Technique, Indications and Outcomes of Pure Laparoscopic Right Donor Nephrectomy

Laparoscopic Right Donor Nephrectomy: A Two-Center Comparative Study

Introduction As the field of laparoscopic living donor nephrectomy (LLDN) has progressed over the years, there has been a growing emphasis on optimizing surgical techniques and outcomes to ensure the safety and well-being of living kidney donors. The early experiences with right LLDN, marked by challenges and concerns such as high conversion rates to open surgery and early graft loss due to technical reasons, prompted a reevaluation of the approach toward right-sided donor nephrectomies. In this article, we aim to compare the safety and efficacy of right LLDN to left LLDN performed in our centers and to provide valuable insights that can ultimately enhance patient outcomes and ensure the well-being of living organ donors. Methods Between January 2018 and January 2022, we conducted 16 cases of right LLDN and compared them with 134 cases of left LLDN procedures done in the Kingdom of Bahrain and Jordan over the same time period. We analyzed differences in donor age, sex, operative time, warm ischemia time (WIT), graft function, complications, and conversion to open technique. Patient data and surgical outcomes were extracted from medical records and surgical databases. Statistical analysis was conducted to identify significant differences between the two groups. Categorical variables such as complications and safety outcomes were compared using chi-square tests and logistic regression analysis. The primary outcomes of interest included safety metrics such as complication rates, vascular complications, graft loss, and postoperative serum creatinine levels for the recipients. Results Our study showed similar demographics in both groups. However, the operative time was shorter for the left LLDN, with 81 minutes compared to 96 minutes for the right. Warm ischemia times (WITs) were comparable at 4.5 minutes for the left and 5.2 minutes for the right. There was less incidence of delayed graft function on the left side (none in the left group compared to one case in the right group). Both groups had similar six-month graft function in terms of serum creatinine levels (0.98 mg/dL for the left and 1.2 mg/dL for the right), hospital stays (2.5 days for the left and 2.8 days for the right), and estimated blood loss (EBL) (90 mL for the left and 50 mL for the right). Additionally, no blood transfusions were required in either group, but there was one case of conversion to open surgery in the right LLDN group. Conclusion Our data confirm the safety and efficacy of the right LLDN, consistent with the current literature. This increases the cumulative evidence supporting the use of laparoscopic retrieval on the right side when indicated.

Does the Side Matter? A Retrospective Cohort Study Comparing Left and Right Pure Laparoscopic Donor Nephrectomies

OBJECTIVES

Right laparoscopic donor nephrectomy (RLDN) is no longer regarded inferior to left LDN (LLDN). However, this knowledge is based on many studies suffering from inherent learning curves, center-specific imbalances, and different laparoscopic techniques.

METHODS

Pure LDNs at a high-volume referral center from 2011 to 2016 were retrospectively analyzed. Patient, graft characteristics, outcomes of LDNs, and corresponding open kidney transplantations were compared between LLDN and RLDN including a follow-up.

RESULTS

160 (78.4%) LLDNs and 44 (21.6%) RLDNs only differed regarding graft characteristics, as more right grafts had multiple veins (34.1 vs. 6.9%, p < 0.001) and worse scintigraphic function (44 vs. 51%, p < 0.001). RLDNs were shorter (201 vs. 220 min, p = 0.032) with longer warm ischemia time (165 vs. 140 s, p < 0.001), but left grafts were transplanted faster (160 vs. 171 min, p = 0.048). Recipients of right kidneys had more postoperative complications (grade 3: 25.6 vs. 11.3%, p = 0.020). At a follow-up of 45 (range 6-79) months, neither the kidney function, nor death-censored graft (5-year: LLDN 89 vs. 92%, p = 0.969) and patient survival (5-year: LLDN 95 vs. 98%, p = 0.747) differed.

CONCLUSIONS

Pure LLDN and RLDN can have different outcomes at high-volume centers, especially higher complications for recipients of right grafts. However, long-term function and graft survival are the same irrespective of the chosen side.

