Laparoendoscopic Single-Site Pfannenstiel Versus Standard Laparoscopic Donor Nephrectomy

Abstract

Objectives:

To compare laparoendoscopic single-site (LESS) Pfannenstiel donor nephrectomy with a contemporary series of standard laparoscopic (SL) donor nephrectomies.

Methods:

The initial 6 LESS donor nephrectomies were compared with a case-matched 6 SL donor nephrectomies within the same time period (June 2008 till March 2009). Patient characteristics (sex, age, body mass index, graft volume, and vascular anatomy), perioperative data (operative time, warm ischemia time [WIT], and estimated blood loss), and postoperative information (complications, length of stay, visual analog scale [VAS], and total morphine requirements) were collected prospectively and analyzed retrospectively.

Results:

In the LESS group, there were no conversions to SL or open. There was no significant difference between the two groups in terms of baseline characteristics (age, body mass index, allograft volume). However, SL group included more right-sided patients (three compared with one) and more venous anomalies (retrorenal veins in two patients and multiple veins in another). There was no significant difference between SL and LESS in terms of operative time (117 vs. 142 minutes), WIT (5 minutes in both groups), estimated blood loss (150 vs. 100 mL), median length of stay (2 days in both), and total morphine equivalents (42 vs. 83 mg). None of the patients received transfusions perioperatively. A patient in the SL group developed a wound infection requiring packing and antibiotics. There were no perioperative complications in the LESS group. Although VAS scores were lower in the LESS versus SL group at each of post-operative day (POD) #2 (1.5 vs. 4) and discharge (0 vs. 2), this did not reach statistical significance.

Conclusions:

In this small retrospective series, SL was associated with more complex renal anatomy. However, there was no difference between the two groups in terms of WIT, narcotic requirements, and VAS scores. Therefore, the advantages of LESS may only be cosmesis. To verify these results, both procedures need to be compared prospectively in a randomized fashion.

Introduction

S ince the initial report of Ratner and colleagues¹ on laparoscopic donor nephrectomy, it has become the gold-standard approach for harvesting kidneys from live donors. This is because laparoscopic donor nephrectomy, when compared with open donor nephrectomy, offers significantly lower blood loss, shorter hospitalization, decreased postoperative pain, and shorter convalescence (3.9 vs. 3.4 weeks, p = 0.024).² However, the search for even less morbid procedure without compromising renal function in these altruistic patients continues. Recently, two theoretically less morbid modifications of the standard laparoscopic (SL) donor nephrectomy have been described by two different teams. In a consensus statement, the term “laparoendoscopic single site (LESS) surgery” was coined to describe these latest trends in further minimizing morbidity of laparoscopic surgery and maximizing cosmesis.³ By definition, during LESS surgery, all of the laparoscopic ports are placed at a single incision in the skin without any additional ports or needlescopic instruments. This skin incision is then used to extract the specimen out of the peritoneal cavity. Traditionally, SL donor nephrectomy is performed through three trocars with the laparoscope placed at the umbilical port. Once the kidney is completely free, it is then removed through a Pfannenstiel incision.

The first four cases of LESS donor nephrectomy were described by Gill and colleagues⁴ from the Cleveland Clinic. This team used the R-port (Advanced Surgical Concepts, Dublin, Ireland) at the umbilicus and the kidney was extracted from the umbilicus.⁴ However, the authors describe the use of an additional 2 mm needlescopic port at the left subcostal area to aid in traction during dissection. The second LESS series is from the Smith Institute for Urology (SIU). Here the authors included four LESS donor nephrectomies performed through a Pfannenstiel incision, where the kidney is extracted.⁵ The aim of the present study was to compare the initial LESS Pfannenstiel donor nephrectomy series at SIU with SL donor nephrectomies that took place concurrently at SIU.

Materials and Methods

Patients

Healthy donors presenting for laparoscopic donor nephrectomy were selected to undergo either SL or LESS donor nephrectomy at the discretion of the senior surgeon (L.R.K.). Baseline patient characteristics are described in Table 1. The first case of LESS Pfannenstiel donor nephrectomy was performed on July 21st, 2008, and the sixth case was performed on February 23rd, 2009. The initial six LESS Pfannenstiel donor nephrectomies were compared with six SL donor nephrectomies that took place in the same time period. Patient characteristics (sex, age, body mass index, graft volume, and vascular anatomy), perioperative data (operative time, warm ischemia time (WIT), and estimated blood loss), and postoperative information (complications, length of stay [LOS], visual analog scale [VAS], and total morphine requirements) were collected prospectively and analyzed retrospectively. The two-tailed Student t-test was used for comparison of continuous variables.

Table 1.

