FATE OF DONOR KIDNEY: LAPAROSCOPIC VERSUS OPEN TECHNIQUE

Novel surgical techniques, regenerative medicine, tissue engineering and innovative immunosuppression in kidney transplantation

On the 60th anniversary of the first successfully performed renal transplantation, we summarize the historical, current and potential future status of kidney transplantation. We discuss three different aspects with a potential significant influence on kidney transplantation progress: the development of surgical techniques, the influence of regenerative medicine and tissue engineering, and changes in immunosuppression. We evaluate the standard open surgical procedures with modern techniques and compare them to less invasive videoscopic as well as robotic techniques. The role of tissue engineering and regenerative medicine as a potential method for future kidney regeneration or replacement and the interesting search for novel solutions in the field of immunosuppression will be discussed. After 60 years since the first successfully performed kidney transplantation, we can conclude that the greatest achievements are associated with the development of surgical techniques and with planned systemic immunosuppression.

Laparoscopy, dorsal lumbotomy and flank incision live donor nephrectomy: comparison of donor outcomes

BACKGROUND

Flank incision (FL), dorsal lumbotomy (DL) and laparoscopic surgery have been effective approaches to donor nephrectomy. While laparoscopic donor nephrectomy (LDN) has become increasingly popular, there has yet to be a direct comparison of the three modalities.

METHODS

We performed a retrospective chart review of FL, DL and LDN operations between 2002 and 2010 within a single institution. Donor and recipient characteristics, as well as surgical outcomes, were assessed.

RESULTS

There were 496 donor nephrectomy operations available for analyses. Patients in the LDN group had the lowest estimated blood loss, compared to the DL and FL groups (p < 0.001), lowest rate of complications (p < 0.01), and shortest hospital stay (p < 0.0001). Donors who underwent DL used an average of 60.12 ± 5.0 mg of morphine, which was significantly less than that used by patients in the LDN (93.2 mg, p < 0.0001) and FL (111.82 mg, p < 0.001) groups. Mean serum creatinine of recipients at day 1 post-op was the highest in the FL group (p < 0.0001 FL vs. LDN, p < 0.001 FL vs. DL), but there were no significant differences between the three groups at 2 weeks, 6, 12, 18, and 24 months post-operation (p > 0.45).

CONCLUSIONS

Although a lower pain experience of LDN was not indicated, the use of LDN should be favoured over DL and FL as it is associated with fewer complications, and shorter length of stay. Of note, DL appears to be associated with higher complications and is likely not a preferred option for donor nephrectomy.

Long-term graft function in a randomized clinical trial comparing laparoscopic versus open donor nephrectomy

OBJECTIVES

To evaluate and compare the long-term graft and survival rates in kidney transplant recipients who had undergone laparoscopic donor nephrectomy versus those who underwent open donor nephrectomy.

MATERIALS AND METHODS

Our study was done with 100 cases of laparoscopic donor nephrectomy and 100 cases of open donor nephrectomy, performed between July 2001 and September 2003. Mean follow-up of recipients in this study was 6.6 ± 2.4 years (range, 1-9.3 y). This study has a longer follow-up than previous randomized clinical trials. We compared patient and graft survival in recipients of laparoscopic donor nephrectomy versus those who had open donor nephrectomy.

RESULTS

Mean duration of kidney warm ischemia time was 8.7 ± 2.7 minutes for laparoscopic donor nephrectomy and 1.8 ± 0.92 minutes for open donor nephrectomy. There were no significant differences in 5-year graft survival between the laparoscopic donor nephrectomy and open donor nephrectomy groups (89.5% vs 84.3%; P = .96). There were no differences in delayed graft function between the laparoscopic donor nephrectomy and open donor nephrectomy groups (8 and 11 patients; P = .135). There was a significant difference in 5-year graft survival between recipients with a history of delayed graft function and those without delayed graft function (63.2% vs 89.7%; P = .04). Despite a longer warm ischemia time in laparoscopic donor nephrectomy group (8.69 vs 1.87 min; P = .0001), warm ischemia time had no effect on graft outcome in long-term follow-up.

