Technical Modification for Laparoscopic Donor Nephrectomy to Minimize Testicular Pain: A Complication with Significant Morbidity

Abstract

The laparoscopic approach to donor nephrectomy is becoming increasingly common. While it is felt that the recovery from laparoscopic nephrectomy is quicker and less painful, a number of complications have been reported. A rarely reported on complication in the literature with significant morbidity is ipsilateral orchalgia. From 1998 to 2008, 257 hand-assisted laparoscopic donor nephrectomies were performed at our institution. Eight of 129 (6.2%) men complained of de novo ipsilateral orchalgia postoperatively. The average duration of pain was 402 days. Patients reported significant morbidity related to this complication. None, however, required further treatment. Three patients reported that they would reconsider organ donation as a result of testicular pain. Our technique originally included dissection and ligation of the gonadal vein en bloc with the ureter at the level of the left common iliac artery. Since recognizing this complication, we have adopted a gonadal vein sparing approach so as not to disturb the vessel below its point of ligation at the renal vein. To date, 50 patients have undergone the modified technique without experiencing orchalgia. In conclusion, ipsilateral testicular pan is a relatively frequent complication of laparoscopic donor nephrectomy and may be a source of significant morbidity. Using a modified surgical technique, this complication can be reduced or eradicated.

Introduction

Laparoscopic nephrectomy has gradually become the procedure of choice in living donor nephrectomy. In our experience (1) and that of others (2, 3) between 50% and 100% of donor nephrectomies in tertiary centers are done via laparoscopy. The reduced recovery time, diminished analgesic requirements, and shorter hospital length of stay have contributed to the general acceptance of this technique (4–6). Our center, amongst others, has found no difference in long-term graft survival with this approach (1,7,8). The complication rates for such surgeries have been reported widely. Some authors have noted no significant differences in complication rates (7,9), while others, including our center, have found a slightly increased number of complications related to laparoscopic donor nephrectomy (1,10,11). One rarely reported on but common complication noted has been ipsilateral orchalgia in men after laparoscopic donor nephrectomy. One report exists (12) in the transplantation literature, and very few reports address this issue after nephrectomy for oncologic indications (13,14). Here we report our experience with ipsilateral orchalgia after laparoscopic donor nephrectomy and its impact on patients.

Patients and Methods

Data Collection

A retrospective review was performed of our center's living donor nephrectomy database under preexisting Institutional Review Board approval. Patients complaining of orchalgia were identified and further evaluated. Perioperative factors, including operative complications were recorded. Long-term follow-up of the orchalgia was ascertained. Patients were directly contacted and questioned on a variety of aspects of their testicular pain, including severity on a 10-point scale, duration, alleviating or exacerbating factors, evaluation and treatment. All responses were internally corroborated with chart documentation whenever possible.

Modification of Technique

Since recognizing the postoperative complication of ipsilateral orchalgia, we have modified our laparoscopic approach of gonadal vein dissection and ligation. This modified technique has been employed for the last 50 patients undergoing laparoscopic donor nephrectomy.

In the original procedure, the vein was dissected en bloc with the ureter and ligated at the distal most aspect at the level of the left common iliac artery (Figure 1A). The most proximal insertion of the gonadal vein was ligated very close to the renal vein confluence. Our modification is different in that the gonadal vein is dissected meticulously off the ureter and periuretal tissues and skeletonized up to the level of the renal vein confluence (Figure 1B). It is not disturbed at all below this most proximal level, and neither is any periureteral tissue. As close as possible to the renal vein, the gonadal vein is clipped and ligated without any ligation or clipping/stapling of adjacent tissues. The gonadal artery is spared in both versions of the procedure.

Figure 1. (A) The gonadal vein is dissected en bloc with the ureter. (B) The ureter is dissected off the gonadal vein preserving the periureteral tissue. A = adrenal vein; B = ureter; C = gonadal vein and D = aorta.

Results

From 1998 to 2008, 413 live donor nephrectomies, including 257 (62.2%) laparoscopic donor nephrectomies were performed at our center. Of these, eight males were identified with ipsilateral orchalgia of new onset after surgery. All of these were in the laparoscopic donor group, forming 6.2% of all male laparoscopic donors and 3.85% of all male donor nephrectomies performed. The average age at the time of survey was 44.2 years (range 30–59). Intraoperatively, no complications were recorded. No patients required conversion to open nephrectomy, transfusion of autologous or heterologous blood products, postoperative dialysis, or intensive care unit admission. The Foley catheter was routinely removed on postoperative day 1. We did not observe an increase in orchalgia associated with catheterization time.

The onset of pain was noted to be a mean of 15.5 days postoperatively (range 4–60 days). Patient-reported pain averaged 7 with a range of 4–9 on a scale of 1–10. All patients experienced orchalgia on the ipsilateral side to the laparoscopic donor nephrectomy. Four (50.0%) men reported exacerbation of their symptoms with sexual intercourse. Motion and touch during daily activities worsened the pain in 5 (62.5%) cases. Relief of pain with medications, both narcotic and NSAIDs, was noted by 5 (62.5%) men. Three (37.5%) patients reported that the pain was present at the time of discharge from the hospital. The same number reported resolution of the pain at the time of discharge.

