Laparoscopic donor nephrectomy vs. open live donor nephrectomy: a quality of life and functional study

Living Kidney Donation: A Narrative Review of Mid- and Long-term Psychosocial Outcomes

Living kidney donors make a significant contribution to alleviating the organ shortage. The aim of this article is to provide an overview of mid- and long-term (≥12 mo) living donor psychosocial outcomes and highlight areas that have been understudied and should be immediately addressed in both research and clinical practice. We conducted a narrative review by searching 3 databases. A total of 206 articles were included. Living donors can be divided into those who donate to an emotionally or genetically related person, the so-called directed donors, or to an emotionally or genetically unrelated recipient, the so-called nondirected donors. The most commonly investigated (bio)psychosocial outcome after living donation was health-related quality of life. Other generic (bio)psychological outcomes include specific aspects of mental health such as depression, and fatigue and pain. Social outcomes include financial and employment burdens and problems with insurance. Donation-specific psychosocial outcomes include regret, satisfaction, feelings of abandonment and unmet needs, and benefits of living kidney donation. The experience of living donation is complex and multifaceted, reflected in the co-occurrence of both benefits and burden after donation. Noticeably, no interventions have been developed to improve mid- or long-term psychosocial outcomes among living donors. We highlight areas for methodological improvement and identified 3 areas requiring immediate attention from the transplant community in both research and clinical care: (1) recognizing and providing care for the minority of donors who have poorer long-term psychosocial outcomes after donation, (2) minimizing donation-related financial burden, and (3) studying interventions to minimize long-term psychosocial problems.

A Prospective Study Comparing Quality of Life after Laparoscopic Donor Nephrectomy versus Open Donor Nephrectomy

Laparoscopic donor nephrectomy (LDN) has advantages over open donor nephrectomy (ODN), with less bleeding and pain, and earlier discharge. However, the quality of life (QOL) has not been compared between these techniques. All consecutive donors undergoing left LDN or ODN from 2013 to 2015 at our center were included. The donors' QOL was measured with the brief World Health Organization QOL (WHOQOL-BREF) and the Hospital Anxiety and Depression Scale (HADS) questionnaires preoperatively and at 3 and 6 months postoperatively. Cosmesis was measured by the body image questionnaire, and patient satisfaction was scored on a verbal rating scale at 3 and 6 months. Of the 264 donors, 228 met the inclusion criteria (100 - LDN and 128 - ODN). The LDN group showed no difference in WHOQOL-BREF scores at 3 months, and significant improvements in the psychological and social domains at 6 months versus the baseline. The ODN group showed a significant decrease in the physical, psychological, and environmental domains at 3 and 6 months versus the baseline. Compared with the ODN group, the LDN group had better QOL scores at 3 and 6 months in all domains. The responses to the HADS questionnaire were similar between the groups at all time points. The mean body image, cosmesis, and satisfaction scores were significantly better in the LDN group. LDN minimized the negative effects of surgery on the donors' QOL, with improvements in the long-term psychological and social aspects versus the baseline. LDN was more cosmetic and was associated with higher satisfaction than ODN.

The Prevailing Preference for Left Nephrectomy in Living Donor Transplantation Does Not Adversely Affect Long-Term Donor and Recipient Outcomes

BACKGROUND

In living donor renal transplantation, surgeons traditionally prefer the left kidney for donation. The aim of this study was to assess the effects of the choice of laterality of donor nephrectomy on donor and recipient outcomes.

METHODS

The data was obtained from the UK National Health Service Blood and Transplant (NHSBT). During the study period, 7919 donor nephrectomy and transplantation were carried out in 24 transplant centers. Of these procedures, 6407 (80.9%) were left and 1512 (19.1%) were right kidney donors.

RESULTS

Right kidney donation was associated with higher incidence of surgical site infection in the donor. Recipient outcome was superior for left-sided kidneys in terms of immediate graft function, delayed graft function, graft loss within 30 days, and graft survival at 3 years, but not at 1 and 5 years. Open donor nephrectomy (n = 2396, 30.2%) was associated with higher rates of pneumothorax and hemorrhage, longer hospital stay, and inferior graft survival at 3 and 5 years compared with laparoscopic donor nephrectomy (n = 5523, 69.8%).

CONCLUSIONS

A right donor nephrectomy is associated with higher rate of wound infection in the donor and similar long-term graft outcomes in the recipients. Laparoscopic donor nephrectomy offers lower rate of major complications in the donor and a better overall graft survival.

Perioperative factors associated with persistent post-surgical pain after hysterectomy, cesarean section, prostatectomy, and donor nephrectomy: a systematic review and meta-analysis

ABSTRACT

Persistent postsurgical pain (PPSP) is a common, and often disabling postoperative morbidity, but many questions remain about factors associated with PPSP. This systematic review and meta-analysis aimed to identify preoperative, intraoperative and postoperative factors associated with PPSP after gynecological surgeries, namely hysterectomy and cesarean section (C-section), and urological surgeries, namely prostatectomy and donor nephrectomy. Overall, 18 gynecological surgery studies, 4 prostatectomy studies, and 2 donor nephrectomy studies met the review criteria providing data that could be meta-analyzed. Average (±SD) PPSP occurrence after gynecological surgery was 20±11%; factors associated with increased risk of PPSP included smoking, preoperative abdominal or pelvic pain, preoperative pain elsewhere in the body, longer duration of surgery, more intense acute postoperative pain, and surgical wound infection. The use of neuraxial anesthesia was associated with decreased PPSP risk. Average PPSP occurrence was 20±9% after prostatectomy and 15±2% after donor nephrectomy. For urological procedures, the existing data did not allow for identification of significant factors associated with PPSP, except for laparoscopic and hand assisted laparoscopic approaches that were associated with lower incidence of PPSP for donor nephrectomy, and the use of neuraxial anesthesia which was associated with lower incidence of PPSP after prostatectomy. PPSP after gynecological and urological surgeries is common. This systematic review identified important factors associated with C-section and hysterectomy that can help identify women who are at high risk of PPSP. More high-quality studies with consistent methodology are needed to understand the factors associated with PPSP risk, particularly for surgeries such as prostatectomy and nephrectomy.

