Strategies to Perform Pure Retroperitoneoscopic Donor Nephrectomy: A Single-Center Cohort Study

Abstract

Background:

Considering the increase in a number of vascular complications, right laparoscopic donor nephrectomy is less preferred due to achieving not only shorter renal vein but also longer renal artery. However, recent studies have indicated that the side of the surgery would not affect the outcomes.

Aim:

The aim of this study is to evaluate the outcomes and strategies to increase the safety of pure retroperitoneoscopic donor nephrectomy (RDN).

Methods:

We analyzed the prospectively collected medical records of 158 kidney donors who underwent RDN from January 2010 to August 2018. The patients were divided into two groups based on their side of surgery. Right- and left-sided RDNs were compared in terms of demographics, intraoperative, and postoperative data, including the development of incisional hernia (IH). The outcomes of the recipients were also evaluated.

Results:

Right RDN was performed in 40 (25.3%) and left RDN was performed in 118 (74.7%) donors. Operation time (P = .593), warm ischemia time (P = .271), blood loss (P = .787), and length of hospital stay (P = .908) were statistically similar in right and left RDN groups. Intraoperative and postoperative complications were statistically showed no difference between right and left RDNs. No IH was observed in any group. One-year and five-year patient survival and graft survival rates were 100% versus 97% (P = .299) and 100% versus 95% (P = .126) on both sides, respectively.

Conclusion:

Right RDN is an effective and safe method as on the left side. RDN has an additional advantage in the absence of IH. Experience with other retroperitoneoscopic urological interventions may have had a positive effect on the outcomes of pure RDN.

Introduction

Minimally invasive live laparoscopic donor nephrectomy (LDN) has become a standard of care since it leads to a decrease in morbidity and shortens the convalescence.¹ It has undergone a variety of modifications over time.

Retroperitoneoscopic donor nephrectomy (RDN), which is a challenging procedure due to the limited space of the retroperitoneum, is one of the minimally invasive techniques that allow reaching renal hilum directly without interference to the intraperitoneal organs.²

Previously, it has been stated that the right-sided donor nephrectomy has a slightly increased risk of venous thrombosis regardless of using an open or minimally invasive approach due to the right renal vein shortness.³ Therefore, it is generally a fact that surgeons have refrained from the right kidney donor nephrectomy even if the right kidney has a single renal artery and vein compared to the left counterpart.⁴ This is the case in RDN as in other laparoscopy approaches as well.⁴

It has been reported in recent retrospective studies, which have included a comparable number of the right and left RDN cases, that right and left RDN were similar in terms of donor and recipient outcomes.^5,6

In this study, we evaluated the pure RDN technique applied in our clinic and aim to compare the outcomes of RDNs according to the side of the surgery. To our knowledge, this is the first article ever reported on pure RDN from Turkey.

Materials and Methods

After institutional review board approval (OMU KAEK 8.02.2019/79), we retrospectively evaluated 158 consecutive kidney donors undergoing pure RDN for transplantation at Ondokuz Mayis University from January 2010 to August 2018. All operations were performed by a single surgeon with experience in retroperitoneoscopic laparoscopic surgery and kidney transplantation.

The split renal function was evaluated by Tc-99m mercaptoacetyltriglycine (MAG3) renal scintigraphy. Renal vascular structures and collecting system were evaluated by triphasic computed tomography angiography. In addition, renal vascular structures were evaluated by generating three-dimensional configurations. The final decision for the eligibility of the kidney donor candidates and laterality of the surgery was obtained at the transplantation medical review board. The decision was based on the conviction that the better kidney remains with the donor. If both kidneys have equal characteristics in terms of functionality, then, the left kidney or the kidney with simpler vascular anatomy was procured.

The 158 subjects allocated in two groups, including 40 subjects in the right RDN group and 118 subjects in the left RDN group. Demographic data such as age, gender, body mass index (BMI), number of renal arteries, and number of renal veins were recorded. Intraoperative data, including operation time, warm ischemia time (WIT), estimated blood loss (EBL), and preoperative and postoperative complications were compared. In addition to this, the results of renal transplant recipients were evaluated in terms of graft survival, graft function, as well as complications.

