Materials and methods

Between November 2022 and January 2023, seven patients underwent RDN performed by a single surgeon during the surgeon’s initial independent experience after having assisted in more than 100 RDN procedures at a high-volume center. All procedures were left-sided donor nephrectomies. The donor cohort comprised two males and five females. None of the donors had a history of previous abdominal surgery, and the retroperitoneoscopic approach was adopted as the standard technique.

All donors underwent a standard pretransplant evaluation, including medical, surgical, and psychological assessments. All donor evaluations were reviewed at a multidisciplinary transplant selection meeting. According to the transplant center’s policy, the left kidney was preferred for donor nephrectomy whenever anatomically and functionally suitable. Consequently, all donor nephrectomies in the present series were left-sided. Preoperative imaging was performed using CT urography with CT renal angiography. Renal function was evaluated using a technetium-99m diethylenetriaminepentaacetic acid (99mTc-DTPA) renal scan.

Donor demographic and baseline clinical characteristics, including age, sex, BMI, and nephrectomy laterality, were recorded. Additional anatomical variables, such as the number of renal arteries, renal veins, and ureters, were also documented. Perioperative parameters, including operative time, warm ischemia time, cold ischemia time, estimated blood loss, intraoperative complications, conversion to open surgery, length of hospital stay, and postoperative complications, were analyzed.

Surgical technique

The patient was catheterized and placed in a standard flank position at the edge of the operating table, with the flank muscles stretched by table flexion or through the use of a kidney bridge (Figure 1).

Figure 1: Patient positioning for left retroperitoneoscopic donor nephrectomy

The patient was then securely stabilized using adhesive tape or broad straps, and the surgical field was prepared to include the tenth rib and the ipsilateral groin. Port placement was performed using the following anatomical landmarks: the paraspinous muscles, costal margin, iliac crest, and midaxillary line (Figure 2).

Figure 2: Schematic representation of trocar placement for retroperitoneoscopic donor nephrectomyA: 5 mm port; B: 10 mm port; C: 10 mm port; D: extraction incision

The first 10-mm port (B) was placed 1 cm below the intersection of the costal margin and the mid-axillary line. The second 10-mm port (C) was inserted at the renal angle, at least 3 cm away from the first port. The third 5-mm port (A) was positioned three fingerbreadths anterior to the first port, in a straight line with the other ports.

Retroperitoneal access was established through a 1.5 cm incision. The lumbodorsal fascia was incised, and perinephric fat was identified by respiratory movement and swept anteriorly off the psoas muscle using a peanut dissector. A balloon was inserted, inflated with 500 mL saline to create the working space. After confirming the extraperitoneal location by palpation, the balloon was deflated, and the space was inspected to ensure its integrity. Fixation sutures were placed to secure the access site, although these may be omitted in obese patients. A port was subsequently inserted, and carbon dioxide insufflation was initiated.

The laparoscope was used to confirm peritoneal integrity and optimal port position by visualizing and then obscuring the fascial edge. The scope was rotated 30° up to identify the peritoneal reflection; digital pressure confirmed that a second 5 mm port site lay posterior to this before insertion. The laparoscope was then redirected posteriorly and inferiorly, and digital indentation was used to guide placement of the third 10-mm port; insufflation was switched here (12-15 mmHg). The psoas muscle serves as the key landmark and was kept horizontal. Gerota’s fascia was incised near the psoas muscle from the mid-ureter to the upper pole, exposing the perinephric fat, ureter, and renal hilum. The ureter was bluntly dissected while preserving the periureteric fascia, and the gonadal vein was retained or divided later. Elevation of the kidney via the 5-mm port, cushioned by posterior fat, stretches the hilum, allowing fibrolymphatic tissue to be divided and the vessels to be exposed. Variable tributaries of the left renal vein, including the adrenal, gonadal, and lumbar veins, were delineated (Figure 3).

Figure 3: Retroperitoneoscopic view demonstrating the anatomical relationships of the kidney within the retroperitoneal spaceThe left kidney, left renal vein, and left renal arteries are identified

The posterior lumbar vein, often adherent to the renal artery, was carefully separated and divided using clips or energy devices. The gonadal vein was managed at its confluence, either by division or preservation as a stay structure. The renal artery was exposed bluntly or sharply proximally to its aortic origin, while avoiding thermal injury. Posterior fat was excised, exposing the kidney. The kidney was mobilized anteriorly, from the upper to lower pole, and pushed posteriorly and inferiorly while avoiding arterial stretch, followed by division of the adrenal vessels. The lower pole was flipped laterally and superiorly, and dissection between the periureteric fat and peritoneum completed mobilization. The ureter was clipped distally and divided. A 6-7 cm extraction incision was made superior to the inguinal ligament; the muscles were split while preserving preperitoneal fat, and the wound was packed. The renal artery was divided and clipped using Hem-o-lok clips, ensuring a clean 2-3 mm stump. It was the operating surgeon’s standard practice to secure the left renal artery and vein with Hem-o-lok clips during left retroperitoneoscopic donor nephrectomy to maximize vascular stump length for transplantation (Figure 4).

Figure 4: Intraoperative image demonstrating the divided renal artery with Hem-o-lok clips securely applied

The renal vein was stretched and divided (securing Hem-o-lok clips), and the kidney was retrieved via the incision for cold perfusion (Figure 5).

Figure 5: Harvested donor kidney following retroperitoneoscopic donor nephrectomyThe image demonstrates intact renal parenchyma with preserved peri-hilar anatomy and adequate length of the renal artery, renal vein, and ureter before transplantation

The incision was closed in layers. The pneumoperitoneum (5 mmHg) was re-established to inspect for venous bleeding; lymphatics near the artery stump were clipped. No topical hemostatic agents were used on the vascular stumps. Ports were removed under vision; the camera port sheath was closed if feasible. Skin was closed in a subcuticular fashion.