Functional advantages of laparoscopic live-donor nephrectomy compared with conventional open-donor nephrectomy

Mini-laparoscopic live donor nephrectomy with the use of 3-mm instruments and laparoscope

PURPOSE

To analyze our preliminary outcomes on the use of 3 mm instruments for laparoscopic live donor nephrectomy (LLDN).

METHODS

Our series includes thirteen patients, who underwent LLDN using 3-mm instruments and laparoscope and 5-mm transumbilical trocar. The patients were followed at 7 and 14 days from discharge and were specifically asked about their cosmetic satisfaction. At follow-up, the recipient graft function was controlled, as well as the donor's cosmetic results. Eight months after surgery, all thirteen patients were asked to fill out the Patient Scar Assessment Questionnaire and Scoring System (PSAQ).

RESULTS

All patients presented good recovery after surgery. Regarding cosmetic outcomes, the donors expressed their satisfaction toward the minimal incision size and optimal esthetic results at 7 and 14 days from discharge home. The low scores on each section of the PSAQ confirmed the favorable outcomes. Early graft function was satisfactory at 1 and 3 months after the kidney transplantation. Furthermore, there were no major complications in the recipients.

CONCLUSIONS

Our persistent positive results with the use of 3-mm instruments during LLDN support this technique as a good alternative to the standard laparoscopic approach for minimizing the incision site, while maintaining safety and excellent clinical outcomes. The fact that the general laparoscopic standards are maintained could make this approach a very attractive alternative to the other minimally invasive approaches for live donor nephrectomy. The hope is in that the higher degree of satisfaction in the donor population demonstrated in this study may likely enhance living kidney donation.

Utility of inguinal incision in retroperitoneoscopic live donor nephrectomy

BACKGROUND

Retroperitoneoscopic live donor nephrectomy has been performed in many countries. The purpose of this study was to evaluate the inguinal incision as a route for hand-assisted manipulation and allograft retrieval.

METHODS

From April 2011 to June 2012, a prospective clinical study of 21 cases of retroperitoneal live donor nephrectomy was performed at our hospital. All donors were grouped in a test group (n = 11, inguinal incision) or a control group (n = 10, lumbar incision). The operative time, warm ischaemia time, blood loss, hospital stay, cosmetic satisfaction, incision complications, and recipient's serum creatinines were compared between groups.

RESULTS

All 21 cases of retroperitoneal live donor nephrectomy were accomplished successfully without serious complications. There was no difference in blood loss and operative time between groups. The mean warm ischaemic time and hospital stay was shorter (P < 0.01), and satisfaction with cosmesis was greater (P < 0.05) in the test group. The abdominal asymmetry (4/10) and wound dehiscence occurred only in the control group. The recipient's serum creatinine was lower in the test group at 1 day (P < 0.01) and 3 days (P < 0.05) after transplantation.

CONCLUSION

The inguinal incision offers an ideal route for hand-assisted manipulation and allograft retrieval during retroperitoneoscopic live donor nephrectomy, and has a potential to be generally applied in the future.

Quality of life following laparoscopic living-donor nephrectomy

Kidney donors experience significant mental stress compared with those undergoing extirpative kidney surgery. Better preoperative counseling and postoperative monitoring is suggested by the authors.

Background and Objectives:

This study compares donor quality of life (QOL) with extirpative (simple or radical) patients' QOL after laparoscopic nephrectomy and analyzes factors predictive of mental QOL for donors.

Methods:

One hundred one donors and 48 extirpative laparoscopic nephrectomy patients filled out the SF-36v2 form at pre- and postoperative visits, and scores were transformed to norm-based. Donor characteristics were collected and analyzed using univariate analysis.

Results:

Donor patients had a decline in the mental summary at all time points that became significant at 7 months (–2.9), whereas extirpative patients trended positive at 7 months (+2.6). Both groups had a significant decline in the physical summary at 1 month, which rebounded by 4 months. Female gender, positive social/psychiatric history, and major graft recipient complications were all significant predictors of a decline in mental health at 1 month.

