- Email: [email protected]
Extending Anatomic Barriers to Right Laparoscopic Live Donor Nephrectomy
Surgical Techniques in Urology Extending Anatomic Barriers to Right Laparoscopic Live Donor Nephrectomy Atul Bagul, Jodie H. Frost, Umasankar Mathuram Thiyagarajan, Ismail H. Mohamed, and Michael L. Nicholson OBJECTIVE
To analyze the effects of a right-sided-complex laparoscopic live donor nephrectomy, defined as bifurcation of the right renal artery behind the inferior vena cava. Right-sided laparoscopic live donor nephrectomy is now a widely accepted procedure when complex anatomy is encountered on the left.
TECHNICAL CONSIDERATIONS The present retrospective case note review involved 59 of 303 laparoscopic live donor nephrectomy procedures performed in a single center from January 2001 to April 2010 (group 1, simple, n ⫽ 48; and group 2, complex, n ⫽ 11). The effect of a donor right procedure on warm ischemia, graft function, and donor/recipient complications was analyzed. RESULTS No difference in donor or recipient age or first and second warm ischemic times was found between the 2 groups. No difference was found in the estimated glomerular filtration rate or serum creatinine at 1 week and 3 and 6 months [estimated glomerular filtration rate (6/12), 49 ⫾ 15 vs 60 ⫾ 9 mL/min, P ⫽ .087; and serum creatinine (6 months), 159 ⫾ 116 vs 120 ⫾ 25 mol/L; P ⫽ .356]. No cases of delayed graft function were reported, and none of the grafts developed vascular thrombosis. The cumulative estimated glomerular filtration rate at 6/12 was 51 ⫾ 15 mL/min and the serum creatinine was 153 ⫾ 108 mol/L. Two patients (4%) required conversion to open surgery in group 1, and the cumulative conversion rate was 3.3%. In the complex group with retrocaval dissection, 8 kidneys were retrieved with a single artery and 3 had multiple vessels (2 with 2 vessels and 1 with 3 vessels; anastomotic time 26 ⫾ 6 minutes). CONCLUSION Complex vasculature in a right-sided donation should not be considered a contraindication, because the kidneys procured had excellent function compared with those with single vasculature with no increase in the conversion or vascular thrombosis rate. In addition, the described techniques permit improved arterial length and, importantly, organs procured with a single artery. UROLOGY 79: 465– 469, 2012. © 2012 Elsevier Inc.
L
aparoscopic live donor nephrectomy (LLDN) has now been deemed the preferred approach for retrieving kidneys from live donors1-5 ever since it was shown to be a safe alternative to open nephrectomy.6-13 This procedure is associated with many benefits, including a shorter hospital stay, reduced postoperative pain, early return to work, improved cosmesis, and greater overall patient satisfaction.6,14-16 The procedure has been pioneered to such a great extent that this complicated operation, offering no benefit to the donor, is now performed as a laparoscopic endoscopic single-site procedure.3 This procedure is probably the single most leading cause of the recent increase in organ donation, although
From the Transplant Department, University Hospitals of Leicester, Leicester General Hospital, Leicester, United Kingdom Reprint requests: Atul Bagul, M.B.B.S., M.R.C.S., F.R.C.S., M.D., Transplant Department, Leicester General Hospital Leicester LE5 4PW United Kingdom. E-mail: [email protected] Submitted: June 14, 2011, accepted (with revisions): October 5, 2011
© 2012 Elsevier Inc. All Rights Reserved
many centers still hesitate to perform right-sided LLDN. Right-sided LLDN creates a sense of fear for the surgeon taking the organ, because the procedure is technically more demanding, as well for the surgeon transplanting the organ. This results from the decreased renal vein length and thin vein quality, additional back table grafting, increased risk of vascular thrombosis, and inferior venal caval (IVC) injury, all of which lead to graft compromise.17 A number of studies have shown rightsided LLDN as a viable option and thus have made right-sided LLDN a widely acceptable procedure when complex left-sided anatomy is encountered, including proximal right renal artery narrowing, duplication of the left collecting system, right pelviureteral junction obstruction, right hydronephrosis, right complex cysts, and associated right renal stones, during robust evaluation of a donor.1-3,17 However, right-sided LLDNs only form a very small number of LLDNs performed (10.5%),2 because centers seem to shy away from this laparoscopic procedure or 0090-4295/12/$36.00 doi:10.1016/j.urology.2011.10.008
465
Donor Operative Technique
Figure 1. (A) CT scan of patient in group 1 showing simple vasculature. (B) CT scan of patient in group 2 showing complex vasculature.
proceed to an open approach, especially once the anatomy becomes complicated. In the present study, we focused on our right-sided LLDN experience in a single center in which complex anatomy was delineated on the right side, defined as bifurcation of the right renal artery behind the IVC (Fig. 1).
