Donor Nephrectomy JOHN C. LAMATTINA and ROLF N. BARTH
Deceased Donor Nephrectomy Donation After Brain Death Donation After Circulatory Death Living Donor Nephrectomy Anesthetic Management Open Donor Nephrectomy Laparoscopic Donor Nephrectomy Hand-Assisted Technique
Deceased Donor Nephrectomy Deceased donor renal donation predominates as the source of transplantable kidneys. In the US, deceased donors provide approximately 13,000 kidneys per year or 70% of the available pool of transplantable kidneys (Fig. 8.1).1 Recent years have seen an increase in the number of deceased donors secondary to the opioid crisis in North American (and Europe) and the resultant number of referrals for organ donation. Despite assumptions that these donors would be predominantly younger and without comorbidities, data support growth in all age categories and this growth in donor population has been associated with extensive medical and substance abuse histories.2 Anoxic brain injury is the primary mechanism of terminal injury in these donors and this can be accompanied by significant hypotensive periods before resuscitation. Such an insult can frequently manifest itself as acute kidney injury at the time of donation. Deceased donors are divided into subgroups of donation after brain death (DBD) and donation after circulatory death (DCD). DBD donors are pronounced dead by both clinical and radiologic evaluations that are clearly defined. The operations from these donors are conducted in controlled settings with careful physiologic monitoring to ensure optimal organ perfusion and oxygenation until perfusion and cooling of donor organs. DBD donors account for the overwhelming majority of deceased donors representing 82.3% of donors in 2015. DCD donation rates have increased over the past decade, and the proportion of DCD donors contributing to the donor pool more than doubled from 7.3% to 17.7% between 2005 and 2015 (Fig. 8.2).1 Other countries have higher rates of DCD donation, for example, in the UK in 2017 to 2018, 40% of all deceased donors were DCD (https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/11628/transplant-activityreport-2017-2018.pdf). The US introduced a new deceased donor renal transplant allocation system in 2013. This system was designed to match donor kidneys with recipients who would receive
Total Laparoscopic Approach Right Donor Nephrectomy Single-Port Donor Nephrectomy Robotic Donor Nephrectomy Complications Summary
the maximal benefit in terms of life years. In essence, donor kidneys are evaluated for quality using the Kidney Donor Risk Index (KDRI; see Fig.8.2).3 Donor-specific factors from the KDRI (including age, ethnicity, height, weight, history of hypertension or diabetes, hepatitis C status, and donation after cardiac death status) are used to create a Kidney Donor Profile Index that assigns a score between 0 and 100, setting the median donor as the 50th percentile. A kidney with a lower perceived risk (and likely of higher quality) scores lower. Recipients are likewise risk stratified for expected posttransplant survival (EPTS) using age, history of diabetes, duration of dialysis, and history of prior transplant. The lowest 20th percentile kidneys (which are expected to have the longest graft survival) are allocated preferentially to recipients in the highest 20th percentile of expected survival (who are expected to have the longest patient survival). The new system also offers priority allocation to highly sensitized recipients, with patients having a calculated panel reactive antibody (cPRA) ≥99 receiving the greatest benefit, but also increasing access for patients with a cPRA ≥98%. Zero-antigen mismatch donors will still be offered priority under the new system. Recipients are still offered points based on years on the waiting list (or maintenance dialysis), prior living donation, degree of sensitization, and one degree of HLA mismatch).4
Donation After Brain Death Kidneys from DBD donors are usually recovered in conjunction with recovery of other abdominal and thoracic organs and require coordination of the surgical teams performing different roles. Often, thoracic teams will have complicated recipients with redo-transplantation, mechanical support devices, or other complicated histories, and this can result in significant delays until cross-clamp for abdominal recovery teams. Initial midline laparotomy, and isolation and control of the infrarenal abdominal aorta is accomplished. In cases where the liver is recovered, isolation of either the inferior 115
Kidney Transplantation: Principles and Practice
Living donor All 5000 0 2004
Year Fig. 8.1 Transplanted kidneys in US from 2004 to 2015 by donor type. Recent years have observed increased numbers of deceased donors. (OPTN/ SRTR 2015 Annual Data Report. HHS/HRSA.)
Percentage of donors
Donor age >50 Black race Diabetes Hypertension Weight >80 kg Terminal SCr >1.5 mg/dL DCD CVA death
30 20 10 0 2004
Year Fig. 8.2 Components of the Kidney Donor Risk Index 2004 to 2015. Significant increases in the percent of DCD donors has been observed over the past decade. These components have resulted in no net changes in overall KDRI since 2004. (OPTN/SRTR 2015 Annual Data Report. HHS/HRSA.)
mesenteric vein or portal vein can also be achieved. The aorta is cannulated after administering heparin, and in appropriate cases venous cannulation is performed. In coordination with thoracic recovery, perfusion is initiated, the aorta is clamped in a supraceliac location, and either the inferior vena cava or the right atrium are transected and suction or drainage devices are placed to facilitate perfusion. The abdominal organs are packed with ice for cooling while flushing and recovery of other organs are performed. Mobilization of the ascending and descending colon can be performed to allow for more direct exposure of the kidneys to ice. Recovery of thoracic organs, liver, and pancreas generally precedes recovery of the kidneys (Fig. 8.3). Recovery of the kidneys can be performed either individually or en bloc. Individual recovery of the kidneys is performed by transecting the left renal vein at the vena cava. The aorta and vena cava can both be transected superior to the level of cannulation (usually just superior to bifurcation) and at the origin of the superior mesenteric artery (SMA) and superior to the right renal vein. Division of the aorta should be performed by incising the base of the SMA and, with an oblique angle, entering the aorta superiorly to identify renal arteries because they often enter at this level or higher. Superior transaction of the aorta should be performed ideally to preserve a Carrel patch on both the right and left renal arteries. The right renal vein should be identified before transaction of the vena cava to preserve a
superior cuff that can be used to construct a venous extension when necessary. Individual recovery starts with either side by isolating the ureter and gonadal vein and transecting distally. Care should be taken to leave tissue around the ureter with sharp dissection to minimize the risk of devascularizing the ureter by stripping it of adjacent tissues. The anterior wall of the aorta can be longitudinally sharply transected, followed by division of the posterior wall, with care taken to identify single or multiple renal arteries and leave sufficient tissue for Carrel patches around each vessel. From an inferior approach, working from the midline and posterior to the aorta, all tissues can be sharply divided with attention to the location of the ureter to avoid inadvertent injury. Working both superiorly and laterally, the vasculature and kidneys can be separated from the lateral abdominal and retroperitoneal attachments. Posterior dissection proceeding directly against the psoas muscle will minimize the risk of injuring renal arteries. Regardless of extent, Gerota’s fascia should be removed with the kidneys to be separated at later time. The right kidney should be removed with all remaining vena cava to preserve the conduit for venous extension grafts when necessary. En bloc recovery of the kidneys is performed without longitudinal transection of the aorta or division of the renal vein. Inferior to superior dissection is performed posterior to the aorta and vena cava, and with initial isolation of the ureters to avoid injury. Separation of the kidneys is then
