RETROPERITONEOSCOPY ASSISTED LIVE DONOR NEPHRECTOMY: THE YONSEI EXPERIENCE

0022-5347/01/1654-1099/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®

Vol. 165, 1099 –1102, April 2001 Printed in U.S.A.

RETROPERITONEOSCOPY ASSISTED LIVE DONOR NEPHRECTOMY: THE YONSEI EXPERIENCE SEUNG CHOUL YANG, WOO JIN KO, YOUNG JOON BYUN

AND

KOON HO RHA*

From the Department of Urology, College of Medicine, Yonsei University, Seoul, Korea

ABSTRACT

Purpose: Retroperitoneoscopy assisted live donor nephrectomy has become standard based on our experience with 103 consecutive cases operated on between January 1993 and May 2000. We describe the advantages of retroperitoneoscopy assisted compared to laparoscopic live donor nephrectomy. Materials and Methods: After performing more than 1,200 cases of open live donor nephrectomy (S. C. Y.), we combined our experience with open and laparoscopic surgery to develop a specific technique of minilaparotomy live donor nephrectomy. Operations were performed by 1 senior surgeon and 1 assistant, with the help of specially designed piercing abdominal and peritoneal retractors. A 5 to 7 cm. transverse pararectal skin incision is made at the level of 10th rib and the abdominal muscles are split without division. A 10 mm. port is placed at the lower abdomen to allow for the telescope. The procedure is performed extraperitoneally, combining open and laparoscopic instruments under direct vision. Renal pedicles and ureters are ligated using laparoscopic clips and sutures. The kidney is removed via laparotomy and the wound is closed. Results: Average operating time for the 103 live donor nephrectomies was 130 minutes (range 85 to 210), and there was no case of kidney loss, open surgical conversion or blood transfusion. Mean warm ischemia time was 2.3 ⫾ 1.2 minutes and average incision length was 6.5 cm. (range 5.1 to 7.0). Postoperative pain was minimal and analgesics were generally not required by postoperative day 2. Patients were fully ambulatory a mean 1.5 days (range 1 to 3.5) postoperatively. Conclusions: Retroperitoneoscopy assisted live donor nephrectomy is not only feasible, but reproducible. Any surgeon with previous experience with conventional open live donor nephrectomy can perform this hybrid, minimally invasive procedure. KEY WORDS: laparotomy, laparoscopy, living donors

Open live donor nephrectomy is a safe and well established procedure1 but lengthy hospitalization, postoperative pain and large skin wound are its shortcomings. To overcome such problems laparoscopic live donor nephrectomy has been performed and is preferred by donors.2, 3 However, conventional laparoscopic surgery using carbon dioxide insufflation is not appropriate for live donor nephrectomy because it is difficult to control for vascular accident, warm ischemia time is increased, obtaining the longest vascular pedicle is not always possible and operating time is prolonged. In an attempt to overcome the shortcomings of conventional laparoscopic live donor nephrectomy, in 1993 we developed a new surgical method of retroperitoneoscopy assisted live donor nephrectomy, which is a hybrid of laparoscopic and open surgery that combines the advantages of both.4 After performing more than 1,200 cases of open live donor nephrectomy (S. C. Y.), we combined our experience with open and laparoscopic surgery to develop a specific technique of minilaparotomy live donor nephrectomy. We report our experience with 103 consecutive cases of retroperitoneoscopy assisted live donor nephrectomy, and compare the results to 95 cases of open donor nephrectomy performed by the same surgeon. This experience has allowed to modify and improve

the technical aspects of each step, and to make the procedure standardized and reproducible. OPERATIVE TECHNIQUE