MATERIAL AND METHODS Patients This was a retrospective case note review involving 59 right-sided LLDNs of 303 LLDNs performed in a single center from January 2001 to January 2011. The cases were divided into 2 groups according to the high-resolution computed tomography (CT) angiography findings with 3-dimensional reconstruction: group 1, simple (n ⫽ 48), with a single renal artery with bifurcation in the renal hilum (Fig. 1A); and group 2, complex (n ⫽ 11), with renal artery bifurcation behind the IVC (Fig. 1B). All CT angiograms were reviewed and reported by a single radiology consultant. Subsequently, all cases were preoperatively discussed in the live donor multi disciplinary teammeeting, where 2 consultant surgeons reviewed and agreed with the delineated anatomy. All patients underwent a detailed unit protocol preoperative evaluation according to the British Transplant Society guidelines. 466
A 4-port technique, with a 6-cm Pfannenstiel incision (extraction site), fully transperitoneal approach was used. Two 10-mm ports, the first for access placed right paramedian supraumbically, followed by the second in the right lumbar, in particular for liver retraction. The next 5-mm port was placed in the right iliac fossa to facilitate dissection. The renal artery was stapled with a linear cutting stapler, and the renal vein was divided after controlling with 2⫻ Hemo-o-Lok clips (Weck Closure System, Research Triangle Park, NC). In addition to this welldescribed standard procedure, extra renal artery length was obtained by dissecting along the posterolateral border and posterior surface of the IVC, permitting the IVC to be rolled medially.17 This was achieved using a fourth 5-mm port, placed subcostally in the right upper quadrant, such that a dissecting forceps could be used to roll or retract the IVC. Gentle dissection, preferably with the suction device, helps to clearly demonstrate the planes and anatomy, thus avoiding damage to the lumbar veins and catastrophic bleeding. The lumbar veins encountered posteriorly can be divided using Hem-o-Lok clips, permitting additional dissection and roll/retraction of the IVC. Additional retrocaval dissection could be performed on the medial aspect, again using the suction device and hook diathermy. A posterior lumbar vein can be ligated with clips or harmonic dissector, permitting the IVC to be rolled medially. This not only maximizes the renal vein length, but also permits the renal artery to be divided before its bifurcation. Thus, adequate space can be obtained to apply the stapling device subcavally or to lift up the cava and divide the renal artery on the medial aspect of the cava. A detailed review of the CT angiogram is of upmost importance, because the 11 patients in the present series were found to have the renal artery either posterior or posteroinferior to the IVC. We believe the only possible contraindication to apply these techniques will be patients in whom the renal artery lies posterior to the IVC and superior to the renal vein. This retrocaval dissection will thus lead to procurement of an organ with not only a longer, but also a single, vessel.
Graft Preparation The organs were perfused on the back table with cold Soltran (Baxter, Berkshire, UK) kidney perfusion solution. After this back table, dissection of the renal hilum was performed. The renal arteries were either “trousered” or in the case of 3 vessels, the use of explanted recipient internal iliac artery technique was performed.18
Statistical Analysis The present retrospective analysis of clinical data and outcomes of donors and recipients was performed using the patient medical notes. The follow-up period was ⱕ6 months, and the donors were divided into 2 groups according to the anatomy, as delineated on the CT scan. Continuous variables are expressed as the mean ⫾ standard deviation and compared with an unpaired t test. All reported P values are 2-tailed and P ⱕ .05 was considered significant. All statistical analyses were performed using a statistical software program (GraphPad InStat, San Diego, CA). UROLOGY 79 (2), 2012
Table 1. Donor and recipient demographics and intraoperative outcomes Variable
Group 1 (n ⫽ 48)
Donor details Age (yr) 47 ⫾ 10 Sex (n) Male 23 Female 25 (47) American Society of 48 Anesthesiologists grade I Recipient details Age (yr) 43 ⫾ 11 Sex (n) Male 23 Female 25 (47) Predialysis status (n) 25 (52) Hypertension (n) 39 (81) Diabetes (n) 6 (12.5) HLA mismatches (n) 3 ⫾ 1.6 Intraoperative outcomes First warm ischemic time (min) 4⫾3 Second warm ischemia time 27 ⫾ 8 (min) External/internal iliac artery 14:34 (30) ratio (n) Conversion to open surgery (n) 2 (4) Multiple arteries (n) 0
Group 2 (n ⫽ 11) 44 ⫾ 10 8 3 (72) 11 44 ⫾ 16 7 4 (63) 6 (54) 8 (73) 0 3⫾1 4⫾2 26 ⫾ 6
Variable eGFR (mL/min) 1 wk 3 mo 6 mo Serum creatinine (mol/L) 1 wk 3 mo 6 mo
Group 1 (n ⫽ 48)
Group 2 (n ⫽ 11)
49 ⫾ 17 52 ⫾ 14 49 ⫾ 15
54 ⫾ 17 61 ⫾ 10 60 ⫾ 9
.338 .058 .087
135 ⫾ 46 111 ⫾ 24 120 ⫾ 25
.692 .185 .356
144 ⫾ 74 140 ⫾ 67 159 ⫾ 116
P Value
eGFR, estimated glomerular filtration rate.
glomerular filtration rate (6 months), 49 ⫾ 15 vs 60 ⫾ 9 mg/dL, P ⫽ .087; and serum creatinine (6/12), 159 ⫾ 116 vs 120 ⫾ 25 mol/L, P ⫽ .356]. No cases of delayed graft function were reported, and none of the grafts developed vascular thrombosis. The cumulative estimated glomerular filtration rate at 6/12 was 51 ⫾ 15 mg/dL and the serum creatinine was 153 ⫾ 108 mol/L.
5:6 (45) 0 3 (27)
Data in parentheses are percentages.