Portal vein Aorta Left gastric artery Celiac axis Splenic artery Hepatic artery Catheter in splenic vein
Incised gallbladder Transected common bile duct Right gastric artery Inferior vena cava Gastroduodenal artery
Superior mesenteric artery and vein
B R. gastric artery
Bowel, duodenum, and pancreas retracted
Hepatic artery Splenic artery and vein
Short gastric arteries L. gastric artery Portal vein Aorta
Loose ligament around retracted superior mesenteric artery
Superior mesenteric artery and vein
Celiac artery Superior mesenteric artery L. kidney
R. kidney Perfusion catheters
Aorta Vena cava
Ureter Inferior mesenteric artery Aorta IVC
Fig. 8.3 Deceased donor organ retrieval. (A) The chest and abdomen are opened through a midline incision. The abdominal cavity is inspected for any evidence of disease or injury. Initial control of the distal aorta is obtained in the case that urgent flushing becomes necessary. (B) The splenic vein is catheterized through the inferior mesenteric vein for portal perfusion. Limited portal dissection should include distal ligation of the common bile duct and incision and flushing of the gallbladder. (C) Pancreas dissection can be performed by division of the short gastric vessels and medial visceral rotation of the spleen and pancreas in a plane posterior to the splenic vein and artery. (D) The duodenum should be widely mobilized allowing for access to the superior mesenteric artery and infrahepatic vena cava. (E) The distal aorta is cannulated with a perfusion catheter after heparinization, and drainage devices may be placed in the distal vena cava. (F) Aortic cross-clamp is performed in the supraceliac location, and perfusion and cooling with ice is performed. After removal of thoracic organs, liver, and pancreas, kidney dissection is commenced. Additional attention should be directed to preserving ureteral length and aortic cuff around the origin of single or multiple renal arteries. Kidneys can be recovered individually or en bloc.
Kidney Transplantation: Principles and Practice
performed after removal with the similar goals of leaving an aortic cuff for all renal arteries and the vena cava with the right kidney. Local procurement centers have preferences for marking the ureters with ligature or other labeling to identify right versus left kidneys. If concerns exist for the quality of perfusion based on the appearance of the kidneys, direct cannulation and perfusion of the right and left renal arteries can be performed on the back table. Although this step is not usually necessary, concern regarding poor perfusion or the mottled appearance of the kidneys should direct additional flushing.
Donation After Circulatory Death Whereas in total numbers DBD donors account for the vast majority of recovered and transplanted kidneys, DCD has become an increasingly common source of deceased donor kidneys in recent years. In the US in 2015, DCD donors provided more than 2000 donor kidneys (nearly 20% of the total deceased donation). DCD donors yielded more kidneys per donor (1.56) than brain dead donors (1.44).1 Recovery of kidneys from DCD donors is performed in a similar manner to brain dead donors with a few modifications. Individual hospitals and organ procurement organizations (OPOs) set specific guidelines for time limits for recovery to be performed after withdrawal of life support that vary between 60 and 120 minutes. These waiting periods occur either in a perioperative setting or in the operating room; outside the US, this time may extend to 180 to 240 minutes. According to local practice, patients are declared deceased after cessation of pulse, cardiac rhythm, or electrical activity. The cessation of all pulseless electrical activity (PEA) has not been deemed necessary as a criterion for declaration in the absence of pulse pressure.5 An additional waiting period between 2 and 5 minutes occurs before initiation of organ recovery. The period of warm ischemic time between withdrawal of life support and the initiation of cooling and perfusion with organ preservation solutions contributes to the increased rates of delayed graft function and organ dysfunction seen with DCD organs. Thus the surgical procedure needs to be performed in an expedited fashion to cool and perfuse organs as soon as possible. A midline incision from sternal notch to pubis is rapidly performed and, using combinations of sharp and blunt dissection, the abdominal cavity is entered and the distal aorta is cannulated with a perfusion catheter with or without isolated control. Immediate perfusion should commence at this point. Transection of the distal inferior vena cava and placement of drainage device or suction catheter can be performed to facilitate perfusion. Depending on recovery of the liver or thoracic organs, the aorta can be clamped at the level of the descending thoracic aorta after opening the chest. DCD recoveries for kidneys alone can avoid opening the chest, and clamping of the aorta should occur at the supraceliac level. The abdominal cavity should then be packed with ice during perfusion. A rapid surgical technique designed to minimize the time taken to achieve cross-clamp and
explant of the organs from the abdominal cavity, and facilitate organ cooling may improve renal outcomes as has been reported with other organs.6 While infusion of the preservation solution is underway, surgical recovery of the kidneys can be performed with a similar technique to recovery in DBD donors. Whereas an expedient technique is important, precision remains paramount in these circumstances to prevent the higher rates of surgical damage and organ discard that have been reported.7 After removal of the kidneys from the abdominal cavity, additional perfusion can be performed once the kidneys are in cold solution depending on either preference or concerns regarding the quality of intraabdominal perfusion. Modified technical approaches including balloon catheter placement for in situ preservation or use of extracorporeal support after death have not achieved substantial effect in improving results.5,6 Although supportive data exist regarding the ability of hypothermic pulsatile perfusion to improve outcomes for DCD kidneys, conflicting data still exist and thus this conclusion is not uniform.8,9 Additional interest in normothermic perfusion devices has been generated in recent years. Although no definitive conclusions can be reached, potential for improved function and decreased rates of DGF are under investigation.10 Although a variety of strategies have been proposed, including initiating normothermic perfusion in situ, ex vivo at the donor hospital, or on return to the recipient center, a single system that has reliably improved outcomes has yet to be reported.
Living Donor Nephrectomy Living renal donation provides an invaluable resource in regard to both organ quantity and quality. There are 5600 living kidney donations annually in the US, which accounts for approximately 30% of annual US renal transplant volume. The absolute number of living donors nearly equals the number of deceased donors and thus remains critical as a source of transplantable organs. Living donor kidneys are of superior quality in every objective measurement including immediate graft function rates, graft half-life, and life years gained for recipients. The available pool of donors has remained relatively stable over the recent decade, although demographics have demonstrated increases in donors over 50 years old (29.5%) and women (63.5%; Fig. 8.4). The primary responsibility of the donor surgeon is patient safety, and this overarching concern must guide every pre-, intra-, and postoperative decision. The reliably safe outcomes with donor nephrectomy and good long-term renal function of donors are paramount to preserve the justification for removing a kidney from a healthy donor. As the transplant community has continued to gain experience caring for living donors, conditions that had previously served as absolute or relative contraindications to living donation are being reconsidered. Select centers now accept donors with prior surgical histories that affect the technical complexity of the operation. These include prior histories of bariatric procedures, gynecologic operations, hernia repair, appendectomy, and cholecystectomy. Although not contraindications for surgery, these procedures may predict a more complicated technical operation.
