|Year : 2022 | Volume
| Issue : 4 | Page : 384-389
Laparoscopic versus open donor nephrectomy: Which is better for vessel length preservation – A randomized clinical study
Nripesh Sadasukhi, Ketul Patel, T Chand Sadasukhi, Manish Gupta, HL Gupta, Ashish Sharma, Sandeep Malik
Department of Urology and Renal Transplant, Mahatma Gandhi Medical College, Jaipur, Rajasthan, India
|Date of Submission||13-Sep-2021|
|Date of Acceptance||23-Oct-2022|
|Date of Web Publication||30-Dec-2022|
Dr. Nripesh Sadasukhi
Mahatma Gandhi Medical College, Jaipur - 302 022, Rajasthan
Source of Support: None, Conflict of Interest: None
Objectives: The objective of this study is to report the difference in loss of length of the renal artery and vein between an open and laparoscopic renal donor nephrectomy. Methodology: We take 50 open and 50 laparoscopic renal donors for comparison of loss of length of the renal artery and vein. This is a single-blinded study. All patients considered for left donor nephrectomy with a single renal artery and vein are included in the study. Patients considered for right donor nephrectomy, abnormal renal artery and vein anatomy, atherosclerotic renal artery or vein are excluded from the study. Results: In our study, we take 50 open renal donor nephrectomies and 50 laparoscopic renal donor nephrectomies from a total of 115 renal donor nephrectomies from December 2020 to April 2021. For removing bias, we take only the left side nephrectomy which has a single artery and vein. We used study randomizer software which uses cluster randomization which decides case should be operated on either open or laparoscopy. Conclusions: In our study, the difference between preoperative and intraoperative artery length for open donor nephrectomy (ODN) was 0.3 cm, and vein length was 2.3 cm and the difference between preoperative and intraoperative artery length for laparoscopic donor nephrectomy (LDN) was 0.5 cm, and vein length was 2.5 cm. The difference between renal artery length in open versus LDN is 0.2 cm, and the difference between renal vein length in ODN versus LDN is 0.2 cm, which is statistically insignificant.
Keywords: Laparoscopic donor nephrectomy, open donor nephrectomy, renal artery, renal transplant, renal vein
|How to cite this article:|
Sadasukhi N, Patel K, Sadasukhi T C, Gupta M, Gupta H L, Sharma A, Malik S. Laparoscopic versus open donor nephrectomy: Which is better for vessel length preservation – A randomized clinical study. Indian J Transplant 2022;16:384-9
|How to cite this URL:|
Sadasukhi N, Patel K, Sadasukhi T C, Gupta M, Gupta H L, Sharma A, Malik S. Laparoscopic versus open donor nephrectomy: Which is better for vessel length preservation – A randomized clinical study. Indian J Transplant [serial online] 2022 [cited 2023 Feb 5];16:384-9. Available from: https://www.ijtonline.in/text.asp?2022/16/4/384/364628
| Introduction|| |
Kidney transplantation is widely accepted as the best form of renal replacement therapy but has always been restricted by a shortage of suitable cadaveric organs. One response to this problem has been to increase transplantation using living donors. Live donors yield kidneys of the highest quality and it is not surprising that this type of kidney transplantation yields the best allograft survival results. The majority of laparoscopic living donor kidneys are procured from the left side due to the longer renal vein and improved transplantation. Since its first description in 1995, laparoscopic donor nephrectomy (LDN) has gained widespread acceptance. LDN is now the gold standard for graft harvesting.,, This study aimed to compare the donor renal artery and vein length loss in ODN versus LDN and if this difference would lead to any subjective or objective outcomes in recipient surgeon agreement or early graft function, respectively. To the best of our knowledge, it is the first of its kind study with randomization and modified single-blinded pattern being done to eliminate possible bias.
| Methodology|| |
After taking ethical committee clearance from the institute, informed consent was taken in accordance with the Helsinki Declaration of the subset of patients with the following inclusion/exclusion criteria.
- All patients are considered for left donor nephrectomy with single renal artery and vein.
- Patients considered for right donor nephrectomy
- Abnormal renal artery and vein anatomy
- Atherosclerotic renal artery
- A detailed preanesthetic checkup including history, physical examination, and routine investigations as guided by age was carried out in all patients
- Potential candidates for donor nephrectomy underwent a standard preoperative evaluation by the transplant division with high-resolution computed tomographic angiography to assess the vascular anatomy and the presence of two functional kidneys. Standard arteriography was performed for unequivocal results
- In this study, we used study randomizer software for cluster randomization to decide on the modality of donor nephrectomy (open or laparoscopy) a day before surgery for case-appropriate consent
- This is a single-blinded study modified in such a way that the single observer who is measuring the length of renal artery and vein from the cut end to the first segmental division on the bench does not know about the type of donor nephrectomy performed either open or laproscopic, which helps to remove bias.