Midline Rotation of the Right Renal Hilum During Hand-Assisted Laparoscopic Living Donor Nephrectomy

BACKGROUND/OBJECTIVES

Laparoscopic living donor nephrectomy (LLDN) of the right kidney is currently considered as part of standard of care; however, dealing with the renal hilum when performing ligation/division of its renal vessels is still a main concern. Here, we describe a simple-to-perform technique, i.e., flipping the fully mobilized right kidney to the midline so that the renal artery becomes anteriorly, which offers better visualization and easier dissection of the renal vessels (achieving maximized lengths) when performing hand-assisted LLDN of the right kidney.

METHODS

Living donors who underwent hand-assisted LLDN of the right kidney, along with their respective renal transplant recipients, were included in this report. Donor characteristics included renal artery and vein lengths; recipient characteristics included creatinine at months 12 - 36. Graft vein and arterial anastomosis data were also reported.

RESULTS

Nineteen living donors and 19 recipients, with median donor and recipient ages being 39 (24 - 60) and 53 (3 - 81) years, respectively, were included. None of the 38 patients had intra- or postoperative complications. Donor renal vein was anastomosed to the right external iliac vein (n = 16), right common iliac vein (n = 2), and inferior vena cava (n = 1). Gonadal vein (n = 1) and deceased donor iliac vein (n = 2) were used to increase the right renal vein length in 3 cases. Four donor kidneys had 2 arteries reconstructed side by side. None of the recipients developed any vascular or urological complications.

CONCLUSIONS

The laparoscopic technique described is safe and allows better visualization of the right hilum, mainly the renal artery, and helps in stapling the renal vein and renal artery.

Endo-Satinsky Clamp Hybrid In Situ Perfusion in Retroperitoneoscopic Donor Nephrectomy For Right-sided Kidney

OBJECTIVE

To introduce our hybrid technique using an endo-Satinsky clamp and in situ cold perfusion for right-sided retroperitoneoscopic donor nephrectomy (RDN) and to investigate efficacy and safety compared with those standard right-sided RDN.

METHODS

This retrospective study included 16 transplant donors who underwent right-sided RDN from January 2016 to January 2018. Donors received either hybrid RDN (n = 6) or standard RDN (n = 10). Perioperative outcomes, including operative time, estimated blood loss, warm ischemic time, hospital stay, length of renal vein obtained as well as postoperative renal function of their recipients were collected and compared between the hybrid RDN and standard RDN groups.

RESULTS

Procedures were performed successfully in all 16 donors. The hybrid RDN group required longer operation times (135 vs 115 minutes), demonstrated increased blood loss (175 vs 140 mL), but shorter warm ischemic times (1.5 vs 5.5 minutes) and resulted in longer length of the procured renal vein (2.8 vs 1.7 cm) as compared with the standard RDN group. No difference in perioperative complication rates was witnessed between the 2 groups. Also, there were no significant differences in serum creatinine levels and glomerular filtration rates of recipients between the 2 groups at both postoperative day 3 and 1 month.

CONCLUSION

The hybrid RDN potentially extends the length of the right donor renal vein. The perioperative outcomes of hybrid RDN were comparable with those of the standard RDN. This hybrid technique can be a technically safe and feasible option for right kidney donation.

Perioperative Events and Complications in Minimally Invasive Live Donor Nephrectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive live donor nephrectomy has become a fully implemented and accepted procedure. Donors have to be well educated about all risks and details during the informed consent process. For this to be successful, more information regarding short-term outcome is necessary.

METHODS

A literature search was performed; all studies discussing short-term complications after minimally invasive live donor nephrectomy were included. Outcomes evaluated were intraoperative and postoperative complications, conversions, operative and warm ischemia times, blood loss, length of hospital stay, pain score, convalescence, quality of life, and costs.

RESULTS

One hundred ninety articles were included in the systematic review, 41 in the meta-analysis. Conversion rate was 1.1%. Intraoperative complication rate was 2.3%, mainly bleeding (1.5%). Postoperative complications occurred in 7.3% of donors, including infectious complications (2.6%), of which mainly wound infection (1.6%) and bleeding (1.0%). Reported mortality rate was 0.01%. All minimally invasive techniques were comparable with regard to complication or conversion rate.

CONCLUSIONS

The used techniques for minimally invasive live donor nephrectomy are safe and associated with low complication rates and minimal risk of mortality. These data may be helpful to develop a standardized, donor-tailored informed consent procedure for live donor nephrectomy.

