Laparoscopic Right Donor Nephrectomy: A Large Single-Center Experience

Abstract

Background. 

Laparoscopic procurement of right donor kidneys is frequently avoided or performed using hand-assist devices because of concerns regarding donor safety, adequate exposure, and vessel length. The present study describes the authors’ large series of right donor nephrectomies performed laparoscopically without the use of hand ports or other manual assist devices.

Methods. 

The authors retrospectively analyzed all right laparoscopic donor nephrectomies performed at their center from November 1, 1999, to February 20, 2004. Study variables included operative times, blood loss, hospital stay, graft function, and donor and recipient complications. Left donor nephrectomies performed during the same period served as controls.

Results. 

Of 387 laparoscopic kidney procurements, 54 (14 %) were right nephrectomies. Blood loss, extraction times, length of stay, and overall complication rates were similar between right and left donor groups. The mean operative time in the right nephrectomy group was significantly shorter than in the left nephrectomy group (169±25 and 186±29 min, respectively; P=0.003). Graft function 1 month after transplantation and the incidence of delayed graft function were similar in both groups. There was one graft loss caused by thrombosis in the left nephrectomy group; other graft-related complications in the recipients were similar in both groups.

Conclusions. 

This large single-center experience demonstrates that laparoscopic right donor nephrectomy performed without hand-assist devices is safe and yields kidneys with excellent function. The authors conclude that selection of the appropriate kidney for donation using this approach can be based on the same criteria that have traditionally governed open donor nephrectomy.

Laparoscopic donor nephrectomy was first introduced by Ratner et al. in 1995 and has since evolved into the preferred approach for procuring kidneys from living donors (^{1, 2}). When compared with open nephrectomy, the procedure is associated with shorter hospital stay, less postoperative pain, earlier return to work, better cosmesis, and greater overall patient satisfaction (³). Perhaps as a result of these advantages, living-donor kidney transplantation has become increasingly used to the point that the number of living donors currently surpasses the number of cadaveric donors in the United States (^{4, 5}). Review of the literature on donor nephrectomy shows that many of the earlier studies limited the laparoscopic approach to left donor kidneys; right kidneys were not used or were procured using standard open techniques (^{1, 3}). Laparoscopic right kidney procurement was avoided primarily because of concerns regarding renal vein length, inadequate surgical exposure, and potential injury to the vena cava. Indeed, several reports documented increased frequencies of graft loss, vascular (venous) complications requiring back-table reconstruction, and delayed graft function (DGF) in right kidneys procured laparoscopically (^{6, 7}). More recently, several centers have reported on their experience with laparoscopic procurement of right kidneys and have shown that the approach can in fact be performed with donor and graft outcomes similar to those found with left kidneys. Although a variety of operative approaches were used in these studies, the overwhelming majority involved mid or upper abdominal hand ports or other manual assist devices to aid in the mobilization of the donor organs (^8–10). Such techniques may shorten operative times and facilitate procurement but can also result in greater postoperative pain and less desirable cosmesis when compared with predominantly laparoscopic approaches. In the present study, we describe our large experience with laparoscopic procurement of right kidneys performed without the use of hand-assist devices and demonstrate that this approach is safe and yields organs that function as well as those procured from the left side.

PATIENTS AND METHODS

Between November 1, 1999, and February 20, 2004, 387 laparoscopic kidney procurements were performed at the University of California, San Francisco by three surgeons (C.F., S-M. K., and A.M.P.) as part of the living-donor kidney transplant program. Fifty-four (14 %) of these patients underwent right donor nephrectomies. Demographic data were gathered from patient charts and clinic encounters and were analyzed retrospectively after protocol approval by the Committee on Human Research and the Institutional Review Board of the University of California, San Francisco.

Preoperative donor evaluations included a history and physical examination by a transplant nephrologist, renal function assessment with serum electrolytes and creatinine, and a urinalysis with spot urinary protein. Renal anatomy was evaluated with renal angiograms and intravenous pyelograms in the majority of our patients. In two of the more recently evaluated donors, high-resolution computed tomographic angiograms with three-dimensional reconstructions were used as the sole imaging study.

