Kidney transplantation in adults: Benefits and complications of minimally invasive live-donor nephrectomy

INTRODUCTION AND OVERVIEW — With the improvements in outcomes after kidney transplantation over the past decade, the limiting factor has continued to be the number of organs available for transplantation. Deceased-donor donation rates have remained relatively stable, and as of mid-2021, there were over 93,000 people on the United Network of Organ Sharing (UNOS) waiting list for a kidney transplant in the United States [1]. As a result, many programs have focused on trying to increase the rate of living-donor kidney transplantation.

Coincident with this renewed interest in living donation has been the development of laparoscopic-assisted donor nephrectomy [2-6]. This procedure has been adopted by the majority of transplant programs across the United States [7].

A significant number of studies have been published concerning the relative effectiveness of this technique, although many are not well designed [8-15]. A 2008 meta-analysis evaluated 73 studies that included 3751 and 2843 patients who had undergone laparoscopic surgery and open nephrectomy, respectively [14]. Compared with open nephrectomy, the laparoscopic surgery group had a significantly shorter hospital stay and a quicker return to work (by 1.48 days and 2.58 weeks, respectively). Both groups had similar rates of delayed allograft function and allograft loss. Overall, a consistent reported observation is that laparoscopic donor nephrectomy (LDN), compared with open donor nephrectomy, is associated with less donor morbidity and similar allograft function and overall safety, but more expense.

A meta-analysis of 31 studies, including five randomized trials and 26 cohort studies, concluded that hand-assistance reduces the operation and first warm ischemia times and may improve safety for surgeons with less experience in LDN [16]. Further, the retroperitoneoscopic approach was significantly associated with fewer complications. Another meta-analysis of nine studies compared 461 of laparoendoscopic single-site (LESS) living-donor nephrectomy with 1006 laparoscopic living-donor nephrectomies [17]. There were more left-side cases in the LESS living-donor nephrectomy group (96.5 versus 88.6 percent), longer operative time, and a greater likelihood of conversion to an open procedure, but a lower analgesic requirement.

The technical aspects of laparoscopic-assisted donor nephrectomy are described separately; this topic review will assess the known risks and benefits associated with LDN and compare them with those seen with open donor nephrectomy.

A discussion of the different surgical techniques is presented separately. (See "Deceased- and living-donor kidney allograft recovery".)

MORTALITY — In general, mortality rates associated with minimally invasive donor nephrectomy are low and similar to those associated with open donor nephrectomy. In one study of more than 80,000 live kidney donors, the 90-day operative mortality rate was 0.03 percent with both open and minimally invasive donor nephrectomy [18]. (See "Kidney transplantation in adults: Risk of living kidney donation", section on 'Mortality and cardiovascular disease'.)

A 2016 systematic review of 190 studies (32,038 live-donor nephrectomies) evaluated perioperative complications after minimally invasive donor nephrectomy [19]. The majority of nephrectomies were performed with a laparoscopic (57 percent) or hand-assisted laparoscopic (25 percent) technique. Three deaths occurred among 25,116 donors for whom mortality data was available (0.01 percent).

DONOR MORBIDITY — The overall incidence of perioperative complications is low with minimally invasive live-donor nephrectomy. Evidence from multiple observational studies, randomized trials, and a systematic review has shown that laparoscopic donor nephrectomy (LDN) is associated with significantly reduced postoperative pain and length of stay and more rapid recovery and return to work when compared with open donor nephrectomy [2,3,10,11,20-28]. In one study, however, complications requiring reoperation, complications not requiring reoperation, and readmission rates were two- to threefold more common with laparoscopic compared with open donor nephrectomy [29]. Most were gastrointestinal complications, such as nausea, vomiting, constipation, ileus, and dehydration, although bleeding and rhabdomyolysis were also more common with LDN.

