The advent of laparoscopic donor nephrectomy (LDN) has resulted in decreased donor morbidity with less pain, shorter hospital stay, more rapid return to normal activities, and improved cosmesis compared with the open donor nephrectomy (ODN) conventional approach (1). The left kidney is preferred for both LDN and ODN because of the longer left renal vein, which facilitates the implantation process. However, because the “better” kidney should always remain with the donor, (2) occasionally, the right kidney may need to be transplanted. The early experience with right LDN, however, met with a high rate of vascular complications, such as renal vein thrombosis and graft loss (3/8, 37.8%) (3). This led the Johns Hopkins group to modify their technique to a semi-open procedure, where renal vein division was performed through a subcostal incision (3). The same group also concluded that “multiple left renal arteries are less problematic than a right kidney” (4). In agreement with this philosophy, several centers have reported that they perform only left LDN for living donors (5).
A multicenter review of right LDN, performed by either a transperitoneal pure laparoscopic or hand-assisted approach, documented a low incidence of graft loss (2/96, 2%), with no graft losses occurring after a learning curve of 10 right LDNs (6). Recently, Gill et al. (7) reported on a laparoscopic retroperitoneal approach to donor nephrectomy and autotransplantation where successful allograft outcome was achieved without vascular complications. Herein, we compare donor and recipient outcomes of a hand-assisted transperitoneal approach (HALDN) versus a pure retroperitoneal approach to right LDN (RLDN).
MATERIALS AND METHODS
Data were recorded prospectively in 59 patients undergoing right LDN using hand-assisted (n=31) or pure retroperitoneoscopic (n=28) approaches between January 2000 to November 2002. All HALDN cases were performed at the University of Cincinnati, and all RLDN cases were performed at the Cleveland Clinic Foundation, representing 15.4% and 19.6% of the live–kidney-donor population in each institution, respectively. Statistical analyses were performed using Student’s t test and chi-square test. The surgical technique for these approaches have been detailed elsewhere (6,7).
The HALDN procedure was performed with a four-port transperitoneal approach (Fig. 1): a 5 mm port for liver retraction, a 10 mm primary port for camera, a 12 mm port for the articulating stapler, and an additional 5 mm port for dissection purpose. The hand-port, Lapdisk (Ethicon, Cincinnati, OH), is placed through a 6.5 cm transverse incision paralleling a Rocky-Davis incision. The colon is mobilized and retracted medially. The superior attachments of the kidney to the liver are divided, allowing cephalad retraction of the liver with an endo-Kitner. The inferior vena cava (IVC) is visualized by medial rotation of the duodenum. The ureter is retracted laterally, allowing dissection of the renal vein and its caval junction. Cephalad retraction of the renal vein aids in identification of the renal artery. The adrenal is dissected from the kidney upper pole. The lateral attachments of the kidney are divided, and the kidney is flipped forward, allowing the posterior aspect of the renal artery to be exposed. Extensive posterior dissection is performed to retract the IVC medially and to circumferentially mobilize the renal artery (Fig. 2). After inducing diuresis with 12.5 gm of mannitol, the kidney is retracted laterally using hand-assistance, placing the renal hilum on traction. The renal artery is clipped and divided. Subsequently, the renal vein is controlled with an endo-stapler. The ureter is divided after the kidney is delivered through the hand-assist port incision.
Right RLDN is performed with three ports (Fig. 3). Balloon dilation (Origin Medsystems, Menlo Park, CA) is used to create the initial retroperitoneal working space. The kidney is then retracted anteriorly, and the renal artery is circumferentially mobilized at its retrocaval location. The proximal renal vein is circumferentially mobilized, and a generous segment of the adjacent IVC is exposed. The ureter, with adequate periureteral tissue, is dissected distally. Gerota’s fascia is entered, and the kidney upper pole is separated from the adrenal gland. The anterior kidney surface is mobilized minimally to prevent the kidney from falling posteriorly. A modified Pfannensteil or a low muscle-splitting Gibson incision is performed up to the level of transversalis fascia without entering the pelvic extraperitoneal space, thus maintaining pneumoretroperitoneum. Brisk diuresis is induced with 12.5 g of mannitol and 10 mg of furosemide. The renal artery is clipped using two locking (Weck) clips and is divided. An articulating Endo-GIA stapler is used to transect the renal vein flush with the vena cava (Fig. 4). The anterior surface of the kidney is completely freed. The retroperitoneum is entered through the previously created extraction incision, and the kidney is manually extracted. The ureter is divided extracorporeally after the kidney is delivered.