The following intraoperative donor parameters were collected prospectively during each case: (1) operative time, defined as the time from initial incision to closure of the final skin incision; (2) extraction time, defined as the time from renal artery clipping to initiation of the back-table flush; and (3) estimated blood loss. Postoperative donor parameters included hospital stay, approximate time to initiation of oral intake, need for blood transfusions, and complications. Recipient data that were collected included implantation time, defined as the time from removal of the kidney out of slush to reperfusion; renal function as assessed by decrease in creatinine over the first 24 hr after transplant and by baseline creatinine levels more than 1 month after transplantation; and graft-related complications. DGF was defined as the need for dialysis within the first week after transplantation.

The operative procedure used in this report is similar for both right and left nephrectomies and has been described previously (¹¹). Briefly, the procedure for right nephrectomy is as follows. The patient is positioned in a flexed, modified right lateral decubitus position, and pneumoperitoneum (15 mm Hg) is achieved using a Veress needle inserted into the right subcostal space. Three 11-mm trocars and one 12-mm trocar are then introduced into the upper abdomen (Fig. 1). The 12-mm port is used for introduction of the clip applicator and vascular stapler. The uppermost port is used by the assistant to retract the liver, and the port caudal to it holds the camera. The dissection begins by incising the right triangular ligament to allow medial and cephalad retraction of the liver, identifying the vena cava just below the liver, and then by mobilizing the right colon medially if necessary. The gonadal vein is identified and followed caudally for a distance of 5 to 10 cm. The ureter is identified superior and lateral to the gonadal vein, encircled with a vessel loop, and mobilized carefully to preserve a generous amount of periureteral tissue. The renal vein is identified and skeletonized to its origin with the vena cava. Lumbar branches and small accessory renal veins are identified, double-clipped, and transected. Accessory renal veins that have a diameter greater than 50% of the main renal vein are preserved. The renal artery is then isolated. Mobilization can proceed for some distance behind the vena cava if there are arterial branches that need to be preserved. Silastic vessel loops are placed around both the vein and artery and traction on these structures further aids in the dissection. Once the vessels and ureter have been isolated, the kidney is rotated medially and fully mobilized using a harmonic scalpel and electrocautery. When this is completed, the pneumoperitoneum is relaxed, and a 7- to 8-cm transverse suprapubic incision is made and the anterior rectus fascia is incised. The muscle bellies are retracted laterally and the peritoneum is identified to facilitate entrance into the peritoneal cavity later in the operation. The patient is systemically heparinized and receives intravenous furosemide (Lasix) and mannitol, and the distal end of the ureter is double-clipped and transected. The renal artery is double-clipped using a combination of a locking plastic clip (Hem-o-lok) and a metal clip, and divided distal to both clips with Endoshears, taking care to preserve an adequate cuff of 2 to 3 mm on the clipped stump. The heparin is reversed with protamine and the renal vein is stapled at its origin on the vena cava using a 2.5-mm vascular TA stapler (US Surgical), leaving staples on the caval side only (Fig. 2). Traction on the vessel loop at this point ensures that the staple line lies flush with the cava and that maximal venous length has been obtained. The vein is divided with laparoscopic scissors and the kidney is removed through the suprapubic incision after introduction of the donor’s surgeon’s left hand into the peritoneal cavity. The operative site is then inspected for signs of bleeding, the pneumoperitoneum is evacuated, and the trocar and suprapubic incisions are closed after local anesthetic has been injected into the surrounding subcutaneous tissues. Postoperatively, patients receive patient-controlled analgesia machines for the first night and are encouraged to begin ambulation as soon as possible. Oral intake is initiated with clear liquids and advanced as tolerated.

FIGURE 1.: Patient positioning for laparoscopic right nephrectomy. Three 11-mm ports and one 12-mm port are inserted. Liver retraction is achieved through the most cephalad port. The kidney is removed through the suprapubic incision. (Adapted from the original and provided courtesy of C. M. Brown, Indiana University School of Medicine Medical Illustration Department; and Shalhav AL, Siqueira TM Jr, Gardner TA, et al. Manual specimen retrieval without a pneumoperitoneum preserving device for laparoscopic live donor nephrectomy. J Urol 2002; 168: 941–944.)

FIGURE 2.: Photograph of the right renal vein (long arrow) after stapling at its origin from the vena cava. The clipped and divided renal artery is also visible (short arrow).

Differences between study groups were evaluated using Student’s t test for continuous variables and Fisher’s exact test for categorical variables. Values of P<0.05 were considered statistically significant.

