Single-Site Retroperitoneoscopic Donor Nephrectomy M. Maruyama, N. Akutsu, K. Ohtsuki, H. Aoyama, I. Matsumoto, M. Hasegawa, K. Saigo, and T. Asano ABSTRACT We have performed retroperitoneoscopic nephrectomy for living kidney donor surgery since 2000. Recently, we introduced singleesite retroperitoneoscopic donor nephrectomy (RDN) as a less invasive donor surgery. The procedure was performed in 7 donors (5 women and 2 men) by a single surgeon. The mean age and body mass index of the donors were 62.6 years (range, 53e74 years) and 24.3 kg/m2 (range, 22.3e29.0 kg/m2), respectively. Left-sided nephrectomy was performed in all the donors. The donors were positioned in the right lateral position, and a 7-cm-long incision was made in the left flank. The incision was extended to the retroperitoneal space using the muscle-splitting technique. The retroperitoneal space was then expanded using an inflation balloon. A GelPOINT Advanced Access Platform (Applied Medical, Rancho Santa Margarita, Calif, United States) was placed in the incision. The subsequent technique and equipment were the same as those used in conventional 3-port RDN. The renal artery and vein were dissected using a vascular stapler, and the kidney graft was directly extracted through the incision. The mean operative time was 197 28 minutes, warm ischemic time was 4.1 1.2 minutes, and blood loss was 75 113 mL. No statistical differences were found between the present method and conventional 3-port RDN. Intraoperative and postoperative complications were not observed in any of the donors. Graft function after transplantation was good, and delayed graft function was not observed in any of the recipients. This technique can be easily introduced in the clinical setting by surgeons experienced in RDN.
S
INCE laparoscopic living-donor nephrectomy (LLDN) was first reported [1], it has been the primary option for living kidney donor surgery. It offers many advantages, such as cosmetic improvement, less postoperative pain, shorter hospital stay, earlier return to normal activity, and earlier return to work. Since 2000, we have performed retroperitoneoscopic donor nephrectomy (RDN) without the use of hand-assist devices. RDN can prevent intestinal injuries and abdominal wall scar hernia, which are commonly associated with LLDN. Recently, laparo-endoscopic singlesite (LESS) donor nephrectomy via a Pfannenstiel incision and transperitoneal route [2] or via a groin incision (ie, below the “bikini line”) and retroperitoneal approach [3] has been reported. In the present report, we describe our technique involving a single-site RDN (SSRDN) via a flank incision. MATERIALS AND METHODS Between May 2012 and March 2013, 7 consecutive patients, including 5 women and 2 men, underwent SSRDN. Left-sided nephrectomy was performed in all the donors. All potential donors ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 321e322 (2014)
met the usual criteria for kidney donation. Data from 14 consecutive left-side RDN procedures (from 10 women and 4 men) were obtained and compared with the SSRDN data. The donors were positioned in the right lateral position, and a 7-cm-long incision was made in the left flank. The incision was extended to the retroperitoneal space using the muscle-splitting technique. The retroperitoneal space was then expanded using an inflation balloon (PDB Balloons, Covidien, Dublin, Ireland). A GelPOINT Advanced Access Platform (Applied Medical, Rancho Santa Margarita, Calif, United States) was placed in the incision, and carbon dioxide pressure was established at 6 mm Hg via the GelPOINT. Three ports were placed on the GelPOINT (Fig 1). The subsequent technique and equipment were the same as those used in conventional 3-port RDN. A telescope that can adjust the direction of view between 0 and 120 degrees (ENDOCAMELEON, Karl Storz, Tuttlingen, Germany) was used as the retroperitoneoscope.
From the Department of Surgery, Chiba-east National Hospital, Chiba City, Japan. Address reprint requests to Michihiro Maruyama, Department of Surgery, NHO Chiba-east national hospital, 673 Nitona Chuoku, Chiba City, 2608712 Japan. E-mail: [email protected] 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.036 321
322
MARUYAMA, AKUTSU, OHTSUKI ET AL
warm ischemic time was 4.1 1.2 minutes, and blood loss was 75 113 mL. No statistical differences were found between SSRDN and conventional 3-port RDN (MannWhitney U test). Intraoperative and postoperative complications were not observed in any of the donors. The graft function after transplantation was good, and delayed graft function was not observed in any of the recipients.