RESULTS Of the 59 cases of right-sided LLDNs assessed, 48 were in group 1 and 11 in group 2 (Fig. 1). The donor and recipient demographics are listed in Table 1. No difference was present in age (P ⫽ .356) or American Society of Anesthesiologists grade in the donor cohort, with an exception of the sex distribution, with 72% male in group 2 and 47% male in group 1. In the recipient cohort, age (P ⫽ .917), the sex distribution, predialysis status, hypertension, and HLA mismatches (P ⫽ .476) showed no difference, with the exception of diabetes status, with no patients with diabetes in group 2 compared with 12.5% in group 1. The intraoperative outcomes are listed in Table 1. The first and second warm ischemic times (P ⫽ .804) showed no differences. The internal iliac artery was the preferred artery for arterial anastomosis in both groups (group 1, 70%; and group 2, 55%; cumulative 68%). Two patients required conversion (4%) to open surgery in group 1. In group 2, the complex retrocaval dissection led to 8 kidneys (73%) retrieved with a single artery and 3 kidneys (27%) with multiple renal arteries (2 with 2 vessels and 1 with 3 vessels). This did not have an effect on the anastomosis time, which was similar in both groups (group 1, 27 ⫾ 8 vs group 2, 26 ⫾ 6 minutes; P ⫽ .804). The cumulative conversion rate to open surgery was 3.3% (2 of 58 patients). The recipient outcome was measured in terms of renal function (Table 2). No difference was found in the estimated glomerular filtration rate or serum creatinine at 1 week and 3 and 6 months postoperatively [estimated UROLOGY 79 (2), 2012
Table 2. Recipient renal function
COMMENT The literature review showed multiple publications that have demonstrated the safety of right-sided LLDN as the primary method of procurement of organs from live donors.1-3,6,17 These studies have shown that there is essentially no difference in complications or graft outcomes in the recipients despite the reported initial early complications associated with right donor grafts.17,19-23 Although all these were based on very simple straight forward vascular anatomy encountered during the LLDN procedure. Our study has reported that when complex vasculature exists on both sides, right-sided LLDN can be safely performed and leads to the procurement of an organ with excellent renal function, with no added extra morbidity, such as increased risk of conversion to open surgery or vascular thrombosis, and mostly leads to an organ procured with a single vessel (73%). The published data are very limited when complex right-sided anatomy is encountered. Modi et al24 published the first case report showing the feasibility and safety of right-sided donor nephrectomy, where they encountered a pre- and postcaval renal artery, although this procedure was performed with retroperitoneoscopic dissection. Chung et al25 presented a series of hand-assisted laparoscopic right donor nephrectomy dissection in which they placed the stapling device on the wall of the IVC, thus gaining maximal vein length. Ko et al17 presented their 7-year series, including 41 cases of right-sided fully laparoscopic transperitoneal dissection and suggested dissection along the posterolateral IVC border would possibly help to gain maximal length of the renal vein. Other technical modifications during right-sided LLDN hilar control have been described and included transverse anastomosis stapling and cutting, Satinsky clamping, and cutting to maximize the renal length.19,20,26-28 The use of Hemo-o-Lok clips 467
leads to extra length29 of the vessels; however, this system is now contraindicated exclusively for securing the renal artery in donor nephrectomy28 but can be used safely in the low-pressure venous system. Multiple renal arteries or a procedure that will lead to multiple renal vessels is technically more challenging to the surgeon, because it might jeopardize, not only the safety of the donor, but could also lead to translation of the increasing morbidity to the recipient, affecting the survival and outcome of the kidney graft. The incidence of multiple vessels is quite common, ranging from 18% to 30% for unilateral multiple renal arteries and 2% to 15% for bilateral multiple renal arteries.6,23,30 Several series have shown that multiple renal arteries do not significantly affect the overall donor and recipient complication rates or kidney graft function.6,7,22 Although all these series included kidneys obtained from a left LLDN, for which the additional problem of a short and thinquality renal vein is not encountered. Crane et al6 included all their single-vessel, right-sided LLDN as a part of the complex LLDN group in their study. In our series, we accepted the associated risk of the retrieval of organs with multiple vessels when dealing with complex anatomy. In contrast, we procured 73% of organs with single vessels with no added comorbidities, such as bleeding, conversion to open surgery, or associated mortality. Similarly, none of these 27% of kidneys transplanted were lost during transplantation because of vascular thrombosis and kidneys from group 2 had renal function similar to that of the kidneys from group 1. In our series, we were able to reproduce similar outcomes of no delayed graft function, no vascular thrombosis, and excellent graft function. When encountering a kidney with an extremely short vein and/or multiple renal arteries, we always prefer to use the internal iliac artery for anastomosis (68%), which provides more maneuverability to place the kidney in a position in which it is least likely to be compromised, reducing the risk of vascular thrombosis. In addition to this, we manage all multiple vessels on the back table, where most double arteries are “trousered.” For ⬎2 arteries, we explant the internal iliac artery, perform a back-table reconstruction and then transplant the kidney with a single end-to-end anastomosis.18 This does not affect our second warm ischemic time, for which our anastomosis time ranges from 27 ⫾ 8 minutes for group 1 and 26 ⫾ 6 minutes for group 2 (P ⫽ .804). None of the patients from group 2, when managing retrocaval dissection, required conversion to open surgery. In group 1, 2 conversions to open surgery occurred, the first because of bleeding from the IVC and the second because of stapler failure. The cumulative conversion rate was 3.3% for right LLDN and ⬍1% for our total LLDN series. All patients underwent duplex ultrasound scan in the operating room after skin closure to assess Doppler flow 468
and perfusion in the transplanted kidney before the patient was awakened. The limitation of our series was the small patient numbers; however, as experience increases and the laparoscopic surgical equipment improve and other centers uptake the described techniques, so will the number. Donor safety is of upmost importance and no extra risk should be taken with living donor transplantation, especially not to the donor.
