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Technical Modifications of Retroperitoneoscopic Live Donor Nephrectomy: Chinese Experience
Technical Modifications of Retroperitoneoscopic Live Donor Nephrectomy: Chinese Experience L. Ma, J. Ye, X. Tian, G. Wang, X. Hou, and L. Zhao ABSTRACT Objective. The objective of this article is to report a single-center experience and technical modifications of retroperitoneoscopic live donor nephrectomy (RPLDN). Materials and Methods. One hundred twenty-one 3-port RPLDNs were performed at our institution. No prisoners or organs from prisoners were used to collect the data for this study. The tributaries of renal artery and vein were transected using a harmonic scalpel after both ends of the tributary were coagulated intermittently until the color turned light yellow. Transection was made using shifting coagulation. A longitudinal 6 – 8-cm skin incision was extended inferiorly from the primary trocar with muscles intact. The renal artery was clipped using two Hem-o-Lok clips at the proximal end, and then sheared by scissors without any clips on the kidney side. The renal vein was controlled similarly. The graft was retrieved by insertion of a hand through the longitudinal lumbar incision. Results. The mean operative time and warm ischemia time were 126.1 and 3.6 minutes, respectively. No blood transfusion or open conversion was required. None of the donors encountered a major complication, but 7 suffered minor complications. Preoperative and postoperative mean serum creatinine levels of the donors were 1.00 and 1.29 mg/dL, respectively. The mean serum creatinine levels of the recipients postoperatively at day 1 and month 1 were 5.48 and 1.60 mg/dL, respectively. Conclusions. The modified approach of RPLDN may be a useful alternative with flexible control of the renal vessels and tributaries and easy retrieval of the graft. APAROSCOPIC donor nephrectomy (LDN) has been adopted as a standard procedure to procure kidney graft for the optimal treatment strategies for end-stage renal failure. However, LDN, especially retroperitoneoscopic live donor nephrectomy (RPLDN) with limited working space, still remains a great technical challenge for transplantation surgeons at centers with a low volume of renal donors. To our knowledge, there are at least 3 key steps that make this procedure challenging: vascular control of the renal pedicle, hemostatic management of the renal vessel tributaries, and retrieval of the graft. Since many institutions have established unique techniques of RPLDN, we have reported our technical modifications in the 3 above steps among 121 consecutive RPLDNs.
L
MATERIALS AND METHODS Between December 2003 and March 2009, 121 3-port RPLDNs were performed at our institution, not using prisoners or organs from prisoners. All potential donors and recipients were evaluated
using extensive medical, psychological, laboratory, and radiographic aspects in accord with our institutional guidelines. They were presented for ethical selection by an interdisciplinary transplantation team and an ethics committee at our institution.1 All of these procedures were performed by the surgeon (L.M.). Our cost-effective approach of 3-port RPLDN has been described in detail before.2 Briefly, the patient was placed in lateral decubitus position under general anesthesia. A 1–2-cm skin incision was made just below the tip of the twelfth rib. The initial retroperitoneal space was created by index finger dissection and expansion using a self-made balloon dilator. First a 12-mm trocar was inserted and pneumoretroperitoneum established under a pressure of
