Laparoscopic Living Donor Nephrectomy For Kidney Transplantation

Stephen T. Bartlett, M.D., Eugene J. Schweitzer, M.D.

This article appeared in Dialysis & Transplantation 1999; 28(6): 318-331

• Abstract
• Introduction
• Renewed Interest In Living Donors
• Laparoscopic Nephrectomy
• Outcomes: Laparoscopic vs. Open Nephrectomy
• Growing Acceptance of Living Donation
• Minimizing ESRD Costs
• Conclusion

Abstract The growing shortage of organs available for transplantation has resulted in the increased use of living donors for kidney transplantation. Nearly all of the 250 transplant centers in the United States perform living donor kidney transplants, usually via a retroperitoneal flank approach. A laparoscopic technique is now available for removal of kidneys from living donors which is superior to the old approach. Potential benefits include less pain, shorter hospitalization, rapid return to normal activity, and improved cosmesis. The University of Maryland has the world’s largest experience with this technique, having performed over 300 procedures. Our experience indicates that this procedure not only provides outstanding outcomes but also provides the most cost-effective strategy to manage ESRD patients.

Introduction There is an extraordinary shortage of suitable kidneys for transplantation into patients with end stage renal disease (ESRD). The United Network for Organ Sharing (UNOS) is a government contracted organization that has oversight of transplant programs and organ procurement organizations. All patients awaiting transplants in the United States are registered on UNOS waiting lists. As of February 12, 1998 the UNOS renal transplant waiting list had 42,570 registrants⁽¹⁾. This list compares to 8,606 cadaver kidneys transplanted in 1997. Unfortunately, the renal transplant waiting list has grown by more than 13% per year for the last five years ⁽²⁾ while the number of kidneys from cadaver donors has remained relatively stable at approximately 8,500 per year for the past five years ⁽³⁾. Moreover, the average quality of cadaver donor kidneys has declined as the donor population has increased in age. This has been primarily due to an overall decrease in motor vehicle fatalities with enforcement of seat belt, speed and driving-while-intoxicated laws. While young donors who suffer brain death from accidents are a source of the highest quality organs for transplantation, many cadaver organs now are from older donors who have died from fatal strokes or myocardial infarctions. To increase the safety of cadaver renal transplantation, careful assessment of kidney function in potential organ donors and evaluation of kidney biopsies must be done. Cautious assessment of the donor social history and viral serology also leads to the exclusion of some otherwise suitable donors.

Renewed Interest In Living Donors In light of the severe cadaver organ donor shortage and the increasing waiting times, there has been renewed interest in kidney transplants from living donors. This is particularly true since Terasaki’s report which showed that kidneys from living unrelated donors, such as spouses and friends, succeed as well as kidneys obtained from brothers and sisters who share half of the tissue matching antigens (HLA antigens) with the kidney recipient⁽⁴⁾. This report has significantly expanded the pool of potential living kidney donors from siblings, children and parents (first-degree relatives) to additionally include distant relatives, spouses and close friends. The success rate of living donor kidneys, no matter what the donor-recipient relationship, is significantly greater than for cadaver kidneys. The estimated half-life (the time after which 50% of transplanted kidneys are still functioning) of cadaver kidneys is 8.6 years while for living donor kidneys it is 14.7 years ⁽⁵⁾. Furthermore, it is important to understand that these estimates by Terasaki are based on estimated success rates with immunosuppressive protocols that are now somewhat out of date. With current immunosuppression the risk of rejection is significantly less and even longer half-lives for both cadaver and living donor transplants can be anticipated. Nevertheless, the advantage of living donor kidneys will remain apparent.

Laparoscopic Nephrectomy Until recently, living donor nephrectomy required an eight to nine inch incision in the flank either through or just below the twelfth rib. The procedure is extremely safe (mortality 0.03%) and provides a kidney that is in optimal condition. However, the morbidity is substantial, ranging from 15-20% or higher. The risk of wound complications including flank hernia approaches 9% and the risk of pneumothorax is 8%. Chronic wound bulging or diastasis occurs in as many as 25% of patients. Return to normal activity may be as long as 6 to 8 weeks. The well-known limitations of the standard flank-incision open nephrectomy, combined with the success of other laparoscopic solid organ surgery such as splenectomy and adrenalectomy, provided the impetus to develop a minimally invasive method to remove kidneys from living donors. Potential benefits include less pain, shorter hospitalization, rapid return to normal activity, and improved cosmesis.