Surgical technique for RDN

After induction of general anesthesia, a urinary drainage catheter and an orogastric tube were placed for decompression of the bladder and stomach during insufflation. Then, patients were positioned in a 90-degree flank-up position, and the table was flexed to expand the space between the lower ribs and the iliac crest to facilitate trocar placement. Trocar configuration and surgical technique were previously described by Rassweiler et al. This technique has been modified for RDN.⁷ A 15 mm transverse incision was made in the posterior axillary line, midway between the 12th rib and the iliac crest, parallel to the psoas muscle. After the dissection was deepened downward through the lumbodorsal fascia, the retroperitoneal space was expanded by using blunt dissection with the fingertip and then a balloon dilator. The space between the psoas muscle and posterior aspect of Gerota's fascia was further expanded by balloon dilatation. A three-trocar technique was used with the primary 12 mm trocar placed as an optic trocar at the site of entry. The gas pressure was increased up to 12 mmHg to create a retroperitoneal space. Under direct vision, another 10 mm trocar was placed anteriorly on the anterior axillary line, 3–4 cm cephalad to the iliac crest. A 5 mm additional trocar was also placed near the 12th rib on the anterior axillary line. Gerota's fascia was then incised longitudinally along the psoas muscle to expose the renal hilum. The ureter within the periureteral sheath was identified and dissected distally until the crossing of the iliac artery. The renal hilum was identified posteriorly. The renal artery was circumferentially dissected from the renal hilum to its retrocaval location. Posterior and lateral aspects of the renal vein and also the anterior part of the renal vein were dissected. The renal vein and junction to inferior vena cava (IVC) were identified. The posterior and anterior part of the perirenal fat was dissected from the renal capsule, respectively, and the kidney was mobilized. The adrenal gland was dissected and separated from the upper pole of the right kidney. The ureter was clipped distally and divided. An 8 cm muscle-splitting modified Gibson incision was performed for the extraction of the kidney, before achieving vascular control with staplers. Mannitol and intravenous fluids were given before dissection of renal vascular structures. Before the stapler application, the 10 mm working-trocar was used as an optical trocar. The stapler was applied through the 12 mm trocar. After applying an endo-TA-30 (COVIDIEN, Mansfield, MA) stapler to the renal artery, it was divided distally to the staple line. Then, a second endo-TA-30 stapler was applied over the IVC at the level of the intersection with the renal vein. The renal vein was divided distally to the staple line giving a cuff of IVC (Fig. 1). The retroperitoneum was accessed through the previously created extraction incision, and the kidney was taken out manually.

FIG. 1.

(A) Numbers show trocars position; (1) 12 mm optic (2) and (3) 10 and 5 mm working trocars. The red arrow indicates the incision. (B) Applying of endoTA-30 stapler to the renal artery. (C) The posterior view of right renal vein after dividing the right renal artery over the stapler line. (D) A second endoTA-30 stapler was applied over the IVC at the level of the intersection with the renal vein. (E) The renal vein was divided over the stapler line. (F) The posterior view of the right renal hilum after vascular control. IVC, inferior vena cava.

Statistical analysis

The data were analyzed with SPSS^® for Windows^® version 24. Continuous variables were expressed as mean ± SD. Independent sample t test and Mann–Whitney U test were used to compare the study groups. Chi-square test was used to compare categorical variables. A P < .05 was considered statistically significant. The graft survival was identified by Kaplan–Meier analysis.

Results of the donors

The right RDN and left RDN groups had a similar distribution in terms of age, gender, and BMI. Table 1 is shown the characteristics of both groups. While the number of renal arteries was similar, the number of renal veins was statistically different in both groups. In the right RND group, a patient with two renal veins was converted to open surgery, due to right main renal vein and vena cava injury during dissection. The graft was transplanted seamlessly to the recipient, but postoperative transfusion was required for the donor. In the left RDN group, the renal vein could not be fully controlled with Endo-TA-30 stapler in another patient who had a single renal vein; and laparoscopic control was achieved after the graft kidney was taken out. Postoperative transfusion was also required for this patient. Both of the perioperative complications developed during the first 40 cases. Other than this, the decrease in mean hemoglobin values in both groups was similar, when preoperative and postoperative hemoglobin values were compared. The mean hemoglobin drop was −1.4 ± 1.7 g/dL in the right and −1.03 ± 1.9 g/dL in the left RDN groups (P = .278). In addition, both groups were similar in terms of EBL 85.50 ± 118.62 and 81.44 ± 65.62 mL, P = .787 in the right and left RDN groups, respectively.

Table 1.

