TECHNIQUES AND OUTCOMES - Redalyc

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324 P. M. Lewandowski, S. Leslie, I. S. Gill, and M. M. Desai. TABLE III. WARM ISCHEMIA TIME AND GRAFT OUTCOMES. Canes (6) Kurien (9) Lunsford (10) LESS-DN LDN LESS-DN LDN LESS-DN LDN WIT (min) 6.1 3.0 7.15 5.11 - - 1 month Cr† 1.5 Cr 1.3 eGFR‡ 94.6 eGFR 86.5 Cr 1.4 Cr 1.4 3 months Cr 1.5 Cr 1.3 eGFR 88.9 eGFR 86.1 12 months eGFR 81.5 eGFR 80.9 † Creatinine (mg/dL) ‡ estimated Glomerular filtration rate (ml/min) demonstrates safety for the donor undergoing LESS- DN with only a small number of complications, and no complication considered Clavien (14) grade III or higher. Graft Outcome. The mean warm ischemia time (WIT) for each of the five series is outlined in Table II. WIT is defined as the time from when the renal artery is clipped to when the kidney is re-perfused by the transplant surgeon on the back table. The average WIT for the five series is 5.6 minutes (3.96 – 7.2). Table III looks at the WIT and graft function in the series which directly compared LESS-DN to standard LDN. In the series by Canes6 the WIT for LESS-DN is twice that of standard LDN (6.1 v. 3.0). The reason for the increased WIT in the LESS-DN procedure is primarily due to the time taken to remove the R-port, extend the fasciotomy and skin incision to allow safe extraction of the kidney. In the case of standard LDN, where the kidney is removed via a pfannenstiel incision, this delay is not encountered. However, despite the longer WIT, this does not seem to impact on graft function, with the 1 month and 3 month recipient creatinine levels not significantly different between the two groups (1.5 mg/dL v 1.3 mg/dL). In the study by Lunsford10, although the WIT was not reported, the recipient creatinine level on discharge was equal in both the LESS-DN and the standard LDN groups (1.4 mg/dL). In the randomized study by Kurien (9), there is again a significant difference in WIT between the LESS-DN and the LDN (7.15 v 5.11). But once again, this did not translate into inferior graft outcomes in the recipient. Long term follow up of eGFR in the recipient did not demonstrate any difference between the LESS- DN group and the standard LDN group. This data suggests that a slightly increased WIT does not have any detrimental impact on graft function either in the short or long term. It is also important to appreciate that these studies included the very first LESS-DN procedures, and it would be expected that with time, refinement of the technique will allow for shorter WIT in the future. Morbidity. The average hospital length of stay (LOS) in the published series is 2.5 days (Table IV). In the studies comparing LESS-DN and standard LDN (Table V), there is minimal difference in LOS between the two groups. The mean visual analogue pain score (VAS) on discharge is 1.9 for the five series, and in the studies of Canes (6) and Lunsford10, there was no difference in the VAS pain scores between the LESS- DN group and the LDN. The randomized study of TABLE IV. POSTOPERATIVE OUTCOMES. Canes (6) Ganpule (7) Gimenez (8) Kurien (9) Lunsford (10) (mean) Length of Stay (days) 3 - 1.8 3.9 1.3 2.5 Visual Analogue Pain Scale 2.7 2.9 1.4 1.2 2.5 1.9
LAPARO-ENDOSCOPIC SINGLE-SITE DONOR NEPHRECTOMY: TECHNIQUES AND OUTCOMES 325 Kurien (9) demonstrated that in the first 48 hours after the procedure there was no difference in pain between the two groups. However, after 48 hours there is divergence of VAS scores with significantly less pain observed in the LESS-DN group. The VAS pain score on discharge between the LESS-DN group and the LDN group were 1.2 and 2.1 respectively. In the study by Canes6, although there was no difference in the VAS score it did demonstrate that the number of days patients were using oral analgesia and the number of days until patients returned to work were significantly shorter in the LESS-DN group (Table V). In terms of the cosmetic satisfaction, Kurien (9) did not demonstrate any difference in body image or cosmetic satisfaction between the two groups. This is in contrast to the study of Canes (6) where the patients were asked to report their “scar satisfaction” on a scale of 1 to 10. A significant difference was noted with the LESS-DN group more satisfied with their scar compared to the standard LDN group (9.7 v. 7.7) (Figure 7). In these studies, the morbidity following LESS- DN in terms of post-operative pain and perceived cosmetic results are at least equivalent and in some cases superior to conventional LDN. The extent to which a psychological bias plays a role in these outcomes is difficult to determine. Patients in the LESS- DN group are aware that they have undergone an innovative, less-invasive procedure, and the better results may be related to a confirmation bias where their preconceptions of the procedure may affect how they rate the outcome. DISCUSSION Donor nephrectomy is a unique surgical procedure as it is the only one performed on a healthy patient in urological practice. Donor kidneys are in critical shortage. The renal transplant waiting list in the United States is increasing annually, and has more than doubled in the last 15 years from 35,939 patients listed in 1997 to 89,442 in 2011 (15). This is despite an increase of more than 85% TABLE V. COMPARISON OF LESS-DN TO STANDARD LDN. LESS-DN Standard LDN Canes (6) Kurien (9) Lunsford (10) Canes (6) Kurien (9) Lunsford (10) Total no 17 25 10 17 25 20 Mean age 38 44.4 47 39 47.2 46.5 Intraoperative Outcomes OT (minutes) 269 172 179 239 176 187 EBL (mL) 108 84 50 141 92 75 WIT (minutes) 6.1 7.15 - 3 5.11 - Postoperative Outcomes Length Stay (days) 3 3.9 1.3 3.5 4.6 1.1 VAS on discharge 2.7 1.2 2.5 1.4 2.1 2 Days back to Work 18 - - 46 - - Days 100% recovery 29 - - 83 - - Days oral pain pills 6 - - 20 - -
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