LAPAROSCOPIC LIVING DONOR NEPHRECTOMY: FEASIBILITY AND FIRST EXPERIENCE IN INDONESIA

Objective: To report our first experience laparoscopic living donor nephrectomy (LLDN). Material & Method: A 37 year-old man was planned for the living-donor transplantation. The recipient was a 63 year-old man sufferingfrom end stage renal disease, and hypertensive heart disease. The donor and recipient were allowed for positive qualification evaluated preoperatively. We applied a transperitoneal approach for the left kidney. Results: The operation time was 300 minutes and the estimated blood loss was 600 mL. The first warm ischemia time was 15 minutes and 24 seconds. There were no major intraoperative and postoperative complications. The donor began oral intake and mobilization within 10 hours and was hospitalized for 4 days. The recipient’s serum creatinine levels reached near baseline levels (1,5 mg/dL) at day 6. Conclusion: LLDN is technically feasible in Indonesia and may increase the rate of kidney donation in Indonesia due to the minimally invasive nature of the procedure. Keywords: Renal transplantation, laparoscopic living donor nephrectomy , Indonesia . Normal 0 false false false EN-US X-NONE X-NONE /* Style Definitions */ 
 table.MsoNormalTable 
 {mso-style-name:"Table Normal"; 
 mso-tstyle-rowband-size:0; 
 mso-tstyle-colband-size:0; 
 mso-style-noshow:yes; 
 mso-style-priority:99; 
 mso-style-qformat:yes; 
 mso-style-parent:""; 
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt; 
 mso-para-margin:0cm; 
 mso-para-margin-bottom:.0001pt; 
 mso-pagination:widow-orphan; 
 font-size:11.0pt; 
 font-family:"Calibri","sans-serif"; 
 mso-ascii-font-family:Calibri; 
 mso-ascii-theme-font:minor-latin; 
 mso-fareast-font-family:"Times New Roman"; 
 mso-fareast-theme-font:minor-fareast; 
 mso-hansi-font-family:Calibri; 
 mso-hansi-theme-font:minor-latin; 
 mso-bidi-font-family:"Times New Roman"; 
 mso-bidi-theme-font:minor-bidi;}


INTRODUCTION
Living donor kidney transplantation is better than deceased donor kidney transplantation because of better patient and graft survival rates, better cost-effectiveness and improved quality of life  155,15; p < 0,001). There is no clinically demonstrated negative effect on kidney function if the warm ischaemia is less than 10 minutes, which is the 9 case in almost all laparoscopic series.
There is an ongoing discussion whether right or left donor nephrectomy is to be preferred. Most centers prefer to use the left kidney for living kidney donation because the renal vein is longer, 10 which is advantageous during implantation. However, some surgeons prefer the right kidney because it is easier to recover than the left kidney and the risk of splenic laceration is decreased. A singlecentre randomized controlled trial revealed no differences between left-and right-sided donor nephrectomy in donor hospital stay, donor quality of life, donor and acceptor complication rates, or graft 11 survival.
In earlier studies the implantation of kidneys with multiple arteries has been associated with an increased incidence of vascular and urological complications, such as thrombosis and ureteral ischaemia, and was considered a relative contraindication by some. However, more recent reports state that renal transplantation can be performed safely in case of multiple arteries. Special care has to be taken with the lower kidney pole accessory renal arteries as they often provide substantial blood supply to the renal pelvis and ureter in a transplanted kidney and otherwise giving urological compli-

OBJECTIVE
In Indonesia, this is the first experience of laparoscopic living donor nephrectomy. In this article, we aim to present our experience with LLDN which was performed on November 8, 2011.