Overview of Prognostic Systems for Hepatocellular Carcinoma and ITA.LI.CA External Validation of MESH and CNLC Classifications

Prognostic assessment in patients with HCC remains an extremely difficult clinical task due to the complexity of this cancer where tumour characteristics interact with degree of liver dysfunction, patient general health status, and a large span of available treatment options. Several prognostic systems have been proposed in the last three decades, both from the Asian and European/North American countries. Prognostic scores, such as the CLIP score and the recent MESH score, have been generated on a solid statistical basis from real life population data, while staging systems, such as the BCLC scheme and the recent CNLC classification, have been created by experts according to recent HCC prognostic evidences from the literature. A third category includes combined prognostic systems that can be used both as prognostic scores and staging systems. A recent example is the ITA.LI.CA prognostic system including either a prognostic score and a simplified staging system. This review focuses first on an overview of the main prognostic systems for HCC classified according to the above three categories, and, second, on a comprehensive description of the methodology required for a correct comparison between different systems in terms of prognostic performance. In this second section the main studies in the literature comparing different prognostic systems are described in detail. Lastly, a formal comparison between the last prognostic systems proposed for each of the above three categories is performed using a large Italian database including 6882 HCC patients in order to concretely apply the comparison rules previously described.

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.

Psychosocial risk factors for impaired health-related quality of life in living kidney donors: results from the ELIPSY prospective study

Living kidney donors' follow-up is usually focused on the assessment of the surgical and medical outcomes. Whilst the psychosocial follow-up is advocated in literature. It is still not entirely clear which exact psychosocial factors are related to a poor psychosocial outcome of donors. The aim of our study is to prospectively assess the donors' psychosocial risks factors to impaired health-related quality of life at 1-year post-donation and link their psychosocial profile before donation with their respective outcomes. The influence of the recipient's medical outcomes on their donor's psychosocial outcome was also examined. Sixty donors completed a battery of standardized psychometric instruments (quality of life, mental health, coping strategies, personality, socio-economic status), and ad hoc items regarding the donation process (e.g., motivations for donation, decision-making, risk assessment, and donor-recipient relationship). Donors' 1-year psychosocial follow-up was favorable and comparable with the general population. So far, cluster-analysis identified a subgroup of donors (28%) with a post-donation reduction of their health-related quality of life. This subgroup expressed comparatively to the rest, the need for more pre-donation information regarding surgery risks, and elevated fear of losing the recipient and commitment to stop their suffering.

Same-Day Discharge for Laparoscopic Donor Nephrectomy

Introduction:

Laparoscopic donor nephrectomy has provided advantages of decreased postoperative pain and length of stay when compared to the open approach. We provide our results of same-day discharge for laparoscopic donor nephrectomy.

Case Presentation:

We examined the safety and efficacy of same-day discharge for laparoscopic donor nephrectomy in a retrospective cohort analysis. This institutional review board–approved study began in July 2015, when all consecutive patients who underwent laparoscopic donor nephrectomy were offered same-day discharge. Experimental and control groups were analyzed for differences in sex, age, body mass index, surgery time, estimated blood loss, procedure, complications, length of stay, and distance lived from hospital. Statistical analyses were completed with Mann-Whitney U or Fisher's exact test, as appropriate.

Management and Outcome:

Eight patients underwent laparoscopic donor nephrectomy during the study period. Of the 8 donors, 4 were discharged on the same day as surgery. The other 4 were discharged the following day. No significant differences were found between the 2 groups with respect to the aforementioned variables. At a median follow-up of 206 days, no complications have been reported.

Discussion:

The results of our pilot study revealed that same-day discharge is safe and feasible, could have a significant impact on patient satisfaction and healthcare costs, and warrants further study.

Patient-Reported Outcomes for Open versus Laparoscopic Living Donor Nephrectomy

Background

Rates of living kidney donation have increased dramatically in recent years, in large part because of improved surgical techniques such as laparoscopic nephrectomy.

Objective

To compare patient-reported outcomes of laparoscopic nephrectomy versus open donor nephrectomy in 84 adult live kidney donors.

Outcome Measures

Outcomes included perceptions of pain and surgical scarring, number of surgical/medical complications, hospital length of stay, physical health problems related to donation, return to work, financial impact, health-related quality of life, and satisfaction with the donation experience.

Results and Conclusion

The 2 groups did not differ significantly in pain perceptions, number of surgical/medical complications, physical health problems, financial impact, health-related quality of life, or overall satisfaction. However, laparoscopic nephrectomy donors had significantly fewer hospital days and faster return to work time than open donor nephrectomy donors. The majority of donors report excellent health-related quality of life and no complications in the months following surgery. In addition, it appears that laparoscopic nephrectomy, in comparison to open donor nephrectomy, may reduce barriers to living kidney donation by reducing hospital length of stay and time away from work. Being able to return to work much sooner after surgery may significantly reduce the indirect costs (ie, lost wages) associated with living donation.

Retroperitoneoscopic donor nephrectomy with a gel-sealed hand-assist access device

Background

The hand-assisted technique enables the rapid extraction of the graft, shortening the warm ischemia time (WIT), and the retroperitoneoscopic approach is potentially associated with a less incidence of postoperative ileus in donor nephrectomy for living kidney transplantation. The aim of this study was to assess the efficacy and safety of retroperitoneoscopic donor nephrectomy with a gel-sealed hand-assist access device (GelPort), which is a wound sealing device that permits the access of the hand to the surgical field, free trocar site choice within it, and rapid conversion to open surgery if necessary, while preserving the pneumoperitoneum/pneumoretroperitoneum.

Methods

Seventy-five consecutive donors receiving this procedure were retrospectively studied. A 2-cm skin incision was made at the midpoint between the tip of the 12th rib and superior border of the iliac bone in the midaxillary line, through which retroperitoneal space was made. Preperitoneal wound with a 6 – 7-cm pararectal incision in the upper abdominal region was connected to the retroperitoneal space. A GelPort was put inside the pararectal surgical wound. The principle was pure retroperitoneoscopic surgery; hand-assist was applied for retraction of the kidney in the renal vessel control and graft extraction.

Results

The mean operation time including waiting time for recipient preparation was 242.2±37.0 (range: 214.0–409.0) min, and the mean amount of blood loss was 164.3±146.6 (range: 10.0–1020.0) ml. The mean WIT was 2.8±1.0 (range: 1.0–6.0) min. The shortage of renal vessels or ureter was observed in none of the grafts. No donor experienced blood transfusion, open conversion, or injury of other organs. Blood loss was greater in patients with body mass index (BMI) of 25 kg/m² or higher than in those with BMI of <25 kg/m² (218.4±98.8 vs. 154.8±152.1 ml, P=0.031). No donor had postoperative ileus or reported wound pain leading to decreased activity of daily life or wound cosmetic problem.

