Indications and contraindications
Donor nephrectomy is unique among surgeries performed in urology. Unlike most procedures offered to patients, there are no discrete medical indications—it is elective in the truest sense of the word. In addition, there are no direct health benefits for the donor patient other than the reward of knowing they have provided a life-changing gift to the transplant recipient, whether it be a family member, friend, or individual previously unknown to them. The patient must be willing to be a kidney donor, competent to consent, and completely confident in their decision.
Contraindications to laparoscopic donor nephrectomy include uncorrected coagulopathy, the presence of medical renal disease, and active infection. There are also relative contraindications including history of renal stone disease, the presence of medical comorbidities that could affect long-term renal function (e.g., uncontrolled diabetes or hypertension), and the presence of communicable disease (e.g., human immunodeficiency virus or hepatitis). Patients must also be in good mental health. Prior abdominal surgery is not a contraindication to donor nephrectomy, but the extent and nature of the prior surgery must be carefully considered when discussing the risks of the procedure and may influence the surgical approach. The presence of microscopic hematuria is not a contraindication to renal donation, provided that appropriate urologic evaluation to rule out malignancy or significant stone disease is performed preoperatively. Upper urinary tract imaging (ultrasound, computed tomography [CT] or magnetic resonance imaging [MRI]), urine cytology, and cystoscopy are the critical elements of the microscopic hematuria workup. Nephrology evaluation and possible renal biopsy can also be considered if there is a suspicion of early medical renal disease as the cause of the microscopic hematuria.
The evolution of protocols for recipient immunosuppression has also allowed for the expansion of the donor pool such that ABO incompatibility and positive crossmatch are not necessarily prohibitive. Donor swap and donor chain programs are also making transplants possible when they may not have been feasible otherwise.
Patient preoperative evaluation and preparation
Evaluation of prospective kidney donors involves a multidisciplinary approach to evaluate both their physical and mental health and is typically coordinated through the transplant team. The goal of donor screening is primarily to determine whether renal function would be significantly compromised by donor nephrectomy. Internists, nephrologists, radiologists, and donor surgeons are most commonly involved. Additional medical subspecialties may also be required if there are specific elements in the patient’s medical history that may play a role in the perioperative course or in determining suitability for kidney donation. As the pool of potential donors expands to include patients with advanced age or prior history of malignancy, subspecialties are playing an increasing role in the donor evaluation process.
If a volunteer for renal donation is a suitable candidate for donor nephrectomy, CT angiography is performed to assess renal size and vascular and ureteral anatomy. Imaging results play the most critical role in determining which kidney will be selected for donation. Institutions and surgeons may have their own criteria for selecting the donor kidney. At some centers the left side is almost always preferred owing to the longer renal vein, even in the presence of multiple renal arteries. Others prefer to select the kidney with simpler arterial anatomy to minimize the need for vascular reconstruction. Nuclear renal scans are used on occasion to assess differential function, although symmetry in the enhancement of kidneys on the nephrogram phase of the CT angiogram and renal size assessment on cross-sectional imaging can be used as surrogates to estimate differential renal function. Ureteral duplication is occasionally encountered but does not strongly influence the choice of kidney for donation.
Mechanical bowel preparation prior to donor nephrectomy is falling out of favor. Rather, patients may be instructed to drink clear liquids in the afternoon and evening the day prior to surgery. The patient is given a single dose of prophylactic antibiotic in the operating room within one hour before incision.
Operating room configuration and patient positioning
Transperitoneal approach
Laparoscopic donor nephrectomy can be performed with either a transperitoneal or a retroperitoneal approach, a choice that is the main determining factor influencing operating room configuration. A transperitoneal approach means positioning the patient in either a modified or full-flank position. For a modified flank position, the side of the donation is elevated 20 to 30 degrees with gel bumps placed to support the scapula and hip ( Fig. 18.1 ). It is not necessary to flex the operative table or use a kidney rest or axillary roll in this position. The patient’s legs are slightly flexed at the knee with a pillow under the knees for support. Foam padding is placed around the ankles to eliminate pressure on the heels. The arm contralateral to the donor side if left out is perpendicular to the operative table on an arm board, which allows easy access for the anesthesiologist. The ipsilateral arm is gently folded across the patient’s chest, above the costal margin to allow exposure to the full abdominal wall. Sequential compression devices are placed for deep venous thrombosis prophylaxis before the induction of anesthesia. The patient is secured to the table with wide silk tape with towels or foam pads to protect the skin. A Foley catheter is placed. The kidney extraction site is also marked before putting the patient in modified flank position to avoid anatomic distortion when the patient is rotated. Usually a mini-Pfannenstiel incision 4 to 5 cm in length is adequate. Upper and lower body warming devices are used to maintain the patient’s temperature.