CONCLUSIONS Complex vasculature in right-sided donation should not be considered a contraindication, because the kidneys procured had excellent function compared with single vasculature with no additional increase in morbidity, such as conversion to open surgery or vascular thrombosis. In addition, the techniques described permit improved arterial length and, importantly, organs procured with single arteries. References 1. Dols LFC, Kok NFM, Alwayn IPJ, et al. Laparoscopic donor nephrectomy: a plea for the right sided approach. Transplantation. 2009;87:745-750. 2. Hsu JW, Reese PP, Naji A, et al. Increased early graft failure in right-sided living donor nephrectomy. Transplantation. 2011;91: 108-114. 3. Afaneh C, Ramasamy R, Lesser DB, et al. Is right sided laparoendoscopic single-site donor nephrectomy feasible? Urology. 2011;77: 1365-1369. 4. Lind MY, Hazebroek EJ, Hop WC, et al. Right sided laparoscopic live-donor nephrectomy: is reluctance still justified? Transplantation. 2002;74:1045-1061. 5. Minnee RC, Bemelman WA, Maartense S, et al. Left or right kidney in hand-assisted donor nephrectomy? A randomized controlled trial. Transplantation. 2008;85:203-208. 6. Crane C, Lam VWT, Alsakran A, et al. Are there anatomical barriers to laparoscopic donor nephrectomy? ANZ J Surg. 2010;80: 781-785. 7. 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;5:1312-1318. 8. Buell JF, Edye M, Johnson M, et al. Are concerns over right laparoscopic donor nephrectomy unwarranted? Ann Surg. 2001; 233:645-651. 9. Mandal AK, Cohen C, Montgomery RA, et al. 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;71:660-664. 10. Abrahams HM, Freise CE, Kang S-M, et al. Technique, indications and outcomes of pure laparoscopic right donor nephrectomy. J Urol. 2004;171:1793-1796. 11. Boorjian S, Munver R, Sosa RE, et al. Right laparoscopic live donor nephrectomy: a single institution experience. Transplantation. 2004;77:437-440. 12. Saad S, Paul A, Treckmann J, et al. Laparoscopic live donor nephrectomy for right kidneys: experience in a German community hospital. Surg Endosc. 2008;22:674-678. 13. Hsu THS, Su L-M, Ratner LE, et al. Impact of renal artery multiplicity on outcomes of renal donors and recipients in laparoscopic donor nephrectomy. Urology. 2003;61:323-327.
UROLOGY 79 (2), 2012
14. Simforoosh N, Basiri A, Tabibi A, et al. Comparison of laparoscopic and open donor nephrectomy: a randomized controlled trial. BJU Int. 2005;95:851-855. 15. Andersen MH, Mathisen L, Oyen O, et al. Postoperative pain and convalescence in living kidney donors—laparoscopic versus open donor nephrectomy: a randomized study. Am J Transplant. 2006;6: 1438-1443. 16. Wolf JS Jr, Merion RM, Leichtman AB, et al. Randomized controlled trial of hand-assisted laparoscopic versus open surgical live donor nephrectomy. Transplantation. 2001;72:284-290. 17. Ko EY, Castle EP, Desai PJ, et al. Utility of the endovascular stapler for right-sided laparoscopic donor nephrectomy: a 7-year experience at Mayo Clinic. J Am Coll Surg. 2008;207:896-903. 18. Firmin LC, Johari Y, Nicholson ML. Explantation of the recipient internal iliac artery for bench-surgery during live donor renal transplants with multiple renal arteries. Ann R Coll Surg Engl. 2010;92: 356. 19. Posselt AM, Mahanty H, Kang SM, et al. Laparoscopic right donor nephrectomy: a large single-center experience. Transplantation. 2004;78:1665-1669. 20. Sundaram CP, Martin GL, Guise A, et al. Complications after a 5-year experience with laparoscopic donor nephrectomy: the Indiana University experience. Surg Endosc. 2007;21:724-728. 21. Diner EK, Radolinski B, Murdock JD, et al. Right laparoscopic donor nephrectomy: the Washington Hospital Center experience. Urology. 2006;68:1175-1177.
UROLOGY 79 (2), 2012
22. Husted TL, Hanaway MJ, Thomas MJ, et al. Laparoscopic right living donor nephrectomy. Transplant Proc. 2005;37:631-632. 23. Kay MD, Brook N, Kaushik M, et al. Comparison of right and left laparoscopic live donor nephrectomy. BJU Int. 2006;98:843-844. 24. Modi PR, Rizvi SJ, Gupta R, et al. Retroperitoneoscopic right-sided donor nephrectomy with pre- and post caval renal arteries. Urology. 2008;72:672-674. 25. Chung MS, Kim SJ, Cho HJ, et al. Hand assisted laparoscopic right donor nephrectomy: safety and feasibility. Korean J Urol. 2010;51: 34-39. 26. Jacobs SC, Cho E, Foster C, et al. Laparoscopic donor nephrectomy: University of Maryland 6-year experience. J Urol. 2004;171: 47-51. 27. Chin EH, Hazzan D, Herron DM, et al. Laparoscopic donor nephrectomy: intraoperative safety, immediate morbidity, and delayed complications with 500 cases. Surg Endosc. 2007;21:521-526. 28. Medical Device Recalls. Class 2 Recall. Weck Hem-o-Lok L Polymer Ligating Clips. Available from: http://www.accessdata.fda.gov/scripts/ cdrh/cfdocs/cfRes/res.cfm?ID_45875. Accessed July 29, 2008. 29. Kaushik M, Bagul A, Yates PJ, et al. Comparison of techniques of vascular control in laparoscopic donor nephrectomy: the Leicester experience. Transplant Proc. 2006;38:3406-3408. 30. Roza AM, Perloff LJ, Naji A, et al. Living-related donors with bilateral multiple renal arteries: a 20-year experience. Transplantation. 1989;47:397-399.
