Laparoendoscopic Single-Site Nephrectomy in Obese Living Renal Donors

Abstract

Background and Purpose:

Laparoendoscopic single-site (LESS) surgery has been shown to be feasible in living donor nephrectomies (DNs). Obesity is an established risk factor for perioperative morbidity. We sought to determine whether LESS-DN is safe and effective in the obese (body mass index [BMI] ≥30 kg/m²) population.

Patients and Methods:

Between August 2009 and September 2010, 125 consecutive LESS-DN were performed; 32 patients were obese. This group was matched to 32 nonobese LESS-DN (BMI <30 kg/m²) patients, 32 obese conventional laparoscopic DN (obese LAP-DN) patients, and 32 nonobese LAP-DN patients. Comparison parameters included organ recovery time, operative time, estimated blood loss (EBL), warm ischemia time (WIT), incision length, complications, and recipient allograft function.

Results:

Demographic data were similar between the groups, except BMI (P>0.0001). Organ recovery time, EBL, WIT, complications, and recipient allograft function were similar between the obese LESS-DN group and the other three groups (P>0.05). Total operative time was longer in the obese LESS-DN compared with the nonobese LAP-DN (P<0.0001); however, incision length was shorter in the obese LESS-DN group compared with either LAP group (P<0.0001). Complete LESS-DN was successful in 62 (97%) cases (two obese donor cases were converted to hand-assisted laparoscopy).

Conclusions:

Our results indicate that LESS-DN can be performed safely in obese donors without increased donor morbidity and similar recipient allograft outcomes compared with ideal-sized donors as well as with conventional LAP-DN patients.

Introduction

A s our population ages, there is an increasing need for living donors to help alleviate the shortage of organs needed for transplantation. Superior outcomes for recipients of living donor allografts combined with increased deceased donor waiting times and a rise in the prevalence of obesity¹ have forced reexamination of donor selection criteria to consider obese persons (body mass index [BMI] ≥30 kg/m²) who are in otherwise good health. The advantages of laparoscopic (LAP) surgery are well documented, including decreased morbidity, decreased pain, improved cosmesis, and shorter recovery times.² LAP live donor nephrectomy (DN), traditionally performed through 3 to 5 small incisions, has become the standard of care at most major academic centers. Previous studies have confirmed that LAP-DNs within the obese population have equivalent complication rates and graft outcomes compared with allografts harvested from ideal sized donors.^2

–5 Some centers have reported longer operative times and higher conversion rates for obese donors, although overall complications are minor.⁴

Laparoendoscopic single-site (LESS) surgery has been reported for several urologic indications, including DN, pyeloplasty, radical and partial nephrectomy.^6

–12 For the most part, these have been performed using dedicated multichannel port devices with fixed operative channels.^6

–12 By using a single small incision partially concealed in the navel, our donors may recover faster and possibly have an improved cosmetic result. Nevertheless, there fails to be any consensus about any potential improvement in cosmesis or shorter hospitalizations using the LESS approach compared with other minimally invasive techniques.

We recently reported our initial data of LESS-DN.¹³ LESS-DN is a technically challenging procedure because of the limitations in providing the surgeon with an ergonomic platform for dissection and suturing. Theoretically, the reduced working space and lack of instrument triangulation afforded by LESS may be more exaggerated in the obese patient, where mobilization of adjacent structures, retraction of surrounding tissues, maintaining intraoperative visualization, and reaching the upper limits of dissection are often more difficult than in nonobese patients.

In this report, we compare our outcomes of LESS-DN in the obese population vs ideal-sized living renal donors at a high-volume kidney transplant center. In addition, we compared these outcomes with obese and nonobese donors undergoing conventional LAP-DN.

