Laparoscopic Versus Open Donor Nephrectomy

Abstract

With great interest we read the article by Kok and colleagues published on March 27, 2006 in Transplantation (1). The authors compared laparoscopic and the mini-incision muscle splitting open donor nephrectomy as two minimal invasive methods to perform a donor nephrectomy and conclude that there are no significant differences. The high conversion rate and perioperative morbidity rate of the total laparoscopic group can be held responsible for that. Perry et al. demonstrated that the mini incision donor nephrectomy is inferior to the laparoscopic approach in many domains (2). The open nephrectomy is especially associated with delayed resumption of normal activities such as return to full activity and driving, and with a diminished quality of life. Unfortunately, these aspects that are especially important for a healthy donor were not included in the analysis by Kok et al. A mini-incision ranging up to 15 cm cannot be considered a mini-incision anymore and but must be counted as a conversion to a formal laparotomy. This in concordance with the definition of a conversion in laparoscopic surgery such as when the intended incision must be enlarged. In the search for the best minimal invasive method for donor nephrectomy, did the authors considered the hand-assisted laparoscopic donor nephrectomy? Various studies demonstrated the advantages of the hand-assisted modality as compared to the total laparoscopic approach. The hand-assisted approach leads to a shorter operation time, shorter warm ischemic time, lower conversion rate, and increased donor safety (3, 4). In addition, we are concerned about the high urological complication rate of over 20% in both groups as described by Kok et al. Recently, two meta-analysis demonstrated that a splinted ureterocystostomy is superior to a nonsplinted anastomosis and that the urological complication rate with a routine splinting policy should be in the 2–3% target range (5). Did the authors use splinted anastomoses and did they harvest the ureter together with the gonadal vein, because this is also demonstrated to reduce the urological complication rate? Mirza M. Idu Ron Balm Willem A. Bemelman Department of Vascular and Transplant Surgery Academic Medical Center Amsterdam, the Netherlands