ORIGINAL

 

Renal transplantation with living donors. A critical analysis of surgical procedures based on 40 years of experience

 

Vela-Navarrete R, Rodríguez Miñón-Cifuentes JL, Calahorra-Fernández J, González-Enguita C, Cabrera J, García-Cardoso JV, Castillon-Vela I, Plaza JJ

 

Departamento de Urología y Unidad de Trasplante Renal. Servicio de Nefrología. Fundación Jiménez Díaz. Universidad Autónoma de Madrid. Madrid (Spain)

 

Actas Urol Esp. 2008;32(10):989-994

 

ABSTRACT

RENAL TRANSPLANTATION WITH LIVING DONORS. A CRITICAL ANALYSIS OF SURGICAL PROCEDURES BASED ON 40 YEARS OF EXPERIENCE

Introduction: Absolute priorities in a live donor kidney transplant (LDKT) program are donor safety and optimal kidney anatomical and functional preservation. Reduced donor morbidities over both the short and long term are important objectives. Excellent technical grafting is a must, as are the strategies employed to this effect. We have reviewed the experience of our global LDKT program (40 years, with 243 donors) to determine whether these requirements have been met, or whether a change involving the adoption of new surgical procedures is recommendable.

Material and methods: Between 1968-2008, a total of 243 nephrectomies and grafts were performed, comprising a reduced number per year (a dead donor program has been running simultaneously since 1964). For the nephrectomies a Turner-Warrick approach was initially used, and starting in 1973 a mini-incisional, anterior, extraperitoneal approach of approximately 10 cm in length was adopted. The right kidney was removed in 75% of the cases, and the right iliac area was used for the implant in 85%. In adjacent operating rooms, one team performs the nephrectomy while the other prepares and dissects the grafting vessels. In most cases the same senior surgeon performed both operations, i.e., nephrectomy and implant. Peroperative and postoperative complications were evaluated by the supervising urologists and nephrologists.

Results: No donor deaths, organ losses or major complications in the donors have been documented. Minor complications such as intestinal paresis, wound infection, and persistent incisional pain were common. The mini-incisional abdominal approach reduced postoperative pain and hospital stay (4 days). At long term, no cases of incisional hernia or abdominal paresis have been documented. Simultaneous work reduces ischemia time (30-45 s warm: 30-45 min cold) and operating room occupation (patient preparation plus anesthesia plus operation) is estimated to be 90-120 min for nephrectomy and 120-160 for grafting. Supervision by the senior surgeon in both procedures facilitates vessel selection for grafting.

Conclusions: No reasons have been found to convert our current nephrectomy procedure to laparoscopic surgery or to modify the applied surgical strategy. Superior safety of open surgery for donors and organs is confirmed. Pain and recovery time are reduced in laparoscopic surgery but not as much when compared with the mini-incisional approach. Open surgery allows optimal anatomical and functional organ extraction, thereby favoring the quality of the implant. As numbers matter in laparoscopic surgery, open nephrectomy is recommended for reduced LDKT programs.

Keywords: Renal transplantation. Live donors. Nephrectomy. Surgical strategies.

 