8 • Donor Nephrectomy
60 55 Male Female
50 45 40 35 2004
Fig. 8.4 Living kidney donors by sex. Increasing rates of female donors has resulted in approximately 2:1 ratio of female:male donors. (OPTN/SRTR 2015 Annual Data Report. HHS/HRSA.)
Anatomic variants that once precluded donation, such as multiple renal arteries and circum- or retroaortic renal veins, no longer eliminate potential donors at many centers. These more complicated patients may be eligible for renal donation, and consideration should be given for referral to centers with experience in these conditions.
Anesthetic Management Communication with anesthesia personnel is important to ensure that good urine output is achieved throughout the case. Pneumoperitoneum has been demonstrated to impair venous return influencing renal perfusion, and volume expansion has been demonstrated as the primary intervention to counteract this effect.11 Patients often require greater than 5 L of crystalloid to achieve a robust urine output. Mannitol can be administered in divided doses of 12.5 g to augment urine output. Urine output should be monitored and low output addressed aggressively by administering additional intravenous fluids and decreasing or eliminating pneumoperitoneum until adequate urine output is achieved. Whereas inadequate volume resuscitation is the most likely factor, identifying other confounding factors for low urine output, including relative hypotension, inability to tolerate pneumoperitoneum, or other physiologic events are important to determine whether the case should proceed. Although extremely unusual, our practice is not to proceed with donation if adequate urine output cannot be achieved. Adequate relaxation is necessary to achieve sufficient pneumoperitoneum to provide abdominal domain to perform surgery. Diminishing abdominal domain will result from patients that are inadequately paralyzed and will result in difficulty making surgical progress. This may be realized at midpoints of the case as initial paralytic agents may require redosing. Participation by experienced anesthesiologists is important throughout the procedure, but especially immediately before division of vascular structures. We do not routinely administer heparin before division of the renal vessels and have not observed complications from this practice. Some surgeons administer low-dose intravenous heparin (3000 units) before vascular division with reversal by administering protamine after removal of the kidney.
Regardless of the technical approach, control of postoperative pain should be initiated during the operative case. Intraoperative administration of narcotics provides transient pain control. The use of local anesthetics and systemic nonsteroidal agents can minimize postoperative pain and narcotic requirements. We routinely inject 0.5% liposomal bupivacaine into port and extraction sites and consider the use of intravenous ketorolac for most patients. The use of liposomal bupivacaine preparations has added to the duration of local anesthesia for up to 72 hours and we have found this useful to facilitate early postoperative pain control and discharge. Additionally, initiating regularly scheduled oral narcotics soon after surgery can prevent intense pain spikes as local agents diminish.
Open Donor Nephrectomy Open donor nephrectomy has been nearly completely replaced by minimally invasive surgical techniques. In fact, surgeons trained in recent eras may have little or no experience with standard open or miniopen techniques. Nonetheless, these techniques may be employed by select centers and/or surgeons based on indication or preference. Relative indications may include the presence of complicated vascular anatomy, prior operations that complicate laparoscopic approaches, or right nephrectomy. Whereas these techniques deserve an appropriate place in the arsenal of living donor nephrectomy, laparoscopic techniques can be successfully used in almost all cases. Despite reduced invasiveness of miniopen incisions, laparoscopic techniques still result in comparatively decreased pain, faster return to work, and higher patient satisfaction.12,13 Standard open techniques depend on the division of muscle and possible rib resection compared with miniopen approaches that are muscle-sparing and avoid rib resection. The miniopen techniques have been reported to improve donor outcomes compared with standard open techniques.14 After the induction of general anesthesia, patients are positioned in a flexed lateral decubitus orientation on the operative table. The patient is prepped and draped from the inferior rib margin to the superior iliac crest. A lateral oblique incision is performed inferior to the 12th rib with division or separation of the oblique and transverse musculature. Segmental resection of the inferior rib may be necessary to improve exposure of the upper
Kidney Transplantation: Principles and Practice
pole of the kidney. Combinations of manual and electrocautery dissection are performed around Gerota’s fascia to permit retractor placement. The peritoneal cavity is swept anteromedially as planes are created to the level of the renal vein and artery. Retractors can be placed either on fixated platforms or by handheld techniques. Retroperitoneal dissection continues around the kidney and inferiorly to identify and isolate the ureter and gonadal vessels. The ureter should be dissected close to the level of the iliac vessels to ensure adequate length. Complete mobilization of the kidney is performed, and the artery and vein are isolated at their origin and insertion in the aorta and vena cava, respectively. The adrenal gland can be separated from the parenchyma of the kidney lateral to medial. The adrenal vein on the left side may be divided between ligatures or clips to maximize renal vein length. Lumbar veins posterior to the renal vein should be divided to also maximize renal vein length. This can be performed between vascular clamps, surgical clips, or stapling devices. After complete isolation of the vascular pedicle, division of the ureter and renal vessels proceeds. The ureter and gonadal vein are divided distally with ligatures, clips, or stapling devices. The renal artery or arteries are then divided. This can be performed by ligation with or without suture or stapling device. Finally, the renal vein can be divided with a similar technique. Vascular clamps can be used to maximize vessel length with subsequent ligation and suturing of vessels after removal of the kidney. The presence of multiple vessels requires planning for the order of division. Placement of multiple vascular clamps may prove difficult with limited space, thus stapling devices may be preferred. Transfixing techniques with either sutures or staples should be used for the renal artery and vein stumps to minimize bleeding risk. Inspection for good hemostasis with or without placement of hemostatic adjuncts is then performed. Abdominal wall closure is performed in multiple layers and with preference for absorbable suture. Local anesthetic can be injected to provide local pain control and minimize systemic requirements. Similarly, intravenous nonsteroidal antiinflammatory drugs may be used to provide pain relief and minimize narcotic requirements. These should be discontinued within 48 hours. Postoperatively, patients can receive intravenous and oral narcotics and can return to normal diet and activity.