469
To analyze the effects of a right-sided-complex laparoscopic live donor nephrectomy, defined as bifurcation of the right renal artery behind the inferior vena cava. Right-sided laparoscopic live donor nephrectomy is now a widely accepted procedure when complex anatomy is encountered on the left.
TECHNICAL CONSIDERATIONS The present retrospective case note review involved 59 of 303 laparoscopic live donor nephrectomy procedures performed in a single center from January 2001 to April 2010 (group 1, simple, n ⫽ 48; and group 2, complex, n ⫽ 11). The effect of a donor right procedure on warm ischemia, graft function, and donor/recipient complications was analyzed. RESULTS No difference in donor or recipient age or first and second warm ischemic times was found between the 2 groups. No difference was found in the estimated glomerular filtration rate or serum creatinine at 1 week and 3 and 6 months [estimated glomerular filtration rate (6/12), 49 ⫾ 15 vs 60 ⫾ 9 mL/min, P ⫽ .087; and serum creatinine (6 months), 159 ⫾ 116 vs 120 ⫾ 25 mol/L; P ⫽ .356]. No cases of delayed graft function were reported, and none of the grafts developed vascular thrombosis. The cumulative estimated glomerular filtration rate at 6/12 was 51 ⫾ 15 mL/min and the serum creatinine was 153 ⫾ 108 mol/L. Two patients (4%) required conversion to open surgery in group 1, and the cumulative conversion rate was 3.3%. In the complex group with retrocaval dissection, 8 kidneys were retrieved with a single artery and 3 had multiple vessels (2 with 2 vessels and 1 with 3 vessels; anastomotic time 26 ⫾ 6 minutes). CONCLUSION Complex vasculature in a right-sided donation should not be considered a contraindication, because the kidneys procured had excellent function compared with those with single vasculature with no increase in the conversion or vascular thrombosis rate. In addition, the described techniques permit improved arterial length and, importantly, organs procured with a single artery. UROLOGY 79: 465– 469, 2012. © 2012 Elsevier Inc.
L
aparoscopic live donor nephrectomy (LLDN) has now been deemed the preferred approach for retrieving kidneys from live donors1-5 ever since it was shown to be a safe alternative to open nephrectomy.6-13 This procedure is associated with many benefits, including a shorter hospital stay, reduced postoperative pain, early return to work, improved cosmesis, and greater overall patient satisfaction.6,14-16 The procedure has been pioneered to such a great extent that this complicated operation, offering no benefit to the donor, is now performed as a laparoscopic endoscopic single-site procedure.3 This procedure is probably the single most leading cause of the recent increase in organ donation, although
From the Transplant Department, University Hospitals of Leicester, Leicester General Hospital, Leicester, United Kingdom Reprint requests: Atul Bagul, M.B.B.S., M.R.C.S., F.R.C.S., M.D., Transplant Department, Leicester General Hospital Leicester LE5 4PW United Kingdom. E-mail: [email protected] Submitted: June 14, 2011, accepted (with revisions): October 5, 2011
© 2012 Elsevier Inc. All Rights Reserved
many centers still hesitate to perform right-sided LLDN. Right-sided LLDN creates a sense of fear for the surgeon taking the organ, because the procedure is technically more demanding, as well for the surgeon transplanting the organ. This results from the decreased renal vein length and thin vein quality, additional back table grafting, increased risk of vascular thrombosis, and inferior venal caval (IVC) injury, all of which lead to graft compromise.17 A number of studies have shown rightsided LLDN as a viable option and thus have made right-sided LLDN a widely acceptable procedure when complex left-sided anatomy is encountered, including proximal right renal artery narrowing, duplication of the left collecting system, right pelviureteral junction obstruction, right hydronephrosis, right complex cysts, and associated right renal stones, during robust evaluation of a donor.1-3,17 However, right-sided LLDNs only form a very small number of LLDNs performed (10.5%),2 because centers seem to shy away from this laparoscopic procedure or 0090-4295/12/$36.00 doi:10.1016/j.urology.2011.10.008
465
Donor Operative Technique
Figure 1. (A) CT scan of patient in group 1 showing simple vasculature. (B) CT scan of patient in group 2 showing complex vasculature.
proceed to an open approach, especially once the anatomy becomes complicated. In the present study, we focused on our right-sided LLDN experience in a single center in which complex anatomy was delineated on the right side, defined as bifurcation of the right renal artery behind the IVC (Fig. 1).
