Objectives: The right kidney is not commonly selected for donor nephrectomy compared with the left kidney. Most left donor nephrectomies are performed by laparoscopic approach, whereas open donor nephrectomies are preferred on the right side. We present our experience of right laparoscopic donor nephrectomy, which was a substantial percentage of all performed laparoscopic donor nephrectomies.

Materials and Methods: We retrospectively analyzed all the donor nephrectomies performed at a single center, including indicators for right side open donor nephrectomy, as well as the demographic details of donors and intraoperative events, complications, and hospital stay for right side laparoscopic donor nephrectomy. Recipients were evaluated for outcome and complications.

Results: We performed 850 donor nephrectomies, including 640 left donor nephrectomies and 210 right donor nephrectomies. Of 210 right donor nephrectomies, 160 cases were performed laparos­copically, and 50 cases were open surgeries. Common indications for choice of right open donor nephrec­tomy were related to the donor. Factors related to the recipient included obesity, left iliac fossa transplant, and robotic transplant to the recipient. The surgical outcomes or complication rates in right side laparoscopic donor nephrectomy were not significantly different. Regarding recipients, we found that graft function, perioperative parameters, and vascular complications did not differ much in right side laparoscopic donor nephrectomy.

Conclusions: The right side laparoscopic donor nephrectomy is as safe as left laparoscopic donor nephrectomy or right side open donor nephrectomy. Careful consideration of recipient factors is very important along with donor factors before opting for an open or laparoscopic approach on the right side. Slight modifications in technique may provide a few additional millimeters of length, which can significantly increase the incentive to choose laparoscopic donor nephrectomy on the right side.

Key words : Left side nephrectomy, Open donor nephrectomy, Retrospective study, Right side nephrectomy

Introduction

Laparoscopic donor nephrectomy (LDN) revolu­tionized the kidney transplant program by increasing the numbers of willing donors.¹ Compared with open donor nephrectomy (ODN), LDN has significantly reduced the donor morbidity with less postoperative pain, brief hospital stay, and improved cosmesis.² Laparoscopic donor nephrectomy is usually preferred on the left side, which has a long and sturdy left renal vein.3 Right side donor nephrectomy (DN) is usually avoided because of the shortness of the right renal vein. Other factors contribute to the disfavor the option for the right DN, such as the need for liver retraction, course of renal artery posterior to the inferior vena cava (IVC), and greater risk for morbidity and difficult complications, eg, possible intraoperative injury to nearby organs such as IVC, duodenum, and liver.^4,5

Laparoscopic donor nephrectomy on the right side is also less favored because of anatomical issues, technical challenges, and higher risks of allograft failure and renal vein thrombosis.6 Various studies have shown a lower percentage of right LDN compared with left LDN.^7,8 At our institute we have completed 4000 renal transplants so far, and we started performing LDN from 2015. Our policy is to recover the best available graft, irrespective of the side. Here, we present our experience of right side LDN, which was a significant percentage of all LDN performed by our team.

Materials and Methods

This study was started after permission was obtained from the institutional ethics committee. We retrospectively analyzed all DN performed at a single center from January 2015 to October 2018. We performed 850 DN in this period, which included 640 left side DN and 210 right side DN. We analyzed the indications to favor the right side option. We further analyzed the 210 right side DN and found that 160 cases were LDN and 50 cases were ODN. The indications for right side ODN were analyzed, regardless of whether these were related to the donor or recipient. The demographic details for donors who underwent right LDN, including age, sex, blood group compatibility, and body mass index (BMI, calculated as weight in kilograms divided by height in meters squared), were analyzed. We analyzed intraoperative events including operative time, estimated blood loss, warm ischemia time, and anastomosis time. Complications and hospital stay were also analyzed for right LDN. Respective recipients were evaluated for outcome and complications.

Technique
The patient was placed in a modified left lateral decubitus position without flexing the operating table. We used a conventional 4-port technique. After the creation of pneumoperitoneum, a 12-mm camera port was placed 4 cm above the umbilicus at the lateral border of the rectus abdominis. One 12-mm working port was placed in the right subcostal area, and another 12-mm working port was placed just below the level of the umbilicus at the lateral border of the rectus abdominis. Another 5-mm port was placed below the xiphisternum for retraction of the liver. The basic steps were the same as conventional LDN.