From the Department of Urology, Peking University Third Hospital, Beijing, China. Drs Ma, Ye, and Tian contributed equally. Address reprint requests to Lulin Ma, MD, Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China. E-mail: bysyuro@gmail. com
0041-1345/10/$–see front matter doi:10.1016/j.transproceed.2010.08.068
© 2010 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
3440
Transplantation Proceedings, 42, 3440 –3443 (2010)
LIVE DONOR NEPHRECTOMY 10 –15 mm Hg. The second 10-mm trocar was placed 2 cm above the anterior superior iliac spine and the third 5-mm trocar at the junction of the anterior axillary line and subcostal margin of the twelfth rib. The 3 key steps are briefly introduced. First, the renal vessel tributaries, including inferior adrenal arteries, adrenal veins, gonadal veins, and lumbar veins, were transected using harmonic scalpels in this order: intermittently coagulating both proximal and distal ends of the tributary with the harmonic scalpel until the colors of the ends turned light yellow. There after transection was performed between the 2 coagulated ends with coagulation shears. Second, vascular control in the renal pedicle was performed using 2 Hem-o-loks. The renal artery was controlled with 2 plastic locking clips (Hem-o-lok, Weck Closure Systems, Research Triangle Park, NC, United States) at the proximal end as close as possible to the origin from the abdominal aorta. And it was sheared with scissors without any clips on the kidney side in laparoscopy. The renal vein was transected similarly. Third, the grafts were harvested by manual retrieval through a longitudinal 6 – 8-cm skin incision extended inferiorly from the lumbar trocar before division of the renal vessels. The subcutaneous tissues were divided following the direction of fibers of the greater psoas muscles, which were kept intact to maintain the pneumoretroperitoneum. Immediately after division of the renal vessels, the muscles under the skin incision were cut following the direction of the fibers. A hand was inserted gently to grasp the kidney and perirenal fat to retrieve the kidney. Perioperative data of donors and recipients were collected for further analysis. Data are presented as mean values ⫾ standard deviations.
RESULTS
The 121 donors who underwent successful consecutive RPLDNs had a mean age of 47.0 ⫾ 9.8 years and a gender distribution of 58 men and 63 women. Their mean body mass index was 23.7 ⫾ 3.5 kg/m2. One hundred ten donors underwent left and 11 right nephrectomies. The mean operative and warm ischemic times were 126.1 ⫾ 42.2 and 3.6 ⫾ 1.2 minutes, respectively. The mean blood loss was 70.5 ⫾ 52.6 mL. No blood transfusion or open conversion was encountered. The mean postoperative hospital stay was 7.1 ⫾ 2.1 days. Also, 12.4% of donors required analgesics by intramuscular injection of 63.3 ⫾ 29.7 (50.0 –150.0) mg meperidine. No donors suffered major complications requiring reoperation or massive bleeding. Seven (5.8%) donors suffered minor complications that could be cured with conservative treatments instead of surgical procedures: 3 (2.5%) of the recipients developed ureteral fistulas which needed reoperations. Four (3.3%) of the recipients encountered minor complications including 2 slight superficial lacerations and 2 subcapsular hematomas. The mean levels of preoperative and postoperative serum creatinine values among the donors were 1.00 ⫾ 0.13 and 1.29 ⫾ 0.22 mg/dL, respectively. The mean levels of postoperative serum creatinine in the recipients at day 1 and month 1 were 5.48 ⫾ 2.58 and 1.60 ⫾ 0.87 mg/dL, respectively. The mean 24-hour urine output of recipients postoperatively on day 1 was 4332 ⫾ 1537 mL. None of the donors required dialysis due to acute tubular necrosis or delayed renal function.