Patient preparation and positioning. Retroperitoneoscopy assisted procedures are performed regardless of patient age or medical or surgical history. General anesthesia is given to all patients, and nothing by mouth since midnight of the day of surgery. No bowel preparation is performed. Ample fluid intake is encouraged until the day before the operation to ensure good urine output. The patient is placed in a semilateral position with the contralateral knee flexed and the ipsilateral arm stretched. The brachial plexus is protected by padding the axillar area. A kidney rest is elevated and the table is flexed to tense the lateral abdomen. A Foley catheter is inserted and the bladder drained. The abdomen is shaved from the xiphoid to the pubic bone. The entire chest and abdomen are prepared with iodine based disinfectant and draped. A video system, including a television monitor and electrically controlled abdominal wall elevator, is across the table from the surgeon. Surgeon positioning and equipment. One surgeon and 1 assistant are on the same side of the patient while performing the operation. The assistant stands alongside the surgeon, and works mostly with the telescope with light source and partially with the piercing peritoneal wall retractor. An electrically controlled abdominal wall elevator is used to elevate the abdominal wall retractors. The standard equipment for open live donor nephrectomy plus basic laparoscopic

Accepted for publication November 3, 2000. Supported by NHS R & D Health Technology Assessment Programme, Project 94/04/5. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NHS Executive. * Requests for reprints: Department of Urology, Yonsei University, C.P.O. Box 8044, Seoul, Korea 120-752. 1099

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YONSEI EXPERIENCE WITH RETROPERITONEOSCOPY ASSISTED LIVE DONOR NEPHRECTOMY

surgical equipment are sufficient but modifications are dictated by surgeon preferences (see Appendix). Incision and trocar positioning. A 6 cm. transverse skin incision is made transversely anteriorly from the costal margin corresponding to the level of the 10th rib, and deepened through the subcutaneous tissue with electrocautery. At the left lateral border of the rectus sheath a perpendicular incision is made to the external oblique aponeurosis and rectus sheath. The transversus muscles are split without division with a Kelly clamp and army-navy retractors, and the cleavage plane between the peritoneum and aponeurosis is widely developed by blunt dissection. The abdominal wall medial to the incision is punctured by the sharp end of a piercing abdominal wall retractor (fig. 1). The piercing retractor is connected to the electrically controlled abdominal wall elevator via a steel horizontal metal connector. At the anterior axillary line a skin stab 1.5 cm. long is made 5 cm. below the main incision. The stab is deepened by a tonsil clamp, and a 10 mm. Hassan balloon trocar with 30 cc ballooning is introduced. The telescope is introduced via the Hassan trocar. The rest of the operation is performed with newly devised surgical instruments while the operating area is observed either directly or through the video monitor. Kidney mobilization. A self-retaining retractor is placed at the operating table, and narrow Deaver, splanchnic, wide Deaver and Mayo blades are connected to the retractors. After securing the operative field, the left ureter is identified overlying the psoas muscle beneath the posterior peritoneum and is carefully dissected to the level of the iliac vessel crossing. To expose the kidney, Gerota’s fascia is dissected from the lower pole of the kidney to the posterolateral portion and then the upper pole. Perinephric fat is completely dissected and the renal capsule is preserved. We administer 12 gm. mannitol intravenously, while the kidney is further mobilized. The gonadal and adrenal veins are ligated with silk ties at the renal vein side and proximal portions are clipped then cut. The renal vein is dissected further to identify the posteroinferior portion that drains the lumbar vein, which is then cut in a similar manner. The renal vein and artery are dissected. During this manipulation 2% lidocaine solution is applied to the renal pedicle to minimize vascular spasm. Ureter mobilization. Another puncture is made with the peritoneal retractor at the periumbilical site. The handle of the piercing peritoneal retractor is connected to the end of the peritoneal retractor, thus pulling the handle of peritoneal retractor to make ample surgical space. The ureter is dis-

FIG. 1. Piercing abdominal wall retractor connected to electrically controlled abdominal wall elevator via steel horizontal metal connector. Self-retraining blade and retractor, and telescope are also shown.

