Is Laparoscopic Donor Nephrectomy Like Riding a Bike?

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In this current study, Koch et al.¹ compare 4 different techniques for donor nephrectomy to delineate the safety of each technique and to understand the physical and mental burden on the donors. They compare laparoscopic/transabdominal donor nephrectomy (LDN), retroperitoneoscopic donor nephrectomy, open retroperitoneal nephrectomy, and open abdominal nephrectomy. Despite the Kidney Disease: Improving Global Outcomes guidelines, the authors report that about 20% of donor nephrectomies in Germany are still via the open technique. They conclude that all techniques are safe without significant differences in perioperative complications.

Since 1995, with the first laparoscopic donor nephrectomy being performed, there have been a multitude of publications comparing the outcomes, safety, postoperative complications, pain, estimated blood loss, hospital length of stay (LOS), etc., of laparoscopic donor nephrectomy to that of the traditional open surgical approach.² A review by Greco et al.³ in 2010 of all the literature pertaining to “living donor nephrectomy” found 629 records from the PubMed database and 686 records from the Web of Science database. In their analyses, they found that the minimally invasive technique was superior to open surgery with regard to hospital LOS, estimated blood loss, and postoperative pain. They also reported that despite the longer warm ischemia times, the allograft function was not inferior with the laparoscopic technique. The authors concluded that both laparoscopic and open live donor nephrectomy are standard-of-care. In 2017, the Kidney Disease: Improving Global Outcomes Clinical Practice Guidelines on the Evaluation and Care of Living Kidney Donors stated that “mini-open laparoscopy or hand-assisted laparoscopy by trained surgeons should be offered as optimal approaches to donor nephrectomy.”⁴

Although this study shows that all 4 techniques for donor nephrectomies are safe, their data is incongruent with much of the literature showing decreased hospital LOS for LDN. In the USA, the average hospital LOS for LDN is typically approximately 2 days.⁵ In fact, Kuo et al.⁶ showed that their donors who stayed 23 hours postoperation, did not incur additional complications or donor dissatisfaction and rather helped to decrease disincentives for donation with a shorter hospital LOS. However, in this study, the median hospital LOS for all techniques were 4 to 7 days with retroperitoneoscopic donor nephrectomy having the shortest LOS of 4 days. The median hospital LOS for LDN was 6 days. Practice patterns in different countries may account for this large difference; however, perhaps the scarcity of LDN performed preclude earlier discharges because of the unfamiliarity of early discharges after a straight-forward and uncomplicated laparoscopic procedure.

In addition, the minimally invasive techniques of donor nephrectomies have mostly shown superiority over the open techniques in terms of postoperative pain. Nevertheless, this study does not address postoperative pain specifically but rather uses the Short-From 12 questionnaire to measure quality of life. They note that the Physical Component Summary score were not any better for the LDN and retroperitoneoscopic donor nephrectomy groups than that of the open retroperitoneal nephrectomy and open abdominal nephrectomy groups.

The number of living kidney donors reported in this paper begs the question: how many laparoscopic donor nephrectomies is enough to be proficient? The recruitment period in this study was almost 4 years (January 2020–September 2024) in 30 German transplant centers. The total number of recruitable living kidney donors was 1745 (although only 1020 were able to be analyzed). This implies that each center performed about 14 donor nephrectomies each year. To further break this down, the authors report that out of the total, about 58% were LDN, about 21% were retroperitoneoscopic donor nephrectomy, about 16% were open retroperitoneal nephrectomy, and about 5% were open abdominal nephrectomy. Then roughly, each center only performed about 8 LDNs/yr. If there are multiple surgeons who perform this procedure at a given center, then it raises the question of how many laparoscopic donor nephrectomies must be performed per year to maintain proficiency.

The American Society of Transplant Surgeons requires fellows to perform 12 LDNs during the course of their fellowship to be certified.⁷ The Organ Procurement and Transplantation Network requires 15 LDN cases to be certified as a primary surgeon.⁸ Raque et al.⁹ performed a review to assess the learning curve for LDN and found that about 35 LDN cases are needed to be considered proficient. Martin et al.S1 also report that the learning curve for LDN flattens after 37 cases and that the majority of their complications occurred in the first 30 cases. Serrano et al.S2 studied the learning curve for transplant surgery fellows and found that there is a “tipping point” at about 24 to 28 LDN cases in terms of operative time, estimated blood loss, and intraoperative complications. They also note that proficiency is achieved by 35 to 38 cases. There is not much literature in regard to the maintenance of proficiency of LDN. However, it is commendable that the authors were able to safely perform the donor nephrectomies in the various techniques despite performing < 1 case/mo.

The paradigm for donor nephrectomies is currently changing to add robotics into the armamentarium. To ensure maintenance of proficiency, Intuitive Surgical recommends that a surgeon does 2 robotic cases/wk. Jenison et al.S3 found that robotic surgical skills “degrade significantly within 4 weeks of inactivity. In regard to donor nephrectomy, safety is the utmost priority for the donors. Therefore, the surgeon should perform the surgery with the technique that is the safest in their capable hands.

The most important take away point from this article for the general public is that irrespective of the technique, most donors at 3 months expressed satisfaction and that they would be would be willing to donate again if possible. The authors report that out of the 84 donors with complications reported by the transplant centers, 45 donors self-reported having no complications. Interestingly, the authors state that there was no difference in donor well-being among the different surgical techniques despite earlier studies showing reduced physical burden with minimally invasive techniques compared with open procedures.S4^,S5 With this, it is imperative to emphasize to potential donors that irrespective of technique, donor nephrectomies are a safe surgery in experienced hands so that we can help to decrease the ever-growing list of people dying waiting for a kidney transplant.

Disclosure

All the authors declared no competing interests.

Supplementary Material

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