3441
DISCUSSION
RPLDN provides advantages of direct, rapid renal exposure, flexible control of the renal hillum on both sides, and reduced interference from intraabdominal viscera, as well as low morbidity, little postoperative pain, short convalescence, and high donation rates. Therefore many centers have performed this technique, making many modifications.3–7 With 6 years of experience of retroperitoneal laparoscopic nephrectomies and adrenectomies and 5 years of experience of RPLDN at our institution, we made some modifications to improve rapid, flexible control of the renal vessels and fast graft retrieval, with little postoperative pain. Because live donor nephrectomy is performed on healthy people to retrieve kidneys for other patients, it was preferred to be performed by the best skilled surgeon to guarantee donor safety and shorten the learning curve with fewer complications. The retroperitoneal approach is hard to perform and learn because of the limited working space, and the difficulty in renal vessel control and the demand for experience to shorten the warm ischemia time of the kidney. However, based on the criteria of speedy performance and donor safety, hand-assisted retroperitoneoscopy is preferred8,9 and easier for beginners with limited experience than the abdominal wall instruments.10 The most challenging aspect is the precise anatomic dissection of vessels around the kidney. In our experience, the renal artery can be easily identified from the dorsal middle part of the kidney after establishment of a pneumoretroperitoneum. Then it can be circumferentially mobilized from the renal hilum to its retrocaval location after dissection of Gerota’s fascia. The renal vein was mobilized similarly. Care should be taken to avoid the injury to lumbar veins crossing the renal artery. They may be mistaken as accessory renal veins; gonadal veins could be easily mistaken for renal veins when they collect some minute lumbar veins. Circumferential mobilization of all of these confusing vessels to identifying them from the proximal to distal end helps in their control and in prevention from hemorrhage. We have reported a preliminary experience of controlling the tributaries of renal vessels by coagulating shears of harmonic scalpel without any specific clips. The branches of renal vessels, such as inferior adrenal arteries, adrenal veins, lumbar veins, and gonadal veins, were transected with a harmonic scalpel; when both proximal and distal ends of the vessel turned light yellow after intermittent coagulation, transection was made between both ends with coagulating shift. Both ends must be coagulated when the color turns white or light yellow before transection. In our experience, it takes 6 – 8 times of intermittent coagulation with a Harmonic Scalpel (Johnson & Johnson, Cincinnati, OH, United States) or 8 –10 times with a SonoSurg-G2 (Olympus Medical Systems Corporation, Tokyo, Japan) until each coagulated end turned white or light yellow; each coagulation took 1–2 seconds. At most institutions the renal vessel branches are transected with plastic or metallic clips and sometimes staplers, in the presence of large gonadal and
3442
lumbar veins.11,12 The risks of dislodgement of clips had been reported during control of the main renal vessels.13,14 This unique way to control tributaries of renal vessels avoided the risk and did not lead to massive hemorrhage in our experience. No bleeding was noted from coagulated/ transected vessels, therefore, it was not necessary to use ancillary procedures for vascular control after coagulation. Most transplantation centers use vascular staplers to control the renal artery and vein,15 whereas some use plastic locking clips on the renal artery.16,17 In our series, the renal arteries and veins were controlled with Hem-oLoks. Compared with using staplers, Hem-o-Loks have been reported to provide an increased length of graft vessels without compromising graft safety.18 We placed 2 Hem-o-Loks at each proximal end, of the renal artery or vein as close as possible to the origins from the abdominal aorta or vena cava. We then showed the artery or vein with scissors without clips on the kidney side. To avoid dislodgment of the Hem-o-Lok, care should be taken to make sure that the front ends of the Hem-o-Lok should be seen before closure and as little tissue as possible left around the vessels. We reported a unique manual graft retrieval via easy, expeditious access in RPLDN. This technique facilitated retrieval of the retroperitoneal graft with benefits of direct vision and expeditious access through the lumbar incision extending from the