Conclusions

Retroperitoneoscopic hand-assisted donor nephrectomy with the mentioned approach was suggested to be a feasible option without compromising safety, although further improvement in surgical techniques is warranted.

Health care follow-up by live kidney donors more than three yr post-nephrectomy

BACKGROUND

Live kidney donors are advised to follow up regularly with healthcare providers to monitor kidney function and to diagnose and treat relevant comorbidities. We sought to determine the frequency and correlates of follow-up care among live kidney donors.

METHODS

We sent a mailed questionnaire to 606 live kidney donors from a single center who were at least three yr post-nephrectomy.

RESULTS

We received usable responses from 276 (45.5%), at a median of 6.2 yr post-donation. Compared with non-responders, responding donors were more likely to be older (p < 0.001), female (p = 0.002), white (p < 0.001), and married to the recipient (p < 0.001). In the prior year, 87.7% of respondents reported seeing a physician or other healthcare professional, and 79.0% had seen a "general doctor" such as their primary care provider. In univariable analyses of live kidney donors who responded to our survey, lack of medical follow-up in the past year was associated with younger age, current lack of health insurance, and infrequent contact with the transplant recipient.

CONCLUSIONS

Most responding live kidney donors had seen a healthcare provider within the past year. To improve donors' follow-up, transplant centers can consider targeting donors who are younger or lack health insurance.

Prevention of poor psychosocial outcomes in living organ donors: from description to theory-driven intervention development and initial feasibility testing

CONTEXT

Although some living donors experience psychological, somatic, and interpersonal difficulties after donation, interventions to prevent such outcomes have not been developed or evaluated.

OBJECTIVE

To (1) summarize empirical evidence on psychosocial outcomes after donation, (2) describe a theoretical framework to guide development of an intervention to prevent poor outcomes, and (3) describe development and initial evaluation of feasibility and acceptability of the intervention.

METHODS

Based on a narrative literature review suggesting that individuals ambivalent about donation are at risk for poor psychosocial outcomes after donation, the intervention targeted this risk factor. Intervention structure and content drew on motivational interviewing principles in order to assist prospective donors to resolve ambivalence. Data were collected on donors' characteristics at our institution to determine whether they constituted a representative population in which to evaluate the intervention. Study participants were then recruited to assess the feasibility and acceptability of the intervention. They were required to have scores greater than 0 on the Simmons Ambivalence Scale (indicating at least some ambivalence about donation).

RESULTS

Our population was similar to the national living donor population on most demographic and donation-related characteristics. Eight individuals who had been approved to donate either a kidney or liver segment were enrolled for pilot testing of the intervention. All successfully completed the 2-session telephone-based intervention before scheduled donation surgery. Participants' ratings of acceptability and satisfaction were high. Open-ended comments indicated that the intervention addressed participants' thoughts and concerns about the decision to donate.

CONCLUSIONS

The intervention is feasible, acceptable, and appears relevant to donor concerns. A clinical trial to evaluate the efficacy of the intervention is warranted.

Laparoscopic versus open nephrectomy for live kidney donors

BACKGROUND

Waiting lists for kidney transplantation continue to grow and live organ donation has become more important as the number of brain stem dead cadaveric organ donors continues to fall. The major disincentive to potential kidney donors is the pain and morbidity associated with open surgery.

OBJECTIVES

To identify the benefits and harms of using laparoscopic compared to open nephrectomy techniques to recover kidneys from live organ donors.

SEARCH METHODS

We searched the online databases CENTRAL (in The Cochrane Library 2010, Issue 2), MEDLINE (January 1966 to January 2010) and EMBASE (January 1980 to January 2010) and handsearched textbooks and reference lists.

SELECTION CRITERIA

Randomised controlled trials comparing laparoscopic donor nephrectomy (LDN) with open donor nephrectomy (ODN).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary.

MAIN RESULTS

Six studies were identified that randomised 596 live kidney donors to either LDN or ODN arms. All studies were assessed as having low or unclear risk of bias for selection bias, allocation bias, incomplete outcome data and selective reporting bias. Four of six studies had high risk of bias for blinding. Various different combinations of techniques were used in each study, resulting in heterogeneity in the results. The conversion rate from LDN to ODN ranged from 1% to 1.8%. LDN was generally found to be associated with reduced analgesia use, shorter hospital stay, and faster return to normal physical functioning. The extracted kidney was exposed to longer warm ischaemia periods (2 to 17 minutes) with no associated short-term consequences. ODN was associated with shorter duration of procedure. For those outcomes that could be meta-analysed there were no significant differences between LDN or ODN for perioperative complications (RR 0.87, 95% CI 0.47 to 4.59), reoperations (RR 0.57, 95% CI 0.09 to 3.64), early graft loss (RR 0.31, 95% CI 0.06 to 1.48), delayed graft function (RR 1.09, 95% CI 0.52 to 2.30), acute rejection (RR 1.41, 95 % CI 0.87 to 2.27), ureteric complications (RR 1.51, 95% CI 0.69 to 3.31), kidney function at one year (SMD 0.15, 95% CI -0.11 to 0.41) or graft loss at one year (RR 0.76, 95% CI 0.15 to 3.85).

AUTHORS' CONCLUSIONS

LDN is associated with less pain compared with open surgery; however, there are equivalent numbers of complications and occurrences of perioperative events that require further intervention. Kidneys obtained using LDN procedures were exposed to longer warm ischaemia periods than ODN-acquired grafts, although this has not been reported as being associated with short-term consequences.

Live related donors in India: Their quality of life using world health organization quality of life brief questionnaire

Context:

Organ selling is now legally banned in India. Numerous studies have documented that organ vendors have a poor quality of life (QOL) following kidney donation. Aims: This study was designed to assess the QOL of living related donors in India. Settings and Design: This study was a single-center prospective study.

Materials and Methods:

The QOL of 106 consecutive related kidney donors was compared before and 6 months after the donation using the World Health Organisation Quality of Life Brief Questionnaire.

Statistical Analysis Used:

STATA 9.0 (College Station, Texas) was used and a p value less than 0.05 was considered significant.

Results:

The response rate was 94.3% and the mean age was 43.2±11.95 years. Females constituted 73% of the population. Our study showed a significant improvement in the QOL among three of the four domains. The surgical technique (86- mini open donor nephrectomy, and 14 laparoscopic donor nephrectomy), education status, and marital status did not make any difference in the change in the QOL.