Laparoscopic Donor Nephrectomy Initial reports were made of a laparoscopic approach to nephrectomy for tumor with morcellation and extraction in 1991.15 In 1995 this approach had been successfully applied to living donor nephrectomy as Ratner made the first report of laparoscopic nephrectomy for transplantation with immediate graft function.16 Initial comparisons of open and laparoscopic approaches reported substantial improvements in donor recovery.17 These donor benefits were confirmed in subsequent studies.18,19 A recent randomized controlled trial demonstrated improved donor satisfaction, less morbidity, and equivalent graft outcomes.20 Early large series reported concerns regarding complications, especially with regard to the ureter, associated with the laparoscopic technique. These decreased as progressive technical experience was achieved.21 The improved patient recovery and minimally invasive approach has permitted discharge for select patients on the first postoperative day.22 Additionally, the advent of laparoscopic donor nephrectomy was associated with increased living donation rates and overall volumes, providing important recipient benefits.23 In the US in 2015, 97% of living donor nephrectomies were performed by a laparoscopic approach, with a majority performed with a hand-assisted approach (Fig. 8.5). The number of cases performed via an open approach has continued to decrease over the past 5 years with 3% of donor nephrectomies performed via an open retroperitoneal or transabdominal approach.1
HAND-ASSISTED TECHNIQUE Hand-assisted techniques are the preferred approach for many groups and allow for combinations of manual dissection and retraction with laparoscopic visualization and energy devices. Most series report improved speed with hand-assisted techniques compared with other laparoscopic approaches.24 The intraabdominal presence of a hand may also be perceived as an improved safety benefit for manual control of bleeding or other injury that may occur. Whereas large series do not specifically support these concepts, most surgeons are comfortable with open techniques providing direct manual control. The hand port site is also generally used as the extraction site and does not add morbidity, although its location is generally in an upper midline
60 Transabdominal Flank (retroperitoneal) Laparoscopic not assisted Laparoscopic hand assisted Unknown
40 20 0 2004
Year Fig. 8.5 Living kidney donation by procedure type. Laparoscopic approaches dominate technical procedure type with the majority performed hand assisted. (OPTN/SRTR 2015 Annual Data Report. HHS/HRSA.)
8 • Donor Nephrectomy
location and is thus more visible than alternate extraction sites. The technical steps for recovery are similar to the total laparoscopic approach (discussed next) with the obvious addition of a hand to assist.
TOTAL LAPAROSCOPIC APPROACH Total laparoscopic approach for donor nephrectomy is performed with the donor in either a total or modified lateral position with flexion of the operative table to open the space between the iliac crest and the ribs (Fig. 8.6). After sterile preparation and draping of the abdomen, a Veress needle can be placed in the left lower quadrant and used to insufflate the abdomen to 15 mmHg pressure. Our preference is to use camera visualization through the first port that is placed with subsequent direct visualization of each additional port. A combination of 5-mm and 12-mm ports are placed in periumbilical, superior and inferior midabdominal, and lateral locations. Placement of a 12-mm port in the periumbilical location allows for interchange of dissecting and stapling devices. The left colon is mobilized along the line of Toldt by dividing this line with the harmonic scalpel or other energy device (Fig. 8.7). The colon and mesentery should be swept medially with care not to cause a mesenteric defect or injure mesenteric vessels. If a mesenteric defect is identified this should be repaired with suture or clips to avoid potential for internal hernia formation. After the mesentery has been swept medially off the psoas and kidney, the ureter and gonadal vein are identified. The ureter can be identified just superior to the iliac vessels or near the inferior pole of the kidney. Care should be taken not to directly grasp the ureter or use energy devices in direct proximity given the potential for unrecognized injury. A plane should be created under the ureter and gonadal vein that can then be elevated while remaining tissues are dissected (Fig. 8.8). The ureter and gonadal vein are elevated as a bundle, and a lateral window is created with an energy device. Our preference is to use an energy device because small vessels can be present in some of these tissue planes. Dissection should be carried distally
Fig. 8.6 Positioning and incision placement for laparoscopic left donor nephrectomy. The donor is positioned in a right lateral decubitus position with flexion opening the space between costal margin and iliac crest. A 12-mm port is placed periumbilically and options for 5- to 12-mm ports in superior and inferior midclavicular and lateral midaxillary positions. Extraction can be performed through a transverse Pfannenstiel incision.
to a level immediately superior to the iliac vessels to provide adequate recipient length. Proximal to the kidney, elevation of the ureter and gonadal vein is performed as lymphatics and vessels are identified and divided. We generally do not divide the gonadal vein; however, in certain cases this may provide additional exposure to the renal artery and vein. Almost all donors have lumbar veins that can vary from small and singular to multiple and large. Preoperative imaging will identify larger lumbar vessels but may be less effective in identifying multiple branches. Additionally, aberrant venous anatomy including multiple renal
Fig. 8.7 Mobilization of colon. The line of Toldt and splenocolic ligament are divided with an energy device (i.e., harmonic scalpel) and the colon and mesentery are swept medially. Care must be taken to avoid or identify a mesenteric defect during medial mobilization of the colon and mesentery.
Fig. 8.8 Elevation and dissection of the ureter and gonadal vein. A plane is created under the ureter and gonadal vein. Anterior elevation of these structures allows for dissection from a distal level near the iliac vessels to a proximal location of the renal hilum. Attention to the presence of additional renal arteries and lumbar vessels is necessary as dissection proceeds superior to the hilum.
Kidney Transplantation: Principles and Practice
Fig. 8.9 Division of the adrenal and lumbar veins. As the kidney is elevated with instruments dissection of the lumbar vein from surrounding lymphatics can be performed. Smaller adrenal and lumbar veins can be divided with energy devices; larger vessels should either be clipped and divided or divided with a stapling device. Consideration of likely division sites of the renal artery and vein should be performed to avoid interference of clips with stapling devices.
