Case Report
Retroperitoneoscopic Live Donor Nephrectomy: 7 Cases Retroperitoneoskopik Canlı Donör Nefrektomi; 7 Olgu Ayhan Mesci1, Ayhan Dinckan1, Barıs Ozcan1, Alihan Gurkan1 Akdeniz University Medical Faculty, General Surgery, Antalya, Turkey
1
Correspondence to: Ayhan Mesci, Akdeniz Universitesi Arastirma Hastanesi, Genel Cerrahi Anabilim Dali, Arapsuyu 07070, Antalya, Turkey. Phone: +90.242.2496504, Fax: +90.242.2278844, e-mail: [email protected]
Abstract
Özet
Laparoscopic living donor nephrectomy causes less pain, shorter hospital stays and a quicker return to daily activities. Because of potential bowel injuries and risk of intestinal obstruction secondary to adhesions later on, the retroperitoneoscopic donor nephrectomy (RDN) technique has been developed. The first 7 RDN cases carried out at our organ transplantation unit between December 2006 and May 2007 were retrospectively examined. The male/female ratio of the patients was 4/3. Left nephrectomy was performed in all cases. In two patients, the conventional method was performed because of an adhesion in the hilar area in one patient and because of technical difficulty after entering the peritoneum in another patient. Serious complications such as massive hemorrhage and intestinal injury were not observed. None of the patients required blood transfusion. The mean operative time was 161 minutes, with the exception of 2 patients who required conversion to other methods. Mean warm ischemia duration was 125 seconds. Oral feeding began the first postoperative day. The mean inpatient stay was 3.5 days. The mean recipient creatinine levels 24 hours and 1 month post-procedure were 3.78 mg/dl and 1.04 mg/dl, respectively. RDN is technically more difficult and has a steeper learning curve compared to transperitoneal donor nephrectomy. As our RDN cases increase, we will obtain more representative data on complications.
Transperitoneal olgulardaki potansiyel barsak yaralanma ve geç dönemde adezyona sekonder gelişebilecek intestinal obstrüksiyon riskleri nedeniyle retroperitoneoskopik donör nefrektomi (RDN) tekniği gündeme gelmiştir. Transperitoneal donör nefrektomi sıklıkla uygulanan Akdeniz Üniversitesi Organ Nakli Ünitesinde, Aralık 2006-Mayıs 2007 arasında gerçekleştirilen ilk 7 RDN olgusu retrospektif olarak irdelendi. Hastalar E/K oranı 4/3 idi. Ortalama yaş 41,7 (27- 53) idi. Tüm olgulara sol nefrektomi yapıldı. Bir hastada hiler bölgedeki adezyon, bir hastada da periton açılması sonrası teknik zorluk nedeniyle konvansiyonel yönteme geçildi. Masif hemoraji ve barsak yaralanması gibi ciddi komplikasyonlar görülmedi. Hiçbir hastaya kan transfüzyonu yapılmadı. Ortalama operasyon süresi konversiyon olan 2 hasta hariç 161 dk (120-200) olarak bulundu. Sıcak iskemi süresi ortalama 124 sn (95-160) idi. Oral beslenmeye postoperatif ortalama 1. günde geçildi. Olguların hastanede kalış süresi ortalama 3,5 gün (3-4) olarak bulundu. Alıcı kreatin düzeyleri ise ameliyat sonrası 24. saat ve 1.ay sırasıyla ortalama 3,78 mg/dl (1,7-6,2) ve 1,04 mg/dl (0,3-1,6) olarak bulundu. RDN, transperitoneal donör neferektomiye göre teknik olarak daha zor ve öğrenme eğrisi daha uzundur. Ancak RDN olgularımızın sayısının artması ile komplikasyonlarla ilgili daha gerçekçi veriler elde edilebilir görüşündeyiz.