Conclusions:

Despite a number of our donors being unemployed and not being well educated, live related kidney donation improves the QOL of donors.

What is the most preferred wound site for laparoscopic donor nephrectomy?: a questionnaire assessment

INTRODUCTION

Although specimen extraction site selection for laparoscopic donor nephrectomy (LDN) is relatively flexible and is mostly selected by surgeons from the patient's standpoint, the patient's request may differ from the medical worker's recommendation. The cosmetic aspect may also differ with age, gender, and the extent of medical knowledge. We performed an unsigned questionnaire assessment of individual preferences for LDN wound sites.

MATERIALS AND METHODS

Between August 2007 and October 2008, we surveyed LDN wound site preferences among 148 physicians, 263 nurses, and 266 outpatients of urology at Akita University Hospital. They were questioned for their age, gender, occupation (medical worker or not), and for the most preferred surgical wound site among the following: A, lower vertical midline: B, upper vertical midline: C, anterior subcostal: D, Pfannenstiel: E, Gibson: and F, subcostal flank. The valid response rate was 93.5% (677/724).

RESULTS

Wound sites preferred (ranked in descending order) were F (48.3%), D (25.6%), E (10.5%), A (9.0%), C (5.2%), and B (1.4%). The subcostal flank incision was the most preferred in almost all the categories. Second preferences were Pfannenstiel incisions in women and incisions on the lower abdomen in men. Overall, flank and lower abdominal incisions tended to be preferred, and mid and upper abdominal incisions tended to be avoided. Medical workers selected the subcostal flank and Pfannenstiel incisions more frequently than outpatients. With increasing age, the selection rates of the Gibson and the lower vertical midline incisions increased, whereas the subcostal flank and the Pfannenstiel incisions decreased.

CONCLUSIONS

The subcostal flank was the most preferred LDN sites. Age, gender, and the extent of medical knowledge may influence the individual preferences for LDN wound sites.

Long-term follow-up of a randomized trial comparing laparoscopic and mini-incision open live donor nephrectomy

Long-term physical and psychosocial effects of laparoscopic and open kidney donation are ill defined. We performed long-term follow-up of 100 live kidney donors, who had been randomly assigned to mini-incision open donor nephrectomy (MIDN) or laparoscopic donor nephrectomy (LDN). Data included blood pressure, glomerular filtration rate, quality of life (SF-36), fatigue (MFI-20) and graft survival. After median follow-up of 6 years clinical and laboratory data were available for 47 donors (94%) in both groups; quality of life data for 35 donors (70%) in the MIDN group, and 37 donors (74%) in the LDN group. After 6 years, mean estimated glomerular filtration rates did not significantly differ between MIDN (75 mL/min) and LDN (76 mL/min, p = 0.39). Most dimensions of the SF-36 and MFI-20 did not significantly differ between groups at long-term follow-up, and most scores had returned to baseline. Twelve percent of the donors reported persistent complaints, but no major complications requiring surgical intervention. Five-year death-censored graft survival was 90% for LDN, and 85% for MIDN (p = 0.50). Long-term outcome of live kidney donation is excellent from the perspective of both the donor and the recipient.

Quality of life comparison between open and retroperitoneal video-assisted minilaparotomy surgery for kidney donors

This study compared open and video-assisted minilaparotomy surgery in live kidney donors for quality of life (QoL), pain, cosmesis, and recovery. Between January 2003 and March 2006, we reviewed data from 205 patients who underwent live-donor nephrectomy: 116 by video-assisted minilaparotomy and 89 by open surgery. Pain and satisfaction were evaluated using scales from 1 to 10, and QoL, with the 36-item Short Form questionnaire. Hospital stay was significantly shorter among the video-assisted (5.1 +/- 1.6 days) than the open group (6.9 +/- 1.3 days; P < .01). Time to resumption of walking without difficulty and normal activity was significantly shorter among the video-assisted than the open group (P<.01). The video-assisted group showed better QoL scores in 6 of 8 QoL categories, including physical role (P < .01), bodily pain (P < .01), general health (P < .01), vitality (P < .01), emotional health (P < .01), and mental health (P < .01). Patients in the video-assisted group (score, 7.3 +/- 2.4) were more satisfied with the cosmetic outcome than those in the open group (score, 5.1 +/- 3.0; P < .01). In conclusion, donors who underwent nephrectomy via video-assisted minilaparotomy showed better outcomes regarding pain, convalescence, cosmesis, and QoL than those who underwent open surgery.

Randomized clinical trial of laparoscopic versus open donor nephrectomy

Background

This randomized controlled trial was designed to determine the safety and efficacy of laparoscopic donor nephrectomy (LDN) in comparison with short-incision open donor nephrectomy (ODN).

Methods

Eighty-four live kidney donors were randomized in a 2 : 1 ratio to LDN (56 patients) or short-incision ODN without rib resection (28). Primary endpoints were pain relief and duration of inpatient stay.

Results

There was no donor death or allograft thrombosis in either group. The first warm ischaemic time median (range) 4 (2–7) versus 2 (1–5) min; P = 0·001) and the duration of operation (160 (110–250) versus 150 (90–200); P = 0·004) were longer for LDN. LDN led to a reduction in parenteral morphine requirement 59 (6–136) versus 90 (35–312) mg; P = 0·001) and hospital stay (4 (2–6) versus 6 (2–9) days; P = 0·001), and earlier return to employment (42 (14–84) versus 66·5 (14–112) days; P = 0·004). Postoperative respiratory function was improved after LDN. There were more postoperative complications per donor in the ODN group (0·6(0·7) versus 0·3(0·5); P = 0·033). At a median follow-up of 74 months, there were no differences in renal function or allograft survival between the groups.

Conclusion

LDN removes some of the disincentives to live donation without compromising the outcome of the recipient transplant.

Laparoscopic live donor nephrectomy: Are ten cases per year enough to reach the quality standards? A report from a single small-volume transplant center

BACKGROUND

Laparoscopic live donor nephrectomy is the preferred method of kidney donation in high-volume US transplant centers, but for small transplant programs the question of the minimal case load per year necessary to reach the quality standards is open.

PATIENTS AND METHODS

From 1996 to 2007 we performed 130 live kidney donations including 93 laparoscopic donor nephrectomies followed by transplantation in a community hospital with an average case load of 10 laparoscopic cases per year. We compared the results after 37 open and 93 laparoscopic live donor operations with respect to operating time, conversion rate, complications, and recipients' outcome.

