Perspectives of Laparoscopic Donors Toward a New Procedure: Transvaginal Donor Nephrectomy

Introduction

Over the last 10 years, Australia has witnessed an increase in the number of live renal donations. ¹ This has led to a subsequent and much-needed increase in the total number of renal transplants per year. Currently, laparoscopic donor nephrectomy (LDN) is the gold standard technique for live renal donation, and it has largely replaced open donor nephrectomy. The current literature suggests that results after LDN are equivalent to open donor nephrectomy and may have further advantages in terms of faster recovery time, shorter hospital stay, reduced postoperative pain, and improved cosmesis.^2–5 LDN reduces donor morbidity, and potential donors are more willing to consider LDN due to the perceived improved morbidity over open nephrectomy.^6,7

Technological advances in minimally invasive surgery, coupled with initiatives to improve donor morbidity and cosmesis, have led to a search for new techniques to achieve this. One such technique with future potential is natural orifice translumenal endoscopic surgery (NOTES). ⁸ This procedure allows removal of organs such as the kidney, gallbladder, ovary, or appendix using a flexible endoscope, inserted through a natural orifice such as the vagina, stomach, or rectum.^9–11 When comparing the different potential approaches to the peritoneal cavity, the transvaginal (TV) route is favored by many. This TV route avoids a breach in the gastrointestinal tract, thereby preventing contamination of the peritoneal cavity with enteric contents and gut flora. It is also relatively straightforward to repair the defect in the posterior fornix of the vagina at the end of the procedure. ¹² The utilization of a “natural orifice” to gain access to the peritoneal cavity without transgression of the abdominal wall may further improve donor cosmesis and also recovery times by completely avoiding abdominal wall incisions. TVNOTES may also result in reduced postoperative pain compared with standard laparoscopic surgery. ¹³ These factors may further incentivise potential donors in their decision to consider donor nephrectomy and hopefully increase donor nephrectomy rates. To date, we are unaware of any TVNOTES donor nephrectomies having been performed in Australia.

A number of articles have discussed various issues concerning the techniques used in NOTES, the training methods required, and the cost of the procedure.^14–16 However, there are limited data available relating to the perspectives of women toward TVNOTES. Similarly, no data are available relating to the attitudes of female Australians toward such a concept. We believe that it is relevant to obtain the views of women who have experienced LDN and whether the possibility of undergoing TVNOTES as an alternative would have been attractive if available at the time of their nephrectomy. The aim of this study was to analyze this group's views and concerns about the possibility of undergoing donor nephrectomy via the TV route.

Materials and Methods

The opinion of female laparoscopic kidney donors toward the possibility of undergoing a NOTES procedure via the TV route of peritoneal cavity entry was assessed by the use of an anonymous questionnaire. This 15-point questionnaire (Appendix 1) was devised by a multidisciplinary group of surgeons interested in minimally invasive surgery. Female laparoscopic kidney donors were identified from the transplantation department's living related transplant database, and ethical approval for the study was granted by the local Research and Ethics Committee. The results from the questionnaires were de-identified and collated by a single independent researcher and analyzed using SPSS statistical software (version 17.0).

Results

One hundred and fifty female kidney donors who had undergone LDN were sent questionnaires. Forty-nine patients (33%) returned the completed questionnaire. The median age of these patients was 51 years (range 25–67 years). The vast majority of respondents (96%, n = 47) were parous. The respondents were asked about their feelings toward scars as part of an abdominal operation. Eighty-nine percent of these women were not unhappy with scars after surgery. When the women were divided according to age (≤50 or >50 years old), the responses remained very similar (91% where age ≤50 years, 88% where age >50 years).