Conclusion:

Compared with patients who undergo extirpative surgery, kidney donors have significant mental stress associated with donation that persists beyond the postoperative period. Better preoperative counseling and postoperative monitoring might lead to better outcomes, especially for those in high-risk groups.

Technical modifications of hand-assisted retroperitoneoscopic living donor nephrectomy: a single-center experience

OBJECTIVES

To report a single-center experience and technical modifications of hand-assisted retroperitoneoscopic living donor nephrectomy (HARLDN).

METHODS

A total of 78 living donors underwent HARLDN from June 2004 to November 2009. We used a three-port, finger-dissecting, routine retroperitoneal approach. After almost complete mobilization of the kidney, the renal pedicle was dissected to expose the renal vessels. The ureter was dissected and divided at the level of the iliac vessels. An approximately 7-cm Gibson incision was made as the hand-assisted port. The surgeon's hand was introduced through this incision directly. With hand assistance, the renal artery was clipped using two Hem-o-lok clips at the proximal end, and then sheared by scissors without any clips on the kidney side. The renal vein was controlled similarly. Then the kidney was rapidly removed through the incision by hand.

RESULTS

HARLDN was effectively and safely completed in 78 (100%) donors. No conversion to an open operation was necessary. The mean operative time and mean warm ischemic time were 121 minutes (range, 90-134) and 146 seconds (range, 112-247) respectively. The mean blood loss was 61 mL (range, 32-85). Clavien 1 complications including subcutaneous emphysema in 5.1% (4/78). The mean visual analog scales on postoperative days 1 to 5 were: 2.5, 1.2, 0.8, 0.5, and 0.1, respectively. The mean time to resume oral diet was 1.5 days. The mean hospital stay was 4.5 days (range, 4-5). The mean level of postoperative serum creatinines of the donors at 7 days and 1 month thereafter were 1.06 mg/dL (range, 0.74-1.43) and 1.15 mg/dL (range, 0.79-1.61) mg/dL, respectively. The mean level of postoperative serum creatinines of the recipients at 7 days and 1 month were 1.40 mg/dL (range 0.81-1.67) and 1.52 mg/dL (range, 0.76-1.83), respectively. The mean incision length was 6.5 cm (range, 6.0-7.2).

CONCLUSIONS

The modified HARLDN combines the purely laparoscopic technique with quicker, safer organ retrieval by the open access.

Retrospective evaluation of donor pain and pain management after laprascopic nephrectomy

PURPOSE

The purpose of this study was to evaluate donor pain and pain management beginning immediately postoperatively until hospital discharge.

METHODS

All kidney donors were included from 2008 and 2009. Demographic data, operative data, pain scores in the postanesthesia care unit, and visual analog pain scale (VAS) scores were collected for each patient. Standardization for comparison was made by converting doses to intravenous morphine equivalents (ME).

RESULTS

Eighty-five patients were identified as donors, all of which underwent laparoscopic nephrectomy. Daily analgesic requirement was significantly reduced from postoperative day 1 to postoperative day 2 (42.2 mg ME versus 19.7 mg ME, P < .0001). The use of patient-controlled analgesia (PCA) did not demonstrate improved pain management with similar VAS scores for users and nonusers on the day of operation (5.4 vs 5.6, P = .87), postoperative day 1 (4.9 vs 5.4, P = .5), and postoperative day 2 (4.7 vs 4.5, P = .65), respectively. Even though similar VAS scores were found for PCA users and nonusers, PCA users had significantly higher opioid use on the day of operation (P = .007) and postoperative day 1 (P = .004).

CONCLUSIONS

The average VAS score on the day of operation was 5.5, with patients experiencing a significant reduction in VAS score on postoperative day 1. PCA delivery did not provide any additional benefit in pain relief in this cohort.

