Comparison of Single-Port Robotic Donor Nephrectomy and Laparoscopic Donor Nephrectomy

Abstract

Purpose:

To compare the intra- and postoperative outcomes of single-port robotic donor nephrectomies (SP RDNs) and laparoscopic donor nephrectomies (LDNs).

Materials and Methods:

We retrospectively reviewed our institutional database for patients who received LDN or SP RDN between September 2020 and December 2022. Donor baseline characteristics, intraoperative outcomes, postoperative outcomes, and recipient renal function were extracted and compared between LDN and SP RDN. SP RDN learning curve analysis based on operative time and graft extraction time was performed using cumulative sum analysis.

Results:

One hundred forty-four patients underwent LDN and 32 patients underwent SP RDN. LDN and SP RDN had similar operative times (LDN: 190.3 ± 28.0 minutes, SP RDN: 194.5 ± 35.1 minutes, p = 0.3253). SP RDN patients had significantly greater extraction times (LDN: 83.2 ± 40.3 seconds, SP RDN: 204.1 ± 52.2 seconds, p < 0.0001) and warm ischemia times (LDN: 145.1 ± 61.7 seconds, SP RDN: 275.4 ± 65.6 seconds, p < 0.0001). There were no differences in patient subjective pain scores, inpatient opioid usage, or Clavien–Dindo II+ complications. Short- and medium-term postoperative donor and recipient renal function were also similar between the groups. SP RDN graft extraction time and total operative time learning curves were achieved at case 27 and 13, respectively.

Conclusion:

SP RDN is a safe and feasible alternative to LDN that minimizes postoperative abdominal incisional scars and has a short learning curve. Future randomized prospective clinical trials are needed to confirm the findings of this study and to identify other potential benefits and drawbacks of SP RDNs.

Introduction

Living-donor kidney transplantation is the preferred treatment modality for patients with end-stage renal disease, as the procedure provides superior recipient outcomes in comparison with deceased-donor-kidney transplantation and dialysis.¹ Currently, laparoscopic donor nephrectomy (LDN) is considered the gold standard for donor nephrectomy. In comparison with traditional open donor nephrectomy, LDN provides comparable renal allograft outcomes with improved postoperative cosmesis, decreased blood loss, lower complication rates, and shorter lengths of hospital stay.^2,3

Despite the excellent outcomes of LDNs, surgeons have continued to explore advances in minimally invasive donor nephrectomy. Recent studies have shown similar operative and graft outcomes between LDNs and multiport robotic donor nephrectomies (RDNs).^4

–7 Laparoendoscopic single-site donor nephrectomies (LESS DNs) have also demonstrated comparable clinical outcomes with LDN while potentially providing improved postoperative cosmesis.^8

–13 However, disadvantages of LESS DNs included technical complexity, steep learning curve, decreased freedom of movement, and difficult instrument triangulation.^14,15

In 2018, the da Vinci single-port (SP) robotic surgical system was FDA approved. Since then, numerous studies have demonstrated the safety and feasibility of this approach in various urologic procedures, including radical and partial nephrectomies, prostatectomies, and pyeloplasties.^16
–18 For donor nephrectomy, utilizing the SP robotic platform may ameliorate the technical drawbacks of LESS DNs while retaining the cosmetic advantages. Furthermore, the improved freedom of movement and instrument triangulation from the SP platform may allow surgeons to offer minimally invasive donor nephrectomy to patients with complicated anatomy and/or hilar vessel complexity.

In this study, we retrospectively reviewed the intraoperative measures and postoperative outcomes to assess the safety and feasibility of SP RDN. We then compared the clinical outcomes of our initial case series of SP RDN to LDN performed by experienced surgeons. To our knowledge, this is the first study to directly compare the outcomes of SP RDN to LDN.

Methods

After IRB approval, we retrospectively reviewed donor nephrectomies performed at the Mount Sinai Hospital from September 2020 to December 2022. Living kidney donors were included, and patients with donor nephrectomies that were canceled were excluded. The LDNs were performed by three experienced surgeons (two general surgeons and one transplant surgeon) and the SP RDNs were performed by a single urologic surgeon with experience in multiport robotic and LDN. Donors were assigned by the institution to receive either LDN or SP RDN solely based on the surgeon schedule availability.