CONCLUSIONS

Although earlier experiences with laparoscopic donor nephrectomies were associated with concerns about long-term effects of laparoscopic donation on the graft function in the recipient, our long-term results confirm that laparoscopic donor nephrectomy provides similar graft outcome to open donor nephrectomy.

Laparoscopic donor nephrectomy - safety in a small-volume transplant center

INTRODUCTION

Laparoscopy is a standard surgical option for live donor nephrectomy (LDN) at the majority of transplant centers. Equivalent graft survival with shorter convalescence has been reported by several large volume centers. With the arrival of an experienced laparoscopic surgeon in 2002, we began to offer laparoscopic LDN at our institution. We report our experience as a large volume laparoscopic surgery program but a low volume transplant center.

METHODS

A retrospective review of the previous 34 LDN (17 open, 17 laparoscopic) performed at the University of Missouri were included. A single laparoscopic surgeon performed all laparoscopic procedures. Hand assisted laparoscopy was performed in 15 and standard laparoscopy with a pfannenstiel incision in two. Open procedures were performed through anterior subcostal or flank incision. A single surgeon performed all open procedures.

RESULTS

There was no statistical difference in age, body mass index or American Society of Anesthesiologies Score between the two groups. Mean operative time, estimated blood loss and hospital stay were 229 minutes, 324 cc and 2.2 days respectively in the laparoscopic group compared to 202 minutes, 440 cc and five days for the open group. Average warm ischemia time was 179 seconds. Recipient creatinine for the two groups at one week, one month and one year was not statistically significantly different. Each group had one graft loss due to medication noncompliance.

CONCLUSION

For small transplant centers with an advanced laparoscopic program, laparoscopic LDN is a safe procedure with comparable outcomes to major transplant centers.

Open versus laparoscopic live donor nephrectomy: a focus on the safety of donors and the need for a donor registry

PURPOSE

A review of the existing literature showed that the subject of live donor nephrectomy is a seat of underreporting and underestimation of complications. We provide a systematic comparison between laparoscopic and open live donor nephrectomy with special emphasis on the safety of donors and grafts.

MATERIALS AND METHODS

The PubMed literature database was searched from inception to October 2006. A comparison was made between laparoscopic and open live donor nephrectomy regarding donor safety and graft efficacy.

RESULTS

The review included 69 studies. There were 7 randomized controlled trials, 5 prospective nonrandomized studies, 22 retrospective controlled studies, 26 large (greater than 100 donors), retrospective, noncontrolled studies, 8 case reports and 1 experimental study. Most investigators concluded that, compared to open live donor nephrectomy, laparoscopic live donor nephrectomy provides equal graft function, an equal rejection rate, equal urological complications, and equal patient and graft survival. Analgesic requirements, pain data, hospital stay and time to return to work are significantly in favor of the laparoscopic procedure. On the other hand, laparoscopic live donor nephrectomy has the disadvantages of increased operative time, increased warm ischemia time and increased major complications requiring reoperation. In terms of donor safety at least 8 perioperative deaths were recorded after laparoscopic live donor nephrectomy. These perioperative deaths were not documented in recent review articles. Ten perioperative deaths were reported with open live donor nephrectomy by 1991. No perioperative mortalities have been recorded following open live donor nephrectomy since 1991. Regarding graft safety, at least 15 graft losses directly related to the surgical technique of laparoscopic live donor nephrectomy were found but none was emphasized in recent review articles. The incidence of graft loss due to technical reasons in the early reports of open live donor nephrectomy was not properly documented in the literature.

CONCLUSIONS

We are in need of a live organ donor registry to determine the combined experience of complications and long-term outcomes, rather than short-term reports from single institutions. Like all other new techniques, laparoscopic live donor nephrectomy should be developed and improved at a few centers of excellence to avoid the loss of a donor or a graft.

