Expansion of Laparoscopic Approach

Pain, extended hospitalization, time away from work, and long-term disability are barriers to potential donors. The laparoscopic approach provides potential donors with a minimally invasive alternative to open donor nephrectomy. Laparoscopic donor nephrectomy has definitely decreased hospitalization. The average hospital stay for 2339 standard transperitoneal donors reported has been 2.9 days. There is a clear difference between the United States and the rest of the world, where pressure for decreasing length of stay is not as strong. In the United States, transplant programs are even moving to 24-hour stays for donors (27).

In addition to decreasing convalescence, laparoscopic donor nephrectomy is associated with less blood loss when compared to open surgical techniques, though transfusion rates are probably indistinguishable from open surgery.

The introduction of laparoscopic donation has increased the number of donors at many transplant centers (40,117). By the year 2001, nearly two-thirds of the living donor nephrectomies in the United States were performed using a laparoscopic technique (118).

At the University of Maryland, 925 laparoscopic donor nephrectomies have been performed from 1996 to 2004; over the same time frame, only 37 open donor nephrec-tomies have been performed (3.8%).

It is evident that the laparoscopic approach, while not perfect, has done well enough to be considered the first-choice approach for a majority of donors. However, laparoscopic donor nephrectomy is more expensive than open donor nephrectomy, as shown by Mullins et al. (119) in a study evaluating the actual Medicare expenditures, which found that all transplantations were less expensive than dialysis in the long term.

Cadaveric transplantation reaches a break-even point in costs over dialysis at 18 months posttransplant. Laparoscopic living donation reaches the break-even point at 14 months posttransplant. Open donor nephrectomy was most efficient costwise, reaching a break-even point at only 10 months posttransplant compared to dialysis. So, there is a dollar cost to the benefits of laparoscopy for the donors.

However, living donors are not always the best transplant option for all recipients. There are situations when a cadaver kidney may be better than one from a living donor. Mandal et al. suggest that a young cadaver kidney with fewer human leukocyte antigen mismatches may be better than an older living donor kidney (80).

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