Keywords: Donor, Nephrectomy, Retroperitoneoscopic
Anahtar Kelimeler: Donör, Nefrektomi, Retroperitoneoskopi
The Eurasian Journal of Medicine
88
Mesci et al
Introduction aparoscopic donor nephrectomy (LDN) was first performed by Ratner et al. in 1995 [1]. LDN over the last several years has gained widespread acceptance. With studies carried out since 1995, it has been shown that LDN results in less pain, shorter hospital stays and a quicker return to daily activities [1,2]. However, severe bleeding, intestinal complications and bowel injuries have been reported. Therefore, the safety of this procedure has been questioned [3,4]. Because of the potential for bowel injuries and the risk of intestinal obstruction secondary to adhesions later on, the retroperitoneoscopic donor nephrectomy (RDN) technique has been developed [3,4]. Living donor kidney transplantation accounts for approximately 35% of the total number of renal transplantations in our center over the last several years. In December 2006, we introduced RDN. Herein we have presented our experience with the first 7 donors undergoing living donor kidney transplantation using this technique at our center.
L
Case Reports The first 7 RDN cases between December 2006 and May 2007 carried out at our organ transplantation unit—where transperitoneal donor nephrectomy is commonly used—were retrospectively examined. The male/ female ratio of the patients was 4/3. The mean age was 41.7 years old (range: 27- 53). Left nephrectomy was performed in all cases. The procedure was performed under 8-10 mmHg pressure to the retroperitoneal area using 4 trocars. In two patients, the procedure was switched to the conventional method because of an adhesion at the hilar area in one patient and because of technical difficulties after entering the peritoneum in another patient. Serious complications such as massive hemorrhage and intestinal injury were not observed in any of the 7 patients. None of the patients needed a blood transfusion. The mean operation time was 161 minutes (range: 120-200), excluding the 2 patients who were converted to other
EAJM: 40, August 2008
methods. The mean warm ischemia duration was 125 seconds (95- 160). All patients were switched to oral feeding during the first postoperative day. The mean hospital stay was 3.5 days (34). The mean recipient creatinine levels at 24 hours and 1 month post-procedure were 3.78 mg/dl (1.7-6.2) and 1.04 mg/dl (0.31.6), respectively (Table 1).
Discussion Ratner et al. first performed a laparoscopic living donor nephrectomy in 1995 [1], and, subsequently, this technique has been widely used by surgeons. A retroperitoneoscopic procedure was developed as an alternative to laparoscopic nephrectomy [2]. RDN was first performed by Yang et al. in 1995 [3]. This technique has the advantages of limiting the risk of damage to intra-abdominal organs and providing direct access to the renal artery and vein. The exiguous working space is the most important disadvantage [3-5]. We performed RDN on suitable donors between December 2006 and May 2007. Compared to our previous TDN, we experienced no severe complications intraoperatively and postoperatively in the RDN group. Two patients had to be converted to open surgery—one patient due to an adhesion in the hilar area and the other patient due to technical difficulties arising after entering the peritoneum. RDN is technically more difficult and has a steeper learning curve compared with transperitoneal donor nephrectomy [4,5]. As our RDN cases increase, we will obtain more representative data on complications. We assume that, with widespread acceptance of the minimally invasive laparoscopic donor nephrectomy technique, more renal donors will come forward to increase organ availability and that surgeons proficient in retroperitoneoscopy will increasingly offer retroperitoneoscopic donor nephrectomy. Conflict interest statement The authors declare that they have no conflict of interest to the publication of this article. Acknowledgement This study was supported by Akdeniz University Scientific Research Unit, Antalya, Turkey
89
Retroperitoneoscopic Live Donor Nephrectomy
References 1. Ratner LE, Ciseck LJ, Moore RG, Cigarroa FG, Kaufman HS, Kavoussi LR. Laparoscopic live donor nephrectomy. Transplantation 1995; 60: 1047-9. 2. Jacobs SC, Flowers JL, Dunkin B, Sklar GN, Cho E. Living donor nephrectomy. Curr Opin Urol 1999; 2: 115–20.
EAJM: 40, August 2008
3. Yang SC, Park DS, Lee DH, Lee JM, Park K. Retroperitoneal endoscopic live donor nephrectomy: report of 3 cases. J Urol 1995; 153: 1884-6. 4. Ishikawa A, Suzuki K, Saisu K, Kageyama S, Ushiyama T, Fujita K. Endoscopy-assisted live donor nephrectomy: comparison between
laparoscopic and retroperitoneoscopic procedures. Transplant Proc 1998; 30: 165–7. 5. Hemal AK, Singh I. Minimally invasive retroperitoneoscopic live donor nephrectomy: Point of technique. Surg Lap Endos Tech 2001; 11: 341-3.