After incision of the Toldt fascia, the ascending colon and duodenum were mobilized medially. The ureterogonadal complex was identified, and the ureter was separated from the gonadal vein. The ureter was adequately mobilized distally up to the iliac vessels and lifted gently. Then the hilar dissection was performed, and the renal vein was identified, dissected, and exposed up to its insertion in the IVC. The IVC was also dissected adequately below and above the renal vein insertion for optimal use of the endovascular stapler. The renal artery was identified posterior to the renal vein. The vessels were completely skeletonized to remove all tissue between the vessels, and we examined whether adequate length would remain after ligation. We dissected the renal artery at the posterolateral aspect of the IVC to obtain an adequate length by rolling the IVC medially.

Next, the upper pole was dissected while sparing the adrenal gland. The kidney was completely mobilized, with it suspended on the ureter and vessels. In the event that the length of the artery were deemed inadequate, the kidney may be flipped medially, with the artery dissected behind the IVC. At this stage, we evaluated whether the recipient was prepared to receive the graft. After confirmation, we made an adequate lower abdominal incision to permit the surgeon to extract the graft by hand, with the peritoneum intact to avoid a gas leak.

We clipped the ureter as distal as possible but retained it intact to provide traction for the next steps in the procedure. Then, we clipped the renal artery with 2 Hem-o-lok polymer ligation clips and divided the artery with no clip on the graft side. After that, the kidney was lifted by the renal vein, and the endovascular stapler was applied on the vein, with careful technique to grasp part of the IVC wall into the jaws of the stapler to obtain extra length of the renal vein. For the final step, the ureter was divided above the previously placed clip.

After incision of the peritoneum at the previously placed incision, the graft was extracted and delivered to the recipient’s surgeon. After closure of the extraction site incision, pneumoperitoneum was re-created, and hemostasis was restored. We avoided the use of a drain except for a few cases with vascular complications.

Statistical analyses
The latest SPSS software was used for data analyses. The data are presented as percentages or mean values ± SD.

Results

We performed a total of 850 DN from January 2015 to October 2018, including 640 left DN and 210 right DN. In accordance with India’s Transplantation of Human Organs Act, we only perform living related transplants, and most of our donors are first-degree relatives of recipients. Of 210 donors selected for right DN, most (76.2%, 160/210) were first-degree relatives and 23.8% (50/210) were second-degree relatives. Among the first-degree relatives, most donors were mothers (30%, 48/160), followed by spouses (25.6%, 41/160), fathers (15.6%, 25/160), sisters (13.1%, 21/160), brothers (9.4%, 15/160), and daughters/sons (6.3%, 10/160). Among 50 second-degree relatives, the predominant donors were aunts (54%, 27/50), followed by grandparents (30%, 15/50) and uncles (16%, 8/50).

The indications for preference of right side DN are shown in Table 1. The common indication for choice of the right DN was to avoid the complex arterial anatomy on the left side, which included multiple vessels on the left side in 145 cases and very early branching of the left renal artery in 28 cases. Of 145 cases with multiple vessels on the left side, there were 2 arteries in 117 cases, 3 or more arteries in 18 cases, and 3 or more veins in 10 cases. There were other indications, including improved function of the left kidney in 25 cases (>10% differential function), renal artery stenosis at the origin of the right renal artery in 4 cases, and small calyceal stones in the right kidney in 8 cases.

Of 210 right DNs, 160 cases were LDN, and 50 cases were ODN. The common indications for right ODN are shown in Table 2, ie, related to the donor, which included very short renal veins in 20 donors, branching of the renal artery medial to the IVC in 11 donors, and double right renal veins in 8 donors. Factors related to the recipient were present in 17 cases of right side ODN, which included recipient obesity in 13 cases, left iliac fossa transplant in 3 cases, and robotic transplant to the recipient in 1 case.

Of 160 cases of LDN, 148 cases had a single renal artery and renal vein, whereas 12 cases had 2 arteries and single vein. The demographic characteristics of 160 cases of right side LDN are shown in Table 3. The mean age of donors was 42.3 ± 11.5 years, and the mean BMI of donors was 27.15 ± 0.62. The female donors (100) outnumbered the male donors (60). There were 135 ABO-compatible donors.

