Renal and Pancreatic Transplant News

Kidney Transplant: Physicians Perfect Laparoscopy

The laparoscopic technique for harvest ing grafts has dramatically expanded the availability of live kidney donations for transplantation. This approach has rapidly been adapted as a standard of care worldwide because of its considerable advantages, but transplant surgeons at NewYork-Presbyterian Hospital were pioneers in this procedure and continue to perfect the protocol.

Lloyd E. Ratner, MD, FACS

"The dramatic increase in live-donor kidney transplants parallels the development of laparoscopic techniques. In the United States, more than 80% of all live kidney donations are now performed laparoscopically, and it has meant that far more patients with failing kidneys are receiving potentially lifesaving transplants," observed Lloyd E. Ratner, MD, who participated in the very first laparoscopic harvesting of a donor kidney in 1995 and has since instructed hundreds of surgeons on how to perform the procedure at centers around the world.

"In animal models, we are now looking at minimally invasive procedures for kidney grafts in the recipient. The early work is promising and may be leading to clinical applications," he said. According to Dr. Ratner, recipients would derive the same types of benefits, particularly rapid recovery, that donors now derive from procedures performed laparoscopically.

Joseph J. Del Pizzo, MD, started his work in minimally invasive live-donor kidney transplants at the University of Maryland, soon after Dr. Ratner initiated the procedure. Dr. Del Pizzo noted that although the technical demands of the laparoscopic procedure are greater than those for an open live-donor transplant, the benefits not only extend to the graft donors but to others on the waiting list for a donor organ.

"If you increase the number of donors, everyone benefits, including those who move up on the waiting list for a cadaveric organ," he said. "With the open procedure, there are a lot of disincentives even for the motivated donor, including significant risk of morbidity and a substantial recovery time. In the past, donors often have to put their whole life on hold for a couple of months."

According to the United States Organ Procurement and Transplantation Network (OPTN), there are currently 71,600 patients on the waiting list for a kidney transplant. The majority of these individuals are those who have been unable to provide their own living donor and are now waiting for suitable cadaveric organs. Based on survival, living donor organs are preferable. Each step toward reducing the risks and morbidity for donors is likely to increase the number of patients who are able to locate suitable volunteers.

Importantly, when the procedure is performed laparoscopically, complication rates are reduced with no change in graft survival, according to follow-up that now extends to 10 years in some patients. Asked about the quality of the grafts, Sandip Kapur, MD, reported that "the quality of the grafts is at least as good," and more live donors means better preoperative planning.

"From my perspective, the minimally invasive procedure has been a major step forward," added Dr. Kapur, who works with surgeons in planning the harvesting of donor grafts in order to facilitate the transfer. "By reducing the recovery time, it increases the number of individuals who are willing to be donors, and it permits some individuals who would not have been considered good candidates for the stress of an open procedure, such as older individuals, to donate an organ. There really is no substantial downside."

In an open procedure, typical hospital stays were 10 days and sufficient recovery allowing patients to return to normal daily activities could be 3 months or longer. When the live donor transplant is performed laparoscopically, the patient goes home the next day and may only need 2 or 3 weeks before returning to normal activities.

The national conversion rate is about 5%; at NewYork-Presbyterian/Weill Cornell, the conversion rate is less than 1%, according to Dr. Del Pizzo. The same can be said for the work at NewYork-Presbyterian/Columbia University Medical Center.

"It is true that the laparoscopic procedures are more difficult to perform than open procedures from a technical perspective, but these can be converted to open procedures if necessary," Dr. Del Pizzo said.