RESULTS

There were no significant differences in terms of safe outcome of donor patients after open or laparoscopic donor nephrectomy. The mean operating time was significantly shorter (p < 0.001) in the open group (125 min, OG) than in the laparoscopic group (150 min, LG). Mean hospital stay was significantly shorter (p < 0.001) in LG (6.8 days) versus OG (9.7 days). The conversion rate was 3.2% in the LG. Postoperative complication of donors consisted of temporary nerve irritation (two patients) and retroperitoneal hematoma (one patient) in the LG, and wound infection followed by hernia formation (one patient) and ileus 1 year after organ donation (one patient) in the OG. Safe outcome of the recipients after open (RaOD) or laparoscopic donation (RaLD) was similar. Uneventful transplantation occurred in 94.6% of the RaOD and in 92.5% of the RaLD. One kidney was lost due to renal vein thrombosis (RaLD). Mean postoperative creatinine after 4 weeks showed no difference between RaOD (1.6 mg/dl) and RaLD (1.7 mg/dl).

CONCLUSION

Approximately ten cases per year may be enough to ensure safety and quality of laparoscopic live donor nephrectomy.

A comparative study of quality of life issues relating to open versus laparoscopic nephrectomy: a prospective pragmatic study

PURPOSE

We determined whether laparoscopic nephrectomy confers improved health related quality of life in the early postoperative period compared with open nephrectomy.

MATERIALS AND METHODS

Patients undergoing open or laparoscopic nephrectomy were prospectively recruited. Patients completed the Comorbidity Symptom Scale preoperatively as well as the SF-36(R) quality of life health survey and pain visual analog scale preoperatively, and 2 days and 1 month postoperatively.

RESULTS

A total of 100 patients were recruited, of whom 71 completed all questionnaires, including 38 in the laparoscopic group and 33 in the open group. In the 2 groups mean patient age was the same (56.8 years) and there was a similar sex distribution. The laparoscopic group had improved quality of life scores with significantly higher physical component scores 1 month postoperatively vs the open group (-5.7% vs -22.2%, p = 0.009). The laparoscopic group also had significantly higher mental component scores 2 days postoperatively vs the open group compared to baseline (6.0% vs -6.6%, p = 0.009). The laparoscopic group had significantly lower pain visual analog scale scores 1 month postoperatively compared to baseline. Patients with higher Comorbidity Symptom Scale scores were more likely to undergo a laparoscopic approach (p = 0.036). Despite this they had a significantly shorter hospital stay (4 vs 6 days, p <0.001).

CONCLUSIONS

Quality of life benefits of laparoscopic over open nephrectomy were found in the early postoperative period despite more comorbidities in the laparoscopic group. This provides further evidence of the benefits of the laparoscopic approach over open surgery.

Psychosocial factors in living organ donation: clinical and ethical challenges

Living donor surgery has come to the forefront of public attention because increasing numbers of potential donors respond to the organ shortage. Because of several factors including decreased morbidity from donor surgery, online resources appealing for organs, and increased publicity about donation, new populations of unrelated donors are seeking evaluation for donor surgery. However, concern about potential coercion of vulnerable individuals, the potential for adverse psychosocial outcomes, and recent reports of donor deaths have reinvigorated discussion within the medical community about how best to assess donors. Research on the long-term quality of life outcomes for donors suggests that most donors are satisfied with their decision to donate. Small single-center studies on psychosocial outcomes have reported psychiatric sequelae after donor surgery. Little is known about the psychosocial outcomes for donors who are psychosocially excluded from donating. A multidisciplinary team approach, including social work and psychiatry evaluations, allows for the comprehensive assessment of important areas including motivation and expectations about surgery, current and past psychiatric conditions, history of substance or alcohol abuse, family support, understanding of the risks and alternatives of donor surgery for the donor and recipient, and motivation for donation including any evidence of coercion.

Retroperitoneoscopic donor nephrectomy for retroaortic renal vein draining into left common iliac vein

Laparoscopic donor nephrectomy (LDN) for both retroaortic and circumaortic veins is described. LDN for left retroaortic vein draining into the common iliac vein (CIV) is not described previously. We report 2 cases of laparoscopic harvesting of left kidney having retroaortic renal vein draining into the left CIV and successful transplantation.

Live donor nephrectomy for kidney transplantation

The number of patients with end-stage renal disease is increasing substantially every year around the world. Renal transplantation is the best treatment option to improve survival and quality of life. Although the numbers of living, related and deceased transplant donors has also increased, this growth is insufficient to keep up with the expansion rate of the renal failure population. The introduction of laparoscopic donor nephrectomy has gained widespread acceptance by physicians and patients, and seems to be better than open donor nephrectomy in terms of reduced postoperative pain, quick recovery and improved cosmetic outcomes. Evidence strongly suggests that graft survival is similar in recipients of kidneys from living related and unrelated donors. Fortunately, this information has raised awareness of the suitability of potential live, unrelated donors, including spouses, friends, or even anonymous donors. In this Review we touch on sociological aspects of living related kidney transplantation and review the available and proposed methods of increasing the live donor pool, including organ exchange and desensitization protocols for ABO-incompatible and cross-match-positive donor pairs.

[Living donor transplantation. Surgical complications]

Although nephrectomy by open surgery is the most used technique for the extraction of kidney transplants in the living donor, nephrectomy under laparaoscopy is increasingly practiced. Laparoscopic nephrectomy is less invasive and performed under videoscopy control, after insufflation of the peritoneal cavity. Three to four incisions are done in order to enter the surgical instruments. The kidney is extracted through a horizontal sus-pubic incision. The exposition is either exclusively transperitoneal, retroperitoneal or hand assisted. The advantages of laparoscopy are esthetical, financial due to a shorter hospitalisation and a quicker recovery, as well a confort for the donor. The disadvantages are a longer warm ischemia time and possibly a higher risk of delayed graft function. Randomised studies having compared laparoscopy and open surgery in the living donor have not find any significant difference regarding the per- and perioperative in the complications.

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.

Quality of life after randomization to laparoscopic versus open living donor nephrectomy: long-term follow-up

BACKGROUND

The aim of this randomized study was to compare patient-reported outcome after laparoscopic versus open donor nephrectomy during 1 year follow-up. The evidence base has so far not allowed for a decision as to which method is superior as seen from a long-term quality of life-perspective.