Role of Minimally Invasive Surgery in the Reoperative Abdomen or Pelvis

Laparoscopy has become widely accepted as the preferred surgical approach in the management of benign and malignant colorectal diseases. Once considered a relative contraindication in patients with prior abdominal surgery (PAS), as surgeons have continued to gain expertise in advanced laparoscopy, minimally invasive approaches have been increasingly incorporated in the reoperative abdomen and pelvis. Although earlier studies have described conversion rates, most contemporary series evaluating the impact of PAS in laparoscopic colorectal resection have reported equivalent conversion and morbidity rates between reoperative and non-reoperative cases, and series evaluating the impact of laparoscopy in reoperative cases have demonstrated improved short-term outcomes with laparoscopy. The data overall highlight the importance of case selection, careful preoperative preparation and planning, and the critical role of surgeons' expertise in advanced laparoscopic techniques. Challenges to the widespread adoption of minimally invasive techniques in reoperative colorectal cases include the longer learning curve and longer operative time. However, with the steady increase in adoption of minimally invasive techniques worldwide, minimally invasive surgery (MIS) is likely to continue to be applied in the management of increasingly complex reoperative colorectal cases in an effort to improve patient outcomes. In the hands of experienced MIS surgeons and in carefully selected cases, laparoscopy is both safe and efficacious for reoperative procedures in the abdomen and pelvis, with measurable short-term benefits.

Urologic considerations and complications in kidney transplant recipients

Urologic considerations during the kidney transplantation process, starting with initial recipient evaluation and continuing through the post-transplant, long-term follow-up, are critical for minimizing urologic complications and improving graft survival. Appropriate, targeted, preoperative urologic evaluation of the recipient allows for an optimized urinary tract to accept the graft, whereas post-transplant urologic follow-up and monitoring decrease the risk of graft lost secondary to a urologic cause, particularly in patients with a urologic reason for their kidney failure and in those patients with concomitant urologic diagnoses. Urologic complications comprise the second most common adverse post-transplant event, occurring in 2.5% to 14% of patients and are associated with high morbidity, graft loss, and mortality. Early and late urologic complications, including hematuria, hematoma, lymphocele, urine leak, ureteral stricture, nephrolithiasis, and vesicoureteral reflux, and their causes and treatment options are explored. A multidisciplinary team approach to kidney transplantation, including transplant surgery, urology, and nephrology, optimizes outcomes and graft survival. Although the current role of the urologist in kidney transplantation varies greatly by institution, appropriate consultation, participation, and monitoring in select patients is essential.

Urological involvement in renal transplantation

Historically, urologists were the primary surgeons in renal transplantation. Specialization and increased complexity of the field of transplantation, coupled with a de-emphasis of vascular surgical training in urology, has created a situation where many renal transplants are carried out by surgeons with a general surgery background. Because of its genitourinary nature, however, urological input in renal transplantation is still vital. For living donors, a urologist should be involved to help evaluate and prepare certain patients for eventual donation. This could involve both medical and surgical intervention. Additionally, urologists who carry out living donor nephrectomy maintain a sense of ownership in the renal transplant process and provide a unique opportunity to the trainees of that particular program. For renal transplant recipients, preoperative evaluation of voiding dysfunction and other genitourinary anomalies might be necessary before the transplant. Also, occasional surgical intervention to prepare a patient for renal transplant might be necessary, such as in a patient with a small renal mass that is detected by a screening pretransplant ultrasound. Intraoperatively, for patients with complex urological reconstructions that might be related to the etiology of the renal failure (urinary diversion, bladder augmentation), a urologist who is familiar with the anatomy should be available. Postoperatively, urological evaluation and intervention might be necessary for patients who had a pre-existing urological condition or who might have developed something de novo after the transplant. Although renal transplant programs could consult an on-call urologist for particular issues on an as-needed basis, having a urologist, who has repeated exposure to the particular issues and procedures that are involved with renal transplantation, and who is part of a dedicated multidisciplinary renal transplant team, provides optimal quality of care to these complex patients.

Hand-assisted laparoscopic right donor nephrectomy: safety and feasibility

Purpose

We aimed to prove the safety and feasibility of right-sided hand-assisted laparoscopic donor nephrectomy (HALDN).