Patients and Methods

Between August 2009 and September 2010, 125 consecutive LESS-DNs were performed. At our institution, we have no minimum BMI cutoff for living donors, but our maximum BMI cutoff is greater than 40 kg/m². Of these 125 patients, 32 (26%) had a BMI ≥30 kg/m² and were classified as obese (obese LESS-DN group) as defined by the World Health Organization. Thirty-two controls with a BMI <30 kg/m² (nonobese LESS-DN group) were matched to the obese donors by sex, age, preoperative creatinine clearance, and laterality of kidney procured. The obese LESS-DN was also matched, in a similar fashion, to 32 obese (BMI ≥30 kg/m²) and 32 nonobese (BMI <30 kg/m²) patients undergoing conventional LAP-DN. The obese LESS-DN cohort was compared with the nonobese LESS-DN cohort as well as the obese and nonobese LAP-DN cohorts. Since we began performing LESS-DN in August 2009, all donors underwent this procedure, until we commenced our randomized controlled trial in January 2011.

A retrospective review was performed using our prospectively managed, Institutional Review Board-approved database. Perioperative parameters were defined as follows: (1) operative time to organ recovery—time from skin incision to allograft extraction; (2) total operative time—time from operative field skin preparation to skin closure; (3) estimated blood loss (EBL)—as recorded in the operative records; (4) warm ischemia time (WIT)—time from renal artery occlusion to back-table perfusion with ice-cold Custodiol^® histidine-tryptophan-ketoglutarate solution; (5) incision length—measured at the end of the procedure; (6) length of stay—from admission to the hospital the day of donation until discharge, including the operative day; (7) operative complications—an unexpected event leading to injury to the donor or donor kidney at the time of surgery; (8) postoperative complications—an unexpected event in the donor within the first 30 days after the procedure.

Postoperative complications were classified using the Clavien-Dindo system.¹⁴ Grades I and II complications were regarded as minor complications necessitating noninvasive interventions, while grades III to V complications were considered major complications necessitating invasive interventions. Pain scores were measured using a visual analog pain score (VAPS) system. A questionnaire was administered by the surgeon at 4 weeks postoperatively to assess the surgical scar satisfaction score (1–10). Allograft outcomes, including the incidence of delayed graft function, recipient creatinine at 1 week, 1, 3, and 6 months, were also analyzed. Delayed graft function was defined as the need for hemodialysis in the first week post-transplant.

The operative technique used at our center for LESS-DN was previously described by Gimenez and associates.¹³ A single access GelPort device (Applied Medical, Rancho Santa Margarita, CA) was inserted into the abdomen through a 4 to 5 cm periumbilical incision. A bariatric camera with a right angle attachment for the light cord was used to maximize triangulation. No extraumbilical ports were used, unless a case was converted to hand-assisted laparoscopy. Our LAP-DN operative technique has been previously described by Cheng and colleagues.¹⁴ In this study, we performed 60 left-sided LESS-DN and 4 right-sided LESS-DN. Left-sided LESS-DN was performed with three trocars through the device. In the right-sided LESS-DN, a fourth port was placed through the device for liver retraction. WIT is minimized by preentraping the specimen in the Endo Catch™ bag (Covidien Surgical, Mansfield, MA) before stapling the vasculature. In this study, we did not go into long-term outcomes and possible complications of living with a solitary kidney, specifically for the obese donors, as long-term follow-up of donors has been poor, and for the majority of patients unavailable at the time of preparation of this article.

Statistical analyses were performed using GraphPad Prism version 5.03 (La Jolla, CA). Data are reported as mean plus or minus standard deviation (SD) unless otherwise specified, and the means were compared using a Kruskal-Wallis test for group comparisons and Mann-Whitney U test (two-tailed) for two sample comparisons. Categorical variables were compared using chi-square or Fisher exact test. Two-tailed P values<0.05 were considered significant.