Demographics, Intraoperative, and Postoperative Data

Variables	Right RDNs	Left RDNs	P
Number (%)	40 (25.3)	118 (74.7)
Age (year)	44.23 (12.25)	43.42 (10.21)	.681^a
Gender (Male/Female) (%)	13/27 (32.5/67.5)	51/67 (43.2/56.8)	.233^b
BMI (kg/m²)	27.0 ± 3.35	26.9 ± 3.98	.997^a
Number of renal arteries
1	38 (95%)	107 (90.7%)	.390^b
2	2 (5%)	11 (9.3%)
Number of renal veins
1	32 (80%)	115 (97.5%)	.005^b
2	8 (20%)	3 (2.2%)
OT (minutes)	80.51 ± 25.56	78.05 ± 24.67	.593^a
WIT (seconds)	148.89 ± 48.18	134.44 ± 76.79	.271^a
EBL (mL)	85.50 ± 118.62	81.44 ± 65.62	.787^a
Baseline Hgb (g/dL)	13.16 ± 1.37	13.55 ± 1.92	.235^a
Postoperative Hgb (g/dL)	11.75 ± 2.26	12.52 ± 1.77	.028^a
Hgb Drop (g/dL)	−1.41 ± 1.7	−1.03 ± 1.9	.278^a
Preop. Cre (mg/dL)	0.83 ± 0.85	0.77 ± 0.60	.674^c
Postop. Cre (mg/dL)	1.19 ± 1.65	0.99 ± 0.25	.200^a
LOS (day)	2.83 ± 0.91	2.86 ± 1.6	.908^a

Independent sample t test.

Chi-square test.

Mann–Whitney U test.

BMI, body mass index; Cre, serum creatinine; EBL, estimated blood loss; Hgb, hemoglobin; LOS, length of stay; OT, operation time; RDN, retroperitoneoscopic donor nephrectomy; WIT, warm ischemia time.

Although the mean operation time and WIT were slightly longer in the right RDN group, there was no statistically significant difference between the groups. It was 80.51 ± 25.56 versus 78.05 ± 24.67 minutes (P = .593) in the right and left RDN groups, respectively. In the left RDN group, 2 patients developed incisional infection and were treated with local wound dressing and appropriate antibiotics. Another patient received conservative treatment of prolonged chylous drainage. Perioperative complications are summarized in Table 2. Not a single patient in the cohort developed an incisional hernia (IH).

Table 2.

Intraoperative and Postoperative Complications

Variables	Right RDNs (n = 40)	Left RDNs (n = 118)	P
Overall complications, n (%)	2 (5%)	6 (5.1%)	.983
Intraoperative complications			.42^a
IVC injury	1	—
Left lumber vein injury	—	1
Postoperative complications			.62^a
Blood transfusion	1	2
Wound infection	—	2
Prolonged chylous drainage	—	1
Incisional hernia	—	—
Trocar-site hernia	—	—

Chi-square test: statistically similar.

IVC, inferior vena cava.

Results of the recipients

Table 3 summarizes the characteristics of the recipients in the right RDN and left RDN groups. The distribution of age, sex, BMI, as well as follow-up creatinine values was similar between the groups. Renal biopsy was taken from a total of 44 recipients, as 12 patients in the right RDN group and 32 patients in the left RDN group. Detailed pathology reports are given in Table 4. In the left RDN group, within the first 3 months, 1 patient developed renal vein thrombosis, 1 coagulation necrosis, and another one developed acute humoral rejection and underwent graft nephrectomy. Meanwhile, other 3 patients died due to septic causes. Graft functions at 6 months and 2 years were found to be similar in both groups during the follow-up (Table 3). One-year patient survival was 100% versus 97% and 1-year graft survival was 100% versus 95% in group 1 and in group 2, respectively. Furthermore, 5-year patient and graft survival were statistically similar in both groups, as 100% versus 97% and 100% versus 95% (P = .299 and P = .126), respectively (Fig. 2).

FIG. 2.

The mean graft survival according to the side of donor nephrectomy

Table 3.

Results of the Recipients

Variables	Right RDNs	Left RDNs	P
Number (%)	40 (25.3)	118 (74.7)
Age in years (SD)	39.38 ± 16.14	38.47 ± 14.19	.738^a
BMI	24.36 ± 4.79	23.6 ± 5.00	.487^a
The mean preoperative Cr: mg/dL (SD) (n = 40/118)	6.51 ± 2.13	6.42 ± 2.45	.833^a
Mean postoperative 1st day Cr (n = 40/118)	2.0 ± 1.75	1.80 ± 1.37	.455^a
Mean postoperative 6th month Cr (n = 40/112)	1.09 ± 0.29	1.25 ± 1.19	.426^a
Mean postoperative 2nd year Cr (n = 40/112)	1.16 ± 0.27	1.17 ± 0.58	.907^a
Survival			.126^b
1-year graft survival	100%	95%
5-year graft survival	100%	95%
6-year graft survival	100%	91%

Independent sample test

Kaplan–Meier analysis.

