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Kidney transplantation
KIDNEY Rational
TRANSPLANTATION* Approach
J. P. W. HEATON, T. A. SALERNO,
to Vascular Anastomoses
M.D. M.D.
From the Department of Urology, Queen’s University, Kingston, and the Department of Surgery, University of Toronto, Toronto, Ontario
ABSTRACT-A simple techniquefor performing the vascular anastomoses in renal transplantation is presented. It utilizes ipsilateral side-to-end vascular anastomoses using the external iliac arteries and punch anastomoses. Using this method, transplantation of kidneys is simplified despite short, multiple, or unequal caliber of renal arteries or calcified recipient iliac arteries.
Renal transplantation is now an established therapeutic modality in the management of renal failure. The medical aspects of transplantation have received vigorous attention in recent years. Concurrently, surgical techniques have been refined in an effort to use more of the limited supply of organs. There have been many reports of surgical approaches that allow a surgically successful result using kidneys with major vascular abnormalities. No one technique has become pre-eminent. In our center we sought to do three things: (1) minimize the time taken for anastomosis; (2) maximize the capacity to use donor kidneys (regardless of the anatomic variations); (3) standardize technique. Achieving the last objective, while complying with the first two, enhances the familiarity with a single technique, facilitates teaching, and improves surgical results. In rationalizing our approach to the anastomoses in renal transplantation free use was *Supported Council.
340
by the Grant
MA-7870
from the Medical
Research
made of advances in the techniques of aortocoronary bypass surgery. In particular, bypass graft surgery has demonstrated unequivocally the success of the side-to-end anastomosis and its place in the anastomosis of vessels of markedly different caliber. We applied these concepts and exclusively used punch arteriotomies, running monofilament sutures and sideto-end anastomoses. Further consideration of the anatomy and the freedom allowed by our approach to the vascular anastomoses prompted us to adopt ipsilateral kidney placement as the ideal and the routine. Our experience with 34 kidneys is presented. Material and Methods In a five-year period, 6 kidneys from live donors and 28 cadaver kidneys were transplanted. The same vascular surgeon performed all the vascular anastomoses, and one of the three urologists performed the ureteric implantation. The outcome of patients in the program
UROLOGY
i
OCTOBER
1984
/ VOLUME
XXIV. NUMBER
4
Vascular anastomoses during kidney transplant. Note two separate holes in external iliac arteries; insert shows punch that was used.
FIGURE 1.
has been discussed in detail elsewhere.’ This group, defined by the particular technique of vascular anastomosis, suffered no demonstrable vascular problems to date. Two patients were hypertensive, 6 were in renal failure, and 3 had ureteric problems. Three patients died; 2 after myocardial infarctions and 1 after an episode of sepsis. In these patients, direct side-to-end anastomoses from the external iliac vessels to the donor vessels were used. A punch arteriotomy was employed in the external iliac artery (EIA). In most cases the kidney was placed in the ipsilateral iliac fossa. In recommending this approach a number of factors can be stressed: (1) The technique requires minimal dissection and minimal disruption of the native vascular bed; (2) side-to-end anastomosis using a punch arteriotomy (analogous to the proximal anastomoses in coronary artery surgery) is relatively safe in diseased vessels in comparison with end-to-end anastomosis; (3) multiple arteries and arteries of various sizes may all be anastomosed using the same technique; (4) it is readily adaptable to autotransplantation; (5) contralateral kidneys may be transplanted with nearly equal facility; and (6) the technique is fast and easily taught.
kidney hilum 90 degrees posteriorly about a longitudinal axis brings the RA into a lateral position. The RV will be medial, the ureter will continue to lie caudad, and the hilum will be posterior to the kidney. A donor kidney, therefore, may be placed in the ipsilateral iliac fossa and its vessels will lie naturally adjacent and perpendicular to the recipient vessels. This simple translocation facilitates the placement of one or more renal arteries along the exposed EIA. A single punch arteriotomy can be used for each renal artery. The renal veins will be similarly well placed and conventional stab venotomies, 1 for each donor vein, should be used. Technique of Vascular Anastomoses
The normal anatomy of the renal hilum places the renal artery (RA) posterior to the renal vein (RV). The recipient vessels lie with the EIA placed laterally and anteriorly to the external iliac vein (EIV). A simple rotation of the
A transplant incision is used for the exposure of the external iliac vessels and iliac fossa. The vessels are freed of overlying tissue and the donor kidney placed within the wound to assess the vascular relationships. It will be found that the natural location for the anastomoses is quite distal as the external iliac vessels curve anteriorly a few centimeters proximal to the take off of the deep circumflex iliac vessels. The EIV should be isolated and proximal and distal ties of umbilical tape placed as snares (Fig. 1 in a left iliac fossa). The EIA should then be clamped with two vascular clamps isolating the segment for anastomosis. No heparin is used. The EIV snares should be tightened and stab
UROLOGY
4
Rationale
/
OCTOBER
1984
/ VOLUME
XXIV. NUMBER
341
tion can also be accomplished simply with the side-to-end anastomosis although some distortion of the hilum will be inevitable. Using this technique dissection time and warm ischemic time have been markedly reduced. Comment
FIGURE 2.