The intraoperative and perioperative parameters are shown in Table 4. The mean operative time was 116 ± 15.2 minutes, and mean estimated blood loss was 65 ± 11.2 mL. The mean warm ischemia time was 4.2 ± 070 minutes, the mean duration of reperfusion with ice-cold Ringer lactate was 9 ± 2.5 minutes, and the mean anastomosis time was 24 ± 3.5 minutes. The mean hospital stay of the donor was 4 ± 1.2 days (range, 2-9 days).

Table 5 shows complications in donors and recipients. There were 4 vascular complications during LDN. Inferior vena cava injury occurred in 2 cases due to stapler malfunction. Adrenal vein and gonadal vein injury occurred in 1 case each. There was conversion to open surgery in 3 cases, 1 to mitigate difficult access caused by massive hepatomegaly, 1 to mitigate adrenal vein injury, and 1 to mitigate IVC injury. There was 1 case of liver laceration during retraction, which required neither repair nor conversion.

Postoperatively, paralytic ileus was noted in 11 cases, with all cases managed conservatively, and 1 case required blood transfusion in the postoperative period. No intraoperative complications were observed in recipients, and all recipients had immediate diuresis. Acute rejection was noted in 15 recipients, and delayed graft function was noted in 10 recipients. Major lymphocele developed in 10 recipients; 9 were managed with ultrasonography-guided aspiration, and 1 needed laparoscopic fenestration and intraperitonealization. One recipient developed ureteric leak, which was managed conservatively.

Discussion

Ratner and associates⁹ performed the first live DN in 1995, and since then laparoscopy has become the preferred method of graft retrieval, mainly on the left side.¹⁰ The right kidney is not commonly selected for DN compared with the left kidney because the left kidney has a long and sturdy vein.^11,12 The right kidney is only selected if the left kidney is not anatomically or functionally suitable for DN. The presence of multiple arteries on the left side is a common indication to disfavor the left kidney for donation; in addition, significant differences in renal function among the kidneys, a right kidney with small stones, or a renal artery stenosis are common reasons for selection of the right kidney for donation.¹¹

We also observed that early branching of the left renal artery with less than a 5-mm length of the main stump on the left side results in 2 arteries for anastomosis in most cases. In this scenario, if the right kidney has a single artery with late branching, then it is advantageous to recover the right kidney in order to allow a single arterial anastomosis. Therefore, we selected the right kidney with the dual goal to retain the best kidney for the donor and allow for a simple and safe surgery for the recipient.

The selection of a kidney, either the right or the left, for recovery also depends on the surgeon’s experience. Mandal and colleagues11 performed right side DN in 17 cases (7.5%) from a total of 227 kidneys transplants during the period from 1995 to 1999.

However, Wang and colleagues performed a meta-analysis of 15 studies and found variable use of the right kidney for DN. They found right side DN was performed in 653 (22%) of 3073 donors.¹³ Harrison and colleagues studied anatomic variations in a select donor pool and found bilateral single renal arteries in 46% of donors, ie, less than half of those studied.¹⁴ Thus, one may conclude that right side DN should constitute at least 10% to 15% of all DN for reduction or exclusion of selection bias. However, the actual numbers are lower, which suggests that the left kidney is disproportionately favored for donation. Thus, despite early reports of right LDN that showed higher complication rates, it may be asserted that transplant centers with high volumes of patients should perform more right side LDN, as these teams have most probably achieved a higher level of proficiency than teams at other centers.¹⁵ We are a high-volume center, and 24.7% (210/850) of our DN were performed on the right side during the study period, as we allowed the better kidney to remain with the donor and yet also facilitated a safe and simple surgery for the recipient.