For the SP RDNs, patients were positioned in a modified lateral decubitus position, with the operating table flexed downward to extend patients' flank area. A 7 cm Pfannenstiel or modified Gibson incision was made. For the first 20 SP RDN cases, the GelPOINT^® Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA) was placed in the incision. For the subsequent cases, the da Vinci SP^® Access Port for large incision (Intuitive Surgical, Sunnyvale, CA) was used.

The single-port da Vinci robotic platform was then docked through the Pfannenstiel incision. An additional 12 mm paraumbilical assistant port was used primarily for the introduction of vascular staplers. The detailed steps of the SP RDN with photographs of the setup are reported in our previous publication.¹⁹ LDNs were done by a transperitoneal approach, primarily using a Pfannenstiel incision as the extraction site.

Patient demographics, baseline characteristics, intraoperative measures, as well as postoperative and graft outcomes were extracted. Intraoperative measures included warm ischemia time, extraction time, and operative time. Warm ischemia time was defined as time between renal artery clamping and initiation of cold perfusion. Extraction time was defined as the time between renal artery clamping and delivery into an ice bath. Donor postoperative outcomes included estimated blood loss, hematocrit change, hemoglobin change, inpatient opioid usage, inpatient subjective pain scores, as well as adverse events, emergency department visits, and readmissions within 90 days of procedure.

Inpatient subjective pain scores (0–10) were reported for each postoperative day by averaging all reported pain scores within 24-hour increments. Inpatient opioid usage was reported by converting patient's opioid usage per postoperative day into milligram morphine equivalent (MME). Postoperative complications were categorized based on the Clavien–Dindo classification. Donor renal function and recipient graft function were assessed by using the estimated glomerular filtration rate (eGFR), calculated with the Chronic Kidney Disease Epidemiology Collaboration creatinine equation. Short- and medium-term renal function were defined as renal function measured by eGFR at ≤1 month and from >1 month to ≤1 year, respectively.

Statistical analyses were performed using GraphPad Prism 9.3.1. Mann–Whitney U test was used for comparison of continuous data. Continuous data were reported with standard deviations. Chi-squared analysis or Fisher's exact test (for data with <5 records) were used to analyze differences in categorical data. For all statistical tests, p-values <0.05 were used to denote statistical significance. Learning curves based on extraction and operative time were assessed with the cumulative sum analysis (CUSUM).

Results

One hundred forty-four patients underwent LDN, and 32 patients underwent SP RDN. Baseline patient characteristics were similar between the groups (Table 1). LDN and SP RDN had similar operative times (LDN: 190.3 ± 28.0 minutes, SP RDN: 194.5 ± 35.1 minutes, p = 0.3253). SP RDN patients had significantly greater extraction times (LDN: 83.2 ± 40.3 seconds, SP RDN: 204.1 ± 52.2 seconds, p < 0.0001) and warm ischemia times (LDN: 145.1 ± 61.7 seconds, SP RDN: 275.4 ± 65.6 seconds, p < 0.0001).

Table 1.

Donor Baseline Characteristics

	LDN, mean (SD)	SP RDN, mean (SD)	p
Age (years)	43.4 (12.3)	45.9 (12.7)	0.2845
BMI (kg/m²)	26.5 (3.9)	25.9 (3.0)	0.3133
Preoperative eGFR (mL/min/1.73 m²)	104.4 (14.8)	100.2 (13.8)	0.1010
Total No. of incisions	4.7 (0.6)	2 (0)	—

	LDN, % (N)	SP RDN, % (N)	p
Legal sex
Male (%)	31.3% (45/144)	43.8% (14/32)	0.1755
Female (%)	68.7% (99/144)	56.2% (18/32)	0.1755
ASA status
ASA 1	57.6% (83/144)	59.4% (19/32)	0.8572
ASA 2	42.4% (61/144)	40.6% (13/32)	0.8572
Abdominal surgery history	39.6% (57/144)	40.6% (13/32)	0.9133
Left kidney (%)	85.4% (123/144)	87.5% (28/32)	>0.9999
Single renal artery (%)	78.5% (113/144)	81.3% (26/32)	0.7272
Multiple renal arteries (%)	21.5% (31/144)	18.7% (6/32)	—
2 arteries	28	4	—
3 arteries	3	2	—
Single renal vein (%)	96.5% (139/144)	93.8% (30/32)	0.6123
Multiple renal veins (%)	3.5% (5/144)	6.2% (2/32)	—
2 veins	5	1	—
3 veins	0	1	—

ASA = American Society of Anesthesiologists; BMI = body mass index; eGFR = estimated glomerular filtration rate; LDN = laparoscopic donor nephrectomy; SP RDN = single-port robotic donor nephrectomy.