Results

Table 1 summarizes preoperative demographic, laboratory, and vascular anatomic information. The ratio of male to female patients, left to right kidneys, and male to female right kidneys in each group was equal. The mean (±SD) BMI in the obese LESS-DN group was 33.4±2.2 kg/m², and 25.4±2.2 kg/m² in the nonobese LESS-DN group. In the conventional LAP-DN groups, the mean BMI in the obese group was 32.3±1.9 kg/m² and 26.0±2.9 kg/m² in the nonobese group. There were 5 (16%) cases involving an accessory renal artery in the obese LESS-DN group, 4 (13%) cases in the non-obese LESS-DN group, 10 (31%) cases in the obese LAP-DN group, and 7 (22%) cases in the nonobese LAP-DN group. For demographic data, only BMI was significantly different between the four groups (P<0.0001).

Table 1.

Patient Demographics ^*

	LESS		LAP
	Obese (n=32)	Nonobese (n=32)	Obese (n=32)	Nonobese (n=32)	P
Male: Female	14:18	14:18	14:18	14:18	1.0
Age (years)	48±11.7	47±12.1	46±11.8	47±10.7	0.95
Left kidneys	30	30	30	30	1.0
Male:female	13:17	13:17	13:17	13:17
Right kidneys	2	2	2	2	1.0
Male:female	1:1	1:1	1:1	1:1
BMI (kg/m²)	33.4±2.2	25.4±2.2	32.3±1.9	26.0±2.9	<0.0001
Preoperative CrCl^a (mL/min)	147.3±25.5	132.6±32.0	143.6±37.1	133.6±24.1	0.07
Renal artery single: double	27:5	28:4	22:10	25:7	0.26

Kruskal-Wallis test

Creatinine clearance calculated by the Cockcroft-Gault method.

LESS=laparoendoscopic single site; LAP=laparoscopic; BMI=body mass index; CrCl=creatinine clearance.

Table 2 outlines donor operative and perioperative variables. When comparing the obese LESS-DN group with the nonobese LESS-DN group, there were no significant differences in the organ recovery time (P=0.23), operative time (P=0.91), EBL (P=0.07), WIT (P=0.67), incision length (P=0.08), length of stay (P=0.25), VAPS at discharge (P=0.39) and 2 weeks postoperatively (P=1.0), as well as surgical scar satisfaction scores at 4 weeks postoperatively (P=0.99) (Fig. 1). There was a trend toward more blood loss and longer incisions in the obese group, but it did not reach statistical significance (P=0.07 and P=0.08, respectively). Complete LESS-DN was successfully completed in 62 of 64 (97%) cases included in this cohort as well as 121 of 125 (97%) cases in our entire LESS series to date. One left-sided case in the obese LESS-DN group was converted to hand-assisted laparoscopy for failure to maintain pneumoperitoneum because of a device leak, which prevented completion of the upper pole dissection. One right-sided LESS-DN in the obese group was converted to hand-assisted laparoscopy because of failure to progress.

FIG. 1.

The images depict donors approximately 2 weeks after laparoendoscopic single-site donor nephrectomy. (A), a nonobese donor; (B), an obese donor.

Table 2.

Donor Operative And Perioperative Variables: A Comparison of Body Mass Index and Procedure to Obese Patients Undergoing Laparoendoscopic Single-Site Donor Nephrectomies ^*

	Obese LESS (n=32)	Nonobese LESS (n=32)	P	Obese LAP (n=32)	P	Nonobese LAP (n=32)	P
Operative time to organ recovery (min)^a	93±19.7	86±14.3	0.23	96±24.6	0.63	86±18.3	0.27
Total operative time (min)^a	160±29.9	156±29.3	0.91	149±37.9	0.10	129±36.9	<0.0001
Estimated blood loss (mL)	106±90.5	73±46.2	0.07	100±99.8	0.91	104±104.0	0.91
Warm ischemia time (min)	3.81±0.63	3.85±0.52	0.67	4.01±0.55	0.08	4.00±0.82	0.50
Incision length (cm)	5.04±0.15	4.98±0.12	0.08	6.13±0.41	<0.0001	6.08±0.41	<0.0001
Hospital LOS (d)	2.06±0.49	1.92±0.44	0.25	2.11±0.49	0.69	2.11±0.51	0.60
VAPS at discharge	1.4±1.2	1.7±1.1	0.39	1.7±1.4	0.54	1.5±1.3	0.95
VAPS at 2 weeks (mean)	0	0	1.0	0	1.0	0	1.0
Scar satisfaction score (1–10)^b	9.5±0.7	9.5±0.6	0.99	7.3±1.3	<0.0001	7.3±1.4	<0.0001

