Laparoscopic Kidney Transplantation—Novel or Novelty?

Abstract

The authors discuss the rationale for considering laparoscopic kidney transplantation. See case report by Modi et al on page 1320. The authors discuss the rationale for considering laparoscopic kidney transplantation. See case report by Modi et al on page 1320. In 1951 René Kuss performed an unrelated living donor kidney transplant using for the first time an retroperitoneal approach to expose in the iliac fossa the iliac vessels and the bladder (1Cinqualibre J Kahan BD René Kuss: Fifty years of retroperitoneal placement of renal transplants.Transplant Proc. 2002; 34: 3019-3025Crossref PubMed Scopus (13) Google Scholar). Although his initial five cases all failed secondary to acute rejection, in 1954 Murray used his technique to perform the first successful living donor kidney transplant using an identical twin as the donor (2Merril JP Murray JE Harrison JH Guild WR Successful homotransplantation of the human kidney between identical twins.J Am Med Assoc. 1956; 160: 227-282Google Scholar). This technique is still commonly used in clinical kidney transplantation, virtually unchanged despite 60 years of spectacular progress in other areas of solid organ transplantation. The technique allows easy access to the target vessels and the bladder without violating the peritoneal cavity, allows continuation of peritoneal dialysis if necessary and easy access to the graft for percutaneous biopsy, localizes urinary leaks and infection outside the peritoneal cavity and it is very well tolerated in terms of postoperative pain. It is clearly very hard to improve on such a safe and efficient procedure, and very few attempts have been made to modify it over the years. The last 20 years have witnessed a widespread application of minimally invasive surgical techniques in all fields. In kidney transplantation the most influential contribution has been the development of laparoscopic donor nephrectomy, pioneered by Ratner in 1995 and now widely considered the procedure of choice in living donor kidney transplantation. However, until recently laparoscopic kidney transplantation has not been attempted. ‘Minimally invasive’ techniques, however, have been proposed to minimize the length of incision; several groups have been able to perform kidney transplantation through 6–7 cm lower quadrant incisions (3Oyen O Scholz T Hartmann A Pfeffer P Minimally invasive kidney transplantation: The first experience.Transplant Proc. 2006; 38: 2798-2802Crossref PubMed Scopus (33) Google Scholar). In these cases, the vascular anastomosis and the uretero-neocystostomy have been performed conventionally, and the only claim to ‘minimally invasive’ is basically the reduced length of the wound. Of course these techniques are commonly applied in recipients of ideal body weight. More recently, in 2010, a case report of laparoscopic kidney transplantation from Spain was published, and in the past several months, a technique for transabdominal fully robotic kidney transplantation in obese recipients was reported by a US center (4Giulianotti P Gorodner V Sbrana F et al.Robotic transabdominal kidney transplantation in a morbidly obese patient.Am J Transplant. 2010; 10: 1478-1482Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar). The small series of laparoscopic kidney transplants published by Modi et al. in this issue of AJT confirms the technical feasibility of a fully laparoscopic approach to complete all the steps of the standard kidney transplant procedure in the hands of experienced laparoscopic surgeons (5Modi P Rizvi J Pal B et al.Laparoscopic kidney transplantation: An initial experience.Am J Transplant. 2011; 11: 1320-1324Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar). Once the technical feasibility has been demonstrated, the next step is of course to identify the potential advantages of the laparoscopic or robotic approach over the standard open procedure. The main advantage proposed by the authors is the reduction in the overall