Aaron D. Martin, Children's National Medical Center, Division of Pediatric Urology, 111 Michigan Avenue, NW, Washington, DC 20010-2970 USA. e-mail: email@example.com
Study Type – Therapy (case series)
Level of Evidence 4
What's known on the subject? and What does the study add?
Extirpation of polycystic kidneys for various medical reasons has been performed using many different approaches in attempts to limit morbidity from such a large operation. In indicated patients, it has usually been offered in a staged approach with renal transplantation to avoid graft complications. We published the first case of simultaneous laparoscopic bilateral native nephrectomy with kidney transplant in 2008.
The present study shows our continued experience with offering this minimally invasive, single surgery alternative. The results are comparable to a staged laparoscopic approach with significantly shorter total hospital stay and one recovery for the patient and his/her family.
• To analyse the perioperative outcomes of native bilateral laparoscopic nephrectomy (BLN) with simultaneous kidney transplantation.
PATIENTS AND METHODS
• From November 2000 to April 2011, 37 patients were seen for renal failure secondary to autosomal-dominant polycystic kidney disease (ADPKD) and underwent renal transplant with native nephrectomies at a single tertiary academic centre.
• In all, 15 patients underwent BLN for ADPKD followed by simultaneous kidney transplantation.
• The other 22 patients underwent BLN for ADPKD with kidney transplant performed at a separate setting.
• Demographic data, perioperative outcomes, complications regardless of need for intervention, and graft function were analysed in both groups.
• The combined surgery was completed without intraoperative complication in all cases.
• The median total operative duration was 372 min, estimated blood loss was 300 mL with two patients requiring transfusion, and the median (range) hospital stay was 5 (3–7) days.
• All patients had immediate graft function with additional relief of compressive symptoms.
• In comparison to our staged cohort, the simultaneous group had a significantly shorter total hospital stay.
• All other outcomes and complication rates were comparable.
• In ADPKD, a less invasive laparoscopic approach for native nephrectomies with simultaneous renal transplant offers comparable morbidity without graft compromise and the convenience of one operation and one recovery for the patient.
Autosomal-dominant polycystic kidney disease (ADPKD) leads to end-stage renal disease (ESRD) and the need for transplantation in almost half of these patients by the age of 60 years . The massive enlargement of these kidneys can create additional problems for these individuals unrelated to their renal failure – abdominal pain, early satiety, infection, haematuria, intracystic haemorrhage, nephrolithiasis, dyspnoea, and hypertension . Their size alone can preclude the placement of a donor kidney (Fig. 1). Many different techniques have been proposed to manage these kidneys from open bilateral nephrectomies to unilateral nephrectomy to cyst decortication and cryoablation. The first unilateral laparoscopic nephrectomy (ULN) for ADPKD was performed in 1996 . Since then many groups have performed both transperitoneal and retroperitoneal bilateral LNs and hand-assisted nephrectomies for ADPKD [3–9]. We reported our technique with BLNs for ADPKD in ESRD in 2008. We also reported the first published case of BLN for polycystic kidneys with simultaneous kidney transplant . We have continued to offer this procedure in properly selected patients and present here the only series of BLNs with simultaneous renal transplant in ADPKD with ESRD. We have also compared this to our cohort of staged BLN and renal transplantation.
PATIENTS AND METHODS
After Institutional Review Board approval, a secured database was created to track all LN patients. Review of the database from November 2000 to April 2011 revealed 15 patients that underwent BLN for ADPKD with simultaneous kidney transplantation, and 22 patients that underwent BLN for ADPKD with staged renal transplantation. The simultaneous LN-transplant approach was not offered until March 2007. At that point, all patients were extensively evaluated and those who had a suitable donor, significant justification for bilateral nephrectomies (persistent pain requiring narcotics, recurrent infections, persistent haematuria, or abdominal crowding inhibiting transplantation), and were psychologically motivated were offered this new simultaneous procedure. Importantly in the simultaneous group, deceased donor organs were allowed only in cases where sufficient time existed to properly prepare the laparoscopic team without delaying transplant or prolonging cold ischaemia time.
