Removal of kidneys from living donors. Comparison between open surgery and laparoscopy

Donor nephrectomy from living relatives reduces the waiting timefor the kidney recipient in comparison with cadaveric organ transplantation.It provides good quality kidneys and improves the outcomeof transplantations. Nevertheless kidney removal is a heavyoperation performed in otherwise healthy subjects. In the USA,more than 50 % kidneys donors are living donors, in Europe 15 to30 % and in France only 5 %. The classical approach by lombotomyis painful, and associated with a prolonged hospital stay.Ratner performed the first laparoscopic nephrectomy in a livingdonor (LNLD) in 1995. At the present time, 200 centres worldwideroutinely perform LNLD and more than 10 000 kidneys have beenremoved through this new approach. The transperitoneal route is themost often used. Five trocars are inserted, the organ is removedusing an Endobag through an hemi-Pfannenstiel incision (6 cm).From June 1995 to January 2005, 55 transplantations with kidneysfrom living donors were performed in our department. Forty nineleft kidneys and six right kidneys were removed. Eighteen openapproaches and 37 LNLD (20 through a retroperitoneal approachand 17 through a transperitoneal one) were used.The complications observed in the donor after open surgery were :one wound infection, one haemorrhage, one partial wound of controlateralrenal artery, i.e. 3 out of 18 (17 %). After LNLD : oneabcess, one renal vein trauma and two postoperative haemorrhagesrequiring a conversion, i.e. 4 out of 37 (11 %). The hospital staywas 9.5 days after open surgery versus 6 days after laparoscopicprocedures.In the recipient the graft function seems a little delayed after LNLDbut no impact on 6 and 12 months renal function was noticeable.The urinary complications were : one ureteral stenosis after conventionallombotomy and one urinoma after LNLD, both requiringureteral reimplantation into the bladder.The arterial complications were : three stenoses after conventionallombotomy (3 out of 18 : 17 %) treated by angioplasty (one case)and surgical repair (one case), nine arterial stenoses (9 out of 37 :24 %) after LNLD, treated by angioplasty (5 cases) with 2 stentsand 3 surgical repairs.We lost three kidneys : the first by mismatching, the second byrenal vein thrombosis and the third by impaired hemodynamics in aTakayashu female patient.Conclusion: the results of nephrectomy in living kidney donors areequivalent through conventional approach or LNLD. The latter hasbecome the standard approach for kidney removal in our center. It requires a prolonged learning time. It may increase the number ofrenal donors since it may facilitate the acceptance of donationfrom potential living donor relatives.