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• W2023704148 abstract "Laparoscopic donor nephrectomy (LDN) is a remarkable technical achievement. We don’t do it. The advantages and disadvantages of LDN are outlined in Table 1. Although well-documented by others (1), the decreased analgesic requirement for LDN has been brought into question by a recent study (3). Decreased hospital stay is an advantage of LDN, with reported mean lengths of hospital stay of 2–3 days (4) for that procedure compared to the 4–6 days for open donor nephrectomy (ODN) (6). Our length of hospital stay for ODN is 4 days (8). Table 1: Advantages and disadvantages of LDN compared with ODNAlthough the morbidity associated with the rib-resecting flank approach is eliminated by the use of LDN, it is also avoided by anterior transperitoneal and extraperitoneal approaches (6) and by the supracostal approach (10). Regardless of the surgical approach, an incision large enough to remove the kidney still must be made, and a scar will result (Figure 1). We agree with our LDN colleagues that rib-resecting procedures are unnecessary, and we think that they should be abandoned. Figure 1: Flank scar from right supracostal donor nephrectomy in a 36-year-old woman. This approach eliminates the potential for a painful rib stump, provides excellent exposure for right or left donor nephrectomy, and allows rib approximation to contribute to the strength of the wound closure. Pain management is with epidural analgesia, intraoperative intercostal nerve block, ketorolac injection for 48 hr, and patient-controlled narcotic analgesia. Subcuticular skin closure with absorbable suture eliminates the need for removal of skin clips or sutures.Some have attributed the increase in the numbers of living renal donors (4) to the availability and marketing of LDN, but we do not do LDN at our institution, and the number of living renal donors in our renal transplant program more than doubled from 24 to 56 per year between 1994 and 1999. Laparoscopic living renal donation is a more expensive procedure for the hospital and its transplant program than is ODN (12) because the former has a longer “operating room door-to-door time,” special equipment is required (much of it disposable), and usually two skilled LDN surgeons are necessary, rather than the usual one ODN surgeon and a resident. Has the criterion that the better kidney remain with the donor been compromised by the LDN teams’ preference for the left kidney (13)? It is our practice, as an ODN program, to do the following: leave the larger kidney with the donor, leave the most normal kidney with the donor, and in the case of women who may become pregnant and who otherwise have two equivalent kidneys, remove the right kidney for transplantation because pyelonephritis and hydronephrosis of pregnancy are more common in that kidney (14). On the basis of these criteria, 35% of the living donor kidneys transplanted at our institution are right kidneys. This is in marked contrast to the 2% right donor nephrectomy rate reported by the major LDN program (4). Right ODN provides the transplanting team with the complete length of the short right renal vein plus a cuff of inferior vena cava (IVC). The IVC cuff provides a technical advantage for the recipient team because the right renal vein in women is often delicate and does not hold a suture well. The inability to provide an IVC cuff and a long renal artery is a disadvantage of right LDN. The impaired short term function of LDN kidney transplants when compared with ODN kidney transplants may be due to diminished blood flow associated with the pneumoperitoneum of the LDN, the more traumatic removal of the kidney graft through a small incision, and the longer warm ischemia time (Table 2) (5). The long-term effects of this early impairment of kidney graft function are unknown. Earlier reports revealed a significantly higher rate of ureteral complications in transplantations with laparoscopically retrieved kidneys (Table 3) (16). Although this problem seems to have been solved by modifying the ureteral dissection during LDN, a learning curve exists for transplant programs developing the LDN technique. Table 2: Early function of LDN and ODN Kidney TransplantsaTable 3: Kidney transplant ureteral problems after LDN and ODNaThe technique of LDN continues to evolve, and members of our kidney donor team have observed the procedure on two occasions since 1997. We continue to be concerned that the better of the two kidneys may not always be left with the donor when LDN is done and that the morbidity for the donor may be transferred to the recipient in terms of poorer graft function and increased ureteral complications when compared with kidney transplants retrieved by an ODN technique (18). In short, we don’t do LDN…but we might." @default.
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• W2023704148 title "LAPAROSCOPIC DONOR NEPHRECTOMY: CON" @default.
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