SP RDN patients also had greater estimated blood loss (LDN: 25.6 ± 11.0 mL, SP RDN: 46.6 ± 39.7 mL, p = 0.0014) as well as greater decreases in postoperative hemoglobin (LDN: −2.20 ± 0.90 g/dL, SP RDN: −2.82 ± 0.89 g/dL, p = 0.0003) and hematocrit (LDN: −7.2% ± 3.3%, SP RDN: −8.4% ± 2.6%, p = 0.0121). Postoperative inpatient subjective pain scores and opioid usage are summarized in Table 2. Throughout their hospital stays, LDN and SP RDN patients reported similar pain scores; however, SP RDN patients utilized less opioids on postoperative day 2 (LDN: 24.0 ± 19.4 MME, SP RDN: 15.7 ± 19.2 MME, p = 0.0474).).

Table 2.

Donor Regional Anesthesia Use, Subjective Pain Score, and Opioid Utilization During Their Postoperative Inpatient Course

	LDN, mean (SD), % (N)	SP RDN, mean (SD), % (N)	p
Regional nerve block	86.1% (124/144)	71.9% (23/32)	0.0496
Pain score POD1	3.0 (1.5)	3.2 (1.5)	0.2943
Pain score POD2	2.9 (1.6)	2.6 (1.6)	0.4807
Pain score during hospital stay	2.8 (1.4)	2.9 (1.2)	0.5367
POD1 opioid use (MME)	48.4 (48.5)	43.6 (35.8)	0.7287
POD2 opioid use (MME)	24.0 (19.4)	15.7 (19.2)	0.0474 ^*
Total opioid use (MME)	63.3 (62.2)	58.9 (49.5)	0.8628
Opioid use per day (total MME/LOS)	41.5 (35.4)	33.1 (23.7)	0.3185

p-Values in bold and with asterisk denote statistical significance based on Mann-Whitney U Test or Chi-Squared Analysis.

LOS = length of stay; MME = milligram morphine equivalent; POD = postoperative day.

Kidney implantation was performed in the same institution for 82.6% (119/144) of LDN and 96.9% (31/32) of SP RDN cases. One LDN recipient required hemodialysis in the immediate postoperative period because of delayed graft function. In contrast, no SP RDN recipients required dialysis in the immediate postoperative period. Short- and medium-term postoperative donor and recipient renal function were similar between the groups (Table 3).

Table 3.

Donor and Recipient Postoperative Estimated Glomerular Filtration Rate

eGFR (mL/min/1.73 m²)	LDN, mean (SD)	SP RDN, mean (SD)	p
Donor post-op 2 weeks eGFR	68.0 (17.7)	68.4 (17.7)	0.8906
Donor post-op 30–90 days eGFR	70.9 (18.0)	67.9 (15.9)	0.4828
Donor post-op 6 months eGFR	69.3 (16.8)	72.6 (14.9)	0.3263
Recipient pre-op eGFR	8.9 (4.9)	8.1 (3.7)	0.7152
Recipient POD1 eGFR	28.5 (22.8)	30.8 (21.3)	0.9521
Recipient POD2 eGFR	48.7 (28.0)	52.4 (31.0)	0.5947
Recipient POD3 eGFR	60.4 (28.5)	62.1 (29.7)	0.6309
Recipient post-op 2 weeks eGFR	63.4 (26.9)	63.0 (26.3)	0.9203
Recipient post-op 1 months eGFR	62.0 (23.4)	62.8 (25.1)	0.9044
Recipient post-op 3 months eGFR	62.6 (23.5)	61.4 (22.5)	0.8248
Recipient post-op 6 months eGFR	61.2 (21.7)	66.8 (23.2)	0.4505

Rates of postoperative emergency department visit (LDN: 2.8% [4/144], SP RDN: 3.1% [1/32], p > 0.9999) and readmission (LDN: 2.1% [3/144], SP RDN: 3.1% [1/32], p = 0.5553) were similar between LDN and SP RDN. 36.8% (53/144) of LDN and 31.3% (10/32) of SP RDN patients reported postoperative nausea during their inpatient hospital stay (p = 0.5532). Clavien–Dindo II complications were reported in 3.5% (5/144) LDN patients and 9.4% (3/32) SP RDN patients (p = 0.1601).

