Living donor nephrectomy
When is this procedure indicated?
Living donor transplantation represents a valuable alternative to deceased donor transplantation as it allows to:
- avoid, if scheduled early enough, the waiting time on the patient's list;
- circumvent the inevitable damage resulting from the duration of cold ischemia time of the kidney taken from a deceased donor;
- guarantee the certainty, if planned in advance, of being transplanted before the beginning of the dialysis treatment (preventive transplantation).
How is it performed?
Living kidney donation is done under general anesthesia. The choice of the kidney to be taken depends on the characteristics of the patient, considering that in principle the best kidney should be left to the donor. In line with this principle, all kidney donors undergo accurate study (CT or MRI cmc) of the renal vascular anatomy, and sequential renal scintigraphy to assess the performance of each organ among preoperative investigations.
It is now a standard to perform nephrectomy with minimally invasive access, whether laparoscopic or robot-assisted, based on the experience of the Center. For nephrectomy, three or four small incisions are made in the abdomen, plus a service incision of about 5-7 in the suprapubic location for extraction of the organ.
After surgery, the patient is mobilized early. Fluid intake can occur 4 hours after surgery, and solid foods from the first postoperative day, depending on the patient's clinical condition. In the absence of complications, the postoperative course is 3-4 days; however, convalescence is 15-20 days.
Common complications to any major abdominal surgery: wound infection, venous thrombosis with possible pulmonary embolism, postoperative bowel occlusion (due to the formation of postoperative adhesions, which occurs at a considerably lower rate than the same surgery performed by laparotomy), postoperative laparocele. Such complications occur in 2% or less of cases.
Slightly more frequent is postoperative pneumonia, which occurs in about 4% of cases.
A specific complication of this type of surgery, on the other hand, is the collection of blood or serous material at the operation site, which is why the placement of a surgical drain may be preferred to the operative act, which is then removed in the first few days of the postoperative course.
The mortality rate of this surgery is 0.02-0.03%, depending on the case series.
The choice to undergo donor nephrectomy with a minimally invasive technique allows, as reported in the literature, for better control of postoperative pain and faster return to daily activities by the patient.
Long-term complications are: laparocele, which is the breakdown of muscle fascia at surgical incisions. This complication develops in less than 2% of cases, requiring surgical correction. Another long-term complication may be the formation of postoperative intraperitoneal adhesions, which can lead to disturbances in channelling up to intestinal occlusion. In fact, the minimally invasive technique is burdened with a significantly lower risk of their formation than laparotomy, but not zeroed out. Treatment of intestinal obstruction may be conservative, with placement of nasogastric tube for detention purposes combined with intravenous hydration, or may need surgery to proceed with lysis of adhesions. The same surgery can be performed, depending on the type of occlusive picture, by minimally invasive technique.