The success and widespread adoption of laparoscopic techniques for live donor kidney transplantation (LDKT) have obliged those surgical teams that have used open nephrectomy for years to reconsider the persistent validity of their procedures, and to evaluate the need to incorporate these new techniques to their daily practice. In centers with limited LDKT programs, comparative studies are not possible. On the other hand, open nephrectomy has numerous variants, in the same way as laparoscopic surgery, and only the experience of a given center would be valid for comparing the benefits and inconveniences of both procedures. The existing literature on live donor laparoscopic surgery clearly indicates the existence of cosmetic benefits, reduced analgesic use and rapid donor recovery, as well as a formidable media impact1-3. However, laparoscopic surgery also poses a series of particularities that require careful assessment. In effect, the technique shares with open surgery the need for an incision for organ extraction. It involves technical difficulties that can only be resolved with numerically important programs, involving a prolonged learning curve4. On the other hand, there are complications specific of the technique5-10, and the necessary rigor has been lacking in divulgating these complications – particularly those not acceptable in the context of a LDKT program, such as donor or organ loss11. Likewise, emphasis is not placed on the potential difficulties of laparoscopic extraction in relation to ulterior organ implantation, though the frequent extraction of the left kidney (due to its longer vein segment) explicitly alerts to the existence of other difficulties or inconveniences for securing optimum organ anatomy. Consequently, it is an ethical imperative to analyze the priority references of a LDKT program maintained over the course of many years, before converting to novel and attractive procedures that are even considered to be essential or inexcusable12. The basic references chosen for this comparison of techniques, in the context of a rigorous examination of our long 40 years of experience, have been the following: donor morbidity and mortality; organ loss; and graft anatomical and functional quality after extraction (decapsulation, vessel damage, vessel quality and length, ischemia time). The influence of our surgical strategy in relation to technical facilities for renal grafting and operating room occupation also has been examined. These data in turn have been compared with the information most recently published by those groups that predominantly perform laparoscopic nephrectomy13-15.

 

Material and methods

Our kidney transplant program started in 1964 with dead donor organs, and in 1968 with live donor grafts. Between June 1968 and June 2008, we performed a total of 243 LDKT (a reduced number of transplants per year). The nephrectomy procedure used in the period 1968-1972 was the supracostal approach proposed by Turner-Warrick, while starting in 1972 an anterior extraperitoneal subcostal mini-incision technique was adopted. The technical particularities of this mini-incisional nephrectomy can be found in the videos of TTMED Urology (ttmed.com/urology/surgicalvideolibrary)16. Conventional lumbotomy with resection of the last rib has never been practiced. The right kidney was harvested in 78% of the cases, with implantation in the right iliac fossa in 85% of the patients. Donor and recipient surgeries were performed simultaneously in two adjacent operating rooms by two different teams – a single surgeon supervising both procedures (i.e., nephrectomy and graft implantation). The per- and postoperative complications potentially related to nephrectomy, or of a different nature, were evaluated by the urology and nephrology teams.

 

Discussion

Open nephrectomy variants

The term “open nephrectomy” comprises a broad range of approaches. In 1968, the few centers that performed LDKT usually employed a conventional lumbotomy involving resection of the last rib17-19.

We began with the approach proposed by Turner-Warrick20-21, which offered two clear advantages over the abovementioned technique: rib resection was obviated, and frequent damage to the intercostal nerve (resulting in abdominal paresis) was avoided. Nevertheless, the risk of pleural damage (with the resulting pneumothorax) persisted, as did potential damage to the intercostal artery - with the risk of cutaneous or even more serious hematoma formation. We soon found that a more medial incision from the tip of the last rib extended horizontally to the fascia of the rectus abdominis muscle offered the same benefits as the supracostal technique, though with greater surgical facilities, since the abdominal structures are easier to displace to one side or the other compared with maneuvering within the limits imposed by the intercostal space. The length of the incision was gradually shortened to ten centimeters, and even to eight centimeters in thin males and females, while a slightly larger incision was used in muscular, obese or elderly donors. Among the latter, the vascular pedicle required more careful handling to avoid tension and tearing of the intima, which is more fragile than in younger individuals. The right side, due to the lower position of the kidney and its greater mobility (particularly in women), offers greater dissection ease than on the left side22. It is interesting to note that some laparoscopic surgeons use this type of incision for final organ extraction instead of the more commonly proposed hypogastric midline or Pfannenstiel incision. The same incision is also used for manually-assisted laparoscopic surgery23,24. The abdominal muscles are sectioned, and in no case have we attempted muscle prophylactic surgery. Some series of pararectal nephrectomy similar to the incision used in renal autotransplantation did not yield satisfactory results25.