Cr, creatinine.

Table 4.

The Outcomes of Graft Biopsy and the Reason for Graft and Patients Loss

	Right RDNs (n = 40)	Left RDNs (n = 112)	P
Renal biopsy	12 (30%)	32 (28.5%)	.73^a
ACR	2	9
AHR	1	2
ACR+AHR	—	1
BK nephropathy	1	1
ATN	1	—
Acute interstitial nephritis	1	—
Borderline	1	—
Coagulation necrosis	—	1
Minimal changes	5	18
Graft nephrectomy	0	3	.31^a
Venous thrombosis	—	1
Coagulation necrosis	—	1
AHR	—	1
Patient loss in the first 6 months due to septic complications	0	3	.31^a

Chi-square test: statistically similar.

ACR, acute cellular rejection; AHR, acute humoral rejection; ATN, acute tubular necrosis.

Discussion

The present study revealed that right and left RNDs to have similar perioperative outcomes. The fact that no IH is detected in any case can be considered as an advantage of the technique. Retroperitoneoscopic approach reduces the technical difficulties associated with the transperitoneal approach, including requiring the retraction of the liver and mobilization of the duodenum, to expose the IVC. It provides an early exploration of the renal hilum as well. In addition, control of the right renal vein in parallel with the vena cava by stapler is a technique that has been described in terms of preserving the length of the renal vein. Besides, factors including smaller working space, absence of anatomic landmarks, and the steep learning curve can be considered as challenging reasons for RDN.^8,9 We may speculate that experience that gained other retroperitoneoscopic interventions such as retroperitoneoscopic radical and partial nephrectomy and pyeloplasty related to the upper urinary tract may facilitate the adaptation process of pure RDN. Therefore, we have performed the retroperitoneoscopic laparoscopic procedures in our tertiary care institution since 2009 routinely.

The rates of right living donor nephrectomy are ∼10% or less in published series in the literature, when compared to open donor nephrectomy.^3,4 A recent systematic review and meta-analysis states that pure RDN is only performed to 3.7% of living kidney donors around the globe. Moreover, hand-assisted RDN has a similar rate with pure RDN as well.¹ The harvesting rates of the right kidney were lower in RDN. In early studies, the right RDN rate was 10% or less of the overall cohort.^8,10–12 Nevertheless, recent comparative studies are stated that the right RDN rates are more than 23%.^5,6,13 In our cohort, the right RDN consists of 25% of all RNDs, which is similar to recent comparative studies.

The learning curve for RDN has been identified as ∼40 cases by different authors based on the criteria such as reduction in operation time (OT), WIT, EBL, and number of complications.¹⁰ Pal et al. evaluated the learning curve for pure RDN in 102 kidney donors. They concluded that OT and WIT were significantly reduced after 35 cases. The mean OT was around 200 minutes, after completing the learning curve. On the contrary, increased surgical experience has been shown to provide a significant reduction in WIT.¹⁴ Tokodai et al. have retrospectively evaluated the hybrid RDN technique. They accepted the first 30 cases as a learning curve and divided 120 consecutive patients into four different groups to compare perioperative and postoperative outcomes. The authors stated that WIT, length of stay (LOS), EBL, and graft function were statistically similar, while the operative time was significantly reduced after the completion of the learning curve.⁵ In our study, the learning curve was not evaluated in detail. Nevertheless, OT and WIT are shorter both right and left RDN groups than in previous studies that evaluated the learning curve and compared right versus left RDN.^5,6,14 However, there were no major complications, including conversion to open surgery and vascular injury after completion of the first 40 cases. Our complication rate is found to be similar to the previous literature.^5,10,14 On the contrary, the length of the right renal vein was thought to increase the risk of venous thrombosis. Ng et al. compared to 26 right RDNs versus 106 left LDNs. The authors stated that while graft kidney artery length was similar in both groups, the venous length was shorter in the RDN group (3.9 versus 2.3 cm). However, a shorter right renal vein did not cause any vascular complication and graft loss and both techniques were found to be similar in terms of donor and recipient outcomes.⁹ The graft kidney vein length is not available in our data. The number of grafts with double renal vein was higher in the right RDN group (20% versus 2.2%), (P = .005). WIT was found to be similar to 148 and 134 seconds. (P = .271) in the right and left RDN groups, respectively. Furthermore, intraoperative venous complications developed in 1 patient in both right and left RDN groups. In the right RDN group, conversion to open surgery was required in 1 patient due to IVC injury. In the left RDN group, another patient had lumbar vein injury and was controlled laparoscopically. While only 1 patient in the left RDN group underwent graft nephrectomy on day 2 postoperatively due to graft venous thrombosis, no venous complication was observed in the right RDN group during the postoperative period.

