incision related problems and pneumothorax in the opennephrectomy group. However, intraperitoneal complicationsseem to be more common in the laparoscopic group.8, 12 Re-cently, significant reductions in intraperitoneal complica-tions with increased surgical experience have been well es-tablished.11

There are some disadvantages to the hand assisted ascompared with the classic laparoscopic technique. The ab-dominal incision may be 1 or 2 cm. longer and will vary withthe size of the hand of the surgeon. It appears that therecovery time for this patient group is slightly longer thanthat for classic laparoscopic nephrectomy. In this series ileuswas seen in 2 patients, both of whom were in the handassisted group. Recovery of bowel function appears to beslower in the hand assisted laparoscopic group based on ourclinical impression, perhaps because of the increase in man-ual bowel handling. Unfortunately, the actual time to oralintake, which may provide more information regarding bowelfunction recovery, was not recorded. However, review of thecharts revealed that poor oral intake was always the mainfactor keeping patients in the hospital.

In the laparoscopic groups only oral narcotics were given tothe patients once they left the recovery room. Preemptiveanalgesics, including treatment before incision with localanesthetic and intravenous ketamine, have been shown todecrease postoperative pain by some authors.13, 14 Althoughcontroversy exists regarding the effectiveness of preemptiveanesthesia, we believe that administration of local anestheticwith or without ketamine before incision may decrease thepostoperative narcotics requirements. Also, postoperative ex-pectations and recovery goals are thoroughly discussed withthe patient before surgery, which may increase pain toler-ance.

CONCLUSIONS

The laparoscopic approaches to nephrectomy effectivelyreduce the 2 greatest concerns of living donors, which arepain and time to recovery. The latter is especially important,as time to recovery usually translates to time off work and, iftoo long, may simply make it impossible to be a donor. Be-cause laparoscopic nephrectomy makes kidney donation eas-ier for the donor and has been shown to be safe and providewell functioning transplantable kidneys, we believe it is nowthe standard by which the technical expertise exists. Com-paring the hand assisted laparoscopic and laparoscopic tech-niques reveals that the hand assisted approach decreasesoperating and ischemic times. Outcomes of graft survival andfunction in all groups were comparable.

REFERENCES

1. Clayman, R. V., Kavoussi, L. R., Soper, N. J. et al: Laparoscopicnephrectomy. N Engl J Med, 324: 1370, 1991

2. Ratner, L. E., Ciseck, L. J., Moore, R. G. et al: Laparoscopic livedonor nephrectomy. Transplantation, 60: 1047, 1995

3. Schulam, P. G., Kavoussi, L. R., Cheriff, A. D. et al: Laparoscopiclive donor nephrectomy: the initial 3 cases. J Urol, 155: 1857,1996

4. Flowers, J. L., Jacobs, S., Cho, E. et al: Comparison of open andlaparoscopic live donor nephrectomy. Ann Surg, 226: 483, 1997

5. Fabrizio, M. D., Ratner, L. E., Montgomery, R. A. et al: Laparo-scopic live donor nephrectomy. Urol Clin North Am, 26: 247,1999

6. Wolf, J. S., Jr., Tchetgen, M. B. and Merion, R. M.: Hand-assisted laparoscopic live donor nephrectomy. Urology, 52:885, 1998

7. Slakey, D. P., Wood, J. C., Hender, D. et al: Laparoscopic livedonor nephrectomy: advantages of the hand-assisted method.Transplantation, 68: 581, 1999

8. Philosophe, B., Kuo, P. C., Schweitzer, E. J. et al: Laparoscopicversus open donor nephrectomy: comparing ureteral complica-tions in the recipients and improving the laparoscopic tech-nique. Transplantation, 68: 497, 1999

9. Nogueira, J. M., Cangro, C. B., Fink, J. C. et al: A comparison ofrecipient renal outcomes with laparoscopic versus open livedonor nephrectomy. Transplantation, 67: 722, 1999

10. Jacobs, S. C., Dunkin, B. J. and Flowers, J. L.: Evolution of thetechnique for laparoscopic donor nephrectomy. Presented atthe Eighth International Meeting of the Society of Laparoen-doscopic Surgeons, New York, December 4–7, 1999

11. Jacobs, S. C., Cho, E., Dunkin, B. J. et al: Laparoscopic live donornephrectomy: the University of Maryland 3-year experience.J Urol, 164: 1494, 2000

12. Ratner, L. E., Kavoussi, L. R., Shulam, P. G. et al: Comparison oflaparoscopic live donor nephrectomy versus the standard openapproach. Transplant Proc, 29: 138, 1997

13. Pasqualucci, A.: Experimental and clinical studies about thepreemptive analgesia with local anesthetics. Possible reasonsof the failure. Minerva Anestesiol, 64: 445, 1998

14. Schmid, R. L., Sandler, A. N. and Katz, J.: Use and efficacy oflow-dose ketamine in the management of acute post operativepain: a review of current techniques and outcomes. Pain, 82:111, 1999

EDITORIAL COMMENT

This manuscript is the first in which 3 methods of living donornephrectomy done at 1 institution in significant numbers are de-scribed. Unfortunately, the methods were done sequentially not con-currently, probably biasing the study towards the latest method.Randomized trials for donor nephrectomy will be extremely difficultto perform. The public has already decided that anything “laparo-scopic” is better than open surgery. The University of Michigan

FIG. 2. Hospital stay of patients who underwent laparoscopic (L) and hand assisted (H) nephrectomy

LONG-TERM OUTCOMES AFTER LAPAROSCOPIC NEPHRECTOMY 1273

performed a randomized trial of 2 methods and found little differencebetween hand assisted and open flank nephrectomy but the studywas flawed by the use of an abnormally, highly skilled open nephrec-tomy surgeon, thus reducing any differences that might be seen.Although randomized trials need to be done, they must be multi-institutional if they are to portray actual differences. What is best atone particular institution may not be applicable across the board.

These authors actually describe the proper sequence (open ne-phrectomy, laparoscopic nephrectomy and hand assisted laparo-scopic nephrectomy) for deciding at each institution which method isbe used locally. Laparoscopic nephrectomy should be done by thoseskilled at open nephrectomy. Hand assisted laparoscopic nephrec-tomy should be done by those skilled at laparoscopy.

Concentration on the welfare of the living renal donor and stream-lining donor recovery by all donor surgeons has improved all tech-niques. Although statistically significant differences may be difficult

to prove, currently, it is apparent that standard laparoscopic donornephrectomy is superior in regard to incisional stability, cosmesisand incisional pain. Hand assisted laparoscopic nephrectomy ap-pears to be superior in operating time, emergency vascular control,warm ischemia time and if less advanced laparoscopic experience isrequired. Although open nephrectomy has significantly poorer pain,cosmesis, incisional stability and hospital stay profile, it is superiorin warm ischemia, operating room supplies cost, lack of intraperito-neal complications and vessel length obtained. Now that equivalentrecipient renal function is seen with all methods, it is important tofocus on improving the safety and decreasing the morbidity for thedonor.

Stephen C. JacobsDivision of UrologyUniversity of Maryland School of MedicineBaltimore, Maryland

LONG-TERM OUTCOMES AFTER LAPAROSCOPIC NEPHRECTOMY1274