The laparoscopic tower accommodating the monitor and light source are placed on the side of kidney donation; the primary surgeon and assistant stand on the contralateral side facing the abdomen. The equipment required for insufflation, suction, and cautery is positioned at the discretion of the surgeon. The surgical technician stands at the elevated hip, and the instrumentation table is at the foot of the operative table. A standard laparoscopic drape with side pockets is used ( Fig. 18.2 ).
Retroperitoneal approach
For a retroperitoneal approach, the patient is placed in the full-flank position with the donor side facing up. An axillary roll is used, and the table is flexed to expand the space between the anterior superior iliac spine and the costal margin. For this approach, both arms are out in front of the patient, with the lower arm resting on an arm board perpendicular to the table and the other resting either on stacked blankets or on a purpose-built arm rest. Wide silk tape is used to secure the patient in position with towels or foam strips to protect the patient’s skin. Upper and lower body warming devices are used to maintain the patient’s temperature.
The laparoscopic tower is positioned in front of the patient in this configuration, opposite the surgeon and assistant, who stand at the patient’s back. The insufflation device, suction, and cautery equipment are positioned at the surgeon’s discretion. The surgical technician stands opposite the surgeon at the hip, with the instrumentation table at the foot of the operating table. The extraction site for a retroperitoneal approach may be in the flank, or a mini-Gibson incision may be used, but the site does not necessarily have to be marked before positioning.
Hand-assisted approach
Positioning during left hand-assisted laparoscopic donor nephrectomy is similar to that for the pure laparoscopic technique. For left-sided cases, the patient is placed in a right lateral decubitus position with the aid of either bolsters placed behind the shoulder blades and back or with use of a deflatable air-tight beanbag. In general, a full-flank position is not necessary; rather, a modified flank position should be utilized as contralateral rotation of the bed allows for passive displacement of the intestinal context and easier exposure to the retroperitoneum. The contralateral leg should be slightly flexed and the ipsilateral leg in a straight position with a pillow placed in between. An axillary roll should be utilized to reduce the risk for brachial plexus injury. The contralateral arm is placed on an armrest straight out while the ipsilateral arm may be placed either across the chest on an Allen armrest with 30 degrees of flexion at the elbow or straight downward alongside the side of the patient. It is critical to ensure all pressure points are padded. The table can be flexed approximately 30 degrees to open up the space between the rib cage and the iliac crest of the pelvis. The kidney rest is generally unnecessary for laparoscopic surgery. The bed should be rotated prior to draping to ensure the patient is properly secured.
It is important, as in all laparoscopic cases, that a nasogastric tube and Foley catheter are placed to decompress the stomach and bladder respectively during the case.
Trocar placement
Transperitoneal approach
A Veress needle is inserted through the umbilicus to achieve insufflation to 15 mm Hg. Three trocars are initially placed, including an 11-mm umbilical port to accommodate the camera, a 6-mm subcostal working port, and a 12-mm working port 2 cm medial and superior to the anterior superior iliac spine on the side ipsilateral to the donor kidney ( Fig. 18.3 ). Additional trocars may be necessary in some cases for the purpose of retraction, depending on internal anatomy and the patient’s body habitus. Shifting the trocars laterally may be necessary if the patient is overweight or obese. A suprapubic trocar may also be used to insert a specimen bag at the time of extraction, as a portal port for retraction, or to aid in the ureteral dissection.
Retroperitoneal approach
A working space posterior to the kidney must be developed before trocar placement for a retroperitoneal approach. There are several well-established techniques for creating this space. First, a 12- to 15-mm incision is made off the tip of the 12th rib. A fingertip may then be used to push into the retroperitoneum, posterior to the kidney, and a sweeping motion of the finger allows for the creation of a small space. The surface of the psoas muscle, the kidney, or both can often be palpated with the fingertip and aid in initial dissection. Then, with either the tip of a surgical glove attached to a catheter or a purpose-built trocar with a balloon at the tip, the space is further expanded by insufflating the tip of the globe or balloon. A camera port is then inserted and the space is inspected. Further blunt dissection with the tip of the laparoscope may also be performed to additionally expand the space as needed. Once adequate space is established, two additional working trocars are placed under laparoscopic vision. A 5-mm or 12-mm trocar is placed in the midaxillary line two or three fingerbreadths above the anterior superior iliac spine. The second trocar, either 5-mm or 12-mm in size, is placed at the junction of the 12th rib and erector spinae muscle.
