Robotic-Assisted Laparoscopic Left Donor Nephrectomy for Living Kidney Donation

Kidney transplantation is the preferred treatment for patients with end-stage renal disease and is associated with a better quality of life and survival compared to other renal replacement therapies. Compared to deceased donor kidneys, living donor kidney donation is associated with shorter wait times, improved patient and graft survival, and the possibility of preemptive transplantation. After the initial learning curve, robotic-assisted living donor nephrectomy has similar outcomes compared to open and laparoscopic nephrectomy, and in some settings an overall decreased length of stay. In this article, we present a case of a robotic-assisted living donor nephrectomy, including evaluation, technique, and considerations for the surgeon preoperatively and intraoperatively.

Renal transplantation; living donors; robotic surgical procedures; warm ischemia; treatment outcome.

Kidney transplantation is the treatment of choice in end-stage renal disease (ESRD), but deceased donor organ shortage is a major limiting factor. About one-third of kidney transplants in the United States are living donor transplants.¹ This is in contrast to 40–90% living donor transplants in some developing countries where living donor transplant is the most feasible option due to the lack of infrastructure for deceased organ donation and high cost and low accessibility of chronic dialysis.² Minimally invasive techniques are now the standard of care, and robotic-assisted living donor nephrectomy has been shown to have similar postoperative outcomes compared to laparoscopic nephrectomy, with decreased overall length of stay.^3–6 

The donor was a 38-year-old male who presented to the transplant center to donate a kidney to his brother. He had no significant medical history (no history of kidney stones, urinary tract infections, diabetes, hypertension, or malignancy). His past surgical history included an open appendectomy at 13 years of age due to ruptured appendicitis without anesthesia related issues. His body mass index (BMI) was 31.46 kg/m². The patient’s functional status was 4 metabolic equivalents (METs), and he was American Society of Anesthesiologists (ASA) class 1. He was allergic to penicillin, gentamicin, and vancomycin. He has a family history of fatty liver and kidney disease in his brother (from IgA nephropathy). He underwent comprehensive testing for living kidney donation, and he met medical and surgical criteria for donation.

Physical examination was unremarkable except for abdominal obesity and a well-healed right lower quadrant open appendectomy scar. He underwent standard donor preoperative workup including renal function testing, infectious testing, and age-appropriate malignancy screening. Blood type (ABO) and immunologic (HLA) compatibility between donor and recipient were established. Preoperative electrocardiogram and chest x-ray were performed and showed no abnormalities. Given his ASA status and medical history, no further preoperative workup was indicated. Cross-sectional imaging was performed to assess kidney size and vasculature in order to determine the donor kidney laterality. 

CT angiogram of the abdomen was performed to evaluate the size of kidneys as well as anatomical variations in the kidney vasculature and collecting system (Figure 1). In this case, the estimated volume of the kidneys had a less than 10% discrepancy, which is the cut-off for our center for functional testing. The donor had bilateral single renal arteries and single renal veins. No abnormalities were noted in the renal pelvis or ureters. A 2-cm simple benign appearing cortical cyst was seen in the upper pole of the left kidney. No stones or abnormal masses were noted in the kidneys.

Figure 1. CT Angiogram Abdomen (Kidney). Left: axial view demonstrating single renal artery and vein on the left side; Right: coronal view Left kidney.

Living donor nephrectomy can be performed through open laparoscopic, hand-assisted laparoscopic, or robotic-assisted approaches.

Living donor kidney donation is associated with shorter wait times and improved patient and graft survival when compared to deceased donor kidneys. While preemptive transplantation before the recipient starts dialysis is an option with a kidney from deceased donation, living donation allows for a much shorter wait-time and higher likelihood of preemptive transplantation.

General anesthesia and neuromuscular blockade are administered with the patient in the supine position. After induction of anesthesia, a nasogastric tube to keep the stomach decompressed throughout the operation, and Foley catheter are placed. Perioperative antibiotics are administered. A laparotomy instrument set is kept available in the operating room for potential emergent conversion to an open procedure.

The patient is placed in the right lateral decubitus position with the arms hugging a pillow. When using the robot, the use of the lateral arm board can lead to pressure from the robotic arm, so it is preferred to have the arm positioned slightly downward. This is followed by flexing the table to help separate the ribs from the iliac crest for better access. All pressure points need to be padded, and an axillary roll should be placed to prevent nerve compression injuries. The patient should be secured to the operating table. We use a bean bag to help position the patient. Confirm palpable radial pulses bilaterally at the conclusion of positioning. Sequential compression devices should be placed on both lower extremities. The operative field is clipped, then prepped and draped in the usual sterile fashion, extending from the xiphoid to below the symphysis pubis, and posterior axillary line on the nephrectomy side till the beanbag on the contralateral side. 