Laparoscopic live donor nephrectomy with the use of 3-mm instruments and laparoscope: initial experience at a tertiary center

Laparoscopy has become the standard of care for kidney recovery during live donor nephrectomy (LDN) because of the well-documented better outcomes of minimally invasive surgery compared with the open approach. Especially in the donor population, the cosmetic results are of great importance; therefore, an effort to reduce the incision size should be attempted while maintaining the safe general principles of surgery. We present our initial experience with the use of 3-mm instruments for laparoscopic LDN.

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.

Postoperative pain and convalescence in living kidney donors-laparoscopic versus open donor nephrectomy: a randomized study

The aim of the present study was to compare postoperative pain and convalescence in patients randomized to laparoscopic or open donor surgery in a prospective, controlled trial. The donors were randomly assigned to undergo laparoscopic (n = 63) or open (n = 59) donor nephrectomy. Our end points were amount of administered analgesics in the recovery period, postoperative pain on the second postoperative day and at one month after surgery and duration of sick leave. There was a significant difference in favor of the laparoscopic group regarding administered analgesics on day of surgery (p < 0. 02). No difference was observed between groups regarding self-reported pain on the second postoperative day. One month post donation, significantly fewer donors in the laparoscopic group reported pain (p < 0. 02) or had used analgesics (p < 0.05). The duration of sick leave was significantly shorter in the laparoscopic group (p = 0.01). The laparoscopic group experienced a more rapid convalescence and a shorter period of sick leave. Although immediate postoperative pain can be managed efficiently regardless of procedure, a lower consumption of opioids and incidence of pain in the convalescent period suggest a clinically relevant patient-experienced benefit from a successful laparoscopic procedure.

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.

Comparison of laparoscopic and open donor nephrectomy: a randomized controlled trial

Authors from Iran compare various outcomes between laparoscopic and open donor nephrectomy in kidney transplantation; they carried out a large comparative trial, and found that laparoscopic donor nephrectomy gave better donor satisfaction and morbidity, with equivalent graft outcome.

OBJECTIVE

To compare the graft survival, donor and recipient outcome, donor satisfaction, and complications of laparoscopic (LDN) and open donor nephrectomy (ODN) in kidney transplantation.

PATIENTS AND METHODS

In a randomized controlled trial, 100 cases each of LDN and ODN were compared. We modified the standard LDN procedure to make it less expensive.

RESULTS

The mean (sd) operative duration was 152.2 (33.9) min for ODN and 270.8 (58.5) min for LDN, and the mean duration of kidney warm ischaemia was 1.87 min for ODN and 8.7 min for LDN. Only one LDN required conversion to ODN because of bleeding. The mean follow-up in the LDN and ODN groups was not significantly different (406.1 vs 403.8 days). The mean (sd) score for donor satisfaction was 17.3 (3.5) for ODN and 19.6 (1.0) for LDN. The rate of ureteric complications was 2% for ODN and none for LDN. As determined by serum creatinine levels at 3, 21-30, 90, 180 and 365 days after surgery, graft function was not significantly different between ODN and LDN. Long-term graft survival was 93.8% for LDN and 92.7% for ODN.

CONCLUSIONS

Compared to ODN, LDN was associated with greater donor satisfaction, less morbidity and equivalent graft outcome.

Living donors' experiences 1 wk after donating a kidney

In Norway living kidney donors account for approximately 40% of all renal transplants. There is a shortage of information about how living kidney donors experience the donation process during the initial recovery from surgery. The aim of this study was to explore physical and psychosocial issues related to the experiences of living kidney donors 1 wk after open donor nephrectomy. A total of 12 living kidney donors participated in the study. Data were collected by individual in-depth interviews and analysed using empirical phenomenological method. Being a living kidney donor is a complex experience. The informants expressed strong feelings of responsibility and obligation concerning the recipients and had a positive attitude towards the donation. On the other hand, the donors experienced it strange to be a fit individual and go through a major operation. Several of the donors reported that it was painful to go through donor surgery and regarded the recovery period as troublesome. Some donors also reported the double role of being both a patient and a relative to be a stressful experience. This study reveals the importance of being aware of the complex situation of living kidney donors. Health professionals need to understand the nature of the donation process and the donors' needs. It is essential to focus on physical, mental and interpersonal factors when counselling potential living kidney donors.