MATERIAL AND METHODS Patients This was a retrospective case note review involving 59 right-sided LLDNs of 303 LLDNs performed in a single center from January 2001 to January 2011. The cases were divided into 2 groups according to the high-resolution computed tomography (CT) angiography findings with 3-dimensional reconstruction: group 1, simple (n ⫽ 48), with a single renal artery with bifurcation in the renal hilum (Fig. 1A); and group 2, complex (n ⫽ 11), with renal artery bifurcation behind the IVC (Fig. 1B). All CT angiograms were reviewed and reported by a single radiology consultant. Subsequently, all cases were preoperatively discussed in the live donor multi disciplinary teammeeting, where 2 consultant surgeons reviewed and agreed with the delineated anatomy. All patients underwent a detailed unit protocol preoperative evaluation according to the British Transplant Society guidelines. 466
A 4-port technique, with a 6-cm Pfannenstiel incision (extraction site), fully transperitoneal approach was used. Two 10-mm ports, the first for access placed right paramedian supraumbically, followed by the second in the right lumbar, in particular for liver retraction. The next 5-mm port was placed in the right iliac fossa to facilitate dissection. The renal artery was stapled with a linear cutting stapler, and the renal vein was divided after controlling with 2⫻ Hemo-o-Lok clips (Weck Closure System, Research Triangle Park, NC). In addition to this welldescribed standard procedure, extra renal artery length was obtained by dissecting along the posterolateral border and posterior surface of the IVC, permitting the IVC to be rolled medially.17 This was achieved using a fourth 5-mm port, placed subcostally in the right upper quadrant, such that a dissecting forceps could be used to roll or retract the IVC. Gentle dissection, preferably with the suction device, helps to clearly demonstrate the planes and anatomy, thus avoiding damage to the lumbar veins and catastrophic bleeding. The lumbar veins encountered posteriorly can be divided using Hem-o-Lok clips, permitting additional dissection and roll/retraction of the IVC. Additional retrocaval dissection could be performed on the medial aspect, again using the suction device and hook diathermy. A posterior lumbar vein can be ligated with clips or harmonic dissector, permitting the IVC to be rolled medially. This not only maximizes the renal vein length, but also permits the renal artery to be divided before its bifurcation. Thus, adequate space can be obtained to apply the stapling device subcavally or to lift up the cava and divide the renal artery on the medial aspect of the cava. A detailed review of the CT angiogram is of upmost importance, because the 11 patients in the present series were found to have the renal artery either posterior or posteroinferior to the IVC. We believe the only possible contraindication to apply these techniques will be patients in whom the renal artery lies posterior to the IVC and superior to the renal vein. This retrocaval dissection will thus lead to procurement of an organ with not only a longer, but also a single, vessel.
Graft Preparation The organs were perfused on the back table with cold Soltran (Baxter, Berkshire, UK) kidney perfusion solution. After this back table, dissection of the renal hilum was performed. The renal arteries were either “trousered” or in the case of 3 vessels, the use of explanted recipient internal iliac artery technique was performed.18
Statistical Analysis The present retrospective analysis of clinical data and outcomes of donors and recipients was performed using the patient medical notes. The follow-up period was ⱕ6 months, and the donors were divided into 2 groups according to the anatomy, as delineated on the CT scan. Continuous variables are expressed as the mean ⫾ standard deviation and compared with an unpaired t test. All reported P values are 2-tailed and P ⱕ .05 was considered significant. All statistical analyses were performed using a statistical software program (GraphPad InStat, San Diego, CA). UROLOGY 79 (2), 2012
Table 1. Donor and recipient demographics and intraoperative outcomes Variable
Group 1 (n ⫽ 48)
Donor details Age (yr) 47 ⫾ 10 Sex (n) Male 23 Female 25 (47) American Society of 48 Anesthesiologists grade I Recipient details Age (yr) 43 ⫾ 11 Sex (n) Male 23 Female 25 (47) Predialysis status (n) 25 (52) Hypertension (n) 39 (81) Diabetes (n) 6 (12.5) HLA mismatches (n) 3 ⫾ 1.6 Intraoperative outcomes First warm ischemic time (min) 4⫾3 Second warm ischemia time 27 ⫾ 8 (min) External/internal iliac artery 14:34 (30) ratio (n) Conversion to open surgery (n) 2 (4) Multiple arteries (n) 0
Group 2 (n ⫽ 11) 44 ⫾ 10 8 3 (72) 11 44 ⫾ 16 7 4 (63) 6 (54) 8 (73) 0 3⫾1 4⫾2 26 ⫾ 6
Variable eGFR (mL/min) 1 wk 3 mo 6 mo Serum creatinine (mol/L) 1 wk 3 mo 6 mo
Group 1 (n ⫽ 48)
Group 2 (n ⫽ 11)
49 ⫾ 17 52 ⫾ 14 49 ⫾ 15
54 ⫾ 17 61 ⫾ 10 60 ⫾ 9
.338 .058 .087
135 ⫾ 46 111 ⫾ 24 120 ⫾ 25
.692 .185 .356
144 ⫾ 74 140 ⫾ 67 159 ⫾ 116
P Value
eGFR, estimated glomerular filtration rate.
glomerular filtration rate (6 months), 49 ⫾ 15 vs 60 ⫾ 9 mg/dL, P ⫽ .087; and serum creatinine (6/12), 159 ⫾ 116 vs 120 ⫾ 25 mol/L, P ⫽ .356]. No cases of delayed graft function were reported, and none of the grafts developed vascular thrombosis. The cumulative estimated glomerular filtration rate at 6/12 was 51 ⫾ 15 mg/dL and the serum creatinine was 153 ⫾ 108 mol/L.
5:6 (45) 0 3 (27)
Data in parentheses are percentages.