The nonobese LESS, obese LAP, and nonobese LAP groups are compared individually with the obese LESS group for each listed category (Mann-Whitney U test). The P values listed correspond to the comparison of the adjacent group with the obese LESS group.

All cases were included in these calculations including those converted to hand-assist.

Administered by the surgeon at 4 weeks postoperatively in a questionnaire.

LESS=laparoendoscopic single-site; LAP=laparoscopic; LOS=length of stay; VAPS=visual analog pain score.

When comparing the obese LESS-DN group with the obese LAP-DN, there were no significant differences in organ recovery time (P=0.63), operative time (P=0.10), estimated blood loss (P=0.91), length of stay (P=0.69), and VAPS at discharge (P=0.54) and 2 weeks postoperatively (P=1.0) (Table 2). The mean incision length was significantly longer in the obese LAP-DN group compared with the obese LESS-DN (6.13±0.41 cm vs 5.04±0.15 cm, respectively; P<0.0001). There was a trend toward longer WITs in the obese LAP-DN group (4.01±0.55 min vs 3.81±0.63 min, respectively; P=0.08); however, this did not reach statistical significance.

Additional analyses that compared the obese LESS-DN group with the nonobese LAP-DN group demonstrated similar results when compared with the obese LAP-DN group, including a longer mean incision length (6.08±0.41 cm; P<0.0001); however, the total operative time was significantly shorter in the nonobese LAP-DN group compared with the obese LESS-DN (129±36.9 min vs 160±29.9 min, respectively; P<0.0001). The surgical scar satisfaction score was significantly higher in the obese LESS-DN group compared with the obese LAP-DN (P>0.0001) or the nonobese LAP-DN group (P>0.0001).

The recipient allograft function in the obese LESS-DN group was equivalent in comparison with the other groups at all recorded time points (Table 3). Mean recipient serum creatinine in the obese LESS-DN group at 1 week, 1, 3, and 6 months was 1.46 mg/dL, 1.40 mg/dL, 1.31 mg/dL and 1.29 mg/dL, respectively. Mean recipient serum creatinine in the nonobese LESS-DN group at 1 week, 1, 3, and 6 months was 1.36 mg/dL, 1.37 mg/dL, 1.32 mg/dL and 1.32 mg/dL, respectively. The obese LAP-DN group had mean recipient serum creatinine values of 1.52 mg/dL, 1.31 mg/dL, 1.26 mg/dL, and 1.25 mg/dL, respectively, while the nonobese LAP-DN group had mean recipient serum creatinine values of 1.50 mg/dL, 1.30 mg/dL, 1.35 mg/dL, and 1.34 mg/dL, respectively. No differences were statistically significant when compared with the obese LESS-DN group (P>0.05).

Table 3.

Allograft Outcomes: A Comparison of Body Mass Index And Procedure To Obese Patients Undergoing Laparoendoscopic Single-Site Donor Nephrectomies ^*