Materials and Methods

Between May 2006 and May 2009, 16 patients underwent right-sided HALDN at our institution. Of these patients, 15 showed significantly lower renal function in the right kidney than in the left one and 1 had a stone in the right kidney. When the right renal vein was divided, an EndoGIA stapling device was placed on the wall of the inferior vena cava to gain a maximal length of the vein. We evaluated intraoperative and postoperative parameters such as operative time, delivery time, warm ischemic time, estimated blood loss, intraoperative and postoperative complication rates, length of hospital stay, and serum creatinine levels of donors (at the time of discharge) and recipients (4 weeks postoperatively), comparing the right-sided HALDN group (our study) with a left-sided HALDN group (from a previously reported study).

Results

A total of 16 right-sided HALDNs were successfully performed without any complications or open conversion. All of the intraoperative and postoperative parameters were similar between the right-sided HALDN and left-sided HALDN groups. There were no technical problems in the recipients in the anastomosis of the renal vein, and the ureteral anastomoses were also successful.

Conclusions

Right-sided HALDN is safe and technically feasible in a donor, showing favorable graft outcomes. The results of our study suggest that right-sided HALDN may be preferable in patients with significantly lower renal function in the right kidney than in the left one.

Evaluation of cadaveric renal vein lengths and their extension loss with three types of ligature and section

BACKGROUND AND PURPOSE

The right kidney has been less frequently used in live donor nephrectomy, because of the shorter length of the right renal vein (RRV) that is associated with technical difficulties and higher rates of venous thrombosis. In live open donor or deceased donor transplant nephrectomy, an additional cuff of the inferior vena cava is usually removed, but this is a more difficult and risky maneuver in laparoscopic nephrectomy. For this reason, laparoscopic right nephrectomy (LRN) for renal transplantation (RT) is not frequently performed in most medical institutions. We evaluate the difference between RRV and left renal vein (LRV) lengths in cadavers, as harvested for RT by three clamping methods. Our objective was to obtain information that could clarify when LRN for RT should be encouraged or avoided with regard to conventional surgery.

MATERIALS AND METHODS

Ninety adult fresh unfrozen cadavers were randomly divided into three groups of 30, according to the clamping device used: Satinsky, stapler, and Hem-o-lok clip. The abdominal viscera were removed through a median xyphopubic incision, and the veins were measured on the bench. Two lateral limits were used: The renal hilum and the tangential line of the renal poles. As for medial limits, the inferior vena cava or the laparoscopic clipping device on the RRV were used on the right side, while on the LRV, the medial border of the emergence of the adrenal vein was considered. After section of the renal vein, a slight traction of the extremity was applied for the measurement. All measurements were obtained three times using a metallic millimetric ruler, and the arithmetic mean was considered. The chi-square, one-way analysis of variance, and paired t tests were used for statistical analysis. Statistical significance was accepted at P <or= 0.05.

RESULTS

The groups of cadavers were homogeneous in demographic characteristics. Regardless of the clamping method and considering the useful length of the LRV, the RRV was statistically smaller. The evaluation of the vein length did not depend on the lateral limit considered. Independent of the clamping method, on both sides, the lengths after the vein section were larger than before the section, a fact attributed to traction. Use of a stapler and a single Hem-o-lok presented the same waste of vein length on the right side. On average, the RRV was 13.7% shorter than the LRV.

CONCLUSIONS

With the wide acceptance of laparoscopic live donor nephrectomy, the length difference between the veins of both kidneys is an important issue, and the right kidney is therefore used less than the left, compared with conventional surgery. This article represents the first step to quantify the anatomic length of renal veins in different situations. Certainly, more imagenologic or surgical studies should be carried out before decisions can be made for better selection of patients for LRN.

[Experience initial right side laparoscopic live donor]

Live donor nephrectomy laparoscopic technique is now standard. However, the right side is controversial because of the short length of the renal vein and the incidence of venous thrombosis.

METHODS

A prospective study of patients live donors since May 2006 to September 2008 in which right nephrectomy was performed by laparoscopic live donor. The placement of trocares was usual and the transperitoneal approach. Incision was used for the extraction of Gibson.

