Right-sided laparoscopic live-donor nephrectomy: Is reluctance still justified?

Abstract

Background.  

Laparoscopic donor nephrectomy (LDN) of the right kidney is performed with great reluctance because of the shorter renal vein and possible increased incidence of venous thrombosis.

Methods.  

In this retrospective, clinical study, right LDN and left LDN were compared. Between December 1997 and May 2001, 101 LDN were performed. Seventy-three (72%) right LDN were compared with 28 (28%) left LDN for clinical characteristics, operative data, and graft function.

Results.  

There were no significant differences between the two groups regarding conversion rate, complications, hospital stay, thrombosis, graft function, and graft survival. Operating time was significantly shorter in the right LDN group (218 vs. 280 min).

Conclusion.  

In this study, right LDN was not associated with a higher number of complications, conversions, or incidence of venous thrombosis compared with the left LDN. Thus, reluctance toward right LDN is not justified, and therefore, right LDN should not be avoided.

With considerably decreased morbidity and favorable graft function, laparoscopic donor nephrectomy (LDN) is progressively accepted (¹). However, controversy persists about whether procurement of the right kidney can be done successfully by the laparoscopic approach. Most surgeons performing laparoscopic live-donor nephrectomy prefer the left kidney because of a longer renal vein. Mandal et al. (²) observed that right kidneys are at risk for allograft thrombosis, presumably because of the short renal vein. Exclusion of donors with arterial or venous anomalies on the left side, because of a reluctance toward right LDN (RLDN), would deprive a significant proportion of donors of the benefits associated with laparoscopy.

We prefer right-sided donor nephrectomy and find RLDN to be less complicated because of the lack of side branches of the renal vein. In this article, we compare left LDN (LLDN) and RLDN performed at our hospital.

Patient Selection

LDN was performed in 101 patients from December 1997 through May 2001. Patient data were retrospectively collected from medical records. Operative and postoperative data included blood loss, warm ischemia time, operating time and postoperative complications (influencing the postoperative course), and length of postoperative hospitalization (starting the first day after operation). Perioperative urine production (directly after declamping of the renal vessels), mean serum creatinine levels, and graft survival were compared for all recipients. All potential donors were subjected to routine examination, renography, Seldinger angiography, percutaneous ultrasonography, and magnetic resonance imaging angiography. In case of normal function of both kidneys and assessment of one vein and artery on both sides, the right kidney was preferred for LDN. All renal transplantations were performed by the same transplant surgeon (J.N.M.IJ.).

Operative Technique

In eight cases, a pneumatic sleeve was used to allow performance of hand-assisted nephrectomy. LDN was performed as previously reported (^3,4). In recipients, the iliac vein was circumferentially mobilized and elevated slightly to enable implantation of the renal vein. No grafts or other special techniques were used to extend the renal vessels.

Statistical Analysis

Statistical analysis was performed using the SPSS 9.0 (SPSS Inc., Chicago, IL) statistical software package. Comparisons of continuous data between right and left donor nephrectomy groups were performed using the Mann-Whitney U test. Categorical data were reported as absolute numbers of patients, percentages, or both and were compared using the chi-square test. Analysis of serum creatinine values in the recipient was performed by mixed-model analysis of variance after logarithmic transformation. A P value of less than 0.05 was considered to be statistically significant.

Demographic characteristics such as age, gender, body mass index, and origin (living related or unrelated) were comparable for both groups. In eight cases (6%), a transperitoneal hand-assisted approach was used: six on the right side (8%) and two on the left side (7%). LDN was initially performed on the left side. After five LLDN, the first RLDN was performed. Operative characteristics for RLDN and LLDN are shown in Table 1. Overall, mean operative time from skin incision to closure was significantly longer for LLDN (P <0.001). Median estimated blood loss, mean warm ischemia time, number of conversions, and length of hospital stay were comparable for both groups. The number of postoperative complications, which resulted in additional therapy, was comparable for both groups.

Table 1: Operative characteristics

The number of recipients with graft diuresis directly after declamping of the renal vessels is shown in Table 2 and was not significantly different between the two groups. In the postoperative period, 98% of the grafts were producing urine. Two recipients (RLDN) required postoperative hemodialysis.

Table 2: Graft function and survival

There was one patient (1%) with an arterial thrombosis of the graft. This consisted of a kidney that was procured by an RLDN and had developed the thrombosis 1 day postoperatively because of a problem of the arterial anastomosis, possibly an intima lesion. Laparoscopic procurement of this kidney graft, however, was uneventful.

The number of ureter complications such as obstruction or urine leakage was not significantly different and decreased with time. The difference between the number of grafts lost between RLDN and LLDN was not significant; one graft developed an arterial thrombosis during implantation, and three other recipients had graft loss for which no technical failure could be accounted for.

Mean serum creatinine of the recipient after logarithmic transformation is shown in Figure 1. Statistical analysis does not show any significant differences between the two groups after correction for preoperative serum creatinine (P =0.15).

Figure 1: Geometric means of serum creatinine (standard error) according to postoperative day and left or right laparoscopic donor nephrectomy (day 0 represents preoperative values). ⋄, RLDN; □, LLDN.

To our knowledge, there have been no reports comparing large groups of RLDN to LLDN. However, the reluctance of transplant surgeons remains, excluding donors of laparoscopy when eligible to donate their right kidney.

In our study, the operating time for LLDN was 60 min longer than for RLDN. The RLDN takes 218 min, which is comparable with other reported studies (^5–7). LLDN operating time, however, is longer than reported in most studies. The difference of 60 min can be explained by the fact that we initiated the LDN on the left side. Also, the total number of RLDN can reduce the learning curve and, subsequently, operating time. Recent operating time for left kidneys, performed when the anatomy of the right kidney precludes its use, is now comparable to that of RLDN. RLDN did not result in additional perioperative or postoperative complications.

In all RLDNs, adequate length of renal vessels could be obtained. In addition, no problems occurred when performing the venous anastomosis. In contrast to other reported incidences of venous thrombosis in the right kidney (^2,7,8), we found no venous thrombosis. Mean warm ischemia time was comparable for both groups but longer than reported in other studies (^9,10). Considering graft function in recipients, there were no significant differences between the RLDN and LLDN groups regarding urine production subsequent to reperfusion, serum creatinine, and graft survival. The higher number of ureter problems of LLDN grafts can be explained by the learning curve. Modification of dissection of the ureter, leaving the periureteral tissue, resulted in a reduction in the number of ureteral complications.

We acknowledge the fact that LDN is not accepted by all surgeons as an alternative to open donor nephrectomy because LDN is associated with longer operating and warm ischemia time, a learning curve, and a possible increase in ureteral complications. In this study there were no differences between RLDN and LLDN regarding conversions, complications, thrombosis, graft function, and graft survival. We conclude that right-sided laparoscopic kidney donation and subsequent implantation is safe, with a low incidence of venous thrombosis. Therefore, reluctance toward right-sided donor nephrectomy is not justified and RLDN should not be avoided. A change in attitude toward RLDN would enable donors suitable for right kidney donation to benefit from the advantages associated with laparoscopy.