The first report of successful laparoscopic removal of a donor kidney was by Ratner and Kavousi ⁽⁶⁾. We have modified the technique originally described by Ratner. The surgery is performed in a fashion similar to other laparoscopic surgeries. The donor is under general anesthesia and is positioned on her side. The surgical dissection is done through four small laparoscopic operating ports ranging in size from 0.5 to 1.2 cm (Figure 1).

Figure 1. Intraoperative photograph of laparoscopic instrument placement during minimally invasive living donor nephrectomy. The patient's head is to the left, with her right side down. The left-most port in the photograph is for the camera, and the other two are operating ports.

By addition of an endoscopic retreival bag to the technique, the kidney extraction incision has been markedly reduced, making the operation truly minimally invasive. The extraction incision can be either a 6 cm periumbilical incision, or a suprapubic 5 cm Pfannenstiel (bikini) incision for women. The quality of laparoscopically-procured kidneys is excellent when performed at centers which have a large experience with the technique (Figure 2).

Figure 2. The quality of this kidney removed by the laparoscopic technique, including the length of the renal artery and vein, is as high as that of kidneys removed by the traditional open technique.

The laparoscopic ports are dressed with band-aids and the extraction incision is closed with an absorbable subcuticular stitch and dressed with skin tapes. The procedure has had very high patient acceptance, because the hospital stay and time away from work and normal activity are significantly reduced. The small incisions are associated with minimal morbidity, and the cosmetic result is excellent (Figure 3).

Figure 3. Four months after surgery the donor has an excellent cosmetic result. The periumbilical extraction incision will undergo further blanching over the next year to the point where it will be hardly noticable.

Outcomes: Laparoscopic vs. Open Nephrectomy We have had an opportunity to compare the outcome of laparoscopic living donor nephrectomy in our first 70 cases with an age and gender-matched group which had had open donor nephrectomy in the time period immediately prior to initiation of this program. These results were presented at the annual meeting of the American Surgical Association in April, 1997 and were published in the Annals of Surgery, October, 1997 ⁽⁷⁾. We found that the laparoscopic procedures were completed in 94% of cases. Conversion to an open procedure was required in only three cases, one due to obesity and inability to maintain pneumoperitoneum, one due to renal vascular anomaly, and one due to bleeding. The immediate graft function rate was 97% in the laparoscopic donor nephrectomy group and 100% in the open group (p = 0.50). Long-term graft survival at one year was the same for both groups, 97% and 98% for the laparoscopic and open groups, respectively (p = 0.62). Blood loss, length of stay, narcotic requirements, time to resumption of normal diet, and return to normal activity (16 days for laparoscopic vs. 51 days for open nephrectomy) were all dramatically lower in the laparoscopic group (all comparisons, p < 0.001). There was no mortality in either study group.

As of February 12, 1999, we have performed 302 laparoscopic living donor transplants. Since we began this procedure in March, 1996, only 12 (3.8%) patients were committed to open nephrectomy at the time of their evaluation for various reasons including patient habitus inappropriate for laparoscopy, renal artery aneurysm, concomitant gynecologic removal of an endometrioma, patient choice (early in the program) and past left upper quadrant surgery. Thus less than 4% of donors could not be done laparoscopically and only 3 were converted to an open procedure. None of the last 180 have been opened, a reflection of our increasing understanding of the procedure and appropriate selection for this technique. As we gained experience with this technique, we also adopted the newer immunosuppressive medication tacrolimus (FK, Prografâ ), which is a substitute for cyclosporine (CSA). We routinely administer tacrolimus with mycophenolate mofetil (MMF, CellCeptâ ) to our living donor kidney recipients postoperatively to prevent acute rejection. When we compared the earlier group of 135 recipients of laparoscopically-procured kidneys who received CSA-MMF to the more recent group of 165 recipients who received FK-MMF, the 2-year graft survival rate for the CSA-MMF group was 91.0%, versus 96.4% for the FK-MMF group (Figure 4). Two-year patient survival for the CSA-MMF group was 94.7%, versus 97.7% for the FK-MMF group.

