Franqois Mosimann Vincent Bettschart RCmi Schneider zyxwvutsr laparoscopic live donor nephrectomy for transplantation: urgent need for standardising procedures zyxwvuts Received 8 June 2000 Accepted: 6 September 2000 Sir: The persistent shortage of ca- daveric organs for renal transplan- tation has stimulated live kidney donation [6]. The excellent results obtained using both genetically re- lated [2l] and unrelated donors zyxwvutsr [S, 231 have increased this trend, and the recent promotion of allograft harvesting by laparoscopy may fa- vour this option even further. Many teams have indeed already aban- doned the traditional and safe trans- and retroperitoneal open nephrec- tomy techniques. At first glance, this switch to minimally invasive surgery appears as a significant advance. A closer look indicates however that this is far from being established. It is therefore our purpose to suggest a critical and careful approach to this question, so as to comply with the Hippocratic primurn zyxwvutsrq non nocere principle. Previous observational studies have established that the mortality- and major morbidity rates of open live nephrectomy are in the order of 0.03 zyxwvutsr YO [2] and 24% [lo], respec- tively. Our current clinical practice guidelines are based on these fig- ures. It may however be illegitimate to use them blindly when advising donors to undergo the endoscopic procedure. Although many of the established advantages of laparos- copy zyxwvutsrq - improved cosmesis, less pain, early resumption of diet, shorter hospitalisation, and time away from work and social activi- ties - are likely to be confirmed in the donation setting, other major issues remain to be settled. These relate to the quality and function of the graft. Pioneer series seem to in- dicate that the recipients of laparo- scopically procured kidneys are not disadvantaged [7, 191, but the fol- low-up studies must be longer [14]. Endoscopic harvesting indeed in- creases the warm ischemia time by several minutes, an injury that may adversely impact on long term graft survival [17]. In addition, the early operations have been performed by leading laparoscopic surgeons, and the retrieved kidneys were selected according to more restrictive crite- ria than those usually accepted for the open approach [7,19]. The most striking difference is that right kid- neys were rarely considered for laparoscopy for fear that stapling the right renal vein would shorten this 1-2 cm-long-vesseltoo much, thus making anastomosis in the re- cipient problematic. Similarly, kid- neys with more than one artery have only occasionally been pro- cured. Since these initial reports - and because of their positive con- clusions - laparoscopic donation has quickly become so attractive as to virtually abolish the traditional method at many transplant centres. Simultaneously, the industrial equipment has improved, and the surgical techniques have developed so far that several variants of the operation - some strictly endoscop- ic and others only video-assisted - are now being performed. Right nephrectomies are now more fre- quent and vascular anomalies are not regarded as absolute contrain- dications anymore [l]. More lapa- roscopists - some with possibly lesser skills than their pioneer col- leagues, and many with minimal or no experience in transplantation - have joined the venture so that some failures may well go unre- ported. The scene is therefore set for a replay of the laparoscopic cholecystectomy saga, i. e. the rapid spread of a new surgical procedure without a thorough preliminary sci- entific assessment. Concerning the gall bladder, the penalty has been that it took a full decade to obtain a clear picture of the advantages and complications of the new operation [20]. Should history repeat itself, the delay will be even longer for the comparatively uncommon live do- nor nephrectomy. Of course, a large multicenter randomised controlled trial comparing open and laparo- scopic nephrectomy is highly desir- able [13,15]. Such a study, however, is unlikely to be performed for the following reasons. Firstly, fund rais- ing for this long term and logistical- ly complex trial would be difficult: medical schools and universities are unlikely to provide financial re- sources; governmental authorities may not regard the issue as a public health priority, and industrial sup- port may introduce a methodologi- cal bias. Secondly, should this eco- nomic hurdle be overcome, it is probable that many physicians and surgeons would feel uncomfortable mixing the issues of altruistic ne- phrectomy and randomisation when informing potential donors only concerned with the health of a sick relative. Finally, even if enough pa- tients were recruited, the results would not be available for several years, at a time when the coelio- scopic procedure has already gained much acceptance and enthusiasm among transplant surgeons, neph- rologists and, most importantly, po- tential donors. Under these circumstances, are we therefore condemned to lack scientific assessment of live donor laparoscopic nephrectomy? Will our good practice guidelines be based on the proliferation of un- controlled case series only? If so, healthy donors and patients may undergo avoidable complications, and the already questioned credi- bility of surgical research [8] will decline further. If this sequence of