	Obese LESS (n=32)	Nonobese LESS (n=32)	P	Obese LAP (n=32)	P	Nonobese LAP (n=32)	P
No. of patients with DGF	1	0	0.48	0	0.48	1	1.0
Recipient serum Cr at 1 week (mg/dL)	1.46±0.94	1.36±0.55	0.87	1.52±0.68	0.29	1.50±0.73	0.54
Recipient serum Cr at 1 month (mg/dL)	1.40±0.46	1.37±0.46	0.87	1.31±0.48	0.53	1.30±0.36	0.45
Recipient serum Cr at 3 months (mg/dL)	1.31±0.38	1.32±0.33	0.85	1.26±0.40	0.69	1.35±0.43	0.57
Recipient serum Cr at 6 months (mg/dL)	1.29±0.40	1.32±0.33	0.67	1.25±0.40	0.98	1.34±0.35	0.49

The nonobese LESS, obese LAP, and nonobese LAP groups are compared individually to the obese LESS group for each listed category (Mann-Whitney U test). The P values listed correspond to the comparison of the adjacent group to the obese LESS group.

LESS=laparoendoscopic single-site; LAP=laparoscopic; DGF=delayed graft function; Cr=creatinine.

All but one allograft in the obese LESS-DN group functioned immediately at transplantation. One kidney harvested from a patient with a BMI of 31.1 kg/m² had delayed graft function. This is the aforementioned case that necessitated a conversion to hand-assisted laparoscopy because of failure to maintain pneumoperitoneum. Postoperative Doppler ultrasonography revealed good flow to the majority of the transplant kidney; however, renography demonstrated prompt cortical uptake with minimal transition and excretion, consistent with acute tubular necrosis. The kidney function ultimately improved, and the patient's serum creatinine level reached its nadir at 1.1 mg/dL after 12 days. One allograft in the nonobese LAP-DN group also had delayed graft function as a result of a urinoma compressing the ureter, which was drained percutaneously. After successful drainage of the urinoma, the creatinine level declined successfully, and at 1 month follow-up, the serum creatinine level had reached 0.72 mg/dL.

Table 4 summarizes all donor surgical morbidity, including postoperative complications graded by the Clavien-Dindo classification system.¹⁵ When all procedure-related complications were compared, the LESS donors with a BMI ≥30 kg/m² had a similar overall complication rate compared with LESS donors with a BMI <30 kg/m² (9% vs 9%, respectively; P=1.0). Moreover, the obese LESS-DN overall complication rate was not significantly different from the obese LAP-DN group (13%; P=1.0) nor the nonobese LAP-DN group (16%; P=0.71). Although the only two conversions occurred in the obese LESS-DN group, this was not significantly different from the nonobese LESS-DN group (P=0.49), obese LAP-DN group (P=0.49), or the nonobese LAP-DN group (P=0.49).

Table 4.

Complications For All Cohorts Using The Clavien-Dindo System ¹⁵

	LESS		LAP
	Obese (n=32)	Nonobese (n=32)	Obese (n=32)	Nonobese (n=32)
Conversion to open/hand assisted laparoscopy	2	0	0	0
No. of operative complications, (%)	1 (3%)	0 (0%)	1 (3%)	1 (3%)
Adrenal vein injury, n=1				x
Splenic laceration, n=1			x
Renal laceration on extraction, n=1	x
No. of postoperative complications, (%)	2 (6%)	3 (9%)	3 (9%)	4 (13%)
Blood transfusion, n=1				Grade I
Hyponatremia, n=1	Grade I
Hydrocele, n=1				Grade II
Epididymitis, n=1				Grade II
Urinary tract infection, n=1		Grade II
Wound infection (no antibiotics), n=3		Grade I	Grade I	Grade I
Wound infection (antibiotics), n=2		Grade II	Grade II
Arrythymia, n=1	Grade II
Reexploration for bleeding, n=1			Grade IV
Total no. of complications, (%)	3 (9%)	3 (9%)	4 (13%)	5 (16%)

LESS=laparoendoscopic single-site; LAP=laparoscopic.