Can magnetic resonance angiogram be a reliable alternative for donor evaluation for laparoscopic nephrectomy?

BACKGROUND

While hand-assisted laparoscopic donor nephrectomy (HLDN) is less invasive, which can encourage kidney donation, it requires more exact information about the renal vascular anatomy because of its limited visual field during nephrectomy. MRA is also an attractive choice because of its minimal invasiveness; further, it is an outpatient-based procedure, it uses non-nephrotoxic contrast material and it has no radiation. The aim of our study was to evaluate the effectiveness of gadolinium enhanced three-dimensional MRA (GdE-3D MRA) in a group of potential live donors who were candidates for HLDN.

METHODS

From September 2002 to December 2004, 40 potential live renal donors were evaluated prospectively with GdE-3D MRA, and this imaging modality was performed before the gold standard, the intra-arterial digital subtraction angiogram (IA-DSA), was carried out. All the images were reviewed in a blinded manner by the attending vascular radiologist. The MRA findings were compared with the DSA findings and the surgical findings as the reference methods. We evaluated the accuracy of MRA for imaging the renal architectures, and especially for imaging the renal accessory arteries and the early branching arteries that are important determinants for selection of the donor kidney.

RESULTS

Both the MRA and DSA images showed consistent findings with the surgical findings in 92.5% of the 40 donors. There were no discrepant cases in depicting the main renal artery. MRA showed 100% specificity for imaging both the renal accessory arteries and the early branching arteries, when compared with the surgical findings. The kappa values for the MRA and DSA for the accessory arteries were all 0.66 compared with the intraoperative findings. MRA also depicted one huge renal cyst in one donor and many small renal cysts in the other donors that could not be imaged by DSA. There were no adverse events during the MRA procedure. None of the findings missed by MRA resulted in deleterious consequences at laparoscopic nephrectomy for the donor and graft.

CONCLUSIONS

Our limited experience with GdE-3D MRA for imaging the renal structures in kidney donor evaluation for HLDN has been quite satisfactory.

Ten Years of Laparoscopic Living Donor Nephrectomy: Retrospect and Prospect From the Nephrologist’s Point of View

The laparoscopic living kidney donor nephrectomy introduced in 1995 has become an accepted method of kidney harvest for transplantation. The method has proven its usefulness as well as its superiority compared to open donor nephrectomy. Based on the results of a decade, an overview from a nephrologist's point of view is presented here in; a view that is known to be quite different from (and sometimes contrary to) the surgeon's approach. While urologists and surgeons focus more on the technique and complication rates, the nephrologist tends to estimate the new procedure with regard to his dialysis patients' outcomes (ie, whether it will result in an increased number of kidney transplantations in the long term). The latter aspect has to be the benchmark in the estimation of the effects of this procedure; it is the ultimate goal of every surgery in kidney transplantation. The 10-year results are more than encouraging, but nevertheless it will take at least one more decade for a valid evaluation.

Effect of Warm Ischemia on Graft Outcome in Laparoscopic Donor Nephrectomy

PURPOSE

To assess the impact of warm ischemia time (WIT) on delayed graft function (DGF), graft loss, and graft function in laparoscopic donor nephrectomy (LDN).

PATIENTS AND METHODS

We prospectively studied 100 kidney recipients from LDN donors from 2001 to 2003. For comparison of graft outcome with different extents of WIT, recipients were divided into three groups: group A received kidneys having 4 to 6 minutes, group B kidneys having >6 to 10 minutes, and group C kidneys having >10 minutes of WIT. The median follow-up was 415 days (range 11-791) days.

RESULTS

The mean kidney WIT was 8.7 minutes (range 4-17 minutes). Graft outcome (DGF, graft loss, and median serum creatinine) was not significantly different in the three groups.

CONCLUSIONS

Different extents of WIT in LDN, within the range of our study, were not associated with an adverse outcome in kidney transplantation.