For LDN, one patient reported an infected seroma, two patients had extraction site hematomas managed with drainage, one patient had a subcutaneous hematoma managed with pressure dressing and antibiotics, and one patient had both a urinary tract infection (UTI) and a confirmed DVT. The SP RDN complications included one chyle leak treated with antibiotics and diet restriction, one UTI, and one suspected wound infection managed with antibiotics. LDN and SP RDN patients had similar average length of stay (LDN: 1.6 ± 0.8 days, SP RDN: 1.7 ± 0.6 days, p = 0.1256). No patients in either the LDN or SP RDN group reported Clavien–Dindo III or IV complications.

CUSUM learning curve for SP RDN extraction and operative time are shown in Figure 1. For graft extraction time, the learning curve reached plateau from cases 8 to 13 and the CUSUM showed a consistent decrease after case 13. For operative time, the learning curve reached plateau from cases 17 to 27 with a consistent decline in CUSUM after case 27.

FIG. 1.

Cumulative sum or CUSUM analysis for single-port robotic donor nephrectomy based on (a) extraction time and (b) operative time.

Discussion

For the past three decades, minimally invasive techniques have become the primary approach for donor nephrectomies because of decreased donor morbidity and increased donor satisfaction without compromising long-term graft-survival outcomes.^2,3 A recent advancement in minimally invasive donor nephrectomy is the development of single-site donor nephrectomy. LESS DN was introduced as the initial modality of single-site donor nephrectomy in 2008.²⁰ Although LESS DN may provide superior postoperative cosmetic outcomes, the adoption of the approach was limited by its technical complexity and steep learning curve.²¹

The next evolution of single-site donor nephrectomy utilizing the novel da Vinci SP robotic platform provides three instruments with ability to move at the elbow and wrist to alleviate the technical challenges previously associated with the LESS DN.²² In single-site donor nephrectomies where workspace is limited and laparoscopic instruments often clash, the additional freedom of movement and instrument triangulation of the SP robotic platform may translate to improved surgeon and patient experiences. In this study, we directly compared the clinical and operative outcomes of SP RDN and the current gold standard approach for donor nephrectomies, LDN, at a high-volume tertiary care center.

Our study did not have exclusion criteria based on body mass index or vessel complexity. The baseline patient characteristics and the complexities of renal anatomy were similar between the LDN and SP RDN groups. The SP RDNs reported in our study represent the first 32 cases performed at our institution. Surprisingly, there were no differences in overall operating time between our initial SP RDN case series and LDNs performed by experienced surgeons. The SP RDN operative time learning curve plateaued at case 17 and achieved consistent decrease by case 27. In comparison, Troppmann et al. previously reported achievement of operating time learning curve for LESS DN at case 61.¹⁴ Together, our results indicate the number of cases required to develop proficiency with SP RDN is relatively short.

LDN and SP RDN in our study showed similar postoperative pain scores, postoperative complication rates, as well as comparable short- and medium-term postoperative renal function for both donor and recipients. This is consistent with prior LESS LDN studies, which showed that most intra- and postoperative outcomes between LESS LDN and LDN were comparable.^{9
–11,13,21} On postoperative day 2, when the analgesic effects of regional nerve blocks are expected to wear off, LDN patients had greater opioid requirements than SP RDN patients.

We hypothesize that the combination of decreased port sites and reduced shearing trauma may account for this decrease in opioid requirement in SP RDN patients.²³ Patients undergoing SP RDNs also showed significantly greater decreases in postoperative hematocrit and hemoglobin. However, this is likely clinically insignificant, as there were no differences in transfusion rates, length of stay, or postoperative complications. None of the 32 SP RDNs in our study required additional laparoscopic site placements, conversion to an open approach, or conversion to laparoscopic approach.

This supports the idea that SP RDNs likely reduce the technical difficulties of single-site donor nephrectomy in comparison with LESS DNs. In contrast, most studies on LESS DN reported conversion rates to multiport laparoscopy that ranged from 4% to 13%.^9
–11,21 We hypothesized that this decreased conversion rate was caused by the increased freedom of movements of the SP robotic platform and may also allow accessible dissection of the kidney upper pole even in patients with complicated anatomy.