A comparison of traditional open, minimal-incision donor nephrectomy and laparoscopic donor nephrectomy

Laparoscopic donor nephrectomy (LDN) and minimal-incision donor nephrectomy (MILD) are less invasive procedures than the traditional open donor nephrectomy approach (ODN). This study compares donor and recipient outcome following those three different procedures. Sixty consecutive donor nephrectomies were studied (n = 20 in each group). Intra-operative variables, analgesic requirements, donor recovery, donor/recipient complications and allograft function were recorded prospectively. Operating and first warm ischaemia times were longer for LDN than for ODN and MILD (232+/-35 vs 121+/-24 vs 147+/-27 min, P < 0.001; 4+/-1 vs 2+/-2 vs 2+/-1 min, P < 0.01). Postoperative morphine requirements were significantly higher after ODN than after MILD and LDN (182+/-113 vs 86+/-48 vs 71+/-45 mg; P < 0.0001). There was no episode of delayed graft function in this study. Donors returned to work quicker after LDN than after ODN and MILD (6+/-2 vs 11+/-5 vs 10+/-7; P = 0.055). Donor and recipient complication rates and recipient allograft function were comparable. We concluded that MILD and LDN reduce postoperative pain and allow a faster recovery without compromising recipient outcome.

Optimizing open live-donor nephrectomy - long-term donor outcome

INTRODUCTION

The technique of laparoscopic or retroperitoneoscopic donor nephrectomy has been increasingly propagated in recent years. The central advantage is supposed to be a reduction of perioperative discomfort. However, there have not been many reports describing the subjective feeling associated with an open donor nephrectomy, particularly with respect to the pain level in the perioperative and long-term course. This retrospective study examines the perioperative pain and morbidity and long-term outcome of living kidney donors from 35 yr of experience at the University Hospital Benjamin Franklin of the Free University of Berlin.

METHODS

A total of 102 living kidney donors were asked to fill out a questionnaire. Five epidemiological questions were posed and the rest dealt mainly with lasting subjective and objective surgical impairments. There were also questions relating to the perioperative pain level (VAS/NAS-Score). In addition, basic information was obtained regarding the donor's current health status (physical examination, serum creatinine; sometimes also ultrasound, protein IU, blood pressure), and/or examinations were performed.

RESULTS

The mean age at the time of donation was 45.5 and 55% were women. Donor nephrectomies were left-sided in 78 cases and right-sided in 24. There was a total complication rate of 53%, but serious complications only occurred in two cases (1.9%). A total of 53 donors could be reached. Although 41.5% felt they had a lasting impairment, somatic sequelae like respiratory, abdominal or scar problems were rare, affecting a maximum of only four patients in each case. Fifteen patients reported neurological problems such as sensory disturbances. The mean serum creatinine was 89.9 micromol/L in female and 114.2 micromol/L in male donors. Microalbuminuria was found in 22.6% of the donors, hypertension in 35.8%. Persistent pain was reported by 20.7%, its occurrence being permanent in two of the donors and very frequent in one. All the others rarely have pain. The median perioperative VAS/NAS score was 8 on the first day after surgery, 5 after 1 wk and 1 after 1 month. The analgesia was rated as good or very good by 71%. Everyday life was managed as well as before surgery after 2-4 wk by the highest percentage (42%) of patients, but working capacity was only regained after 1-3 months by a comparable percentage (44%). Forty-six percent had a very good and 33% a good feeling after the kidney donation. The relationship to the recipient had intensified in most cases. Ninety-one percent would again decide in favor of a donation.