METHODS

The donors were randomized to laparoscopic (n=63) or open (n=59) nephrectomy, with follow-up at 1, 6, and 12 months. Primary outcomes were health status (SF-36) and overall quality of life (QOLS-N). Secondary outcomes were donor perception of the surgical scar, the donation's impact on personal finances, and whether the donor would make the same decision to donate again.

RESULTS

There was a significant difference in favor of laparoscopic surgery regarding the SF-36 subscale bodily pain at 1 month postoperatively (P<0.05). Analysis based on intention to treat revealed no long-term differences between groups in SF-36 scores. When subtracting the reoperated/converted donors of the laparoscopic group, significant differences in favor of laparoscopy were revealed in the subscales bodily pain at 6 months (P<0.05) and social functioning at 12 months (P<0.05). No significant differences were found in QOLS-N scores between groups.

CONCLUSIONS

Laparoscopic donor nephrectomy is an attractive alternative to open donor nephrectomy because of less postoperative pain. However, long-term comparison only revealed significant differences in favor of laparoscopy when adjusting for reoperations/conversions. Both groups reached baseline scores in most SF-36 subscales at 12 months and this may explain why possible minor benefits are hard to prove.

Cost effectiveness of laparoscopic versus mini-incision open donor nephrectomy: a randomized study

BACKGROUND

Cost-effectiveness remains an issue surrounding the introduction of laparoscopic donor nephrectomy (LDN).

METHODS

In a randomized controlled trial the cost-effectiveness of LDN versus mini-incision open donor nephrectomy (ODN) was determined. Fifty donors were included in each group. All in-hospital costs were documented. Postoperatively, case record forms were sent to the donors during 1-year follow-up to record return-to-work and societal costs. To offset costs against quality of life, the Euroqol-5D questionnaire was administered preoperatively and 3, 7, 14, 28, 90, 180, and 365 days postoperatively.

RESULTS

Mean total costs were euro6,090 (US$7,308) after LDN and euro4,818 ($5,782) after ODN (P<0.001). Disposables influenced the cost difference most. Mean productivity loss was 68 and 75 days after LDN and ODN respectively, corresponding to euro783 ($940) gained per donor after LDN. The main gain in quality of life in the LDN group was realized within 4 weeks postoperatively. LDN resulted in a mean gain of 0.03 quality-adjusted life years at mean costs of euro1,271 ($1,525) and euro488 ($586) from a healthcare perspective and a societal perspective, respectively. This implies that one additional Quality-Adjusted Life Year after LDN costs about euro16,000 ($19,200) from a societal point of view and about euro41,000 ($49,200) from a health-care perspective. Activities other than work were resumed significantly earlier after LDN (66 vs. 91 days, P=0.01).

CONCLUSION

In addition to a clinically relevant donor-experienced benefit from LDN, this technique appeared, given a societal perspective, a cost-efficient procedure mainly due to less productivity losses.

[Laparoscopic nephrectomy in a living donor]

Kidney transplantation is the therapeutic option of choice for patients with end-stage renal disease. With the advent of safer harvesting techniques and immunosuppression, both donor and recipient outcomes have markedly improved in recent years. Kidney donation from Living donors remains the single most important factor responsible for improving patient and graft survival. The laparoscopic donor nephrectomy has revolutionized renal transplantation, allowing expansion of the donor pool by diminishing surgical morbidity while maintaining equivalent recipient outcome. This technique is now becoming the gold-standard harvesting procedure in transplant centres worldwide, despite its technical challenge and ongoing procedural maturation, especially early in the learning curve. Previous contraindications to laparoscopic donor nephrectomy are no longer absolute. In the following analysis, the procedural aspects of the laparoscopic donor nephrectomy are detailed including pre-operative assessment, operative technique and a review of the current literature delineating aspects of both donor and recipient morbidity and mortality compared with open harvesting techniques.

Laparoscopic live donor nephrectomy for right kidneys: Experience in a German community hospital

BACKGROUND

Laparoscopic live donor nephrectomy has become the new gold standard for kidney procurement in many high-volume transplant centres worldwide, but it is often limited to left-sided donor kidneys. Concerns about adequate anatomical renal vessel length and sufficient surgical exposure are the main obstacles to the use of the laparoscopic approach for right kidney live donors as well.

MATERIAL AND METHODS

From 1998 to 2006 we performed laparoscopic kidney procurement in 73 live kidney donors on an intention-to-treat basis, harvesting a total of 48 left (LKG) and 25 right kidneys (RKG) for transplantation. We compared these two groups with respect to operating time, conversion rate, complications, hospital stay, and recipient outcome.

RESULTS

There were no differences in outcome of donor patients after left (D-LKG) or right laparoscopic donor nephrectomy (D-RKG). Operating time was 160 min in D-RKG versus 164 min in D-LKG. Warm ischemia was below 150 s in both groups. Hospital stay was 7.0 (D-RKG) versus 6.7 days (D-LKG). Negative events on the donor site were one temporary nerve irritation in each group and one postoperative retroperitoneal hematoma in the left kidney group. Reasons to convert to open nephrectomy were bleeding in two patients in the left kidney group and adhesions in one patient in the right kidney group. The outcome of the recipients after left (R-LKG) or right kidney (R-RKG) transplantation was similar. One kidney was lost due to renal vein thrombosis (R-LKG). Postoperative ureter complications occurred in one patient of each group. One patient of the R-RKG and two patients of the R-LKG required lymphocele fenestration. All other kidney transplants worked without problems.

CONCLUSION

Laparoscopic donor nephrectomy is a safe procedure and has been established as the method of choice for live kidney donation in our clinic. Laparoscopic procurement of right and left kidneys can be performed with comparable quality and outcome for donors and recipients.

Obtaining Cuff of Inferior Vena Cava by Use of the Endo-TA Stapler in Retroperitoneoscopic Right-Side Donor Nephrectomy

OBJECTIVES

To determine the feasibility of obtaining an adequate cuff of the inferior vena cava (IVC) for vascular anastomosis during retroperitoneoscopic donor nephrectomy.

METHODS

Between September 2004 and May 2005, a total 100 retroperitoneoscopic donor nephrectomies were performed. Fifteen cases were performed on the right side. The Endo-TA stapler was used to obtain the cuff of IVC in all cases of right-side donor nephrectomy.