primary trocar inferiorly in RPLDN. Manual retrieval was advocated because of fewer technical difficulties, shorter warm ischemia times, and less graft and other tissue, injury compared with entrapment bag retrieval.19 Although the latter permits a smaller extraction site opening, it does produce more technique difficulties in a limited working space, longer warm ischemia time, and more risks of injury to the graft and other tissues. Our lumbar incision may be related to direct, fast retrieval of the graft compared with the Gibson incision3 and Pfannenstiel incision.20 In our series, a longitudinal 6 – 8-cm incision of the skin and subcutaneous tissues was extended from the primary trocar inferiorly before division of the renal vessels. The muscles were cut following the direction of the fibers without cutting the nerves. None of the graft was injured due to this manual retrieval in our series. It be related to the advantages of direct and fast retrieval of the graft, less postoperative pain, and less uncomfortable ispilateral hypogastric sensation. In our experience, indications for right donor nephrectomy included the following: right nephroptosis, right renal calculus, multiple left renal vessels, duplication of left kidney and ureter, and postoperatively after left ureteropyeloplasty. Although reluctance for right-sided living donor nephrectomy was proven to not be justified by Ruszat et al,21 we preferentially chose the left kidney because of its longer renal vein because we experienced 2 cases of short right renal veins. With enough experience there were no diffulties with its retrieval or subsequent implantation, because we dissected and floated a long length of the external iliac vein to anastomose the short renal veins
MA, YE, TIAN ET AL
successfully instead of vein patches if the renal vein was not satisfactory. Compared with other series, our hospital stay was longer because donors insist on a 1-week stay in hospital before returning to nearly normal lives with the antiquated concept of discharge after removal of dermal sutures in China. Lack of sanity in the medical care system in China also made the donors intend to stay longer in hospital for their further convenience. In conclusion, this study demonstrated that technical modifications of RPLDN were associated with flexible and safe control of the renal vessels and the branches on both sides and fast retrieval of the graft to decrease warm ischemia time. REFERENCES 1. Lei Z, Lulin M, Guoliang W, et al: Ensuring the safety of living kidney donors and recipients in China through ethics committee oversight: an early experience. Am J Transplant. 8:1840, 2008 2. Ye J, Huang Y, Hou X, et al: Retroperitoneal laparoscopic live donor nephrectomy: a cost-effective approach. Urology 75:92, 2010 3. Ng CS, Abreu SC, Abou El-Fettouh HI, et al: Right retroperitoneal versus left transperitoneal laparoscopic live donor nephrectomy. Urology 63:857, 2004 4. Tanabe K, Miyamoto N, Ishida H, et al: Retroperitoneoscopic live donor nephrectomy (RPLDN): establishment and initial experience of RPLDN at a single center. Am J Transplant 5:739, 2005 5. Bachmann A, Wyler S, Wolff T, et al: Complications of retroperitoneoscopic living donor nephrectomy: single center experience after 164 cases. World J Urol 26:549, 2008 6. Bachmann A, Giannini O, Wolff T, et al: Retroperitoneoscopic living donor nephrectomy: a comparison with the open approach in respect of early postoperative pain management. Transplant Proc 37:609, 2005 7. Suzuki K, Ishikawa A, Ushiyama T, et al: Retroperitoneoscopic living donor nephrectomy without gas insufflation: the five-year Hamamatsu University experience. Transplant Proc 34: 720, 2002 8. Gjertsen H, Sandberg AK, Wadstrom J, et al: Introduction of hand-assisted retroperitoneoscopic living donor nephrectomy at Karolinska University Hospital Huddinge. Transplant Proc 38: 2644, 2006 9. Yashi M, Yagisawa T, Nukui A, et al: Strategic hand assistance for effective and safe retroperitoneoscopic live donor nephrectomy. Transplant Proc 41:88, 2009 10. Yagisawa T, Sakuma Y, Fujiwara T, et al: Retroperitoneoscopic living donor nephrectomy: a safe and minimally invasive procedure for the donor. Transplant Proc 37:617, 2005 11. Ratner LE, Ciseck LJ, Moore RG, et al: Laparoscopic live donor nephrectomy. Transplantation 60:1047, 1995 12. Gill IS, Uzzo RG, Hobart MG, et al: Laparoscopic retroperitoneal live donor right nephrectomy for purposes of allotransplantation and autotransplantation. J Urol 164:1500, 2000 13. Fisher PC, Montgomery JS, Johnston WK, et al: 200 consecutive hand assisted laparoscopic donor nephrectomies: evolution of operative technique and outcomes. J Urol 175:1439, 2006 14. Ruszat R, Sulser T, Dickenmann M, et al: Retroperitoneoscopic donor nephrectomy: donor outcome and complication rate in comparison with three different techniques. World J Urol 24:113, 2006 15. Wright AD, Will TA, Holt DR, et al: Laparoscopic living donor nephrectomy: a look at current trends and practice patterns at major transplant centers across the United States. J Urol 179:1488, 2008
