Laparoscopic Donor Nephrectomy – Evolution of Technique and Donor Outcomes

Background: The interest in living donor transplantation has been driven by the continuing fall in available cadaveric organs for transplantation. During the last five years there has been a substantial growth in living donor kidney transplantation in the UK but there is still considerable room for expansion in comparison with activity in Scandinavia and the USA. Traditionally kidneys have been harvested from donors via a loin incision with partial resection of the twelfth rib, which placed a considerable burden on the donors in terms of post-operative pain, absence from work, and morbidity. Laparoscopic live donor nephrectomy developed in 1995, promised to reduce these burdens on the donors and reduce some of the disincentives to kidney donation. Several comparative studies have shown this new technique to hold promise in terms of less pain and faster inpatient and outpatient recovery. However there were some concerns in procuring the kidneys with this technique, namely, increase in warm ischaemia times and the quality of graft. Methods: This was addressed in the setting of a prospective randomised controlled trial of laparoscopic versus limited incision live donor nephrectomy. Live kidney donors were randomly assigned in a 2:1 ratio to laparoscopic (LDN n=56) or short incision open donor nephrectomy (ODN n=28). Quality of life was assessed using the Short-Form 36 questionnaire. Postoperative analgesia was by morphine PCAS. Pain scores were recorded using visual analogue and verbal response scales. Donor convalescence was self-reported using a prospective diary system. Our study was the first randomised control trial to present live donor transplant recipient data at a minimum follow-up of four years. There were no differences in renal function or allograft survival for kidneys removed by LDN (laparoscopic donor nephrectomy) or ODN (open donor nephrectomy) at this point. The other aspect of this study is that this is the first study to compare respiratory function after LDN and ODN. During the evolution of LDN, the vessels are secured with various methods (endoclips, polymer clips and stapling device). These methods were compared with respect to complications and maximum length of vessels obtained. Technical modifications and improvement of techniques especially when comparing right and left donor nephrectomy are described. Results: Postoperative morphine requirement was lower in the LDN group [median (range) 59 (6-136) vs ODN 90 (35-312)mg; p=0.01]. Donors in the LDN group returned to normal activities more quickly compared to the ODN group [median (range) days to: driving 21 (7- 70) vs 28 (7-70); p=0.05), exercise 28 (7-77) vs 42 (14-84); p=0.001, return to work 42 (14- 84) vs 66.5 (14-112); p=0.001]. When compared to the pre-operative baseline, norm adjusted physical component scores (PCS) fell significantly at 6 weeks in both the LDN (mean±SD 46.3±8.9 vs 55±6.9; p=0.001) and ODN groups (44.0±7.9 vs 52.7±9.0; p=0.008). Nonetheless, the bodily pain domain score of PCS was significantly better in the LDN group (57.5 to 49.5; p=0.0001). The mental component score also fell in the ODN group (48±10.2 vs 53.5±7.6; p=0.02). In contrast, there was no fall in the mental component score after LDN (mean±SD 51.9±7.2 vs 53.8±6.4; p=0.29). Conclusions: In conclusion, our trial has shown that laparoscopic donor nephrectomy removes some of the disincentives to live kidney donation. This can be achieved without any additional morbidity in the recipient. This study provides high-level evidence to show that laparoscopic donor nephrectomy improves recovery back to the normal activities of daily life, is less painful than open surgery and improves the mental component of quality of life.