Indications for right LDN are listed in Table 1. Demographics were similar between the HALDN and RLDN groups: male/female (15/16 vs. 10/18, P =0.7), age (41.1±11.5 vs. 44.5±8.5 years, P =0.6), body mass index (26.8±4.4 vs. 26.0±3.8 kg/m2, P =0.5), and human leukocyte antigen mismatches (2.7±1.8 vs. 2.6±1.6, P =0.8). Anatomic complexities in the donor were encountered with similar frequency: multiple arteries (8 vs. 4 patients) and multiple veins (3 vs. 2 patients). The HALDN group had a longer operative time (3.4±0.7 vs. 3.0±0.7 hours, P =0.04) and shorter warm ischemia time (3:55±1:47 vs. 4:55±0:55 minutes, P <0.001) (Table 2). Length of the harvested renal vein and artery was equivalent between the groups. Donor complication rate was similar (3/31 [10%] vs. 2/28 [7%], P =0.5). Complications in the HALDN group included conversion to open surgery (n=1), accessory upper pole artery transection (n=1), and swollen testicle (n=1). Complications in the RLDN group included a small renal parenchymal injury (n=1) and a capsular tear (n=1). The HALDN extraction incision was smaller than in the RLDN group (6.5±0.2 vs. 7.4±0.6 cm, P <0.001). Donor length of stay (43.5±14.1 vs. 45.7±25.3 hours, P =0.1), postoperative analgesic requirement, MSO4 equivalent (22.0 vs. 28.9; P =0.8), and convalescence time to return to work (23.5 vs. 20.2 days, P =0.5) were similar in both groups. The need for postoperative recipient dialysis in the first week posttransplant (0/31 [0%] vs. 3/28 [10%], P <0.06) and the incidence of episodes of acute rejection (5/31 [16%] and 2/28 [7%], P =0.3) were comparable in both groups. Graft function was also similar at 1 week, 1 month, and 1 year (1.7, 1.5, 1.2 vs. 2.3*, 1.6, 1.3 gm/dL [*including patients that required dialysis first week postoperative]; P =0.5). No grafts were lost in either group.
Although consensus dictates that the better kidney should remain with the donor (2), many laparoscopic surgeons have avoided the right kidney for LDN, even in the presence of a more anatomically complex left kidney. Notwithstanding the preference for the left kidney, there are several instances wherein the right kidney should be harvested, particularly when the left kidney possesses multiple or complex vascular anatomy or when the right kidney has a noncritical pathology, such as a small cyst, stone, or minor arterial lesion.
As to concern over the length of the renal vessels, no significant difference was identified between the artery and vein lengths in either the HALDN and RLDN group in our study. However, the initial experience with right RLDN was marked by a high incidence of renal-vein thrombosis and graft loss (3/8, 37.8%) (3). Subsequently, certain technical modifications were proposed in an attempt to overcome the short length of the right renal vein. The Johns Hopkins group (3) shifted the Endo-GIA stapler port to the right lower quadrant. In this manner, the stapler was placed across the renal vein in a plane parallel to the vena cava, in an effort to maximize the vein length. This group also suggested that, in the presence of a right renal vein shorter than 3 cm, a subcostal open approach might be performed to obtain a caval collar. With a conventional Satinsky clamp (Aesculap, Inc., Center Valley, PA) placed across the vena cava, the vein was divided along with a vena cava cuff, and the cavotomy was repaired through this incision by traditional open surgical technique. Nevertheless, this semi-open approach may compromise the merits of pure minimally invasive surgery. Recently, Turk et al. (8) used a modified laparoscopic Satinsky clamp to harvest a renal vein with a cava cuff completely laparoscopically in four patients. An intracorporeal running suture was used to repair the cavotomy after kidney retrieval. However, we believe that this laparoscopic technique significantly increases the risk of a major vascular accident from the cavotomy and recommend against its routine laparoscopic application. The Cleveland Clinic group uses a pure laparoscopic retroperitoneal approach to right-side donor nephrectomy (7). With retroperitoneoscopy, an articulated Endo-GIA stapler can be placed across the renal vein parallel to and flush with the vena cava, obtaining maximal renal vein length by actually firing the stapler on the vena cava wall. The Cincinnati group uses a technique of lateral traction of the kidney using hand-assistance (6). This method allows the renal vein to be extended and a similar small portion of the vena cava to be safely incorporated in the staple line. Although an adequate length of renal vein can be obtained, both these minimally invasive approaches likely result in a somewhat shorter renal-vein length than that obtained open surgically, wherein a formal cuff of the vena cava can be obtained. Nevertheless, no vascular complications were noticed in this study, and a tension-free renal-transplant venous anastomosis was achieved after dissection of the renal hilar vessels on the bench table and with adequate mobilization of the recipient external iliac vein.