LIVE DONOR NEPHRECTOMY 16. Baumert H, Ballaro A, Arroyo C, et al: The use of polymer (Hem-o-lok) clips for management of the renal hilum during laparoscopic nephrectomy. Eur Urol 49:816, 2006 17. Kumar A, Chaudhary H, Srivastava A, et al: Laparoscopic live-donor nephrectomy: modifications for developing nations. BJU Int 93:1291, 2004 18. Modi P, Goel R, Dodia S: Retroperitoneoscopic left donor nephrectomy: use of Hem-o-Lok clips for control of renal pedicle. J Endourol 21:1029, 2007
3443 19. Ratner LE, Montgomery RA, Kavoussi LR: Laparoscopic live donor nephrectomy. A review of the first 5 years. Urol Clin North Am 28:709, 2001 20. Simforoosh N, Basiri A, Tabibi A, et al: Comparison of laparoscopic and open donor nephrectomy: a randomized controlled trial. BJU Int 95:851, 2005 21. Ruszat R, Wyler SF, Wolff T, et al: Reluctance over rightsided retroperitoneoscopic living donor nephrectomy: justified or not? Transplant Proc 39:1381, 2007
L
MATERIALS AND METHODS Between December 2003 and March 2009, 121 3-port RPLDNs were performed at our institution, not using prisoners or organs from prisoners. All potential donors and recipients were evaluated
using extensive medical, psychological, laboratory, and radiographic aspects in accord with our institutional guidelines. They were presented for ethical selection by an interdisciplinary transplantation team and an ethics committee at our institution.1 All of these procedures were performed by the surgeon (L.M.). Our cost-effective approach of 3-port RPLDN has been described in detail before.2 Briefly, the patient was placed in lateral decubitus position under general anesthesia. A 1–2-cm skin incision was made just below the tip of the twelfth rib. The initial retroperitoneal space was created by index finger dissection and expansion using a self-made balloon dilator. First a 12-mm trocar was inserted and pneumoretroperitoneum established under a pressure of
From the Department of Urology, Peking University Third Hospital, Beijing, China. Drs Ma, Ye, and Tian contributed equally. Address reprint requests to Lulin Ma, MD, Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China. E-mail: bysyuro@gmail. com
0041-1345/10/$–see front matter doi:10.1016/j.transproceed.2010.08.068
© 2010 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
3440
Transplantation Proceedings, 42, 3440 –3443 (2010)
LIVE DONOR NEPHRECTOMY 10 –15 mm Hg. The second 10-mm trocar was placed 2 cm above the anterior superior iliac spine and the third 5-mm trocar at the junction of the anterior axillary line and subcostal margin of the twelfth rib. The 3 key steps are briefly introduced. First, the renal vessel tributaries, including inferior adrenal arteries, adrenal veins, gonadal veins, and lumbar veins, were transected using harmonic scalpels in this order: intermittently coagulating both proximal and distal ends of the tributary with the harmonic scalpel until the colors of the ends turned light yellow. There after transection was performed between the 2 coagulated ends with coagulation shears. Second, vascular control in the renal pedicle was performed using 2 Hem-o-loks. The renal artery was controlled with 2 plastic locking clips (Hem-o-lok, Weck Closure Systems, Research Triangle Park, NC, United States) at the proximal end as close as possible to the origin from the abdominal aorta. And it was sheared with scissors without any clips on the kidney side in laparoscopy. The renal vein was transected similarly. Third, the grafts were harvested by manual retrieval through a longitudinal 6 – 8-cm skin incision extended inferiorly from the lumbar trocar before division of the renal vessels. The subcutaneous tissues were divided following the direction of fibers of the greater psoas muscles, which were kept intact to maintain the pneumoretroperitoneum. Immediately after division of the renal vessels, the muscles under the skin incision were cut following the direction of the fibers. A hand was inserted gently to grasp the kidney and perirenal fat to retrieve the kidney. Perioperative data of donors and recipients were collected for further analysis. Data are presented as mean values ⫾ standard deviations.
