Discussion

Kidney transplantation is the definitive treatment for end-stage renal disease. Among transplant options, living donor kidney transplantation offers better recipient outcomes than deceased donor transplantation, and laparoscopic donor nephrectomy (LDN) is now considered the gold standard approach in most transplant centers. Currently, there are two main approaches for LDN: transperitoneal and retroperitoneoscopic. Retroperitoneoscopic living donor nephrectomy is a novel approach, and the majority of transplant centers prefer the transperitoneal over the retroperitoneoscopic approach [11-13].

Open donor nephrectomy has traditionally been performed through a retroperitoneal approach using a flank incision. The retroperitoneoscopic approach offers several advantages, including avoidance of intraperitoneal organ manipulation, a reduced risk of bowel-related complications such as perforation, and a lower incidence of postoperative ileus. Compared with the transperitoneal approach, it is associated with a decreased incidence of bowel adhesions and obstruction. The retroperitoneoscopic approach provides direct access to the kidney while minimizing manipulation of intraperitoneal structures and reducing the risk of injury to intra-abdominal organs. It also provides direct access to the posterior aspect of the renal hilum, allowing early identification of lumbar veins. This approach is considered safer in patients with a history of previous abdominal surgery, as it minimizes entry into the peritoneal cavity and reduces the risk of adhesiolysis-related complications. However, although the retroperitoneoscopic approach has fewer complications, it has disadvantages, including limited working space and a longer learning curve [5,12,14,15].

Across the reviewed studies, the mean operative time varied from 117 to 211 minutes for transperitoneal living donor nephrectomy and from 173 to 249 minutes for retroperitoneoscopic living donor nephrectomy. Some studies reported no significant differences in operative times between the two approaches. In our study, the mean operative time was 210 ± 22.9 minutes, which is comparable with those reported in other studies. The mean warm ischemia time reported for retroperitoneoscopic living donor nephrectomy varied between 240 and 264 seconds across the studies. The mean warm ischemia time in our study was 265 ± 21.41 seconds. The mean estimated blood loss with the retroperitoneoscopic approach ranged from 43 mL to 187 mL across several studies. The mean estimated blood loss in our study was 110.71 mL, which was comparable with previous studies [11,15-20].

The incidence of bowel injuries and splenic injuries is significantly higher with the laparoscopic transperitoneal approach than with the retroperitoneoscopic approach. The conversion rate for retroperitoneoscopic living donor nephrectomy has been reported to range from 0% to 0.7%. In our series of seven cases, there were no conversions to open procedures. There were no postoperative complications and no cases of delayed graft function among recipients [5,17,21]. The incidence of postoperative shoulder pain was significantly lower in retroperitoneoscopic living donor nephrectomy compared with transperitoneal living donor nephrectomy [15]. Patients undergoing retroperitoneoscopic living donor nephrectomy had a significantly shorter hospital stay than those undergoing the laparoscopic transperitoneal approach; however, some studies reported no difference in hospital stay between the two surgical approaches. The mean duration of hospital stay in our study was 3.86 ± 0.90 days [15,16].

Retroperitoneoscopic living donor nephrectomy is also feasible in donors with renal vein anomalies, such as circumaortic or retroaortic renal veins [13]. Several studies have shown that the laparoscopic retroperitoneal approach is associated with lower transfusion rates and lower conversion rates due to reduced vessel injury, fewer complications, and fewer cases of delayed graft function. However, patient-reported outcomes, including satisfaction with postoperative pain, scar appearance, and overall quality of life, were not significantly different between the laparoscopic retroperitoneal and transperitoneal approaches. There was also no significant difference in postoperative inflammatory marker levels between the two approaches [18,21-23].

Limitations

This study has certain limitations, including the small number of cases, its single-center design, and the absence of a control group for comparison. As these procedures represent the early experience of a single surgeon, the findings may have been affected by the initial learning curve and possible case selection bias. In addition, the limited follow-up duration did not allow for evaluation of long-term donor safety or recipient graft function.

Future directions

Advancements in laparoscopic technology, such as robotic-assisted surgery, could further enhance the safety and efficacy of laparoscopic retroperitoneoscopic donor nephrectomy (LRDN). Robotic systems offer improved dexterity and precision, potentially reducing complication rates and improving surgical outcomes. Expanding training programs for laparoscopic techniques will help disseminate best practices and improve outcomes globally. Increased access to high-quality training and mentorship can ensure that more surgeons are equipped to perform LRDN safely and effectively.