90
Retroperitoneoscopic Live Donor Nephrectomy: 7 Cases Retroperitoneoskopik Canlı Donör Nefrektomi; 7 Olgu Ayhan Mesci1, Ayhan Dinckan1, Barıs Ozcan1, Alihan Gurkan1 Akdeniz University Medical Faculty, General Surgery, Antalya, Turkey
1
Correspondence to: Ayhan Mesci, Akdeniz Universitesi Arastirma Hastanesi, Genel Cerrahi Anabilim Dali, Arapsuyu 07070, Antalya, Turkey. Phone: +90.242.2496504, Fax: +90.242.2278844, e-mail: [email protected]
Abstract
Özet
Laparoscopic living donor nephrectomy causes less pain, shorter hospital stays and a quicker return to daily activities. Because of potential bowel injuries and risk of intestinal obstruction secondary to adhesions later on, the retroperitoneoscopic donor nephrectomy (RDN) technique has been developed. The first 7 RDN cases carried out at our organ transplantation unit between December 2006 and May 2007 were retrospectively examined. The male/female ratio of the patients was 4/3. Left nephrectomy was performed in all cases. In two patients, the conventional method was performed because of an adhesion in the hilar area in one patient and because of technical difficulty after entering the peritoneum in another patient. Serious complications such as massive hemorrhage and intestinal injury were not observed. None of the patients required blood transfusion. The mean operative time was 161 minutes, with the exception of 2 patients who required conversion to other methods. Mean warm ischemia duration was 125 seconds. Oral feeding began the first postoperative day. The mean inpatient stay was 3.5 days. The mean recipient creatinine levels 24 hours and 1 month post-procedure were 3.78 mg/dl and 1.04 mg/dl, respectively. RDN is technically more difficult and has a steeper learning curve compared to transperitoneal donor nephrectomy. As our RDN cases increase, we will obtain more representative data on complications.
Transperitoneal olgulardaki potansiyel barsak yaralanma ve geç dönemde adezyona sekonder gelişebilecek intestinal obstrüksiyon riskleri nedeniyle retroperitoneoskopik donör nefrektomi (RDN) tekniği gündeme gelmiştir. Transperitoneal donör nefrektomi sıklıkla uygulanan Akdeniz Üniversitesi Organ Nakli Ünitesinde, Aralık 2006-Mayıs 2007 arasında gerçekleştirilen ilk 7 RDN olgusu retrospektif olarak irdelendi. Hastalar E/K oranı 4/3 idi. Ortalama yaş 41,7 (27- 53) idi. Tüm olgulara sol nefrektomi yapıldı. Bir hastada hiler bölgedeki adezyon, bir hastada da periton açılması sonrası teknik zorluk nedeniyle konvansiyonel yönteme geçildi. Masif hemoraji ve barsak yaralanması gibi ciddi komplikasyonlar görülmedi. Hiçbir hastaya kan transfüzyonu yapılmadı. Ortalama operasyon süresi konversiyon olan 2 hasta hariç 161 dk (120-200) olarak bulundu. Sıcak iskemi süresi ortalama 124 sn (95-160) idi. Oral beslenmeye postoperatif ortalama 1. günde geçildi. Olguların hastanede kalış süresi ortalama 3,5 gün (3-4) olarak bulundu. Alıcı kreatin düzeyleri ise ameliyat sonrası 24. saat ve 1.ay sırasıyla ortalama 3,78 mg/dl (1,7-6,2) ve 1,04 mg/dl (0,3-1,6) olarak bulundu. RDN, transperitoneal donör neferektomiye göre teknik olarak daha zor ve öğrenme eğrisi daha uzundur. Ancak RDN olgularımızın sayısının artması ile komplikasyonlarla ilgili daha gerçekçi veriler elde edilebilir görüşündeyiz.
