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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 33  |  Issue : 3  |  Page : 145-151

Safety and efficacy of laparoendoscopic single-site donor nephrectomy: A comparison of the transperitoneal and retroperitoneal approaches


1 Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
2 Department of Urology, Kaohsiung Medical University Hospital; Department of Urology, School of Medicine, College of Medicine; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Date of Submission10-Oct-2021
Date of Decision30-Nov-2021
Date of Acceptance22-Jan-2022
Date of Web Publication25-Aug-2022

Correspondence Address:
Chung-Yu Lin
No. 100, Tzyou 1st Road, Kaohsiung 807
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_146_21

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  Abstract 


Purpose: Laparoscopic living-donor nephrectomy is the main technique at high-volume renal transplant centers. Laparoendoscopic single-site donor nephrectomy (LESS-DN) is s an evolutionary minimally invasive surgery, which could be performed by transperitoneal or retroperitoneal approaches. We present a retrospective analysis of our single-institution donor nephrectomy series comparing the transperitoneal to retroperitoneal LESS-DN regarding operative outcomes. Materials and Methods: Seventeen patients who underwent LESS-DN from 2017–2020 were enrolled at our center. The same surgeon performed all cases. The two approaches were compared for the operation time, blood loss, warm ischemia time (WIT), postoperative pain, length of stay (LOS), postoperative wound size, postoperative pain, and the postoperative renal function for twelve months retrospectively. Results: Operating time (257 vs. 180 min, P = 0.016) and LOS (6.5 vs. 5 days, P = 0.013) were significantly longer in the transperitoneal group. The postoperative wound size (47.5 vs. 75 mm, P = 0.038) was substantially smaller in the transperitoneal group. There was no significant difference in other parameters, including blood loss, WIT, complication rate, and postoperative pain from day one to day three. Conclusion: Retroperitoneal LESS-DN results in similar perioperative outcomes as transperitoneal LESS-DN without compromising donor safety and providing a faster operation time, shorter LOS, and a trend toward a shorter WIT. Both approach methods may be safe and effective procedures for living kidney transplantation.

Keywords: Kidney transplantation, laparoscopy, nephrectomy, warm ischemia


How to cite this article:
Lin CY, Li CC, Ke HL, Wu WJ, Chou YH, Wen SC. Safety and efficacy of laparoendoscopic single-site donor nephrectomy: A comparison of the transperitoneal and retroperitoneal approaches. Urol Sci 2022;33:145-51

How to cite this URL:
Lin CY, Li CC, Ke HL, Wu WJ, Chou YH, Wen SC. Safety and efficacy of laparoendoscopic single-site donor nephrectomy: A comparison of the transperitoneal and retroperitoneal approaches. Urol Sci [serial online] 2022 [cited 2022 Sep 30];33:145-51. Available from: https://www.e-urol-sci.com/text.asp?2022/33/3/145/354707




  Introduction Top


End-stage renal disease (ESRD) has a high prevalence in Taiwan, placing a considerable economic burden on the national health system.[1] Currently, kidney transplantation is one of the main therapies for ESRD as it improves the patients' quality of life. Transplantation is now a routine medical practice worldwide, especially in highly developed countries.[2],[3],[4] For patients with ESRD, the cost of hemodialysis is greater than the combined cost of transplantation, postoperative care, and follow-up.[5]

Currently, the number of patients receiving a kidney from their spouse or other family members is increasing.[6] Living-donor kidney transplantation is associated with several advantages, such as a short waiting period, elective timing of surgery, and better graft function than cadaveric kidney transplantation.[7],[8],[9],[10]

The first donor nephrectomy surgery was performed in 1954 using an open method, and it became the gold standard surgery for almost 45 years.[11] Currently, laparoscopic living-donor nephrectomy is the main technique performed at high-volume renal transplant centers, and laparoendoscopic single-site donor nephrectomy (LESS-DN) represents an advancement in minimally invasive surgery. The procedure can be performed using either the transperitoneal or retroperitoneal approach. Retroperitoneoscopic living-donor nephrectomy provides a direct access to the renal hilum without the need to mobilize the colon; however, it is limited by a lack of anatomical landmarks to guide orientation, a smaller working space, and a steep learning curve.[12]

Although some studies have compared the transperitoneal and retroperitoneal approaches in conventional laparoscopic donor nephrectomies,[13],[14] only a few studies have investigated other approaches for LESS-DN. In this article, we present a retrospective analysis of our single-institution donor nephrectomy series and compare transperitoneal and retroperitoneal LESS-DN in terms of operative outcomes.