CONCLUSION

Donor nephrectomy in an open technique is a safe and reliable procedure with low morbidity. After a median post-operative period of 7 yr, however, 42% of the donors still report general impairment due to the intervention, although concrete somatic problems were only detected in a few cases. Nearly all these patients underwent surgery in a full flank position. Wound-healing impairments were also significantly more frequent with this surgical technique. This positioning should thus be avoided. The post-operative pain level was relatively high, but a marked improvement was achieved in the course of the observation period by optimizing analgesic management.

Laparoscopic v open donor nephrectomy: a cost-utility analysis of the initial experience at a tertiary-care center

BACKGROUND AND PURPOSE

Laparoscopic donor nephrectomy (LapDN) offers donors more rapid postoperative recovery and recipients equivalent graft function when compared with open donor nephrectomy (OpenDN). Nonetheless, costs are less favorable for LapDN than for OpenDN. We compared LapDN and OpenDN with cost-utility analysis.

METHODS

A decision analysis modeling approach was performed: utilities derived using time trade-off and quality-adjusted life year (QALY) techniques; probabilities derived from a systematic review of the literature. All costs were included from a societal perspective using actual cost data from OpenDN and LapDN patients performed contemporaneously between July 1, 2000 and December 31, 2000. Costs of lost employment were estimated using mean provincial annual earnings. Incremental cost-effectiveness ratio (ICER) was calculated with "best-case" and "worst-case" scenarios for confidence intervals; sensitivity analyses were used to assess robustness.

RESULTS

LapDN costs are higher ($10,317.40 vs. $9,853.70), while quality of life (QOL) is superior (0.7683 vs. 0.7062). The ICER from a societal perspective was C$7,471.11/QALY. If all donor nephrectomies nationally were performed laparoscopically, there would be an additional annual cost of C$665,240 with a societal gain of 24.84 QALYs.

CONCLUSIONS

LapDN offers improved QOL at marginally higher cost. A societal ICER of $7,471.11/QALY compares favorably to many accepted health-care interventions. By potentially increasing organ donor rates, LapDN may be cost saving by decreasing the number of patients on dialysis.

Multiple renal arteries do not pose an impediment to the routine use of laparoscopic donor nephrectomy

Since the first description by Ratner and collegues in 1996, laparoscopic live-donor nephrectomy is gaining wide acceptance in an attempt to minimize the donor morbidity, length of hospital stay and length of time to return to work. It is unknown whether multiple renal arteries pose additional problems with laparoscopic donor nephrectomy. In November 1998, our institution initiated laparoscopic donor nephrectomy program. In the ensuing 19 months, we performed 25 living donor renal transplants, 24 of them using laparoscopic donor nephrectomy. The left kidney was procured in all cases. Eight donor candidates (33%) had two or more renal arteries (two arteries in five patients and three patients).

RESULTS

In six cases (25%), findings at surgery differed from the CT angography results (in four cases, CT angiogram reported fewer arteries than were found at surgery and in two cases it reported more). We found no significant differences in both donor outcomes and recipient, based on the presence or absence of multiple renal arteries. Among donor outcomes, we found equivalent results for donor warm ischemia time total donor operating time, and donor length of stay. For recipient outcomes, we found no significant differences between groups for the incidence of acute tubular necrosis (ATN), graft survival and most recent serum creatinine. In one case, we constructed two arteries into a single conduit on the backtable prior to transplantation. However, in most cases with multiple arteries, we implanted the arteries separately into the recipient external iliac artery. Based on this experience, we do not find the presence of multiple renal arteries to be a barrier to the successful use of kidney grafts procured by laparoscopic donor nephrectomy.