RESULTS

Of the 10 selected patients, 1 was excluded due to conversion to open technique. The criteria for lateralization were sex, renal volume and complex vascular anatomy. 6 patients had made back-table reconstruction surgery with prosthetic vascular due to the length of the renal vein. The average operative time was 158.3 minutes and the bleeding averaged 272 cc. Warm ischemia time averaged 3.2 minutes. The average hospital stay was 1.6 days. 1 recipient presenting delayed graft dysfunction.

CONCLUSIONS

Laparoscopic live donor right nephrectomy offers an excellent quality of graft, being a technique feasible and safe, maintaining the principle of leaving the best kidney donor.

Living Donor Nephrectomy: Open versus Laparoscopic Technique

Background

The living donor nephrectomy has to be safe and effective, allowing a good graft function in the recipient. In the past, donor nephrectomy was performed only by open technique; more recently this nephrectomy has also been performed by laparoscopic technique. The best technique has not been established in literature. The purpose of this study is to report the results of open and laparoscopic nephrectomy in living donors.

Materials and Methods

From January 1992 to August 2008, 37 living donor nephrectomies were performed. 23 nephrectomies were achieved by laparoscopic procedure (LDN) and 14 by open technique (ODN). The 2 groups were comparable regarding both donor and recipient characteristics.

Results

All laparoscopic nephrectomies were successfully performed without conversion to open procedure. No donor deaths were reported in either groups. 3 complications (13%) in the LDN group and 1 (7.1%) in the ODN group (p=0.6) were observed. Mean operative time was higher in the LDN group (p<0.036). Mean warm and cold ischemia time, resumption of oral intake and hospital stay were shorter in the LDN group (p<0.04)(p<0.03) (p<0.0001), whereas the return to normal occupational life was similar (p<0.52). We had no significant differences in the surgical complication rates, graft and patient survival.

Conclusions

Our experience suggests that both procedures can be used safely and efficiently, and assure a good renal function in the recipient. Laparoscopic nephrectomy, although more difficult, provides post-operative advantages. However, laparoscopic procedure must be performed by experienced centres only to prevent serious complications in the donor.

Laparoscopic living donor nephrectomy: a look at current trends and practice patterns at major transplant centers across the United States

PURPOSE

Laparoscopic living donor nephrectomy is now the preferred technique for living donor renal transplantation. To our knowledge we provide the first published multi-institutional consensus describing practice patterns, technical considerations and interesting controversies involved in laparoscopic living donor nephrectomy.

MATERIALS AND METHODS

We designed a survey with 33 multiple choice questions looking at demographics, patient selection, technical considerations, postoperative care and followup involved in laparoscopic living donor nephrectomy. Surveys were sent to the 58 fellowship training programs in the United States accredited by the American Society of Transplant Surgeons.

RESULTS

The 32 responding programs performed approximately 40% of laparoscopic living donor nephrectomies in the United States in 2005. We found that almost all centers used a donor committee to screen candidates, enforce a body mass index cutoff, and use right kidneys when necessary and left kidneys in women of childbearing age. Regarding laparoscopic access, pure laparoscopy was favored 2 to 1 over the hand assisted technique and most of those who use nonbladed trocars do not close the fascia. Most surgeons divide the adrenal vein in left cases, use a vascular stapler on the renal artery and vein, and keep the ureter with the gonadal vein in the specimen. At most centers heparin is given before controlling the vessels. Extraction in pure laparoscopic cases is usually performed using a preplaced entrapment bag through a modified Pfannenstiel incision.

CONCLUSIONS

Our survey describes how most renal transplant centers with accredited fellowship programs in the United States approach laparoscopic living donor nephrectomy. Specifically trends are revealed regarding patient selection, laparoscopic access and surgical technique.

Novel Technique for Hand Assisted Laparoscopic Right Donor Nephrectomy

PURPOSE

Most surgeons divide the renal vein with a laparoscopic stapler during laparoscopic donor nephrectomy. The right renal vein is usually shorter than the left one and using the stapler on the right side can result in a higher incidence of vascular complications for right kidney recipients. We present our experience with a new technique for hand assisted laparoscopic right donor nephrectomy.

MATERIALS AND METHODS

We designed a new vascular clamp to be completely inserted into the peritoneal cavity through the hand port incision in hand assisted laparoscopy. The renal vein with a cuff of the inferior vena cava was then excised. The defect in the inferior vena cava was sutured intracorporeally.

