Safety and Efficacy of Retroperitoneoscopic Living Donor Nephrectomy: Comparison of Early Complication,Donor and Recipient Outcome with Hand-Assisted Laparoscopic Living Donor Nephrectomy

Abstract

Introduction:

Laparoscopic surgery has been a standard procedure of living donor nephrectomy (LDN). Transperitoneal hand-assisted laparoscopic LDN (HALDN) has been commonly reported by many centers with excellent outcome. However, there are few studies reporting retroperitoneoscopic LDN (RPLDN).

Materials and Methods:

Four hundred four consecutive kidney donors (124 men, 280 women) were enrolled in this study. Age of the donors was 55.0 ± 10.7 years. RPLDN was performed for 294 donors, and HALDN for 110 donors. We compared perioperative donor outcome and early complication rates between RPLDN and HALDN to evaluate the safety and efficacy of RPLDN.

Results:

Intraoperative blood loss was significantly less in RPLDN than in HALDN (p < 0.05). The conversion rate to open surgery was similar between the two groups. The intraoperative complication rate was 1.0% (two vascular injuries and one bowel injury) in RPLDN and 0.9% (one vascular injury) in HALDN. The postoperative complication rate was 3.4% (six surgical site infections, two postoperative bleeding, one colon perforation, one ileus, one rhabdomyolysis) in RPLDN and 1.8% (two surgical site infections) in HALDN. Although warm ischemic time was significantly longer in RPLDN than in HALDN (p < 0.01), the incidence of delayed graft function was similar between the two groups. Furthermore, there was no difference in 1-year graft survival between the two groups.

Conclusions:

Both RPLDN and HALDN procedures were well tolerated with minimal complication rates, and both procedures showed similar impact on recipient graft function. These results suggest that RPLDN could be a feasible option for LDN as well as HALDN.

Introduction

Reducing the risk of complications and morbidity is particularly important in living donor nephrectomies, because they are performed on healthy voluntary donors for the benefit of another person. For the same reason, it is also important to allow donors to return to normal activities as soon as possible. The first laparoscopic living donor nephrectomy (LDN) was reported in 1995; this technique has since become a widely accepted procedure.¹ Many studies have reported the benefits of laparoscopic LDN, including lower rates of complications, faster return to normal activities, better cosmetic outcome, and similar graft function in comparison with conventional open living donor nephrectomies.^2,3 Although there are various reports on laparoscopic LDN, more than 90% of laparoscopic LDNs are performed via the transperitoneal approach and only a few centers have reported retroperitoneoscopic LDN (RPLDN).^3
–5

Hand-assisted laparoscopic LDN (HALDN) has been commonly studied by many centers with excellent outcomes. The advantages of HALDN have been proven to be safety, easy manipulation of tissue to retract and compress during bleeding, and short learning curve.^6

–9

Retroperitoneal access enables an approach to the renal hilum with better access to the renal vessels without interfering with any abdominal organs. Some reports suggest it resulted in less postoperative pain and lower complication rates compared with other laparoscopic techniques. For renal-cell carcinoma, retroperitoneoscopic radical nephrectomies yield excellent surgical outcomes, which are comparable with transperitoneal laparoscopic nephrectomies.^10
–12 Although this procedure is the most logic approach to the retroperitoneal organs, the practicality of RPLDN is controversial because it is more difficult to find proper orientation, there is less working space, and surgeons have a steeper learning curve compared with the transperitoneal approach.

The aim of this study was to evaluate the safety and efficacy of RPLDN. To this end, we analyzed perioperative donor outcomes and early complication rates with RPLDN and compared them with HALDN, which has been commonly studied by many centers with excellent outcomes.

Materials and Methods

Donors

From 2001 to 2012, 404 consecutive kidney donors who were operated on in two Japanese hospitals were enrolled in the study. Two hundred ninety-four of these underwent RPLDN and 110 underwent HALDN by eight surgeons during an 11-year period. This study was approved by the Ethics Review Committee of Hokkaido University Hospital and Sapporo City General Hospital.

Surgical techniques

RPLDN technique

With the donor placed in a lateral (right or left) decubitus position under general anesthesia, the operative bed is flexed just above the level of the iliac crest and the lumbar bridge is elevated to expand the space between iliac crest and costal margin. A retroperitoneal working space was developed with a balloon dilator. Three 12-mm ports or two 12- and 5-mm ports were inserted. In some cases, one 5-mm port was added. In most cases, a 6-cm Pfannenstiel incision was made, just before transection of the renal artery and vein. In some cases, a 6-cm pararectal incision was made. The renal artery was secured with a triple proximal staple by Endo TA (Medtronic, Dublin, Ireland), and divided. The renal vein was divided following double proximal clips (Hem-o-lok; Teleflex, Wayne, PA). The renal graft was extirpated out of the incision by purse (End Catch II; Medtronic).

