| Abstract|| |
Laparoscopic donor nephrectomy (LDN) can be performed via either transperitoneal or retroperitoneal approach. Very few studies have been carried out till now, comparing immunologic and inflammatory responses in donors after these two approaches. This is a prospective observational study. Selection of approach was decided by the operating surgeon. All patients underwent peripheral venous blood sampling preoperatively and 24 h postoperatively for the measurement of C-reactive protein (CRP), interleukein-6 (IL-6), total leukocyte count (TLC), blood urea nitrogen (BUN), and serum creatinine (SCr). Operative time, warm ischemia time, hospital stay, requirement of analgesia, and complications were also recorded. From February 2013 to January 2015, we performed 54 LDNs (38 transperitoneal and 16 retroperitoneal). There were 49 females and five males. Mean operative time was not significantly different in these two approaches, but warm ischemia time was significantly less in the retroperitoneal laparoscopic donor nephrectomy (RLN) group. Postoperative inflammatory markers' (IL-6, CRP, and TLC) levels, BUN, and SCr rise in both of these approaches, but there was no significant difference observed between these two approaches. RLN is a safe and effective approach to preserve a longer right renal vein. It combines the benefit of both hand assistance and retroperitoneal approach. Warm ischemic time is significantly less in RLN group.
|How to cite this article:|
Gogoi D, Pal DK, Bera MK. Systemic immunologic and inflammatory response after transperitoneal versus retroperitoneal laparoscopic donor nephrectomy: A prospective observational study. Saudi J Kidney Dis Transpl 2016;27:985-91
|How to cite this URL:|
Gogoi D, Pal DK, Bera MK. Systemic immunologic and inflammatory response after transperitoneal versus retroperitoneal laparoscopic donor nephrectomy: A prospective observational study. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Jun 2];27:985-91. Available from: http://www.sjkdt.org/text.asp?2016/27/5/985/190868
| Introduction|| |
Traditionally, a live donor nephrectomy required a large transcostal flank incision through 11 th or 12 th rib which was associated with significant pain and a long hospital stay and recovery period for the donor. Open donor nephrectomy was also associated with significant body disfigurements such as long scar and frequent parietal bulging.
Laparoscopic live donor nephrectomy was developed with the intent to limit these deterrents by reducing the impact of operation on the donor's life. This procedure was first reported by Ratner et al in 1995 and by Yang et al in the same year. , This minimally invasive procedure has a shorter recovery period and less morbidity with good transplant kidney function.
Laparoscopic donor nephrectomy (LDN) can be performed either transperitoneally or retroperitoneally. Each of these approaches has its own advantages and has a different anatomical approach. However, very few studies have been carried out till now comparing the physiological changes that occur after these two approaches.
This study was designed to compare the transperitoneal versus retroperitoneal laparoscopic donor nephrectomy (RLN) in terms of markers of inflammation [C-reactive protein (CRP), and interleukein-6 (IL-6) ], total leukocyte count (TLC), blood urea nitrogen (BUN), and serum creatinine (SCr) as well as operative time, warm ischemia time, hospital stay, requirement of analgesia, and complications.
| Materials and Methods|| |
This is a prospective nonrandomized observational study. Selection of surgical approach was decided by the operating surgeon. A diethylenetriaminepentaacetic acid (DTPA) renal scan was used to assess the split renal function. A computed tomography angiogram was used to delineate the renal vascular anatomy. Usually, the left side was selected for transperitoneal and right side for retroperitoneal donor nephrectomy. We choose to harvest the right kidney when there was a significant difference in renal function (>10%) and left kidney was the better functioning one, also in women who wish pregnancy in future. Retroperitoneal approach was selected in the presence of previous major upper abdominal surgery and presence of double renal artery in the left side.
For transperitoneal LDN (TLDN), a standard four-port technique was used. The operation begins with mobilization of the colon by incising the lateral peritoneal reflection. First, we identify the ureter and the gonadal vein. Then, the ureter and gonadal vein complex are lifted up, and dissection is carried out medial to the gonadal vein to identify the renal vein. The plane of dissection is carried along the cephalad border of the renal vein between the adrenal gland and the upper pole of the kidney. Vascularized tissue in this region is divided with ligature, and the upper pole is shelled out of the envelope of Gerota's fascia. After transecting the lumber veins, the renal artery is then gently dissected free to demonstrate its origin from the aorta. With complete posterior dissection, kidney can be fall down medially. The ureter is mobilized with a generous amount of periureteral tissue down to the level of the pelvic inlet. The ureter is clipped and divided.
At this stage, a 5-6 cm kidney retrieval incision is made just above the pubis. A pursestring suture is placed in the peritoneum. A 12mm port is placed at the center of the Pfannenstiel incision. This port is used during the remainder of the operation to provide medial retraction of the colon. The renal artery is clipped with double hem-o-lock clip flush with the aorta [Figure 1] and divided distally with scissors, and the renal vein is divided in the same manner [Figure 2]. The kidney is then retrieved through the Pfannenstiel incision using surgeon's hand.