For the nephrectomy portion, standard laparoscopic techniques with an infraumbilical midline hand-port were used allowing extraction by extension of the infraumbilical incision if needed as we have previously described . Considerable laparoscopic experience is needed to optimise patient outcomes, as working space is greatly limited and anatomy is greatly distorted by the renal cysts. The procedure requires meticulous patience with every move to avoid inadvertent injury to structures (e.g. bowel, pancreas, spleen, etc.), which are more easily reflected away from the operative field in a standard nephrectomy. The abdominal crowding due to the size of these kidneys can distort the surgeon's typical landmarks and frame of reference. Hand-assistance is used only if additional retraction is beneficial to avoid crowding the surgical field more than necessary. This is generally provided by an additional assistant to the primary surgeon and camera person allowing the primary surgeon to continue operating with two laparoscopic instruments. Care also must be taken when extracting the specimen not to inadvertently rupture cysts or tear attachments to other abdominal structures. The specimens are typically too large to bag intracorporeally.
For the simultaneous group, kidney transplantation was then performed via the midline extraction incision or a separate Gibson incision. This decision was made based on transplant surgeon preference and patient body habitus allowing adequate access to the iliac vessels for anastomosis. Immunosuppression was not varied from our typical renal transplant protocols including induction with aleutzemab (Campath) unless patients were sensitised at which time they received rabbit-anti-thymocyte globulin. Maintenance immunosuppression included tacrolimus and mycophenolate mofetil. Steroids were rapidly tapered by discharge in non-sensitised patients.
Demographic, perioperative, and graft function outcomes were collected and analysed using basic descriptive statistics. The Wilcoxon-Mann-Whitney test and Fisher's exact test were used to compare the two groups. All complications were recorded and classified regardless of severity or need for intervention .
Table 1 summarises the simultaneous BLN/transplant group. All but two patients complained of kidney-related pain preoperatively. Of the 15 patients, six were pre-emptive to dialysis. The specimens were quite large with a median total mass of 3785 g extracted. Seven patients had an additional Gibson incision made for transplantation. Of the eight patients with only one incision, four were able to have the transplant kidney placed retroperitoneally by closing the peritoneum anteriorly to avoid an intraperitoneal transplant.
Table 1. Characteristics of patients undergoing simultaneous BLN with kidney transplantation
Transfusion for preoperative anaemia/re-operation to check cortical flow (no intervention needed)
space for transplant
Transfusion for hypotension
All 15 patients originally selected for the simultaneous approach were able to be completed without any intraoperative complications or conversion to open extraction. One patient with extraperitoneal placement via Gibson incision required re-operation on postoperative day 1 due to poor arterial flow. The kidney was re-positioned intraperitoneally with subsequent graft success. One patient required re-operation due to poor cortical flow on ultrasonography. There was no evidence of poor flow intraoperatively and subsequent graft recovery. This patient did require 6 units of packed red blood cells due to preoperative anaemia (haemoglobin level of 8.1 g/dL) and history of Osler-Weber-Rendu syndrome with prior bleeds. Only one other patient required a 2-unit transfusion postoperatively due to symptomatic hypotension (postoperative haemoglobin level of 8.7 g/dL; estimated blood loss 550 mL) which quickly resolved. One patient required re-operation for a forniceal leak after initial discharge. Three other patients required re-admission within 30 days (transient hypotension secondary to antihypertensives, diarrhoea secondary to subacute pancreatitis, and subacute pulmonary embolus 27 days postoperatively requiring anticoagulation only).
Patient and graft survival after the combined procedure was 100% at time of last follow-up with a mean (range) follow-up of 14 (0–33) months. All patients had immediate graft function with no need for postoperative dialysis. Long-term function at last follow-up has been excellent; however, two patients are being treated for recurrent antibody-mediated rejection with good graft function.
One of the patients did have significant pathology found on nephrectomy specimen despite a benign cystic appearance on preoperative CT. This patient had an incidental 16-cm cystic papillary RCC (Fuhrman grade 2) on pathological examination of the native kidney. There was no vascular or peripheral invasion with negative surgical margins. The patient remains free of malignancy 2 years later on immunosuppression with close surveillance.
