ENDOUROLOGY & LAPAROSCOPY

Open versus laparoscopic live donor nephrectomy: a focus on the safety of donors and the need for a donor registry
Shokeir AA
Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
J Urol. 2007; 178: 1860-6

• Purpose: A review of the existing literature showed that the subject of live donor nephrectomy is a seat of underreporting and underestimation of complications. We provide a systematic comparison between laparoscopic and open live donor nephrectomy with special emphasis on the safety of donors and grafts.
• Materials and Methods: The PubMed(R) literature database was searched from inception to October 2006. A comparison was made between laparoscopic and open live donor nephrectomy regarding donor safety and graft efficacy.
• Results: The review included 69 studies. There were 7 randomized controlled trials, 5 prospective nonrandomized studies, 22 retrospective controlled studies, 26 large (greater than 100 donors), retrospective, noncontrolled studies, 8 case reports and 1 experimental study. Most investigators concluded that, compared to open live donor nephrectomy, laparoscopic live donor nephrectomy provides equal graft function, an equal rejection rate, equal urological complications, and equal patient and graft survival. Analgesic requirements, pain data, hospital stay and time to return to work are significantly in favor of the laparoscopic procedure. On the other hand, laparoscopic live donor nephrectomy has the disadvantages of increased operative time, increased warm ischemia time and increased major complications requiring reoperation. In terms of donor safety at least 8 perioperative deaths were recorded after laparoscopic live donor nephrectomy. These perioperative deaths were not documented in recent review articles. Ten perioperative deaths were reported with open live donor nephrectomy by 1991. No perioperative mortalities have been recorded following open live donor nephrectomy since 1991. Regarding graft safety, at least 15 graft losses directly related to the surgical technique of laparoscopic live donor nephrectomy were found but none was emphasized in recent review articles. The incidence of graft loss due to technical reasons in the early reports of open live donor nephrectomy was not properly documented in the literature.
• Conclusions: We are in need of a live organ donor registry to determine the combined experience of complications and long-term outcomes, rather than short-term reports from single institutions. Like all other new techniques, laparoscopic live donor nephrectomy should be developed and improved at a few centers of excellence to avoid the loss of a donor or a graft.
  
  
• Editorial Comment
  The author performed a very comprehensive review of the literature (live donor laparoscopic nephrectomy) revealing only 7 randomized trials that concluded that when compared to open live donor nephrectomy, laparoscopic live donor nephrectomy provides equal graft function at 1 year, an equal rejection rate, equal urological complications, and equal patient and graft survival. Analgesic requirements, pain data, hospital stay and time to return to work are significantly in favor of the laparoscopic procedure.
  On the other hand, laparoscopic live donor nephrectomy has the disadvantages of increased operative time, increased warm ischemia time and increased major complications requiring reoperation. These complications may decrease with more operative experience. The learning curve for laparoscopic procedures has been extensively discussed in the literature. It is pivotal that better simulation, education models can be created to decrease the challenging issues of learning this new operative technique.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Director of Minimally Invasive Urological Oncology
Tony Grampsas Ca Ctr, Univ Colorado Health Sci Ctr