RESULTS
The 121 donors who underwent successful consecutive RPLDNs had a mean age of 47.0 ⫾ 9.8 years and a gender distribution of 58 men and 63 women. Their mean body mass index was 23.7 ⫾ 3.5 kg/m2. One hundred ten donors underwent left and 11 right nephrectomies. The mean operative and warm ischemic times were 126.1 ⫾ 42.2 and 3.6 ⫾ 1.2 minutes, respectively. The mean blood loss was 70.5 ⫾ 52.6 mL. No blood transfusion or open conversion was encountered. The mean postoperative hospital stay was 7.1 ⫾ 2.1 days. Also, 12.4% of donors required analgesics by intramuscular injection of 63.3 ⫾ 29.7 (50.0 –150.0) mg meperidine. No donors suffered major complications requiring reoperation or massive bleeding. Seven (5.8%) donors suffered minor complications that could be cured with conservative treatments instead of surgical procedures: 3 (2.5%) of the recipients developed ureteral fistulas which needed reoperations. Four (3.3%) of the recipients encountered minor complications including 2 slight superficial lacerations and 2 subcapsular hematomas. The mean levels of preoperative and postoperative serum creatinine values among the donors were 1.00 ⫾ 0.13 and 1.29 ⫾ 0.22 mg/dL, respectively. The mean levels of postoperative serum creatinine in the recipients at day 1 and month 1 were 5.48 ⫾ 2.58 and 1.60 ⫾ 0.87 mg/dL, respectively. The mean 24-hour urine output of recipients postoperatively on day 1 was 4332 ⫾ 1537 mL. None of the donors required dialysis due to acute tubular necrosis or delayed renal function.
3441
DISCUSSION
RPLDN provides advantages of direct, rapid renal exposure, flexible control of the renal hillum on both sides, and reduced interference from intraabdominal viscera, as well as low morbidity, little postoperative pain, short convalescence, and high donation rates. Therefore many centers have performed this technique, making many modifications.3–7 With 6 years of experience of retroperitoneal laparoscopic nephrectomies and adrenectomies and 5 years of experience of RPLDN at our institution, we made some modifications to improve rapid, flexible control of the renal vessels and fast graft retrieval, with little postoperative pain. Because live donor nephrectomy is performed on healthy people to retrieve kidneys for other patients, it was preferred to be performed by the best skilled surgeon to guarantee donor safety and shorten the learning curve with fewer complications. The retroperitoneal approach is hard to perform and learn because of the limited working space, and the difficulty in renal vessel control and the demand for experience to shorten the warm ischemia time of the kidney. However, based on the criteria of speedy performance and donor safety, hand-assisted retroperitoneoscopy is preferred8,9 and easier for beginners with limited experience than the abdominal wall instruments.10 The most challenging aspect is the precise anatomic dissection of vessels around the kidney. In our experience, the renal artery can be easily identified from the dorsal middle part of the kidney after establishment of a pneumoretroperitoneum. Then it can be circumferentially mobilized from the renal hilum to its retrocaval location after dissection of Gerota’s fascia. The renal vein was mobilized similarly. Care should be taken to avoid the injury to lumbar veins crossing the renal artery. They may be mistaken as accessory renal veins; gonadal veins could be easily mistaken for renal veins when they collect some minute lumbar veins. Circumferential mobilization of all of these confusing vessels to identifying them from the proximal to distal end helps in their control and in prevention from hemorrhage. We have reported a preliminary experience of controlling the tributaries of renal vessels by coagulating shears of harmonic scalpel without any specific clips. The branches of renal vessels, such as inferior adrenal arteries, adrenal veins, lumbar veins, and gonadal veins, were transected with a harmonic scalpel; when both proximal and distal ends of the vessel turned light yellow after intermittent