Increasing numbers of living donor kidney transplants are being performed worldwide, and the majority of donor operations are now laparoscopic. Transperitoneal ‘pure’ and hand-assisted laparoscopic donor nephrectomy (HALDN) are the two most commonly performed procedures, although retroperitoneal approaches are advocated by some centers (1).
The ‘pure’ transperitoneal laparoscopic donor nephrectomy (LDN), first described by Ratner and colleagues in 1995, is the preferred technique in many transplant centers. It typically uses four ports and is performed in the lateral decubitus position by surgeons with prior experience of other complex laparoscopic procedures. On retrieval, the organ is prebagged or extracted by hand, typically through a Pfannenstiel incision.
The HALDN uses an additional air-tight port, thus enabling the surgeon to bring one hand into the operating field, mostly for blunt dissection or for hemorrhage control. Given its shorter learning curve compared with LDN, HALDN is often used by surgeons during the transition phase from open to LDN. Other advantages of HALDN over LDN include shorter operative and warm ischemia times. Potential disadvantages of HALDN are the higher cost caused by the disposable hand port and a higher rate of incisional hernia (1).
Retroperitoneoscopic approaches to the donor kidney have been developed to further increase donor safety, without compromising efficiency and cosmesis. Intraperitoneal organs such as the colon, the spleen, and the liver are much less likely to be injured, and postoperative ileus or internal herniation is theoretically less frequent. However, the smaller working space, compared with transperitoneal LDN, represents a technical challenge to the surgeon.
In their article, Omoto et al. (2) present their ample expertise in retroperitoneoscopic living donor nephrectomy. Because authors applied this elegant minimally invasive technique almost exclusively on the left donor side, they were forced to use kidneys with multiple renal arteries in almost 25% of cases. Despite this limitation, likely prolonging total operating and warm ischemia times, donor and recipient outcomes herein reported are excellent. Facing these encouraging results, reluctance toward the use of living donor kidneys with multiple arteries may not seem justified. However, according to previous large studies, the use of living donor kidney grafts with multiple arteries is associated with a higher incidence of ureteral complications (3, 4). Because lower pole renal arteries are critical for ureteral blood supply, their reanastomosis should always be attempted (3). Although complex vascular anatomy is not considered a contraindication to laparoscopic living donor nephrectomy, recipients of allografts with more than two arteries experience a greater incidence of slow or delayed graft function as shown in the Article by Omoto et al. and by others (2, 4). Making increased use of right living donor kidneys is a simple way to keep the use of left kidneys with multiple arteries to a minimum. An earlier report from a high volume renal transplant center clearly advocates laparoscopic right donor nephrectomy as a safe and straightforward procedure with excellent donor and recipient outcomes (5).
Large prospective studies comparing donor and recipient outcomes of different minimally invasive donor nephrectomy techniques are yet to come. At present, none of the three techniques, that is, pure laparoscopic, hand-assisted or retroperitoneoscopic, shows clear superiority over the others, and surgeon preference is pivotal. No matter which approach is used, two principles of living donor nephrectomy should be followed: (1) do not harm the donor and (2) make optimal use of available living donors to overcome organ shortage. It may no longer seem acceptable to exclude otherwise suitable living donors only on grounds of technical obstacles. Apart from reluctance to apply minimally invasive techniques to right donor kidneys or to kidneys with multiple arteries, another obstacle could be the lack of expertise in advanced vascular anastomosis techniques. In selected cases, open donor nephrectomy, especially on the right side, should remain a viable option to overcome technical shortcomings of laparoscopy in the presence of a complex renal vascular anatomy.
1. Banga N, Nicol D. Techniques in laparoscopic donor nephrectomy. BJU Int
2012; 110: 1369.
2. Omoto K, Nosaki T, Inui M, et al. Retroperitoneoscopic donor nephrectomy with multiple renal arteries does not affect graft survival and ureteral complications. Transplantation
2014; 98: 1175.
3. Carter JT, Freise CE, McTaggart RA, et al. Laparoscopic procurement of kidneys with multiple renal arteries is associated with increased ureteral complications in the recipient. Am J Transplant
. 2005; 5: 1312.
4. Cooper M, Kramer A, Nogueira JM, et al. Recipient outcomes of dual and multiple renal arteries following 1000 consecutive laparoscopic donor nephrectomies at a single institution. Clin Transplant
. 2013; 27: 261.
5. Dols LF, Kok NF, Alwayn IP, et al. Laparoscopic donor nephrectomy: a plea for the right-sided approach. Transplantation
. 2009; 87: 74.