The operative complication rate of the obese LESS donors was not significantly different from the nonobese LESS donors (3% vs 0%, respectively; P=1.0), the obese LAP donors (3%; P=1.0), or the nonobese LAP donors (3%; P=1.0). Three operative complications occurred across the various cohorts. One allograft harvested from an obese LESS donor sustained a grade III laceration during extraction, likely because of extraction of the kidney from an incision that was not large enough to accommodate the size of the kidney plus the extensive amount of perirenal fat. The laceration was identified and repaired during back table preparation of the allograft. Retrograde instillation of methylene blue through a ureteral catheter confirmed no postrepair extravasation. The repair was managed with an indwelling ureteral stent for 4 weeks.

The second complication took place in the obese LAP-DN group; a splenic laceration occurred during exposure of the left kidney. Hemostasis was achieved by applying absorbable hemostatic agents to the tear. Lastly, in the nonobese LAP-DN group, one patient experienced an adrenal vein injury necessitating primary repair for hemostasis and a 1-unit blood transfusion.

Postoperative complications occurring within the first 30 days postdonation are listed in Table 4. The postoperative complication rate in the obese LESS-DN group was not significantly different from the nonobese LESS-DN group (6% vs 9%, respectively; P=1.0), the obese LAP-DN group (9%; P=1.0), or the nonobese LAP-DN group (13%; P=0.67). The obese LESS donor postoperative complications included one case of hyponatremia that was treated conservatively and one case of tachyarrhythmia that responded to pharmacologic intervention. The nonobese LESS donor postoperative complications included one wound infection treated with oral antibiotics, one wound infection treated with local wound care, and one urinary tract infection treated with oral antibiotics. In the obese LAP donor cohort, one patient was taken back to the operating room for a bleed from the staple line of the renal artery. The remainder of the patient's hospitalization was uncomplicated, and the patient was discharged on postoperative day 5. This was the only major complication in all groups combined.

The other complications in the obese LAP group included one wound infection that was treated with local wound care, and one wound infection that was treated with oral antibiotics. In the nonobese LAP group the postoperative complications included a 1-unit blood transfusion for postoperative anemia; one wound infection that was treated with local wound care; one case of epididymitis that was treated with oral antibiotics; and one case of hydrocele that was treated conservatively. There were no mortalities in any of the groups.

Discussion

The obese renal donor has now become a fixture in living kidney donation. The obese patient, however, presents the surgeon with several unique challenges, mostly centered on difficulties of adjacent organ mobilization, exposure of key landmarks, and diminished visualization from increased intra-abdominal fat. This study demonstrated the feasibility of procuring kidneys from obese donors using the LESS surgery technique. Although obese donors who are undergoing LESS-DN had longer operative times than nonobese LAP-DN patients, this did not increase surgical morbidity or affect recipient allograft function. These findings suggest that obesity should not preclude kidney donation via the novel LESS approach.

Obesity has been associated with increased surgical morbidity. Jacobs and associates⁴ analyzed the outcomes of markedly obese living renal donors who were undergoing undergoing LAP-DN. Their results demonstrated the feasibility of performing this procedure safely in obese individuals. In addition, they reported a longer operative time, an increased port site requirement, a higher conversion rate, and increased blood loss in this patient population. The overall complication rate and allograft function, however, were similar to that of their nonobese controls.

We found that obese donors undergoing LESS-DN have longer operative times as well and trended toward more intraoperative blood loss. Although the obese LESS-DN conversion rates were not significantly different from the other groups, the only two conversions occurred in obese donors. In a study by Heimbach and colleagues,¹⁶ obese donors had slightly longer operative times and an increased rate of postoperative complications, predominantly wound infections, but similar major complication rates and length of hospitalizations to nonobese donors. Although we demonstrated similar results regarding increased operative times and equivalent length of hospitalizations, we did not find obesity to be a risk factor for perioperative complications in LESS-DN.