Most left DN are performed by the laparoscopic approach, whereas ODN is preferred on right side because of short and thin right renal veins and also because of the close proximity to vital structures such as IVC, duodenum, and liver, and the laparoscopic approach is reserved for simple anatomy and therefore not commonly performed.16 The factors for consideration in donors to select for laparoscopic or an open approach on the right side in our series were (1) the length of the renal vein from the IVC, (2) the number of renal arteries and renal veins, and (3) the level of branching of the main renal artery. We also avoided the laparoscopic approach in cases with complex vascular anatomy, as most (148/160) of the right side LDN performed by our team were cases with a single artery and vein, whereas only 12 cases had 2 arteries with a single vein. We opted for open surgery in cases with < 1 cm of right renal vein (20 cases), branching of right renal artery medial to the lateral border of the IVC (11 cases), and/or multiple vessels (8 cases).

The open approach allows a better IVC cuff and a 4- to 5-mm longer vein compared with LDN.^4,7,16 In addition to the donor factors, the choice for open and laparoscopic approach also depends on recipient status. Recipient obesity increases the complexity of the right side graft because the surgeon is required to work at depth, for which vascular anastomosis is more difficult.^17,18 Therefore, in recipients who were not obese and without any atherosclerosis of external iliac vessels, LDN was the choice for graft retrieval. We encountered 13 obese recipients and proceeded with an open approach to obtain a robust cuff of the IVC along with the renal vein to facilitate greater ease with the vascular anastomosis. We also preferred the open approach in 1 case of robotic renal transplant, which was early in our experience with robotic transplant technique, and so we desired a robust IVC cuff for robotic suturing to better ensure our success with this new method.

We performed ODN for graft transplant in the left iliac fossa for 3 recipients. Of these 3 recipients, 2 had a previous transplant in the right iliac fossa, and 1 had an inguinal hernia repair with mesh on the right side. The placement of the right kidney into the left iliac fossa is a difficult procedure because of a deep iliac vein and a short renal vein.¹⁹ Therefore, in recipients for whom the left iliac fossa was the target, the decision was to proceed with ODN if the right kidney was selected for donation. So, barring these 50 cases, we opted for the laparoscopic approach in most cases for right side DN (76.2%, 160 cases).

The LDN was performed with the 4-port technique. We also preferred the working port of 12 mm to facilitate the convenient use of an endovascular stapler from any of the ports with sufficient length. Also, division of the ureter after division of the vessels helped to provide traction and stretched the vessels for easy placement of clips or staples at the desired place. A deliberate and safe attempt was performed to obtain the maximum possible length of the renal artery and renal vein. This included adequate dissection of the IVC below and above the renal vein insertion to facilitate optimal use of the endovascular stapler, adequate circumferential dissection of the vein and artery with no tissue between the vessels, and successful dissection of the renal artery posterior to the IVC to obtain adequate length.

Pandarinath and colleagues⁷ also mobilized the kidney and flipped it medially to view the renal hilum from its posterior aspect. This technique facilitated trace of the renal artery from its origin to the aorta⁷ and also helped to mitigate any unexpected vascular complications. In 1 case in our series, the vascular staples failed, and we applied the laparoscopic Satinsky clamp below the stapler while the IVC remained cleanly dissected and thereby managed to repair the IVC intracorporeally. Thus, adequate dissection of the renal vein, renal artery, and IVC is paramount during LDN.

The limiting factor for right kidney donation is the short length of the renal vein compared with the left kidney.20 Various techniques have been reported to overcome this limitation, which include adequate mobilization of the common and external iliac vein of the recipient,²⁰ use of donor gonadal vein for elongation of donor vein,^21,22 use of a polytetrafluoroethylene graft,²³ and/or use of the saphenous or superficial femoral vein of the recipient.²⁴ Mandal and associates performed extensive mobilization of the renal vein, and, to increase the length of the right renal vein, they divided the vein parallel to the IVC after grasping a small portion of the caval wall in the jaws of the stapler.¹¹ We also perform complete mobilization of the renal vein and the IVC cranial and caudal to the junction and place the stapler to include a portion of the IVC during recovery of the organ. For this, we usually insert the stapler through a working port on the left side, in the left iliac fossa, and then position the stapler parallel to the IVC. In addition, a proper selection of donor for LDN or ODN is vital; in the donor with a length of renal vein less than 1 cm, we planned an open approach to maximize the length of the renal vein with an appropriate IVC cuff and sought to avoid the use of a stapler. Also, division of the ureter in last helped us to provide traction and enabled us to stretch the vessels for easy and advantageous placement of clips or staples. The approach of DN, whether laparoscopic or open, was a choice dependent on our assessment of the body habitus of the recipient and the need to implant the kidney in the left iliac fossa. Therefore, in 13 obese recipients and in 3 recipients with left iliac fossa implant, ODN was the preferred choice for the donors.

