LAPAROSCOPIC DONOR NEPHRECTOMY: PRO

At the time of its introduction laparoscopic live donor nephrectomy (LDN) was considered a radical development. Despite this perception, LDN represented a logical next step in a conceptual and technical evolution. Currently, LDN is being performed at over 100 centers worldwide. Its adoption is progressing rapidly, fueled largely by patient demand and the related economic necessity felt by many transplant centers. We present data that we believe demonstrates that LDN is not only safe for both the donor and recipient, but the preferred method of live organ procurement, because of its inherent benefits. Renal transplantation is the optimal treatment for endstage renal disease. However, its therapeutic application is limited by the organ supply. Despite numerous attempts to increase cadaveric donation, only a minimal increase in cadaveric organ donors has been realized compared to the exponential growth in the renal transplant waiting list. This has resulted in prolonged waiting times with a concomitant increase in the number of people dying while awaiting renal transplantation. Strategies to increase the organ supply include the following: 1) educating both the general public and medical professionals about organ donation; 2) passing legislation for presumed consent or required request; 3) using expanded criteria donor organs; 4) using non-heart beating donors; 5) reducing the rate of retransplantation; 6) xenotransplantation; and 7) increasing the use of live donors. Increasing live donor rates is the most immediately applicable strategy and also should decrease the rate of retransplantation. We hypothesized that many individuals who might wish to donate are prohibited by both financial and logistical disincentives to donation (2). If potential donors faced shorter recuperative times, less pain, and better cosmetic results, more individuals might be willing to donate. Application of minimally invasive techniques to cholecystectomy resulted in an increase in the number of patients undergoing laparoscopic cholecystectomy than the open operation (3). Clayman and associates demonstrated that laparoscopic nephrectomy for disease resulted in less pain, shorter hospitalization, and quicker recuperation than nephrectomy performed via a flank approach (4). Gill et al. demonstrated the feasibility of laparoscopic donor nephrectomy in an animal model (5). Living donor renal transplantation is associated with multiple advantages for the recipient, including improved patient and graft survival, improved graft function, immediate graft function, shorter hospital length of stay, decreased morbidity, and decreased overall costs (6, 7). The procedure is performed on an elective basis and allows for the optimization of the recipient’s clinical status before transplantation. Yet, despite these advantages, live donor renal transplantation remains an underused option. Although there is some psychological benefit for the donor, the traditional open technique for donor nephrectomy extracts a high cost. Donors face the morbidity of a flank incision with its incumbent pain, cosmetic deformation, prolonged convalescence, and the potential for pneumothorax, rib resection, chronic pain, and hernia formation. The convalescent period of 4–8 weeks carries an “opportunity” cost with lost wages, suspension of familial responsibilities, such as childcare and housework, and the need for other family members to fulfill these obligations. These costs form a nearly insurmountable disincentive to all but the obsessively committed donor. With regard to LDN at Georgetown University Hospital, we have demonstrated that the availability of the laparoscopic approach with its associated decrease in opportunity costs increases the number of living donors by ;40%, primarily represented by increased numbers of living unrelated donors (8). Similarly, at Johns Hopkins Hospital, 20% of donors report that they would not have donated if the laparoscopic approach had not been available. Fully two thirds of donors claim that the availability of the laparoscopic operation greatly influenced their decision to donate. Hence, we have seen an ;200% increase in live donor renal transplants performed at Johns Hopkins since the introduction of LDN. Other centers have experienced similar increases in live donation. We conclude that LDN overcomes many of the disincentives to donation and is a viable alternative to the traditional open approach for donor nephrectomy.