coagulation, transection was made between both ends with coagulating shift. Both ends must be coagulated when the color turns white or light yellow before transection. In our experience, it takes 6 – 8 times of intermittent coagulation with a Harmonic Scalpel (Johnson & Johnson, Cincinnati, OH, United States) or 8 –10 times with a SonoSurg-G2 (Olympus Medical Systems Corporation, Tokyo, Japan) until each coagulated end turned white or light yellow; each coagulation took 1–2 seconds. At most institutions the renal vessel branches are transected with plastic or metallic clips and sometimes staplers, in the presence of large gonadal and
3442
lumbar veins.11,12 The risks of dislodgement of clips had been reported during control of the main renal vessels.13,14 This unique way to control tributaries of renal vessels avoided the risk and did not lead to massive hemorrhage in our experience. No bleeding was noted from coagulated/ transected vessels, therefore, it was not necessary to use ancillary procedures for vascular control after coagulation. Most transplantation centers use vascular staplers to control the renal artery and vein,15 whereas some use plastic locking clips on the renal artery.16,17 In our series, the renal arteries and veins were controlled with Hem-oLoks. Compared with using staplers, Hem-o-Loks have been reported to provide an increased length of graft vessels without compromising graft safety.18 We placed 2 Hem-o-Loks at each proximal end, of the renal artery or vein as close as possible to the origins from the abdominal aorta or vena cava. We then showed the artery or vein with scissors without clips on the kidney side. To avoid dislodgment of the Hem-o-Lok, care should be taken to make sure that the front ends of the Hem-o-Lok should be seen before closure and as little tissue as possible left around the vessels. We reported a unique manual graft retrieval via easy, expeditious access in RPLDN. This technique facilitated retrieval of the retroperitoneal graft with benefits of direct vision and expeditious access through the lumbar incision extending from the primary trocar inferiorly in RPLDN. Manual retrieval was advocated because of fewer technical difficulties, shorter warm ischemia times, and less graft and other tissue, injury compared with entrapment bag retrieval.19 Although the latter permits a smaller extraction site opening, it does produce more technique difficulties in a limited working space, longer warm ischemia time, and more risks of injury to the graft and other tissues. Our lumbar incision may be related to direct, fast retrieval of the graft compared with the Gibson incision3 and Pfannenstiel incision.20 In our series, a longitudinal 6 – 8-cm incision of the skin and subcutaneous tissues was extended from the primary trocar inferiorly before division of the renal vessels. The muscles were cut following the direction of the fibers without cutting the nerves. None of the graft was injured due to this manual retrieval in our series. It be related to the advantages of direct and fast retrieval of the graft, less postoperative pain, and less uncomfortable ispilateral hypogastric sensation. In our experience, indications for right donor nephrectomy included the following: right nephroptosis, right renal calculus, multiple left renal vessels, duplication of left kidney and ureter, and postoperatively after left ureteropyeloplasty. Although reluctance for right-sided living donor nephrectomy was proven to not be justified by Ruszat et al,21 we preferentially chose the left kidney because of its longer renal vein because we experienced 2 cases of short right renal veins. With enough experience there were no diffulties with its retrieval or subsequent implantation, because we dissected and floated a long length of the external iliac vein to anastomose the short renal veins
MA, YE, TIAN ET AL
