title: Mini-incision living donors nephrectomy using anterior muscle-splitting approach with hybrid technique.
abstract: BACKGROUND
  Significant morbidity is associated with standard open flank living donor nephrectomy. Laparoscopic donor nephrectomy is criticized for a steep learning curve and a tendency to avoid the right kidney. The anterior muscle-splitting technique uses principles or advantages of an open extraperitoneal approach with minimal morbidity and the advantageous muscle-splitting (instead of cutting) procedure.
  
  
  OBJECTIVE
  To compare mini-incision laparoscopic instrument-assisted (MILIA) live donor nephrectomy using a muscle-splitting technique to the standard open-flank donor nephrectomy (ODN) approach for efficacy and safety.
  
  
  METHODS
  MILIA living donor nephrectomies were performed in 119 donors and compared to a cohort of open-flank nephrectomy donors (n=38) from the same center. Both donor groups were matched for body mass index as well as other personal characteristics.
  
  
  RESULTS
  The mean donor age was 35 (range: 18-60) years. The right kidney was procured in 28% of cases. The majority of donors were female (58%) and Caucasian (60%). No differences were observed between MILIA and ODN donors for the age, gender and ethnicity. However, MILIA donors experienced a longer mean±SD operative time (234±47 vs. 197±33 min, p<0.0001) but a shorter hospital stay (4±1 vs. 6±3 days for the ODN group, p<0.0001) and less intraoperative blood loss (215±180 vs. 331±397 mL, p<0.02). No difference was found in the number of units of blood transfused (0.13±0.6 vs. 0.34±1.0 units, p=0.13). Right-sided kidneys were almost equally harvested in both groups (29% of MILIA donors vs. 26% of ODN donors). Post-operatively, MILIA donors had a significantly lower mean pain scores at one week and one month after surgery (p<0.001). They showed significant better post-operative recovery-earlier stopping of pain medications and restoration of other preoperative activities. Moreover, they were better satisfied with their scar appearance. Scores on the short form-36 quality of life questionnaire were comparable for both groups.
  
  
  CONCLUSIONS
  MILIA is a viable option as an alternative for pure laparoscopic donor nephrectomy. MILIA appears to be as safe as open donor nephrectomy and may provide advantages over ODN, such as smaller incision, shorter hospital stay, and less incisional pain. Patient recovery and satisfaction after MILIA are excellent. This technique avoids the possibility of adhesive intestinal obstruction and also improves handling of major complications (e.g., bleeding) of laparoscopic donor nephrectomy. Utilization of this hybrid technique is particularly feasible on smaller (BMI<24 kg/m(2)) and medium-sized (BMI<28 kg/m(2)) donors. We believe that this technique should be adopted by centers that have limited advanced laparoscopic surgical experience and also it could be used selectively for the right donor nephrectomies, even in centers performing hand assisted donor nephrectomies by including a small patch of inferior vena cava for a better quality of right donor kidney during transplantation.
authors.affiliation: Transplantation Division, University of Tennessee, Memphis, TN, USA, ; Transplant Institute, Memphis, TN, USA.
authors.forename: N
authors.initials: N
authors.lastname: Nezakatgoo
authors.affiliation: Department of Urology, University of Alexandria, Alexandria, Egypt.
authors.forename: M M
authors.initials: MM
authors.lastname: Hashad
authors.affiliation: The Methodist Hospital Transplant Center, Houston, TX, USA.
authors.forename: A
authors.initials: A
authors.lastname: Saharia
authors.affiliation: The Methodist Hospital Transplant Center, Houston, TX, USA.
authors.forename: L W
authors.initials: LW
authors.lastname: Moore
authors.affiliation: The Methodist Hospital Transplant Center, Houston, TX, USA.
authors.forename: A
authors.initials: A
authors.lastname: Osama Gaber
keywords: Transplant; kidney; laparoscopy; laparotomy; nephrectomy