Hand-assisted approach
In general, three ports are used for left hand-assisted laparoscopic donor nephrectomy, with one of these being the hand port ( Fig. 18.4 ).
The hand port is traditionally placed in the midline above the umbilicus, although at our institution, we prefer placement of the hand port below the midline ( Fig. 18.4 ). The width of the hand port is roughly the size of the surgeon’s medical glove in inches. We utilize the GelPort device (Applied Medical, Rancho Santa Margarita, CA) for the hand port as it possesses a sheath that protects the incision from infection, a wound retraction element that enables removal of the kidney while minimizing incision size, and most importantly, a gel seal cap that maintains pneumoperitoneum despite continuous insertion and removal of the surgeon’s hand and instruments.
In the case where significant abdominal adhesions are suspected due to prior history of abdominal surgery, the hand-assisted laparoscopic technique affords flexibility in terms of the order for placement of ports because a wide cut down can be performed first at the site of the hand port to enable takedown of adhesions under direct visualization for placement of the GelPort device.
Once the GelPort device is inserted, a 5-mm trocar is placed at the intersection of the mid-clavicular line and the costal margin. This will serve as the camera port. A 12-mm trocar is placed in the mid-clavicular line or anterior axillary line at the height of the umbilicus. This will serve as the working port for laparoscopic instruments ( Fig. 18.4 ) . These trocars can be placed by tactile guidance or under direct visual guidance after pneumoperitoneum is established through temporary insertion of a trocar into the peritoneal cavity through the GelPort. At our institution, we place the trocars by cupping the surgeon’s intraperitoneal hand beneath the trocar site and introducing the trocar directly into the surgeon’s palm with the cupped hand protecting surrounding viscera.
Placement of the GelPort site can vary based on patient preference or body habitus. A modified Pfannenstiel incision can be used for increased cosmesis in select patients. Also, in obese patients, a paramedian incision can be used to place the GelPort.
Transperitoneal left laparoscopic donor nephrectomy ( 
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Surgical procedure
Colon mobilization and deflection
After initial port placement, the surgery is begun by incising the white line of Toldt ( Fig. 18.5 ). For this step, our instruments of choice are laparoscopic DeBakey forceps for retraction and monopolar cautery shears. The use of these instruments allows medial mobilization of the colon by developing the avascular plane between the mesentery and the Gerota fascia with a combination of sharp and blunt dissection ( Fig. 18.6 ). The kidney capsule may or may not already be visible at this point, depending on the volume of perinephric fat. Care is taken at this point to avoid entry into the Gerota fascia, the preservation of which facilitates dissection. It is also recommended to avoid dissecting posterior lateral to the kidney at this point to prevent the kidney from falling medially and obscuring the hilar vessels. The colon is reflected to allow adequate exposure of the kidney and ureter down to the level of the common iliac vessels.
Mobilization of the spleen and pancreas
The splenorenal and splenocolic attachments are divided with the LigaSure (Medtronic, Minneapolis, MN) device, facilitating exposure of the upper pole ( Fig. 18.7 ). Once divided, the plane medial to the upper pole and adrenal gland is further developed and the spleen and pancreas to fall together toward the midline. Partially rolling the surgical table toward the surgeon can facilitate both the dissection and exposure along the medial aspect of the kidney and will maximize visualization of the renal hilum. A paddle retractor may also be used through a suprapubic trocar if visualization of the hilum is not sufficient.
Location of the gonadal and main renal veins
The left gonadal vein and ureter should be visible at this stage. If not, they are most easily located below the lower pole of the kidney ( Fig. 18.8 A). Development of the plane between the posterior portion of the kidney and underlying psoas muscle is undertaken at this time ( Fig. 18.8 B), which allows for gentle traction on the hilar vessels and significantly accelerates their safe dissection. The gonadal vein is traced superiorly to the left renal vein ( Fig. 18.9 A) and ligated with 10-mm titanium clips before division ( Fig. 18.9 B). Care must be taken to allow for adequate space along the renal vein to accommodate the endovascular stapling device such that the clips are well away from the jaws of the stapler. It is recommended to dissect the renal vein as completely as possible at this point to ensure ample length and space for the stapler before placing gonadal vein clips.
