From open to laparoscopic surgery: Evolution of living donor nephrectomy in SG

A Singapore study has confirmed the safety of living-donor nephrectomies in a centre with a modest volume of kidney transplants.

“The best-in-class outcomes … can be achieved by maintaining a high standard of surgical discipline and proficiency,” the researchers said. “This is accomplished by concentrating the caseloads to a dedicated team of transplant surgeons.”

All living-donor nephrectomies performed at the Singapore General Hospital from 1976 to 2018 were retrospectively identified. Donors were classified according to surgical techniques: open (ODN), hand-assisted laparoscopy (HALDN), and full laparoscopy (LDN).

The researchers then reviewed changes in donor demographics over the years and compared surgical outcomes between groups from 2000 to 2018. They also assessed the learning curve by comparing outcomes of LDN between different time periods.

Between 2000 and 2018, a total of 214 living-donor nephrectomies were carried out, majority of which were left sided (93 percent) and had single renal artery anatomy (90 percent). In terms of surgical techniques, 163 were LDN, 22 ODN, and 20 HALDN. [Proc Singapore Healthc 2020;29:239-244]

The mean operating time was 84±43 min for ODN, 151±32 min for HALDN, and 179±37 min for LDN (p<0.001). No statistically significant between-group differences were observed in mean warm ischaemia times (p=0.921) and length of hospital stay (p=0.114). The overall 3-day surgical morbidity rate was 9.3 percent, with a major complication rate of 0.9 percent.

Furthermore, a significantly different mean warm ischaemia time was noted for LDN between time periods: 281±260, 184±94, and 140±42 sec for the periods between 2005–2009, 2010–2014, and 2015–2018, respectively.

A shift in donor demographics has been observed since the first LDN in Singapore was performed in 1976, according to the researchers. Today, living kidney donors are older and more frequently biologically unrelated to the recipients compared to the preceding decades.

Despite a significant percentage of donors being >50 years of age, the overall surgical morbidity rate of the current study was comparable to those reported in larger series. [Eur Urol 2014;65:659-664]

Over the last two decades, the practice of living kidney procurements at the Singapore General Hospital has shifted from open surgery to minimal incision techniques. HALDN was used in transition to the adoption of full laparoscopy.

“While others have touted the advantages of HAL techniques over full laparoscopy, especially the superior surgical manipulation and blunt dissection using a hand, we have not experienced significant advantages over full laparoscopy,” the researchers said. [J Urol 2001;166:1270-1273]

“Furthermore, LDN confers better cosmesis, as our kidney extraction scar in the lower abdomen can be easily hidden by underwear,” they added.

Studies comparing the three techniques reported shorter operating time and warm ischaemia time for ODN, followed by HALDN and LDN, as well as longer length of hospital stay for ODN. [Transplant Proc 2012;44:22-25; Int J Urol 2008;15:206-209]

“Until a newer approach has been proven to be better, safe and cost-effective, LDN and traditional ODN will remain our core surgical techniques of donor nephrectomy,” the researchers said.