Essay 11 The Living Organ Donor Laparoscopic Donor Nephrectomy

Joseph R. Leventhal

There is a steadily increasing disparity between cadaver donor organ supply and demand. UNOS registry data indicate the number of patients on waiting lists for renal transplants has almost tripled from 13943 to 53044 between 1988 and 2001, while the number of kidney transplants being performed using cadaver donors increased by only 14%, from 7208 to 8203, during the same period.1 As one would expect, the waiting time for cadaver organs has also increased; between 1992 and 1999 the mean waiting period for a kidney increased from 624 to 1144 days. Consequently, living donors have assumed increasing importance in renal transplantation. Living donors accounted for 5949 (42%) of the 11458 kidney alone transplants reported to UNOS in 2001, more than three times the 1809 reported in 1988.2

There are several advantages to living donor renal transplantation. The use of living donors is associated with improved patient and graft survival. UNOS registry reports for 1995-96 live donor one-year graft and patient survival rates of 91.2% and 97.2% respectively, compared with one-year cadaveric donor graft and patient survival rates of 80.6% and 93.3%. At three years graft and patient survival rates for living donor transplants are 83.9% and 94.3% respectively, while cadaveric organs have fallen to 69% and 87.4%.3 Improved graft survival has been observed for recipients of both living-related and living-unrelated (i.e., so-called emotionally related) allografts. Living donor transplantation helps avoid the prolonged waiting times for a cadaveric organ, and offers the ability to plan such a transplant in advance. Other advantages of live donor renal transplantation include a decreased incidence of delayed graft function and a shorter recipient hospitalization. Furthermore, the elective nature of the live donor procedure allows for optimization of the recipient's medical condition before surgery.

Live renal donation has been performed since the 1950s. Longitudinal studies of patients undergoing unilateral nephrectomy have not shown them to have an increased incidence of renal failure or diseases attributable to having donated a kidney.4-6 Currently, live renal donation is most commonly performed via a retro-peritoneal flank incision. The operation is safe, with reported mortality rates of 0.03-0.06%.7-9 However, this extraperitoneal flank approach is not without minor morbidity. Wound complications including infection and hernia occur in 9% of patients.10 Pneumothorax requiring pleural space drainage may occur. Chronic incisional pain and so-called wound diastasis has been reported in up to 25% of patients.11,12 Patients undergoing a large flank incision have a duration of hospitalization averaging 4-5 days.9,13 Adequate pain control often requires the use of epidural analgesics and the prolonged use of parenteral narcotics. There is a delayed return to normal activities for as long as 6-8 weeks after surgery. Finally, potential donors commonly express concerns regarding the cosmesis of the large flank incision.

The limitations of the extraperitoneal approach to donor nephrectomy, combined with advances in techniques of laparoscopic solid organ surgery, have provided the impetus for development of a minimally invasive approach to live renal donation. Potential benefits of a laparoscopic donor procedure include less postoperative pain, shorter hospitalization, less incisional morbidity, more rapid return to normal activity, and improved cosmesis. Moreover, the potential advantages of a minimally invasive operation could lead to increased acceptance of the donor operation and expansion of the pool of potential kidney donors.

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