veins, circumaortic, and or retroaortic renal veins may also be associated with variants in lumbar venous anatomy. Smaller lumbar veins can be divided with energy devices. Larger lumbar vessels (>6 mm) should be divided with either clip appliers or stapling devices (Fig. 8.9). Judgment as to the possible interference of metallic clips with subsequent stapling devices needed to divide renal artery and vein is important, because clips can interfere with proper closing and stapling. Vascular staples, in contrast, do not generally interfere with the ability to place stapling devices over or in close proximity. Elevation of the kidney from the lower pole can then reveal the renal artery and vein. Lymphatics are present in varying amounts and density around the vessels, and require dissection, isolation, and division. Division of the periaortic lymphatics demands precision with energy devices because the risk of injury and bleeding exists if these devices come into contact with blood vessels. The artery should be completely isolated from the renal vein by careful dissection and should be exposed as proximal to the aorta as is safely possible. This is of increased importance in early branching arteries that may require more extensive dissection down to the level of the aorta. Multiple arteries are present in approximately one-quarter of donors. Preoperative knowledge of the location of each additional vessel is important to anticipate as dissection is performed. Arteries that originate significantly inferior to the main renal artery require additional care in elevation of the ureter, gonadal vein, and kidney, because traction injuries become increasingly possible. Likewise, avoiding overdissection of smaller, more inferior arteries can prevent inadvertent injury. The upper pole of the kidney is separated from the renocolic and splenorenal ligaments using a combination of blunt dissection and energy devices. The spleen can be retracted medially in combination with lateral retraction of the kidney to open this space. Retraction of the spleen and surrounding tissues can also be a potentially hazardous maneuver and should be done with blunt instruments or graspers to avoid injury to the spleen. As this space is
developed, the adrenal gland requires separation from the upper pole of the kidney. The adrenal gland is often identifiable and can be gently positioned with a grasper as dissection is performed immediately lateral to the gland. In obese donors, it may be difficult to identify the adrenal gland, and dissection along separate tissue planes that belong either medially with the adrenal gland or laterally with Gerota’s fascia is performed in potentially ambiguous territory. Upper pole vessels often occupy the space between the adrenal gland and kidney; therefore closer proximity to the adrenal gland and away from the renal hilum is preferred. Dissection of the upper pole of the kidney should be carried posteriorly to the level of the psoas muscle and superiorly to the diaphragm. We perform separation of Gerota’s fascia from the diaphragm and psoas with energy devices to minimize even small amounts of venous bleeding. Care needs to be taken with dissection around the diaphragm to not inadvertently injure or perforate it with resultant pneumothorax. Unrecognized injuries manifest as progressive billowing of the diaphragm into the operative field. These injuries can be repaired laparoscopically by suturing the identified defect with reduced pneumoperitoneum and Valsalva maneuvers. The renal and adrenal veins are apparent at various stages during the procedure. The adrenal vein is usually divided from the renal vein to provide additional venous length on the left kidney. The adrenal vein should be completely isolated from the renal vein and with clear posterior planes as the renal artery and aorta are in immediate proximity. The adrenal vein can be divided with either energy devices or clip appliers. Care with clip placement is important to not interfere with stapling devices necessary for division of the renal vein. After division of the adrenal vein, the renal artery is easier to identify and can be dissected from the periaortic lymphatics. Tissues can be swept medially off the anterior surface of the renal vein to provide maximal length. Elevation of the renal vein with a blunt instrument and clearance of a posterior plane can also be completed. We perform separation of the kidney from its posterior retroperitoneal attachments at varying times during individual cases, depending on our ability to visualize key structures. As a general rule, if the kidney is mobilized too early in the case, the kidney can inadvertently rotate medially and complicate vascular dissection. We typically leave Gerota’s fascia intact with the kidney as we perform this retroperitoneal dissection. Separation of the kidney from the Gerota’s fascia, even when extensive, can be difficult with densely adherent fat that may risk capsular injury to the kidney. As the kidney is completely mobilized medially, the psoas muscle and origin of the renal artery become apparent. Dissection of the posterior and superior aspects of the renal artery can sometimes be facilitated with the kidney in a medial location. Likewise, lumbar vessels may sometimes be easier to identify and or divide with the kidney medially rotated. Extraction can be performed via either a Pfannenstiel or lower midline incision. Through either approach, the rectus is exposed and a 15-mm port is inserted to accommodate a large endocatch bag for retrieval. Alternatively, the endocatch bag can be directly placed through a small defect in the peritoneum. Care needs to be taken not to have an
8 • Donor Nephrectomy
Fig. 8.10 Division of the renal artery. The kidney can be retracted laterally and anteriorly with instruments as a vascular stapling device is placed just beyond the origin of the renal artery. Cutting or noncutting staplers can be used, but attention to the distal location of the stapler is important to avoid clips or other improper positioning.
uncontrolled violation of the peritoneal cavity, otherwise pneumoperitoneum will not be maintained during vascular stapling. Division of the ureter and gonadal vein is performed first with a vascular staple load. This is performed distally with direct observation of the distal stapler to confirm that the iliac vessels are not in proximity. The renal artery is then divided with the kidney elevated to maximal height. If multiple arteries exist and are separated by more than 5 to 10 mm, we divide the inferior vessel first followed by new staple loads for superior arteries. If arteries are in close proximity they can be taken with a single staple load. After arteries are divided, the kidney is retracted to a maximally lateral extent and a stapler is placed on the renal vein as close to the vena cava as is safely possible. Stapling requires care and attention to the stapling device and staple loads. An experienced scrub nurse or technician should be familiar with expedient reloading of the stapler. Any concern regarding the function or proper reloading of the device justifies replacement with a new stapling device that should be immediately available in the operating room. Before firing the stapling device, direct visualization of proper alignment of the stapler, including the distal extent of the device and proper position of the staple cartridge, should be confirmed by the surgical team (Fig. 8.10). This includes care not to close the stapler across metal clips, which can cause misfire. There have been limited reports of stapler misfires; however, they can be catastrophic and require expedient management.25 The most significant danger is for improper stapling before division of the vessel with a cutting device. A transected bleeding artery or vein should be controlled directly with a laparoscopic instrument or hand if possible. If the vessel can be controlled, determination can be made whether the vessel can be restapled, clipped, or oversewn with laparoscopic techniques. If this is not possible, direct pressure should be attempted while a midline laparotomy incision is made for direct exposure and repair. Noncutting stapling devices
Fig. 8.11 Placement of the kidney into endocatch bag. After division of the ureter and vascular structures, the kidney and entire ureter should be placed into an endocatch bag under direct visualization. Once all structures are inside the bag, it can be closed and extracted through the selected incision site.
