The preceding article on simultaneous bilateral laparoscopic nephrectomy and renal transplantation introduces an important and interesting concept: Why not?
There is nothing simple about a laparoscopic ‘simple’ nephrectomy for autosomal-dominant polycystic kidney disease (ADPKD). Space is limited and these kidneys displace and alter the spatial anatomy of intra-abdominal organs and cross the midline making laparoscopic dissection of the hilum difficult. The danger of proximity to the large vessels should not be underestimated. Therefore, a unilateral laparoscopic ‘simple’ nephrectomy for ADPKD is enough of a challenge in and by itself, let alone it being accompanied by a contralateral nephrectomy followed by renal transplantation. There is potential for significant blood loss and transfusion, resulting in hypotension and sensitisation with its potential inherent effects on subsequent graft function. Complications from one massive bilateral operation preceding the transplantation can have an immediate and direct impact on the renal transplantation procedure.
A unilateral laparoscopic nephrectomy on the symptomatic side followed by immediate renal transplantation might be sufficient to alleviate symptoms, provide room for transplantation and save the patient another anaesthetic. Otherwise, a staged unilateral or bilateral laparoscopic nephrectomy followed by renal transplantation at another setting might still be an excellent viable option. The patient will be given the chance to recover from their previous nephrectomy before embarking on a lifesaving, life altering transplantation procedure. With the short supply of donor kidneys worldwide, where a patient often gets one chance for transplantation success, a more conservative approach might still be a more prudent approach.
The authors do not propose this approach for every patient with ADPKD and clearly state that appropriate patient selection is mandatory. This procedure has a role in select patients and appropriate clinical scenarios for the experienced laparoscopic surgical and transplant team. A high degree of coordination is inherently mandatory.