Open donor nephrectomy
- The patient is placed in a full lateral decubitus position and through an extraperitoneal approach 11th rib cutting flank, the incision is given. Gonadal, adrenal, and lumbar veins draining into the left renal vein are clamped with silk 2–0 sutupak and cut. The renal artery is double secured with silk 1–0 sutupak and cut. The renal vein is then double secured with silk 2–0 sutupak and cut. The rest of the procedures are as per the standards. Renal artery and vein cut as close to their origin to get the maximum length.
Laparoscopic donor nephrectomy
- All the standard steps of the transperitoneal approach are followed. Gonadal, adrenal, and lumbar veins are secured with medium (Weck) hem-o-lok clips and cut. Double large (Weck) hem-o-lok clips are then applied on the renal artery and then cut. Double extra-large (Weck) hem-o-lok clips are then applied on renal vein and then cut. Through an inguinal muscle-splitting incision, the hand is inserted and the kidney was taken out. Renal artery and vein cut as close to their origin to get the maximum length
- Postnephrectomy/bench surgery
- The allograft is immersed immediately in iced saline solution and transferred to the recipient operating suite, where it is perfused with Euro-Collins solution before implantation
- At this point, after tying all the fat and lymphatics, in the LDN grafts clips on adrenal, lumbar, and gonadal veins are replaced with sutupak 3–0 ties to remove bias and to provide sufficient space for anastomosis
- The single observer then measures the length of the artery and vein stump. The observer remains the same in all the surgery
- The recipient operation is started soon after the donor operation to minimize the cold ischemia time of the allograft
- Recipient surgery.
Standard operating steps are followed for recipient surgery with graft placed in the right iliac fossa. Immediately after completion of the procedure, the surgeon is asked to fill the questionnaire to minimize recall bias.
- The following variables were calculated:
- Warm ischemia time: Time from artery clamped to perfusion with a cold solution
- Cold ischemia time: Time from perfusion to anastomoses done and recirculation started
- Operative time: Total operative time for transplant from inducing donor to extubating recipient
- Preoperative artery length: Length of artery from aorta to the first segmental division on contrast-enhanced computed tomography (CECT) renal angiography
- Preoperative vein length: Length of vein from vena cava to the first segmental division on CECT renal angiography
- Intraoperative or bench artery/vein length: Length of artery/vein from cut margin to the first segmental division measured on the bench after donor nephrectomy
- Postoperative urine output and serum creatinine
- Complications, if any.
| Methods|| |
- The following parameters were recorded during the study: CT renal angiography arterial blood vessel and vein length till first segmental division, warm ischemia time, cold ischemia time, total duration of surgery, and postoperative renal function
- In this study, we used a self-structured nonvalidated questionnaire [Annexure 1] consisting of five questions, with each question given 1 point so the maximum of 5 points and a minimum of 0 points. This questionnaire was filled by one recipient surgeon for removing bias, and scoring was done as follows:
- 0 – unacceptable; 1 – poor; 2 – weak; 3 – good; 4 – acceptable; and 5 – excellent.
Data are expressed as mean ± variance. Statistical analysis used the Student's t-test to assess group differences for continuous variables and statistical significance was defined as P < 0.05.
The extracted data were tabulated, and Prism GraphPad software (v6) (GraphPad Software 2365 Northside Dr.Suite 560 San Diego, CA 92108, California, USA) was used for comparative statistical analyses. We used unpaired t-tests for continuous variables and Fisher's exact tests for categorical variables. Differences between groups were considered statistically significant with a P < 0.05. For the questionnaire, the calculated mean was rounded off as per the mathematical rules of decimal with but 0.5 rounding off to the original number and ≥0.5 rounding off to the next counting number. This was in deep trouble qualitative assessment of means of questionnaire scores.
Declaration of patient consent
The patient consent has been taken for participation in the study and publication of clinical details and images. Patients understand that their names and initials would not be published, and all standard protocols will be followed to conceal their identity.
The ethical clearance was taken from MGUMST, Jaipur ethics committee on January 7, 2021, with IRB number NO. MGMCH/IEC/JPR/2021/211. All protocols were followed as per the Declaration of Helsinki.
| Results|| |
A total of 115 donor nephrectomies were done from December 2020 to April 2021 [Table 1] and [Figure 1]. Following the inclusion/exclusion criteria, 50 open and 50 laparoscopic donor nephrectomies were randomized [Table 1] and [Figure 1]. Following data were obtained and a consort diagram was made.
In the open group, the average length for arteria renalis in preoperative CECT renal angiography was 2.3 cm, and the average length for vena in preoperative CECT renal angiography was 5 cm. Intraoperative or bench artery and vein length were 2 cm and a pair of 2.7 cm, respectively. The difference between preoperative and intraoperative artery length was 0.3 cm, whereas the difference between preoperative and intraoperative vein length was 2.3 cm [Table 2].
In the laparoscopic group, the average length of artery and vein in preoperative CECT renal angiography was 2.4 cm and 5.3 cm, respectively. Intraoperative or bench artery and vein mean length was 1.9 cm and 2.8 cm. respectively. The difference between preoperative and intraoperative artery length was 0.5 cm, whereas the difference between preoperative and intraoperative vein length was 2.5 cm [Table 2].