sected by the conventional laparoscopic surgical instruments through the minilaparotomy wound. The ureter is ligated with metal endoclips, cut and delivered through the main wound. The powerful stream of urine is confirmed. Harvest of donor kidney. The kidney is entrapped in a sac in preparation for removing the donor kidney. Following administration of heparin and a 3-minute wait the renal artery is double clipped with metal clips at the level of the aorta. The renal vein is clamped with a Satinsky vascular clamp, and the renal vessels are cut with Metzenbaum scissors. The kidney is removed through the minilaparotomy wound (fig. 2), 2 or more metal clips are used to ligate the renal artery and the renal vein is sutured with 5-zero polypropylene. Wound closure. After all bleeders are controlled with electric cauterization, a silicone drain is placed through the previous laparoscopic port in the dependent portion of the renal fossa. The transverse abdominis muscles are approximated with 1-zero polyglactin and the anterior rectus sheath is closed with 1-zero polyglactin. The fascia is reinforced with interrupted No. 5 silk and subcutaneous tissue is reinforced with interrupted No. 3 silk. The skin is closed with metal staples and dressing is applied. RESULTS

From January 1993 to May 2000, we analyzed retrospectively the medical records of 103 patients who underwent retroperitoneoscopy assisted live donor nephrectomy (table 1). Patient average weight was 62 kg. and average age was 42 years. There were 83 left and 20 right kidney donors. Average operating time, defined as time from first incision into the skin to final skin closure, was 130 minutes. Mean warm ischemia time, defined as time from application of a hemostatic clip to the donor renal artery to start of flush with cold preservation solution, was 2.3 minutes. Average incision length was 6.5 cm. (range 5 to 7). The donor hospital records were reviewed to obtain data on the operating time, estimated blood loss during surgery, blood transfusion, length of hospitalization and parenteral analgesic requirements. The parenteral analgesic requirements as a measure of postoperative pain were described in terms of total mg. of morphine equivalents administered during hospitalization (table 2). There were no intraoperative complications except for 2 cases of an easily controlled lumbar vein tear. No transfusion

FIG. 2. Donor kidney enveloped in sac is delivered via minilaparotomy wound.

YONSEI EXPERIENCE WITH RETROPERITONEOSCOPY ASSISTED LIVE DONOR NEPHRECTOMY TABLE 1. Patient characteristics Retroperitoneoscopy Assisted Donor Nephrectomy

Open Donor Nephrectomy

103 57⬊46 42.5 ⫾ 5.4 62.7 ⫾ 2.5 20⬊83 90⬊13

95 56⬊39 43.7 ⫾ 6.8 67.2 ⫾ 3.1 35⬊60 75⬊20

No. pts. No. male: female Mean pt. age ⫾ SD Mean wt. ⫾ SD (kg.) No. rt.: lt. No. renal artery single:multiple

was required. Patients experienced less postoperative pain and faster recovery. Paresthesia and flank bulging due to the operative wound were not seen postoperatively. Due to the expertise with this technique, we could perform 3 cases each day. DISCUSSION

It is a unique medical situation when a young, completely healthy donor must undergo a major surgical procedure to provide an organ for transplantation. It is mandatory to offer a surgical technique that is safe with minimal complications. It is also obvious for any organ transplantation that the integrity of the organ remains intact to enable its successful transplantation into the recipient. An acceptably short ischemia time and adequate lengths of ureter and renal vasculature are required. Live donor nephrectomy should be minimally invasive as it requires delicate handling and precise dissection but the conventional laparoscopic assisted live donor nephrectomy has many limitations. Richards et al reported the theoretic concern that increased intra-abdominal pressure diminishes renal blood flow and can cause acute renal failure.5 Harman et al demonstrated that with an intra-abdominal pressure of 20 mm Hg, renal blood flow and glomerular filtration rate decrease to less than 25% of normal.6 Because the gas administered during surgery increases abdominal pressure and may cause renal damage and to our knowledge there is no long-term study on the survival of the donor kidney following laparoscopic live donor nephrectomy, the possibility of kidney damage cannot be ignored. Also, because laparoscopic dissection produces small operating space and allows only the 2-dimensional view through the video monitor, the delicate manipulation during surgery is difficult, operating time is prolonged and the possibility of a vascular accident is high.7 In 1998 Wolf et al developed hand assisted laparoscopic nephrectomy to overcome the spatial limitation and successfully performed live donor nephrectomy.8 However, because this method requires incision of peritoneum and carbon dioxide gas, hand assisted laparoscopic nephrectomy still possesses the problems associated with conventional laparoscopic live donor nephrectomy. Furthermore, hand assisted live donor nephrectomy involves unnecessary intestinal manipulation with possible intestinal adhesions, making it more than minimally invasive. Our retroperitoneoscopy assisted live donor nephrectomy, combining the advantages of open surgery and conventional laparoscopic nephrectomy, allows easy maintenance of anatomical direction since the operation is performed under ob-

