Nephrol Dial Transplant (2001) 16: 383-386
© 2001 European Renal Association-European Dialysis and Transplant Association
Laparoscopic or open surgery for living donor nephrectomy
Transplant Unit, Sahlgrenska University Hospital, Göteborg, Sweden
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Abstract |
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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 feasable. 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.
Keywords: graft function; hospital stay; kidney transplantation; laparoscopic nephrectomy; living-donor nephrectomy; post-operative pain
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Introduction |
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The anterior extraperitoneal approach for living donor (LD) nephrectomy has been used in more than 700 living donor kidney transplantations in the unit and proved to be safe for the donor [1,2]. In February 1998, a laparoscopic nephrectomy technique was introduced and used in parallel with the conventional technique. We found it essential to investigate the consequences of the new procedure.
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Subjects and methods |
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Laparoscopic nephrectomy was considered in cases of a single artery to the left kidney unless this kidney was larger than the right one. A few donors who were offered this option preferred the established technique of open surgery. The laparoscopic nephrectomies were performed in collaboration between experienced transplant surgeons and laparoscopy surgeons. Four trocars were used and the kidney was delivered through a 6 cm infra-umbilical incision. One hundred LD kidney transplantations were performed from 1998 to June 2000, 45 with a laparoscopic technique, 55 with open surgery. Of the 34 nephrectomies performed in the first year, 11 were with the laparoscopic technique.
Table 1
shows demographic data for the donors and their recipients with the two types of nephrectomy. Similar gender distribution for donors and recipients was observed. The laparoscopy nephrectomy donors were somewhat older, P=0.01, but there was no significant recipient age difference. Biopsy-verified chronic glomerulonephritis, found in 32% of the recipients, was the most frequent diagnosis in both groups.
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Data from the records
Data on parenteral analgesic drugs given post-operatively to the donors were collected, the various opoids used measured as number of injections, whereas the total dose of the non-steroidal anti-inflammatory drug (NSAID) ketorolac (Toradol®) was measured in milligrams. The duration of post-operative hospital stay for the donors was also recorded. The recipents' serum creatinine values on days 3 and 7 after transplantation were obtained as well as their glomerular filtration rate (GFR) after 6 months, measured as plasma clearance of [Cr51] EDTA. For calculations of median values, patients who required dialysis were set as having serum creatinine 1000 µmol/l and GFR 0 ml/min. The cumulative graft survival was also calculated.
Interviews
Before the nephrectomy, all 100 donors were invited to participate in a follow-up programme including an interview by telephone 4 weeks after surgery, and none of them declined. All interviews were conducted by the same investigator (AL) and lasted 15–60 min. The themes were predetermined and included the wound, actual pain, physical activity, physical energy, and mental energy. The donors' answers to each theme were categorized according to the following definitions. The wound: (i) no unexpected problems; (ii) undue irritation; (iii) a history of infection. Actual sensation of pain: (i) no pain or discomfort; (ii) slight, not requiring any analgesic drugs; (iii) requiring oral analgesic drugs. Physical activity: (i) as normal; (ii) some feeling of restraint or fear; (iii) considerable limitations in the activities of daily life. Physical energy: (i) as normal; (ii) slightly reduced; (iii) tired enough to require rest or sleep during daytime. Mental energy: (i) as normal; (ii) slightly reduced, e.g. less patience or intolerance to sounds; (iii) depression.
During the interviews the donors were also asked whether or not they had resumed work, and if not, for how many further weeks they were to be on sick-leave. In cases that remained unclear at this time point, additional information was later obtained from the records or the donors themselves.
Statistical analyses
StatView® 5.0.1 was used for the statistical analyses. Differences in frequencies between patient groups were calculated with the 
2 test and differences in continuous variables with the Mann–Whitney U rank test. Cumulative survival was calculated according to Kaplan–Meier. P-values >0.05 were considered not significant.
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Results |
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There were no major complications among the donors. The eighth laparoscopic nephrectomy was converted to open surgery because of bleeding. The post-operative course for the donors is described in Table 2
. The requirement of opoid analgesics was significantly less after laparoscopic nephrectomy (P=0.02), whereas the use of parenteral NSAIDs was similar. Rather than pain from surgical wounds, many laparoscopy donors complained of shoulder pain, which was quite resistant to analgesics. During the follow-up interview after 4 weeks, seven of 45 donors with laparoscopic nephrectomy and five of 46 donors with open surgery complained that they had had undue irritation from the wound(s), and one donor in each group had had wound infection. The donors' responses to questions about their actual health are presented in Table 3. Fewer donors in the laparoscopy group felt pain to the extent that they took oral analgesic drugs (P=0.0004). There were no significant differences with respect to physical activity, physical energy, or mental energy. Three donors suffered from mental depression, two of them after laparoscopic nephrectomy. The post-operative hospital stay and the duration of sick-leave tended to be shorter following laparoscopic nephrectomy but the differences did not reach statistical significance.
