The AUBMC has introduced Laparoscopic Donor Nephrectomy for removal of kidneys from living donors, and their use in renal transplantation. This novel procedure was first pioneered in Baltimore in 1995 (at the University of Maryland and Johns Hopkins University), and is currently used in a handful of centers in the United States. The vast majority of centers continue to do the traditional open surgical approach for removing kidneys for transplantation. AUB launched this procedure for the first time in January 2000 and thus became the first institution to perform the operation in Lebanon and the Middle East.
Laparoscopic Donor Nephrectomy entails the removal of the kidney using small holes in the abdomen, without resorting to a large flank incision. The impact of this procedure on the field of renal transplantation is enormous since currently living donors constitute the major source of kidneys in Lebanon and the Middle East. There are two types of kidney transplantation:
The first has many religious and social hurdles, which have slowed down its growth. In this part of the world kidneys from living related donors depend on the availability of a motivated donor. He or she must be willing to endure several disincentives when undergoing the standard surgical open nephrectomy. Thus, while the open surgical nephrectomy approach has evolved as the standard for living kidney donation, Laparoscopic Donor Nephrectomy emerged as an attractive alternative in the mid- 90’s.
- cadaveric transplantation
- living donor transplantation
In 1997, an AUBMC group visited the University of Maryland and the University of Massachusetts for first hand exposure to this procedure. Laparoscopic Donor Nephrectomy was introduced in 1998 at the AUBMC in a controlled fashion in the animal laboratory. A multi- disciplinary approach using the surgical services of Urology, Laparoscopic Surgery and Transplantation was employed. Dr. Raja Khauli and Dr. Maher Hussein conducted the laboratory experiments under the direction of Dr. Steven Jacobs from the University of Maryland with whom there was no continued contact during the introduction of this procedure. The same principles were then taken from the animal laboratory to the first human operation, performed in January of 2000.
Since the initiation of the program at AUBMC in 2000, the medical center has performed more than 100 donor recipient pairs and the experience with laparoscopic nephrectomy has been very promising. The initial report was issued on the initial 20 patients and subsequently on 40 patients who have donated the kidney using the laparoscopic approach. These were then compared with the operative data of donors who underwent a classical surgical approach. A follow up report on 100 consecutive donor nephrectomy procedures was presented in the International Transplant Congress (September 2004, Vienna) comparing the Laparoscopic and other nephrectomy approaches.
All the above presentations have yielded the following observations regarding Laparoscopic Donor Nephrectomy: There was statistically no significant difference in the operative time, and the time needed to remove the kidney from the abdomen, which is known to be an important factor. Furthermore, kidneys removed by the Lap Nx approach were comparable to those removed by open surgery.
Patients undergoing nephrectomy by the laparoscopic approach had a significantly faster recovery of their bowel sounds, resumption of regular diet in hospital, and a significantly shorter hospital stay compared to open nephrectomy. Return to normal activity averaged about 9 days for the laparoscopic nephrectomy group but took 27 days in the open nephrectomy group.
Finally, the actual success of the transplantation operation was very similar amongst patients who received kidneys that were retrieved via the open surgical approach and the laparoscopic approach. In the series at AUBMC, the actuarial graft success has exceeded 96% in both groups of patients in one year.
On comparing the outcome of the kidney transplant for both the laparoscopic retrieval and the open retrieval, the function of these kidneys were equivalent, as judged by the rapidity of the recovery in the patients who received the kidneys. There was a fast recovery of normal function in both groups, open and the laparoscopically retrieved kidneys, judged by the examination of the serum creatinine in the recipients of these grafts.On
comparing the outcome of the kidney transplant for both the
laparoscopic retrieval and the open retrieval, the function of
these kidneys were equivalent, as judged by the rapidity of the
recovery in the patients who received the kidneys.
At present, AUBMC is one of a handful of centers worldwide to perform this procedure in a routine fashion and on a wide- scale. It is the only center in the Middle East offering this service as a routine to patients presenting for kidney donation. In the past year, this technology was expanded, and applied to patients with kidney cancer, adrenal cancer, and other urologic problems and diseases.
With the great success of the pioneering work in laparoscopic donor nephrectomy initiated in the year 2000, the Division of Urology at the American University of Beirut was one of the first units to apply the technology to urologic cancer. This started with upper tract diseases including kidneys and adrenals, and slowly expanded to complex situations like prostate cancer. As of June 2004, the AUBMC has performed more than 200 laparoscopic renal procedures that also include renal cell cancers and transitional cell cancers of the ureter and renal pelvis, and the latter are treated by laparoscopic radical nephroureterectomy. We have performed also pelvic lymphadenectomy as well as para-aortic and para- caval lymphadenectomy for testicular tumors using this approach. The cut- off tumor size for renal cell carcinoma that can be approached laparoscopically at our center has been set at 10-13 cm, which is higher than what is performed comfortably at most centers in the region. Furthermore, the division has performed laparoscopic partial nephrectomies for small exophytic tumors.
Parallel to the advancement of laparoscopic urologic oncology and its application for renal neoplasms, the division has pioneered the use of laparoscopic techniques for approaching adrenal glands, both benign and malignant. More than 50 procedures have been performed on adrenal diseases, and have included patients with Cushing’s syndrome, Aldosterone producing adenomas, and Pheochromocytomas. Our division has put more than 10 audio- visual movies and has presented this work in several regional and international meetings. At present, almost all retroperitoneal diseases can be approached laparoscopically. The application of urologic laparoscopic oncology to other benign diseases for diagnostic and therapeutic purposes has expanded on the lower urinary tract as well. At present, AUBMC has been regarded as a pioneering center and the first center to introduce laparoscopic urology to its training program. We are expanding our experience and knowledge to regional centers in the area, and have been invited to several congresses in the region as key speakers on the subject.