Table 2 summarises the comparison of the simultaneous vs the staged group. All variables were clinically similar with a statistically significant difference in total length of hospital stay (5 vs 7 days, P= 0.02). The post-transplant creatinine level (mean 1.6 vs 2.3 mg/dL, P= 0.07) was not statistically significant despite favouring the simultaneous approach. However, as previously explained, living donors were used more frequently in the simultaneous approach (13/15 in simultaneous group vs 13/22 in staged group), which would result in a shorter ischaemia time and possibly healthier/younger donor kidneys. The mean (median; range) time between BLN and transplantation was 14 (4; 1–53) months. Only five had BLN before initiation of dialysis with subsequent transplantation. In the staged group, 45% (10/22) of patients had BLN performed before transplantation.
Table 2. Simultaneous BLN with transplantation vs BLN with staged transplantation
Staged values reflect summation of both operative settings.
Mean (range) post-transplant creatinine level at discharge, mg/dL
Clavien-Dindo classification of complications , n
1-year graft survival, %
Complications were also low in the staged group with no open conversions. During the BLN portion, one patient was found to have a spontaneous pneumothorax requiring a chest tube 2 days after BLN and one patient had an ileus for 5 days that required treatment with a nasogastric tube. During the transplantation portion, one patient had transient atrial fibrillation, two patients had wound dehiscence, four patients had slow graft function with two having delayed graft function requiring re-admission with short-term dialysis, and one had constipation requiring re-admission. One patient lost three kidney allografts from graft thrombosis before the successful fourth transplant, which is now doing well. All patients now have good long-term function with a mean (range) follow-up of 28 (0–97) months.
Indications for BLN in the staged group were mainly chronic pain and early satiety. Three had recurrent infections thought to be due to infected kidneys. Three had renal lesions on imaging prompting removal before transplant. Of these three patients, two had malignancies (pT1a papillary RCC and pT1a chromophobe RCC) and both are free of any recurrences (>72 months follow-up) with good graft function. No patients in this group had incidentally found malignancies on pathology with prior negative imaging.
While most patients with ADPKD, even with ESRD, are asymptomatic, there are a percentage of patients who will require treatment for their massively enlarged kidneys. This may be due to symptoms (e.g. pain, early satiety, hypertension, nephrolithiasis, infection, haematuria, cystic haemorrhage) or merely to establish space for a renal transplant [1,3]. Surgical treatment for these conditions has been purposely avoided in the past because of high morbidity . However, our group and others have shown improved tolerability and success with a laparoscopic approach [2–8,10]. We previously reported the first case of simultaneous polycystic LNs with simultaneous kidney transplant and now have been able to offer this to several others with comparable outcomes.
Simultaneous open bilateral native nephrectomy with kidney transplant has been done successfully before although rarely [13–15]. The magnitude and risk of morbidity of such an operation has been the main deterrent. However, advancements in surgical techniques, perioperative medical care, and preoperative optimisation of transplant candidates have made the simultaneous approach much more alluring. There are many potential advantages to the combined approach, including but not limited to potentially one infraumbilical incision, one anaesthetic, one hospitalisation, and most importantly one recovery. In addition, the laparoscopic approach further minimises the impact on the patient. Even the largest specimens can be removed through an extended hand-port incision that is significantly smaller than the incision used in open surgical extirpation. Those that argue against this approach use perioperative risks, e.g. sepsis due to infected cyst rupture, intraperitoneal graft torsion, increased fluid shifts, increased risk of blood loss requiring transfusion, hypotension with resultant graft hypoperfusion due to magnitude of the procedure, excessive operative duration, increased risk of postoperative acute tubular necrosis of allograft, and donor cancellation, as justifications . Fortunately, none of these perioperative risks were significant issues in the present cohort, but certainly are points of concern. We previously described our technique and methods used to avoid these potentially devastating pitfalls .