As outpatients, four patients were worked up for persistent pain with ultrasound and urinanalysis. Ultrasound revealed an epididymal cyst in one patient and mild decreased blood flow in another. One patient had a urinanalysis positive for trace leukocyte esterase, 6 to 8 white blood cells and more than 1 bacteria. Four patients were treated with antibiotics for a presumptive diagnosis of epididymitis. The remainder of patients were managed expectantly. On both physical exam and ultrasound, no patient was found to have atrophy of the affected testicle.

The mean duration of orchalgia in this cohort was 402.3 days (range 24–1100 days). Only one patient had persistent orchalgia that had not resolved at the time of questioning for this study. One patient reported that he considered this a major surgical complication. The remainder did not feel this was a complication of the surgery. Three patients stated they would rethink organ donation as a result of orchalgia.

Of the most recent 50 patients undergoing the modified technique for gonadal vein ligation, none have complained of testicular pain at last follow up.

Discussion

Laparoscopic donor nephrectomy is rapidly becoming the technique of choice for live renal donation. At our center, the vast majority of donor nephrectomies are performed via laparoscopy. Over the last 10 years, of 413 live donor nephrectomies, 253 were laparoscopic and 160 have been open, with increasing proportion of laparoscopic cases over the most recent years.

While complications of donor nephrectomy have been reported by a number of centers, one complication rarely reported on in the literature is ipsilateral orchalgia. Kim et al. (12), reported that 9.6% of male donors undergoing laparoscopic nephrectomy complained of ipsilateral orchalgia. They report that the average onset of pain was on postoperative day five, with the mean duration of pain being 6.3 months. Of their cohort, one patient underwent spermatocelectomy with improvement of pain. Another patient underwent surgical exploration with orchiopexy after an ultrasound showed evidence of decreased vascular flow to the testis. Half of their patients reported residual pain, with a maximum score of 3 on a scale of 1–10.

Gjertson et al. (13) also reported on testicular pain after laparoscopic surgery. However, their study included patients undergoing a number of laparoscopic renal and adrenal procedures, including radical and simple nephrectomies, adrenalectomies, and pyeloplasties. They reported that 55% of patients undergoing laparoscopic donor nephrectomy and 20% of patients undergoing radical nephrectomy complained of ipsilateral orchalgia. The long-term follow up of patients’ pain was not reported by this group so it is unknown what proportion of these patients experienced relief and/or resolution of pain.

In our study, we report a lower proportion of patients with ipsilateral orchalgia after laparoscopic donor nephrectomy. We encountered 8 patients with this complication out of a total of 129 males undergoing this procedure, resulting in 6.2% of patients with this complication. The average onset of pain was on postoperative day 15.5, 10 days later than that reported by Kim et al. (12). The mean duration of pain in our group was 13.4 months, which is significantly longer than the 6.3 months reported by Kim's group. This may in part be due to two patients who had testicular pain for 30 and 36.6 months, causing a marked increase in the mean of this variable.

The underlying etiology of ipsilateral testicular pain remains uncertain. Kim et al. (12) hypothesized that several mechanisms may ultimately result in orchalgia, including nerve injury to the spermatic plexus composed of the superior, inferior, and middle spermatic nerves, and trauma to the spermatic cord. Given the anatomical location and levels of transection or injury to neuronal tissue, along with experience during a variety of laparoscopic procedures, the authors state that it is likely a combination of events that results in this complication. They recommend preservation of the gonadal vessels or, if ligation is required that usually results in collateral disruption of the neural tissue, it be done at a higher level in the body.

Gjertson et al. (13) hypothesized that vascular congestion from ligation of the gonadal vein may be a causative factor in the development of pain. They also state that interruption of the lymphatic drainage may contribute to orchalgia given subsequent development of ipsilateral hydrocele in 8% of their patients. They do conclude that while still debated, lymphatic and vein sparing surgical approaches do not seem feasible during laparoscopic nephrectomy.

We agree also that the cause of pain after nephrectomy is likely multifactorial. We use Bovie electrocautery for a significant portion of the distal dissection of the ureter and gonadal vein followed by staple ligation of the ureter. We have seen no hydrocele or varicoceles postoperatively. The gonadal vein is currently spared distally with minimal dissection wherever possible. Since adopting a gonadal sparing approach, we have noted that none of our last fifty male patients have complained of testicular pain. While this may be due to diminished vascular congestion, as hypothesized by Gjertson et al. (13), it may also decrease the number of neuronal collaterals ligated during the sacrifice of the gonadal vein as we meticulously skeletonize the gonadal vein along its length to the renal vein confluence. In this way, it is likely that most of the hypotheses previously advanced are correct and contribute to pain in a number of ways.

In conclusion, laparoscopic donor nephrectomy is a safe and effective way of renal donation that is gaining widespread acceptance as the technique of choice for living donor surgery. A number of known major and minor complications have been reported but one complication that is discussed infrequently is ipsilateral orchalgia. We noted this in 6.2% of patients after laparoscopic donor nephrectomy. This can, in rare cases, be a cause of significant morbidity to patients, with three patients reporting they would rethink organ donation based on this issue. As such, ipsilateral orchalgia should be discussed as a potentially morbid complication of the surgery and patients should understand that this may persist for a significant length of time. However, only one patient has residual orchalgia that has not resolved at the time of this study. A modified technique wherein the gonadal vein is dissected and skeletonized and ligated very close to the renal vein has shown promise in eliminating testicular pain after surgery. This may be due to the decreased disruption of adjacent neuronal structures in addition to minimizing vascular congestion as we have seen no varicoceles in this group.

Disclosure

The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.