After graft retrieval, we ligated most of the perihilar tissue during the bench work to expose an adequate length of the renal vein for anastomosis. To maximize the length, all the small tributaries were either ligated or clipped. To avoid the tension on the renal vein anastomosis, we adequately dissected and mobilized the external iliac vessels for suturing. In some cases of LDN (40/160), we ligated the internal iliac vein, which otherwise restricted the mobility of the external iliac vessels. We use polytetraflu­oroethylene sutures for anastomosis, which allows for exceptional knots due to its lack of elastic memory and its ability to swell, which promotes hemostasis.²⁵ We performed the implant by anastomosis of the renal artery to the external iliac artery and anastomosis of the renal vein to the external iliac vein. Simforoosh and colleagues described an easy and safe method of inverted kidney transplant to avoid the vascular complications associated with anastomosis of the short right renal vein after LDN.²⁶ However, we feel a proper routine transplant that follows basic surgical principles will promote successful outcomes. We routinely use vascular sealant whenever the integrity of the anastomosis is uncertain. Given the proper selection of recipient for right LDN, our consideration for all necessary improvisations during DN, and our implementation of new techniques for anastomosis, we have perfor­med 210 successful donor nephrectomies, none of which required renal vein reconstruction, regardless of whether the DN was open or laparoscopic. Also, follow-up of the recipients showed no case of renal vein thrombosis.

The demographic characteristics of donors in our study are similar to previous studies. The mean operative time, mean estimated blood loss, mean warm ischemia time, and anastomosis time were also comparable with other studies.^7,8,13,27 Most comp­lications were vascular; 2 patients had IVC injury, 1 patient had gonadal vein injury, and 1 patient had adrenal vein injury. Both cases of IVC injury were related to stapler malfunction; 1 of these was managed with laparoscopic suturing, and 1 required immediate open exploration and repair. To mitigate the gonadal injury, we clipped the severed parts of the vein; however, the adrenal vein injury required open conversion because of bleeding and obstructed view. We have a low threshold for open conversion, and we choose this option whenever any doubt or difficulty may arise during LDN. There was 1 donor with hepatomegaly, for whom we started with laparoscopy but converted the open procedure when confronted with a difficult retraction. One patient developed liver laceration during retraction, but the only required intervention was the placement of a hemostatic agent. The postoperative period was uneventful in most patients, except for paralytic ileus in 11 donors and a blood transfusion for 1 donor. Most patients were discharged on day 5. Various studies have shown that choice of kidney, whether right or left side, does not significantly change the surgical outcomes or complication rates in the donor.^13,15,16,27

Early studies reported higher complication rates and poor graft outcomes for right LDN due to short right renal veins and difficult venous anastomoses that led to renal vein thrombosis.^28,29 Various studies have shown that the choice of the laparoscopic or the open approach for right side DN did not change the complication rates, intraoperative or postoperative parameters, and allograft function in recipients; this is probably attributable to improvements in laparoscopic instruments and the endovascular stapler, despite the short and thin aspects of the renal vein on the right side.^7,15,16,27 With regard to recipient outcomes, we also found that graft function, perioperative parameters, and vascular complications do not differ much in right LDN despite a short renal vein compared with right side ODN or left side LDN.

The limitations of our study are the retrospective nature of the study and the fact that all cases were from a single center.

Conclusions

The right LDN is as safe as left LDN or right ODN and does not negatively affect surgical outcomes or complication rates in donors. Also, the complication rates and allograft function in recipients do not differ much with right LDN compared with right side ODN or left side LDN. Careful consideration of recipient factors is crucial, just as for donor factors, before the choice for an open or laparoscopic approach on the right side. In obese recipients, the open approach may promote a simple anastomosis by means of a robust IVC cuff. Slight modifications in technique can provide a few extra millimeters of vein length and thereby significantly increase the incentive to choose LDN on the right side.

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