Microinvasive donor nephrectomy

[Surgical aspects of living donor nephrectomy]

CONTEXT

Living donor renal transplant surgery has evolved from the classical nephrectomy by lumbotomy to less invasive surgery, the laparoscopic and robotic nephrectomy currently being the most important. It is important to know the available evidence on whether nephrectomy in patients with multiple arteries, right kidney and in obese patients can be performed safely when there is a correct indication.

OBJECTIVE

To perform a review of the different surgical techniques in living donor nephrectomy, adapted to the current surgical evidence and other aspects related to the indication.

EVIDENCE ACQUISITION

A systematic review was made in PubMed (1997-2011). This included previous reviews randomized controlled clinical studies, cohort studies, and meta-analyses of this surgical aspects of living donor nephrectomy.

CONCLUSIONS

Currently, there is sufficient evidence to consider living donor laparoscopic nephrectomy as the technique of choice, although the role of hand-assisted retroperitoneoscopic technique is still not totally clear. Open surgery techniques using mini-incision are an acceptable alternative for the sites that have not yet implemented laparoscopic surgery. Right kidney nephrectomy, of those cases that present multiple pedicles and in obese donors, is justified in selected cases.

Living Kidney Donation: Evolution and Technical Aspects of Donor Nephrectomy

For more than 40 years, living donor nephrectomy was performed through a flank incision drawn on the urologic experience with nephrectomy for cancer. Since its introduction one decade ago, laparoscopic donor nephrectomy has gained widespread acceptance and popularity; currently over one-half of donor nephrectomies in the United States are performed with this technique. The changing practice of donor nephrectomy resembles in many ways the evolution of minimally invasive in other subspecialties. The lessons learned from these technical developments are valuable and can be adapted by general surgeons and urologists when called upon to perform nephrectomy for organ donation or kidney disease.

Fatal and nonfatal hemorrhagic complications of living kidney donation

OBJECTIVE

After anecdotal reports of severe hemorrhage from failure of surgical clips to sustain closure of renal artery stumps in live donor nephrectomies were received, this study was designed to identify specific surgical techniques that are associated with an increased risk of failure to control bleeding and might represent opportunities to improve patient safety.

BACKGROUND

Preventing complications for living kidney donors must be paramount in addressing end-stage renal failure through living kidney donation. Major hemorrhage from technical failure, albeit an infrequent occurrence, can cause significant, yet preventable, morbidity or death. Open and laparoscopic approaches to living kidney donation use several vascular control methods, some of which may be more prone to failure and life-endangering hemorrhage than others.

METHODS

To define hemorrhagic complications of living kidney donation, a survey was sent to all 893 surgeon-members of the American Society of Transplant Surgeons. Descriptive and bivariate analyses were used to ascertain study participant characteristics, most frequently used vascular control techniques, and incidence of events (death, transfusion, reexploration or conversion to open nephrectomy, or contralateral [remaining kidney] renal failure). Outcomes of hemorrhage and comments by respondents were sought as were data from other sources.

RESULTS

In 213 surveys returned (24%), 66 and 39 episodes of arterial and venous hemorrhage were reported, respectively. Among arterial control problems, 2 resulted in donor death and 2 resulted in renal failure; 19 episodes required transfusion. Open conversions in laparoscopic nephrectomy or late reoperations for hemorrhage were reported for 29 cases. Locking and standard clips applied to the renal artery were associated with the greatest risks.

CONCLUSIONS

Significant hemorrhagic complications occur with living kidney donation in both open and laparoscopic approaches. Loss of arterial control jeopardizes donor life and health, especially when it occurs in the postoperative period. Vascular transfixion provides the best vascular control of major vessels.

Keeping up with the Jones's: open donor nephrectomy in the laparoscopic era

Several new approaches have been developed to perform donor nephrectomy. These include laparoscopic donor nephrectomy and open donor nephrectomy performed through small incisions, herein referred to as "mini-open donor nephrectomy". In the past, we performed open donor nephrectomy via a standard flank incision. In October 2002, we introduced mini-open donor nephrectomy via an anterior, retroperitoneal approach. Contemporaneously, we offered the option of laparoscopic donor nephrectomy. Herein, we review our single-center experience with these three techniques. Mini-open donor nephrectomy was comparable to the laparoscopic approach for duration of narcotic requirement and donor length of stay. The laparoscopic procedure was more expensive. Both procedures demonstrated improvement over the flank approach by eliminating the risk of pneumothorax, neuropathy, and flank bulge. In addition, length of stay and narcotic requirements were higher with the flank approach. Mini-open donor nephrectomy provides a good alternative to laparoscopic surgery, offering the donor an equivalent convalescence at lower cost and potentially with reduced morbidity.