The most comprehensive data on perioperative complications come from a 2016 systematic review of 32,038 minimally invasive live-donor nephrectomies [19]. Most nephrectomies were performed with a laparoscopic (57 percent) or hand-assisted laparoscopic (25 percent) technique, with retroperitoneoscopic, hand-assisted retroperitoneoscopic, laparoendoscopic single-site (LESS), robot-assisted laparoscopic, and mini-open procedures each accounting for less than 5 percent of the nephrectomies. Intraoperative complications occurred in 2.3 percent of donors and primarily involved bleeding (1.5 percent). The postoperative complication rate was 7.3 percent, which mainly included infectious complications (2.6 percent) and bleeding (1 percent). Injury to other organs, cardiopulmonary complications, thromboembolic events, and gastrointestinal complications each occurred in fewer than 1 percent of cases. Conversion to an open donor nephrectomy and surgical reinterventions were required in 1.1 and 0.6 percent of minimally invasive procedures, respectively.

This systematic review also compared different minimally invasive techniques and found similar intraoperative and postoperative complication rates between hand-assisted versus non-hand-assisted, laparoscopic versus retroperitoneoscopic, and multiport versus single-port procedures.

Laparoscopic donor nephrectomy has been associated with chronic postsurgical pain, with a prevalence ranging from 6 to 25 percent of patients [30,31]. In one study, younger donor age and a longer postoperative hospital stay were independently associated with chronic pain [30,31].

RECIPIENT MORBIDITY — Early in the development of the laparoscopic technique, an increased incidence of ureteral injury and even allograft thrombosis was described, but this has also decreased over time [32-35]. In an analysis of the United Network of Organ Sharing (UNOS) database comparing 2734 laparoscopic donor kidneys with 2576 open donor kidneys, there was no difference in early function, defined as >40 mL/hour of urine or a decrease in the serum creatinine by >25 percent, or the rate of delayed graft function (5.9 percent versus 5 percent, respectively) [34]. However, a discharge creatinine above 1.4 mg/dL (124 micromol/L) and 2.0 mg/dL (177 micromol/L) was more common in recipients of a laparoscopic donor kidney. At six months and one year, serum creatinine levels did not differ and were <1.5 mg/dL (133 micromol/L) in both groups. Acute rejection rates and one-year graft survival also were not different. This and subsequent studies [36] have confirmed the results of earlier reports [37,38].

However, a retrospective, single-center study found increased ureteral complications with laparoscopic procurement of kidneys with multiple renal arteries [39]. The authors concluded that laparoscopic procurement of a kidney with a single artery is preferred, independent of side, to that of one with multiple arteries, although the role of open surgery in this setting is unclear.

A paucity of data exists concerning the morbidity among pediatric kidney recipients that is associated with laparoscopic techniques [40,41]. A retrospective study from the UNOS database found a higher incidence of delayed graft function (13 versus 3 percent for ages zero to five years) and acute rejection (19 versus 6 percent for similar age groups) with laparoscopic live-donor nephrectomy than with open nephrectomy [40]. Overall, allograft survival was similar with both methods of procurement. A second study, however, reported no difference in the incidence of delayed allograft function or acute rejection in children [41].

ROBOT-ASSISTED LAPAROSCOPIC DONOR NEPHRECTOMY — The first reported of the use of robot-assisted laparoscopic donor nephrectomy (RALDN) was in 2002 in a series of 12 cases [42]. There have been several subsequent reports, mostly confined to RALDN used for left donor nephrectomies [42-44]. In a study of 20 right-sided laparoscopic donor nephrectomies (LDNs) compared with five right-sided RALDN, there was no obvious benefit from the use of robotic surgery in terms of operative time, postoperative donor glomerular filtration rate (GFR), or recipient GFR at six months [45]. There was a trend for blood loss to be less with RALDN compared with standard LDN (30 versus 76.4 mL, respectively; p = 0.07). It is not clear at present that robotic assistance offers any advantage over conventional LDN, and its added expense is not trivial. However, as individual centers acquire experience, it is likely that any potential advantages, if present, will become apparent. The procedure is utilized in a small minority of programs. Use of robot-assisted laparoscopic nephrectomy and use in organ transplantation has been reviewed [46].