Third Prize: Randomized Trial of Laparoscopic Donor Nephrectomy with and without Hand Assistance

PURPOSE

To compare the early results of standard laparoscopic (SL) and hand-assisted laparoscopic (HAL) donor nephrectomy in a randomized study.

PATIENTS AND METHODS

Forty donors were randomly assigned in equal numbers to either SL or HAL. Two donors in the SL group and three patients in the HAL group underwent right nephrectomy; the others underwent left nephrectomy. In the SL group, specimen extraction was performed via a Pfannenstiel incision and in HAL group through a periumbilical midline incision. Objective intraoperative, hospital stay, and postoperative data as well as pain analog scores were collected prospectively. Patients completed the quality-of-life (QoL) SF-36 questionnaire preoperatively and at 1 month and 3 months of follow-up.

RESULTS

There was a statistically significant difference in the mean operative time in the two groups (200 +/- 20.8 minutes for SL v 219 +/- 28.3 minutes for HAL; P = 0.02). There was no difference in the mean estimated blood loss (141.5 +/- 221.8 mL v 97.4 +/- 73 mL, respectively; P = 0.41), warm ischemia time (157.5 +/- 76.3 seconds v 135.5 +/- 53.7 seconds; P = 0.32), length of postoperative hospital stay (1.9 +/- 0.5 days v 2.1 +/- 0.5 days; P = 0.61), intravenous analgesia (22.1 +/- 14.0 mg v 28.3 +/- 14.8 mg of morphine sulfate equivalent; P = 0.18), or pain score on postoperative day 1 (6.1 +/- 1.0 v 6.2 +/- 1.1) and 2 (3.3 +/- 1.2 and 3.4 +/- 1.3). There were five minor complications in the SL group and three in the HAL group. The mean preoperative (89.7 +/- 4.8 v 89.2 +/- 7.4; P = 0.84), 1-month (63.4 +/- 13.9 v 64.5 +/- 12.6; P = 0.82), and 3-month (82.7 +/- 7.4 v 80.2 +/- 8.4; P = 0.41) postoperative QoL scores did not differ significantly between the groups. None of the recipients required postoperative dialysis, and there was no statistical difference between the two groups in the serum creatinine concentration.

CONCLUSION

Laparoscopic and hand-assisted donor nephrectomies have similar outcomes and postoperative pain. Both approaches are well tolerated with minimal complication rates and have similar impact on patients' quality of life.

Maintaining urine production and early allograft function during laparoscopic donor nephrectomy

OBJECTIVES

Intraoperative oliguria and its impact on early postoperative allograft function have been expressed as potential concerns of laparoscopic kidney donation. We evaluated our ability to maintain adequate diuresis during laparoscopic donor nephrectomy and its potential impact on early graft function compared with open donation.

METHODS

We performed a retrospective review of 98 laparoscopic and 80 open donor nephrectomies from 1999 to 2002. All laparoscopic donors received infusions of mannitol (grams of mannitol equaled patient weight in kilograms) and dopamine (2 to 3.0 microg/kg/min) throughout the pneumoperitoneum. All open donors received a single dose of mannitol (12.5 g). Multiple donor variables were compared, including operative time, estimated blood loss, intraoperative fluid administration (in milliliters per kilogram per hour), intraoperative urine production (milliliters per kilogram per hour), and change in creatinine at discharge. The postoperative recipient data were compared, including initial 24-hour urine output, 1-week creatinine level, 1-month creatinine level, and need for postoperative hemodialysis.

RESULTS

No significant differences were noted in the donor groups with respect to age, weight, intraoperative fluid administration, or change in creatinine at discharge. The mean operative urine production was greater in the laparoscopic group at 5.22 mL/kg/hr than in the open group at 2.43 mL/kg/hr (P = 0.0001). The mean estimated blood loss was significantly lower (P = 0.0001) for the laparoscopic donors (106.7 mL) than for the open donors (184.7 mL). No significant differences were seen among the recipient groups.