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servation through the video monitor or direct vision. Because the newly devised piercing abdominal and peritoneal retractors create sufficient operating space, dissection of the ureter and 2 or more renal arteries is just as safe as in open live donor nephrectomy. This technique minimizes use of disposable equipment (see Appendix), thus reducing operating costs. The most common vascular accident in laparoscopic surgery9 can be treated in a timely manner during retroperitoneoscopy assisted live donor nephrectomy. Direct compression of a bleeder and meticulous hemostasis are possible through the minilaparotomy wound. After vascular pedicle dissection a sac is used to minimize any manipulation of the donor kidney and warm ischemia time. Following kidney insertion into the sac, the renal artery and vein are transected, and the kidney is extracted through the minilaparotomy. The warm ischemia time for retroperitoneoscopy assisted live donor nephrectomy is generally less than 3 minutes, which is equivalent to open surgery but faster than conventional laparoscopic live donor nephrectomy.10 Average operating time of 130 minutes is much shorter than for laparoscopic live donor nephrectomy and no longer than open live donor surgery.1 It is well known that pain following laparoscopic live donor nephrectomy is significantly less than that after open surgery.3, 10 For conventional laparoscopic live donor nephrectomy a 1 to 2 cm. incision is made in 4 or more places for inserting the trocar and another 7 to 8 cm. incision is made for delivering the kidney.1, 11 For retroperitoneoscopy assisted live donor nephrectomy incision length is reduced to 5 to 7 cm. and the muscles are split without division. As a result, nerve and muscle damage is minimal, and postoperative analgesics (average 21 mg. morphine equivalent) are less than half those required for open surgery.12 The warm ischemia time and blood loss are comparable to those of open live donor nephrectomy, and there is no postoperative skin sensitivity. The concept of this retroperitoneoscopic assisted live donor nephrectomy is a hybrid of the familiar open surgical principles and basic laparoscopic techniques with a minimal learning curve. The advantages include improved visualization of the anatomy with 3-dimensional orientation, reduced blood loss, exact dissection and prevention of inadvertent pedicle spasms and injuries, and easier recovery. This technique has not only been the subject of experiments and trials, but most importantly it has also been completely standardized. It is currently used at our institution for all live donor nephrectomy candidates regardless of laterality, body configuration or number of arteries. The early clinical outcome and actual videotapes have been presented previously.13 We also use this technique for other urological surgery, including radical nephrectomy, nephrolithotomy, adrenalectomy and ureterolithotomy with similar success.14, 15 CONCLUSIONS

Retroperitoneoscopy assisted live donor nephrectomy is a minimally invasive technique that is safe, feasible, standardized and reproducible with a minimal learning curve. We believe that retroperitoneoscopic live donor nephrectomy may become daily urological practice.