successfully instead of vein patches if the renal vein was not satisfactory. Compared with other series, our hospital stay was longer because donors insist on a 1-week stay in hospital before returning to nearly normal lives with the antiquated concept of discharge after removal of dermal sutures in China. Lack of sanity in the medical care system in China also made the donors intend to stay longer in hospital for their further convenience. In conclusion, this study demonstrated that technical modifications of RPLDN were associated with flexible and safe control of the renal vessels and the branches on both sides and fast retrieval of the graft to decrease warm ischemia time. REFERENCES 1. Lei Z, Lulin M, Guoliang W, et al: Ensuring the safety of living kidney donors and recipients in China through ethics committee oversight: an early experience. Am J Transplant. 8:1840, 2008 2. Ye J, Huang Y, Hou X, et al: Retroperitoneal laparoscopic live donor nephrectomy: a cost-effective approach. Urology 75:92, 2010 3. Ng CS, Abreu SC, Abou El-Fettouh HI, et al: Right retroperitoneal versus left transperitoneal laparoscopic live donor nephrectomy. Urology 63:857, 2004 4. Tanabe K, Miyamoto N, Ishida H, et al: Retroperitoneoscopic live donor nephrectomy (RPLDN): establishment and initial experience of RPLDN at a single center. Am J Transplant 5:739, 2005 5. Bachmann A, Wyler S, Wolff T, et al: Complications of retroperitoneoscopic living donor nephrectomy: single center experience after 164 cases. World J Urol 26:549, 2008 6. Bachmann A, Giannini O, Wolff T, et al: Retroperitoneoscopic living donor nephrectomy: a comparison with the open approach in respect of early postoperative pain management. Transplant Proc 37:609, 2005 7. Suzuki K, Ishikawa A, Ushiyama T, et al: Retroperitoneoscopic living donor nephrectomy without gas insufflation: the five-year Hamamatsu University experience. Transplant Proc 34: 720, 2002 8. Gjertsen H, Sandberg AK, Wadstrom J, et al: Introduction of hand-assisted retroperitoneoscopic living donor nephrectomy at Karolinska University Hospital Huddinge. Transplant Proc 38: 2644, 2006 9. Yashi M, Yagisawa T, Nukui A, et al: Strategic hand assistance for effective and safe retroperitoneoscopic live donor nephrectomy. Transplant Proc 41:88, 2009 10. Yagisawa T, Sakuma Y, Fujiwara T, et al: Retroperitoneoscopic living donor nephrectomy: a safe and minimally invasive procedure for the donor. Transplant Proc 37:617, 2005 11. Ratner LE, Ciseck LJ, Moore RG, et al: Laparoscopic live donor nephrectomy. Transplantation 60:1047, 1995 12. Gill IS, Uzzo RG, Hobart MG, et al: Laparoscopic retroperitoneal live donor right nephrectomy for purposes of allotransplantation and autotransplantation. J Urol 164:1500, 2000 13. Fisher PC, Montgomery JS, Johnston WK, et al: 200 consecutive hand assisted laparoscopic donor nephrectomies: evolution of operative technique and outcomes. J Urol 175:1439, 2006 14. Ruszat R, Sulser T, Dickenmann M, et al: Retroperitoneoscopic donor nephrectomy: donor outcome and complication rate in comparison with three different techniques. World J Urol 24:113, 2006 15. Wright AD, Will TA, Holt DR, et al: Laparoscopic living donor nephrectomy: a look at current trends and practice patterns at major transplant centers across the United States. J Urol 179:1488, 2008
LIVE DONOR NEPHRECTOMY 16. Baumert H, Ballaro A, Arroyo C, et al: The use of polymer (Hem-o-lok) clips for management of the renal hilum during laparoscopic nephrectomy. Eur Urol 49:816, 2006 17. Kumar A, Chaudhary H, Srivastava A, et al: Laparoscopic live-donor nephrectomy: modifications for developing nations. BJU Int 93:1291, 2004 18. Modi P, Goel R, Dodia S: Retroperitoneoscopic left donor nephrectomy: use of Hem-o-Lok clips for control of renal pedicle. J Endourol 21:1029, 2007
3443 19. Ratner LE, Montgomery RA, Kavoussi LR: Laparoscopic live donor nephrectomy. A review of the first 5 years. Urol Clin North Am 28:709, 2001 20. Simforoosh N, Basiri A, Tabibi A, et al: Comparison of laparoscopic and open donor nephrectomy: a randomized controlled trial. BJU Int 95:851, 2005 21. Ruszat R, Wyler SF, Wolff T, et al: Reluctance over rightsided retroperitoneoscopic living donor nephrectomy: justified or not? Transplant Proc 39:1381, 2007