RESULTS Of the 59 cases of right-sided LLDNs assessed, 48 were in group 1 and 11 in group 2 (Fig. 1). The donor and recipient demographics are listed in Table 1. No difference was present in age (P ⫽ .356) or American Society of Anesthesiologists grade in the donor cohort, with an exception of the sex distribution, with 72% male in group 2 and 47% male in group 1. In the recipient cohort, age (P ⫽ .917), the sex distribution, predialysis status, hypertension, and HLA mismatches (P ⫽ .476) showed no difference, with the exception of diabetes status, with no patients with diabetes in group 2 compared with 12.5% in group 1. The intraoperative outcomes are listed in Table 1. The first and second warm ischemic times (P ⫽ .804) showed no differences. The internal iliac artery was the preferred artery for arterial anastomosis in both groups (group 1, 70%; and group 2, 55%; cumulative 68%). Two patients required conversion (4%) to open surgery in group 1. In group 2, the complex retrocaval dissection led to 8 kidneys (73%) retrieved with a single artery and 3 kidneys (27%) with multiple renal arteries (2 with 2 vessels and 1 with 3 vessels). This did not have an effect on the anastomosis time, which was similar in both groups (group 1, 27 ⫾ 8 vs group 2, 26 ⫾ 6 minutes; P ⫽ .804). The cumulative conversion rate to open surgery was 3.3% (2 of 58 patients). The recipient outcome was measured in terms of renal function (Table 2). No difference was found in the estimated glomerular filtration rate or serum creatinine at 1 week and 3 and 6 months postoperatively [estimated UROLOGY 79 (2), 2012
Table 2. Recipient renal function
COMMENT The literature review showed multiple publications that have demonstrated the safety of right-sided LLDN as the primary method of procurement of organs from live donors.1-3,6,17 These studies have shown that there is essentially no difference in complications or graft outcomes in the recipients despite the reported initial early complications associated with right donor grafts.17,19-23 Although all these were based on very simple straight forward vascular anatomy encountered during the LLDN procedure. Our study has reported that when complex vasculature exists on both sides, right-sided LLDN can be safely performed and leads to the procurement of an organ with excellent renal function, with no added extra morbidity, such as increased risk of conversion to open surgery or vascular thrombosis, and mostly leads to an organ procured with a single vessel (73%). The published data are very limited when complex right-sided anatomy is encountered. Modi et al24 published the first case report showing the feasibility and safety of right-sided donor nephrectomy, where they encountered a pre- and postcaval renal artery, although this procedure was performed with retroperitoneoscopic dissection. Chung et al25 presented a series of hand-assisted laparoscopic right donor nephrectomy dissection in which they placed the stapling device on the wall of the IVC, thus gaining maximal vein length. Ko et al17 presented their 7-year series, including 41 cases of right-sided fully laparoscopic transperitoneal dissection and suggested dissection along the posterolateral IVC border would possibly help to gain maximal length of the renal vein. Other technical modifications during right-sided LLDN hilar control have been described and included transverse anastomosis stapling and cutting, Satinsky clamping, and cutting to maximize the renal length.19,20,26-28 The use of Hemo-o-Lok clips 467
leads to extra length29 of the vessels; however, this system is now contraindicated exclusively for securing the renal artery in donor nephrectomy28 but can be used safely in the low-pressure venous system. Multiple renal arteries or a procedure that will lead to multiple renal vessels is technically more challenging to the surgeon, because it might jeopardize, not only the safety of the donor, but could also lead to translation of the increasing morbidity to the recipient, affecting the survival and outcome of the kidney graft. The incidence of multiple vessels is quite common, ranging from 18% to 30% for unilateral multiple renal arteries and 2% to 15% for bilateral multiple renal arteries.6,23,30 Several series have shown that multiple renal arteries do not significantly affect the overall donor and recipient complication rates or kidney graft function.6,7,22 Although all these series included kidneys obtained from a left LLDN, for which the additional problem of a short and thinquality renal vein is not encountered. Crane et al6 included all their single-vessel, right-sided LLDN as a part of the complex LLDN group in their study. In our series, we accepted the associated risk of the retrieval of organs with multiple vessels when dealing with complex anatomy. In contrast, we procured 73% of organs with single vessels with no added comorbidities, such as bleeding, conversion to open surgery, or associated mortality. Similarly, none of these 27% of kidneys transplanted were lost during transplantation because of vascular thrombosis and kidneys from group 2 had renal function similar to that of the kidneys from group 1. In our series, we were able to reproduce similar outcomes of no delayed graft function, no vascular thrombosis, and excellent graft function. When encountering a kidney with an extremely short vein and/or multiple renal arteries, we always prefer to use the internal iliac artery for anastomosis (68%), which provides more maneuverability to place the kidney in a position in which it is least likely to be compromised, reducing the risk of vascular thrombosis. In addition to this, we manage all multiple vessels on the back table, where most double arteries are “trousered.” For ⬎2 arteries, we explant the internal iliac artery, perform a back-table reconstruction and then transplant the kidney with a single end-to-end anastomosis.18 This does not affect our second warm ischemic time, for which our anastomosis time ranges from 27 ⫾ 8 minutes for group 1 and 26 ⫾ 6 minutes for group 2 (P ⫽ .804). None of the patients from group 2, when managing retrocaval dissection, required conversion to open surgery. In group 1, 2 conversions to open surgery occurred, the first because of bleeding from the IVC and the second because of stapler failure. The cumulative conversion rate was 3.3% for right LLDN and ⬍1% for our total LLDN series. All patients underwent duplex ultrasound scan in the operating room after skin closure to assess Doppler flow 468
and perfusion in the transplanted kidney before the patient was awakened. The limitation of our series was the small patient numbers; however, as experience increases and the laparoscopic surgical equipment improve and other centers uptake the described techniques, so will the number. Donor safety is of upmost importance and no extra risk should be taken with living donor transplantation, especially not to the donor.
