renal transplantation confers substantial benefits to children with end - stage renal disease ( esrd ) , including improved growth , longer life , and better quality of life . the advent of laparoscopic donor nephrectomy ( ldn ) has lead to a significant increase in the number of living donor renal transplants performed in pediatric recipients . benefits to the donor of ldn compared with odn include shorter postoperative hospital stay , reduced requirements for postoperative analgesia , and improved convalescence and cosmesis . a few studies have shown higher postoperative creatinine values among ldn recipients compared with odn recipients . observed that pediatric recipients of age < 18 years who underwent laparoscopic donor graft procurement had significantly more acute rejection episodes , and higher incidence of delayed graft function , with poor graft survival rates . these studies warrant careful analysis of the role of ldn grafts being transplanted into recipients in this age group . we compare here the surgical and functional outcomes of all pediatric living donor renal transplant recipients . the medical records of all pediatric transplant patients from 1985 through june 2006 were reviewed at muljibhai patel urological hospital . the etiology of end - stage renal disease ( esrd ) , demography of donors and recipients , vascular anatomy of the donor kidney , method of donor nephrectomy ( ldn vs odn ) , warm and total ischemia time , the need for bench surgery , and any intra and perioperative complications that occurred were analysed . postoperative renal function was measured by serum creatinine levels at day 0 , 1 , 2 , 7 , 14 , and 30 . the incidence of early and delayed graft function , acute rejection episodes , complication rates , and graft survival was recorded . early graft function was defined as > 25% decline of two separate serum creatinine samples taken within first 24 h. delayed graft function was defined as requirement of hemodialysis within seven - post transplantation . acute rejection was defined as treatment for rejection given for rising serum creatinine ( postrenal biopsy histopathologically confirmed ) . graft failure was defined as permanent return to dialysis or death with a functioning graft . kidney was procured through a flank incision overlying the 11 or 12 rib depending on the topography of the kidney . the incision was carried out through all the muscle layers , kidney dissected , and hilum bared . prior to ligation of the renal pedicle , patients received a bolus of 10 mg of intravenous frusemide and 100 ml of 20% mannitol . the kidney was then harvested through a flank incision , immediately placed in an ice bath , and perfused with a heparinized ringer lactate solution . nasogastric tube and urethral catheter was placed intraoperatively and patient was put in 45 lateral tilt position . pneumoperitoneum was created in closed technique with the initial flow rate of 1l / min . the kidney perfusion was maintained throughout the procedure with a urine output of 10 ml / min . was placed and deepened upto the peritoneum taking care not to incise the peritoneum at this point of time . prior to securing the renal artery , the patient received a bolus of 10 mg of intravenous frusemide and 100 ml of 20% mannitol . the kidney was retrieved through the preplaced pfannenstiel incision and was immediately placed in an ice bath and perfused with a solution of heparinized ringer lactate . a modified gibson incision was made and the renal bed prepared by dissecting the external iliac vein and internal / external iliac artery . appropriate measures were taken to preserve the cord structures in male recipients and secure the lymphatics . the donor renal vein was anastomosed to the recipient external iliac vein in an end - to - side fashion . standard end - to - end renal artery to internal iliac artery anastomosis was done with single artery grafts ( n = 46 ) . bench surgery was done in early branching renal artery ( n = 2 ) , and separate double anastomosis , one with external iliac ( end - to - side ) and other with internal iliac artery ( end - to - end ) was done for double renal artery ( n = 6 ) patients . kidney was procured through a flank incision overlying the 11 or 12 rib depending on the topography of the kidney . the incision was carried out through all the muscle layers , kidney dissected , and hilum bared . prior to ligation of the renal pedicle , patients received a bolus of 10 mg of intravenous frusemide and 100 ml of 20% mannitol . the kidney was then harvested through a flank incision , immediately placed in an ice bath , and perfused with a heparinized ringer lactate solution . all the donors underwent overnight hydration and enemas for bowel preparation . nasogastric tube and urethral catheter pneumoperitoneum was created in closed technique with the initial flow rate of 1l / min . the kidney perfusion was maintained throughout the procedure with a urine output of 10 ml / min . was placed and deepened upto the peritoneum taking care not to incise the peritoneum at this point of time . prior to securing the renal artery , the patient received a bolus of 10 mg of intravenous frusemide and 100 ml of 20% mannitol . the kidney was retrieved through the preplaced pfannenstiel incision and was immediately placed in an ice bath and perfused with a solution of heparinized ringer lactate . a