RESULTS

A total of 80 kidney donors underwent hand assisted laparoscopic right donor nephrectomy using the new technique. Mean +/- SD operative time was 184 +/- 36 minutes. Operative time was decreased in the last 30 patients to 152 +/- 22 minutes. Intracorporeal suture time on the inferior vena cava was 16 +/- 3 minutes. No intraoperative complications were noted and there was no partial or total graft loss. Mean blood loss was 50 +/- 35 cc. Mean warm ischemia time was 4 +/- 2 minutes. Hospital discharge was on postoperative day 1 or 2 in 81% of patients. Graft function was normal in 78 recipients with a day 5 postoperative serum creatinine of 1.6 +/- 0.9 mg/dl. Two recipients showed delayed graft function and were treated medically.

CONCLUSIONS

This technique for hand assisted laparoscopic right donor nephrectomy has proved to be safe and reproducible. We recommend practicing laparoscopic inferior vena cava suturing in the animal laboratory before performing it in humans.

Right laparoscopic donor nephrectomy and the use of inverted kidney transplantation: an alternative technique

OBJECTIVES

To report a novel approach to overcome the problems associated with a short right renal vein harvested by clipping the vein during right laparoscopic donor nephrectomy (RLDN).

PATIENTS AND METHODS

This prospective study included 32 donors and their recipients; all donors had transperitoneal RLDN. The right renal artery and vein were ligated by Hem-o-lok and titanium clips, which resulted in a very short renal vein (<1.5 cm). When the kidney was positioned inverted in the recipient, the renal vein was placed posteriorly, adjacent to the external iliac vein, making a safe and simple venous anastomosis possible.

RESULTS

All RLDN were completed with no conversion or re-operation. The mean (range) warm ischaemia time was 9.59 (3-17) min and there was no malfunction of the vascular clips on the major vessels. After a mean follow-up of 14 months the recipient survival rate was 97%. Graft function was excellent, with a mean (sd) serum creatinine level of 1.35 (0.31) mg/dL at 3 months after surgery, and there was no renal artery or vein thrombosis in any of the grafts. There were two ureteric complications (6%), i.e. one ureterocutaneous fistula resolved by secondary ureteroureterostomy, and one stricture at the site of ureteric anastomosis, which was managed by ureteroneocystostomy.

CONCLUSION

The right renal vein obtained by LDN, after clipping the renal vein, is quite short, but by placing the kidney upside-down in the right iliac fossa transplantation is possible with no increased incidence of vascular thrombosis. This simple modification might obviate the need for removing a patch from the inferior vena cava, which is a challenging procedure for laparoscopic surgeons during RLDN.

Comparison of Graft Survival in Live Donor Nephrectomy: Hand-Assisted Laparoscopic v Open Procedures

PURPOSE

Laparoscopic donor nephrectomy is associated with decreased morbidity while maintaining similar graft function in short-term follow-up compared with open surgery. We investigated hand-assisted laparoscopic donor nephrectomy (HALDN) in comparison with standard open donor nephrectomy (ODN) in living donors.

PATIENTS AND METHODS

Two hundred patients who received a living-donor kidney and were followed up for more than 1 year were enrolled. The procedure was performed exclusively on the left kidney through either HALDN or ODN from January 2001 to July 2004. The probability of graft survival was determined using the Kaplan-Meier method. Multivariate analysis using a Cox regression hazard model was performed to identify the predictors of graft survival.

RESULTS

The mean operative time, estimated blood loss, warm ischemic time, and operation-related complications were compared. There was no difference in graft function. The cumulative graft survival at 1 and 3 years was similar in the two groups: 98% and 97%. Episodes of acute rejection were an independent predictor of graft survival.

CONCLUSIONS

Hand-assisted laparoscopic nephrectomy in living donors is safe and effective with results similar to those of open nephrectomy with regard to graft function.

Comparison of right and left laparoscopic live donor nephrectomy

OBJECTIVE

To compare the anatomy and function of right and left kidneys retrieved by laparoscopic live donor nephrectomy (LDN).

