PDF-MINI.pdf 353Vol. 9 | No. 1 | Winter 2012 |U R O LO G Y J O U R N A L Keywords: nephrectomy, laparoscopy, tissue donors INTRODUCTION Rdonor nephrectomy (LDN)(1,2) and now it is performed in the most major transplant centers for donor nephrectomy. Further attempts are made to make this minimally invasive technique more acceptable for donors by introduc- ing transumbilical and pfannenstiel laparoendoscopic single site surgery (LESS) nephrectomy.(3,4) not only more cosmetic comparing to standard laparoscopy (SL), but also more ergonomic and user-friendly than LESS technique. TECHNIQUE - lateral to the umbilicus and were used for grasping and scissoring, respectively. - nenstiel incision, which would be used for the kidney extraction (Figure 1). This trocar was used for suctioning, traction, and bipolar coagulation for the adrenal and lumbar veins during nephrectomy. Vascular clips for controlling the renal pedicle were also introduced through this trocar. Laparoscopic nephrectomy was Shahid Labbafinejad Medical Center, Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sci- ences, Tehran, Iran Nasser Simforoosh, Mohammad Hossein Soltani, Ali Ahanian Rapid Communication Mini-Laparoscopic Donor Nephrectomy A Novel Technique Corresponding Author: Nasser Simforoosh, MD Department of Urology, Shahid Labbafinejad Medi- cal Center, 9th Boustan St., Pasdaran Ave., Tehran, Iran Tel/Fax: +98 21 2258 8016 E-mail: simforoosh@iurtc. org.ir Website: www. iurtc.org.ir Received January 2012 Accepted January 2012 354 | Rapid Communication performed as we reported in detail previously.(1) The colon was mobilized medially and the spleno- renal ligament was divided. The left ureter together with the gonadal vein was freed from surrounding tissues while preserving peri-ureteral tissue. The renal vein was dissected distal to the gonadal vein by bipolar coagulation and division of the lumbar veins and adrenal vein (Figure 2). Renal artery was exposed after the lumbar veins were divided. The rest of the kidney was dissected free from sur- rounding tissues as we do in LDN. A transverse incision was made lateral to suprapubic trocar and the rectus muscles were separated from each other without opening the peritoneum. The renal artery and vein and the ureter were clipped through su- prapubic trocar using Hem-o-lok clip applier and titanium clip applier. The renal artery and vein and the ureter were divided and the kidney was hand extracted. RESULTS Mini-laparoscopic donor nephrectomy (MLDN) was successfully performed in a 27-year-old male donor using 3-mm instrument. His body mass in- dex was 18.5 kg/m². Operation time was 135 min- utes with a warm ischemia of 5 minutes. Pain score was zero at discharge and the patient left hospital in 36 hours (less than 2 days). No peri-operative complications occurred. Harvested kidney started diuresis immediately post transplant and nadir se- DISCUSSION Laparoscopic donor nephrectomy has encouraged donors for the kidney donation. Randomized and large retrospective studies have shown that LDN has similar graft outcome in recipients while has less morbidity in donors.(1,5) Recently, LDN has be- come the standard of care for donor nephrectomy in the most major transplant centers around the world. Several attempts have been made to make LDN - sumbilical and pfannenstiel LESS, have been intro- duced in this regard. Gill and colleagues reported (E-NOTES) in 4 patients.(3) Kurien and associates compared SL donor nephrectomy versus transum- bilical LESS in a randomized comparative study graft function, shorter hospital stay, and longer warm ischemia time (P Figure 2. Renal vein was freed from surrounding tissues using mini-laparoscopic scissors. Figure 1. Two 3.5-mm trocars were placed above and lateral to the umbilicus and a 10-mm trocar with 5 mm reducer was fixed through the fascia from a 5-cm pfannenstiel incision, which would be used for the kidney extraction. 355Vol. 9 | No. 1 | Winter 2012 |U R O LO G Y J O U R N A L Mini-Laparoscopic Donor Nephrectomy | Simforoosh et al that LESS donor nephrectomy is challenging even for expert SL surgeons.(6) Andonian and their col- leagues performed LESS pfannenstiel donor ne- phrectomy in 6 patients with acceptable results and median warm ischemia time of 5 minutes.(4) There- after, they compared the initial 6 LESS donor ne- phrectomies with 6 cases matched SL in the other study. Final results were similar in both groups and the only advantage of LESS in comparison with SL was better cosmetic appearance.(7) Both of these techniques have some limitations: Laparoendoscopic single site surgery technique is not ergonomic, requires new training and exper- assistants. Another limitation is the lack of trian- gulation and rolls over of the instruments both in- side and outside the peritoneal cavity, which makes the afore-mentioned techniques, the surgeons have routinely used in SL techniques, which adds to the cost of procedure in addition to deep learning curve for using these unfamiliar instruments. Novitsky and colleagues revealed that mini-lapa- roscopic cholecystectomy is concomitant with less pain and shorter hospital stay and recovery time comparing to SL.(8) hence, surgeons perform the procedure more com- fortably and no new videoscope is needed while achieving excellent cosmetic results. Likewise, working instruments are regular pediatric and adult instruments already used in SL operating rooms. Mini incision in this approach requires no suturing CONCLUSION Mini-laparoscopic donor nephrectomy offers the - nor nephrectomy while being more ergonomic and more comfortable for laparoscopic surgeons do- ing LDN. Randomized clinical trials are needed to compare MLDN and SLDN. CONFLICT OF INTEREST None declared. REFERENCES 1. Simforoosh N, Basiri A, Tabibi A, Shakhssalim N, Hosseini Moghaddam SM. Comparison of laparoscopic and open donor nephrectomy: a randomized controlled trial. BJU Int. 2005;95:851-5. 2. Dols LF, Ijzermans JN, Wentink N, et al. Long-term follow-up of a randomized trial comparing laparoscopic and mini- incision open live donor nephrectomy. Am J Transplant. 2010;10:2481-7. 3. Gill IS, Canes D, Aron M, et al. Single port transumbilical (E-NOTES) donor nephrectomy. J Urol. 2008;180:637-41; discussion 41. 4. Andonian S, Herati AS, Atalla MA, Rais-Bahrami S, Richstone L, Kavoussi LR. Laparoendoscopic single-site pfannenstiel donor nephrectomy. Urology. 2010;75:9-12. 5. Jacobs SC, Cho E, Foster C, Liao P, Bartlett ST. Laparoscopic donor nephrectomy: the University of Maryland 6-year experience. J Urol. 2004;171:47-51. 6. Kurien A, Rajapurkar S, Sinha L, et al. First prize: Standard laparoscopic donor nephrectomy versus laparoendoscopic single-site donor nephrectomy: a randomized comparative study. J Endourol. 2011;25:365-70. 7. Andonian S, Rais-Bahrami S, Atalla MA, Herati AS, Richstone L, Kavoussi LR. Laparoendoscopic single-site Pfannenstiel versus standard laparoscopic donor nephrectomy. J En- dourol. 2010;24:429-32. 8. Novitsky YW, Kercher KW, Czerniach DR, et al. Advan- tages of mini-laparoscopic vs conventional laparoscopic cholecystectomy: results of a prospective randomized trial. Arch Surg. 2005;140:1178-83.