MATERIAL & METHOD
A 37 years-old man was planned as the living donor. The recipient was a 63 year-old man suffering from end stage renal disease and hypertensive heart disease, and was on chronic haemodialisis. The donor was evaluated preoperatively. The evaluation included medical, surgical, and psychosocial suitability for live donation. Absolute contraindications to laparoscopic donor nephrectomy included absence of two functional kidneys, ABO incompatibility, certain infectious diseases (hepatitis B or C, human immunodeficiency virus), significant renal arterial occlusive disease, renal parenchymal diseases such as malignancy or polycystic kidney disease, uncorrectable coagulopathy, and horseshoe kidney. Relative contraindications to laparoscopic donor nephrectomy include underlying medical conditions (extremes of age, hypertension, diabetes mellitus, nephrolithiasis), inability to tolerate general anesthesia or pneumoperitoneum, prior left colonic or splenic surgery, retroperitoneal inflammatory processes (diverticulitis, retroperitoneal fibrosis), morbid obesity, and ascites. Informed consent was obtained together with detailed explanations provided by both the surgeon and the renal physician, and a patient information sheet was given preoperatively. His renal and other organs function was excellent and allowed for positive quali? cation. Intravenous urography showed normal function of kidneys and no abnormalities, such as stones or obstructions. Ultrasonography and chest X-ray also showed no abnormalities. Renal angiography showed one left main renal artery with one small branch just off its aortic origin. Renal scintigraphy showed normal and even function in both kidneys (left kidney's GFR: 47 ml/mnt, right kidney's GFR: 50 ml/mnt). The donor signed the informed consent for laparoscopic donor nephrectomy.
General anaesthesia was given to the patient and Foley catheter for diuresis control was introduced. Laparoscopic donor nephrectomy was pre-planned to be performed on the left kidney to maximize the length of renal vein available to the transplant surgeon. The patient is placed in lateral decubitus position, 4 trocars (in diamond-shaped fashion) are introduced. The colon is mobilized and displaced medially. The line of Toldt is opened and the kidney is exposed (Figure 1). The ureter and spermatic vein are dissected free from its surrounding tissue with leaving a sufficient amount of periureteric tissue/fat (Figure 2).The left spermatic vein is followed up to the left renal vein. The spermatic vein is clipped and cut 2 cm from the renal vein ( Figure 3). A lumbar vein was identified and also clipped and cut ( Figure 4). The left renal artery is dissected free at its aortic origin. The adrenal vein is identified, clipped and cut ( Figure 5). Near the adrenal gland, Gerota's fascia is opened. Then, the upper pole of the kidney is freed (Figure 6). The ureter is identified and cut (Figure 7), and the kidney released from all surrounding attachments except for the hilum (Figure 8). A low transverse suprapubic (Pfannenstiel) incision is made, creating a gate for extraction of the kidney. After clipping and cutting the small arterial branch close to the aorta, the renal artery is clipped with hem-o-lok (Weck Closure system, Research Triangle Park NC, USA) clips applied as close as possible to the aorta, and cut distal to the clips (Figure 9). The renal vein is clipped with hem-o-lok clips and cut distally from the clips ( Figure 10).         The kidney is then immediately retrieved with the operator's right hand introduced through the extraction incision and placed in the icy solution for perfusion.
After control of hemostasis and inspection of peritoneum was performed, a drain tube is inserted and the abdominal wounds are closed at the fascia and skin levels, and the procedure is concluded. The kidney, immediately after having been retrieved from the donor, is flushed and immersed in histidinetryptophan ketoglutarate (Custodiol) solution of 18 0°C. After that, the kidney is transported to the recipient operating room. The implantation procedure began immediately afterwards. For preparation of the recipient, a Gibson incision was used. The muscle was opened and peritoneum was set aside to mediocranial. The external iliac vessels were identified. Perivascular sheath was released and bladder was identified. Ureteroneocystostomy was prepared. The graft came up and two vascular anastomoses are performed between the renal and external iliac vessels in an "end-to-side" manner. Reperfusion proceeded immediately, and shortly after that the urine output from the ureter was observed. Ureteroneocystostomy (Lich-Gregoir technique) was conducted. Patency of the anastomosis was secured by an indwelling double-J ureteral stent.

RESULTS
The total operating time was 300 minutes (skin-to-skin). The estimated blood loss was 600 mL. The warm ischaemia I time, cold ischaemia time, and warm ischaemia II time were 15 minutes and 24 seconds, 37 minutes, and 63 minutes respectively. The time to first initial urine output was 87 minutes. Postoperatively, the donor resumed oral diet10 hours after operation. The patient started ambulating after 10 hours and was discharged 4 days after surgery. There were no significant intraoperative complications. At postoperative day-1 urinary catheter was pulled out, but the patient suffered from an acute urinary retention. Catheter was inserted for another two days, and at day-3 underwent a successful trial without catheter (TWOC). There were no other postoperative complications. Postoperative pain was mild if none at all (the patient was put on epidural analgesia since operation day, hence the probable cause of AUR). The recipient had immediate graft function posttransplantation and the serum creatinine levels reached near baseline levels (1,5 mg/dL) at day 6. There was no incidence of vascular or ureteral complications in the recipient.

DISCUSSION
Donor nephrectomy is unique among major surgical procedures, because it exposes an otherwise healthy patient to the risks of major surgery entirely for the benefit of another person. For LLDN to become a viable option for procuring kidneys for renal transplantation, several conditions must be met. Most important, the laparoscopic donor should suffer no additional or unique morbidity when compared to the open donor. In addition, kidneys harvested using laparoscopic techniques must have graft survival and function rates equivalent to those obtained by the "gold standard" of open nephrectomy. Finally, the laparoscopic approach should convey some advantage to the patient such as less pain, shorter hospital stay, and earlier return to  term graft outcome. However, the effect of warm ischaemia time on delayed graft function is controversial according to the literature. Delayed graft function is defined as hemodialysis requirement within one week of transplantation. In a Cochrane Database Systematic Review article, 5 Wilson et al. mentioned that the extracted kidney was exposed to longer warm ischaemia periods (2 to 17 minutes) on LLDN with no associated short-term 23 consequences. Jacobs et al, compared warm ischaemia time < 3 minutes vs. < 3 minutes and warm ischaemia time < 5 minutes, 5-10 minutes, and > 10 minutes, and showed that prolonged warm ischaemia time did not affect graft function. In 24 contrast, in a series reported by Sasaki et al. a warm ischaemia time of > 10 minutes was associated with acute tubular necrosis and an elevated serum creatinine concentration at 7 days posttransplantation. In this case, the recipient had immediate graft function post-transplantation and the serum creatinine levels reached near baseline levels (1,5 mg/dL) at day 6.
The lack of LLDN experience in our institution contributed to the longer operating time and higher estimated blood loss. This technique has become the preferred method of allograft procurement for many transplantation centers worldwide but still remains technically challenging 25 with a steep learning curve.

CONCLUSION
Although this is the first experience of LLDN in Indonesia, laparoscopic live donor nephrectomy is technically feasible and can be performed with low morbidity and mortality rates