RESULTS

Mean warm ischemia time was 4.9 minutes (range, 2.96 to 8.0 minutes). Mean length of the cuff of IVC was 4 mm (range, 3 to 6 mm) at the upper end and 6 mm (range, 4 to 8 mm) at the lower end of the vein. All grafts functioned immediately, and there was one graft loss due to vascular rejection.

CONCLUSIONS

Control of the renal vein by use of the Endo-TA stapler during retroperitoneoscopic donor nephrectomy helps in obtaining a good vascular cuff of the IVC.

Impact of retroperitoneoscopic donor nephrectomy on renal allograft in Indian and African recipients

AIM

To evaluate the impact of laparoscopic donor nephrectomy on renal allografts in Indian and African recipients.

MATERIAL AND METHODS

Between September 2004 and August 2006, 125 retroperitoneoscopic donor nephrectomies were performed. Ninety-four donors were Indian (group A) and 32, African (group B). Three ports were used for left-sided and four for right-sided surgery, respectively. Hem-o-lok clips were used to control arteries and veins on left side and arteries on right side while an Endo-TA stapler was used on the right side to obtain an inferior vena caval cuff.

RESULTS

The mean operative times in groups A and B were 130 and 134 minutes; mean blood loss, 100.4 mL and 85.3 mL; and mean warm ischemia time, 242.1 seconds and 234.5 seconds, respectively. Recipient mean serum creatinine value on day 7 was 1.9 and 1.6 mg%, and on day 28, 1.44 mg% and 1.4 mg%, respectively.

CONCLUSION

Early adequate allograft function following retroperitoneoscopic donor nephrectomy was comparable in African and Indian patients, suggesting that no racial advantage was observed in this procedure.

Does mini-incision donor nephrectomy improve quality of life in living kidney donors?

BACKGROUND

Living kidney donation helps to avoid or reduce the time period of dialysis and on waiting lists in patients requiring a new organ. Mini-incision donor nephrectomy (MIDN) shows to result in better clinical outcome in comparison with traditional open donor nephrectomy (ODN). This study was performed to evaluate the impact of different surgical procedures on the quality of life (QoL) in patients that underwent donor nephrectomy.

METHODS

The aim of the study was to detect differences in QoL assessed with the Short Form-36 Version 2 (SF-36v2) questionnaire between MIDN (n = 34) and ODN (n = 36). Furthermore, the development of QoL from prior to surgery until one yr afterwards, as well as outcomes of QoL in comparison with norm-based scores was investigated.

RESULTS

Sixty-one of 70 patients, which is 87% (MIDN: 86%, ODN: 88%) resent a whole set questionnaires. QoL was similar at all time-points (prior to surgery, one wk, three months and one yr) in both groups. A tendency of better QoL in MIDN (Bodily Pain) after one wk was detectable (p = 0.075). Physical Component Summaries (PCS) significantly decreased from prior to surgery until one wk after surgery (p = 0.001) and improved significantly until three months (MIDN: p = 0.006, ODN: p = 0.001) and also until one yr after surgery (p = 0.002). Mental Component Summaries (MCS) were stable throughout the whole investigated time period. In comparison with norm-based scores, MIDN (p = 0.005) and ODN (p = 0.001) showed significantly higher PCS prior to, lower scores one wk after (p = 0.001), similar scores three months after and better scores (MIDN: p = 0.023, ODN: 0.015) one yr after surgery. Mental Component Scores were similar in both prior to and one wk after surgery. After three months and one yr scores were significantly better in MIDN (three months: p = 0.049, one yr: p = 0.037) and ODN (three months: 0.020, one yr: 0.073).

CONCLUSION

Quality of life after living donor nephrectomy is not influenced by the surgical technique. Nevertheless the standardized instrument of the SF-36v2 Health Survey is a useful, practicable and universally interpretable tool to gain and estimate recovery from surgical procedures in the perioperative period and its development thereafter.

Psychosocial health of living kidney donors: a systematic review

Knowledge of the psychosocial benefits and harms faced by living kidney donors is necessary for informed consent and follow-up. We reviewed any English language study where psychosocial function was assessed using questionnaires in 10 or more donors after nephrectomy. We searched MEDLINE, EMBASE, Web of Science, Psych INFO, Sociological Abstracts and CINAHL databases and reviewed reference lists from 1969 through July 2006. Independently, two reviewers abstracted data on study, donor and control group characteristics, psychosocial measurements and their outcomes. Fifty-one studies examined 5139 donors who were assessed an average of 4 years after nephrectomy. The majority experienced no depression (77-95%) or anxiety (86-94%), with questionnaire scores similar to controls. The majority reported no change or an improved relationship with their recipient (86-100%), spouse (82-98%), family members (83-100%) and nonrecipient children (95-100%). Some experienced an increase in self-esteem. A majority (83-93%) expressed no change in their attractiveness. Although many scored high on quality of life measures, some prospective studies described a decrease after donation. A small proportion of donors had adverse psychosocial outcomes. Most kidney donors experience no change or an improvement in their psychosocial health after donation. Harms may be minimized through careful selection and follow-up.

Psychosocial and Physical Impairment After Mini-Incision Open and Laparoscopic Donor Nephrectomy: A Prospective Study

BACKGROUND

The aim of the present study was to prospectively investigate how mini-incision donor nephrectomy (MIDN) and laparoscopic donor nephrectomy (LDN) affected the donor's quality of life and fatigue.

METHODS

Forty-five donors underwent MIDN and 55 donors underwent LDN. Quality of life and fatigue were recorded preoperatively and four times during one year follow-up on the Short-Form 36 (SF-36) and Multidimensional Fatigue Inventory-20 (MFI-20), respectively.

RESULTS

One-year response rates were 89% and 95% following MIDN and LDN, respectively. After MIDN, all dimensions of the SF-36 significantly declined. Most dimensions returned to preoperative values at three months except for "vitality" (six months) and "bodily pain" (12 months). After LDN, the scores of the SF-36 dimensions returned to preoperative values at three months, except for "vitality" and "role physical" (both six months). Between-groups analysis revealed significantly better scores of the SF-36 dimensions "physical function" (P = 0.03) and "bodily pain" (P = 0.04) following LDN at one month postoperatively. Fatigue scores did not significantly differ between the groups at any point in time. General and physical fatigue (MFI-20) remained affected up to one year after either type of surgery. After MIDN, 4% of the donors had returned to work at four weeks postoperatively versus 28% after LDN (P = 0.04). Return to preoperative activity level was not significantly different between groups.