RESULTS

All laparoscopic donor nephrectomies (n=387) performed at the University of California, San Francisco between November 1999 and February 2004 were analyzed and the donor demographic data are listed in Table 1. There were 333 left procurements over this entire period. Laparoscopic right donor nephrectomy was first performed at our institution in November 2001; since then, 54 right and 237 left procedures have been performed. Indications for right donor nephrectomy included multiple left arteries (57%), abnormal right renal arteries (36%), renal stones (5%), ureteropelvic junction obstruction (2%), renal cysts (2%), significant ptosis (2%), and retroaortic left renal veins (2%). Abnormalities in right renal arteries that led to the selection of right kidneys for donation consisted primarily of early fibromuscular dysplasia, early atherosclerosis, or both. Because the majority of prospective donors were evaluated by angiography, accurate venous anatomy was generally not available and, with the exception of one donor with an obvious retroaortic left renal vein, was not used in the selection process.

TABLE 1: Donor demographics and outcomes

Intraoperative donor parameters are listed in Table 1. Multiple arteries were encountered in 13% of right and 11% of left kidneys; these accessory arteries were preserved in 86% and 74% of right and left kidneys, respectively. Arteries that were not preserved were typically small-diameter upper pole vessels. Multiple veins were significantly more common in right (22%) than in left (2%) kidneys, although the majority (83% in both groups) were small and thus did not require reimplantation in the recipient. Estimated blood loss and extraction times were similar between the two groups. The mean operative times were significantly shorter for right kidneys than for left kidneys. This difference persisted even when the mean operative time for only the last 50 left nephrectomies was calculated, suggesting that technical factors related to the procedure itself rather than a learning effect accounted for the shorter times seen with right nephrectomies.

Intra- and postoperative donor complications were similar in both groups (Table 2) and included one conversion to open left nephrectomy because of a stapler malfunction, two small bowel injuries (one in each group) that were repaired primarily and occurred during creation of the suprapubic extraction site, and one episode of rhabdomyolysis that resulted from a prolonged operative time caused by complications with the recipient. Transfusions were limited to five patients in the left kidney group. The patient who underwent open conversion because of stapler malfunction required an intraoperative transfusion; the other four patients received postoperative transfusions. One patient in the postoperative group required a 3-unit transfusion for port site bleeding exacerbated by inadvertent heparin overanticoagulation that was not recognized immediately. The other three patients had port site bleeding or abdominal hematomas, and each required 1-unit transfusions. In all these patients, bleeding stopped without intervention. Notably, we did not experience any complications related to the use of vascular locking clips in any of our patients. Patients in both groups were initiated on oral diets within 12 to 18 hr after surgery, and overall hospital stays averaged 3.2 days and 3.3 days for the right and left donor groups, respectively (Table 1).

TABLE 2: Donor complications

Recipient outcomes are depicted in Table 3. All right kidneys had sufficient vessel length to permit standard implantation into the iliac vessels of the recipient without need for ex vivo reconstruction. Graft function, as determined by change in creatinine over the first 24 hr after transplantation and baseline creatinine 1 month after transplantation, was indistinguishable between the two groups. Recipient complications are listed in Table 4. The rates of DGF, ureteral problems, and overall graft-related complications were similar between the two groups. There was one episode of graft thrombosis (in the left nephrectomy group) that was most likely caused by a prolonged period of hypoperfusion resulting from an intraoperative myocardial infarction in the recipient.

