The advantages of laparoscopy over conventional open surgery have justified its application for nephrectomy in renal atrophy, renal tumours, polycystic kidney disease and living-related kidney donation. The common indications for native nephrectomy in renal transplant recipients include tumours, uncontrolled hypertension, recurrent infections and stones. Indeed, the native kidneys have a significantly greater risk of malignant transformation. Herein we present the technique and advantages of retroperitoneoscopic nephrectomy (RN) of native kidneys in renal transplant recipients, and highlight it as a safe and effective option in these patients.
We performed three RNs in two patients (one man and one woman, aged 49 and 39 years, respectively). The man, who was on warfarin for pulmonary embolism (converted to heparin before surgery) had a two-stage procedure. After native radical nephrectomy for renal tumour ipsilateral to the transplant, he had a contralateral prophylactic RN 6 weeks later. The woman had a nephrectomy ipsilateral to the renal allograft and is awaiting a contralateral nephrectomy. The access technique for RN in this situation is modified from the original Gaur method  and differs from transperitoneal nephrectomy (TN) in three key aspects: the location and technique of primary trocar placement, optimum positioning of the balloon dilator, and location and technique for safely placing the secondary ports. We used a three-port technique. Under general anaesthesia the patient is placed in the lateral position with the surgeons standing at the dorsal aspect. The first port (12 mm) is placed by the open technique, and is 2.5 cm below the tip of the 12th rib for introducing the balloon dilator to create a retroperitoneal space. Downward balloon dissection is not used, to avoid injuring the transplant, which is usually visible in the retroperitoneum through the balloon port. Pneumoperitoneum is maintained at 12–15 mmHg. Two subsequent 12 mm ports are introduced under direct vision, the location being as shown in Fig. 1, i.e. one along the same transverse level as the first incision, in the posterior axillary line, and the other ≈ 5 cm superior to the anterior superior iliac spine in front of the anterior axillary line, but staying well away from the transplanted kidney. If there are renal tumours the kidney is dissected outside Gerota's fascia, directly on to the vessels. The renal arteries and vein are controlled using clips and then resected. The ureter is clipped and cut. The resected kidney is then extracted in a laparoscopic sac by widening the middle port incision. The anterior port is deliberately avoided for this purpose, again to minimize injury to the renal allograft. A tube drain is placed at the end of the procedure. In our experience, the mean (range) blood loss was 45 (10–100) mL and the operating time 180 (150–210) min.
COMPARISON WITH OTHER METHODS
Bilateral hand-assisted laparoscopic nephrectomy (HALN)  or TN are alternatives to RN. HALN in particular has the advantage of not having to significantly alter the patient's position on the operating table, and saves time. Although we are familiar with HALN and have used it in this patient group, it may not be a suitable technique in those with previous intra-abdominal surgery due to the presence of adhesions and the risk of inadvertent bowel injury. The same applies to TN. Both patients described here had previously had peritoneal dialysis for end-stage renal disease (ESRD).
ADVANTAGES AND DISADVANTAGES
The main advantages of RN are minimal blood loss, less postoperative pain, low morbidity, a short hospital stay (3 days) and early full recovery (within 4 weeks). RN can be performed in those with previous intraperitoneal surgery; this is usual in patients with ESRD, as they may have been on peritoneal dialysis. Creatinine levels are maintained after surgery, with no adverse effect on the transplants.
The chief disadvantage is the smaller working space, particularly when operating on the side of the renal transplant. These patients also need careful anaesthetic evaluation, as they have a higher cardiovascular risk and are on immunosuppressants.
Early experience indicates that RN is a good option for removing native kidneys in functioning renal-transplant recipients. Its role needs to be better established in these high-risk patients, many of whom may develop tumours in their native kidneys. Perhaps they need surveillance of their native kidneys with annual ultrasonography. Technical modifications as described are the key to the success of the laparoscopic approach in such patients, many of whom have traditionally been treated with open surgery in the past.
Guy's and St. Thomas’ Charitable Foundation, and Abhay Rane, Nizam Mamode and Geoff Koffman.
CONFLICT OF INTEREST
None declared. Source of funding: Guy's and St. Thomas Charity.