Laparoscopic kidney transplantation – a pointless technical exercise?

I read with some interest a case series in this month’s AJT from a group in India, reporting an initial experience of laparoscopic kidney transplantation (AJT 2011; 11: 1320).  Modi and colleagues provide the rationale that transplant patients are at increased risk of wound related complications (due to renal failure and immunosuppression) and so a laparoscopic approach may reduce the risk of such complications.  The manuscript reports four technically successful deceased donor kidney transplants via a transperitoneal laparoscopic approach.  Compared to open transplants of the paired kidney from the same donor, warm ischaemic time and total operative time were significantly longer in the laparoscopic patients, but with a reduction in overall wound length from 18.4 to 11 cm.

Whilst performing a renal transplant laparoscopically is clearly an impressive technical feat, I remain unconvinced about the merits of such a procedure.  As the accompanying editorial in AJT points out, whilst there is a reduction in total wound length with the laparoscopic approach, the new procedure requires that the peritoneum is breached, increasing the risk of bowel trauma and postoperative ileus.  Minimal incision open techniques have been previously described that allow for similar overall incision length without peritoneal breach.  Modi and colleagues do not report any data regarding post-operative pain, ileus, wound complications or length of hospital stay.

Another consideration is of patient safety.  Vessels are isolated and controlled with slings rather than clamps, and of course there is no direct access to the kidney on reperfusion to deal with any reperfusion bleeding increasing the risk of substantial blood loss.   Whilst blood loss in the four patients described here was comparable, a much larger series would be required to prove that this technique is safe.

My major concern, however, is the significantly longer warm ischaemic times with the laparoscopic technique.  Prolonged warm ischaemia is associated with increased risk of delayed graft function and poorer long-term outcomes, and so any new procedure for implantation must minimise warm ischaemia to allow the optimum long-term outcomes, particularly in light of the shortage of donor organs.

What Modi and colleagues have presented is a proof of concept; an impressive technical achievement which I suspect in the course of time will prove to offer very limited clinical benefit.  If they are serious about pursuing this technique, their next step must be a formal randomised controlled trial with adequate follow-up to compare outcomes with a traditional open technique.