TABLE 2. Results of 103 retroperitoneoscopy assisted and 95 open live donor nephrectomies Mean ⫾ SD

Operating time (mins.) Blood loss (cc) Warm ischemia time (mins.) Oral intake resumed (hrs.) Full ambulation resumed (days) Analgesics (mg. morphine equivalent)

Retroperitoneoscopy Assisted Donor Nephrectomy

Open Donor Nephrectomy

130 ⫾ 28 100 ⫾ 10.2 2.3 ⫾ 0.6 16.4 ⫾ 7.3 1.6 ⫾ 0.5 21 ⫾ 11.3

138 ⫾ 15 115 ⫾ 13.2 2.2 ⫾ 0.8 34.6 ⫾ 9.3 3.4 ⫾ 1.7 46 ⫾ 16.3

p Value 0.07 0.18 0.31 ⬍0.01 ⬍0.01 ⬍0.01

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Drs. T. Dorflinger, P. Hellstrom, M. K. Li, S. Jahnson and P. O. Madsen provided support for this review. 7. APPENDIX: LAPAROSCOPIC INSTRUMENTS FOR RETROPERITONEOSCOPIC ASSISTED LIVE DONOR NEPHRECTOMY

0-degree, 10 mm. laparoscope with built in light source 1 Hassan ballon trocar (disposable) 5 mm. atraumatic grasping forceps (disposable) 5 mm. curved electrosurgical scissors (disposable) Retrieval/entrapment bag (disposable)

8.

9.

10.

REFERENCES

1. Ruiz, R., Novick, A. C., Braun, W. E. et al: Transperitoneal live-donor nephrectomy. J Urol, 123: 819, 1980 2. Ratner, L. E., Ciseck, L. J., Moore, R. G. et al: Laparoscopic live donor nephrectomy. Transplantation, 60: 1047, 1995 3. Philosophe, B., Kuo, P. C., Schweitzer, E. J. et al: Laparoscopic versus open donor nephrectomy: comparing ureteral complications in the recipients and improving the laparoscopic technique. Transplantation, 68: 497, 1999 4. Yang, S. C., Park, D. S., Lee, D. H. et al: Retroperitoneal endoscopic live donor nephrectomy: report of 3 cases. J Urol, 153: 1884, 1995 5. Richards, W. O., Scovill, W., Shin, B. et al: Acute renal failure associated with increased intra-abdominal pressure. Ann Surg, 197: 183, 1983 6. Harman, P. K., Kron, I. L., McLachian, H. D. et al: Elevated

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intra-abdominal pressure and renal function. Ann Surg, 196: 594, 1982 Knoepp, L., Smith, M., Huey, J. et al: Complications after laparoscopic donor nephrectomy: a case report and review. Transplantation, 68: 449, 1999 Wolf, J. S., Jr., Moon, T. D. and Nakada, S. Y.: Hand assisted laparoscopic nephrectomy: comparison to standard laparoscopic nephrectomy. J Urol, 160: 22, 1998 Fahlenkamp, D., Rassweiler, J., Fornara, P. et al: Complications of laparoscopic procedures in urology: experience with 2,407 procedures at 4 German centers. J Urol, 162: 765, 1999 Kerbl, K., Clayman, R. V., McDougall, E. M. et al: Transperitoneal nephrectomy for benign disease of the kidney: a comparison of laparoscopic and open surgical techniques. Urology, 43: 607, 1994 Slakey, D. P., Wood, J. C., Hender, D. et al: Laparoscopic living donor nephrectomy: advantages of the hand-assisted method. Transplantation, 68: 581, 1999 Ratner, L. E., Kavoussi, L. R., Sroka, M. et al: Laparoscopic assisted live donor nephrectomy: a comparison with the open approach. Transplantation, 63: 229, 1997 Yang, S. C. and Kim, J. H.: Laparoscopy assisted extraperitoneal live donor nephrectomy. J Urol, suppl., 159: 129, abstract V23, 1998 Yang, S. C., Ryu, J. K. and Rha, K. H.: Gasless laparoscopyassisted extraperitoneal surgery in urology. J Endourol, 10: 186, 1996 Byun, Y. J. and Yang, S. C.: Laparoscopy-assisted urologic surgery through minilaparotomy. Yonsei Med J, 40: 596, 1999