傳統手術、經腹腔與經後腹腔腹腔鏡活體腎臟移植取腎手術之比較
顧明軒1、陳正彥2、黃子豪1、3、4、鍾孝仁1、3、4、
張延驊1、3、4、龍藉泉2、林登龍1、3、4、陳光國1、3、4
臺北榮民總醫院 泌尿部1；臺北榮民總醫院 外科部移植外科2；
國立陽明大學醫學院泌尿學科3；書田泌尿科學研究中心4
Comparison of Perioperative Outcome in Open, Transperitoneal Laparoscopic, and Retroperitoneal Laparoscopic Nephrectomy for Living-Donor Kidney Transplant
Ming-Hsuan Ku1, Cheng-Yen Chen2, Tzu-Hao Huang1,3,4, Hsiao-Jen Chung1,3,4,
Yen-Hwa Chang1,3,4 , Che-Chuan Loong2, Alex T.L. Lin 1,3,4, Kuang-Kuo Chen 1,3,4
Department of Urology, Taipei Veterans General Hospital 1,
Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital 2
Department of Urology 3, School of Medicine and Shu-Tien Urological Science Research Center 4,
National Yang-Ming University, Taipei, Taiwan
Purpose: To compare clinical outcome in open, transperitoneal laparoscopic and retroperitoneal laparoscopic nephrectomy for living donor kidney transplant.
Materials and Methods: We retrospectively reviewed our database of living-donor kidney transplant. From February 2010 to July 2017, 67 living donor nephrectomies were included in the study. We analyzed the duration of hospital stay from surgery to discharge, oral intake record, pain scale, operative data, and surgical complication rates. Modification of diet in renal disease equation. (MDRD) was used to calculate estimated glomerular filtration rate (eGFR) after nephrectomy. The increments and reduction percentage of the donors and recipients’ renal function within postoperative 7 days (POD) were also evaluated. Statistical significance was analyzed using Krystal-Wallis test and Fisher exact test.
Results: In our study, 22 donors underwent open nephrectomy, 22 underwent transperitoneal laparoscopic nephrectomy, and 23 underwent retroperitoneal laparoscopic nephrectomy. For open, transperitoneal laparoscopic and retroperitoneal laparoscopic nephrectomy, average hospital stay from surgery to discharge was 8.3± 2.2 days, 8.2± 2.8 days and 8.8± 1.9 days respectively (p= 0.195); oral intake above 500 mg had been recorded on postoperative 1.4±0.8 days, 1.8±0.7, and 1.3±0.6 days respectively (p= 0.039); average operative time was 267.2±53.4, 290.8±53.5 and 348.9±79.4 minutes (p<0.001); average operative blood loss was 165.8±131.4, 68.5±90.5, and 54.4±47.9 ml (p< 0.001); the highest postoperative pain scale within postoperative 3 days was 4.2 ± 2.4, 5.8 ±1.7, and 4.0 ± 1.9 visual analogue scale (VAS) (p=0.097); average postoperative pain scale within postoperative 3 days was 3.0±0.75, 3.0 ±1.0, and 2.7±0.8 VAS (p=0.593). Two (9.1%) donors undergone open nephrectomy had Clavien-Dindo grade I complication, four (18.2%) donors undergone transperitoneal laparoscopy had grade I complication and one (4.3%) donor undergone retroperitoneal laparoscopy had grade I complication (p= 0.287). After open, transperitoneal and retroperitoneal laparoscopic nephrectomy, average eGFR decline compared to baseline level in donor on POD1 was 48.2 ±15.6%, 36.5 ± 13.2% and 42.2 ± 8.7% respectively (p=0.183); on POD4 was 33.5±12.0%, 33.7±9.0% and 35.4 ± 9.0% respectively (p = 0.794). For evaluation of recipients’ renal function, we excluded ten patients with positive panel reactive antibody(PRA), two with acute rejection, two ABO-incompatible kidney transplant, one with vascular surgical complication, and one with donor-related IgA nephropathy. 19 recipients from open nephrectomies, 18 from transperitoneal laparoscopic nephrectomies and 16 from retroperitoneal laparoscopic nephrectomies were evaluated. Median improvement of eGFR compared to postoperative level in recipients on POD1 were 56.3% ± 51.6%, 86.9% ± 48.9%, and 78.0% ± 41.4% (p= 0.367); on POD4 were 480.5% ± 296.1% and 886.6 ± 534.7% and 519.6% ± 374.1% (p= 0.171); on POD7 were 447.1% ± 406.8%, 938.2% ± 597.0% and 565.9%±504.7% (p= 0.061) for open, transperitoneal laparoscopy and retroperitoneal laparoscopy respectively.
Conclusion: In our study, oral intake above 500 mg would be achieved later in donors receiving transperitoenal laparoscopic nephrectomies, comparing to donors receiving open or retroperitoneal laparoscopic nephrectomies. Estimated operative blood loss seemed more in open donor nephrectomies. On account of average hospital stay, postoperative pain scale, complication rates in donors and changes of renal function within 7 days after transplant in donors and recipients, all three nephrectomies methods showed no differences.