ENDOUROLOGY & LAPAROSCOPY

Laparoscopic versus open donor nephrectomy: ureteral complications in recipients
Lind MY, Hazebroek EJ, Kirkels WJ, Hop WCJ, Weimar W, Ijzermans JNM
From the Departments of Surgery, Urology, Biostatistics and Nephrology, Erasmus Medical Center, Rotterdam, The Netherlands
Urology. 2004; 63: 36-9

• Objectives: To describe our experience with laparoscopic donor nephrectomy (LDN) and open donor nephrectomy (ODN) regarding ureteral complications. LDN has proved to be safe and to offer significant benefits to the donor compared with ODN. Of major importance is the effect of the surgical technique on the graft. Studies have shown an increased incidence of ureteral complications in recipients of laparoscopically procured kidneys. Operative reconstruction results in additional morbidity for the recipient.
• Methods: Living donors and their recipients, who underwent surgery from January 1994 to April 2002, were included in this retrospective study. A total of 122 LDN and 77 ODN recipients were included.
• Results: Of the 122 LDN and 77 ODN recipients, 15 (12%) and 10 (13%), respectively, required percutaneous nephrostomy drainage. In total, 5 LDN (4.1%) and 5 ODN (6.5%) recipients required reconstruction of the ureter because of obstruction of the ureter or urine leakage (P value not statistically significant, excluding reconstruction required for technical errors). The operating time, warm ischemia time, and serum creatinine were comparable between recipients with or without ureter complications requiring reconstruction.
• Conclusions: In our experience, LDN was not associated with an increased incidence of ureteral complications in the recipient compared with ODN.
  
  
• Editorial Comment
  Dr. Stephen Jacobs, one of the pioneers of laparoscopic donor nephrectomy, wrote an excellent commentary following this article that touched on all of the important points. He pointed out that, although the results of the study are reassuring with regards to no difference between the open surgical and laparoscopic kidneys in terms of recipient ureteral complications, the results must be interpreted cautiously because the groups were not synchronous and therefore significant bias could enter. Nonetheless, all recipients underwent ultrasonography and nuclear medicine scanning, and percutaneous nephrostomy tubes were used for initial management in all cases. In addition, in those patients who required operative repair the findings were similar. One criticism of the study that cannot be easily addressed is the low power for detecting a difference between groups, given the expected 3 – 5% frequency of transplant ureteral complications. That the incidence appears greater in this study (in both groups) is likely due at least in part to the routine assessment of all kidneys with ultrasonography and nuclear medicine scanning. What we can take home from this study is that any difference in ureteral complications between the 2 harvest methods is unlikely to be great. A small difference would have been missed by this study. Certainly, however, the fears that laparoscopically harvested ureters might be stripped of their vascularity and cause a dramatic increase in the incidence of ureteral complications appears to be unfounded.

Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA