Laparoscopic living donor nephrectomy for kidney transplantation

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摘要

The description of the laparoscopic living donor nephrectomy for kidney transplantation covers all aspects of the surgical procedure used for the management of kidney transplantation.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: left nephrectomy, opening of space, left vascular approach, right nephrectomy, right vascular approach, preparation of the ureter, perirenal freeing, preparation/extraction, division/extraction.
Consequently, this operating technique is well standardized for the management of this condition.

媒體類型

刊物

2002-04

普通的

最愛

音訊

數位出版

WeBSurg.com, Apr 2002;2(04).
URL: http://www.websurg.com/doi-ot02en261.htm

Laparoscopic living donor nephrectomy for kidney transplantation

1. Introduction

Kidney transplantation is the best therapeutic modality for end stage renal disease (ESRD). It is also the most economical treatment. Its results are among the most satisfying of all solid organ transplantations. It is limited by the shortage of suitable kidneys for transplantation. Living donor nephrectomy could contribute to alleviating this shortage. Over the last 20 years, this practice has taken root in numerous countries. However, fear of morbidity and suffering related to the nephrectomy has often held back potential donors, their families and the medical profession. Laparoscopic nephrectomy can help overcome this resistance. Less than 5 years after it was first described, laparoscopic nephrectomy has already increased the number of living donors (Ratner et al., 1995; Schweitzer et al., 2000). The graft function rate is similar to that obtained by open surgery (Flowers et al., 1997). It is mandatory to have mastered laparoscopic colectomy, splenectomy and adrenalectomy, as well as laparoscopic vascular control, before performing this procedure.

2. Anatomy

• Anatomical relationships

The kidney is a paired organ, the largest part of which is situated below the ribs. The left kidney lies slightly more cephalad than the right kidney (by about 1.5 cm), and is often smaller.
Posteriorly, both kidneys are in contact with the psoas muscle, the quadratus lumborum muscle and the aponeurotic tendon of the transversus abdominis muscle. Superiorly, they are in direct posterior contact with the diaphragm.
Superior poles of the kidneys: just above the level of the 12th rib
Inferior poles: body of the 3rd lumbar vertebra corps
Renal hilum: in the axis of the tip of the 9th costal cartilage, at about 5 cm from the midline
1. Inferior vena cava
2. Aorta
3. Psoas major muscle
4. Quadratus lumborum muscle
5. Aponeurotic tendon of the transversus abdominis muscle
6. Diaphragm

• Left kidney

The superior portion of the left kidney is covered by the parietal peritoneum of the omental bursa. Its middle third is in direct contact with the pancreas and splenic vessels, and its inferior portion is covered by the peritoneum of the abdominal cavity.
1. Left adrenal gland
2. Stomach
3. Spleen
4. Pancreas and splenic vessels
5. Small intestine descending colon

• Right kidney

The largest part of the right kidney is anteriorly in contact with the right lobe of the liver. The right renal convexity is covered by the parietal peritoneum.
1. Right adrenal gland
2. Descending part of duodenum
3. Right lobe of liver
4. Right colic flexure small intestine

3. Vascularization

• Veins

The left renal vein passes anterior to the aorta, immediately distal to the superior mesenteric artery, before draining into the vena cava. It may be crossed by the inferior mesenteric vein. The left adrenal and gonadal veins drain into the left renal vein, at a right angle outside the renal hilum. The origin of the right renal vein is slightly more distal. This vein is often very short.
Direct lumbar branches, on the posterior surface of the renal veins, can be found on both sides.
The renal venous system includes numerous large intra-parenchymatous anastomoses. As a result, the ligation of an accessory renal vein is of no consequence.
1. Right gonadal vein
2. Right renal vein
3. Right adrenal vein
4. Left adrenal vein
5. Left renal vein
6. Left gonadal vein

• Arteries

The left renal artery is found posterior to the left renal vein, the body of the pancreas and the splenic vessels.
The right renal artery is longer. It courses posterior to the vena cava and the right renal vein.
As they penetrate into the hilum, each artery gives rise to 4 or 5 branches.
Just before this division, one or several small branches arise that vascularize the ureter.
The branches of the renal artery are terminal arteries. Ligating them leads to an infarct of their area of vascularization.
1. Right renal artery
2. Left renal artery

• Excretory system

The ureter runs almost parallel to the spine, anterior to the psoas muscle. Before penetrating into the pelvic cavity, it crosses anterior to the genito-femoral nerve and is crossed by the gonadal vessels, whose course is slightly more oblique.
1. Renal pelvis
2. Ureter

• Variations

One or two accessory renal arteries are encountered in 30% of cases. They have an aortic origin or more rarely an iliac origin. They are more frequent on the left side, in a position that is inferior to the main trunk. The inferior polar arteries pass anterior to the ureter. On the right side, they can be found in a precaval position.
The kidney may be located in its embryonic pelvic position. In this case, the vessels arise at the iliac level and the hilum is found in an anterior position.
In the case of a horseshoe kidney, the ureters are anterior to the parenchymatous bridge that connects the 2 kidneys.
1. Left accessory renal arteries
2. Precaval right accessory renal artery

4. Evaluation

Inclusion criteria
Donors must be in good general health. They must not suffer from a chronic disease. Their examination must be thorough. Glucose intolerance, hypertension or kidney disease (proteinuria or hematuria) must be ruled out. Age is not a limiting factor. Kidneys from living donors over 65 years of age can provide excellent function. For valid consent, the donor must be over 18 years old. Potential donors who are obese must be encouraged to lose weight before the procedure. Cardiovascular disease is an exclusion factor, although there is no consensus concerning the exclusion of potential donors with a cardiovascular risk (smokers, hyperlipemia, family history). Most centers exclude donors with mild hypertension, as well as those with even mild diabetes. Renal function must be normal, with a normal creatinine clearance. The opinion of a nephrologist is recommended in cases of abnormal renal function. Serologic studies should check for cytomegalovirus, hepatitis B surface antigen (HbsAG), hepatitis C, Epstein-Barr virus and HIV.

Exclusion criteria
General criteria: hypertension, diabetes, cardiopulmonary disease that could increase the risk of surgery, cancer, infectious disease, patients under the legal age of consent.
Renal criteria: lowered creatinine clearance, proteinuria, hematuria, urinary lithiasis, polycysitic kidneys, anatomical anormalities, multiple bilateral renal arteries.
Criteria that make an open approach preferable: obesity (particularly in men), past history of pyelonephritis, horseshoe kidney, multiple previous laparotomies, short right renal vein in the presence of multiple left arteries.

Vascular criteria
Three considerations pertaining to vascularization must be taken into account when choosing the donor and the kidney to be used.
1. The acceptable number of renal arteries for a nephrectomy depends on the team’s experience in carrying out vascular reconstruction (Kuo et al., 1998; Mandal et al., 2001). A reconstruction of more than 2 arteries is often hazardous and can affect the outcome of the transplant. On the right kidney, the arteries are not accessible at the level of their aortic origin during the nephrectomy. An early retrocaval bifurcation requires a reconstruction.
2. The presence of branches of the iliac artery: these branches supply the inferior pole of the kidney and ureter. They are often narrow and their reimplantation can be difficult. They are not always visible on a scanner. In the three-dimensional reconstruction of renal vessels, the surgeon sometimes feels that the vasculature for the inferior structures is missing.
3. The length of the right vein, which is often shorter than the left vein: in the past, nephrectomies of the right kidney often resulted in failure due to venous thrombosis of the transplant. If a right nephrectomy is performed, the surgeon must be prepared to lengthen the vein of the graft (using saphenous veins, for example) and to consequently mobilize the external iliac vein of the recipient.

Choice of side:
Left kidney:
- the arteries are short, so they are removed at the origin;
- the vein is long and of good quality;
- the volume of the left kidney is often larger;
- disadvantages pertaining to the surgical approach: the need to mobilize the left colon, spleen and pancreas, and the difficulty in gaining access to the distal ureter following diverticulitis.
Right kidney:
- the artery is long, but inaccessible in its retrocaval course;
- the vein is short and friable;
- the volume of the right kidney is often smaller;
- advantages pertaining to the surgical approach: easy mobilization of the right colon and of the duodenum;
- potential disadvantage pertaining to the surgical approach: in cases of hepatomegaly or steatosis, access to the kidney is difficult.

5. Preoperative imaging

Most centers no longer perform conventional angiography with excretory urography. Instead, a high resolution spiral computed tomography is done, providing three-dimensional reconstruction of the vascular anatomy and detecting the existence of supernumerary or aberrant vessels with great precision (Del Pizzo et al., 1999). Magnetic resonance imaging (MRI), which also provides three-dimensional reconstruction, is not as precise, but it often offers better visualization of the venous anatomy. MRI also offers better distal evaluation of the excretory system. However, a CT scan is sufficient for detecting a duplication. The size of the kidneys is best measured using a volumetric calculator. The right kidney is usually smaller, and therefore right nephrectomies are usually performed to leave the larger kidney to the donor. Finally, many teams carry out a renal scintigraphy, which gives useful information on the reciprocal function of the 2 kidneys.
1. 3D reconstruction
2. MRI of veins

6. Operating room

• Patient

- lateral decubitus (left for a right nephrectomy and vice versa);
- endotracheal intubation;
- urinary catheter, nasogastric tube for aspiration;
- 2 peripheral IVs;
- bean bag;
- arm against the table at a right angle;
- arm on the side of the nephrectomy raised above the head;
- sternum and antero-superior iliac spine at the edge of the table;
- 30° flexion of the hip joint on the side against the table; maximum extension of the hip joint on the side of the nephrectomy;
- padded cushion between the legs;
- table bent down 140° at lumbar level;
- 12° to 25° Trendelenburg position.

• Team

The surgeon performs the nephrectomy with one assistant. A second assistant may be helpful if the surgeon is inexperienced.
1. Surgeon
2. First assistant
3. Second assistant (optional)
4. Scrub nurse

• Equipment

1. Laparoscopic unit
2. Supplementary instrument table (40 x 50 cm)
3. Anesthetic unit
4. Ultrasound generator for ultrasonic scissors
5. Monopolar cautery
Table
The operating table must be easily adjustable, both laterally and longitudinally. It should be possible to angulate the table at 40° in the middle.
Insufflator
A high flow insufflator (>15 L/min) is used. The insufflation pressure is limited to 8 mm Hg to avoid disturbing the renal venous return.
Laparoscope and camera
A 30° laparoscope provides better visualization of the superior pole of the kidney and of its posterior aspect.
A 3CCD camera is required.
Surgical knife
The use of ultrasonic scissors, although not mandatory, greatly facilitates the procedure. They can grasp, cut and coagulate, and preclude the need for repetitive changes in instruments. They also keep the operative field free from bleeding.

• Second operating room

The operation for the transplant recipient takes place in a second operating room, ideally adjacent to the first operating room. This second room is installed and equipped to suit the needs of the transplantation team. The recipient is anesthetized 30 minutes after the first incision of the donor. If a bilateral nephrectomy is planned for the recipient, both procedures begin at the same time.

7. Trocar placement

• Principles

Four trocars are used for a left nephrectomy, and 5 for a right nephrectomy.
The diameter of trocar A depends on the type of vascular stapler used. Most models can be introduced through a 12 mm trocar.
The diameters of trocars B and C depend on the sizes of the laparoscope, ultrasonic scissors and clip applier used. It must be possible to move the instruments and laparoscope between trocars A, B and C. We use 10 mm trocars for B and C and 5 mm trocars for D and E.
1. Left nephrectomy
2. Right nephrectomy

• Trocars

Trocar A (12 mm operating trocar for the left hand) is introduced using an open technique. It is located 2 to 5 cm cephalad to McBurney’s point. The vascular stapler is inserted through this trocar. The position of this trocar is crucial. It should be placed as far caudad as possible so that the renal vein can be divided as parallel as possible to the vena cava. At the same time, it must be cephalad enough to permit the surgeon to work at the level of the superior pole of the kidney. The grasping forceps, ultrasonic scissors, scissors, clip applier and vascular stapler are introduced through this trocar.

Trocar B (10 mm), the main trocar for the laparoscope, is situated in periumbilical position, about 3 cm lateral and cephalad to the umbilicus.

Trocar C (10 mm operating trocar for the right hand) is situated 6 to 8 cm cephalad to trocar B. The grasping forceps, ultrasonic scissors, scissors and clip applier are introduced through this trocar.

Trocar D (5 mm) is situated in the flank, at the level of the convex border of the kidney. This trocar is used by the assistant who stabilizes the kidney at the end of the dissection, and places tension on the renal pedicle during division of the vascular structures. Grasping forceps and the aspirating tube are inserted through this trocar.

Trocar E (5 mm) is a retracting trocar. It is used only for right nephrectomies. It is placed below the xiphoid process and is introduced under visual guidance, to the left of the round ligament. It accommodates the static grasping forceps, which are placed under the liver and which grasp the diaphragm.

8. Instrumentation

• Instruments

1. Four 5 mm fenestrated graspers
2. 5 mm straight and curved scissors
3. Coagulating hook
4. Bipolar coagulating grasper
5. Ultrasonic scissors
6. Two 5 mm curved tip graspers and one 10 mm curved tip grasper
7. Clip applier
8. Two needle holders
9. Vascular stapler
10. Retrieval bag with an opening of at least 15 cm, made of sturdy material. If the bag has an opening-closing system, it must be atraumatic. A bag without an opening-closing system is preferable.

• Laparoscope

1. A laparoscope with a 30° lens is used.

• Others

Ex-vivo kidney perfusion kit, containing:
- standard open vascular surgical instruments (forceps, scissors, needle holder);
- sterile ice;
- a container of appropriate size.
1. Smooth perfusion tip
2. Sterile IV tubing

9. Basic principles

The goal is to maintain the functionality of the kidney for the recipient while exposing the donor to minimal morbidity. The donor is not a patient, but a healthy person who accepts the risks of surgery to help another person. The kidney is not a pathological specimen, but an organ that must remain functional. Even when perfused with preservative fluid and maintained at 4° C, it continues to perform metabolic functions.
Consequently, the priorities of the procedure are as follows:
1. assure the donor’s safety;
2. maintain the lowest possible level of morbidity for the donor;
3. maintain renal perfusion during the procedure;
4. minimize the time of hot and cold ischemia.
In order to respect these principles, the surgeon must be ready to convert to open surgery if in any doubt. The donor must be warned that this may occur.

10. Preop management

Preparation of the donor
The donor is admitted to the hospital the evening before or on the morning of the operation. The donor must drink a minimum of 2 L of water per day during the 48 hours preceding surgery. To prevent deep venous thrombosis, low molecular weight heparin is administered subcutaneously on the morning of the procedure. Prophylactic antibiotic therapy (a single intravenous dose of a second generation penicillin and of clavulinic acid) is administered 30 minutes before the incision. The torso and pubic area are shaved just before the operation.

Anesthesia of the donor
General anesthesia with endotracheal intubation is administered in a classical manner. The following points are specific to this procedure:
- intraoperative hyperhydration: cristalloid (20 mL/kg/hour);
- deep muscle relaxation;

- forced diuresis:
- mannitol (0.5-1 g/kg) at the end of vessel dissection,
- furosemide (40 mg) at the end of the freeing of perirenal fat.

- systematic anticoagulation of the donor:
- heparin (70 UI/kg) IV 5 minutes before division of the renal artery,
- protamine (0.7 mg/kg) IV after extraction of the kidney.

11. Left nephrectomy

Exploration
Exploration of the visible half of the abdominal cavity is mandatory. On the left side, there may be sequelae of previous colic or pancreatic inflammation that can make exposure difficult.

Exposure
The quality of the exposure is a determining factor of the facility of the surgical act.
The small intestine and omentum must be pushed into the inferior half of the abdominal cavity. The force of gravity will maintain the intestinal loops in this position. A 10° to 15° ventral rotation can be helpful. Any adhesions that get in the way of the exposure are freed. Complete muscle relaxation is necessary.
1. Transverse colon
2. Descending colon

12. Opening/space

• Mobilization

The sigmoid colon, descending colon, tail of the pancreas and spleen are mobilized ventrally en bloc, providing wide access to the retroperitoneum.

• Sigmoid loop

Coloparietal mobilization is begun at the level of the sigmoid loop. The paracolic gutter is incised, starting at the summit of the sigmoid loop. The surgeon thereby reaches the retroperitoneal space, posterior to the posterior leaflet of the mesosigmoid and anterior to Toldt’s fascia.
1. Sigmoid colon
2. Posterior leaflet of the mesosigmoid
3. Left gonadal vein

• Colic mobilization

The descending colon and the splenic flexure are mobilized.
The coloparietal mobilization is pursued by the caudal to cephalic incision of the peritoneum of the left colic gutter. Dissection is done posteriorly to the mesocolon, taking care not to open its posterior leaflet, which is used as a landmark. The splenic flexure is mobilized in the same way, without opening the splenorenal ligament.
1. Mobilized splenic flexure

• Splenic mobilization

Peritoneal attachments of the spleen to the diaphragm, which are found frequently, are divided. The peritoneum of the splenorenal ligament is then incised by continuing the coloparietal peritoneal incision to the left diaphragmatic crus. The dissection is extended posterior to the tail of the pancreas and anterior to the adrenal gland, in an avascular plane of loose connective tissue. Ideally, this mobilization is pursued cephalad and medial to the esophageal hiatus.
The colo-spleno-pancreatic complex is mobilized ventrally to the left edge of the aorta. Because the dissection is done in an avascular plane, it is bloodless. The duodeno-jejunal flexure must frequently be mobilized ventrally over a few centimeters.
1. Spleen
2. Descending colon
3. Tail of pancreas
4. Left kidney

13. Left vascular approach

• Vein

The left renal vein is approached anteriorly from the aorta, slightly to the left, after opening Toldt’s fascia, where there is the lowest risk of injury to the veins. A vessel loop is passed around the vein . Dissection of the vein is then carried out towards the hilum of the kidney. The adrenal vein and the gonadal vein are identified and divided between ligatures (clips are not used, to avoid the risk of interposing clips in the vascular stapler during division of the renal vein). The surgeon should check to see if there is a lumbar vein draining into the renal vein. Where these lumbar veins are present, they are short and must be divided between ligatures.
1. Left renal vein
2. Gonadal vein
3. Adrenal vein

• Artery

The left renal artery is found posterior to the renal vein. It is usually easy to identify by its pulsing. After a vessel loop is placed around the artery, it is dissected as close as possible to its origin. Care must be exerted to avoid any injury to the arterial wall that could compromise the success of the transplantation. An arterial spasm can be avoided by applying a papaverine solution.
1. Left renal artery
2. Inferior polar artery
3. Stump of gonadal vein

14. Right nephrectomy

• Exposure

As described for a left nephrectomy, a right nephrectomy begins by exploration and exposure. The small intestine and the omentum are pushed into the inferior half of the abdominal cavity, where they are maintained by gravity. Adhesions caused by previous surgery (appendectomy or cholecystectomy) are freed. Sequelae of cholecystitis or the presence of a hepatomegaly can make the procedure difficult.

• Freeing of right liver

The subhepatic posterior parietal peritoneum is incised, starting medially at the level of the foramen of Winslow. This incision is followed by the division of the triangular ligament of the right liver, which is thereby mobilized ventrally. Grasping forceps are introduced through the trocar placed below the xiphoid process. The forceps are passed posteriorly to the liver, where they are used to grasp the diaphagm and maintain the right lobe in a ventral position.
1. Right kidney
2. Adrenal gland
3. Retracted right liver
4. Vena cava

• Retroperitoneal space

The retroperitoneal space must be opened widely.

Right coloparietal mobilization:
The incision of the peritoneum of the right paracolic gutter begins at the base of the cecum and is extended to the hepatic flexure. The duodenum is the ventral limit of this right coloparietal mobilization.

Mobilization of the duodenum:
The duodenal bloc is entirely mobilized, from the bulb to the root of the mesentery. The goal is to reveal the entire length of the subhepatic vena cava to the iliac bifurcation.
1. Vena cava
2. Duodenum
3. Small intestine

15. Right vascular approach

• Vein

Once the vena cava has been freed from the cellular tissue that covers it anteriorly, it is very easy to identify the inferior commissure of the right renal origin. The superior commissure is then identified. A vessel loop is placed around the vein. The right border of the subhepatic vena cava is then dissected along its entire length, with care taken to avoid injury to the right adrenal vein. The right gonadal vein is divided between clips at its caval origin.
1.Right renal vein
2.Subhepatic vena cava

• Artery

The surgeon looks for the artery posterior to the vein. A vessel loop is passed around the artery. An early retrocaval bifurcation cannot always be dissected at the point. It is dissected when the kidney is mobilized ventrally.
1. Right renal artery
2. Right renal vein

16. Preparation of the ureter

This step, as well as those that follow, are identical for left and right nephrectomies.
The ureter is found anterior to the iliac vessels. It is surrounded by a vessel loop at this level. From this point, the ureter is dissected caudad to cephalad, removing as much areolar tissue as possible. When the level of the inferior pole of the kidney is reached, the direction of the dissection is changed in order to reach the renal parenchyma. Gerota’s fascia is opened for this purpose.
1. Ureter surrounded by loop anterior to iliac vessels

17. Perirenal freeing

The fat that surrounds the kidney is removed. The dissection plane is found against the renal capsule. Once the anterior surface of the kidney has been entirely freed, the superior pole is separated from the adrenal gland. On the left, the stump of the adrenal vein provides both a good landmark and a useful point of traction.
Starting from the inferior pole, the kidney is then freed posteriorly from the perirenal fat. It can thereby be rotated ventrally, revealing the vessel loops, ie the vascular landmarks, posteriorly. The circumferential dissection of these vessels is then achieved and the kidney is entirely freed.
1. Right kidney freed from perirenal fat

18. Preparation/extraction

• Division of the ureter

The ureter is divided at the bifurcation of the iliac vessels, at the level where it was previously identified. A distal clip is applied before dividing. The quality of the vascularization is evaluated by the bleeding of the cut surface. Abundant diuresis is usually obtained.
1. Divided left ureter

• Suprapubic incision

A 6 cm long transverse incision is made just above the pubic symphysis. The aponeurosis is divided transversally and the rectus abdominis muscles are retracted.

• Retrieval bag

A bag is introduced directly through the peritoneum, without a trocar. It is placed around the kidney and held firmly, without obstructing the vessels, either using grasping forceps introduced through the suprapubic incision or using the device designed for this purpose. Care must be taken to avoid injuring the vessels with the opening-closing system of the bag. For this reason, we prefer to use bags that do not have an opening-closing system.

19. Division/extraction

• Renal vessels

The goal is to minimize the time of warm ischemia, which is defined as the interval between the arterial occlusion and the beginning of the cold perfusion. All instruments must be readily available, including the equipment for the cold perfusion, and all members of the surgical team must know exactly what they are supposed to do.
The grasper introduced in the suprapubic area, which keeps the retrieval bag closed, exerts traction on the renal vessels to make them as long as possible. This is particularly important when extracting the right kidney whose vein is short.
1. Traction exerted on the right renal vein

• Arterial-venous division

Arterial division:
One or two clips are applied onto the artery on its aortic side. The renal side is left open. The artery is divided in 2 steps to ensure it is properly occluded.
Venous division:
The vein is divided with a vascular stapler. For a right nephrectomy, a small cuff of the vena cava is brought along to lengthen the renal vein. This does not lead to serious stenosis on the vena cava.

• Exteriorization/perfusion

The suprapubic peritoneal opening is dilated manually and the kidney is extracted effortlessly. It is immediately perfused on ice using 4° C UW conservation. When multiple arteries are present, they are perfused individually. The perfused volume corresponds to about 300 mL. Perfusion must be continued until the flow of fluid from the renal vein becomes perfectly transparent.
Our experience has showed us that it is extremely useful to take a few minutes to demonstrate the vascular structures, while on ice, to the surgeon who is going to perform the implantation.

20. Conclusion

Worldwide, several hundred donors have undergone laparoscopic nephrectomy. The considerations involved in a living donor transplantation program are not only technical, but also logistical and ethical. The use of a living donor has not been unanimously accepted by the medical community. The loss of a kidney donated by a living donor due to lack of experience is totally unacceptable. The surgeon who performs a laparoscopic nephrectomy on a living donor must have advanced laparoscopic skills in order to best serve the donor’s altruism and the recipient’s cause (Bettschart et al., 2000).

21. Reference

Bettschart V, Schneider R, Berutto C, Groos R, Wauters JP, Edye M et al. A step-by-step approach to
laparoscopic live donor nephrectomy. Transplant Proc 2000;32:117-8.
Del Pizzo JJ, Sklar GN, You-Cheong JW, Levin B, Krebs T, Jacobs SC. Helical computerized
tomography arteriography for evaluation of live renal donors undergoing laparoscopic nephrectomy. J
Urol 1999;162:31-4.
Flowers JL, Jacobs S, Cho E, Morton A, Rosenberger WF, Evans D et al. Comparison of open and
laparoscopic live donor nephrectomy. Ann Surg 1997;226:483-9; discussion 489-90.
Kuo PC, Cho ES, Flowers JL, Jacobs S, Bartlett ST, Johnson LB. Laparoscopic living donor
nephrectomy and multiple renal arteries. Am J Surg 1998;176:559-63.
Mandal AK, Cohen C, Montgomery RA, Kavoussi LR, Ratner LE. Should the indications for
laparascopic live donor nephrectomy of the right kidney be the same as for the open procedure?
Anomalous left renal vasculature is not a contraindiction to laparoscopic left donor nephrectomy.
Transplantation 2001;71:660-4.
Ratner LE, Ciseck LJ, Moore RG, Cigarroa FG, Kaufman HS, Kavoussi LR. Laparoscopic live donor
nephrectomy. Transplantation 1995;60:1047-9.
Schweitzer EJ, Wilson J, Jacobs S, Machan CH, Philosophe B, Farney A et al. Increased rates of
donation with laparoscopic donor nephrectomy. Ann Surg 2000;232:392-400.

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