may offer advantages when preserving early bifurcations because of a decreased width of the device. Additional, noncutting devices allow for confirmation of the correct placement of staples before subsequently dividing the vessel with endoscopic scissors. Plastic or metallic clips should not be used to ligate main renal vessels and the US Food and Drug Administration (FDA) issued a specific alert in 2011 that updated 2006 warnings regarding the use of Weck Hemo-Lok Ligating Clip for renal artery ligation in living kidney donors secondary to risk of postoperative dislodgement and hemorrhage.26 Furthermore, it should be noted that transfixion of tissue is the only acceptable method for renal artery division in living donor nephrectomy. After all vessels have been transected, the kidney should be confirmed to be free of all retroperitoneal attachments. Residual attachments can be divided with energy devices or additional staple loads if necessary. The endocatch bag is directly deployed under the kidney and the kidney and ureter are placed completely in the bag under direct visualization (Fig. 8.11). The bag should also be closed under direct visualization because injury to the kidney or ureter can occur if they are not contained within the bag. Rarely, a kidney may be unable to be placed in the bag because of size or other technical issues. Manual retrieval should then be performed quickly and if possible while retaining pneumoperitoneum to aid in identification and control of the kidneys. The rectus can be opened in either a vertical or transverse direction as the kidney is retrieved from the abdominal cavity. The kidney is immediately placed on ice and brought to the back table for preparation. Staple lines should be transected and direct cannulation and flushing of all renal arteries is performed until clear effluent is achieved. The extraction site can be closed with either running or interrupted absorbable (PDS or Maxon) #1 sutures. After closure of the extraction incision, pneumoperitoneum is
Kidney Transplantation: Principles and Practice
reestablished and confirmation of good hemostasis at all dissection and vascular division sites is performed. Occasionally, gonadal vessels will require additional clip placement at the level of the ureteral division. The renal artery and vein should be directly observed. Blood is aspirated from the retroperitoneal space and near the spleen to confirm no unidentified bleeding. Hemostatic agents are not generally required, but can be placed as an adjunct to hemostatic maneuvers when necessary. Mesenteric defects can be repaired at this point if identified (as discussed earlier). Rarely, challenging bleeding can occur from adrenal, splenic, and lumbar venous sources. If adrenal or splenic bleeding cannot be confirmed to be controlled, consideration for removal should be given. Lumbar venous bleeding can be difficult to manage, and if direct control and sealing with energy device or clip placement cannot be achieved, an attempt to directly oversew the vessel should be made. The procedure should never be concluded in the absence of perfect hemostasis, and drains are almost never indicated. Ports can be removed under direct visualization. Larger port (12- and 15-mm) sites can be closed as practiced per routine of the surgical team. The extraction and port sites are anesthetized with injectable agents (lidocaine or marcaine) and closed with absorbable subcuticular sutures. Ketorolac can be used per physician discretion to minimize postoperative discomfort and narcotic use.
Right Donor Nephrectomy Laparoscopic right donor nephrectomy is rarely performed, with rates between 1% to 4% at large US centers. Initial technical challenges with laparoscopic right nephrectomy resulted in increased vascular complications compared with left kidneys. Modifications in donor techniques to preserve donor vein length, and in the recipient to mobilize the iliac venous system, can improve these outcomes.27 Nonetheless, multiple renal arteries and anomalous renal venous anatomy are not contraindications for left donor nephrectomy. The presence of stones, cysts, or lesions within the right kidney are strong indications for right, rather than left, nephrectomy. The operative approach is modified by the requirement of liver retraction. This is achieved through limited right lobe mobilization with placement of a liver retractor to elevate the liver over the superior pole of the right kidney. The operation is further modified by the requirement for division of the right gonadal vein that inserts directly into the vena cava. The right adrenal vein generally does not need to be divided because it is separate from the right renal vein. The shorter right renal vein also requires extra attention to stapling with either cutting or noncutting vascular stapling devices. Maximum retraction of the kidney and exposure of the vena cava are performed to allow placement of the stapling device for maximum vein length.
Single-Port Donor Nephrectomy Although multiport laparoscopic and hand-assisted donor nephrectomy techniques have supplanted the open donor nephrectomy and are clearly the most widely offered
Fig. 8.12 Cosmetic result of single-port donor nephrectomy 2 years postdonation. Single-port donor nephrectomy performed through the umbilicus with transumbilical extraction allows for minimization of the apparent incision length with minimal residual scar. (Ann Surg. 2013;257:527–33.)
donor procedure in the world, select centers perform laparoscopic donor nephrectomy through a single small incision. The technique was first described in 2008 as a feasible approach with good outcomes.28 Some supportive evidence exists that this approach offers improved recovery in comparison to standard laparoscopic techniques.29 Our center transitioned to a single-port laparoendoscopic (LESS) technique in 2009. This is now our standard approach in all cases. The rationale for this transition lay in the ability to perform the entire dissection and extraction through a small incision concealed within the umbilicus of the donor. This has led to a very small residual scar once healed (Fig. 8.12), and we have shown equivalent safety with improved patient satisfaction compared with multiport laparoscopy.30 The single-port devices that are commercially available typically allow for entry of 3 to 4 instruments (Fig. 8.13). Although the technical steps in LESS donor nephrectomy are not significantly different from those in standard multiport approaches, the surgeon’s hands are often closely opposed to each other, and instruments must frequently cross within the confines of the abdominal cavity. Although these conditions are anathema to the basic tenets of laparoscopy as taught to earlier generations, basic maneuvers can lessen their effect. The procedure can be performed with standard laparoscopic instrumentation and camera. The substitution of the single-port device for the multiple ports required in either hand-assisted or total laparoscopic approaches does not demonstrate substantial cost differences. It is difficult to describe the technique and instrumentation with absolutism, and optimum exposure and safety is typically achieved after a brief period of trial and error using alternative bed positioning (both Trendelenburg/reverse
8 • Donor Nephrectomy
Fig. 8.13 Single port donor nephrectomy. Patient position and operating room setup are similar to standard laparoscopic nephrectomy. Surgeon and assistant are in close proximity as multiple instruments and camera are inserted through the umbilical port. The assistant operating the camera and/ or additional instrument must pay attention toward avoiding interference with the primary surgeon’s instruments.
Trendelenburg and leftward/rightward tilting), operating instruments of differential length (bariatric length in one hand, standard length in the other), and alternative port positioning within the single-port device. We have found that the deflectable tip 5-mm camera provides ideal visualization without undue steric hindrance to the operating surgeon. In cases of right donor nephrectomy, we use a single-port device that can accommodate a fourth port for the liver retractor. We found four techniques that were important to mastery of the single-port approach and normalization of operative times compared with total laparoscopic approaches. First, ventilation of smoke and vapor through the single-port device is critical, and recent generations of port devices have incorporated this into their design. Second, elevation of the lower pole of the kidney anteriorly and medially allows for opening of the space between the renal artery and vein for dissection. Third, retraction of the upper pole inferiorly and laterally provides separation of the kidney from splenic and adrenal attachments, and facilitates dissection of the renal artery from a superior/cephalad approach. Finally, a plan
should be determined for extraction of the kidney after division of the vasculature. Depending on the device used, the skin and fascial incisions require extension to safely deliver the kidney without significant trauma. Removal through too small a fascial or skin incision can injure the kidney and should not be aggressively attempted. Ultimately, additional port placement may be required. Once substantial experience has been gained with the technique, this tends to be required in less than 10% of cases. Commitment to early placement of additional ports in challenging cases has allowed for equivalent safety in our experience. The most critical maneuvers in any laparoscopic donor nephrectomy are the vascular dissection around the vein and artery, and subsequent stapling. These maneuvers involve fine movements that we have found not to be hindered by a single-port approach. We have reported on the normalization of our operative times and the ability to perform right and left nephrectomies with single or multiple arteries and veins.30 Although complication rates are similar to other techniques, concern for umbilical hernia necessitates careful attention to the
Kidney Transplantation: Principles and Practice
proper technique for closure of the fascia. The umbilical hernia rate is approximately 3% at our center, and the surgical technical complication rate is comparable to the rates seen in total laparoscopic and hand-assisted approaches at other centers.31 This technique continues to be our preferred approach for all living kidney donors and fits into an algorithm of preferred approaches consisting of (in order) single-port laparoscopy, multiport laparoscopy, handassisted laparoscopy, and open techniques. The improved cosmesis and potential other benefits of this technique may also translate to increased interest in living kidney donation with a further slight reduction in the invasiveness of the surgery.