PATIENTS AND METHODS

In all, 84 transperitoneal LDNs were performed, 66 left and 18 right. Two different right-sided LDN techniques were used: initially, the inferior vena cava (IVC) was controlled with a Satinsky clamp introduced through a 6-8 cm right upper quadrant incision, through which the kidney was also removed (six patients). Subsequently, the IVC was completely mobilized by laparoscopic retrocaval dissection (in 12 patients), allowing the use of a linear stapler-cutter, including the caval ostium with the renal vein. The kidney was then removed through a short Pfannenstiel incision.

RESULTS

Left kidneys had longer renal veins (38 vs 27 mm; P < 0.05), but there were no differences in arterial length (32 vs 31 mm). Three right kidneys required back-table renal vein lengthening. The operative duration was shorter for right-sided LDNs (132 vs 182 min; P < 0.05). The serum creatinine level at 3 months was 131 vs 134 mmol/L for right and left kidneys, respectively.

CONCLUSIONS

Despite faster surgery suggesting that the right LDN is technically easier, there is a greater need for back-table reconstruction of the renal vein. The functional results of right and left kidneys are equivalent.

Hand-assisted right laparoscopic live donor nephrectomy

PURPOSE

Laparoscopic live donor nephrectomy has acquired an important role in the era of minimally invasive surgery. Laparoscopic harvesting of the right kidney is technically more challenging than that of the left kidney because of the short right renal vein and the need to retract the liver away from the right kidney. The aim of this article is to report our experience with right laparoscopic live donor nephrectomies.

MATERIALS AND METHODS

We performed a retrospective review of 28 patients who underwent right laparoscopic donor nephrectomies at our service. Operative data and postoperative outcomes were collected, including surgical time, estimated blood loss, warm ischemia time, length of hospital stay, conversion to laparotomy and complications.

RESULTS

The procedure was performed successfully in all 28 patients. The mean operative time was 83.8 minutes (range 45 to 180 minutes), with an estimated blood loss of 111.4 mL (range 40 to 350 mL) and warm ischemia time of 3 minutes (range 1.5 to 8 minutes). No donor needed conversion to open surgery and all kidneys showed immediate function after implantation. The average time to initial fluid intake was 12 hours (range 8 to 24 hours). Two cases of postoperative ileus and a case of hematoma on the hand-port site were observed. The mean postoperative hospital stay was 3 days (range 1 to 7 days).

CONCLUSIONS

Our data confirm the safety and feasibility of right laparoscopic donor nephrectomy and we believe that the right kidney should not be avoided for laparoscopic donor nephrectomy when indicated.

Outcome of right hand–assisted retroperitoneoscopic living donor nephrectomy

OBJECTIVES

To compare the results of right and left hand-assisted retroperitoneoscopic living donor nephrectomy (HARDN) and assess the usefulness and feasibility of right HARDN.

METHODS

A total of 68 HARDNs performed from July 2001 to February 2005 in Akita University Medical Center were entered into this study. Of these, 12 cases were right-sided HARDN. The reasons for selecting right HARDN were wandering right kidney in 4, multiple left renal arteries in 3, lower glomerular function presenting in the right kidney in 2 patients, and left renal stone, right renal cyst, and right renal aneurysm in 1 patient each. We compared the perioperative and postoperative results of the 12 right-sided HARDNs with those of the 56 left HARDNs.

RESULTS

No significant differences were found between the two groups in the demographic data (ie, age, sex, number of renal arteries), except for the body mass index. None of the right HARDNs resulted in major complications or open conversion, but two left HARDNs required conversion to open surgery. No difference was found between the two groups regarding estimated blood loss, warm ischemia time, or time to oral intake, although the right HARDN group had a longer mean operative time. No significant differences were found in the recipient's postoperative graft function or in the frequency of delayed graft function.

CONCLUSIONS

Right HARDN provided almost similar perioperative and postoperative outcomes compared with those of left HARDN. Our results indicate that right HARDN is a choice for living donor nephrectomy because of its technical feasibility, safety, and minimal invasiveness, which are comparable to those of left HARDN.

Hand-assisted right laparoscopic nephrectomy in living donor

OBJECTIVE

To assess results obtained with the authors' technique of right hand-assisted laparoscopic nephrectomy in living kidney donors.

MATERIALS AND METHODS

We retrospectively analyzed 16 kidney donors who underwent hand-assisted right laparoscopic nephrectomy from February 2001 to July 2004. Among these patients, 7 were male and 9 were female, with mean age ranging between 22 and 58 years (mean 35.75).

