Parameter
Study
Criteria for donation
Renal function
99m Tc-DTPA scintigraphy
GFR >80 mL/min/1.73 m2 and GFR >5th percentile for their age
Proteinuria
Spot urine (U) protein, albumin, creatinine
U protein/U creatinine ratio: <200 mg/g
U albumin/U creatinine <30 mg/g
Obesity
Body mass index (BMI) calculation
If age <30: BMI <32 kg/m2
If age ≥30: BMI <34 kg/m2
Hypertension
BP checked on 2 separate occasions
Acceptable if mild and age >40 years, normal GFR, Caucasian race, single antihypertension agent, and no end-organ damage (LVH, retinopathy, proteinuria)
If SBP >140 or DBP >90, obtain 18-h ambulatory BP
Diabetes
8-h fasting blood glucose (FBG) and HbA1c. If either abnormal, perform 2-h glucose tolerance test (GTT)
Exclude for overt DM (FBG >126 on 2 separate tests or HbA1c ≥6.5 %)
Exclude if FBG 100–125 or HbA1c = 5.7–6.4 % plus any family history, BMI >30, hypertension, dyslipidemia, GDM within 10 years
Nephrolithiasis
CT urogram (standard imaging)
Excluded if + metabolic stone disease (cystinuria, oxaluria), frequent Ca oxalate stone former, anatomic defect leading to struvite stones, asymptomatic with bilateral stones, or numerous unilateral stones
If + imaging or stone history: Serum ionized Ca, PTH, and uric acid plus a comprehensive urine stone evaluation (e.g., Litholink)
Suitable: Asymptomatic + single, unilateral stone with no exclusionary findings
Hematuria
If UA +, repeat; if + evaluate for urologic malignancy and stone disease ± renal biopsy
Asymptomatic microhematuria may be acceptable depending on etiology
Infectious disease
Standard virologic, TB, and syphilis screening
+ HIV and + HCV are exclusionary
HIV/HCV/HBV nucleic acid testing (≤10 days before donation)
The surgeon’s role in the evaluation process is to first review the medical and psychosocial assessments. Unless there is an obvious contraindication, the potential donor undergoes angiography through either computed tomography (CTA, Fig. 4.1) or magnetic resonance (MRA). We perform CTA at the University of Pittsburgh, but the accuracy of MRA is felt to be equivalent in experienced centers.
Fig. 4.1
CT angiography for the evaluation of a living kidney donor
In the setting of normal renal function, studies suggest that CT volumetry correlates well with split radionuclide renography, obviating the need for this additional study. In general, we consider the donor kidneys to be equivalent unless the larger kidney accounts for more than 55 % of the total renal volume. In that scenario, it is prudent to remove the smaller kidney for transplantation, leaving the donor with the larger of the two kidneys. Cystic lesions in the kidney rarely alter which kidney is removed unless they are large (>3 cm) or have a solid or complex component. A lesion of any size that is not purely cystic should mandate the removal of that particular kidney, with prompt pathological evaluation at the time of extraction. A donor with a unilateral, asymptomatic renal stone who is felt to be suitable for donation (see Table 4.1) should undergo nephrectomy of the kidney with nephrolithiasis. If the stone is large and in an amenable location, bench ureteroscopy will facilitate stone extraction. The importance of left-sided, unilateral arterial duplication is controversial; numerous single-center studies in the laparoscopic era suggest that there is a tendency to use the left kidney even if it has multiple arteries, most likely because the recipient surgeon prefers a longer vein or the donor surgeon is uncomfortable with performing right-sided nephrectomy. In the early practice of laparoscopic LDN, there were reports of unacceptably high venous thrombosis rates using right-sided kidneys, but this is no longer felt to be the case and we generally opt for right LDN if there is unilateral left-sided arterial duplication. The charge of the donor surgeon is to be proficient bilaterally, with equivalent and acceptable complication rates and operative times so as to give the recipient surgeon the necessary options to best serve the kidney transplant recipient. The donor, who is expecting an optimal outcome for both patients, also benefits.
4.2.2 Counseling and Donor Education by the Nephrectomy Surgeon
During a donor’s decision-making process, a thorough discussion regarding the specifics of the operative procedure and its expected outcome is required to ascertain an informed consent. The donor is counseled on the well-described donation-related complications, which vary somewhat based on the surgeon’s preferred operative technique (Table 4.2).
