Title:
Comparison of donor, and early and late recipient outcomes following hand assisted and laparoscopic donor nephrectomy.

Abstract:
While laparoscopic donor nephrectomy has encouraged living kidney donation, debate exists about the safest laparoscopic technique. We compared purely laparoscopic and hand assisted laparoscopic donor nephrectomies in terms of donor outcome, early graft function and long-term graft outcome.
We reviewed the records of consecutive laparoscopic and hand assisted laparoscopic donor nephrectomies performed by a single surgeon from 2002 to 2011. Donor operative time and perioperative morbidity were compared. Early graft function for kidneys procured by each technique was evaluated by rates of delayed graft function, need for dialysis and recipient discharge creatinine. Long-term outcomes were evaluated by graft function.
A total of 152 laparoscopic donor nephrectomies were compared with 116 hand assisted laparoscopic donor nephrectomies. Hand assisted procedures were more often done for the right kidney (41.1% vs 17.1%, p <0.001) and in older donors (age 41.4 vs 37.5 years, p = 0.011). Warm ischemia time was shorter for hand assisted than for purely laparoscopic nephrectomy (120 seconds, IQR 50 vs 145, IQR 64, p <0.001). Median operative time was slightly shorter for the hand assisted than for the purely laparoscopic procedure (155 vs 165 minutes, p = 0.038). In each group 2 intraoperative complications required intervention (open conversion in 1 case each). Postoperatively complications developed after 5 purely laparoscopic and 5 hand assisted operations (1 Clavien 3b in each). Median length of stay was 2 days for each surgery. Postoperatively recipient outcomes were also similar. Delayed function occurred after 0% hand assisted vs 0.9% purely laparoscopic nephrectomies, dialysis was required in 0.9% vs 1.7% and rejection episodes developed in 9.7% vs 18.4% (p >0.05). At last followup the organ was nonfunctioning in 6.1% of hand assisted and 7.7% of purely laparoscopic cases (p >0.05). The recipient glomerular filtration rate at discharge home was similar in the 2 groups.
Hand assisted laparoscopic donor nephrectomy had shorter warm ischemia time but perioperative donor morbidity and graft outcome were comparable. The choice of technique should be based on patient and surgeon preference.