[Surgical complications of nephrectomy in living donors]

Renal transplantation from a living donor is now considered the best treatment for chronic renal failure. We reviewed the operative complications in 38 living related donor nephrectomies performed at our institution over the past 14 years. The mean age of our donors was 30 years old with age range between 18 and 58 years old and female predominance (55.2%). These swabs were realized by a posterolateral lumbar lombotomy with resection of the 11 third. The left kidney was removed in 34 donors (90%), surgical complications were noted in 39.4% of the cases: one case of wound of inferior vena cava (2.6%), one case of release of the renal artery clamp (2.6%), four cases of pleural grap (10.5%), one case of pneumothorax (2.6%), one case of pleurisy (2.6%), three cases of urinary infection (7.8%), three cases of parietal infection (7.8%) and one case of patient pain at the level of the wound (2.6%). There were no mortalities. We conclude that the morbidity of living donor nephrectomy is negligible compared with the advantages for the recipient.

Laparoscopic live donor nephrectomy. A review of the first 5 years

Laparoscopic live donor nephrectomy is technically feasible. The operation has evolved over the last 5 years and is greatly improved compared with the procedure originally described. Advantages to the donor when compared with the standard open operation are decreased postoperative pain, shorter hospitalization, a quicker recuperation, an earlier return to driving, and an earlier return to employment. These improvements have resulted in fewer lost wages and a lower financial burden for donors. Live donor nephrectomy also provides improved cosmetic results. It successfully removes many of the disincentives to live kidney donation and has resulted in an increased willingness of individuals to donate their kidneys. The operative risk seems to be equivalent to that of the open donor operation performed through a flank approach. Although there is no financial advantage of the laparoscopic operation in terms of hospital costs, the increase seen in live donor transplantation may result in long-term cost savings overall. Kidneys procured laparoscopically function well in recipents in the short and long term. There is no increased risk for rejection or technical complications, and the recipent's length of hospitalization is unaffected. The laparoscopic donor operation does not have any apparent deleterious effect on the recipient. The procedure is being adopted rapidly by transplant centers around the world and has been performed at more than 100 centers on five continents. The authors believe that laparoscopic live donor nephrectomy will become the standard of care in the not too distant future.

Laparoscopic live donor nephrectomy: rationale, techniques, and implications

Laparoscopic live donor nephrectomy (LDN) was conceived as a means for decreasing donor nephrectomy morbidity and reducing disincentives for kidney donation. Since LDN was first reported in 1995, explosive growth has led to its performance at more than 100 centers worldwide. Despite initial skepticism in some segments of the transplant community, the results of LDN have improved progressively so that it is emerging as a new standard of care for live kidney donation. We review the development and refinement of LDN and its current rationale and applications.

Laparoscopic or open surgery for living donor nephrectomy

BACKGROUND

The anterior extraperitoneal approach for living donor nephrectomy has been used in more than 700 living cases in the unit and proved to be safe for the donor. In 1998, laparoscopic nephrectomy was introduced as an option when technically feasible. We found it essential to investigate the consequences of the new technique.

SUBJECTS AND METHODS

One hundred living donor kidney transplantations were performed from 1998 to June 2000, 45 with laparoscopic, 55 with open nephrectomy. The donors took part in a structured interview 4 weeks after the donation and their responses were categorized in three classes.

RESULTS

In each group, one recipient had delayed initial function. The serum creatinine levels after 3 and 7 days or the GFR values after 6 months did not differ. One graft has been lost following laparoscopic nephrectomy and four after open surgery. For the laparoscopy donors, the median number of post-operative days in hospital was 5.0 days (range 2-9), vs 6.0 (4-8) after open surgery (NS). The requirement of opoid analgesics post-operatively was 5.0 doses (1-22) vs 6.0 (1-38) (P=0.02); and after 4 weeks, 23 of 45 laparoscopic donors were free of pain vs eight of 55 open nephrectomy donors (P=0.0004). Approximately one-third of all donors felt some restriction of physical activity and the majority complained of impaired physical energy. There were no differences between the groups. The duration of sick-leave after laparoscopic surgery was median 6 (2-19) weeks vs 7 (1-16) (NS).

CONCLUSIONS

Laparoscopic nephrectomy is safe. Less post-operative pain is a definite advantage for the donor.