  Materials and Methods Top


Study population

This retrospective study included patients who underwent LESS-DN performed by the same surgeon with relevant experience in single-site laparoendoscopic surgeries. A total of 17 patients underwent LESS-DN (8 transperitoneal LESS-DN and 9 retroperitoneal LESS-DN) at our institution from 2017 to 2020. Technetium 99 m-labeled diethylenetriaminepentaacetic acid imaging studies were conducted preoperatively to evaluate the donors' split renal function. When the donor had asymmetrical renal function (>10% difference in glomerular filtration rate), the kidney with inferior function was selected. Female patients who planned to become pregnant in the future underwent right-sided donor nephrectomy to prevent pregnancy-related hydronephrosis.[15] All living-donor renal transplantation procedures were approved by the ethics committee of our hospital. The present study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital (protocol code KMUHIRB-E(I)-20200063). All procedures were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The requirement for informed consent was waived.

Surgical technique: Retroperitoneal and transperitoneal approaches

A transperitoneal or retroperitoneal approach was employed according to each patient's preference. LESS-DN was performed through a 5-cm single transumbilical incision for the transperitoneal approach or through a 5-cm incision at the midaxillary line with a muscle-splitting technique for the retroperitoneal approach. We used a single-port device (Glove Port; Nelis Medical, Seoul, South Korea) [Figure 1]. For the transperitoneal approach, a pneumoperitoneum was created after placement of the transumbilical multichannel single-port device. The first step was division of the Toldt line, followed by colonic mobilization. The ureter and gonadal vein were localized soon after the dissection of the psoas muscle. The lifting of the ureter from the psoas muscle facilitated the dissection of the renal vein and artery from the surrounding alveolar tissue. Thereafter, we dissected the kidney to remove the perirenal fat, while sparing the adrenal gland, and divided the ureter. Finally, the kidney was directly extracted by hand through the wound retractor of the single-port device. For the retroperitoneal approach, the patient was placed in the full flank position, and the retroperitoneal space was created using a balloon dilator after skin incision and finger dissection. After the single-port device was mounted, we identified the ureter anterior to the psoas muscle and further dissected the renal artery and vein by lifting the ureter. When the renal artery and vein were thoroughly free from the adjacent alveolar and lymphatic tissue, we unmounted the single-port device and used a hand-assisted technique for perirenal dissection. The renal pedicles were divided using EndoTA (Medtronic, Minneapolis, MN, USA) and cut using scissors. Thereafter, we directly extracted the donor kidney by hand after detaching the single-port device. During the extraction procedure, we did not extend the incision wound based on the graft size in either approach.
Figure 1: Laparoendoscopic single-site donor nephrectomy with multi-glove ports

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Postoperative management

All patients received patient-controlled analgesia and took nonsteroidal anti-inflammatory drugs orally every 8 h for postoperative pain control. The patients were evaluated for pain every 2 h on operation day and every 8 h for the remaining days. They were discharged home when pain and oral intake were tolerable without acute complications.

Statistical analysis

We analyzed variables including age, sex, laterality, body mass index (BMI), operation time, estimated blood loss, warm ischemia time (WIT), hospital length of stay (LOS), postoperative pain, wound size, postoperative renal function, and complications. Pain was evaluated using the Visual Analog Scale from days 1–3. The postoperative wound was evaluated at 1 month after the surgery [Figure 2] and [Figure 3]. Renal function after LESS-DN was followed up for up to 1 year, and the serum creatinine level was evaluated before surgery and at 1, 3, 6, and 12 months after surgery. The percentage increase in the serum creatinine level at 12 months after surgery was also evaluated. Postoperative complications were recorded and graded according to the modified Clavien classification. Quantitative variables were expressed as median (interquartile range). The patients were grouped according to the approach (transperitoneal or retroperitoneal). Furthermore, we stratified the patients into two groups according to the BMI (<24 and ≥24 kg/m2). To compare the outcomes between the two independent groups, the Mann–Whitney U test (Wilcoxon rank-sum test) was employed for nonnormally distributed continuous variables and Fisher's exact test for categorical variables. Statistical significance was defined as P < 0.05, and all the reported P values were two-sided. Statistical analyses were conducted using the SPSS software (IBM SPSS Statistics for Windows, version 19.0; IBM Corp., Armonk, NY, USA).
Figure 2: Postoperative wound – Transperitoneal approach

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Figure 3: Postoperative wound – Retroperitoneal approach