CONCLUSIONS

The use of mannitol and dopamine infusions during laparoscopic donor nephrectomy provided superior intraoperative urine production in the donor and equivalent early graft function in the recipient compared with the open approach.

Evaluation of Living Renal Donors: Accuracy of Three-dimensional 16-Section CT

PURPOSE

To retrospectively assess the sensitivity and specificity of three-dimensional (3D) 16-section computed tomography (CT) in the evaluation of vessels, pelvicalyceal system, and ureters in living renal donors, with surgical findings as the reference standard.

MATERIALS AND METHODS

This was a HIPAA-compliant study. Institutional review board approval was obtained for the review of subjects' medical records and data analysis, with waiver of informed consent. Forty-six renal donors (18 men, 28 women; mean age, 42 years) were examined with 16-section CT. Two blinded reviewers independently studied renal vascular and urographic anatomy of each donor CT scans by fist using 3D images alone, then transverse images alone, and finally transverse and 3D data set. Image quality, degree of diagnostic confidence, and time used for review were recorded. Sensitivity and specificity were calculated.

RESULTS

For 3D images, transverse images, and transverse in conjunction with 3D data sets, the respective sensitivity and specificity of CT in evaluation of accessory arteries by reviewer 1 were 100% and 100%, 89% and 100%, and 100% and 100%, and those by reviewer 2 were 89% and 97%, 89% and 100%, and 89% and 100%; the respective sensitivity and specificity in evaluation of venous anomalies by reviewer 1 were 100% and 98%, 100% and 98%, and 100% and 98%, and those by reviewer 2 were 100% and 98%, 100% and 95%, and 100% and 98%. For focused comprehensive assessment of renal donors with 3D scans alone, a reviewer on average (average of reviewers 1 and 2) used 2.4 minutes per scan, demonstrated full confidence in 93%, and rated the quality as excellent in 76%.

CONCLUSION

For focused assessment of renal vascular and urographic anatomy, review of 3D data set alone provides high sensitivity and specificity with regard to findings seen at surgery.

Strategies to increase living donor kidney transplants

There is an insufficient supply of deceased donor kidneys for transplantation. One solution is to increase the number of living donor kidney transplants. Our kidney transplant database was reviewed for 3 periods of 12 months each, separated by 5 years, to show the trends in kidney transplant donor sources and the influence of biologically unrelated living renal donors, minimally invasive living renal donor surgery, transplantation of ABO-incompatible kidneys from living donors, and transplantation in spite of positive cross-matches on the numbers of renal transplants and 1-year kidney transplant survival rates at our center. When results for 1993 were compared with 2003, the annual number of living donor renal transplants increased from 25 to 86, and the annual number of deceased donor renal transplants decreased from 108 to 63. The total number of kidney transplants increased by 12%. However, 1-year living donor kidney transplant survivals were not significantly different (94% for transplants done in 1993 vs 98% for transplants done in 2003). The strategies of living donor renal transplants from genetically unrelated donors, ABO-incompatible donors, and cross-match positive donors as well as the introduction of hand-assisted laparoscopic donor nephrectomy increased the number of living renal donor renal transplants at our center without compromising short-term kidney transplant survival rates.

Modifications of Renal Blood Flow and Serum Interleukin Levels Induced by Laparoscopic and Open Living Donor Nephrectomies For Kidney Transplant: An Experimental Study in Pigs

