Current concepts in transplant surgery: laparoscopic living donor of the kidney

The Evolution of Living Donor Nephrectomy Program at A Hellenic Transplant Center. Laparoscopic vs. Open Donor Nephrectomy: Single-Center Experience

Since its introduction in 1995, laparoscopic nephrectomy has emerged as the preferred surgical approach for living donor nephrectomy. Given the ubiquity of the surgical procedure and the need for favorable outcomes, as it is an elective operation on otherwise healthy individuals, it is imperative to ensure appropriate preoperative risk stratification and anticipate intraoperative challenges. The aim of the present study was to compare peri-and postoperative outcomes of living kidney donors (LD), who had undergone laparoscopic nephrectomy (LDN), with a control group of those who had undergone open nephrectomy (ODN). Health-related quality of life (QoL) was also assessed using the validated SF-36 questionnaire. Data from 252 LD from a single transplant center from March 2015 to December 2020 were analyzed retrospectively. In total, 117 donors in the LDN and 135 in the ODN groups were assessed. Demographics, type of transplantation, BMI, duration of surgery, length of hospital stay, peri- and postoperative complications, renal function at discharge and QoL were recorded and compared between the two groups using Stata 13.0 software. There was no difference in baseline characteristics, nor in the prevalence of peri-and postoperative complications, with a total complication rate of 16% (mostly minor, Clavien–Dindo grade II) in both groups, while a different pattern of surgical complications was noticed between them. Duration of surgery was significantly longer in the ODN group (median 240 min vs. 160 min in LDN, p < 0.01), warm ischemia time was longer in the LDN group (median 6 min vs.2 min in ODN, p < 0.01) and length of hospital stay shorter in the LDN group (median 3 days vs. 7 days in ODN). Conversion rate from laparoscopic to open surgery was 2.5%. There was a drop in estimated glomerular filtration rate (eGFR) at discharge of 36 mL/min in the LDN and 32 mL/min in the ODN groups, respectively (p = 0.03). No death, readmission or reoperation were recorded. There was a significant difference in favor of LDN group for each one of the eight items of the questionnaire (SF1–SF8). As for the two summary scores, while the total physical component summary (PCS) score was comparable between the two groups (57.87 in the LDN group and 57.07 in the ODN group), the mental component summary (MCS) score was significantly higher (62.14 vs. 45.22, p < 0.001) in the LDN group. This study provides evidence that minimally invasive surgery can be performed safely, with very good short-term outcomes, providing several benefits for the living kidney donor, thereby contributing to expanding the living donor pool, which is essential, especially in countries with deceased-donor organ shortage.

Perioperative Events and Complications in Minimally Invasive Live Donor Nephrectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive live donor nephrectomy has become a fully implemented and accepted procedure. Donors have to be well educated about all risks and details during the informed consent process. For this to be successful, more information regarding short-term outcome is necessary.

METHODS

A literature search was performed; all studies discussing short-term complications after minimally invasive live donor nephrectomy were included. Outcomes evaluated were intraoperative and postoperative complications, conversions, operative and warm ischemia times, blood loss, length of hospital stay, pain score, convalescence, quality of life, and costs.

RESULTS

One hundred ninety articles were included in the systematic review, 41 in the meta-analysis. Conversion rate was 1.1%. Intraoperative complication rate was 2.3%, mainly bleeding (1.5%). Postoperative complications occurred in 7.3% of donors, including infectious complications (2.6%), of which mainly wound infection (1.6%) and bleeding (1.0%). Reported mortality rate was 0.01%. All minimally invasive techniques were comparable with regard to complication or conversion rate.

CONCLUSIONS

The used techniques for minimally invasive live donor nephrectomy are safe and associated with low complication rates and minimal risk of mortality. These data may be helpful to develop a standardized, donor-tailored informed consent procedure for live donor nephrectomy.

[Is the traditional open donor nephrectomy in living donor renal transplantation still up to date?]

BACKGROUND

Living donor kidney transplantation is a well-established method to reduce time on the waiting list. Although the laparoscopic donor nephrectomy has already been established worldwide, more than 80% of the living donor nephrectomies are performed as a traditional open donor nephrectomy in Germany. The aim of our study was to analyze perioperative data and long-term outcome of donors and recipients following open donor nephrectomy.

METHODS

From February 2004 to July 2008, a total of 51 open donor nephrectomies were performed in Tuebingen University Hospital. Forty-five data of corresponding transplant donors and recipients were analyzed. The Kocak classification which provides a format to compare postoperative complications after living donor nephrectomy was used.

RESULTS

Five-year graft survival was 100%. No intraoperative complications occurred. Postoperatively Grad I complications were observed in 10 donors (22.2%). In the long term no major complications occurred. Two donors (4.4%) had newly diagnosed hypertension and required antihypertensive medication. None of the donors developed proteinuria. Right-sided transabdominal donor nephrectomy was associated with a shorter mean hospital stay compared to left-sided lumbar nephrectomy. (7.8 ± 2.4 vs. 9.2 ± 1.8 days, p < 0.05).

CONCLUSION

Open donor nephrectomy is a safe procedure with an excellent graft survival. Complication rates in our center are comparable to recent results in laparoscopic living donor nephrectomy. Therefore, the open donor nephrectomy remains important.