The use of LESS in living donor kidney harvesting offers a new set of challenges to the LAP surgeon. Technical limitations, including a reduced working space and lack of instrument triangulation, make it a technically challenging procedure. These limitations are more pronounced in the obese patient, where difficulties in exposure and visualization already exist, including additional visceral adipose tissue that is more difficult to retract. Kok and coworkers¹⁷ compared overweight conventional LAP donors (BMI >27 kg/m²) by sex and found that male overweight donors had a higher conversion rate (10%) than overweight female donors (0%), possibly related to the increased presence of visceral adipose tissue, in addition to its area of distribution. In our study, one conversion occurred in a male obese donor and the other occurred in a female obese donor.

Although results are similar, it is clear that dissection, retraction, and intraoperative exposure are even more challenging in the obese patient who is undergoing LESS-DN compared with the standard or hand-assisted LAP procedure. Retraction by the instrument in the surgeon's nondominant hand, so vital in exposure, is far more limited in the LESS procedure, and even more so in the obese patient.

The incision lengths are significantly shorter in the LESS technique compared with the LAP technique. With this comes concern of trauma to the kidney during the delicate dissection and handling of the allograft. Jacobs and associates¹⁸ described the minimum incision length to ensure a nontraumatic extraction of the allograft to be 7 cm. One allograft harvested from an obese donor sustained a grade III laceration during extraction, likely because of extraction of a kidney from an incision that was not large enough to accommodate the size of the kidney. It is clear that the amount of perirenal fat must be taken in to consideration when planning safe extraction of the allograft from an obese patient. In our experience, however, we have not frequently encountered this type of complication despite our relatively small incisions. The current study shows similar short-term allograft functional results in kidneys harvested from obese donors through the single-port technique compared with the ideal patient group, irrespective of procurement technique.

In the present series, the surgical morbidity and allograft outcomes in our obese LESS donor population are similar to that of our matched nonobese LESS donor group, obese LAP donor group, and nonobese LAP donor group, with the added cosmetic benefit of smaller incisions compared with LAP donors. The operative times in the conventional LAP procedures were shorter. In August 2009, we transitioned to performing all donor operations using the LESS technique. Before this period, all donor operations were performed using the conventional LAP technique. Thus, the discrepancy in operative times may simply represent a temporal bias in operative skill because the LESS groups represent the beginning of our surgical experience with this technique. On the other hand, the majority of the LAP donor operations were performed at the plateau (2007–2009) of our learning curve with this technique. Perhaps with time, the LESS procedure operative times will approach that of the conventional LAP-DN.

Several articles have been published on the use of single-site surgery in the obese population.^19
–21 Most of these reports are within the scope of bariatric procedures. The equivalency of LESS to standard LAP procedures in this population has not been firmly established to date. To our knowledge, there have not been any articles published with direct comparisons of single-site surgical outcomes in the nonobese vs obese donor populations in addition to a comparison with obese and nonobese patients undergoing conventional laparoscopy. Our results indicate that not only is LESS live DN safe and reproducible in obese patients, but also short-term allograft function is similar to the well-established and accepted technique of conventional LAP live DN.

While the results are encouraging, we do recognize the limitations of our study. This is a single center, retrospective review, with a moderate sample size. Perioperative variables may still reflect the learning curve of the LESS procedure. The long-term outcomes of obese persons living with a solitary kidney are not available. In addition, the shorter incision lengths in the LESS groups may be the result of attempts to improve cosmesis in conjunction with innovation in surgical technology. Nevertheless, this is the first reported series in the literature of obese donors undergoing LESS-DN. Moreover, similar outcomes to donors undergoing a technically less challenging procedure further validate our results.

In the hands of an experienced LAP surgeon, LESS-DN is feasible in the obese population. Feasibility, however, should not obviate the need for careful donor selection. The current study does not demonstrate any substantial benefits of the LESS approach over the LAP approach, yet this may still represent the learning curve in this patient population. Randomized trials are needed to determine the efficacy of LESS-DN compared with conventional LAP-DN; however, it is important that this technique can be used in this subset of patients who represent a significant portion of our living renal donor pool.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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