HALDN technique

A 7-cm midline skin incision for the operator's left-hand insertion was placed 2 cm above the umbilicus with the same decubitus position as the above-described technique. Two 12-mm transperitoneal ports were inserted. In some cases, one 5-mm port was added. The renal artery and vein were secured and divided in the same procedure as the RPLDN technique. The graft was taken from the midline incision by hand.

Data analysis

The surgical outcomes achieved using the two approaches were retrospectively analyzed and compared with respect to operative time, blood loss, warm ischemic time (WIT), graft function, intraoperative adverse events, and postoperative complications. Data are presented as mean value ± standard deviation, and the analysis was performed using the chi-square test or Mann–Whitney U test, as appropriate. Survival rates were estimated using the Kaplan–Meier method, and the significance of differences between survival curves was determined using the log-rank test. The statistical analysis was performed using GraphPad Prism software (San Diego, CA), and p values <0.05 were considered statistically significant.

Results

Demographics

Table 1 reports donor characteristics. There was no statistically significant difference in terms of donor age or gender between the two groups. Body mass index (BMI) in RPLDN was significantly lower than in HALDN (22.1 ± 2.7 kg/m² vs 23.4 ± 3.2 kg/m², p < 0.01). Right nephrectomy was performed more in RPLDN than in HALDN (27 cases [9.18%] vs 2 cases [1.85%], p < 0.05). In RPLDN, the reasons for right procurement were as follows: nine donors had left multiple renal arteries, eight had right renal stone, five had inferior right renal function, one had right renal artery stenosis, two had right fibromuscular dysplasia, one had right huge renal cyst, and one had left renal artery early bifurcation. In HALDN, one had inferior right renal function and one had right renal artery stenosis.

Table 1.

Donor Characteristics

	RPLDN (n = 294)	HALDN (n = 110)	p
Age (year)	53.9 ± 10.5	52.2 ± 11.0	NS
Sex
Female	210	70
Male	84	40	NS
BMI (kg/m²)	22.1 ± 2.7	23.4 ± 3.2	<0.01^a
Site of nephrectomy
Left	269	108
Right	27	2	<0.05^b
Reason for right procurement
Left multiple renal arteries	9
Right renal stone	8
Inferior right renal function	5	1
Right renal artery stenosis	1	1
Fibromuscular dysplasia	2
Right huge renal cyst	1
Left renal artery early bifurcation	1
The number of renal arteries			NS
1	235	90
2	53	19
3	5	1
4	1	0

Mann–Whitney U test.

Chi-square test.

BMI = body mass index; HALDN = hand-assisted laparoscopic living donor nephrectomy; NS = not significant; RPLDN = retroperitoneoscopic living donor nephrectomy.

Intraoperative outcome

Table 2 reports intraoperative outcomes. There was no difference in operating time between the two groups (RPLDN: 249 ± 67 minutes vs HALDN: 249 ± 60 minutes). Intraoperative blood loss was significantly less in RPLDN than in HALDN (136 ± 203 mL vs 189 ± 250 mL; p < 0.05). Two donors had more than 1000 mL blood loss: 2600 mL blood loss due to lumbar vein injury in RPLDN and 2000 mL due to gonadal vein injury in HALDN. One of them required blood transfusion. The rate of conversion to open procedure was similar between the two groups (two cases [0.68%] in RPLDN and one [0.91%] in HALDN). All the reasons of open conversion were vascular injury in each group; one aortic injury and one lumbar vein injury in RPLDN, and one gonadal vein injury in HALDN. The incidence of intraoperative complications was similar between two groups (1.0% in RPLDN and 0.9% in HALDN).

Table 2.

Intraoperative Data

	RPLDN (n = 294)	HALDN (n = 110)	p
Operative time (minutes)	249 ± 67	249 ± 60	NS^a
Blood loss (mL)	136 ± 203	189 ± 250	<0.05^a
Intraoperative transfusion, n (%)	1 (0.4)	0 (0)	NS^b
Conversion to open procedure, n (%)	2 (0.7)	1 (0.9)	NS^b
Intraoperative complication, n (%)	3 (1.0)	1 (0.9)	NS^b
Aortic injury	1	0
Lumbar vein injury	1	0
Gonadal vein injury	0	1
Colon injury	1	0

Mann–Whitney U test.