Robotic Donor Nephrectomy
100 6 weeks 6 months 12 months
60 40 20 0 No
Fig. 8.14 Complications of living kidney donation from 2010 to 2014. Overall complication rate of 8.8% observed at 12 months after kidney donation. (OPTN/SRTR 2015 Annual Data Report. HHS/HRSA.)
Robotic technology has been incorporated into laparoscopic donor nephrectomy. Thus far, reports have been limited to single-center studies, and the techniques have not become widely used by the community as a whole.32–34 Although the purported advantages of robotic technology include (1) improved visualization with three-dimensional (3D) camera systems, (2) articulating laparoscopic instrumentation allowing meticulous dissection of complicated vascular anatomy, and (3) ease of intracorporal suturing, their applicability to donor nephrectomy has yet to be broadly accepted or defined. Present robotic approaches are performed with multiple laparoscopic ports and require bedside manual assistant ports for the use of energy devices, staplers, and for renal extraction. Whereas the feasibility of robotic-assisted laparoscopic nephrectomies have been clearly demonstrated, early reports have not demonstrated significant advantages over total laparoscopic and handassisted techniques, while demonstrating increased cost.35 Single-port platforms have recently been introduced, and these platforms have thus far been used predominantly for LESS cholecystectomy.36 Following studies demonstrating the use of the single-port platform in renal surgery,37,38 our group embarked on a brief clinical trial evaluating the robotic single-port platform in donor nephrectomy.39 Although robotic technology (which offers an improved 3D field of view and articulating instrumentation) has the potential to compensate for the visual and technical limitations associated with LESS nephrectomy, current instrumentation for the single-port platform does not allow for adequate instrument articulation or the use of energy devices. Continued technologic advancement may improve the ability of robotic approaches to add significant advantages to donor surgery.
hernia formation, and bowel obstruction (Fig. 8.14).1 In the 5-year period between 2010 and 2015, a total of 17 deaths occurred in prior living renal donors within 1 year of donation. Seven of these deaths were medically related and five were the result of accident or homicide. Prior analysis of more than 80,000 renal donors in the US who donated between 1994 and 2009 revealed a surgical mortality rate of 0.03%.40 Single center reports from large centers tend to provide more granular information regarding the types and frequencies of complications after donation. An early single-center study reporting 1200 laparoscopic renal donors demonstrated an intraoperative complication rate of 1.6% with a conversion rate of 0.92% (most commonly as a result of renovascular injury). An additional 4.0% of patients presented with a postoperative complication with only three patients requiring surgery for internal hernia or ileus.41 Our center had previously reported our experience with more than 700 donors, where we demonstrated an open conversion rate of 1.6% (again most commonly as a result of vascular injury); 1.2% of patients required blood transfusion.42 Five patients also had a bowel obstruction requiring subsequent exploration and one patient required splenic laceration repair. In another report of 1000 hand-assisted donor nephrectomies, a hernia rate of 4% was noted, with 0.3% of patients requiring transfusion and 1.5% requiring reoperation.43 We have recently reported our results with nearly 400 consecutive singleport donor nephrectomies.31 We noted an umbilical hernia rate of 3%. Although only one patient required conversion to an open procedure, an additional seven required a return to the operating room for internal hernia (2), evisceration (1), bleeding (1), enterotomy (1), and wound infection (2).
The 2015 report from the Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR) provides the most recent compilation of donor complications rates in the US. Complications occurred in 5.3% of donors within 6 weeks of donation. Overall 8.8% of donors reported a complication potentially related to the organ donation within the first year of donation. Reported complications included bleeding,
Living donor nephrectomy can be successfully performed through a variety of techniques, both open and laparoscopic. Minimally invasive techniques have been associated with decreased morbidity and improved recovery and should be viewed as the preferred approach for the majority of patients. Nonetheless, the key principle of donor safety should be used to make final decisions regarding donation techniques. Different centers and surgeons may have a
8 • Donor Nephrectomy
variety of approaches that result in good and safe outcomes. Thus surgeon experience becomes an important consideration in determining the specific approach that is best for each patient. Acknowledgement is made to Phil Brazio, MD, for illustrating the technique of laparoscopic donor nephrectomy accompanying this chapter.