A 7–8-cm long Pfannenstiel incision is made to enter the abdominal cavity. The abdominal wall fascia is opened transversely, and flaps are raised superior and inferiorly. The extent of the mobilization of the abdominal wall fascia determines the size of the area for kidney extraction. Make sure there is ample dissection. Then the rectus muscles are spread apart and the peritoneum is opened vertically between the rectus muscles. Take caution to open the peritoneum superiorly to avoid dissection into the bladder. A GelPort laparoscopic system is placed in the incision, and a 12-mm laparoscopic port is placed through the GelPort to establish pneumoperitoneum. Three additional 8-mm robotic ports are placed under direct laparoscopic visualization: in the epigastric area, superior to the umbilicus, and in the left lower quadrant (Figure 2). The ports need to be placed approximately 10 cm apart and at least 2 cm from the ribs and iliac crest. The 12-mm port through the GelPort is an assist port for the bedside assist throughout the operation. The DaVinci robot is then docked to the ports and robotic instruments inserted under direct visualization.

Figure 2. Laparoscopic Donor Left Kidney Nephrectomy Incision Sites. A diagram demonstrating the position of port installations for a laparoscopic donor left kidney nephrectomy. One 7–8-cm long Pfannenstiel incision is made to enter the abdominal cavity. A GelPort laparoscopic system is placed in this incision, and a 12-mm laparoscopic port is placed through the GelPort. Three 8-mm robotic ports are placed in the epigastric area, superior to the umbilicus, and in the left lower quadrant under direct vision.

At the console, the left colon is rotated medially by taking down the attachments to the abdominal wall. The left kidney is visualized. Care is taken to not mobilize the posterior attachments of the kidney at this time so that it remains retracted laterally for easier hilar dissection. The spleen and its attachments to the diaphragm and the kidney are freed and medially rotated to help in the dissection of the vascular structures. The ureter is identified and dissected to the pelvis. It is important to avoid stripping the adventitia of the ureter by leaving some amount of periureteral fat, and to preserve the tissue between the ureter and the inferior pole of the kidney to decrease the chance of ureteral ischemia related complications. 

Attention is turned to the dissection of the hilum, specifically the renal vein, gonadal vein, lumbar vein and adrenal vein. Be certain to not dissect in the hilum itself, but dissect closer to the aorta due to the risk of injuring the numerous vascular branches in the renal hilum. The gonadal vein is divided with the vessel sealer using three burns followed by the adrenal vein and the lumbar veins. Some centers prefer to use clips, but there is a risk of accidentally stapling over the clips, so if clips are used additional caution must be taken at the time of stapling. All of the branches are transected close to the renal vein. Following this, the renal artery is identified and dissection is continued towards the aorta.

Dissection is then continued between the adrenal gland and the hilum of the kidney. Any connective tissue between renal artery and renal vein is carefully transected. After identifying and dissecting the vessels and the ureter, the kidney is completely mobilized from the superior to the inferior pole. This is followed by mobilization of the posterior attachments of the kidney. This portion of the case was complicated by the degree of fat surrounding and adherent to the kidney. 

The renal artery and vein are cleared from all attachments in preparation for stapling. The ureter is clipped and transected as distal as possible with two Hemo-o-lok clips to preserve length. The accepted location for ureter transection in donor nephrectomy is at the level where the ureter passes over the iliac artery. We use Hem-o-lok clips from the assist port, but robotic clips are also available and appropriate for use. The ureter is transected with the cut function of the vessel sealer, robotic scissors, or using scissors from the assist port. 

Variations in renal vasculature occur in approximately 25–50% of cases.^7, 8 The kidney receives end-arterial blood supply, so it is important to identify and carefully preserve any accessory arteries larger than 1–2 mm in diameter, which are usually visualized on preoperative CT scan. Any vessels of smaller diameter encountered intraoperatively can be transected. It is advisable to have a discussion with the recipient surgeon either ideally preoperatively or in real-time if needed.

Once the vessels are dissected and ready for stapling, intravenous mannitol is administered. We give 12.5 g of mannitol. We do not give IV heparin, but some donor centers administer heparin before cross-clamp. The cold flush is prepared, and the robot is undocked. The most inferior 8-mm port is upsized to a 12-mm port to accommodate the Endo GIA stapler. Some robotic donor nephrectomy surgeons may elect to use the robotic stapler. Extend the Pfannenstiel incision to accommodate the kidney if the kidney is large or has adherent perinephric fat, as in this case. The renal artery is stapled with a GIA 30 tan load close to the aorta, followed by stapling the renal vein with a GIA 30 tan load. The kidney is extracted through the Pfannenstiel incision. The kidney is then perfused with a cold University of Wisconsin preservation solution (or another preservative solution of choice) on the back table. The renal artery is flushed until the fluid coming from the renal vein is clear and the parenchyma of the kidney appears flushed. The kidney is then transported to the recipient room. In this case, the extraction was difficult due to the size of the kidney and the perinephric “sticky” fat. The incision was extended further and a laparoscopic retrieval bag was used to remove the kidney, which was then immediately placed on ice and flushed. 