Keywords: Donor, Nephrectomy, Retroperitoneoscopic
Anahtar Kelimeler: Donör, Nefrektomi, Retroperitoneoskopi
The Eurasian Journal of Medicine
88
Mesci et al
Introduction aparoscopic donor nephrectomy (LDN) was first performed by Ratner et al. in 1995 [1]. LDN over the last several years has gained widespread acceptance. With studies carried out since 1995, it has been shown that LDN results in less pain, shorter hospital stays and a quicker return to daily activities [1,2]. However, severe bleeding, intestinal complications and bowel injuries have been reported. Therefore, the safety of this procedure has been questioned [3,4]. Because of the potential for bowel injuries and the risk of intestinal obstruction secondary to adhesions later on, the retroperitoneoscopic donor nephrectomy (RDN) technique has been developed [3,4]. Living donor kidney transplantation accounts for approximately 35% of the total number of renal transplantations in our center over the last several years. In December 2006, we introduced RDN. Herein we have presented our experience with the first 7 donors undergoing living donor kidney transplantation using this technique at our center.
L
Case Reports The first 7 RDN cases between December 2006 and May 2007 carried out at our organ transplantation unit—where transperitoneal donor nephrectomy is commonly used—were retrospectively examined. The male/ female ratio of the patients was 4/3. The mean age was 41.7 years old (range: 27- 53). Left nephrectomy was performed in all cases. The procedure was performed under 8-10 mmHg pressure to the retroperitoneal area using 4 trocars. In two patients, the procedure was switched to the conventional method because of an adhesion at the hilar area in one patient and because of technical difficulties after entering the peritoneum in another patient. Serious complications such as massive hemorrhage and intestinal injury were not observed in any of the 7 patients. None of the patients needed a blood transfusion. The mean operation time was 161 minutes (range: 120-200), excluding the 2 patients who were converted to other
EAJM: 40, August 2008
methods. The mean warm ischemia duration was 125 seconds (95- 160). All patients were switched to oral feeding during the first postoperative day. The mean hospital stay was 3.5 days (34). The mean recipient creatinine levels at 24 hours and 1 month post-procedure were 3.78 mg/dl (1.7-6.2) and 1.04 mg/dl (0.31.6), respectively (Table 1).
Discussion Ratner et al. first performed a laparoscopic living donor nephrectomy in 1995 [1], and, subsequently, this technique has been widely used by surgeons. A retroperitoneoscopic procedure was developed as an alternative to laparoscopic nephrectomy [2]. RDN was first performed by Yang et al. in 1995 [3]. This technique has the advantages of limiting the risk of damage to intra-abdominal organs and providing direct access to the renal artery and vein. The exiguous working space is the most important disadvantage [3-5]. We performed RDN on suitable donors between December 2006 and May 2007. Compared to our previous TDN, we experienced no severe complications intraoperatively and postoperatively in the RDN group. Two patients had to be converted to open surgery—one patient due to an adhesion in the hilar area and the other patient due to technical difficulties arising after entering the peritoneum. RDN is technically more difficult and has a steeper learning curve compared with transperitoneal donor nephrectomy [4,5]. As our RDN cases increase, we will obtain more representative data on complications. We assume that, with widespread acceptance of the minimally invasive laparoscopic donor nephrectomy technique, more renal donors will come forward to increase organ availability and that surgeons proficient in retroperitoneoscopy will increasingly offer retroperitoneoscopic donor nephrectomy. Conflict interest statement The authors declare that they have no conflict of interest to the publication of this article. Acknowledgement This study was supported by Akdeniz University Scientific Research Unit, Antalya, Turkey
89
Retroperitoneoscopic Live Donor Nephrectomy
References 1. Ratner LE, Ciseck LJ, Moore RG, Cigarroa FG, Kaufman HS, Kavoussi LR. Laparoscopic live donor nephrectomy. Transplantation 1995; 60: 1047-9. 2. Jacobs SC, Flowers JL, Dunkin B, Sklar GN, Cho E. Living donor nephrectomy. Curr Opin Urol 1999; 2: 115–20.
EAJM: 40, August 2008
3. Yang SC, Park DS, Lee DH, Lee JM, Park K. Retroperitoneal endoscopic live donor nephrectomy: report of 3 cases. J Urol 1995; 153: 1884-6. 4. Ishikawa A, Suzuki K, Saisu K, Kageyama S, Ushiyama T, Fujita K. Endoscopy-assisted live donor nephrectomy: comparison between
laparoscopic and retroperitoneoscopic procedures. Transplant Proc 1998; 30: 165–7. 5. Hemal AK, Singh I. Minimally invasive retroperitoneoscopic live donor nephrectomy: Point of technique. Surg Lap Endos Tech 2001; 11: 341-3.
90