Chi-square test.

Postoperative complication

Table 3 lists postoperative complications. The postoperative complication rate was 3.4% (six surgical site infections, two postoperative bleeding, one colon perforation, one ileus, one rhabdomyolysis) in RPLDN and 1.8% (two surgical site infections) in HALDN. The incidence of postoperative complication was statistically similar between the two groups. Furthermore, we evaluated postoperative complications according to the Clavien–Dindo classification. The severity of postoperative complications was similar between the two groups (RPLDN: grade 1 in seven donors, grade 2 in two donors, grade 3 in two donors vs HALDN grade 1 in two donors). In both groups, all 13 cases with complications recovered without permanent damage after treatment.

Table 3.

Postoperative Complication

	RPLDN (n = 294)	HALDN (n = 110)	p
Grade 0	283	108	NS^*
Grade 1	7	2
Grade 2	2	0
Grade 3	2	0
Grade 4	0	0
Grade 5	0	0

Chi-square test.

Transplanted graft function

Table 4 reports the parameters of graft function. Although WIT was significantly longer with RPLDN than HALDN (295 ± 107 seconds vs 208 ± 100 seconds; p < 0.01), the incidence of delayed graft function (DGF) was similar between the two groups (2.0% in RPLDN vs 3.6% in HALDN, respectively). Furthermore, there was no difference in 1-year graft survival between the two groups (98.0% in RPLDN and 99.1% in HALDN). In RPLDN, the causes of graft loss within 1 year were as follows: one acute antibody-mediated rejection (AAMR), one focal segmental glomerulosclerosis, one renal vein thrombus, and three deaths with functioning graft. In HALDN, one graft was lost due to AAMR. Primary nonfunction occurred in only one case in RPLDN, who developed renal vein thrombosis. The cause of end-stage kidney disease was congenital nephrotic syndrome (CNS). A hypercoagulable state due to CNS might lead to renal vein thrombosis. Therefore, all causes of graft loss are not related to the donor nephrectomy procedure.

Table 4.

Transplanted Graft Function

	RPLDN (n = 294)	HALDN (n = 110)	p
WIT (seconds)	295 ± 107	208 ± 100	<0.01^a
DGF (%)	6 (2.0)	4 (3.6)	NS^b
PNF (%)	1 (0.3)	0 (0)	NS^b
1-Year graft survival (%)	98.0	99.1	NS^c
Cause of graft loss within 1 year
DWFG	3	—
AAMR	1	1
FSGS	1	—
Renal vein thrombus	1	—

Mann–Whitney U test.

Chi-square test.

Kaplan–Meier method and log-rank test.

AAMR = acute antibody-mediated rejection; DGF = delayed graft function; DWFG = death with functioning graft; FSGS = focal segmental glomerulosclerosis; PNF = primary nonfunction.

Discussion

Since the first laparoscopic LDN was reported in 1995,¹ this procedure has been widely performed in many institutions and has achieved excellent outcome, including lower rates of complications and similar graft function in comparison with conventional open LDNs.^2,3 Although there are various reports on laparoscopic LDN, more than 90% of laparoscopic LDNs are performed via the transperitoneal approach, because this approach provides better working space and easier orientation of abdominal anatomy compared with the retroperitoneal approach.^3,5 However, before the laparoscopic era, most LDNs were performed by the open surgical procedure using a flank incision via the retroperitoneal approach, because it enables direct access to the kidney without interfering with the abdominal organs. In addition, there is little need for retraction or mobilization of abdominal organs, which may result in less postoperative abdominal adhesions. Moreover, Pfannenstiel incision, mostly chosen for extraction in RPLDN, has an advantage of postoperative pain control compared with midline incision in HALDN.^13,14 Therefore, we used RPLDN to apply this advantage to laparoscopic LDN. HALDN was reported in 2001 to enhance the safety of the pure laparoscopic procedure⁶ and has been commonly studied by many centers with excellent outcomes.^7
–9 Thus, we compared perioperative donor outcome and early complication rates between RPLDN and HALDN to evaluate the safety and efficacy of RPLDN.