Participants were asked whether they would opt for a visibly scarless form of donor nephrectomy as opposed to the laparoscopic procedure they had undergone. When asked whether they would prefer an alternative, visibly scarless method to LDN, 57% answered yes, and 43% replied no. For those who answered positively for an alternative to LDN, the reasons behind these responses were investigated. No patients cited cosmesis as the primary benefit of the scarless alternative. 55% felt that an alternative procedure would induce less pain, and 34% felt that the benefit of the alternative procedure would be a combination of less pain and improved cosmesis. Other reasons for the benefit of alternative procedure were voiced by 10% of respondents (which included any benefit for patients with keloid tendency?, time to heal may be faster, lesser chance of infection, small length of the scar, safer, time taken for the procedure lesser?). All respondents were then questioned about the use of their vagina as an entry point for abdominal surgery. Of these, only 18% were unhappy or very unhappy at this prospect, with 55% being neutral to the idea and 26% being either happy or very happy with this type of surgery. The women were also questioned regarding their concern with any potential negative impact on their sexual function after TVNOTES. A third of patients (33%) expressed concern, whereas 47% were not concerned and 20% were unsure of the impact on sexual function postsurgery. When assessed by age, no statistically significant differences were found in the responses from older and younger women. Patients were then asked directly for their preference between LDN and TVNOTES, 63% preferred LDN with 37% opting for TVNOTES. When it was stated that TVNOTES could potentially be equally as effective and safe as LDN, the uptake for TVNOTES increased to 51% (though this increased preference for TVNOTES did not reach statistical significance).

Discussion

Recent advances in technology have empowered surgeons to perform increasingly complex operations with a minimally invasive approach. This has been largely limited to laparoscopic surgery, though this technique still requires transgression of the abdominal wall. The most modern advances in technology (TVNOTES) have the potential to allow complex intra-abdominal operations to take place without leaving visible scars as well as the potential for less pain for the patient.

Our study indicates that the cosmetic result after surgery is of low importance to this group of individuals. This may be due to the altruistic nature of the patients who participate in live organ donation. Other studies, however, investigating the importance of cosmesis in relation to NOTES and standard laparoscopic procedures also found that cosmesis appeared to be a relatively low priority. The results from this study differ from those published earlier, as age did not affect a patient's attitudes toward cosmesis.

Pain was perceived as a more concerning feature of LDN. Eighty-nine percent of patients who would consider a TVNOTES procedure over an LDN felt that the prospect of less pain after the visibly scarless organ donation surgery would be of significant benefit. It should be highlighted, however, that the majority of patients were happy with their LDN, as only a minority would opt for an alternative method for organ donation. Even when it was stated in the questionnaire that TVNOTES and LDN were equally effective and safe but with the possibility of less pain after the former operation, the number of patients opting for each procedure was equal. This would suggest that this group of patients is wary of the introduction of unproved surgical techniques when a safe, well-proved, minimally invasive option (LDN) is available. Patients did not appear to be adverse to the concept of TV surgery for abdominal surgery, and only a minority were concerned with a negative impact to their sexual function. This may be due to the inherent bias in this group, as all but two women were parous and the majority of respondents were over 35 years old. These findings are in contrast to other NOTES based questionnaires in the literature that found a strong association with nuilliparity and younger age with higher levels of concern over sexual function after a TVNOTES procedure.

With the present interest and rapidity of progress in NOTES, it is important to gauge the attitudes of women toward this technique of entry into the peritoneal cavity. This patient profile of respondents in this study is ideal to assess the attitudes of female patients to TVNOTES, as this group already has experience of a major laparoscopic operation. This gives them good insight into answering the questions we have posed to them with regard to TV approach into the peritoneal cavity. This study represents the only survey of opinions of laparoscopic renal donors toward TV surgery to date. Our study may have an inherent bias, as the return rate of the questionnaire was 33%.

Although NOTES procedures are being performed at the present time, the numbers thereof are minimal in comparison to standard laparoscopic procedures. Many of those that are being performed are being done as hybrid procedures (e.g., with laparoscopic assistance, utilizing a laparoscope placed at the umbilicus, or with extra transabdominal ports), mainly as a result of limited technology. Thus far, the instrumentation used has been conventional double-channeled endoscopes and endoscopic instruments (graspers, scissors, clip applicators, diathermy, etc.). Newer technologies are being developed, however until robust methods of being able to safely control major vascular structures exist, the role of TVNOTES in donor nephrectomy will be limited. Due to increasing interest from surgeons, the public and industry alike, these developments will happen, and TVNOTES is likely to be marketed to the public as a procedure that offers less pain and better cosmesis. The results from this study indicate that the important factor to the consumer, however, will still be the established safety of the procedure. Future studies must, therefore, take into consideration this major factor, which will, in turn, help women decide on their own preference between TVNOTES and standard laparoscopic procedures.