results, more individuals might be willing to donate. Application of minimally invasive techniques to cholecystectomy resulted in an increase in the number of patients undergoing laparoscopic cholecystectomy than the open operation (3). Clayman and associates demonstrated that laparoscopic nephrectomy for disease resulted in less pain, shorter hospitalization, and quicker recuperation than nephrectomy performed via a flank approach (4). Gill et al. demonstrated the feasibility of laparoscopic donor nephrectomy in an animal model (5). Living donor renal transplantation is associated with multiple advantages for the recipient, including improved patient and graft survival, improved graft function, immediate graft function, shorter hospital length of stay, decreased morbidity, and decreased overall costs (6). The procedure is performed on an elective basis and allows for the optimization of the recipient’s clinical status before transplantation. Yet, despite these advantages, live donor renal transplantation remains an underused option. Although there is some psychological benefit for the donor, the traditional open technique for donor nephrectomy extracts a high cost. Donors face the morbidity of a flank incision with its incumbent pain, cosmetic deformation, prolonged convalescence, and the potential for pneumothorax, rib resection, chronic pain, and hernia formation. The convalescent period of 4–8 weeks carries an “opportunity” cost with lost wages, suspension of familial responsibilities, such as childcare and housework, and the need for other family members to fulfill these obligations. These costs form a nearly insurmountable disincentive to all but the obsessively committed donor. With regard to LDN at Georgetown University Hospital, we have demonstrated that the availability of the laparoscopic approach with its associated decrease in opportunity costs increases the number of living donors by ∼40%, primarily represented by increased numbers of living unrelated donors (8). Similarly, at Johns Hopkins Hospital, 20% of donors report that they would not have donated if the laparoscopic approach had not been available. Fully two thirds of donors claim that the availability of the laparoscopic operation greatly influenced their decision to donate. Hence, we have seen an ∼200% increase in live donor renal transplants performed at Johns Hopkins since the introduction of LDN. Other centers have experienced similar increases in live donation. We conclude that LDN overcomes many of the disincentives to donation and is a viable alternative to the traditional open approach for donor nephrectomy. DONOR RESULTS LDN was first performed by Ratner and colleagues in 1995 (9). Since then a number of studies have compared the short-term donor outcomes between LDN and open donor nephrectomy. The results have uniformly demonstrated that LDN is associated with significantly decreased estimated blood loss, parenteral analgesic use, length of stay, and time to return to work and also increases operative time by ∼1 hr. At Georgetown University Hospital, all donations are performed using the laparoscopic approach (n=80; June 1998 to September 1999); estimated blood loss is 200 ml, time requiring parenteral analgesia is 12 hr, length of stay is 24 hr, and time to return to work is 2.7 weeks. All patients are admitted postoperatively to the 23-hr stay unit, and 90% are discharged home on the first postoperative day. The conversion rate to open nephrectomy is 2.5% (10). In a study performed at Johns Hopkins that compared contemporaneous groups of open and laparoscopic donors, post-operative pain (measured in terms of analgesic requirements) after discharge from the hospital was significantly less after LDN than after the open donor operation (11). After discharge the requirements for narcotic analgesics were 4.2±3.5 versus 11.8±13.4 days (P =0.004) and subsequent parenteral analgesics 2.9±6.5 versus 16.9±27.3 days (P =0.028) for laparoscopic and open donors, respectively (12). Similarly, the resumption of functional activities such as driving (13.5±10.8 vs. 22.2±17.0 days, P =0.01), exercising (25.2±27.0 vs. 65.8±58.2 days, P =0.003), and household chores (12.7±10.7 vs. 31.7±3.3 days, P =0.02) all occurred significantly sooner after the laparoscopic operation (12). In the Georgetown series, donor complications have been minimal: urinary tract infection (n=1; 1.25%) and below-the-knee deep venous thrombosis (n=1; 1.25%). These results compare favorably with the 8–47% complication rate reported in association with open donor nephrectomy (6). Pneumothorax, wound infection, and urinary tract infection are most commonly reported in this instance. In the Johns Hopkins series, similar donor complication rates have been observed. However, in this series of more than 230 cases there has been one bowel injury that was unrecognized at the time of surgery. Overall, in the combined Georgetown/Johns Hopkins experience of more than 310 cases, the complication rate has been minimal. To date there have been no donor mortalities reported for this operation. There have been no reports of chronic pain or discomfort with LDN as is frequently seen after a flank incision. These data suggest that donor complications associated with LDN are no greater or more severe than those associated with open donor nephrectomy. RECIPIENT RESULTS It is incumbent upon any new donor operation team to produce an intact, functional organ. Original concerns about traumatizing the organ, excessive ischemic times, decreased renal function, or increased allogenicity caused by the laparoscopic operation have not been confirmed. A number of studies have now demonstrated that recipient outcomes are equivalent when comparing those patients that received laparoscopically procured kidneys with those procured by the standard open approach (13). Specifically, a fall in serum creatinine after transplantation is prompt and reaches its nadir by the 4th posttransplant