Table 4.2
Donor education: donation-related complications
Complication | Incidence, % |
|---|---|
Death (first 90 days) | 0.031 |
ESRD: need for donor RRT/KTx | 0.30 |
Bleeding >2 units PRBC or >500 mL | PLDN 0.5 |
HALDN 0.1 | |
Conversion to open nephrectomy | PLDN 1.3 |
HALDN 0.8 | |
Intestinal injury | PLDN 0.4 |
HALDN 0.1 | |
Hernia requiring repair | PLDN 0.1 |
HALDN 0.7 | |
Hypertension (medication required) | 16 (at 10 years) |
Readmission after initial discharge | 2.1 |
4.2.3 Postdonation Management
The postoperative care afforded to the kidney donor is in keeping with that provided to any patient recovering from a major abdominal operation. Intravenous (IV) fluids are discontinued after successful oral fluid intake, which can be initiated within hours of extubation in most cases. The resumption of gastrointestinal function is variable and the diet choice should be adjusted accordingly; a daily stool softener may aid with constipation. Deep vein thrombosis (DVT) prophylaxis appropriate for the patient’s risk factors is provide; most LDNs require only sequential compression devices, and all donors should be fully ambulatory within 24 h of extubation. Our narcotic-minimizing analgesia protocol consists of ketorolac IV (which has a well-published, favorable safety profile in this patient cohort), intravenous acetaminophen, and oral and IV narcotics for pain breakthrough. Typically, donors meet standard postoperative discharge criteria within 1 or 2 days and are reevaluated in the outpatient setting at 1–2 weeks. Long-term follow-up consists of a 6-month check followed by annual visits. At each of these opportunities, the donor undergoes blood pressure measurement, a hemogram and renal function panel, fasting blood glucose, and urinalysis, including a protein/creatinine ratio.
4.3 Operative Techniques
4.3.1 Open Nephrectomy
1.
The patient is positioned with the right or left flank (depending on which kidney is being removed) elevated and exposed. The incision begins posteriorly at the tip of the 12th rib and curves anteriorly in the direction of the umbilicus, stopping at the lateral border of the rectus muscle (black arrow) (Fig. 4.2).
Fig. 4.2
Positioning for open nephrectomy. The incision begins at the tip of the 12th rib and stops at the lateral border of the rectus muscle (broken black line)
2.
The three muscular layers of the lateral abdominal wall are divided. Sometimes a small portion of the tip of the 12th rib requires resection. Deep to the muscular layers, the peritoneum is identified and retracted medially to visualize the retroperitoneal space. The ureter (black arrow) is identified below the lower pole of the kidney, running on the anterior surface of the psoas muscle. It is mobilized down to the pelvis, taking care not to remove the surrounding periureteral tissue. Once the ureter is mobilized, Gerota’s fascia is incised and the kidney is separated from the surrounding perirenal fat (Fig. 4.3).
Fig. 4.3
The ureter is mobilized and Gerota’s fascia is incised
3.
The renal vein is identified and mobilized proximally. For the left kidney, the vein is mobilized to the point where it lies anterior to the aorta (Fig. 4.4). The gonadal vein, adrenal vein, and any lumbar vein branches will need to be ligated and divided. The right renal vein, however, usually has no branches draining into it. The vein on the right side is traced proximally to its junction with the inferior vena cava.
Fig. 4.4
The renal vein is identified and mobilized proximally, to the point where it lies anterior to the aorta (for the left kidney). The gonadal vein, adrenal vein, and any lumbar vein branches will need to be ligated and divided
4.
The renal artery is identified next, usually lying posterior and superior to the lower border of the renal vein. It is useful to retract the kidney medially and carry out the dissection along the posterior aspect of the hilum. The renal artery is mobilized to its junction with the aorta (Fig. 4.5)
Fig. 4.5
The renal artery is mobilized to its junction with the aorta
5.
The ureter is divided distally. At this point, the surgeon can easily check to ensure that the kidney is producing urine. It is best to wait until good urine production is visualized from the kidney before actually removing it. Vascular clamps are applied on the renal artery at its junction with the aorta, and on the renal vein where it runs anterior to the aorta (Fig. 4.6). These structures are divided; the kidney is extracted and given to the recipient team.
Fig. 4.6
The ureter is divided distally. Vascular clamps are applied on the renal artery at its junction with the aorta, and on the renal vein where it runs anterior to the aorta
6.
The vascular stumps are then oversewn with a nonabsorbable suture (Fig. 4.7). One-sided, non-cutting vascular staplers are an alternative approach. After checking for hemostasis, closure is initiated. The abdominal wall is closed in layers.
