Indications and Contraindications
Donor nephrectomy is unique among surgeries performed in urology. Unlike most procedures offered to our 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 that 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 the 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, and other considerations include the presence of any significant medical comorbidities that could affect long-term renal function, presence of communicable disease (e.g., human immunodeficiency virus [HIV], hepatitis), and 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 risks of the procedure and may influence the surgical approach. The presence of microscopic hematuria is not a contraindication to renal donation, provided 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 ensure both 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 subspecialists 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, subspecialists are playing an increasing role in the donor evaluation process.
If a volunteer for renal donation is found to be a suitable candidate for donor nephrectomy, CT angiography is performed to assess renal size and vascular and ureteral anatomy. The imaging plays 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. At our center, nuclear renal scans to assess differential function are not typically performed, and assuming a symmetric nephrogram phase on CT angiogram, renal size is used as a surrogate to estimate differential renal function. Ureteral duplication is occasionally encountered but does not strongly influence the choice of kidney for donation.
Mechanical bowel preparation is not used in our center before donor nephrectomy. Patients are currently being asked to drink clear liquids in the afternoon and evening on the day before surgery. The patient is given a single dose of prophylactic antibiotic in the operating room within 1 hour before incision.
Operating Room Configuration and Patient Positioning
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. At our center, we use a modified flank position with the side of donation elevated 20 to 30 degrees with gel bumps placed to support the scapula and hip ( Fig. 20-1 ). 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 is left out, 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 patient’s 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 insufflations, suction, and cautery are placed at the discretion of the surgeon, and typically at our center are placed behind the surgeon and assistant. 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. 20-2 ).
For a retroperitoneal approach, the patient is positioned in a 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, cautery, and suction equipment remain at surgeon discretion. The surgical technician stands opposite the surgeon at the hip, with the instrumentation table at the foot of the operative 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.
A Veress needle is placed 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. 20-3 ). 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 working port for retraction, or to aid in the ureteral dissection.
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 a small space to be created. The surface of the psoas muscle, the kidney, or both can often be palpated with the fingertip and can 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 glove 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 developed, two additional working trocars are placed under laparoscopic vision. A 5-mm or 12-mm trocar is placed in the midaxillary line, two to three fingerbreadths above the anterior superior iliac spine. The second trocar, also either 5 or 12 mm in size, is placed at the junction of the 12th rib and erector spinae muscle.
Transperitoneal Left Laparoscopic Donor Nephrectomy (See )
Colon Mobilization and Deflection
After initial port placement, the surgery is begun by incising the white line of Toldt ( Fig. 20-4 ). For this step, our instruments of choice are laparoscopic DeBakey forceps for retraction and monopolar cautery shears. This allows medial mobilization of the colon by developing the avascular plane between the mesentery and Gerota fascia with a combination of blunt and sharp dissection ( Fig. 20-5 ). 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 Gerota fascia, preservation of which facilitates dissection. Is it also recommended to avoid dissecting posterolateral 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 LigaSure (Medtronic, Minneapolis, Minn.), facilitating exposure of the upper pole ( Fig. 20-6 ). Once divided, the plane medial to the upper pole and adrenal gland is further developed and the spleen and pancreas 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.