Transplante renal de donante vivo: un análisis crítico de estrategias quirúrgicas basado en 40 años de experiencia

RENAL TRANSPLANTATION WITH LIVING DONORS. A CRITICAL ANALYSIS OF SURGICAL PROCEDURES BASED ON 40 YEARS OF EXPERIENCE Introduction: Absolute priority in an LDKT programme are donnor safety and kidney optimal anatomical and functional preservation. Reduced donnor morbidities,both at short and long term,are important objectives. Excellent technical grafting is a must as are the strategies employed for facilitatig it. We revised the incidences of our whole LDKT programme (40 years 243 donors) to confirm if these exigences have been acomplished or a change to new surgical procedures is recommended. Material and methods: Between 1968-2008 243 nephrectomies and grafting has been performed,a reduced number per year (A cadaver pro- gramme has been running simultaneously since 1964). For the nephrectomies a Turner-Warrick apprach was inititialy used and since 1973 a miniin- cisional, anterior, extraperitoneal approach of approximately 10 cm in length. The right kidney was removed in 75% of the cases and the right iliac area for the implant in 85% In adjacent opperating rooms, one team performs the nephrectomy while the other prepares and dissects free the graf- ting vessels. Most of the time the same senior surgeon performed both operatios: the nephrectomy and the implant. Peroperative and postoperative complications were evaluated by urologists and nephrologists in charge. Results: No donors dead,organs lost or major complications in the donors have been documented Minor complications such as intestinal pare- sia,wound infection,persistent incisional pain were common. Miniincisional abdominal approach reduced postoperative pain and hospital stay (4 days). At long term no incisional hernia or abdominal paresia have been documented. Simultaneous work reduces ischemia time (30-45 s warm: 30- 45 min cold) and opperatig room occupation(patient preparation plus anesthesia plus operation)estimated in 90-120 min for the nephrectomy and 120-160 for the grafting. The responsibility of the senior surgeon in both procedures facilitates vessel selection for the grafting. Conclusions: No reasons have been found to reconvert our current nephrectomy procedure to laparoscpic or modify current surgical strategy. Superior safety of open surgery for donors and organs is confirmed. Pain and recovery time are reduced in laparoscopic surgery but not as much when compared with miniincisional approach. Open surgery permits optimal anatomical and functional organ extration facilitatig the quality of the implant. As numbers matter in laparoscopic surgery open nephrectomy isrecommended for reduced LDKT programmes.