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Comparative Study
. 2008 Apr;51(2):103-10.

"First, do no harm": monitoring outcomes during the transition from open to laparoscopic live donor nephrectomy in a Canadian centre

Simon Bergman  1 , Liane S Feldman, Maurice Anidjar, Sebastian V Demyttenaere, Franco Carli, Peter Metrakos, Jean Tchervenkov, Steven Paraskevas, Gerald M Fried
Affiliations
Free PMC article
Comparative Study

"First, do no harm": monitoring outcomes during the transition from open to laparoscopic live donor nephrectomy in a Canadian centre

Simon Bergman et al. Can J Surg. 2008 Apr.
Free PMC article

Abstract
in English, French

Objective: During the learning curve for laparoscopic live donor nephrectomy (LLDN), donor morbidity and poorer graft function may be increased. To minimize these risks, a dedicated team of laparoscopic, urologic and transplant specialists worked together to introduce the technique. This study was undertaken to validate this approach by comparing donor and recipient outcomes and studying our learning curve during the transition from open (OLDN) to LLDN.

Methods: We compared 59 LLDNs with 34 OLDNs performed for adult recipients. Data were collected prospectively for LLDN and retrospectively for OLDN. We compared donor outcomes and recipient graft function in the 2 groups, and we used the cumulative sum (CUSUM) method to generate learning curves; p < 0.05 was considered statistically significant.

Results: From the donor standpoint, the complication rate was 10% in the laparoscopic group, compared with 21% in the open group. Length of stay was shorter after LLDN (3 v. 5 d, p < 0.001). Among the recipients, there were no significant differences in the incidences of ureteral complications, delayed graft function (DGF), creatinine levels, acute rejection or patient and graft survival. When we used the incidence of DGF after OLDN as a benchmark, CUSUM analysis revealed a downward inflection point for DGF after 30 cases, consistent with an improvement in performance.

Conclusion: At our institution, a team approach has allowed the safe introduction of LLDN without a significant negative impact on recipient outcomes and with a reduction in donor length of stay. Using DGF as an outcome, we observed improved performance after 30 cases.

Objectif: Au cours de la période d'apprentissage de la néphrectomie par laparoscopie pratiquée sur donneur vivant (NLDV), la morbidité chez le donneur et la prise moins bonne du greffon peuvent augmenter. Afin de minimiser ces risques, des spécialistes en laparoscopie, urologie et transplantation ont conjugué leur efforts en équipe pour implanter la technique. L'étude visait à valider cette approche en comparant les résultats pour les donneurs et les receveurs, et en étudiant notre courbe d'apprentissage pendant la transition de l'intervention ouverte (NODV) à l'intervention NLDV.

Méthodes: Nous avons comparé 59 NLDV et 34 NODV pratiquées pour des receveurs adultes. Nous avons recueilli les données prospectivement pour NLDV et rétrospectivement pout NODV. Nous avons comparé les résultats pour les donneurs et le fonctionnement du greffon chez les receveurs dans les deux groupes et nous avons utilisé la méthode de la somme cumulative (SUMCU) pour générer les courbes d'apprentissage. On a considéré que p < 0,05 était statistiquement significatif.

Résultats: Du point de vue des donneurs, le taux de complications s'est établi à 10 % chez ceux qui ont subi la laparoscopie comparativement à 21 % chez ceux qui ont subi l'intervention ouverte. La durée du séjour était plus courte après une NLDV (3 c. 5 j, p < 0,001). Chez les receveurs, il n'y avait pas de différences significatives au niveau des incidences des complications urétérales, du fonctionnement retardé du greffon (FRG), des taux de créatinine, du rejet aigu ou de la survie du patient et du greffon. Lorsque nous avons utilisé l'incidence du FRG après une NODV comme point de comparaison, l'analyse SUMCU a révélé un point d'inflection à la baisse dans le cas du FRG après 30 cas, ce qui concorde avec une amélioration du rendement.

Conclusion: À notre établissement, une stratégie d'équipe a permis d'implanter sans danger la NLDV sans effet négatif important sur les résultats des receveurs tout en réduisant la durée du séjour du donneur. En utilisant le FRG comme résultat, nous avons observé une amélioration du rendement après 30 cas.

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Figures

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FIG. 1. Recipient postoperative serum creatinine levels. Data are presented as means with standard deviation and analyzed with Student's t test. LLDN = laparascopic live donor nephrectomy; OLDN = open live donor nephrectomy; POD = postoperative day.
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FIG. 2. CUSUM learning curves using delayed graft function and ureteral complications as outcomes, with institutional open donor nephrectomy data as the benchmarks. CUSUM = cumulative sum; black squares = ureteral complications; white circles = delayed graft function.
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FIG. 3. CUSUM learning curves using delayed graft function and ureteral complications as outcomes, with high-volume centre laparoscopic donor data as the benchmarks., CUSUM = cumulative sum; black squares = ureteral complications; white circles = delayed graft function.
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References

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