modified gibson incision was made and the renal bed prepared by dissecting the external iliac vein and internal / external iliac artery . appropriate measures were taken to preserve the cord structures in male recipients and secure the lymphatics . the donor renal vein was anastomosed to the recipient external iliac vein in an end - to - side fashion . standard end - to - end renal artery to internal iliac artery anastomosis was done with single artery grafts ( n = 46 ) . bench surgery was done in early branching renal artery ( n = 2 ) , and separate double anastomosis , one with external iliac ( end - to - side ) and other with internal iliac artery ( end - to - end ) was done for double renal artery ( n = 6 ) patients . kidney was procured through a flank incision overlying the 11 or 12 rib depending on the topography of the kidney . the incision was carried out through all the muscle layers , kidney dissected , and hilum bared . prior to ligation of the renal pedicle , patients received a bolus of 10 mg of intravenous frusemide and 100 ml of 20% mannitol . the kidney was then harvested through a flank incision , immediately placed in an ice bath , and perfused with a heparinized ringer lactate solution . all the donors underwent overnight hydration and enemas for bowel preparation . nasogastric tube and urethral catheter pneumoperitoneum was created in closed technique with the initial flow rate of 1l / min . the kidney perfusion was maintained throughout the procedure with a urine output of 10 ml / min . was placed and deepened upto the peritoneum taking care not to incise the peritoneum at this point of time . prior to securing the renal artery , the patient received a bolus of 10 mg of intravenous frusemide and 100 ml of 20% mannitol . the kidney was retrieved through the preplaced pfannenstiel incision and was immediately placed in an ice bath and perfused with a solution of heparinized ringer lactate . a modified gibson incision was made and the renal bed prepared by dissecting the external iliac vein and internal / external iliac artery . appropriate measures were taken to preserve the cord structures in male recipients and secure the lymphatics . the donor renal vein was anastomosed to the recipient external iliac vein in an end - to - side fashion . standard end - to - end renal artery to internal iliac artery anastomosis was done with single artery grafts ( n = 46 ) . bench surgery was done in early branching renal artery ( n = 2 ) , and separate double anastomosis , one with external iliac ( end - to - side ) and other with internal iliac artery ( end - to - end ) was done for double renal artery ( n = 6 ) patients . the demographic profile and the etiology with respect to both the groups are depicted in table 1 . the mean age of recipients was 14.8 years ( range 5 - 18 ) in ldn and 13.9 years ( range 8 - 18 ) in odn . total ischemia time ( tit ) was significantly higher in grafts procured by laparoscopic approach . patient demography between the ldn and odn groups ldn : laparoscopic donor nephrectomy , odn : open donor nephrectomy ldn : laparoscopic donor nephrectomy , odn : open donor nephrectomy five patients in the ldn group received induction immunosuppression ( 4 received daclizumab and 1 basiliximab ) while none of the patients in odn received induction . the ldn group received prednisone all , calcineurin inhibitor [ cyclosporine ( 11 ) , tacrolimus ( 4 ) ] , and purine antagonists [ azathioprine ( 11 ) , mycophenotil ( 4 ) ] . the odn group received prednisone all , calcineurin inhibitors [ cyclosporine ( 35 ) , tacrolimus ( 0 ) , ( not given in 4 ) ] , and purine antagonists [ azathioprine ( 39 ) , mycophenotil ( 0 ) ] . cyclosporine was stopped in two odn patients at 3 and 12 years with stable serum creatinine . postoperative serum creatinine was comparable at day 1 ( p = 0.20 ) , day 2 ( p = 0.12 ) , day 7 ( p = 0.25 ) , day 14 ( p = 0.20 ) , 1 month ( p = 0.39 ) in ldn vs odn groups . there were two delayed graft functions in odn group . both of the patients had acute vascular rejection which required treatment with okt3 . the first patient required one session of hemodialysis on the third day while the second patient required two hemodialysis sessions on the second and fourth day . all graft survival at 1 year was 86.67 and 82.22% ( p = 0.34 ) in ldn and odn groups , respectively . serum creatinine ( mg / dl ) at various postoperative time ldn : laparoscopic donor nephrectomy , odn : open donor nephrectomy the cause of early adverse renal outcome and their complications are shown in table 4 . cause of the six grafts lost ( ldn , n = 1 and odn , n = 5 ) were : graft artery aneurysm in 1 ( ldn ) , graft artery thrombosis ( n = 1 ) , septicemia ( 1 ) , acute left ventricular failure ( 1 ) , acute vascular rejection ( 1 ) , and hypertensive encephalopathy ( 1 ) . early adverse renal function and complications laparoscopic donor nephrectomy has previously been demonstrated to be safe and efficacious in pediatric renal transplant in single institution studies . pediatric renal transplants pose unique challenges , including operative technical aspects , hemodynamics at the time of graft reperfusion , and increased immune reactivity as compared to adults , resulting in higher rejection rates.