The Authors' Reply.

Abstract

We are grateful to Prof. Wadström for commenting on our recent manuscript on the long-term outcomes with 3 different laparoscopic donor nephrectomy (LDN) techniques at the University of Minnesota. It is evident that the group at Karolinska University Hospital has advanced our knowledge of the retroperitoneoscopic LDN (RP-LDN). As Prof. Wadström indicates, our incidence of postoperative ileus and incisional hernia was 3% to 4% and 1% to 4%, respectively. By contrast, in one of the largest series in the literature with RP-LDN, Wadström et al1 did not observe a single case of postoperative ileus and a 0.4% hernia rate in 413 patients. Of interest, this was a multi-institutional study that included 4 different centers and significant differences were noted in the learning curve of the technique between centers. Conceptually, there are theoretical advantages of RP-LDN, namely, direct hilar access, avoidance of intraabdominal organ mobilization, and ease of access in a hostile abdomen. We acknowledge that RP-LDN has the potential to reduce postoperative ileus and intraabdominal adhesions as a result of the avoidance of intraperitoneal (IP) entry. However, despite these advantages, RP-LDN has not been adopted widely. Two recent review articles comparing techniques in LDN concluded that RP-LDN appears to be associated with fewer postoperative complications.2,3 Both articles acknowledge the poor quality and considerable heterogeneity of the included studies. For instance, in their meta-analysis He et al3 reviewed 55 articles on the IP LDN and compared them with only 6 articles on the RP-LDN. Thus, the Karolinska University Hospital experience has not been consistently reproduced by other groups. In our limited and anecdotal experience, we found RP-LDN to be a useful adjunct; however, one that was not easily replicated in the setting of a transplant surgery training program. In our article, we emphasized our diverse experience with LDN as a component of an abdominal transplant surgery fellowship where fellows play an integral role in the kidney program. We speculate that part of our initial reservations with RP-LDN were due to the ease with which fellows could adopt the IP LDN technique. Also, considering that in the current general surgery training paradigm, surgery residents are exposed to extensive IP laparoscopy and are therefore familiar with the logistics of the technique, it is not surprising why RP-LDN was not embraced. These observations are corroborated by a recent study from China, where Ma et al4 explored the learning curve of RP-LDN. They report a 23% complication rate in their first 40 cases. By contrast, we recently presented our experience with teaching transplant surgery fellows the hand-assisted LDN and found that fellows learn the procedure by approximately 36 cases with an estimated complication rate of 3.2%.5 In summary, we acknowledge that RP-LDN is a useful technique in the LDN armamentarium. In certain clinical situations, namely, those in which IP access raises the risks of the procedure, RP-LDN may prove especially valuable. However, we caution that widespread experience with this procedure is limited, and the theoretical advantages have not been reproducibly documented.