The pure retroperitoneoscopic approach allows direct access to the kidney and renal hilum, obviating the need to mobilize the ascending colon and duodenum. This may explain the shorter operative times obtained with the retroperitoneal approach in this study (9). Furthermore, the lack of violation of the peritoneal cavity may reduce postoperative paralytic ileus and decrease the chances of inadvertent intraperitoneal organ injuries. In contrast, when using the hand to manipulate and retract the bowel, one can potentially delay return of normal bowel function. Nonetheless, in this study, the majority of patients resumed oral fluids on the first postoperative day in both groups, and no injuries to the intraperitoneal organs occurred. Potential other benefits of the laparoscopic retroperitoneal approach for right-side donor nephrectomy include rapid access to the renal hilum, allowing for exposure and control of the right renal artery in a retrocaval location, thus ensuring adequate arterial length and avoidance of intra-abdominal adhesions, and is therefore preferable for patients with prior abdominal surgeries.
The hand-assisted technique minimizes warm ischemia time because the kidney is already fully mobilized and secured by the surgeon’s hand during renal hilar vessel control (10). Thereafter, the allograft is extracted quickly through the hand-port incision. Conversely, during pure retroperitoneoscopy, the surgeon’s hand is inserted into the retroperitoneal space after the renal hilar vessels are controlled. This explains the longer warm ischemia time, approximately 1 minute longer, in the pure retroperitoneoscopic approach. In general, warm ischemia times less than 5 minutes were regularly obtained with the pure retroperitoneoscopic approach. An earlier review of 100 LDN demonstrated that only recipients of kidneys with warm ischemia time greater than 10 minutes experienced serum creatinine levels greater than 2 mg/dL at postoperative day 7 (11). Moreover, a recent study from the University of Maryland with 640 LDN showed that warm ischemia time (0.5–12 minutes) does not correlate with recipient graft function within the range of times studied (1 week and 1, 3, 6, and 12 months). These authors concluded that a shorter warm ischemia time associated with HALDN does not necessarily offer a measurable advantage in recipient functional outcome (12).
Several studies have shown that compared with the conventional open approach, both minimally invasive techniques (hand-assisted and pure laparoscopy) result in a shorter convalescence period (13,14). This advantage is related to the small 6.5 to 7.5 cm muscle-splitting extraction incision used during these less-invasive techniques. Stifelman and colleagues (13) reported that hand-assisted laparoscopy was associated with significantly shorter convalescence, including time to driving (2.7±9.9 vs. 4.5±2.7 weeks), nonstrenuous activity (1.6±0.6 vs. 3.5±2.3 weeks), return to work (4.0±0.5 vs. 9.2±3.9 weeks), and number of narcotic tablets ingested after hospital discharge (4.6±4.9 vs. 20.9±19.9) compared with ODN (P <0.05). Similarly, Flowers and colleagues (14) reported that return to normal activities, including time to resume normal house work (8.8 vs. 26.9 days), driving (11.1 vs. 31.6 days), and return to usual preoperative employment (15.9 vs. 51.5 days), was significantly less in the pure laparoscopic group in comparison with the open group (P =0.001). Our preliminary retrospective data suggest that overall patient morbidity (analgesic requirement, hospital stay, convalescence) may be similar between HALDN and RLDN. The standardization of a 6.5 cm incision for the hand-port probably explains the somewhat smaller incision obtained with the HALDN approach. Both approaches can achieve superior cosmetic results by placing the extraction incision and hand-port in the inferior abdomen quadrant (HALDN, paralleling a Rocky-Davis incision; RLDN, Gibson incision). The retroperitoneoscopic approach may further improve cosmesis by using a Pfannensteil incision at the pubic hairline for extraction. Recently, open mini-incision LDN has been proposed as a less-invasive alternative. However, this approach may not be suitable to harvest the right kidney because a formal cuff of the vena cava may be difficult to obtain through a mini-incision. Furthermore, a recent study from the University of California compared quality-of-life parameters after LDN versus open mini-incision donor nephrectomy. This study concluded that pain in the laparoscopic group was significantly less than in the mini-incision group at all follow-up time points (P <0.05) and that laparoscopy led to more rapid recovery time in certain categories, including walking, discontinuation of oral pain relievers, return to driving, and resumption of normal work and daily home activities (15).
Studies have shown a trend toward fewer complications when a pure laparoscopic approach is used in comparison with the hand-assisted technique (16). In the present study, the incidence of donor complications was similar in both groups (10% HALDN, 7% RLDN). In the HALDN group, one case required conversion to open surgery. Situations such as this require thorough preoperative patient counseling because a surgeon may have to perform two different incisions, ultimately increasing morbidity.
