This document discusses the evolution of donor nephrectomy techniques from open surgery to minimally invasive approaches like laparoscopic and robotic-assisted surgery. It provides a brief overview of different surgical techniques for donor nephrectomy and summarizes outcomes research comparing techniques. Minimally invasive approaches are associated with less blood loss, shorter hospital stays, and faster recovery compared to open surgery without compromising graft or donor outcomes. Laparoscopic donor nephrectomy has become the standard technique.

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Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/apme
Review Article
Evolution of donor nephrectomy
Vinay Mahendra
Senior Consultant Urologist, Laparoscopic and Robotic Urological Surgeon, Apollo Gleneagles Hospitals, Kolkata, India
article info abstract
Article history: Live donor nephrectomy has seen a significant change since the first kidney transplant in
Received 27 December 2012 1954. This article gives the evolution of the donor nephrectomy with advances in tech-
Accepted 2 January 2013 nology. The experience at Apollo Gleneagles Hospitals, Kolkata is presented summarily.
Available online 16 January 2013 Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords:
Donor nephrectomy
Laparoscopic donor nephrectomy
Robotic donor nephrectomy
1. Introduction obesity or hypertension can also be accepted as long as renal
function is good.
Live kidney donation is an important alternative for the
treatment of end stage renal disease. To date, the health of
live kidney donors at long term follow-up is good and the 2. Types of donor nephrectomy
procedure of donor nephrectomy is considered to be safe. The
procedure of donor nephrectomy has evolved from the open Live donor nephrectomy technique is justified only if it is safe
lumbotomy, through flank incision, through mini incision for the donor and does not compromise the benefit to the
muscle splitting open donor nephrectomy, to laparoscopic recipient. Along with the above basic essential parameters if
techniques and now with advent of robotic surgery, the ro- any technique offers better postoperative recovery with lesser
botic assisted donor nephrectomy. There are different mini- pain and early recovery to work, that technique will be the
mally invasive techniques including standard laparoscopic, most preferred technique for harvesting the donor kidney.
hand assisted laparoscopic, hand assisted retroperitoneo- The various surgical techniques in use for donor ne-
scopic, pure retroperitoneoscopic, and robotic assisted live phrectomy are mentioned briefly below.1
donor nephrectomy. There is increasing evidence that donor
nephrectomy with multiple arteries and veins and the right 2.1. Open technique e flank incision
side can be safely done with minimally invasive techniques.
Other issues encountered with the live kidney donation The donor is in the lateral position and lumbotomy is per-
include dealing with obese patients and the age of the donor. formed in the 11th or 12th rib bed or below the 12th rib.
Many centers restrict the procedure to younger normal weight Muscles are transacted and the retroperitoneal space opened
donors. Nowadays donors with isolated abnormality like followed by application of a mechanical retractor. The
E-mail address: vmahendra@gmail.com.
0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2013.01.004