Fig. 4.7
The vascular stumps are then oversewn with a nonabsorbable suture
4.3.2 Laparoscopic Donor Nephrectomy
4.3.2.1 Introduction
As demonstrated on the previous pages, open live donor nephrectomy is accomplished with a relatively long incision along the flank, often involving removal of a small portion of the 12th rib, and may be associated with significant pain and significant loss of time from work and other activities. The recovery period was historically around 6 weeks. The short-term disability caused by open donor nephrectomy was the impetus to seek a less invasive method that would result in a smaller incision, less pain, and faster recovery. Even though laparoscopic nephrectomy for disease was performed as early as 1991, laparoscopic donor nephrectomy (LDN) was first performed by Lloyd Ratner at Johns Hopkins University in 1995. Early concerns about an increased incidence of delayed graft function and graft thrombosis were quickly dispelled as experience in the field grew.
Currently, LDN is being performed using several techniques:
Hand-assisted
Pure laparoscopic
Robotic hand-assisted
Robotic pure laparoscopic
Each technique has its advantages and limitations. Hand-assisted LDN is the most commonly used in the United States and is our preferred technique because data suggest lower vascular injury rates, renal artery and vein lengths are optimal (especially for right-sided nephrectomies), and only three incisions are needed.
The pure laparoscopic technique also has its advantages. The extraction site incision is usually smaller because the kidney is delivered using a bag, and the main incision can be placed below the waistline if requested by the donor.
At some centers, robot-assisted LDN became the preferred approach in the early to mid 2000s; some surgeons elected to combine hand assistance with this technique. Robotic assistance has the following advantages:
A 360° articulating wrist for the operating arms, providing greater flexibility and maneuverability
Tremor-free operation due to a built in stabilization system
Increased magnification through the robotic console
Binocular vision at the console, providing a three-dimensional image
The robotic system also has major disadvantages:
Lack of tactile feedback from the end of the instrument to the console
Fixed port and patient positions with limited range of movement, which may sometimes limit moving from the upper pole of the kidney down to the pelvis to dissect the ureter
Added expense, without data to show improved outcomes, lower complication rates, or shorter donor length of stay for justification
4.3.2.2 Preoperative Donor Preparation and Positioning
The donor undergoes a light bowel prep with magnesium citrate the day before donation in an attempt to mitigate postdonation constipation. Cefazolin IV is given for antimicrobial prophylaxis before incision. The donor is placed into the lateral position (a bean bag may be used) and the kidney rest is elevated; the table is retroflexed to open up the angle between the rib cage and the iliac crest (Fig. 4.8).
Fig. 4.8
The table is retroflexed to open up the angle between the rib cage and the iliac crest
4.3.2.3 Hand-Assisted Technique
1.
Incisions and trocar placements: An incision measuring 6–7.5 cm (depending on surgeon hand size) is made either in a midline supraumbilical position for left-sided LDN (Fig. 4.9) or infraumbilically for a right-sided LDN (Fig. 4.10).
Fig. 4.9
Ports for left-sided LDN
Fig. 4.10
Ports for right-sided LDN
2.
A hand port device is placed, pneumoperitoneum is established, and two trocars are placed under direct vision. For left LDN, this includes one 10–12 mm port just slightly inferior and lateral to the umbilicus (camera port) and a second port about 8 cm superolateral to the first one, which is used for dissection (Fig. 4.11). On the right side, an additional 5-mm heavy grasper is inserted via an epigastric incision as the liver retractor.
Fig. 4.11
A hand port device is placed, as well as a camera port and dissection port. The positions shown are for a left LDN
3.
Alternatively, some surgeons prefer a transverse lower quadrant incision for the hand port (Fig. 4.12).
Fig. 4.12
Some surgeons prefer a transverse lower quadrant incision for the hand port
4.
Left colon mobilization: Along the Line of Toldt, the left colon is mobilized with electrocautery or alternative thermal devices from the splenocolic ligament to the pelvic brim. The colon is reflected medially to visualize the retroperitoneal space and the kidney enclosed in Gerota’s fascia (Fig. 4.13a). Minimal digital retraction of the colon yields a nearly avascular plane which requires minimal thermal energy to divide (Fig. 4.13b).
Fig. 4.13
(a) Electrocautery or alternative thermal devices are used to mobilize the left colon by dividing the peritoneum along the line of Toldt. (b) The colon is reflected medially to visualize the retroperitoneal space and the kidney enclosed in Gerota’s fascia
5.
Ureter-gonadal vein identification and mobilization: Once the colon is mobilized, the ureter and left gonadal vein are identified (Fig. 4.14a), encircled, and mobilized off the psoas muscle down to the level of the pelvic brim as it crosses the iliac artery. Subsequently, proximal dissection ends as the renal hilum comes into view (Fig. 4.14b). It is important to avoid ureteral skeletonization by staying close to the psoas muscle.