EFFECT ON ORGAN DONATION — Some proponents of laparoscopic donor nephrectomy (LDN) have claimed, as an important advantage, an increase in the willingness of donors to come forward [47]. It is difficult to assess this contention.

The decision by a family member, spouse, or friend to donate a kidney was studied extensively early in the history of kidney transplantation, and the morbidity associated with donor nephrectomy was not described as a major disincentive once the decision was made to donate [48,49]. The proponents of LDN have pointed to increased donation rates associated with the procedure, but it is hard to separate this out from a renewed emphasis on living donation and the improving results associated with kidney transplantation in general. While the claim of increased donation may be well true, it has not been proven.

LAPAROENDOSCOPIC NEPHRECTOMY — Laparoendoscopic single-site (LESS) nephrectomy is performed through a single site at the umbilicus. A laparoendoscopic approach appears to be a safe alternative to a laparoscopic one for donor nephrectomy. Laparoscopic and laparoendoscopic approaches were compared in a randomized study including 100 kidney donors [50]. Operating time, time to kidney extraction, warm ischemia time, and blood loss were similar between groups. At two months, complete recovery was described by more patients in the laparoendoscopic group, compared with the laparoscopic groups (97 versus 80 percent, respectively). Satisfaction scores and recipient outcomes were similar between groups.

ALTERNATIVE OPEN NEPHRECTOMY TECHNIQUES COMPARED WITH LAPAROSCOPIC NEPHRECTOMY — Newer, less morbid open techniques such as the "mini-nephrectomy" and "mini-incision nephrectomy" use a smaller incision, with an average of 10.5 cm, and can reduce morbidity and hospital length of stay, compared with a more traditional open approach [51,52]. However, these techniques have been studied prospectively in only a small numbers of patients.

One study from the Netherlands reported the outcomes of 51 donors who underwent mini-incision, muscle splitting open donor nephrectomy (MIDN) and 49 donors who underwent laparoscopic nephrectomy [52,53]. Benefits with MIDN included shorter warm ischemia and operation time, less disposable use, fewer major complications (zero versus four intraoperative and two major postoperative complications with laparoscopic nephrectomy), and higher one-year allograft survival (100 versus 86 percent). However, MIDN was associated with more blood loss (200 versus 120 mL) and a longer hospital stay (four versus three days). Morphine requirements, pain and nausea perception, time to dietary intake, and decline in serum creatinine concentration at one year did not significantly differ between groups. The authors concluded that MIDN and LDN both lead to satisfactory results and that both techniques can be used to expand living-donor programs.

After a median follow-up of six years, the mean estimated glomerular filtration rate (eGFR) was similar in the mini-nephrectomy and the laparoscopic nephrectomy groups (75 mL/min versus 76 mL/min, respectively) [53]. The five-year death-censored graft survival was 85 percent for the mini-nephrectomy group and 90 percent for the laparoscopic nephrectomy group. Quality of life, assessed by the short form-36 (SF-36), and fatigue, assessed by the multidimensional fatigue inventory-20 (MFI-20), were not different between groups and had returned to preoperative baseline levels [53].

COST EFFECTIVENESS — One study assessed the cost effectiveness of four living-donor nephrectomy techniques, comparing open surgery, standard laparoscopy, hand-assisted laparoscopy, and robot-assisted laparoscopy [54]. Open surgery was the least cost effective, while hand-assisted laparoscopy was the most cost effective. Robot-assisted laparoscopy was associated with the highest costs but also the best postoperative outcomes.

SUMMARY

●Laparoscopic donor nephrectomy (LDN) was developed as a less morbid alternative for the donor. Learning-curve issues are the most likely cause of the morbidity and mortality that were initially associated with the procedure, but the morbidity has decreased with more experience, and the mortality rate remains low. (See 'Mortality' above.)

●Successful LDN is dependent upon the skillful performance of an advanced and unforgiving laparoscopic procedure. Proponents of the open procedure have argued that its safety record is much better established. However, more surgeons have become familiar with the technique, and the safety record of LDN has become better established. (See 'Mortality' above.)