 

Morbidity and mortality of mini-incisional and laparoscopic nephrectomy

We have recorded no mortality or major operative morbidity in our series. There were two serious clinical complications: an allergic reaction to ampicillin, and another reaction secondary to excessively rapid protamine injection, in the early period when before vascular clamping the patients received 1 mg/kg b.w. of heparin together with an osmotic diuretic. We also documented one pneumothorax and one case of bleeding requiring transfusion and immediate reintervention, possibly attributable to incorrect ligation of the gonadal vein. All these complications have been documented in relation to open surgery26. Up until 1991, a total of 11 live donor deaths were recorded27-29, though since then there have been no further fatalities. However, according to the most recent literature review11, the deaths and major complications associated with laparoscopic surgery appear to be under-documented. There have been 12 reported deaths and numerous complications specifically attributable to the laparoscopic technique, such as incorrect vascular clamping, with bleeding and open reintervention in the immediate postoperative period; conversions from laparoscopy to open surgery; gas embolization; immediate or late intestinal perforation secondary to thermal damage; venous thrombosis; and other problems11,26,30. The number and seriousness of the complications has led to demands for an official registry of LDKT programs, with the consequent control and opportune and obligate accreditation of those centers that adopt programs of this kind11-31.

 

Loss of organs and anatomical and functional graft quality

The published laparoscopic series have documented the loss of 18 kidneys in which parenchymal rupture or vascular damage made organ quality inadequate for grafting11. The results of our series and of the literature confirm the absence of complications of this kind in open surgery. Other problems that limit the anatomical quality of the organ are related to decapsulation, contusion and subcapsular hematomas, and to the length and caliber of the artery and vein, as well as to potential intimal damage secondary to tension or forced organ manipulation during extraction. One of the arguments for more frequent use of the left kidney in laparoscopic surgery is the shortness of the right renal vein32. In mini-incisional surgery, the available surgical space makes it easy to precisely identify the junction of the renal vein with the cava and to place a Satinsky clamp, if needed, with sectioning of the vein in a more distal position – thereby obviating the above mentioned inconvenience. In our series, the shortness of the right renal vein was never a reason for ruling out a right nephrectomy; indeed, as has been mentioned, this organ was extracted in 78% of the cases.

The functional quality of the organ is fundamentally tied to the care taken during extraction, the warm and cold ischemia times, and the quality of perfusion prior to implantation. In our series it was common practice up until the mid-1980s to heparinize the patient (1 mg/kg b.w.) and add an osmotic diuretic before ureteral sectioning and vascular clamping. The extraction procedure started with ureteral sectioning, and successive clamping of the artery and vein was not carried out until excellent diuresis through the sectioned ureter was confirmed. Since our commented incident with protamine injection, improved patient hydration was decided, with no further measures. In our series, the warm ischemia time was estimated to be 45-75 seconds, and was followed by immediate graft perfusion in a cold Euro-Collins organ bath until the time of implantation. The cold ischemia time was variable and depended upon the synchronization of the two surgical teams, the difficulty of exposure of the iliac vessels already prepared by the other team, and the difficulties of vascular anastomosis – though the estimation was 30-45 minutes. It is suspected that late function of the implanted organ is directly related to the warm ischemia time, though in our series the most common cause of delay was conditioned by the nephrotoxic effect of cyclosporine22.

 

Postoperative pain, analgesic use and return to work

Subcostal mini-incisional surgery is much less painful for the patient than a conventional lumbotomy. With the current anesthetic protocol, pain control is secured during the first 24 hours by pump infusion, though this also increases the incidence of ileus. Most of our patients could leave the hospital by the fourth day, though hospital stay is not a valid reference parameter in our series, since our donors are typically patient relatives, who prefer to spend the subsequent days with the graft recipient. It is reasonable to assume that a small midline incision is less painful, and this therefore can be taken to represent the great benefit afforded by laparoscopic surgery. However, this benefit for the patient, which has an enormous media or publicity impact, is not much greater than that afforded by mini-incisional surgery, and should not serve as sole criterion for adopting a laparoscopic LDKT program.

