Letter to the Editor RE: Hirose et al.,Safety and Efficacy of Retroperitoneoscopic Living Donor Nephrectomy: Comparison of Early Complication,Donor and Recipient Outcome with Hand-Assisted Laparoscopy Living Donor Nephrectomy (From: Hirose T,Hotta K,Iwami D,et al. J Endourol 2018;32:1120–1124;DOI: 10.1089/end.2018.0669)

Dear Editor:

We have read with great interest the article by Takayasu Hirose et al. entitled “Safety and Efficacy of Retroperitoneoscopic Living Donor Nephrectomy: Comparison of Early Complication, Donor, and Recipient Outcome with Hand-Assisted Laparoscopic Living Donor Nephrectomy.” ¹ Analysis of functional result of their series demonstrated that both Retroperitoneoscopic Living Donor Nephrectomy (RPLDN) and Hand-Assisted Laparoscopic Living Donor Nephrectomy (HALDN) procedures were well tolerated with minimal complication rates with similar results and incidence of graft dysfunction. We would like to congratulate the authors on their article and respectfully submit these comments.

In this article, renal vein was divided following the double proximal clip (Hem-o-Lok). In our experience, we have seen very short right renal vein in the allograft following division of vein after double proximal clip, which makes the vascular anastomosis in the recipients difficult, especially when the recipient is obese. Control of right renal vein by use of endo TA stapler during RPLDN helps in obtaining right renal vein length as well as good vascular cuff of Inferior Vena Cava (IVC). ² At our institute, it is a routine practice to use endo TA stapler on the right side to increase the length of the right renal vein.

Our second concern is regarding the choice of renal graft extraction by Endo Catch device in which the Warm Ischemia Time (WIT) was 295 ± 107 seconds in RPLDN, which is significantly more than in HALDN. In the discussion of the article, it is mentioned that ∼5 minutes WIT does not have adverse impact on allograft function. However, in some patients, the WIT went up to >5 minutes (WIT 295 ± 107 seconds). In RPLDN, the mean WIT was 2.8 ± 1 minutes by giving a Gibson incision and extraction by hand insertion rather than bagging in an Endo Catch bag. Entrapping the graft increases the WIT as described by Arai et al., ³ which is also consistent with our experience.

We would welcome the author's comments on these technical issues.