CONCLUSIONS

Both procedures clearly impact quality of life and fatigue. The beneficial effect on the quality of life and the earlier return to work encourage us to advocate LDN as the surgical approach to be preferred.

Comparison of laparoscopic and mini incision open donor nephrectomy: single blind, randomised controlled clinical trial

OBJECTIVES

To determine the best approach for live donor nephrectomy to minimise discomfort to the donor and to provide good graft function.

DESIGN

Single blind, randomised controlled trial.

SETTING

Two university medical centres, the Netherlands.

PARTICIPANTS

100 living kidney donors.

INTERVENTIONS

Participants were randomly assigned to either laparoscopic donor nephrectomy or to mini incision muscle splitting open donor nephrectomy.

MAIN OUTCOME MEASURES

The primary outcome was physical fatigue using the multidimensional fatigue inventory 20 (MFI-20). Secondary outcomes were physical function using the SF-36, hospital stay after surgery, pain, operating times, recipient graft function, and graft survival.

RESULTS

Conversions did not occur. Compared with mini incision open donor nephrectomy, laparoscopic donor nephrectomy resulted in longer skin to skin time (median 221 v 164 minutes, P < 0.001), longer warm ischaemia time (6 v 3 minutes, P < 0.001), less blood loss (100 v 240 ml, P < 0.001), and a similar number of complications (intraoperatively 12% v 6%, P = 0.49, postoperatively both 6%). After laparoscopic nephrectomy, donors required less morphine (16 v 25 mg, P = 0.005) and shorter hospital stay (3 v 4 days, P = 0.003). During one year's follow-up mean physical fatigue was less (difference - 1.3, 95% confidence interval - 2.4 to - 0.1) and physical function was better (difference 6.2, 2.0 to 10.3) after laparoscopic nephrectomy. Function of the graft and graft survival rate of the recipient at one year censored for death did not differ (100% after laparoscopic nephrectomy and 98% after open nephrectomy).

CONCLUSIONS

Laparoscopic donor nephrectomy results in a better quality of life compared with mini incision open donor nephrectomy but equal safety and graft function.

[Ten years of laparoscopic living kidney donation. From an extravagant to a routine procedure]

Ten years ago the first laparoscopic living donor nephrectomy (LDN) was performed. Today, LDN is a routine operation in many US-American transplantation centers and an increasing number of centers in Europe are practicing LDN. In this article the different aspects of LDN for donor, kidney, recipient and operating surgeon are evaluated. We performed a literature research concerning LDN and the different aspects. Our own experience, as the largest LDN center in Germany, is part of the evaluation. Laparoscopic extraction of a kidney from a living donor is as safe for the donor as the open approach. At the same time, LDN offers multiple advantages like reduced pain and shorter convalescence. For the donated kidney and the recipient no disadvantages occur from the laparoscopic technique, as long as special intra- and perioperative demands are met. For the operating surgeon multiple developments have expanded the technical armentarium. LDN is safe for donor, recipient and kidney. Central issue of an optimal LDN is sufficient experience with laparoscopic urological techniques.

The direct and indirect economic costs incurred by living kidney donors-a systematic review

BACKGROUND

Despite the many benefits of living donor kidney transplantation, economic consequences can result for donors. We reviewed studies which quantified the direct and indirect costs incurred by living kidney donors, in order to understand the strengths and limitations of existing literature.

METHODS

We identified relevant studies in MEDLINE, EMBASE and ECONOLIT bibliographic databases, in the Science Citation Index and study reference lists. Any study which reported at least one cost relevant to donors was included. The accuracy of abstracted data was verified by two reviewers and reported in year 2004 US dollars.

RESULTS

Thirty-five studies from 12 countries described costs incurred by individuals who donated between the years 1964 and 2003. No study comprehensively quantified all relevant expenses-the sum of select costs considered in one US study averaged Dollars 837 per donor and ranged from Dollars 0 to 28,906. Travel and/or accommodation costs were incurred by 9-99% of donors, and were higher in countries with a larger land mass. Post-discharge analgesics were required by 4-24% of donors, but prescription costs were not reported. Between 14 and 30% of donors incurred costs for lost income, with an average loss of Dollars 3386 in one study from the UK and Dollars 682 in another study from the Netherlands. Costs for dependent care were incurred by 9-44% of donors, while costs for domestic help were incurred by 8% of donors.

CONCLUSIONS

Donors incur many types of costs attributable to kidney donation and the total costs are certainly higher than previously reported. To guide informed consent and fair reimbursement policies, further data on all relevant costs, preferably from a detailed prospective multi-centre cohort study, are required.

Retroperitoneoscopic versus open surgical radical nephrectomy for large renal cell carcinoma in clinical stage cT2 or cT3a: quality of life, pain and reconvalescence

OBJECTIVES

To determine whether retroperitoneoscopic radical nephrectomy for large renal cell carcinoma in stage cT2 or cT3a is a feasible, safe and effective therapy option and if it shows any advantage regarding quality of life in comparison to open procedure.

METHODS

23 patients who underwent RPNx for tumor size greater than 7 cm (group 1) were matched and compared with 25 patients, who underwent ONx (group 2) for tumor with similar size characteristics. Patient and surgical data, QoL variables and complications were statistically analyzed.

RESULTS

The median followup was 12 (range: 6-18) months for both groups. Group 1 had significantly (p < 0.001) less blood loss, shorter hospital stay, and shorter postoperative analgesic requirements. No conversion to open surgery was necessary, and no major complications requiring an invasive intervention occurred. Retroperitoneoscopic patients had significantly better QoL and pain scores postoperatively to 6 months (p < 0.001) and they return to baseline QoL status faster (p < 0.001).

CONCLUSIONS

RPNx for large RCC in stage cT2 or cT3a is a safe and efficacious procedure with good short-term outcome results and significantly shorter recovery of QoL variables.

Health-related quality of life of living kidney donors: review of the short form 36-health questionnaire survey

Kidney transplantation is the ultimate goal and the best treatment for most patients with end-stage renal disease. Organ shortage and steadily growing waiting time for a cadaver kidney transplant have forced the medical community to look for alternatives, such as living kidney donation. However, available data examining health-related quality of life (QOL) issues of living donors are currently limited. In addition, little information regarding factors associated with health-related QOL in living kidney donors is currently available and this issue remains controversial. This review article aims to summarize the data regarding health-related QOL of living kidney donors by using the Medical Outcomes Study Short Form.