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Retroperitoneal Single-port Donor Nephrectomy through Lumbotomy Incision: An Experience of 30 Cases
Reports in literature have shown the retroperitoneal approach has references
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a shorter time to renal artery control which helps in early control
of any major bleeding. 1. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all
patients on dialysis, patients on dialysis awaiting transplantation,
Single-site surgery usually requires special ports and and recipients of a first cadaveric transplant. N Engl J Med
angulated instruments which has actually limited the popularity 1999;341(23):1725–1730.
of procedure due to higher costs and increased surgical difficulty. 2. Hariharan S, Johnson CP, Bresnahan BA, et al. Improved graft survival
Most of the commercially available ports have a small opening after renal transplantation in the United States, 1988–1996. N Engl J
in the abdominal wall which leads to clustering of instruments. Med 2000;342(9):605–612.
Angulated instruments were devised to circumvent this but they 3. Ratner LE, Ciseck LJ, Moore RG, et al. Laparoscopic live donor
increase the difficulty associated with this approach. The average nephrectomy. Transplantation 1995;60(9):1047–1049.
size of retrieval incision in this series was 7 cm and the Alexis port 4. Nicholson ML, Elwell R, Kaushik M, et al. Health-related quality of
life after living donor nephrectomy: a randomized controlled trial of
assembly covered this incision and provided a wider space for laparoscopic vs open nephrectomy. Transplantation 2011;91:457–461.
motion of instruments. There was less fighting as the entry point of 5. Dunn JF, NylanderJr WA, Richie RE, et al. Living related kidney
instruments being mobile, it provided a wider range of motion as donors. A 14 year experience. Ann Surg 1986;203(6):637–643. DOI:
compared to commercially available ports. No special instruments 10.1097/00000658-198606000-00008.
were required with this assembly and routine laparoscopic ports 6. Nanidis TG, Antcliffe D, Kokkinos C, et al. Laparoscopic vs open live
and instruments were used which has significant cost benefits to donor nephrectomy in renal transplantation: a meta-analysis. Ann
the patient over commercially available single ports. Surg 2008;247(1):58–70. DOI: 10.1097/SLA.0b013e318153fd13.
Most of the previously described retroperitoneal techniques 7. Greco F, Hoda MR, Alcaraz A, et al. Laparoscopic living-donor
nephrectomy: analysis of the existing literature. Eur Urol
use balloon dilatation to create retroperitoneal space 26,27 but with 2010;58(4):498–509. DOI: 10.1016/j.eururo.2010.04.003.
the translumbar approach, pneumoretroperitoneum could be 8. Yang SC, Park DS, Lee DH, et al. Retroperitoneal endoscopic live donor
reliably made under vision by using open surgical instruments. nephrectomy: report of 3 cases. J Urol 1995;153(6):1884–1886. DOI:
There have been concerns about retroperitoneal approach 10.1016/S0022-5347(01)67339-7.
to prolong the operative time in donor surgery and prolonged 9. Yagisawa T, Amano H, Ito F, et al. Adrenal hemangioma removed
lateral positioning may lead to neural injuries. In our series, the time by a retroperitoneoscopic procedure. Int J Urol 2001;8(8):457. DOI:
taken to completion in initial few cases was higher but the average 10.1046/j.1442-2042.2001.00352.x.
of 170.3 ± 52 minutes compared favorably with transperitoneal 10. Gill IS, Uzzo RG, Hobart MG, et al. Laparoscopic retroperitoneal
live donor nephrectomy for purpose of allotransplantation and
cases at our center. The learning curve with retroperitoneal donor autotransplantation. J Urol 2000;164(5):1500–1504. DOI: 10.1016/
nephrectomy has been shown to be short in a retrospective S0022-5347(05)67015-2.
review of 120 cases where operative times improved rapidly after 11. Flowers JL, Jacobs S, Cho E, et al. Comparison of open and
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performing 30 procedures. It has been shown in various studies laparoscopic live donor nephrectomy. Ann Surg 1997;226(4):483–489.
that retroperitoneal approach leads to decreased operative time DOI: 10.1097/00000658-199710000-00009.
as time required to mobilize colon is saved and with a single- 12. London E, Rudich S, McVicar J, et al. Equivalent renal allograft function
site approach, time taken to place ports and later close them is with Laparoscopic vs open live donor nephrectomy. Transplant Proc
avoided. 29 1999;31(1–2):258–260. DOI: 10.1016/S0041-1345(98)01526-7.
The homemade port assembly used in this series comprising 13. Ratner LE, Kavoussi LR, Schulam PG, et al. Comparison of laparoscopic
live donor nephrectomy vs the standard open approach. Transplant
of Alexis wound retractor with a surgical glove, is cost-effective Proc 1997;29(1–2):138–139. DOI: 10.1016/S0041-1345(96)00037-1.
and easy to use. The glove sustained the standard intra-abdominal 14. Merlin TL, Scott DF, Rao MM, et al. The safety and efficacy of
pressure without any incidence of rupture. This assembly has laparoscopic live donor nephrectomy: a systematic review.
been used in few other studies which have documented its Transplantation 2000;70(12):1659–1666. DOI: 10.1097/00007890-
effectiveness. 30 200012270-00001.
15. Ryu DS, Park WJ, Oh TH. Retroperitoneal laparoendoscopic single-
lIMItAtIons of technIque /study site surgery in urology: initial experience. J Endourol 2009;23(11):

1857–1862. DOI: 10.1089/end.2009.0254.
There may be difficulty initially in approaching lumbar fascia 16. Pansadoro V. The posterior lumbotomy. BJU Int 2005;95(7):1121–1131.
DOI: 10.1111/j.1464-410X.2005.05483.x.
through this incision for the inexperienced as it is not a popularly 17. Raman JD, Bensalah K, Bagrodia A, et al. Laboratory and clinical
used approach. The working space is a bit limited as is any development of single keyhole umbilical nephrectomy. Urology
retroperitoneal approach but Alexis assembly with a glove adds 2007;70(6):1039–1042. DOI: 10.1016/j.urology.2007.10.001.
to the space and is usually adequate unless the patient is small in 18. Raman JD, Bagrodia A, Cadeddu JA. Single incision, umbilical
size. The limitations of the study include early experience with a laparoscopic vs conventional laparoscopic nephrectomy: a
small sample size and that no comparison has been done with the comparison of perioperative outcomes and short term measures
standard transperitoneal approach. However, a randomized control of convalescence. Eur Urol 2009;55(5):1198–1204. DOI: 10.1016/
trial is already underway at our center to assess the outcomes of j.eururo.2008.08.019.
this approach. 19. Andonian S, Rais-Bahrami S, Atalla MA, et al. Laparoendoscopic single-
site Pfannenstiel vs standard Laparoscopic donor nephrectomy.
J Endourol 2010;24(3):429–432. DOI: 10.1089/end.2009.0185.
conclusIon 20. Canes D, Berger A, Aron M, et al. Laparo-endoscopic single
site (LESS) vs standard laparoscopic left donor nephrectomy:
Single-site translumbar RPLDN is a feasible alternative approach matched-pair comparison. Eur Urol 2010;57(1):95–101. DOI: 10.1016/
to the donor surgery and can avoid the inherent risks associated j.eururo.2009.07.023.
with the transperitoneal technique. It has the potential to further 21. Gupta A, Ahmed K, Kynaston HG, et al. Laparoendoscopic single-
reduce the pain associated with the donor nephrectomy operation. site donor nephrectomy (LESS-DN) vs standard laparoscopic donor

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