Right RLN with three-port retroperitoneal approach has been well described.  The patient is placed in the flank position, and the operating table is flexed to maximize the space between the iliac crest and the 12 th rib. The retroperitoneal space is created by making a 15 mm incision inferior to the tip of the 12 th rib through the lumbodorsal fascia. The space is expanded with blunt finger dissection and then with a balloon dilator. A three-port technique is used [Figure 3]. The renal hilum is identified posteriorly, and the renal artery is isolated and mobilized from the renal hilum to its retrocaval location. The renal vein, along with a segment of inferior vena cava (IVC), is dissected [Figure 4]. The ureter is dissected distally into the pelvis. During most of the procedure, the attachment anterior to the kidney to the parietal peritoneum is maintained. This will prevent the kidney from flopping posteriorly and obscuring the surgeon's view of the renal hilum. In our institution after complete dissection in the hilum, we completely free the anterior attachments of the kidney. Care must be taken not to enter the peritoneal cavity. After transecting the ureter, we made a 6-7 cm subcostal incision in the right flank joining the three ports. Division of the renal artery and renal vein is done through this incision. The renal artery is double ligated on the donor side. Next, we apply a Satinsky vascular clamp over the IVC taking a cuff of IVC along with right renal vein. Renal vein with a cuff of IVC and artery are divided. The kidney is taken out manually.
|Figure 4: Renal artery and vein during retroperitoneoscopic left donor nephrectomy.|
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With this technique, the warm ischemia time is reduced to <2 min. It is also important that a cuff of IVC along with the renal vein has been taken, thus renal vein length is not compromised.
All patients underwent peripheral venous blood sampling preoperatively and 24 h postoperatively. These were analyzed for CRP, IL6, TLC, BUN, and SCr. Operative time, warm ischemia time, hospital stay, requirement of analgesia, and complications were also recorded. An informed consent was obtained from all the donors participating in this study. Standard statistical analysis was used to analyze the results.
| Results|| |
From February 2013 to January 2015, we performed 54 LDNs. Out of these, 38 were transperitoneal (70%) and 16 were retroperitoneal (30%). There were 49 females and five male donors. The donor's age range was 20- 62 years with a mean age of 33.35 years. The right kidney was harvested from 12 donors and the left from 42 donors. TLDN was done exclusively on the left side (total 38). RLN was done in four on the left side and in 12 on the right side [Table 1].
Out of four RLN on the left side, two patients had bilateral double renal arteries [Figure 5] and two patients had major upper abdominal surgery in the past.
In the TLDN group, the operative time range was 129-221 min (mean 177.4 min), and in the RLN group, it was 146-220 min (mean 178.5 min) (P = 0.662).
In the TLDN group, the warm ischemia time range was 190-265 s (mean 231.1 s), and in the RLN group, the range was 90-140 s (mean 110.6 s) (P = 0.000).
In the TLDN group, the preoperative hemoglobin range was 10.6-14.6 g/dL (mean 12.7 g/dL) and postoperative hemoglobin range was 9.6-14.2 g/dL (mean 11.9 g/dL). Mean drop of Hb% was 0.8 g/dL. In the RLN group, pre operative hemoglobin range was 10.6-14 g/dL (mean 12.6 g/dL) and postoperative hemoglobin range was 9.6-11.9 g/dL (mean 11.9 g/dL). Mean drop of Hb% was 0.7 g/dL. The difference of hemoglobin drop across both categories was not statistically significant (P = 1). CRP, IL-6, TLC, BUN, and SCr increased postoperatively in both of these groups.
Base line CRP level was below 6 mg/dL in all the donors. It rose to a mean of 16.4 mg/dL in the TLDN group (range 11.6-22 mg/dL), and to a mean of 16.2 mg/dL in the RLN group (range 10-19 mg/dL) (P = 0.704).
The mean baseline IL-6 in the TLDN group was 21.6 pg/dL (range 12-56 pg/dL), and rose to 31 pg/dL (12-63 pg/dL). The mean baseline IL-6 in RLN group was 21.7 pg/dL (range 12- 44 pg/dL), mean of and rose to 28.1 pg/dL (range 12.6-70 pg/dL) (P =0.454).