No significant differences in immunologic or functional outcomes such as incidence of rejection, requirement of dialysis on the first postoperative week, or long-term serum creatinine levels were noted. Although not statistically significant, the HALDN group had a slightly higher incidence of acute rejection (5/31, 16% vs. 2/28, 7%; P =0.3), and the RLDN group tended to experience more delayed graft function (0/31, 0% vs. 3/28, 11%; P =0.06). This difference in rates of rejection may potentially reflect the differing immunosuppression regimes used in the respective institutions and the different criteria used to perform postoperative dialysis. Furthermore, a recent study at the Cleveland Clinic suggests that delayed graft function after laparoscopic LDN is not related to the laparoscopic technique itself. Instead, variables such as a female donor–male recipient relationship, unrelated highly mismatched donors, and prolonged cold and total preservation times were identified as factors related to delayed graft function (17). Intermediate-term functional outcome (serum creatinine) at the 1-year time period, which is an important predictor of long-term graft outcome (18), was equivalent in both groups (1.2 mg/dL vs. 1.3 mg/dL, P =0.5).
This comparative study demonstrates that groups with significant experience in LDN can perform right donor nephrectomy safely and efficiently with minimally invasive techniques. This brings minimally invasive surgery in line with the established principles of ODN. The individual surgeons should use their prior experience and comfort to guide their choice in selecting the approach (transperitoneal hand-assisted or pure retroperitoneal) for right LDN.
1. Jacobs S, Cho E, Dunkin B. Laparoscopic live donor nephrectomy: the University of Maryland 3-year experience. J Urol 2000; 164: 1494.
2. Murray JE, Harrison JH. Surgical management of 50 patients with kidney transplant including 18 pairs of twins. Am J Surg 1963; 105: 205.
3. Mandal A, Cohen C, Montgomery RA. Should the indications for laparoscopic live donor nephrectomy of the right kidney be the same as for the open procedure? Anomalous left renal vasculature is not a contraindication to laparoscopic left donor nephrectomy. Transplantation 2001; 71: 660.
4. Ratner LE, Kavoussi L, Chavin K. Laparoscopic live donor nephrectomy: technical considerations and allograft vascular length. Transplantation 1998; 65: 1657.
5. Troppmann C, Wiesmann K, McVicar J. Increased transplantation of kidneys with multiple renal arteries in the laparoscopic live donor nephrectomy era. Arch Surg 2001; 136: 897.
6. Buell J, Edye M, Johnson L, et al. Are concerns over right laparoscopic donor nephrectomy unwarranted? Ann Surg 2001; 233: 645.
7. Gill IS, Uzzo R, Hobart MG, et al. Laparoscopic retroperitoneal live donor right nephrectomy for purposes of allotransplantation and autotransplantation. J Urol 2000; 64: 1500.
8. Turk IA, Deger S, Davis JW, et al. Laparoscopic live donor right nephrectomy: a new technique with preservation of vascular length. J Urol 2002; 167: 630.
9. Gill IS, Strzempkowski B, Kaouk J, et al: Prospective randomized comparison: transperitoneal vs. retroperitoneal laparoscopic radical nephrectomy [abstract]. J Urol 2002; 167: 19.
10. Kerche K, Dahl D, Harland R, et al. Hand-assisted laparoscopic donor nephrectomy minimizes war ischemia. Urology 2001; 58: 152.
11. Sasaki T, Finelli F, Bugarin E. Is the laparoscopic donor nephrectomy the new criterion standard? Arch Surg 2000; 135: 943.
12. Buzdon MM, Cho E, Jacobs SC, et al. Warm ischemia time does not correlate with recipient graft function in laparoscopic donor nephrectomy. Surg Endosc 2003; 17: 746.
13. Stifelman MD, Hull D, Sosa ER, et al. Hand assisted laparoscopic donor nephrectomy: a comparison with the open approach. J Urol 2001; 166: 444.
14. Flowers JL, Jacobs S, Cho E, et al. Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 1997; 226: 483.
15. Perry KT, Freedland SJ, Hu JC, et al. Quality of life, pain and return to normal activities following laparoscopic donor nephrectomy versus open mini-incision donor nephrectomy. J Urol 2003; 169: 2018.
16. Gill IS, Kerbl K, Meraney MA, et al. Basics of laparoscopic urologic surgery. In: Campbell’s urology [ed. 8]. Saunders, Philadelphia 2002, pp 3455–3505.
17. Abreu SC, Goldfarb AD, Derweesh I, et al. Factors related to delayed graft function after laparoscopic live donor nephrectomy. J Urol 2004; 171: 51.
18. Hariharan MA, McBride WS, Cherikh CB. Post-transplant renal function in the first year predicts long-term kidney transplant survival. Kidney Int 2002; 62: 311.