 

Effect of organ extraction upon performance and quality of vascular anastomosis

A well-extracted organ, with full preservation of the anatomical structures (capsule, artery, vein, ureter), which are well identified and better exposed during cold perfusion and secured through surgical manipulation avoiding artery tension or intimal tearing, with clean linear (not irregular) vascular sectioning, will facilitate selection of the vessels ideally suited for venous (distal cava, common iliac vein well freed from its collaterals to allow it to be displaced towards the renal vein rather than the other way around) and arterial anastomosis (common iliac or hypogastric artery) – without redundancy or tensions, and securing the precision needed for faster and well sealed suturing. An organ extracted with difficulty producing decapsulation, vascular damage or very short vessel segments not only creates problems for suturing but moreover prolongs the surgical and warm ischemia times.

 

Two surgical teams in adjacent operating rooms, with a single supervisor

In our experience, this approach facilitates the different surgical and technical aspects of LDKT. At the time of vascular pedicle section, the surgeon already notes certain anatomical data that will condition the quality of the vascular anastomoses: number of arterial vessels (rarely different from the information afforded by the current imaging techniques) and veins (more frequent variations); their caliber; divisions proximal or distal to the point of sectioning; length of the artery and vein – with particular reference to the length of the right renal vein – and other parameters. The easy mobilization and even exteriorization of the organ afforded by the mini-incisional surgical approach, without the need for sudden or sustained tension, facilitates vessel sectioning closer to their origin – thereby obviating problems of vessel length. On the other hand, the renal sinus can be kept at a safe distance, preserving adipose tissue and vessels in this zone, as well as the ureter – including the gonadal vein, where applicable. In sum, the surgeon enters the operating room where organ implantation is to be performed with the precise anatomical information needed to quickly select the appropriate vessels for anastomosis. These vessels moreover have probably already been well dissected by the second surgical team, on the basis of the previous comments and reports received. These considerations all contribute to considerably reduce the operating time.

However, this surgical strategy also allows the reduction of operating room occupation, which is often far longer than indicated only by the surgical time (anesthesia time and patient preparation, plus skin-to-skin surgery) – thereby avoiding interferences with the general surgical program of the Service. Our estimated operating room occupation times are 120 minutes for nephrectomy and 180 minutes for implantation. In this way the surgery programmed for the day can continue without problems – this being a positive aspect when operating room occupation has strict economical and functional connotations, as is the current case. In the case of laparoscopic surgery, our sources refer to surgical time (not operating room occupation), and are moreover estimated for nephrectomy (in the best of hands) – with figures that exceed 180 minutes33.

 

CONCLUSIONS

The analysis of the complications registered in 243 LDKT procedures performed over a period of 40 years confirms the fundamental and inexcusable priorities of a well conducted LDKT program: we have documented no deaths, organ losses or major complications derived from nephrectomy. The mini-incisional approach reduces patient pain and time to recovery, as well as the esthetic impact of the operation, to levels similar to those associated with laparoscopic nephrectomy. Simultaneous nephrectomy-implantation by two different surgical teams with a single supervisor facilitates the choice of vessels for implantation, and reduces the operating room and personnel occupation times.

This comparative analysis between our surgical protocol and laparoscopic nephrectomy does not identify any major arguments in favor of replacing our current procedure with the laparoscopic approach. Indeed, it is seen that in the context of limited or recently introduced programs, open nephrectomy offers greater safety than laparoscopy, which should be reserved for centers that operate upon many patients every year, and that have established expertise in laparoscopic surgery. On the other hand, it does not seem appropriate to postpone the introduction of a LDKT program on the argument that the laparoscopic nephrectomy technique has not yet been mastered, if the mini-incisional technique can be used. Lastly, the laparoscopic surgeon also must be skilled in open surgery, since the operative complications of laparoscopy often require conversion to the open technique.

 

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Correspondence author: Dr. R. Vela Navarrete

Departamento de Urología y Unidad de Trasplante renal

Fundación Jiménez Díaz

Avda. de los Reyes Católicos, 2 - 28040 Madrid

Tel.: 915 504 800

Autonr e-mail: rvela@fjd.es

Paper information: Original – Renal transplant

Manuscript received: september 2008

Manuscript accepted: october 2008