Study could lead to more kidney donations

Study could lead to more kidney donations
By TODD ACKERMAN - Houston Chronicle
Web Posted: 08/28/2010 9:19 CDT

Methodist Hospital surgeons are set to study whether kidney transplants are safe if the organ is removed through the vagina, a method that would dramatically reduce the donor's pain, scarring and risk of complications.

The method, part of a growing movement using natural orifices for organ removal rather than incisions, earned fanfare last year when a Johns Hopkins doctor extracted a kidney from a woman as if he were delivering a baby, then transplanted it in her niece. It was thought to be the first such transplant — and a hope for future kidney transplants.

But first, an important question must be answered: Might the kidney become contaminated in the process?

“There is nothing sterile about the vagina,” said Dr. Brian Dunkin, a Methodist surgeon and the study's lead researcher. “The method is a great advance for minimally invasive surgeons looking to push the envelope, but you can imagine the reaction of many transplant doctors: ‘You're going to drag a kidney through there before I put it in an immunosuppressed patient? Where's the data that that's OK?'”

To obtain data, Dunkin's team will analyze the amount of bacteria on a mock kidney placed in the abdomen of women undergoing a hysterectomy and then extracted vaginally.

The results will be compared to the amount of bacteria on real kidneys after they're removed for organ transplantation the conventional way, through an abdominal incision.

If the analysis shows no greater evidence of bacteria through the vagina, Dunkin expects the method to become mainstream and significantly increase the living kidney donor pool, which is 60 percent women. Because there's a shortage of donors, thousands on the waiting list now die annually before a kidney becomes available.

Scars, discomfort

One big obstacle to donation, Dunkin says, is that many recipients are reluctant to put friends or loved ones through the surgery. Although most of the procedure is done laparoscopically — surgeons prepare the kidney for removal through three quarter-inch incisions — a 3- to 4-inch cut has to be made to extract the organ. That cut causes scarring and lingering postoperative discomfort and can lead to infection or a hernia.

Removing the kidney vaginally, if safe for the recipient, should all but eliminate those problems.

Dr. Robert Montgomery, the Johns Hopkins doctor, said that 11/2 years later, the donor from whom he removed the kidney and the recipient are doing great, still free of infection or any other problem. He said he wasn't overly worried about contamination risks because his team prepared the vagina, killing bacteria with antibiotics, and pulled the kidney through the birth canal in a bag so impervious it's usually used to extract cancerous organs.

But he said he welcomes the Methodist study.

“If this technique is to be widely adopted, it's important to demonstrate it poses no additional risks to the recipient,” said Montgomery, who didn't conduct preoperative research on the technique. “So I applaud studying the technique in a systematic way. It's an important study.”

Montgomery hasn't done any additional vaginal removals of donor kidneys — a John Hopkins panel is reviewing his proposal to employ the technique as part of a research project — but he said at least a couple of groups in Europe have.

He said he's not aware of any more done in the United States, although he's received numerous e-mails from doctors interested in using the technique for donor kidneys.

Although Montgomery's transplant was a breakthrough, it didn't mark the first time a vagina has been used for organ removal. Surgeons have been extracting organs, mostly gall bladders and appendixes, using the technique known as natural orifice translumenal endoscopy surgery for eight years now. Dunkin estimates the method has been used to remove more than 150 organs in the U.S. and 1,000 elsewhere.

Natural orifices

The other natural orifices surgeons use are the mouth and rectum, but the vagina is considered the ideal portal, mostly, Dunkin says, because it's easier to close and less complicated if it leaks. Leaks from the rectum and stomach, by contrast, can be life-threatening, the reason the rectum is used only to remove diseased sections of the colon where there is no other alternative.

Still, Dunkin foresees a future five to 10 years away when, thanks to the development of better tools to suture inside the gastrointestinal tract, natural orifice surgery will be common in men and women.

In the meantime, Dunkin looks forward to the contamination study, which starts next month. Dunkin hasn't yet asked any women if they want to participate, but he doesn't envision difficulty enrolling the 15 needed for each of the two arms.

“It can be a little depressing to do laparoscopic surgery, those tiny incisions affording such a beautiful view of the abdomen, then having to make a 4-inch incision to remove the organ,” said Dunkin. “Once this method is ready for prime time, it should be a better way.”

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