RESULTS

Surgical time ranged from 55 to 210 minutes (mean 127.81 min) and warm ischemia time from 2 to 6 minutes (mean 3.78 min) with mean intra-operative blood loss estimated at 90.62 mL. There was no need for conversion in any case. Discharge from hospital occurred between the 3rd and 6th days (mean 3.81). On the graft assessment, immediate diuresis was seen in 15 cases (93.75%) and serum creatinine on the 7th post-operative day was 1.60 mg/dL on average. Renal vein thrombosis occurred in 1 patient (6.25%) who required graft removal, and lymphocele was seen in 1 recipient (6.25%).

CONCLUSION

Hand-assisted right laparoscopic nephrectomy in living donors is a safe and effective alternative to open nephrectomy. Despite a greater technical difficulty, the procedure presented low postoperative morbidity providing good morphological and functional quality of the graft on the recipient.

Laparoscopic donor nephrectomy: an update

PURPOSE OF REVIEW

Laparoscopic donor nephrectomy is considered the gold standard for renal donation. In the hands of experienced laparoscopists it provides a safe and equally effective alternative to open nephrectomy, and recipient graft function has been shown to be equivalent regardless of the procurement method utilized. Complication rates and postoperative donor renal function are equivalent to that of open nephrectomy, whereas recovery time is significantly shorter and surgical scars more cosmetic with the laparoscopic approach.

RECENT FINDINGS

Advances in preoperative imaging and laparoscopic technique have enabled surgeons to broaden the patient population considered for donor nephrectomy. Improved three-dimensional imaging facilitates operative planning and intraoperative dissection, and the retroperitoneoscopic approach has decreased operative time. Acquisition of laparoscopic skills has also enabled surgeons to perform donor nephrectomies on kidneys that previously would have been considered less desirable for donation (e.g. right-sided or with anomalous vasculature).

SUMMARY

End-stage renal disease and the need for renal transplantation continue to be major medical concerns in the United States and worldwide. Advances in donor nephrectomy have reduced the demand for organs by increasing the potential organ pool while limiting risk to donors. As imaging and laparoscopic techniques continue to advance, it is anticipated that minimally invasive donor nephrectomy will continue to evolve. This review summarizes the developments to date.

Laparoscopic procurement of kidneys with multiple renal arteries is associated with increased ureteral complications in the recipient

This study investigates the effect of renal artery multiplicity on donor and recipient outcomes after laparoscopic donor nephrectomy. Three-hundred and sixty-one sequential procedures were performed over a 4-year period. Forty-nine involved accessory renal arteries; of these, 36 required revascularization and 13 were small polar vessels and ligated. The 312 remaining kidneys with single arteries served as controls. Study variables included operative times, blood loss, hospital stay, graft function and donor and recipient complications. Kidneys with multiple revascularized arteries had a longer mean warm ischemia time (35.3 vs. 29.2 min, p = 0.0003), and more ureteral complications (6/36 vs. 10/312, p = 0.0013) than single-artery controls. In contrast, ligation of a small superior accessory artery had no significant effect on donor operative time, blood loss, or complication rate while providing similar recipient graft function compared to single-artery controls. Renal artery number is important in selecting the appropriate kidney for laparoscopic procurement. Given the current excellent results with right-sided donor nephrectomy, kidneys with single arteries should be preferentially procured, irrespective of side.

Looped Silk Tie: Surgical Technique for Management of the Renal Vein during Laparoscopic Live-Donor Nephrectomy

Laparoscopic live-donor nephrectomy has revolutionized the field of kidney transplantation and has been adopted in many tertiary centers as the method of choice in procuring kidneys. While standard techniques for laparoscopic live-donor nephrectomy have been well described in the literature, there continues to be ample discussion about renal-vein ligation. Endo-GIA and other commonly used vascular stapling devices can be costly and prone to mechanical failures and may not be applicable in certain anatomic situations. Vascular clips, although simple to use for arteries, are difficult to apply to large renal veins. To address these issues, we describe a simple, cost-effective method of control that can be used for both right and left renal veins, using a loop constructed from a 0 silk tie.

Laparoscopic Right Donor Nephrectomy: A Large Single-Center Experience

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.