[810 ] troppmann et al . , in united network for organ sharing database study raised concerns about higher incidence of delayed graft function , acute rejection episodes , and higher discharge serum creatinine levels in ldn compared with recipients of odn . the authors hypothesized that probably immunological and hemodynamic properties of these young patients make them unsuitable for additional physiological insults due to laparoscopic renal procurement . it is also postulated that a combination of prolonged pneumoperitoneum and wit occurring during ldn predispose the allograft to increased risk of early graft dysfunction . there is a concern regarding impaired renal function secondary to prolonged warm ischemia in grafts with multiple vessels . however , desai et al . showed that long - term graft survival and graft function at 1 month and 1 year are not adversely impacted by the presence of multiple renal arteries in grafts procured laparoscopically . hypothesized that , due to decreased intravascular volume in these pediatric recipients , allograft receives suboptimal renal perfusion compared to that prior to nephrectomy . this can be deleterious resulting in increased risk of vascular thrombosis , delayed graft function , or primary nonfunction . the recipient outcome did not differ in either renal units harvested by ldn or odn ; graft survival at 1 year was comparable in both the groups . this may be related to a combination of decrease in the total operative time , adequate perioperative and intraoperative donor hydration , measures to reduce wit , and meticulous attention to recipient hydration . modifications in our ldn technique include : preplaced pfannenstiel kidney retrieval incision ; and bathing bare hilum in papaverine to avoid spasm of the renal artery . we ensure that donor veins are full at the time of bed preparation by infusing intravenous fluids . ureter , renal artery , and renal vein are clipped and cut in that order prior to graft retrieval . additionally , intraoperative attention is directed at maintaining recipient central venous pressure at 15 cm h2o and systolic blood pressure above 120 mm hg . if the systolic blood pressure remains low , intravascular volume expansion with colloids is instituted to achieve the desired hemodynamic parameters . just prior to vascular anastomosis declamping , 100 ml of 20% mannitol is given intravenously to diurese the graft . it is believed that pneumoperitoneum of 10 mm hg has a minimal affect on renal physiology . we thus maintain an insufflation pressure of 15 - 20 mm hg throughout the ldn procedure ; this has not been shown to have adverse effect on immediate postoperative renal function in our study . on the contrary , it aids in dissection by minimizing oozing and making the surgery quicker , thus effectively decreasing the operative time . although , the number of patients in our cohort is comparable to any published single institution series , we had no pediatric recipient aged 5 years . finally , our study was limited by its retrospective nature and use of historical odn cohort . further randomized prospective studies would clarify the safety and efficacy of the laparoscopic harvesting in pediatric renal transplantation . we found that in our experience , ldn does not adversely affect graft outcome in pediatric recipients of living donor renal transplants . laparoscopic donor nephrectomy was not associated with an increased risk of delayed graft function , acute rejection , or diminished graft function . in addition to shortening hospitalization and reducing postoperative pain for the adult donors , ldn confers improved convalescence and ameliorates cosmetic concerns . based on our findings , we find no contraindication to the continued use of ldn in pediatric renal transplantation . strict attention to perioperative donor and recipient fluid status and limited use of pneumoperitoneum should be considered for optimal graft outcome .
objective : to evaluate the surgical and functional outcomes of laparoscopic graft procurement in pediatric patients undergoing renal transplantation.materials and methods : a retrospective chart review of the cohort records of 54 pediatric living donor renal transplant recipients from 1985 through june 2006 was performed . 
 we compared results of laparoscopic donor nephrectomy ( ldn , n = 15 ) and open donor nephrectomy ( odn , n = 39 ) . parameters analysed included donor technique and morbidity , operative complications , immediate postoperative renal function , the incidence of early and delayed graft function , and long - term graft survival.results:the mean age of these recipients was 14.8 years ( 5 - 18 ) in the ldn group and 13.9 years ( 8 - 18 ) in odn group . 
 serum creatinine ( mg / dl ) was 1.5  0.7 vs 1.8  1.3 at day 1 ( p = 0.20 ) , 1.0  0.3 vs 1.4  1.3 at day 2 ( p = 0.12 ) , 1.1  0.9 vs 1.3  1.0 at day 7 ( p = 0.25 ) , 1.2  0.5 vs 1.6  1.8 ( p = 0.20 ) at day 14 , 1.1  0.7 vs 1.2  1.4 ( p = 0.39 ) at 1 month in ldn vs odn groups , respectively . 
 early graft function was 35.7 vs 46.4% in the respective groups . 
 there were two delayed graft function and one graft nonfunction in odn group . over all graft and patient survival at 1 year was 86.67 and 82.22% ( p = 0.34 ) in ldn and odn groups , respectively.conclusion:pediatric recipients of the ldn grafts have outcomes comparable to those of odn graft recipients . 
 laparoscopic donor nephrectomy is safe and efficacious for graft procurement for pediatric recipients .