Comparison of Standard Laparoscopic Versus Laparoendoscopic Single-Site Pfannenstiel Donor Nephrectomy

	SL	LESS	p
Patients	6 (3 men, 3 women)	6 (3 men, 3 women)
Age (years)	28 (22–58)	46 (30–50)	0.1
BMI (kg/m²)	25 (24–31)	28 (24–38)	0.1
Allograft volume (cc)	146 (123–172)	175 (123–219)	0.1
Side	3 right, 3 left	1 right, 5 left
Number of arteries	1 in all	1 in 5 patients
		3 in 1 patient
Number of veins	1 in 5 patients with 2 retroaortic	1 in all
	2 in 1 patient
OR time (minutes)	117 (90–163)	142 (87–231)	0.2
WIT (minutes)	5 (4–5)	5 (3–6)	0.7
EBL (mL)	150 (100–300)	100 (75–150)	0.1
LOS (days)	2 (2–3)	2 (2–4)	0.7
Complications	Wound infection in 1 point	None
Morphine equivalents used (mg)	42 (22–78)	83 (24–158)	0.1
VAS at POD#2	4 (0–5.3)	1.5 (0–7.5)	0.9
VAS at discharge	2 (0–5.3)	0 (0–5)	0.6

For each of the continuous variables, median and range is provided.

SL = standard laparoscopic; LESS = laparoendoscopic single site; BMI = body mass index; OR = operative time; WIT = warm ischemia time; EBL = estimated blood loss; LOS = length of stay; VAS = visual analog scale; POD = post-operative day.

Technique

The technique of SL donor nephrectomy has been well established.^1,6 The technique of LESS Pfannenstiel donor nephrectomy has been previously described.⁵ In summary, LESS Pfannenstiel donor nephrectomy involves making a 5 cm Pfannenstiel skin incision and raising a flap of skin on top of the anterior rectus sheath up to the umbilicus after establishing pneumoperitoneum. At this point, two 5 mm Anchorports (SurgiQuest, Orange, CT) are placed under the skin flap in the midline 5 cm apart and the third 5 mm Anchoport is placed 5 cm lateral to the inferior midline port. These three ports triangulate and mimic the same working angles as the SL donor nephrectomy, however, at a more inferior site. A 5 mm flexible-tip Olympus laparoscope (LTF Series; Olympus Surgical, Orangeburg, NY) was used through the inferior midline port. Flexible instruments (Realhand; Novare, Cupertino, CA) in addition to SL instruments were used. A 5 mm LigaSure V was used as a bipolar dissector (Vallylab, Boulder, CO). Laparoscopic donor nephrectomy was performed using the three 5 mm ports similar to the SL donor nephrectomy procedure.⁶ Once the hilar structures were ready to be ligated, the inferior midline trocar was exchanged for a 15 mm EndoCatch II (Covidien, Mansfield, MA) and the superior midline trocar was exchanged for a 12 mm Endopath Xcel trocar (Ethicon Endo-Surgery, Cincinnati, OH) to allow for an Endo-GIA Universal stapler (35-mm-length, 2.5-mm-staples; Covidien). From this point on, the lateral 5 mm port was used for the flexible laparoscope. Upon ligation and division of hilar structures using the Endo-GIA stapler, the kidney was placed in an entrapment sac and the anterior rectus fascia between the two midline ports was incised and the kidney was removed through the incision. WIT started from ligation of the renal artery till cold infusion of the kidney on the back table. The anterior rectus fascia was then closed and the nephrectomy bed was inspected through the lateral 5 mm port. The Pfannenstiel skin incision was closed in a subcuticular fashion. To avoid seromas, a ¼ inch Penrose drain was placed on the rectus abdominis fascia.

Results

Preoperative patient characteristics

The initial six LESS Pfannenstiel donor nephrectomies were compared with six SL donor nephrectomies performed concurrently. None of the LESS cases were converted to SL or open. Similarly, none of the SL cases were converted to open. Both groups consisted of three women and three men. There was no significant difference between SL group and the LESS group in terms of median age (28 vs. 46 years, p = 0.1), median body mass index (25 vs. 28 kg/m², p = 0.1), or median allograft volume on preoperative CT angiography (146 vs. 175 cc, p = 0.1). However, there were more patients with complex renal vascular anatomy in the SL group. In the LESS series, all of the patients had single renal arteries and veins except for the fourth patient, who had three renal arteries. The SL group had more right-sided donors (three vs. one) and more complex venous anatomy, with two patients having retroaortic veins and one patient having two renal veins (Table 1).

Perioperative outcomes

There was no significant difference between the SL group and the LESS group in terms of median operating time (117 vs. 142 minutes, p = 0.2), median WIT (5 vs. 5 minutes, p = 0.7), median estimated blood loss (150 vs. 100 mL, p = 0.1), and median LOS at hospital (2 vs. 2 days, p = 0.7) (Table 1). In the SL group, there was a patient with postoperative wound infection that required packing and antibiotics. There were no perioperative complications in the LESS group. In terms of median postoperative total morphine requirements, there was no significant difference between SL group (42 mg) and the LESS group (83 mg) (p = 0.1). Similarly, there was no significant difference in the median VAS scores on postoperative day 2 (4 vs. 1.5, p = 0.9) and at discharge (2 vs. 0, p = 0.6). Each allograft kidney functioned immediately. There were no ureteral complications or acute rejections. The recipient for the third patient in the LESS group developed retroperitoneal bleed requiring transfusions postoperatively. There were no complications in the SL recipient group.