CONCLUSIONS Complex vasculature in right-sided donation should not be considered a contraindication, because the kidneys procured had excellent function compared with single vasculature with no additional increase in morbidity, such as conversion to open surgery or vascular thrombosis. In addition, the techniques described permit improved arterial length and, importantly, organs procured with single arteries. References 1. Dols LFC, Kok NFM, Alwayn IPJ, et al. Laparoscopic donor nephrectomy: a plea for the right sided approach. Transplantation. 2009;87:745-750. 2. Hsu JW, Reese PP, Naji A, et al. Increased early graft failure in right-sided living donor nephrectomy. Transplantation. 2011;91: 108-114. 3. Afaneh C, Ramasamy R, Lesser DB, et al. Is right sided laparoendoscopic single-site donor nephrectomy feasible? Urology. 2011;77: 1365-1369. 4. Lind MY, Hazebroek EJ, Hop WC, et al. Right sided laparoscopic live-donor nephrectomy: is reluctance still justified? Transplantation. 2002;74:1045-1061. 5. Minnee RC, Bemelman WA, Maartense S, et al. Left or right kidney in hand-assisted donor nephrectomy? A randomized controlled trial. Transplantation. 2008;85:203-208. 6. Crane C, Lam VWT, Alsakran A, et al. Are there anatomical barriers to laparoscopic donor nephrectomy? ANZ J Surg. 2010;80: 781-785. 7. 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;5:1312-1318. 8. Buell JF, Edye M, Johnson M, et al. Are concerns over right laparoscopic donor nephrectomy unwarranted? Ann Surg. 2001; 233:645-651. 9. Mandal AK, Cohen C, Montgomery RA, et al. 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;71:660-664. 10. Abrahams HM, Freise CE, Kang S-M, et al. Technique, indications and outcomes of pure laparoscopic right donor nephrectomy. J Urol. 2004;171:1793-1796. 11. Boorjian S, Munver R, Sosa RE, et al. Right laparoscopic live donor nephrectomy: a single institution experience. Transplantation. 2004;77:437-440. 12. Saad S, Paul A, Treckmann J, et al. Laparoscopic live donor nephrectomy for right kidneys: experience in a German community hospital. Surg Endosc. 2008;22:674-678. 13. Hsu THS, Su L-M, Ratner LE, et al. Impact of renal artery multiplicity on outcomes of renal donors and recipients in laparoscopic donor nephrectomy. Urology. 2003;61:323-327.
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14. Simforoosh N, Basiri A, Tabibi A, et al. Comparison of laparoscopic and open donor nephrectomy: a randomized controlled trial. BJU Int. 2005;95:851-855. 15. Andersen MH, Mathisen L, Oyen O, et al. Postoperative pain and convalescence in living kidney donors—laparoscopic versus open donor nephrectomy: a randomized study. Am J Transplant. 2006;6: 1438-1443. 16. Wolf JS Jr, Merion RM, Leichtman AB, et al. Randomized controlled trial of hand-assisted laparoscopic versus open surgical live donor nephrectomy. Transplantation. 2001;72:284-290. 17. Ko EY, Castle EP, Desai PJ, et al. Utility of the endovascular stapler for right-sided laparoscopic donor nephrectomy: a 7-year experience at Mayo Clinic. J Am Coll Surg. 2008;207:896-903. 18. Firmin LC, Johari Y, Nicholson ML. Explantation of the recipient internal iliac artery for bench-surgery during live donor renal transplants with multiple renal arteries. Ann R Coll Surg Engl. 2010;92: 356. 19. Posselt AM, Mahanty H, Kang SM, et al. Laparoscopic right donor nephrectomy: a large single-center experience. Transplantation. 2004;78:1665-1669. 20. Sundaram CP, Martin GL, Guise A, et al. Complications after a 5-year experience with laparoscopic donor nephrectomy: the Indiana University experience. Surg Endosc. 2007;21:724-728. 21. Diner EK, Radolinski B, Murdock JD, et al. Right laparoscopic donor nephrectomy: the Washington Hospital Center experience. Urology. 2006;68:1175-1177.
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22. Husted TL, Hanaway MJ, Thomas MJ, et al. Laparoscopic right living donor nephrectomy. Transplant Proc. 2005;37:631-632. 23. Kay MD, Brook N, Kaushik M, et al. Comparison of right and left laparoscopic live donor nephrectomy. BJU Int. 2006;98:843-844. 24. Modi PR, Rizvi SJ, Gupta R, et al. Retroperitoneoscopic right-sided donor nephrectomy with pre- and post caval renal arteries. Urology. 2008;72:672-674. 25. Chung MS, Kim SJ, Cho HJ, et al. Hand assisted laparoscopic right donor nephrectomy: safety and feasibility. Korean J Urol. 2010;51: 34-39. 26. Jacobs SC, Cho E, Foster C, et al. Laparoscopic donor nephrectomy: University of Maryland 6-year experience. J Urol. 2004;171: 47-51. 27. Chin EH, Hazzan D, Herron DM, et al. Laparoscopic donor nephrectomy: intraoperative safety, immediate morbidity, and delayed complications with 500 cases. Surg Endosc. 2007;21:521-526. 28. Medical Device Recalls. Class 2 Recall. Weck Hem-o-Lok L Polymer Ligating Clips. Available from: http://www.accessdata.fda.gov/scripts/ cdrh/cfdocs/cfRes/res.cfm?ID_45875. Accessed July 29, 2008. 29. Kaushik M, Bagul A, Yates PJ, et al. Comparison of techniques of vascular control in laparoscopic donor nephrectomy: the Leicester experience. Transplant Proc. 2006;38:3406-3408. 30. Roza AM, Perloff LJ, Naji A, et al. Living-related donors with bilateral multiple renal arteries: a 20-year experience. Transplantation. 1989;47:397-399.
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