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In each group, one recipient had delayed initial function and required dialysis (Table 4
). In the laparoscopy case this was due to technical problems in the recipient, while in the open surgery case there was no apparent reason. The incidence of ureteral complications was 16% after laparoscopic nephrectomy vs 5% after open surgery (NS), and early technical renovascular problems were recorded in equal frequency: 11% in both groups. The serum creatinine levels after 3 and 7 days did not differ and the GFR values after 6 months were similar. A total of five grafts have been lost during follow-up (Table 4). Figure 1 shows the cumulative graft survival.
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Discussion |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionReferences |
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Ratner et al. [3] from the Johns Hopkins University published the first experience of laparoscopic living donor nephrectomy in 1995. Since then their series has expanded considerably, and now comprises more than one hundred cases [4–6]. Several other centres have followed [7–12].
Among the advantages for the donors claimed for this technique are less pain, shorter stay in hospital, faster rehabilitation, and an absence of long-term complications such as neuralgia and herniations. In consequence, the availability of this option is reported to enhance the recruitment of donors. Promoters of the procedure claim that it is safe and does not confer any extra risks to the donor or the recipient [4–6,9,12,13].
On the other hand, warm ischaemia time is inevitably prolonged when laparoscopic nephrectomy is performed [7–9,14]. An adverse effect of the increased intra-abdominal pressure which results from CO2 pneumoperitoneum on the donated and/or remnant kidney has also been feared [15]. To be safe, laparoscopy requires much training and continuing experience [8,13]. It is also resource intensive and tends to increase the direct costs for nephrectomy [6,9]. Ureteral complications were initially reported in high numbers [4,7,10]. The risk-benefit balance is therefore seen differently by different observers [6,7,14].
Our evaluation was made in comparison with a contemporary group of donors operated with the established technique for open nephrectomy. The donors were not randomized to either form of surgery, but the choice was based on vascular anatomy or the donor's preference. The comparison of demographic data show striking similarities between the groups. Thus, the open surgery group was well suited as controls. Most previous reports either did not include any controls or made a comparison with controls who were either historical or underwent surgery in a different hospital [4,6–10,16,17].
We found a significant difference between laparoscopic and open surgery in the post-operative requirement of parenteral opoid drugs. This finding is in line with what has been reported in other investigations, though the difference in our experience was more modest [4,6,9]. Furthermore, after 4 weeks the use of oral analgesic drugs was significantly less among donors in the laparoscopy group.
The duration of hospital stay was not significantly shorter after laparoscopic nephrectomy. This factor was, however, determined not only by the donor's medical condition but on her or his preferences, which often included concern with and a wish to be close to the recipient. Using mere financial considerations, donors may be discharged within 24 h of surgery [12], but from other aspects, this time is inadequate in our experience. Patient hotels for interim stay were not available.
The duration of sick-leave among our donors was also shorter in the laparoscopy group, although the difference was not statistically significant. In principle, the Swedish health care insurance system covers hospital stay as well as the donors' expenses and income loss. The incentives to leave hospital quickly and to resume work may therefore be less than in countries with other socio-economic systems. These aspects may have reduced the differences between the groups.
The donors' answers in the interview 4 weeks after the donation show that many had not by then recovered fully physically or mentally. This was equally true for donors in both groups.
In spite of the number of reports on the benefits of the laparoscopic technique, no previous study includes such detailed follow-up of the donors as our study. We had 100% response rate and the interviews were scheduled to take place at a defined point in time after surgery.
In a comparison between two procedures, the alternative will obviously appear more attractive the more the standard method is burdened with complications. The anterior extraperitoneal approach for open nephrectomy, which has been exclusively used in more than 700 consecutive donors in our unit leads to few acute complications and there are no long-term complications [2]. With other techniques, chronic pain or hernia may ensue [4,9]. Therefore the advantage for our donors may be less than in some other series.
This careful evaluation of clinical aspects of laparoscopic living donor nephrectomy shows that it is safe for the donor and for the recipient. The immediate post-operative pain was less and fewer donors required oral analgesics 1 month after the donation, but their physical activity was not less restricted than in open-surgery donors. Considerable and similar proportions in both groups suffered from physical fatigue at that time.
The evaluation gives support to a continuation of our programme with laparoscopic nephrectomy as an option in technically suitable cases.
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Acknowledgments |
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The financial support from the Jacobsson fund for transplantation research, Växjö, Sweden, is gratefully acknowledged.
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Notes |
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Correspondence and offprint requests to: Gudrun Nyberg MD PhD, Transplant Unit, Division D, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden.
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References |
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Revision received 4. 9.00.
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