3. 48 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 4 7 e4 9
kidney is mobilized along with the ureter and the blood
vessels. The kidney is removed after dividing the ureter and 3. Outcomes of different surgical techniques
blood supply.
3.1. Open e flank vs mini incision techniques
2.2. Open technique e mini incision Conventional open donor nephrectomy (ODN) is associated
with long hospital stay, prolonged postoperative pain, slow
The patient is in lateral position with operating table convalescence and cosmetic issues due to scar. If a rib
maximally flexed. The surgery is done through 10e15 cm reception is required, it adds up to significant morbidity. Sri-
horizontal muscle splitting incision made anterior to the vastava et al showed that patients with subcostal incision had
11th rib. This is done to avoid injury or division intercostal lesser postoperative analgesic requirement than those had rib
nerves. The peritoneum is mobilized anteriorly to enter the resection.7 The hospital stay and convalescence was shorter
retroperitoneal space for the removal of kidney. This in- in subcostal group compared to in rib resection group.
volves use of longer instruments due to limited working Mini incision donor nephrectomy (MIDN) is associated
space. with similar donor safety and equivalent graft function. The
benefit is in reduced blood loss, reduced analgesic re-
quirements, shorter hospital stay convalescence.
2.3. Laparoscopic donor nephrectomy Kok et al5 compared MIDN and ODN. The median operating
time was 158 min and 144 min, blood loss was 210 ml vs
The donor is in lateral position and the surgery is done
300 ml. Intraoperative major bleeding episode 7% vs 1%.
transperitoneally. The surgery is done using 10 mm camera
Postoperative complications were comparable (12%). Hospital
port with 0 or 30 camera, pneumoperitoneum of 12 cm H2O
stay was 4 vs 6 days. Late incisional hernia 2% vs 13%.
pressure and 3e4 5 mm working ports. The kidney is mobi-
The evidence indicates MIDN to be superior to ODN.
lized with the ureter and vessels and after their division is
extracted through a small Pfannenstiel incision.
3.2. Hand assisted techniques (HALDN, HARP)
2.4. Hand assisted laparoscopic donor nephrectomy Hand assisted techniques for donor nephrectomy offer
(HALDN) a perceived advantage of tactile feedback and easier and
rapid control of bleeding over complete laparoscopic techni-
The technique involves pneumoperitoneum after putting que. Sundqvist et al (2004)2 and Wadstrom et al (2005)3
a 10 mm camera port followed by hand assistance device that showed shorter warm ischemia time with HARP compared
helps the surgeon to put his/her hand to assist in the dis- to ODN and LDN.
section and mobilization of the kidney.
3.3. HALDN vs LDN(4,6)
2.5. Hand assisted retroperitoneoscopic (HARP)
technique Bergman et al in a randomized control trial did not show any
difference between two techniques with longer operating
The retroperitoneoscopic space is developed first and then time in HALDN.
camera port is inserted and the pneumoperitoneum is cre-
ated. The surgery is done without opening the peritoneal 3.4. LDN vs ODN
cavity with the help of 2e3 working ports.
Various trials have arrived at the same conclusion, despite
longer operating time and longer warm ischemia time, LDN
2.6. Retroperitoneoscopic technique results in shorter hospital stay with less blood loss and early
convalescence without compromising the graft function. The
The retroperitoneal space is developed digitally or with bal- overall complication rate is less than 3% in most series. LDN
loon dilatation. The retroperitoneum is insufflated with 12 cm has been shown to be superior to ODN.
H2O CO2. The surgery is done using 2e3 working ports without
any hand assistance.
3.5. LDN vs MIDN
2.7. Robotic assisted donor nephrectomy LDN results in better quality of life compared with MIDN
without compromising safety and graft function. LDN resulted
This is performed using the da Vinci robotic system. The in longer operating time compared to MIDN (221 min vs
procedure is done with one robotic camera port, two robotic 164 min), longer warm ischemia time (6 min vs 3 min), less
arms ports and one assistant port. The surgeon is seated on blood loss (100 ml vs 240 ml), less analgesic requirement and
a master console which provides a magnified 3D high defi- shorter hospital stay (3 days vs 4 days).5
nition image from the robotic camera and instrument move- LDN is technically more demanding than the ODN with
ment control mimicking the movement of the surgeon’s wrist a prolonged learning curve. Due to these reasons, it may be
with 7 degree of freedom. difficult to introduce LDN in small centers.

4. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 4 7 e4 9 49
3.6. Robotic assisted donor nephrectomy
5. Conclusion
There are few articles on robotic assisted donor nephrectomy
as this technique is still evolving. The theoretical advantages The surgical procedure of donor nephrectomy has evolved
include magnified 3D high definition image with increased since the first successful renal transplant in 1954. The vari-
degree of freedom in robotic instruments enabling more ac- ous minimally invasive techniques of donor nephrectomy
curate and safe intricate dissection of the hilum. are in use in different centers based on experience and
preferences. There is sufficient evidence in the literature
showing the advantages of minimally invasive techniques
4. Laparoscopic and robotic donor over open or mini incision donor nephrectomy. The role of
nephrectomy e experience at Apollo Gleneagles retroperitoneoscopic donor nephrectomy still needs to be
Hospitals, Kolkata clarified.
Laparoscopic donor nephrectomy has become the gold
4.1. LDN standard.
Robotic assisted donor nephrectomy is still evolving and
Number e 570 further studies are needed to compare it to laparoscopic donor
nephrectomy.
Right e 134
Multiple arteries e 143
Conflicts of interest
Multiple veins e 54
The author has none to declare.
Duplex system e 5
Duration of surgery e 50 mine120 min references
Postoperative stay e 22 he40 h
Warm ischemia time e 1 mine6 min
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Duration of surgery e 70 mine110 min
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