There are some studies to compare the surgical outcome between transperitoneal and retroperitoneal approach in laparoscopic LDN. He and coworkers described that a significantly lower transfusion rate, fewer patients with DGF, less vessel injuries, and less conversion to open surgical approach in RPLDN were found than in transperitoneal LDN.¹⁵ In a meta-analysis, retroperitoneoscopic approach was associated with significantly less complications compared with transperitoneal approach.¹⁶ Another meta-analysis showed there were no differences in perioperative events or complications between retroperitoneal approach and transperitoneal approach.⁵ Although these reports showed the safety and efficacy of retroperitoneoscopic LDN, these were too small to be conclusive. Our study was the largest study to compare the surgical outcome between the two approaches.

In this study, the conversion rate to open surgery, intraoperative complication rate, and postoperative complication rate were similar between the two groups. Severe complication, such as Clavien–Dindo classification grade 3 and open conversion, happened in the early period at our institutes and was supposed to be due to the initial learning curve. The incidence of DGF was comparable between the two groups. There was no difference in 1-year graft survival between the two groups. These data suggested that RPLDN safely provides excellent graft function, similar to HALDN. Furthermore, blood loss was significantly lower in RPLDN than in HALDN. There is no previous report describing significantly reduced blood loss with RPLDN compared with HALDN. In the context of retroperitoneal approach in laparoscopic surgery for renal tumors, rather than donation, Wright and colleagues reported that blood loss in the retroperitoneal approach for laparoscopic partial nephrectomy was less than that in transperitoneal approach.¹⁷ They did not discuss the reason for the difference in the volume of blood loss. However, easier access to vessels could avoid unnecessary vascular injury, such as to the lumbar vein or gonadal vein. In addition, we assume that the HALDN technique might be less likely to keep pneumoperitoneum pressure than RPLDN as pure laparoscopic surgery. Thus, those differences could be explanations for reduced blood loss in RPLDN.

The only inferiority of RPLDN in this study was longer WIT compared with HALDN (mean 4.9 minutes vs 3.5 minutes, p < 0.01). This disparity is supposed to result from the difference in techniques of procuring the kidney. While the graft could be directly extracted by hand in HALDN, the graft kidney needs to be bagged in a purse after the ligation and division of the renal vessels in RPLDN. However, despite the longer WIT, both methods provided excellent 1-year graft survival (RPLDN 98% vs HALDN 99.1%, not significant) with similar incidence of DGF. Kohei and coworkers also reported a mean WIT of 4.8 minutes and 96% 1-year graft survival in RPLDN.⁴ Similarly, previous studies showed that different lengths of WIT, to a certain extent, do not have harmful effects on graft outcomes. Nicholson and coworkers demonstrated that although WIT of transperitoneal laparoscopic LDN (TPLDN) was longer than that of open donor nephrectomy (ODN) in the randomized controlled trial (4 minutes vs 2 minutes; p = 0.001), there were no differences in renal function or allograft survival for kidneys removed by TPLDN or ODN.¹⁸ Minnee and colleagues reported that longer WIT over 4 minutes was not risk factor of DGF after HALDN on univariate analysis.¹⁹ Simforoosh and coworkers demonstrated that there was no significant difference in the incidence of DGF with different levels of WIT between TPLDN and ODN recipients, and nor were there any significant correlations between long-term serum creatinine levels and WIT.²⁰ These data suggest that an ∼5-minute WIT does not have a negative impact on allograft function.

Our study has several limitations. The most significant limitation is that this is a retrospective analysis. Since we initially started HALDN before RPLDN, there might be difference in operative experience. However, we performed both hand-assisted radical nephrectomy and retroperitoneoscopic radical nephrectomy for renal-cell carcinoma more than 100 times before we started HALDN and RPLDN. Therefore, we can minimize the difference between these two operative experiences. Moreover, this study would have been better if RPLDN was compared with pure laparoscopic LDN, rather than HALDN. However, there have been only two surgical techniques (RPLDN and HALDN) in our institutes, and we retrospectively analyzed those outcomes. In terms of donor characteristics, BMI is different between the two groups. The difference in BMI was only 1.3 kg/m², which may not have an impact on surgical outcome. The site of nephrectomy is also different between the two groups. We performed a separate analysis of surgical outcome between the two methods in only left donor nephrectomy, and similar trends were observed. As described above, although the background of the two groups was similar, a randomized study must be conducted to endorse the safety and efficacy of RPLDN.

Conclusions

This is the largest report to compare the outcomes of RPLDN vs HALDN. Both RPLDN and HALDN procedures are well tolerated with minimal complication rates and have a similar impact on recipient's graft function. These results suggest that RPLDN could be a feasible option for LDN, in addition to HALDN.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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