DISCUSSION
Fig 1. Three ports were inserted through the gel of the GelPOINT in a triangle configuration. Special equipment such as a curved grasper for SSRDN was not used. The left ureter and left gonadal vein were dissected and mobilized. The left gonadal vein was divided below the left renal vein by using a vascular stapler (Endo GIA Universal, Covidien). The kidney was exposed by incising Gerota’s fascia. The connective tissue around the kidney was dissected using a harmonic scalpel (Ethicon EndoSurgery, Cincinnati, Ohio, United States). Mannitol, furosemide, and heparin were not used during the nephrectomy procedure. After the kidney was completely mobilized, the ureter was clipped with 2 Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC, United States) and opened using a pair of surgical scissors. The renal artery and vein were dissected using a vascular stapler, and the kidney graft was directly removed through the incision. In case of a large graft (180 g), the graft was removed using a retrieval bag (Endo Catch II, Covidien).
RESULTS
SSRDN was successfully completed in all the donors. The mean age and body mass index of the donors were 62.8 years (range, 53e74 years) and 24.1 kg/m2 (range, 22.3e29.0 kg/m2), respectively. The mean operative time was 197 28 minutes,
The LESS operation has been described in several procedures [4,5]. However, due to the increased level of intraoperative technical difficulty, its application in living kidney donor surgery should be carefully considered. Since 2000, we have performed RDN in more than 300 donors. In this procedure, 3 ports are inserted into the flank to directly approach the hilum of the kidney. In addition, the kidney graft is extracted through a 9-cm incision, which is made by connecting 2 ports. In the SSRDN procedure described herein, a smaller skin incision was made in the same location as that in conventional RDN. Therefore, SSRDN was completed using the same procedure as that in conventional RDN. In fact, the 2 procedures had almost the same operative times (SSRDN vs RDN, 197 vs 202 minutes, respectively). Thus, this technique can be easily introduced in the clinical setting by surgeons experienced in RDN. Moreover, the superior cosmetic result and low invasiveness of SSRDN may contribute to the recruitment of more kidney donors.
REFERENCES [1] Ratner LE, Ciseck LJ, Moore RG, et al. Laparoscopic donor nephrectomy. Transplantation 1995;60:1047e9. [2] Andonian S, Herati AS, Atalla MA, et al. Laparoendoscopic single-site Pfannenstiel donor nephrectomy. Urology 2010;75:9e12. [3] van der Merwe A, Bachmann A, Heyns CF. Retroperitoneal donor nephrectomy. Int Braz J Urol 2010;36:602e8. [4] Uppal S, Frumovitz M, Escobar P, et al. Laparoendoscopic single-site surgery in gynecology: review of literature and available technology. J Minim Invasive Gynecol 2011;18:12e23. [5] Autorino R, Kim FJ. Urologic laparoendoscopic single-site surgery (LESS): current status. Urologia 2011;78:32e41.
S
INCE laparoscopic living-donor nephrectomy (LLDN) was first reported [1], it has been the primary option for living kidney donor surgery. It offers many advantages, such as cosmetic improvement, less postoperative pain, shorter hospital stay, earlier return to normal activity, and earlier return to work. Since 2000, we have performed retroperitoneoscopic donor nephrectomy (RDN) without the use of hand-assist devices. RDN can prevent intestinal injuries and abdominal wall scar hernia, which are commonly associated with LLDN. Recently, laparo-endoscopic singlesite (LESS) donor nephrectomy via a Pfannenstiel incision and transperitoneal route [2] or via a groin incision (ie, below the “bikini line”) and retroperitoneal approach [3] has been reported. In the present report, we describe our technique involving a single-site RDN (SSRDN) via a flank incision. MATERIALS AND METHODS Between May 2012 and March 2013, 7 consecutive patients, including 5 women and 2 men, underwent SSRDN. Left-sided nephrectomy was performed in all the donors. All potential donors ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 321e322 (2014)
met the usual criteria for kidney donation. Data from 14 consecutive left-side RDN procedures (from 10 women and 4 men) were obtained and compared with the SSRDN data. The donors were positioned in the right lateral position, and a 7-cm-long incision was made in the left flank. The incision was extended to the retroperitoneal space using the muscle-splitting technique. The retroperitoneal space was then expanded using an inflation balloon (PDB Balloons, Covidien, Dublin, Ireland). A GelPOINT Advanced Access Platform (Applied Medical, Rancho Santa Margarita, Calif, United States) was placed in the incision, and carbon dioxide pressure was established at 6 mm Hg via the GelPOINT. Three ports were placed on the GelPOINT (Fig 1). The subsequent technique and equipment were the same as those used in conventional 3-port RDN. A telescope that can adjust the direction of view between 0 and 120 degrees (ENDOCAMELEON, Karl Storz, Tuttlingen, Germany) was used as the retroperitoneoscope.
