Elsevier

European Urology

Volume 58, Issue 4, October 2010, Pages 498-509
European Urology

Platinum Priority – Collaborative Review – Transplantation
Editorial by Eric Lechevallier on pp. 510–511 of this issue
Laparoscopic Living-Donor Nephrectomy: Analysis of the Existing Literature

https://doi.org/10.1016/j.eururo.2010.04.003Get rights and content

Abstract

Context

Laparoscopic living-donor nephrectomy (LLDN) has achieved a permanent place in renal transplantation and in some centers has replaced open donor nephrectomy as the standard technique.

Objective

To evaluate the published literature regarding the relative results and complications of open LLDN and the hybrid technique of hand-assisted LLDN.

Evidence acquisition

A systematic review of the literature was performed, searching PubMed and Web of Science. A “free text” protocol using the term living-donor nephrectomy was applied. Six hundred twenty-nine records were retrieved from the PubMed database and 686 records were retrieved from the Web of Science database.

Evidence synthesis

Fifty-seven comparative studies were identified in the literature search. The three techniques of open, laparoscopic, and hand-assisted laparoscopic donor nephrectomy were compared in terms of reported outcomes. With regard to the perioperative outcome parameters, laparoscopy was better than open surgery in terms of blood loss, analgesic requirements, and duration of hospital stay and convalescence. Postoperative graft function was not significantly different between the different forms of donor nephrectomy, although longer warm ischemia times are reported for laparoscopy.

Conclusions

All three techniques of live-donor nephrectomy are standard of care. The laparoscopic techniques result in less postoperative pain and estimated blood loss with shorter hospital stay, while postoperative graft function is not inferior to that after open live-donor nephrectomy.

Introduction

In the half century that has passed since the first successful procedure, living-donor renal transplantation has shown superiority over cadaveric-donor renal transplantation. The advantages of live-donor renal transplantation are several. First, cold ischemia time is significantly shorter than in cadaveric-donor kidney transplantation and thus there is an almost complete absence of ischemic injury to the transplanted kidney. This results in a relative insensitivity to poor tissue matching and better long-term function [1]. Second, kidneys harvested from living donors represent perfect organs from perfectly healthy donors, ensuring a better graft and recipient survival compared with human leukocyte antigen (HLA)–matched cadaveric transplants [2]. Third, live-donor nephrectomy (LDN) reduces the waiting time for the recipient and therefore allows renal transplantation earlier, with the recipient still in better general condition and health.

LDN is unique in that it affects a healthy individual rather than a sick person. This makes it a very demanding and sophisticated surgical procedure. The safety and efficiency of the surgical technique are of utmost concern for the donor, the recipient, and the surgeon. Therefore, the surgical technique used must entail the lowest possible morbidity for the donor without compromising the functional outcome of the graft [3].

Since the early 1990s, laparoscopic techniques have been successfully adapted for various open urologic procedures, including laparoscopic living-donor nephrectomy (LLDN) which was first described in 1995 [4], [5]. Because laparoscopy is generally considered to be less invasive than open surgical techniques, laparoscopy may be preferable if it can be demonstrated to achieve the same result with the same safety for the patient. While pure laparoscopic donor nephrectomy is feasible, some surgeons for reasons of safety prefer hand-assisted laparoscopy for LDN [6], with either a trans- or retroperitoneal approach.

With the introduction of laparoscopy into LDN, some centers have reported an increase in the numbers of renal transplants from living donors [2], [7], [8], [9]. For the United States, the United Network of Organ Sharing (UNOS) reported that in 2005, 83% of all LDNs were performed laparoscopically [10].

However, when laparoscopic donor nephrectomy was first introduced there was great concern that this procedure would be unsafe and that longer warm ischemia times (WITs) would jeopardize postoperative graft function. The purpose of the present systematic review was to evaluate the published literature regarding the relative results and complications of open LDN, purely laparoscopic (LLDN) and retroperitoneoscopic live-donor nephrectomy (RLDN), and the hybrid technique of hand-assisted LLDN (HALLDN).

Section snippets

Evidence acquisition

A literature search was performed on the Internet using the PubMed and Web of Science. The PubMed search included a “free text” protocol using the term living-donor nephrectomy across the “Title” and “Abstract” fields of the records. Subsequently, the following limits were used: humans and language (English). Particular attention was paid to articles focusing on indications, results, complications, and mortality for LDN. The searches of the Web of Science databases used the same free-text

Indications and exclusion criteria

Regarding the indications or exclusion criteria for donors for the different techniques of donor nephrectomy, there were no studies comparing these with relevant outcome parameters. Instead, most studies stated their exclusion criteria for the respective techniques based on surgeon opinion.

In general, selecting an appropriate donor for LDN required a careful evaluation and the involvement of various medical disciplines. Prospective donors needed to be of good general health and at low risk of

Conclusions

Our analysis suggests that based on published series, both techniques of donor nephrectomy have comparable complications and equal functional graft outcomes. Laparoscopic techniques of donor nephrectomy may have advantages in postoperative recovery and duration of pain, but these differences are difficult to quantify and difficult to assess in their impact on long-term outcome. Laparoscopic techniques of donor nephrectomy have reported disadvantages in terms of longer OPT and longer WIT.

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