Figure 4.Two-year graft and patient Kaplan-Meier survival rates for laparoscopic
living donor kidney transplants under FK vs. CSA immunosuppression (p = ns)

Growing Acceptance of Living Donation As this new technology is explained to potential donors and recipients, we have found a dramatic increase in the willingness among the friends and families to consider the living kidney donation option. We have developed a formal teaching program to educate recipients and potential donors about the benefits of living kidney donation ⁽⁸⁾. Our formal education program, combined with the availability of this new laparoscopic technology, has markedly increased living donor volunteer rates. Generally, when patients first develop ESRD, they experience tremendous stress, both physically and emotionally. Many recipients reject the notion of living kidney donation initially since they equate asking another person to donate with asking them to assume this burden of chronic illness. Knowing that their donor may donate a kidney and potentially return home in just one day and return to work after an average of just two weeks has markedly increased patients’ willingness to accept a kidney donated by a friend or relative. Additionally potential donors have embraced the value of laparoscopic kidney donation because those with small children may return to active parenting much sooner. Although most patients remain in the hospital overnight after laparoscopic donor nephrectomy, some have chosen to go home after a few hours in the recovery room. Many patients have returned to work in one week and one has become pregnant less than one month after kidney donation. Since we began this program, the fraction of new evaluations who eventually identify a living donor has increased to 55%.

As information about this technology has spread, we have increasingly been referred patients who live a great distance from Baltimore. We have developed a streamlined protocol to evaluate potential donors and recipients without requiring their travel to Baltimore in advance of the surgery. Working in collaboration with primary care physicians to complete the donor evaluation locally and with referring nephrologists to finalize the recipient evaluation, we have successfully transplanted many patients residing more than 1,000 miles from Baltimore. Living kidney transplants, in nearly every case (97%), function immediately. We have eliminated the use of antibody induction therapy for the living donor transplant cases because of the improvements in currently available oral maintenance immunosuppressive agents. Elimination of antibody induction and immediate graft function markedly hastens the patients’ physiologic recovery. Thus, we have developed for non-diabetic recipients under age 60, a fast-track 2-day length of stay ⁽⁹⁾. After discharge, the patients move to an adjacent hotel. For an additional 5 days they return daily to our infusion center for blood tests, tacrolimus levels and wound checks. After a total of seven days, the patient is able to return home and resume follow-up care with their local nephrologist.

Minimizing ESRD Costs The ideal model of ESRD care would involve minimal use of inpatient services and dialysis related costs. Some of the major costs of ESRD care are those arising from dialysis access surgery and its complications, thrombosis and infection of arteriovenous grafts, and malfunction and infections of peritoneal dialysis catheters. Access surgery and its complications are the leading cause of hospital admissions for ESRD patients. The most cost-effective integrated disease management model should include transition of patients with impending ESRD to a living donor transplant. This has the advantage of avoiding costly dialysis access surgery and the cost of dialysis. Furthermore, this strategy avoids the period of disability associated with ESRD. Thus, a patient with advancing azotemia and impending ESRD should be referred for transplant evaluation and, if possible, receive a living donor transplant timed to maximize the longest function of the native kidneys but avoiding the downward spiral of congestive heart failure, anemia and gastritis experienced by patients with advanced azotemia. While living donor transplantation is the most cost-effective strategy to manage ESRD patients, the availability of the laparoscopic technology increases the likelihood that a living donor will be identified and minimizes the cost of performing the transplant. The small additional cost of travel to the University of Maryland is more than offset by the significant savings experienced by the short length of stay and increased chance of identifying a living donor at a center with a large experience using the laparoscopic technology.

Conclusion In 1996, there were 73,091 new patients with ESRD in the United States, bringing the total to 283,932 patients with ESRD. Of those 73,091 new patients, 39,158 were under age 65. Assuming that two-thirds of those new patients that are under age 45 (13,751 patients) and one third of those between 45 and 64 years of age (25,704 patients) are transplant candidates, there were 22,254 new transplant candidates in the United States in 1996. We estimate that approximately half of potential recipients could identify a living donor. Thus, it is possible that as many as 11,127 living donor transplants are possible in the United States, yearly. Hopefully the use of this new technology will facilitate increased reliance on living donor kidney transplantation, in turn easing the burden on the cadaver kidney supply.

Laparoscopic living donor nephrectomy, like its counterpart laparoscopic cholecystectomy, represents an important advance in surgical technology. It has significantly eased the discomfort and time required to donate a kidney. The procedure is technically demanding and should only be pursued by surgeons with advanced laparoscopic skills. As this technology encourages increased rates of living kidney donation, significant savings for ESRD medical care and increased worker productivity will be realized by avoiding the disability associated with ESRD.

References

1. United Network for Organ Sharing. Critical Data. www.unos.org.
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9. Schweitzer EJ, Wiland A, Evans D, et al. The shrinking renal replacement therapy "break-even" point. Transplantation 1998; 66: 1702-1708.

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