Living-donor nephrectomy at Singapore General Hospital: Evolution of surgical techniques over the last two decades

Background: Laparoscopic living-donor nephrectomy is the current epitome of living kidney donation surgery. We review our experience in living-donor nephrectomies over the last 19 years, transitioning from open surgery to hand-assisted laparoscopy to full laparoscopic techniques. Methods: We retrospectively identified all living-donor nephrectomies performed at our institution from 1976 to 2018. The donors were categorised according to surgical techniques: open (ODN), hand-assisted laparoscopy (HALDN) and full laparoscopy (LDN). We reviewed changes in donor demographics over the years. Surgical outcomes between groups were compared from 2000 to 2018. We also compared the outcomes of LDN between different time periods to evaluate our learning curve. Results: A total of 214 living-donor nephrectomies were performed between 2000 and 2018. The majority were left sided (93%) and had single renal artery anatomy (90%). There were 22 ODN, 20 HALDN and 163 LDN cases. The mean operating time was 84 +/- 43, 151 +/- 32 and 179 +/- 37 minutes for ODN, HALDN and LDN, respectively (p<0.001). There were no statistically significant differences in mean warm ischaemia times (p=0.921) and length of hospital stay (p=0.114) between groups. The overall 30-day surgical morbidity rate was 9.3%, with a major complications rate of 0.9%. The mean warm ischaemia time for LDN was significantly different (p<0.001) between time periods: 281 +/- 260, 184 +/- 94 and 140 +/- 42 seconds for the periods between 2005-2009, 2010-2014 and 2015-2018, respectively. Conclusion: This study confirms the safety of living-donor nephrectomies performed at our institution, a centre with a modest volume of kidney transplants.