References 1. OPTN/SRTR 2015 Annual Data Report. Department of Health and Human Services, Health Resources and Services Administration; 2016. Available online at: http://srtr.transplant.hrsa.gov/annual_ reports/Default.aspx. (accessed 28.02.19). 2. Goldberg DS, Blumberg E, McCauley M, Abt P, Levine M. Improving organ utilization to help overcome the tragedies of the opioid epidemic. Am J Transplant 2016;16(10):2836–41. 3. Rao PS, Schaubel DE, Guidinger MK, et al. A comprehensive risk quantification score for deceased donor kidneys: the kidney donor risk index. Transplantation 2009;88(2):231–6. 4. Israni AK, Salkowski N, Gustafson S, et al. New national allocation policy for deceased donor kidneys in the United States and possible effect on patient outcomes. J Am Soc Nephrol 2014;25(8):1842–8. 5. Wind J, Snoeijs MG, van der Vliet JA, et al. Preservation of kidneys from controlled donors after cardiac death. Br J Surg 2011;98(9):1260–6. 6. Magliocca JF, Magee JC, Rowe SA, et al. Extracorporeal support for organ donation after cardiac death effectively expands the donor pool. J Trauma 2005;58(6):1095–101; discussion 1092–101. 7. Ausania F, White SA, Pocock P, Manas DM. Kidney damage during organ recovery in donation after circulatory death donors: data from UK National Transplant Database. Am J Transplant 2012;12(4):932–6. 8. Jochmans I, Moers C, Smits JM, et al. Machine perfusion versus cold storage for the preservation of kidneys donated after cardiac death: a multicenter, randomized, controlled trial. Ann Surg 2010;252(5):756–64. 9. Watson CJ, Wells AC, Roberts RJ, et al. Cold machine perfusion versus static cold storage of kidneys donated after cardiac death: a UK multicenter randomized controlled trial. Am J Transplant 2010;10(9):1991–9. 10. Minambres E, Suberviola B, Dominguez-Gil B, et al. Improving the outcomes of organs obtained from controlled donation after circulatory death donors using abdominal normothermic regional perfusion. Am J Transplant 2017;17(8):2165–72. 11. London ET, Ho HS, Neuhaus AM, Wolfe BM, Rudich SM, Perez RV. Effect of intravascular volume expansion on renal function during prolonged CO2 pneumoperitoneum. Ann Surg 2000;231(2):195–201. 12. Kok NF, Lind MY, Hansson BM, et al. Comparison of laparoscopic and mini incision open donor nephrectomy: single blind, randomised controlled clinical trial. BMJ 2006;333(7561):221. 13. Perry KT, Freedland SJ, Hu JC, et al. Quality of life, pain and return to normal activities following laparoscopic donor nephrectomy versus open mini-incision donor nephrectomy. J Urol 2003;169(6):2018–21. 14. Yang SL, Harkaway R, Badosa F, Ginsberg P, Greenstein MA. Minimal incision living donor nephrectomy: improvement in patient outcome. Urology 2002;59(5):673–7. 15. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrectomy: initial case report. J Urol 1991;146(2):278–82. 16. Ratner LE, Ciseck LJ, Moore RG, Cigarroa FG, Kaufman HS, Kavoussi LR. Laparoscopic live donor nephrectomy. Transplantation 1995;60(9): 1047–9. 17. Flowers JL, Jacobs S, Cho E, et al. Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 1997;226(4):483–9; discussion 489–90. 18. Wolf Jr JS, Merion RM, Leichtman AB, et al. Randomized controlled trial of hand-assisted laparoscopic versus open surgical live donor nephrectomy. Transplantation 2001;72(2):284–90. 19. Nogueira JM, Cangro CB, Fink JC, et al. A comparison of recipient renal outcomes with laparoscopic versus open live donor nephrectomy. Transplantation 1999;67(5):722–8. 20. Simforoosh N, Basiri A, Tabibi A, Shakhssalim N, Hosseini Moghaddam SM. Comparison of laparoscopic and open donor nephrectomy: a randomized controlled trial. BJU Int 2005;95(6):851–5.
21. Jacobs SC, Cho E, Dunkin BJ, et al. Laparoscopic live donor nephrectomy: the University of Maryland 3-year experience. J Urol 2000;164(5):1494–9. 22. Kuo PC, Johnson LB, Sitzmann JV. Laparoscopic donor nephrectomy with a 23-hour stay: a new standard for transplantation surgery. Ann Surg 2000;231(5):772–9. 23. Schweitzer EJ, Wilson J, Jacobs S, et al. Increased rates of donation with laparoscopic donor nephrectomy. Ann Surg 2000;232(3):392– 400. 24. Slakey DP, Wood JC, Hender D, Thomas R, Cheng S. Laparoscopic living donor nephrectomy: advantages of the hand-assisted method. Transplantation 1999;68(4):581–3. 25. Hsi RS, Ojogho ON, Baldwin DD. Analysis of techniques to secure the renal hilum during laparoscopic donor nephrectomy: review of the FDA database. Urology 2009;74(1):142–7. 26. Friedman AL, Peters TG, Ratner LE. Regulatory failure contributing to deaths of live kidney donors. Am J Transplant 2012;12(4):829–34. 27. Mandal AK, Cohen C, Montgomery RA, Kavoussi LR, Ratner LE. Should the indications for laparascopic live donor nephrectomy of the right kidney be the same as for the open procedure? Anomalous left renal vasculature is not a contraindiction to laparoscopic left donor nephrectomy. Transplantation 2001;71(5):660–4. 28. Gill IS, Canes D, Aron M, et al. Single port transumbilical (E-NOTES) donor nephrectomy. J Urol 2008;180(2):637–41; discussion 641. 29. Canes D, Berger A, Aron M, et al. Laparo-endoscopic single site (LESS) versus standard laparoscopic left donor nephrectomy: matched-pair comparison. Eur Urol 2010;57(1):95–101. 30. Barth RN, Phelan MW, Goldschen L, et al. Single-port donor nephrectomy provides improved patient satisfaction and equivalent outcomes. Ann Surg 2013;257(3):527–33. 31. LaMattina JC, Powell JM, Costa NA, et al. Surgical complications of laparoendoscopic single-site donor nephrectomy: a retrospective study. Transpl Int 2017;30(11):1132–9. 32. Hubert J, Renoult E, Mourey E, Frimat L, Cormier L, Kessler M. Complete robotic-assistance during laparoscopic living donor nephrectomies: an evaluation of 38 procedures at a single site. Int J Urol 2007;14(11):986–9. 33. Gorodner V, Horgan S, Galvani C, et al. Routine left robotic-assisted laparoscopic donor nephrectomy is safe and effective regardless of the presence of vascular anomalies. Transpl Int 2006;19(8):636–40. 34. Horgan S, Vanuno D, Sileri P, Cicalese L, Benedetti E. Robotic-assisted laparoscopic donor nephrectomy for kidney transplantation. Transplantation 2002;73(9):1474–9. 35. Boger M, Lucas SM, Popp SC, Gardner TA, Sundaram CP. Comparison of robot-assisted nephrectomy with laparoscopic and hand-assisted laparoscopic nephrectomy. JSLS 2010;14(3):374–80. 36. Konstantinidis KM, Hirides P, Hirides S, Chrysocheris P, Georgiou M. Cholecystectomy using a novel Single-Site® robotic platform: early experience from 45 consecutive cases. Surg Endosc 2012;26(9):2687–94. 37. Khanna R, Stein RJ, White MA, et al. Single institution experience with robot-assisted laparoendoscopic single-site renal procedures. J Endourol 2012;26(3):230–4. 38. Kaouk JH, Autorino R, Laydner H, et al. Robotic single-site kidney surgery: evaluation of second-generation instruments in a cadaver model. Urology 2012;79(5):975–9. 39. LaMattina JC, Alvarez-Casas J, Lu I, et al. Robotic-assisted single-port donor nephrectomy using the da Vinci single-site platform. J Surg Res 2018;222:34–8.. 40. Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA 2010;303(10):959–66. 41. Leventhal JR, Paunescu S, Baker TB, et al. A decade of minimally invasive donation: experience with more than 1200 laparoscopic donor nephrectomies at a single institution. Clin Transplant 2010;24(2):169–74. 42. Jacobs SC, Cho E, Foster C, Liao P, Bartlett ST. Laparoscopic donor nephrectomy: the University of Maryland 6-year experience. J Urol 2004;171(1):47–51. 43. Serrano OK, Kirchner V, Bangdiwala A, et al. Evolution of living donor nephrectomy at a single center: long-term outcomes with 4 different techniques in greater than 4000 donors over 50 years. Transplantation 2016;100(6):1299–305.