Postoperative hospital stay is significantly shorter in the TLDN group (mean of 5.3 days, range 4-6 days) than in the RLN group (mean 6.4, range 6-8 days) (P <0.0001). Requirement of analgesia (paracetamol) is significantly less in TLDN group (mean 13.5 g, range12-16 g) than in the RLN (mean 17 g, range 12-21 g) P <0.0001 retroperitoneal approach [Table 2].
|Table 2: Postoperative change of Hb%, blood urea nitrogen, creatinine, and inflammatory markers.|
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There was no major complication in either of these groups except one minor wound infection in the TLDN group which resolved with antibiotic treatment and another wound infection in the RLN group requiring secondary suturing.
| Discussion|| |
Historically, donors were operated with a large flank incision. Open donor nephrectomy is a technique that is well-standardized but associated with several disadvantages such as hypoand dysparesthesias, hernias, and unpleasant cosmetic outcome. Open donor nephrectomy on the right side often requires a rib cutting incision. As a result of the evolution of surgical techniques in the last decade has led to the introduction of LDN and mini-incision donor nephrectomy techniques. ,,
Laparoscopic nephrectomy in live donor transplantation is a safe alternative to the open technique with shorter hospital stay and recovery times.  In most of the transplant centers, LDN is predominantly performed on the left side as the right renal vein is shorter and thin walled, and the right renal artery has a retrocaval course. Short renal vein increases the complexity of the recipient operation and associated with an increased risk of venous thrombosis.  Recently, many articles have been published demonstrating the safety and feasibility of right donor nephrectomies. ,,,,, Still, in many centers, most right-sided donor nephrectomies are performed by open approach.
Numerous modifications were described to achieve maximal length of the renal vessels. The first involves division of the renal vessels in a plane parallel to the IVC by introducing the endoscopic GIA device into the right lower quadrant port, rather than the infraumbilical port.
A second technique described making a 5-6 cm transverse incision in the right upper quadrant. Then, open placement of a side-biting vascular clamp across the IVC at the level of the renal vein after the complete laparoscopic dissection of the kidney.  The incision is used for open division of the renal vessels maintaining a generous length of renal vein. A third modification is to introduce a hand port at the right upper abdomen. Then, the kidney is lifted on its pedicle under stretch to divide the vein directly with the endoscopic GIA device, or for a laparoscopic side-biting clamp to be placed through a suprapubic port to divide the renal vein flush with the vena cava. Back-table reconstruction of the vein can be performed using a panel graft of recipient saphenous vein, but this is rarely necessary. 
Modifications are also described using the endo-TA stapler to get a cuff of IVC along with the right renal vein. 
The retroperitoneal laparoscopic live donor nephrectomy initially evolved as an alternative technique to address the technical difficulties of harvesting the right kidney by the transperitoneal approach. As such, most reported series of retroperitoneoscopic donor nephrectomy involve the right kidney. , Although recently, a small series of successful left-sided retroperitoneoscopic donor nephrectomy has been reported. 
The retroperitoneoscopic approach does have certain advantages over transperitoneal laparoscopic live donor nephrectomies. Intra-abdominal adhesions in patients with prior abdominal surgery are avoided. It allows rapid and direct access to the renal hilum, obviating the need to mobilize the colon, liver, and duodenum. The likelihood of postoperative paralytic ileus and iatrogenic injury to intraperitoneal organs are reduced because the peritoneal cavity is not violated.  The right renal artery is effectively skeletonized in a retro-caval location, ensuring optimal arterial length for transplantation. The right renal vein and adjacent vena cava can be dissected much easily from a posterior approach under direct vision.
Disadvantages of the pure retroperitoneoscopic approach to live donor nephrectomy include a short renal vein and longer warm ischemia time of the allograft because anteromedial kidney attachments are not divided until the renal vessels have not been transected.  That is why we slightly modify the technique. In our institution, after complete dissection in the hilum, we completely free the anterior attachments of the kidney. After transecting the ureter, we made a 6-7 cm subcostal incision in the right flank, joining the three ports. Division of the renal artery and renal vein is done through this incision in an open manner. We double ligate the renal artery on the donor side. Next, we apply a Satinsky vascular clamp over IVC taking a cuff of IVC along with the right renal vein. Renal vein and artery are divided. Kidney is taken out manually.
With this technique, we have reduced the warm ischemia time to <2 min and renal vein was divided with a cuff of IVC. Thus, renal vein length is not compromised.
The largest experience with retroperitoneal laparoscopic live donor nephrectomies is reported by Ng et al. In his series, right retroperitoneal laparoscopic live donor nephrectomies are compared with left transperitoneal laparoscopic live donor nephrectomies in a single institutional experience. Operative times were significantly less with the retroperitoneal approach. Whereas hospital stays, analgesic use, and donor-recipient creatinine were similar in both groups. Warm ischemia time, statistically significantly longer with the retroperitoneal technique, in spite of recipient functional outcomes at one week and one month were similar in both groups. 
Aminsharifi et al, compare the systemic immunologic and inflammatory response after laparoscopic versus open donor nephrectomy. No statistical correlation was found between operative time and changes in IL-6, CRP, TNF-α, and TLC. There was less increase in serum IL-6 in laparoscopic group, may explain the smooth convalescence after LDN. 
| Conclusion|| |
RLN is a safe and effective approach to preserve a longer right renal vein. There was no difference in operative time. Warm ischemia time was significantly less in RLN group. The requirement of postoperative analgesia was more in RLN group. The differences in the rise of inflammatory markers were not statistically significant. Although larger prospective studies are required to further confirm these results.
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Dilip Kumar Pal
Department of Urology, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]