The increase of intraabdominal pressure (IAP) during laparoscopy modifies renal blood flow (RBF). However, laparoscopic techniques are less invasive than open procedures. The use of interleukins (IL) to evaluate operative trauma of different surgical techniques is controversial. The aim of the study was to analyze the, modifications induced by laparoscopic and open nephrectomies on RBF, renal function and IL levels. Thirty pigs underwent left nephrectomy, 15 by laparoscopy and 15 by an open approach in an experimental autotransplant model. A significant reduction in RBF was observed among the laparoscopic (80 +/- 27 mL/min) versus the open group (263 +/- 3 mL/min, P < .05). Laparoscopy reduced glomerular filtration (GF) (37.6 +/- 1.1%) to a greater extent than an open technique (80.5 +/- 0.4%; P < .05). Serum levels of IL-2, IL-6, IL-10, and tumor necrosis factor (TNF) were lower during laparoscopic than open nephrectomy: 6.8 +/- 0.6 versus 13 .9 +/- 1.1 pg/mL for IL-2, 46.2 +/- 2.3 versus 84.4 +/- 2.5 pg/mL for IL-6, 26.1 +/- 2.4 versus 92.8 +/- 12.6 pg/mL for IL-10, and 17.6 +/- 2.1 versus 38.5 +/- 4.8 pg/mL for TNF (P <.001). In conclusion, laparoscopic nephrectomy for living donor kidney transplant induced significant reductions in RBF and GF. However, there was less increase in IL levels during laparoscopic than the open approach. The influence of these circumstances on graft function after kidney transplantation is not clearly established.

Laparoscopic donor nephrectomy: an update

PURPOSE OF REVIEW

Laparoscopic donor nephrectomy is considered the gold standard for renal donation. In the hands of experienced laparoscopists it provides a safe and equally effective alternative to open nephrectomy, and recipient graft function has been shown to be equivalent regardless of the procurement method utilized. Complication rates and postoperative donor renal function are equivalent to that of open nephrectomy, whereas recovery time is significantly shorter and surgical scars more cosmetic with the laparoscopic approach.

RECENT FINDINGS

Advances in preoperative imaging and laparoscopic technique have enabled surgeons to broaden the patient population considered for donor nephrectomy. Improved three-dimensional imaging facilitates operative planning and intraoperative dissection, and the retroperitoneoscopic approach has decreased operative time. Acquisition of laparoscopic skills has also enabled surgeons to perform donor nephrectomies on kidneys that previously would have been considered less desirable for donation (e.g. right-sided or with anomalous vasculature).

SUMMARY

End-stage renal disease and the need for renal transplantation continue to be major medical concerns in the United States and worldwide. Advances in donor nephrectomy have reduced the demand for organs by increasing the potential organ pool while limiting risk to donors. As imaging and laparoscopic techniques continue to advance, it is anticipated that minimally invasive donor nephrectomy will continue to evolve. This review summarizes the developments to date.

Laparoscopic Right Nephrectomy Using a Novel Technique to Excise an Inferior Vena-Caval Cuff in a Porcine Model

BACKGROUND AND PURPOSE

Laparoscopic right nephrectomy has been performed using laparoscopic staplers to clamp and divide the renal vessels. In patients who have a tumor thrombus in the renal vein and in rightkidney donors, it is necessary to excise a cuff of the inferior vena cava (IVC) with the renal vein. We present a new technique for excising a cuff of the IVC and suturing it intracorporally using a new vascular clamp designed in our institution.

MATERIALS AND METHODS

The vascular clamp was designed to be completely inserted into the peritoneal cavity through the hand-port incision. The renal vein with a cuff of the IVC was then excised, and the defect in the IVC was sutured with a vascular stitch intracorporally. This procedure was performed in the animal laboratory using a porcine model.

RESULTS

A total of 20 hand-assisted right laparoscopic nephrectomies were performed. In the first five operations, the clamp dimensions and angles were modified until the ideal design was reached. In the next five operations, different suture materials and needle sizes were tried to find the best combination for the intracorporal IVC sutures. The first and second operations were not completed because of the difficulty in applying the initial version of the clamp to the IVC. In the 4th and 6th operations, bleeding occurred from the suture line: because of a missed stitch in the back wall of the IVC in one case and a needle stick to the IVC in the other case. The last 14 operations were successful without any bleeding or injuries. Suturing of the IVC was completed in 13 to 22 minutes.

CONCLUSION

Right hand-assisted laparoscopic nephrectomy with excision of a cuff of the IVC using an intracorporal vascular clamp is safe and reproducible in a porcine model. In our hands, a learning curve of 10 cases was required.