UROLOGICAL SURVEY
Endourology & laparoscopy
Laparoscopic versus open donor nephrectomy: ureteral complications in recipients
Lind MY, Hazebroek EJ, Kirkels WJ, Hop WCJ, Weimar W, Ijzermans JNM
From the Departments of Surgery, Urology, Biostatistics and Nephrology, Erasmus Medical Center, Rotterdam, The Netherlands
Urology. 2004; 63: 36-9
OBJECTIVES: To describe our experience with laparoscopic donor nephrectomy (LDN) and open donor nephrectomy (ODN) regarding ureteral complications. LDN has proved to be safe and to offer significant benefits to the donor compared with ODN. Of major importance is the effect of the surgical technique on the graft. Studies have shown an increased incidence of ureteral complications in recipients of laparoscopically procured kidneys. Operative reconstruction results in additional morbidity for the recipient.
METHODS: Living donors and their recipients, who underwent surgery from January 1994 to April 2002, were included in this retrospective study. A total of 122 LDN and 77 ODN recipients were included.
RESULTS: Of the 122 LDN and 77 ODN recipients, 15 (12%) and 10 (13%), respectively, required percutaneous nephrostomy drainage. In total, 5 LDN (4.1%) and 5 ODN (6.5%) recipients required reconstruction of the ureter because of obstruction of the ureter or urine leakage (P value not statistically significant, excluding reconstruction required for technical errors). The operating time, warm ischemia time, and serum creatinine were comparable between recipients with or without ureter complications requiring reconstruction.
CONCLUSIONS: In our experience, LDN was not associated with an increased incidence of ureteral complications in the recipient compared with ODN.
Editorial Comment
Dr. Stephen Jacobs, one of the pioneers of laparoscopic donor nephrectomy, wrote an excellent commentary following this article that touched on all of the important points. He pointed out that, although the results of the study are reassuring with regards to no difference between the open surgical and laparoscopic kidneys in terms of recipient ureteral complications, the results must be interpreted cautiously because the groups were not synchronous and therefore significant bias could enter. Nonetheless, all recipients underwent ultrasonography and nuclear medicine scanning, and percutaneous nephrostomy tubes were used for initial management in all cases. In addition, in those patients who required operative repair the findings were similar. One criticism of the study that cannot be easily addressed is the low power for detecting a difference between groups, given the expected 3 5% frequency of transplant ureteral complications. That the incidence appears greater in this study (in both groups) is likely due at least in part to the routine assessment of all kidneys with ultrasonography and nuclear medicine scanning. What we can take home from this study is that any difference in ureteral complications between the 2 harvest methods is unlikely to be great. A small difference would have been missed by this study. Certainly, however, the fears that laparoscopically harvested ureters might be stripped of their vascularity and cause a dramatic increase in the incidence of ureteral complications appears to be unfounded.
Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA
Complications of abdominal urologic laparoscopy: longitudinal five-year analysis
Parsons JK, Varkarakis I, Rha KH, Jarrett TW, Pinto PA, Kavoussi LR
From the James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Urology. 2004; 63: 27-32
OBJECTIVES: To analyze complications of abdominal laparoscopic surgery of the urinary tract at a single institution during a 5-year period.
METHODS: From 1996 to 2000, we identified 894 abdominal laparoscopic procedures performed at a single institution: 600 nephrectomies (live donor, simple, radical, nephroureterectomy, and partial), 112 pyeloplasties, 61 renal biopsies, 35 retroperitoneal lymph node dissections, 31 renal cyst ablations, 18 adrenalectomies, and 37 other abdominal procedures. The charts were retrospectively reviewed for complications, which were classified as operative, postoperative, or medical. Complications were correlated with patient age and American Society of Anesthesiologists score. Statistical analysis was performed with Fisher's exact test and chi-square tests.
RESULTS: A total of 118 complications (13.2%) occurred. Two patients (0.2%) died. As a result of operative complications, the procedure of 13 patients (1.5%) was converted to an open one. As a result of postoperative complications, 13 (1.5%) underwent operative and 6 (0.7%) nonoperative intervention. The most common intraoperative complications were vascular (n = 23), adjacent organ (n = 10), and bowel (n = 9) injuries. The most common postoperative complications were neuromuscular pain (n = 12), hematoma (n = 11), urine leak (n = 7), and wound infection (n = 7). The differences in the annual complication rates for all procedures did not attain statistical significance (P = 0.5). Among all procedures, excluding live donor nephrectomy, complications of any kind correlated with a greater patient American Society of Anesthesiologists score (P = 0.01).
CONCLUSIONS: Rather than decreasing, the overall incidence of laparoscopic complications did not change significantly during a 5-year period at our institution. The factors contributing to this observation likely included the progression of inexperienced individual surgeons through the learning curve, the introduction of new, more sophisticated laparoscopic procedures, and stable rates of patient comorbidity. This experience may represent the average complication rate for urologic laparoscopy at a large-volume, academic training center.
Editorial Comment
For years I have been counseling patients pre-operatively that, overall, there is a about a 5% risk of major complication and about a 10% risk of a minor complication associated with laparoscopic nephrectomy. The data from this very large and long series supports those approximations. The context of these figures is important to consider. On one hand, a lower rate of complications might have been expected given the expertise of the senior surgeons at this institution. On the other hand, as pointed out in this article, the performance of many inexperienced trainees is included in this series. In addition, the typical referral patterns that lead the sicker patients to the large medical centers also might tend to increase complication rates. Overall the rates have been stable over time, suggesting that this is about what anyone might expect given a certain level of experience and capability with laparoscopy.
Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA
Publication Dates
-
Publication in this collection
21 May 2004 -
Date of issue
Feb 2004