Discussion

As laparoscopic donor nephrectomy became the standard of care, there has been a transition in obtaining donor kidneys from cadavers to live donors.⁷ This has eased up the demand for the estimated 100,000 patients on the renal transplant waiting list. Given the fact that these altruistic healthy donors are young (18–34 years old), they deserve nothing but the minimal amount of discomfort and best cosmetic results.⁸ There have been two less morbid modifications of the SL donor nephrectomy. Both are LESS, where all of the laparoscopic ports are placed at a single skin incision, through which the kidney is finally extracted. The first LESS donor nephrectomy through the umbilicus was described by Gill and colleagues.⁴ The second LESS donor nephrectomy through a Pfannenstiel incision was described by Rais-Bahrami and coworkers.⁵ In terms of technical difference between the two LESS donor nephrectomy procedures, the trans-umbilical LESS donor nephrectomy series by Gill et al.⁴ uses a 2 mm needlescopic grasper at the subcostal margin in addition to the R-port at the umbilicus. It is important to emphasize that LESS Pfannenstiel donor nephrectomies did not require any needlescopic graspers and all six cases were performed using only the three ports described. There were no conversions to SL or open donor nephrectomies.

Recently, a retrospective comparison of trans-umbilical LESS donor nephrectomy with SL donor nephrectomy has been published.⁹ In that study, there was one right-sided donor in the LESS group that was converted to SL. This is unlike our series that included one right-sided patient who underwent LESS Pfannenstiel donor nephrectomy. Similar to the present study, there was no significant difference between the two groups in terms of in-hospital total morphine equivalents used and visual analog scores at discharge.⁹ Further, the authors used telephone questionnaires to assess postoperative convalescence. The LESS group reported faster convalescence in terms of days on oral narcotics, days off work, and days to 100% physical recover.⁹ However, the telephone questionnaires were administered by the research team in a nonblinded fashion; therefore, bias could not be eliminated.

In another study, Raman and colleagues¹⁰ found that when trans-umbilical LESS nephrectomies were compared with SL nephrectomies, there was no significant difference between the two groups in terms of in-hospital analgesic use and LOS at hospital. Therefore, the authors concluded that the advantages of LESS nephrectomy when compared with SL are limited to cosmetic outcomes. The present series also suggests the same conclusion since there was no significant difference between LESS Pfannenstiel and SL donor nephrectomy groups in terms of postoperative in-hospital morphine requirements and visual analog scores. However, both studies are retrospective with small sample size and are susceptible to biases inherent in retrospective studies. A randomized trial comparing LESS versus SL donor nephrectomy is currently being conducted at SIU to compare the analgesic requirements and the cosmetic results between the two procedures.

Further, a Pfannenstiel incision is associated with lower morbidity. In a retrospective series of 150 patients undergoing laparoscopic extirpative renal surgery including donor nephrectomy, Tisdale and colleagues¹¹ found that specimen extraction through a Pfannenstiel incision rather than an extended port-site incision was associated with shorter hospital stay (2.84 vs 3.37 days, p < 0.05), significantly less morphine use (23.7 vs 47.3 mg, p < 0.006), and lower risk of extraction-site complications. Whereas Pfannenstiel incision was associated with cellulitis (one case in the series), extended port-site incisions were associated with incisional hernias (three cases in the series). The authors concluded that extraction through a Pfannenstiel incision is associated with lower morbidity when compared with extended port-site incisions.¹¹

Unlike the present study, in the Cleveland Clinic series, there was a significantly longer mean WIT (6.1 vs. 3 minutes, p < 0.0001) in the LESS group when compared with the SL group. This may be due to use of the R-port, which needs to be removed, and both the fascial opening and the skin incisions extended to remove the kidney. However, during LESS Pfannenstiel donor nephrectomy, only the fascia between the two midline ports is cut and the kidney is removed. Similarly, in that series, the operative times for both SL and LESS donor nephrectomies were longer than the present study (239 and 269 minutes vs. 117 and 142 minutes).⁹ Another difference between the two series is the LOS at hospital. In the Cleveland Clinic series, the median hospital stay was 3 days for both groups, whereas in the present series, it is 2 days in both groups.

In conclusion, in this small retrospective series, SL was associated with more complex renal anatomy. However, there was no difference between the two groups in terms of WIT. Thus, LESS Pfannenstiel donor nephrectomy does not jeopardize renal function. Further, there was no significant difference between the two groups in terms of narcotic requirements and VAS. Therefore, the advantages of LESS may only be cosmesis. To verify these results, both procedures need to be compared prospectively in a randomized fashion.

Footnotes

Acknowledgments

This work was supported in part by grants from the Quebec Urological Association Foundation and Frank McGill Travel Fellowship to Sero Andonian.

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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