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  Results Top


Eight and nine patients underwent transperitoneal LESS-DN and retroperitoneal LESS-DN, respectively. [Table 1] summarizes the patients' characteristics. No significant differences were observed in age, sex, BMI, preoperative serum creatinine level, or laterality. In terms of laterality, 13 and 4 patients underwent left-and right-sided donor nephrectomy, respectively. [Table 2] summarizes the perioperative outcomes according to the approach. The median operation time (257 vs. 180 min, P = 0.002) and LOS (6.5 vs. 5 days, P = 0.013) were significantly longer in the transperitoneal group. However, the postoperative wound size (47.5 vs. 75 mm, P = 0.002) was significantly smaller in the transperitoneal group. No significant differences were observed in the other parameters, including blood loss (75 vs. 100 mL, P = 0.277), WIT (189 vs. 145 s, P = 0.200), complication rate, and postoperative pain from days 1 to 3. Although the wound pain levels during the postoperative 3 days were similar between the groups, two patients in the retroperitoneal group complained of transient tingling and numbness in the anterolateral aspect of the upper thigh and flank during the follow-up. The symptoms persisted for up to 3 months and were tolerable with analgesic agents. In the transperitoneal group, five patients had grade I complications (five of eight patients required the use of analgesic; three of eight patients had postoperative nausea and vomiting). In the retroperitoneal group, seven patients had grade I complications (seven of nine patients required the use of analgesic). No grade II or more severe complications occurred in either group. Renal function was followed up for 1 year after LESS-DN, and no significant differences were observed between the two groups. [Table 3] summarizes the perioperative outcomes in the subgroup analysis according to the BMI. No significant differences in any parameter were observed between the two BMI subgroups.
Table 1: Characteristics of patients undergoing single site donor nephrectomy

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Table 2: Perioperative outcomes of single-site donor nephrectomy

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Table 3: Perioperative outcomes of single-site donor nephrectomy in body mass index groups

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  Discussion Top


Living-donor kidney donation is usually an altruistic act. Donor nephrectomy is different from other destructive surgeries in that it involves the exposure of a healthy individual to the risks of the procedure. The symptoms and discomfort experienced by patients should be minimized in clinical practice. Compared with open donor nephrectomy, laparoscopic donor nephrectomy has been shown to provide superior postoperative recovery and convalescence,[16],[17] as well as equivalent safety and postoperative outcome for the donor.[18]

LESS is an advancement in laparoscopy owing to the following advantages: less blood loss, less wound pain, less risk of incisional hernia, and better cosmesis.[19] At our institution, surgeons perform single-port laparoscopic surgery techniques, such as LESS adrenalectomy, herniorrhaphy, partial nephrectomy, and robotic single-port radical prostatectomy, in daily practice. LESS-DN has been the standard procedure for living-donor kidney transplantation at our institution since December 2017.

On the basis of previous studies, although the laparoscopic transperitoneal approach provides a broader view and clearer anatomical landmarks to gain a direct access without bowel manipulation, the retroperitoneal approach can reduce the violation of abdominal organs and bypass the intraperitoneal adhesions.[20],[21] This may have contributed to the reduced operation time and shortened recovery period following surgery in our retroperitoneal group. In our study, the faster operation time in the retroperitoneal group did not lead to more blood loss or a longer WIT during the surgery compared with the transperitoneal group. The LOS was significantly shorter in the retroperitoneal group. We believe that the minimal interference with the abdominal organs in the retroperitoneal approach shortens the bowel recovery and hospital stay durations. Furthermore, postoperative nausea and vomiting more frequently occurred as complications in the transperitoneal group, which may have contributed to the longer LOS in this group. In our study, the wound was created on the umbilicus, and an intraumbilical incision was made in the transperitoneal approach. During wound healing, the wound retracted to the inner side of the umbilical ring, and the healing scar was less visible in the transperitoneal group, as also described in other studies.[22] Thus, the wound size at 1 month postoperatively was smaller in the transperitoneal group than in the retroperitoneal group, although the size of the original incision was the same between the two groups. In our opinion, LESS-DN with a transperitoneal approach is suitable for patients who are concerned about cosmetic outcomes. In the study by Choi et al., an unstable renal function at 1 month postoperatively was a predictor of poor recovery of renal function and chronic kidney disease. Therefore, patients with an unstable renal function at 1 month following surgery should be followed up for >1 year to confirm their final renal outcomes.[23] At our institution, all patients were followed up for 1 year following donor nephrectomy to evaluate their postoperative renal function. No significant difference was observed between the transperitoneal and retroperitoneal groups in terms of the change in the serum creatinine levels up to months after surgery, indicating that the safety of LESS-DN is not affected by the approach method. The most common complications of donor nephrectomy are organ injury and ileus.[24] In our series, organ or vessel injury during the surgery did not occur in any patient. During postoperative care, all patients were able to consume a soft diet on postoperative day 1. All complications were minor, and the two approaches did not exhibit significant differences in the outcomes. Five patients in the transperitoneal group needed additional analgesic use for grade I complications. Three of these five patients also had postoperative nausea and vomiting (grade I complications) and needed antiemetics. In the retroperitoneal group, seven patients complained of intolerable wound pain (grade I complication). No postoperative ileus, blood transfusion, or severe complications occurred in both groups. The details are presented in [Supplementary Table 1]. In our experience, LESS-DN is a safe procedure with few morbidities.