While the kidney is being flushed, the first most immediate step is to confirm hemostasis in the operative field. If necessary, use a combination of clips, cautery, and hemostatic agents. Clips may be necessary if there is any concern for lymphatic drainage. The anatomy of the kidney is confirmed on the back table. A transversus abdominis plane (TAP) block can be administered laterally by injecting local anesthetic just superficial to the peritoneum using direct visualization of the nephrectomy side. We perform a unilateral TAP block intraoperatively. Another option is for anesthesia to perform a TAP block once the patient is positioned supine, prior to extubation. The remainder of the local anesthetic is then injected by the port sites and the Pfannenstiel incision before closure. The fascia at the 12-mm port in the left lower quadrant is closed with a 0 Vicryl using a Carter-Thompson device, and the ports are closed with 4-0 Monocryl. After confirming instrument count, the Pfannenstiel incision is closed in 4 layers: the peritoneum is closed with 2-0 Vicryl, the anterior fascia of the rectus muscle with 2-0 PDS, and the skin in two layers using 3-0 Vicryl in Scarpa’s fascia, and 4-0 Monocryl in the subcuticular layer. Surgical glue is applied and repeat instrument count is confirmed.

Living kidney donation can be performed through living related directed donation, kidney paired donation, or non-directed/altruistic donation. With a few exceptions, there has been an overall decline in living kidney donation in the United States since 2005. Rates of living donation fell even further during the COVID-19 pandemic.⁹ Paired donation networks can facilitate an increase in living donor kidney transplantation. Paired donation recipients were more likely to be women, black, have a previous transplant, be highly sensitized, and have public insurance, but they have been shown to have equivalent outcomes to other living donor kidney recipients.¹⁰ 

Screening for living kidney donation may vary between centers but typically, potential donors undergo medical, surgical, and psychiatric evaluation (as indicated) to assess candidacy. Tests may include cardiac and pulmonary function testing if indicated, functional status assessment, malignancy screening, infectious screening, nutrition consult depending on BMI, and ESRD risk testing, especially for those with a family history of kidney disease. Several risk assessment tools are available to calculate predonation risks for donor candidates.^11–13 A renal CTA is also obtained to assess renal anatomy. Although transplant centers have different eligibility criteria for kidney donors, the procedure is generally contraindicated if the potential candidate is less than 18 years old, diabetic, has uncontrolled hypertension, advanced kidney disease, active infection, active or incompletely treated malignancy, untreated psychiatric illness, impaired decision-making capacity, or suspected financial or interpersonal coercion.

Anatomical choices are surgeon dependent. In potential donors with a small uncomplicated unilateral single kidney stone, the affected side may be transplanted after the donor is screened for future stone-forming risks (we use a LithoLink test). Variations in renal vasculature occur in approximately 25–40% of cases. Dual ureters are seen in approximately 0.7–0.8% of the healthy adult population and in 2–4% of adults with urinary tract issues.^7, 8, 1416 At our center, we do not accept donors with horseshoe kidneys or donors with fibromuscular dysplasia. Split renal function testing is assessed in the case of size discrepancy. The criteria for split renal function testing are center-dependent. At our center, we obtain a Nuclear Medicine renal scan when the volume difference between donor kidneys exceeds 10% on CT scan. We take the lower functioning kidney if the split renal function difference exceeds 10% to leave the better functioning kidney after donation. Conventionally, the left kidney is preferred for donation because of the longer length of renal veins which may facilitate easier recipient venous anastomosis. The left kidney is used in about 80% of all living donor kidney transplantations.¹⁷ The right kidney may be used in the absence of a solitary renal artery on the left side, parenchymal abnormalities in the left kidney, or based on size discrepancy.

Perioperative mortality in living kidney donors is 3/10,000, and estimated 20-year risk of ESRD is about 30/10,000, regardless of approach or variation in selection criteria.^11, 18 Postdonation serum creatinine at six months may be associated with subsequent ESRD risk in living kidney donors.¹⁹ Another potential complication is the risk of hernia at the extraction or port sites. The risk of hernia is lower using a Pfannenstiel incision compared to using midline abdominal incisions based on literature from gynecologic surgery.^20, 21 Patients may develop testicular swelling from division of the gonadal vein but this is transient and self-resolves. Robotic-assisted living donor nephrectomy has been shown to have similar postoperative outcomes compared to laparoscopic nephrectomy and overall decreased length of stay.^3–6 Several modifications are described in the literature, including a small series of seven patients that reported feasibility of robotic single-port donor nephrectomy.²²

In this case, the operating time was 3.5 hours and estimated blood loss was 200 ml. We encountered added difficulty due to excessive adherent perinephric fat or “sticky fat,” which caused issues during dissection as well as extraction of the kidney. However, the donor had an uneventful recovery and was discharged on postoperative day three with good pain control on oral analgesics. On follow up, the patient had no issues.

• Da Vinci Xi Surgical System.
• GelPort laparoscopic system for hand-assisted laparoscopy.
• 12-mm disposable laparoscopic port

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.