Laparoscopic live donor nephrectomy

Laparoscopic donor nephrectomy offers numerous advantages when compared with the traditional open approach. For the donor, it has resulted in a shorter hospital stay, fewer postoperative analgesic requirements, earlier return to activities of daily living and employment, and decreased financial loss owing to absence from the workforce. For the recipient, the procedure does not adversely impact on allograft function, graft survival, or patient survival.

The safety and efficacy of laparoscopic live donor nephrectomy: a systematic review

BACKGROUND

The aim of this systematic review was to compare the safety and efficacy of laparoscopic live donor nephrectomy with the "gold" standard of open live donor nephrectomy.

METHODS

SEARCH STRATEGY

Three search strategies were devised to enable literature retrieval from the Medline, Current Contents, Embase, and Cochrane Library databases up until, and including, February 2000.

STUDY SELECTION

Inclusion of a report was determined on the basis of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. English language reports were selected and acceptable study designs included randomized-controlled trials, controlled clinical trials, case series, or case reports. Each report was required to provide information on at least one of several safety and efficacy outcomes as detailed in the protocol.

DATA COLLECTION AND ANALYSIS

Twenty-five reports met the inclusion criteria. They were tabulated and critically appraised in terms of the methodology and design, sample size, outcomes, and the possible influence of bias, confounding, and chance.

RESULTS

High level evidence comparing the safety and efficacy of laparoscopic live donor nephrectomy with open donor nephrectomy was not available at the time of this review. Limited low level evidence suggested that the laparoscopic approach might be advantageous regarding the donor's hospital stay, convalescence, pain, and resumption of employment.

CONCLUSIONS

The ASERNIP-S Review Group concluded that the evidence-base for laparoscopic live donor nephrectomy was inadequate to make a safety and efficacy recommendation. Clinical and research recommendations were developed regarding the introduction and current practice of this procedure in Australia.

Laparoscopic Live Donor Nephrectomy at a Community Hospital

Recently, laparoscopic harvesting of kidneys from live donors has been reported by major university centers. As a community transplant center, we adopted a multidisciplinary cooperative approach, including a full-time transplant surgeon, a laparoscopic general surgeon, and a urologist with laparoscopic experience, in order to perform our first successful laparoscopic live donor nephrectomy in December 1998. The operative time was 234 minutes, and the warm ischemia time was 2 minutes. No intraoperative or postoperative complications occurred. The length of the renal artery was 2.4 cm, the renal vein was 3.0 cm, and the ureter was 10.0 cm. The donor was discharged home the next day and returned to work within 14 days. The transplanted kidney functioned immediately. The recipient serum creatinine concentration dropped from 9.3 mg/dL preoperatively to 3.4 mg/dL within 24 hours and to 1.3 mg/dL on the third day.

Laparoscopic v laparoscopy-assisted donor nephrectomy in the porcine model

PURPOSE

Laparoscopic donor nephrectomy is an established procedure in the porcine model. We sought to compare intraoperative variables between live laparoscopic (LAP) and laparoscopy-assisted (LAP-A) donor nephrectomy.

MATERIALS AND METHODS

Eight domestic pigs underwent either traditional laparoscopic donor nephrectomy (N = 4) or laparoscopy-assisted donor nephrectomy (N = 4) using the Pneumosleeve followed by conventional heterotopic autotransplantation.

RESULTS

No significant differences were noted between the groups with regard to vessel length, ureteral length, or postoperative urine output. The operating room time was 108+/-12 minutes in the LAP group v 75.8+/-10.3 minutes in the LAP-A group (P = 0.0065). Although the difference was not statistically significant, warm ischemic time, tended to be lower in the LAP-A than the LAP group: 70+/-3.0 seconds v 135+/-57 seconds, respectively (P = 0.059). Graft survival was identical in the two groups.

CONCLUSION

Laparoscopy-assisted (via Pneumosleeve) live donor nephrectomy shortens the operative time without affecting graft survival in the domestic swine model.