Anecdotally, the Pfannenstiel or the modified Gibson approach of the SP RDN also allowed excellent view of the renal vessels coming off the aorta or vena cava. This allowed the surgeon to divide the renal vessel as proximally as possible, preserving single vessels for recipient anastomosis even in patients with early branching vessels.

In our study, the greatest differences between LDN and SP RDN intraoperative outcomes were the warm ischemia and graft extraction times. This is not surprising, as previous LESS DN studies have reported that graft retrieval and vessel division are among the most technically challenging steps of single-site donor nephrectomies.⁹ SP RDN in the study had an average warm ischemia time of 4.5 minutes, which was similar to the warm ischemia time of 4 to 7 minutes previously reported for initial studies on LESS LDN.^9
–11

Based on our SP RDN extraction time learning curve analysis, the SP RDN extraction performance consistently improved as the surgeon performed more cases. The first 16 and the last 16 SP RDNs had an extraction time of 3.8 and 3.1 minutes, respectively. However, the SP RDN extraction times after achievement of the learning curve remains significantly longer than the extraction time of LDN. This may be caused by the intrinsic nature of decreased workspace and the challenges of disengaging the SP robot during the extraction phase. However, the increased warm ischemia and extraction times of SP RDNs were not clinically significant as no differences in short- or medium-term graft outcomes were observed.

Our study has several limitations. The single institution retrospective design of the study is susceptible to patient selection bias. However, as donors were assigned to each surgeon by the institution based on schedule availability, the risk of selection bias was minimal. The SP RDNs were conducted by a single surgeon, which may limit the generalizability of the study findings. The SP RDN surgeon's prior experience with SP robotic surgery, multiport donor nephrectomies, and extensive experience with other multiport robotic urologic surgeries may have also contributed to the expedited achievement of the SP RDN learning curve.

For the SP RDN, switching from the GelPOINT to the da Vinci SP Access Port at case number 21 confounded the learning curve analysis as the da Vinci SP Access Port may have improved the extraction process. The CUSUM analysis for total operative time reached plateau at case 27 out of 32. As such, additional cases may be necessary to determine whether the improvement in operative time after case 27 remains consistent.

We were also unable to extract data regarding the proportion of surgical cases performed by trainees, which further limits the learning curve analysis. The comparison of inpatient opioid usage between SP RDN and LDN was limited as postoperative pain management was not standardized among the various surgeons. Previous studies on LESS DNs have reported improved postoperative surgical site cosmetic outcomes in comparison with multiport LDNs.^13,21

As such, we hypothesize that SP RDNs may offer similar improvements in cosmesis, especially as the Pfannenstiel incision is covered by most clothing and the paraumbilical assistant port are well hidden. Since kidney donors are generally young healthy individuals who may place higher emphasis on postoperative cosmesis, SP RDN may be an attractive alternative for potential donors with reservations regarding postoperative surgical scars.

Future studies using validated Body Image Questionnaires to evaluate directly the cosmetic outcomes of SP RDNs are needed. For the SP RDNs performed in the study, we utilized a paraumbilical assistant port, which was primarily used to introduce vascular staplers for vessel division. The future development of SP robotic vessel staplers will allow surgeons to safely perform SP RDN without the use of an assistant port.

Conclusion

SP RDN is a safe and feasible option for living-donor nephrectomy that offers comparable graft outcomes with minimal visible abdominal incision scars when compared with LDN. SP RDN has a short learning curve for experienced multiport robotic surgeons. Future randomized prospective clinical trials are necessary to confirm the findings of our study and to identify other potential benefits and drawbacks of SP RDNs.

Footnotes

Authors' Contributions

Project development, data collection, data analysis, and article writing/editing by M.A.P., C.P.C., E.B.G., J.S.A., and S.S.F. Data collection, data analysis, and article writing/editing by M.L., K.T.R., and F.L. Project development, data analysis, and article writing by O.A.-A. Data analysis and article writing/editing by B.E., D.L.-R., D.H., E.C., A.A., and R.S. Data collection and data analysis by D.W. and H.F.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The study was conducted at Icahn School of Medicine at Mount Sinai without external or grant funding.

Abbreviations Used

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