TABLE 3: Recipient demographics and outcomes

TABLE 4: Graft-related recipient complications

DISCUSSION

Although laparoscopy has become the preferred approach for procuring kidneys from living donors, this technique has until recently been limited to the procurement of left kidneys. Early reports of laparoscopic right donor nephrectomy described higher rates of graft loss and longer duration of DGF, both of which were attributed to the shorter length of the right renal vein and resultant difficulty in implanting the organ. Mandal et al. reported that of eight right kidneys procured laparoscopically, three developed vascular thromboses resulting in graft loss. Modification of their technique to include open division of the renal vein through a subcostal incision improved results significantly, with the next nine procedures having markedly improved outcomes (⁶). Similarly, a multicenter review by Buell et al. found that laparoscopically procured right kidneys had relatively high rates of graft thrombosis (4%), although addition of a hand-assist device could reduce this complication (¹²). These early findings prompted some centers performing laparoscopic nephrectomy to preferentially procure left kidneys, even if this entailed using organs with more complex vascular anatomy (¹³). Since that time, some progress has been made in the technical aspects of right donor nephrectomy, and several centers have now published reports that show similar outcomes in right and left laparoscopic donor nephrectomy groups (^9–12). Many of these approaches have in common the need for a variety of hand-assist devices to aid with the dissection and mobilization of the organs. Proponents of this technique feel that hand-assist devices provide better exposure, are safer, and result in shorter operative times when compared with the pure laparoscopic approach (¹⁴). In addition, it is thought that because hand-assisted laparoscopic nephrectomy is technically easier, it is more conducive to teaching residents and fellows—an important consideration in academic institutions (¹⁵). The present study extends these findings by demonstrating that laparoscopic procurement of right kidneys can be performed safely and yields organs with excellent function. Moreover, it shows that these results can be accomplished using predominantly laparoscopic techniques.

Although the operative protocol we use is similar for right and left nephrectomies, it incorporates several technical points that become particularly relevant for right-sided procurements. To maximize vessel length, the renal vessels (particularly the renal vein) are mobilized meticulously down to their origins, and a vascular TA (rather than a GIA) stapler is used on the renal vein to leave a staple line on the caval side only. Exposure is facilitated by extensive mobilization of the right triangular ligament of the liver and cephalad retraction of the right hepatic lobe through the uppermost port. By applying these principles, all of the right kidneys procured in this manner had sufficient vessel length to permit implantation without the need for back-table vascular reconstruction or extensive mobilization of the iliac vessels in the recipient. We did not experience increased rates of DGF, graft loss, or other complications related to the procurement. When we examined operative times and extraction times, we found that they compared favorably with those reported in other studies describing open nephrectomy or hand-assisted laparoscopic approaches (^{8, 14, 15}). Interestingly, our operative times were consistently shorter in the right nephrectomy group when compared with the left side and were not caused by a “learning curve” effect, a finding reported by other investigators as well (^{16, 17}). This difference is most likely attributable to the absence of adrenal and gonadal venous tributaries draining into the renal vein that must be controlled during left kidney procurement and the less extensive dissection of the colon that is needed to allow adequate mobilization of the right ureter. With respect to the role of housestaff in this approach, we feel strongly that teaching of housestaff is not compromised. These procedures are routinely performed by a transplant surgeon and a senior surgical resident or transplant fellow, with the latter performing increasingly larger portions of the operation as they gain experience with the procedure.

Although this report does not directly compare pure laparoscopic and hand-assisted techniques for right donor nephrectomy, several studies have described significant benefits with the former. Cosmetic outcomes are improved because the extraction incision is suprapubic rather than periumbilical or upper abdominal as it is with standard hand-port incisions, and there appears to be less postoperative pain because a muscle-sparing approach is used and the incision is only manipulated for a brief period of time while the kidney is being removed (^{18, 19}). The hand port can malfunction, interfere with adequate access to the operative field, and cause significant intra-abdominal hand fatigue (^{14, 18}). Some authors have reported an increased incidence of postoperative ileus with the hand-assisted approach as compared with the pure laparoscopic approach, presumably because there is more handling of intra-abdominal organs with the former (²⁰). Finally, there is a significant reduction in material costs when the hand port is not used, although some authors argue that this cost can be partially offset by the shorter operative times associated with hand-assist devices (^{14, 15}).

CONCLUSION

This study describes our large experience with right donor nephrectomy performed laparoscopically without the use of hand-assist devices. With respect to donor safety, organ quality, and operative time, the results of this technique are very similar to those observed with laparoscopic left donor nephrectomy. Furthermore, omission of a hand-assist device does not appear to compromise outcome and in fact may have several significant advantages, as noted above. Given our current experience with right donor nephrectomy, laparoscopy has become the preferred approach for procurement of both right and left kidneys, and selection of the appropriate kidney for donation is now based on the same criteria that were used in the past when open donors were the standard of care. The use of open nephrectomy for kidney donation has all but been abandoned at our center, and is now reserved for the rare donor in whom access to the peritoneal cavity may be complicated by previous extensive abdominal surgery and subsequent adhesions.