In the literature, there are a variety of studies comparing the outcomes of pure right and left RDN in terms of efficacy and safety. However, some of them do not have a sufficient number of right RDN cases to compare.^11,15 Kashiwadate et al. compared 87 (57.6%) right and 64 (42.4%) left RDNs in terms of intraoperative, postoperative, and graft outcomes. No significant difference was found between the two groups in terms of WIT, EBL, LOS, and serum creatinine levels at week 1 after the transplantation. However, overall OT was significantly shorter in right RDNs (OT: 175 versus 195 minutes, P < .01). It was suggested that this result could be related to the simplicity of renal anatomy on the right side. In addition, long-term graft survival was found to be similar in right- and left-sided RDNs.⁶ In our study, although the number of multiple renal veins was more common and the mean OT was higher in the right RDN group as well, no statistically significant difference was found between the two groups in terms of OT. Another retrospective cohort study, in which 251 RDNs (right: 23% versus left: 77%) were included, was published by Schaumeier et al. In this study, it was concluded that right RDN has similar results when compared to the left RDN, including surgical complications, mortality, 1-year graft function, and long-term graft survival between the recipient of the left or right kidney.¹³ In our study, we also found similar outcomes in terms of the graft survey between the right RDN group and the left RDN group. One-year recipient survival was 100% versus 97% and 5-year recipient survival was 100% versus 97% (P = .299) in the right and left RDN groups, respectively. Moreover, there was no statistical difference between the groups in terms of 1-year and 5-year graft survival, 100% versus 95% (P = .126). In the left RDN group, three graft nephrectomies were performed for the reasons, including in 1 patient venous thrombosis, in another patient coagulation necrosis, and the other one for acute humoral rejection and 3 patients passed out due to the infective complications within the first 6 months after transplantation. However, there was no patient and graft loss in the right RDN group.

Kidney donors have not been evaluated for IH in previous comparative pure RDN studies in the literature.^3,6,11 IH is one of the major causes of morbidity in completely healthy donors. DeSouza et al. have evaluated IH rates in their comparative studies. They have stated that no IH observed in the lower transverse abdominal incision group in patients who underwent laparoscopic surgery. The authors concluded that BMI, follow-up, and lower abdominal incision were protectors of IH in multivariate analysis.¹⁶ Incidence of IH is reported to be higher in hand-assisted LDNs than that of other laparoscopic methods. The underlying reason was use of midline incision. Besides, use of Pfannenstiel incision was associated with a reduction in IH incidence.¹⁷ Barlas et al. compared the incision type in donors who underwent hand-assisted RDN. It was stated that there was no IH detected in the donors undergoing lower abdominal incision.¹⁸ However, the incidence of IH associated with donor nephrectomy is reported from 0.6% to 3% in the literature. Moreover, the incidence of trocar-site hernias due to laparoscopic surgery has also been reported as 1%–6%.¹⁹ In our study, we observed that none of the donors in both groups has developed incisional or trocar-site hernias after RDN during follow-up. In our RDN technique, a lower abdominal incision (modified Gibson) with a length of 6–8 cm was used. The factors leading to a reduction in the risk of hernia development in our technique can be speculated as the performance of muscle splitting with a 6–8 cm modified Gibson incision, which was made just before the control of the renal vasculature, and thus avoiding the use of any type of retractor or a hand port.

The limitations of our study include retrospective, single-center, and a relatively small number of patients. However, the comparable number of donors in groups, conversion to open surgery, a decrease in the complication rate, after completion, and learning curve was found to be similar to previous studies. Moreover, the shorter operative time compared to the literature and the absence of IH are positive aspects of this study.