The average warm ischemia time in the open group was 4 min, and in the laparoscopic group was 4.5 min. Average cold ischemia time was comparable in both groups. Postoperative urine output and serum creatinine showed no differences in both groups. The mean of questionnaire scores in both groups was four which shows that the recipient surgery was acceptable in both groups.
| Discussion|| |
This article is a comparison of LDN and open donor nephrectomy (ODN). We present the experience of a single academic center, starting with the advent of LDN and how it evolved over time to the point that it came to replace ODN as the main type of renal procurement surgery. A review of our results reveals that, although there was no statistical difference in the operating time between the two groups as a whole when looking at the last 50 cases of LDN with a left kidney and comparing them to the same number of ODN with a left kidney.
ODN is a very successful surgical procedure, and excellent results have been obtained for patient morbidity and mortality.,, For LDN to be considered a successful procedure, it must equal or exceed the gold standard procedure-ODN in two essential criteria: (1) outcome for the recipient and (2) outcome for the donor. A review of the outcome data comparing LDN to ODN reveals a paucity of randomized prospective studies.,,,,
The laparoscopic approach results in significant benefits to the donor. Various perioperative indices have been compared: blood loss, operative time, resumption of oral intake, parenteral narcotic use, and length of hospital stay. Various studies have shown that LDN results in less blood loss than ODN (122.3–266 mL and 393–408 mL, respectively)., It has also been demonstrated that oral intake can resume quickly after LDN; approximately 2 days earlier than after ODN. Parenteral narcotic use is lower for LDN compared with ODN, both in total dosage of morphine sulfate (LDN, 40 ± 33 mg; ODN 124 ± 88 mg; P < 0.001) and duration of use (LDN, 28.6 h; ODN, 60.1 h; P = 0.0001). The length of hospital stay is also shorter with LDN than with ODN (2.2–2.9 days and 4.5–5.5 days, respectively)., While taking longer to perform than ODN, the operative time required for LDN is reasonable (LDN, 226.3 min; ODN. 212.8 min). The increased operative time for the laparoscopic procedure adds to the total cost of operation without increasing morbidity. However, operation room time is again not relevant to many hospitals across the globe. Although the intraoperative blood loss is less in the laparoscopic group, the transfusion rate was similar in both groups. In the initial series, the conversion rate from laparoscopic to open approach ranged from 6% to 13%. With increasing experience, in the recent large series of the University of Maryland and the John Hopkins University, this had come down to 1.6%–1.8%., The most common cause for conversion was excessive bleeding; however, this complication did not lead to a statistically significant increase in the transfusion rates in the laparoscopic donor nephrectomy group. The reoperative rate in the laparoscopic donor nephrectomy group ranged from 1% to 8% for reasons such as hemorrhage, small bowel obstruction, internal hernia, and splenic injury.
The study has shown that LDN can be as efficacious and at least as safe as ODN, while at the same time offering the advantage of decreased length of stay and improved cosmesis, both of which can have a positive impact on potential living donors. We have seen the paramount importance of the learning curve, as well as the fact that this is an active process where lessons are continuously learned, making it necessary to make adjustments to ensure the safety of the donor and the recipient.
Conclusions and Limitations
In our study, the difference between preoperative and intraoperative artery length for ODN was 0.3 cm and vein length was 2.3 cm and the difference between preoperative and intraoperative artery length for LDN was 0.5 cm and vein length was 2.5 cm.
The difference between renal artery length in open versus laparoscopic donor nephrectomy is 0.2 cm, and the difference between renal vein length in open versus laparoscopic donor nephrectomy is 0.2 cm, which is statistically insignificant. The short-term outcome of graft function as evaluated with the surgeon's perspective on recipient surgery, as well as urine output and serum creatinine in the first 7 days, is similar in both arms. Hence, we conclude that laparoscopic donor nephrectomy is a safe and sound procedure with no significant artery and vein length loss with the added advantage of minimal access surgery.
Our study is a pilot study with a small number of patients. A multicentric study with a large number of patients is required for validation. Although it is a prospective randomized study, it lacks blinding as described by definition with patients not knowing the type of treatment which was not possible in the surgical scenario. The questionnaire we used was a nonvalidated one and hence needs more evaluation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Annexure|| |
Annexure 1: Nonvalidated questionnaire for recipient surgeon
1. Did you have any difficulty in perfusion of the artery or if required vein?
2. Did you have any difficulty in anastomosis of the vein?
3. Did you have any difficulty in anastomosis of the artery?
4. Did you have any difficulty in placing the kidney in the right iliac fossa?
5. How did you feel about the flow status of the artery and vein postanastomosis?
Yes – 0 point satisfactory – 1 point
No – 1 point Nonsatisfactory – 0 point
Total – 0 to 5 points
0 – unacceptable; 1 – poor; 2 – weak; 3 – good; 4 – acceptable; 5 – excellent.
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[Table 1], [Table 2]