Another concern of simultaneous nephrectomy and transplantation in these patients is the discovery of incidental renal malignancy. This did occur in one patient in the simultaneous group with no signs of recurrence to date (27 months follow-up). Preoperative imaging and intraoperative viewing did not reveal concern for malignancy, so transplantation was performed simultaneously as planned. No adjustments were made to postoperative immunosuppression after malignant pathology was known. All patients who had suspicious preoperative imaging were properly staged with BLN before transplantation with excellent outcomes. We do not feel this should preclude simultaneous BLN with transplantation in patients with negative preoperative imaging as incidence of renal malignancy is no different in ADPKD than in the general population .
Kramer et al.  described 20 patients undergoing open bilateral nephrectomy and simultaneous live-donor transplant with few complications and excellent graft survival with patient symptom relief. However, our laparoscopic experience shows better results in mean estimated blood loss (open 723.5 vs 244 mL laparoscopic), blood transfusion rate (open 90 vs 5% laparoscopic), and length of stay (open 7.2 vs 4.9 days laparoscopic) with comparable mean operative duration (open 390 vs 369 min laparoscopic).
Recently, Patel et al.  published their 20-year experience with 31 transplant patients undergoing native nephrectomy (28 bilateral, three unilateral) for ADPKD. Only one of these was done at the same time of transplant, which occurred emergently instead of electively as in the present study, and all but five cases were performed with an open technique. Using the Clavien criteria, Patel et al. reported an overall complication rate of 65% (open 73%, laparoscopic 20%, Clavien grades 1–5) and mortality rate of 3% (Clavien grade 5). The mean length of stay was 12 days for open cases and 5 days for laparoscopic cases. In comparison, the present overall surgical complication rate was 46% (53% simultaneous, 41% staged, Clavien grades 1–5) with 0% mortality. Our major complication rate was 22% (20% simultaneous, 23% staged, Clavien grades 3–5).
Other approaches have been described, e.g. open unilateral nephrectomy with simultaneous transplant with or without staged contralateral nephrectomy; however, results were comparable to those reported here [9,18]. Unilateral nephrectomy leaves the possibility of needing another operation to remove the contralateral kidney if further issues develop. The present data supports that the combined operation can be done with comparable outcomes and a shorter overall hospital stay. Preparing for and recovering from one operation is much easier for both the patient and their families for obvious reasons including time off work, travel costs, supportive care costs, and overall anxiety and stress levels.
The present study and its ability to be statistically analysed is certainly limited by the few patients, but our results are thus far consistent and comprise the largest published cohort of BLNs for ADPKD and the only series with simultaneous kidney transplantation to date. We do not have an open nephrectomy cohort for comparison as morbidity is far better for the laparoscopic procedure in our experience and that of others . No open conversions were necessary in any of the patients in which laparoscopy was planned. Despite published data suggesting that a specimen volume of >3500 mL is a major risk factor for conversion, we were able to avoid this complication with careful dissection and diligence in even the largest of specimens .
The greatest weakness of the present study is the non-randomized design, which certainly creates a selection bias whether intentional or not. Demographically the patients were similar in both groups; however, a clinical decision does have to be made as to the suitability of a patient for this larger simultaneous procedure. Understandably, the operation is best justified in the case of severe abdominal crowding with plans for pre-emptive living-donor transplantation. For patients already on dialysis and room for a kidney transplant, two operations separated by 6 weeks of recovery is perfectly acceptable. We did not and do not advocate this simultaneous procedure for every patient with ADPKD, but we certainly feel it is a medically responsible and personally advantageous option for many overall healthy and motivated patients with ADPKD. As can be seen by the shorter hospitalisation, one recovery as expected is shorter than two.
Native BLNs with simultaneous kidney transplant in ADPKD is feasible with low morbidity and excellent graft function. This approach compares favourably to the open data with many clear advantages for the patient in the hands of an experienced laparoscopic renal surgeon. Appropriate team coordination between urologist, transplant surgeon, and transplant medicine can optimise overall outcomes to best serve the patient.
We would like to thank the Mayo Clinic Department of Pathology for their expertise and evaluation of these large specimens.