Although LESS-DN is a minimally invasive procedure with less trauma than the open method, postoperative pain might need management. A previous study reported that the major cause of postoperative pain in the transperitoneal approach was visceral pain resulting from residual carbon dioxide pneumoperitoneum and shoulder-tip pain resulting from diaphragmatic irritation. The postoperative pain in the retroperitoneal approach results from wound tension at the incision site and subcutaneous emphysema.[25] In our study, no significant difference was observed in the postoperative pain scores between the two approaches. Two patients in the retroperitoneal group had transient pain radiating to the lateral thigh up to 3 months postoperatively, which was not observed in patients in the transperitoneal group. The pain is often considered to be of neuropathic origin. Neuropathic pain originates from the genitofemoral nerve. A previous case report described that the genitofemoral nerve might have been injured during a living-donor nephrectomy.[26] In addition, the flank incision for a single-port or trocar in the full flank position might have damaged the genitofemoral nerve, especially considering that the patient had an anatomical variation.[27] Genitofemoral nerve entrapment due to tissue inflammation or retroperitoneal hematoma might have also occurred in our patients; however, the symptoms improved over time. Although neuropathic pain is a rare complication, it should be considered when performing retroperitoneal LESS-DN.

Previous studies have discussed the impact of obesity on the outcome of laparoscopic nephrectomy.[28],[29] In Taiwan, the Health Promotion Administration defined the normal range of BMI as 18.5–24 kg/m2. In our study, we stratified the patients into two groups, BMI <24 kg/m2 (nonobese) and BMI ≥24 kg/m2 (obese), and compared the perioperative outcomes regardless of the approach method. No significant differences were observed between the BMI <24 and BMI ≥24 kg/m2 groups. Despite the lack of significant difference between the two BMI groups, the operation time was shorter in the nonobese group than in the obese group, and all patients in the nonobese group underwent retroperitoneal LESS-DN. We believe that LESS-DN can be safely performed in patients with a high BMI, with similar outcomes to those in patients with a normal BMI.

The recipient outcomes in our study are presented in [Supplementary Table 2]. No recipients had delayed graft function following surgery. Two cases of primary graft nonfunction in the recipients were recorded. One patient had morbid obesity and poorly controlled diabetes. During the postoperative care, severe wound infection occurred, and the graft kidney was removed on day 30 to control infection. The other patient was a woman with severe scoliosis. Doppler sonography revealed poor perfusion in the transplanted kidney. The subsequent exploratory laparotomy revealed graft venous congestion due to the extremely small external iliac vessel of the recipient, and the graft kidney was removed due to poor graft function. We considered that these complications were related to the recipient and not to the donor or the safety of LESS-DN.



The present evidence demonstrates that retroperitoneal LESS-DN may be a faster surgery without compromising safety under the expertise of an experienced surgeon. Our experience suggests that the transperitoneal approach is suitable for patients who are concerned about the postoperative wound size. However, this study had some limitations. First, the number of included patients was small. Further studies that include more patients are warranted to obtain more robust evidence. Second, all patients underwent surgeries performed by the same team. Therefore, this study may have a nonnegligible bias in terms of the surgeon's learning curve. Third, because none of the patients with obesity underwent LESS-DN with the retroperitoneal approach, the impact of obesity on retroperitoneal LESS-DN may have been underestimated in our study. Nevertheless, we believe that the results of this study demonstrate the safety and efficacy of LESS-DN and reveal the similarities and differences between the two approaches.


  Conclusions Top


In our study, retroperitoneal and transperitoneal LESS-DN resulted in similar perioperative outcomes, and both methods did not compromise donor safety. However, the retroperitoneal approach resulted in a faster operation time, shorter hospital LOS, and a trend toward a shorter WIT. However, further studies are needed to strengthen this conclusion.

Acknowledgments

The authors thank the help from the Division of Medical Statistics and Bioinformatics, Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University.

Financial support and sponsorship

Nil.

Conflicts of interest

Prof. Wen-Jeng Wu, an editorial board member at Urological Science, had no role in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.



 
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