From the Department of Surgery, Chiba-east National Hospital, Chiba City, Japan. Address reprint requests to Michihiro Maruyama, Department of Surgery, NHO Chiba-east national hospital, 673 Nitona Chuoku, Chiba City, 2608712 Japan. E-mail: [email protected] 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.036 321
322
MARUYAMA, AKUTSU, OHTSUKI ET AL
warm ischemic time was 4.1 1.2 minutes, and blood loss was 75 113 mL. No statistical differences were found between SSRDN and conventional 3-port RDN (MannWhitney U test). Intraoperative and postoperative complications were not observed in any of the donors. The graft function after transplantation was good, and delayed graft function was not observed in any of the recipients.
DISCUSSION
Fig 1. Three ports were inserted through the gel of the GelPOINT in a triangle configuration. Special equipment such as a curved grasper for SSRDN was not used. The left ureter and left gonadal vein were dissected and mobilized. The left gonadal vein was divided below the left renal vein by using a vascular stapler (Endo GIA Universal, Covidien). The kidney was exposed by incising Gerota’s fascia. The connective tissue around the kidney was dissected using a harmonic scalpel (Ethicon EndoSurgery, Cincinnati, Ohio, United States). Mannitol, furosemide, and heparin were not used during the nephrectomy procedure. After the kidney was completely mobilized, the ureter was clipped with 2 Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC, United States) and opened using a pair of surgical scissors. The renal artery and vein were dissected using a vascular stapler, and the kidney graft was directly removed through the incision. In case of a large graft (180 g), the graft was removed using a retrieval bag (Endo Catch II, Covidien).
RESULTS
SSRDN was successfully completed in all the donors. The mean age and body mass index of the donors were 62.8 years (range, 53e74 years) and 24.1 kg/m2 (range, 22.3e29.0 kg/m2), respectively. The mean operative time was 197 28 minutes,
The LESS operation has been described in several procedures [4,5]. However, due to the increased level of intraoperative technical difficulty, its application in living kidney donor surgery should be carefully considered. Since 2000, we have performed RDN in more than 300 donors. In this procedure, 3 ports are inserted into the flank to directly approach the hilum of the kidney. In addition, the kidney graft is extracted through a 9-cm incision, which is made by connecting 2 ports. In the SSRDN procedure described herein, a smaller skin incision was made in the same location as that in conventional RDN. Therefore, SSRDN was completed using the same procedure as that in conventional RDN. In fact, the 2 procedures had almost the same operative times (SSRDN vs RDN, 197 vs 202 minutes, respectively). Thus, this technique can be easily introduced in the clinical setting by surgeons experienced in RDN. Moreover, the superior cosmetic result and low invasiveness of SSRDN may contribute to the recruitment of more kidney donors.
REFERENCES [1] Ratner LE, Ciseck LJ, Moore RG, et al. Laparoscopic donor nephrectomy. Transplantation 1995;60:1047e9. [2] Andonian S, Herati AS, Atalla MA, et al. Laparoendoscopic single-site Pfannenstiel donor nephrectomy. Urology 2010;75:9e12. [3] van der Merwe A, Bachmann A, Heyns CF. Retroperitoneal donor nephrectomy. Int Braz J Urol 2010;36:602e8. [4] Uppal S, Frumovitz M, Escobar P, et al. Laparoendoscopic single-site surgery in gynecology: review of literature and available technology. J Minim Invasive Gynecol 2011;18:12e23. [5] Autorino R, Kim FJ. Urologic laparoendoscopic single-site surgery (LESS): current status. Urologia 2011;78:32e41.