day. Incidence, onset, and severity of rejection are unaffected by the donor operation (15). Length of the recipient hospitalization is equivalent in both the open and laparoscopic groups. Late renal function (now with follow-up in some cases >40 months) is comparable. In early series the laparoscopic operation had a slightly increased incidence of ureteral and vascular complications, although these differences did not reach statistical significance. Technical complications in the recipient seemed to be related to a learning curve for the operation itself, patient selection, and the operating surgeon. A number of important technical modifications have been made subsequently, including dissection and removal of the donor ureter with the accompanying gonadal vein to minimize devascularization (16). In a recent review of the last 100 live donor renal transplantations performed with kidneys obtained from laparoscopic donors at Johns Hopkins Hospital, the incidence of ureteral complications was 3%. Two grafts were lost because of vascular thrombosis. One occurred in the face of a severe acute rejection. The other patient was subsequently found to have an hypercoaguable state. Thus, it seems that neither of these cases represented a technical problem that would have been influenced by the donor operation. Similarly, the ureteral complication rate at Georgetown is 2.4%; a single graft was lost on postoperative day 135. The rate of delayed graft function is 2%. One cannot look at a comparison of recipient outcomes without considering the effect that the laparoscopic donor operation has had on increasing live donation. It is incalculable how many patients have been denied a live donor renal transplant because the financial and logistical disincentives imposed by the open donor operation were too great for the potential donor. Many of these patients have been relegated to either prolonged dialysis or transplantation with a cadaver kidney, resulting in suboptimal outcomes. Additionally, the laparoscopic donor operation has shifted the overall donor/recipient risk/benefit ratio. Donors, recipients, and surgeons are all more likely to consider live donor transplantation for higher risk recipients because of the decreased “cost” to the donor with LDN. At Johns Hopkins, this has enabled us to successfully perform live donor transplantations after abrogating a positive donor-specific crossmatch by using plasmapheresis and i.v. immune globulin before transplantation. Similarly, ABO blood group incompatible live donor renal transplantations are now also being performed. At Georgetown, LDN is routinely performed as a “23 hr stay” procedure in a manner similar to that for laparoscopic cholecystectomy patients (10). Additionally, altruistic strangers wishing to donate their kidneys are now coming forward with increasing frequency because of the lower “price” that the donor has to pay (8). At Johns Hopkins Hospital we have received 57 inquiries from individuals wishing to donate into the system since September 1999. This occurred after we performed a transplantation from an altruistic stranger donor that received a large amount of media attention (17). This unexpected phenomenon of altruistic strangers volunteering to donate seems to be a direct consequence of the laparoscopic donor operation. These individuals may be a new untapped source of organs for transplantation. CONCLUSIONS LDN has now been performed for 5 years. Multiple centers have adopted this operation and have reported satisfactory results. LDN is safe for the donor, with complication rates that are comparable to that seen with the open donor operation performed through a flank incision. However, LDN offers significant advantages to the donor in terms of decreased post-operative pain, shorter hospitalization, and quicker recuperation. As hypothesized, LDN has effectively removed some of the disincentives to live kidney donation. This has resulted in increased live donation rates at many centers now performing this operation. Recipient outcome is also comparable with kidneys obtained by LDN as with the standard open operation. Earlier concerns regarding renal integrity or recipient technical complications have been negated. Technical modifications and increased surgical expertise have overcome difficulties associated with a learning curve. Many additional patients with end-stage renal disease have benefited from live donor transplants because of LDN. The debate over the relative merits of LDN versus open donor nephrectomy has breathed new life into what had previously been a relatively moribund field. A literature review of “donor nephrectomy” revealed that from January 1990 to November 1995 (the date when the first LDN was reported) only 24 (∼4.1/year) citations were published. However, from November 1995 to January 2000, 66 (∼15.5/year) publications appeared. The issue of live donor disincentives has now been brought to the forefront as a result of this debate. Novel ideas are now being discussed to further reduce the “cost” of live donation for the donor. Similarly, the question of the appropriate use of the altruistic stranger donor has emerged as a consequence of LDN. Finally, a variety of surgical alternatives to LDN have been proposed to in an attempt to lessen the learning curve for surgeons wishing to adopt this procedure. Most notable is the hand-assisted laparoscopic donor nephrectomy (18). Although this procedure may be beneficial to novice laparoscopists, we recommend that surgeons wishing to adopt any form of the laparoscopic donor operation observe the operation at a center that has performed a large number of these procedures. The minor details or “tricks” that can be learned may be crucial to the surgeon’s successful application of this procedure. If surgeons remain careful and prudent in their adoption of LDN, we anticipate that within a few years this operation will become the standard approach to donor nephrectomy.