Conclusion

Retroperitoneoscopic approach can safely be applied to living kidney donors who are candidates for both right and left donor nephrectomies with the advantage of absence of morbidities such as IHs. It is not possible to talk about a very steep learning curve for RDN, but the surgeon's familiarity with the technique and experience in retroperitoneoscopic approach cannot be excluded. Furthermore, we believe that use of TA vascular stapler may improve the procured right renal vein length, which may enable the increased utilization of right-sided kidney.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References

Kortram

, Ijzermans

, Dor

. Perioperative events and complications in minimally invasive live donor nephrectomy: A systematic review and meta-analysis. Transplantation, 2016; 100:2264–2275.

Shockcor

, Sultan

, Alvarez-Casas

, et al. Minimally invasive donor nephrectomy: Current state of the art. Langenbeck's Arch Surg, 2018; 403:681–691.

Hsu

, Reese

, Naji

, Levine

, Abt

. Increased early graft failure in right-sided living donor nephrectomy. Transplantation, 2011; 91:108–114.

Kumar

, Chaturvedi

, Gulia

, Maheshwari

, Dassi

, Desai

. Laparoscopic live donor nephrectomy: Comparison of outcomes right versus left. Transplant Proc, 2018; 50:2327–2332.

Tokodai

, Takayama

, Amada

, Haga

, Nakamura

, Kashiwadate

. Retroperitoneoscopic living donor nephrectomy: Short learning curve and our original hybrid technique. Urology, 2013; 82:1054–1058.

Kashiwadate

, Tokodai

, Amada

, et al. Right versus left retroperitoneoscopic living-donor nephrectomy. Int Urol Nephrol, 2015; 47:1117–1121.

Rassweiler

, Henkel

, Stock

, Frede

, Alken

. Retroperitoneoscopic surgery—technique, indications and first experience. Min Invas Ther, 1994; 3:179–195.

Kohei

, Kazuya

, Hirai

, et al. Retroperitoneoscopic living donor nephrectomy: Experience of 425 cases at a single center. J Endourol, 2010; 24:1783–1787.

, Abreu

, El-fettouh

HIA

, et al. Right retroperitoneal versus left transperitoneal laparoscopic live donor nephrectomy. Urology, 2004; 63:857–861.

10.

, Ye

, Huang

, Hou

, Zhao

, Wang

. Retroperitoneoscopic live-donor nephrectomy: 5-year single-center experience in China. Int J Urol, 2010; 17:158–162.

11.

Omoto

, Nozaki

, Inui

, et al. Impact of right-sided nephrectomy on long-term outcomes in retroperitoneoscopic live donor nephrectomy at single center. J Transplant, 2013; 2013:546373.

12.

Ruszat

, Wyler

, Wolff

, et al. Reluctance over right-sided retroperitoneoscopic living donor nephrectomy: Justified or not?. Transplant Proc, 2007; 39:1381–1385.

13.

Schaumeier

, Nagy

, Dell-Kuster

, et al. Right retroperitoneoscopic living donor nephrectomy does not increase surgical complications in the recipient and leads to excellent long-term outcome. Swiss Med Week, 2017; 147.

14.

Pal

, Modi

, Rizvi

, et al. The learning curve of pure retroperitoneoscopic donor nephrectomy. Int J Org Transplant Med, 2017; 8:180.

15.

Tanabe

, Miyamoto

, Ishida

, et al. Retroperitoneoscopic live donor nephrectomy (RPLDN): Establishment and initial experience of RPLDN at a single center. Am J Transplant, 2005; 5:739–745.

16.

DeSouza

, Domajnko

, Park

, Marecik

, Prasad

, Abcarian

. Incisional hernia, midline versus low transverse incision: What is the ideal incision for specimen extraction and hand-assisted laparoscopy?. Surg Endosc, 2011; 25:1031–1036.

17.

Wadström

. The higher rates of ileus, readmission and hernia after laparoscopic donor nephrectomy reported can be mitigated by using a retroperitoneal approach via a Pfannenstiel incision. Transplantation, 2016; 100:e104.

18.

Barlas

, Aydogdu

, Sinangil

, et al. Incisional complications and cosmetic evaluation after hand-assisted retroperitoneoscopic donor nephrectomy. Transplant Proc, 2019; 51:2215–2220.

19.

Klop

, Hussain

, Karatepe

, Kok NF

, zermans

, Dor

. Incision-related outcome after live donor nephrectomy: A single-center experience. Surg Endosc, 2013; 27:2801–2806.