Completion
of all anastomoses.
venotomies made, as determined by the configuration of the donor RVS, and extended with a Pott scissors. The donor kidney is then placed in the wound and held laterally. A “Kyper” stitch of 5-O Prolene is placed along the medial suture line of the venovenous anastomosis. The kidney is reflected medially, the stitch tightened down, and the lateral suture line inserted to complete the venovenous anastomosis. Using a no. 15 blade, stab arteriotomies are made opposite each donor RA and a 4-mm punch (Hancock aortic punch extracorporeal, 4 mm, Medical Specialties Inc., Anaheim, CA) is used to create the definitive orifices, one at a time, and the side-to-end arterial anastomoses are fashioned using “Kyper” stitches of 5-O Prolene (Fig. 2). The venous snares are loosened, and arterial flow is established secondarily. Ample mobility remains for rechecking the anastomoses. The procedure is finished by conventional ureteric re-implantation and wound closure. No drains are used. Multiple major renal veins may be handled using this technique. Contralateral implanta-
342
When other incompatibilities have been eliminated, potential anatomic vascular problems should not deter the surgeon from the transplantation of any kidney. Techniques have been described for managing combinations of short, multiple, and unequal caliber arteries.2-5 The problem presented by multiple vessels may be of particular concern in living donors.6.7 The continuing success of widely accepted techniques in coronary artery surgery can stand as a model for renal artery anastomosis. Arteries down to l-2 mm in size are amenable to direct side-to-end anastomosis using the EIA. In summary, renovascular anastomosis in transplantation may be simplified and made more rapid by the almost universal application of the technique of ipsilateral side-to-end anastomosis using the EIA and punch arteriotomies. Division Toronto,
of Cardiovascular Ontario,
Surgery 30 Bond Canada M5B lW8 (DR. SALERNO)
References 1. Ludwin D, et al: Results of renal transplantation in a small centre, Can Med Assoc J 126: 1420 (1982). 2. Starzl TE: Experience in Renal Transplantation, Philadelphia, WB Saunders, 1964, p 48. 3. Belzer FO, Schweizer RT, and Kountz SL: Management of multiple vessels in renal transplantation, Transplant Proc 4: 639 (1972). 4. Mendez R, et al: Management of multiple renal arteries in renal transplantation, Urology 3: 409 (1974). 5. Banowsky LH, et al: Renal transplantation. I. Use of donor organs with multiple vessels, ibid 4: 643 (1974). 6. Simmons RL, et al: Kidney transplantation from living donors with bilateral double renal arteries, Surgery 69: 201 (1971). 7. Merkel FK, rt al: Microvascular techniques for polar arter) reconstruction in kidney transplants, ibid 79: 253 (1976).
UROLOGY
i
OCTOBER
1984
/ VOLUME
XXIV, NUMBER
4
TRANSPLANTATION* Approach
J. P. W. HEATON, T. A. SALERNO,
to Vascular Anastomoses
M.D. M.D.
From the Department of Urology, Queen’s University, Kingston, and the Department of Surgery, University of Toronto, Toronto, Ontario
ABSTRACT-A simple techniquefor performing the vascular anastomoses in renal transplantation is presented. It utilizes ipsilateral side-to-end vascular anastomoses using the external iliac arteries and punch anastomoses. Using this method, transplantation of kidneys is simplified despite short, multiple, or unequal caliber of renal arteries or calcified recipient iliac arteries.
Renal transplantation is now an established therapeutic modality in the management of renal failure. The medical aspects of transplantation have received vigorous attention in recent years. Concurrently, surgical techniques have been refined in an effort to use more of the limited supply of organs. There have been many reports of surgical approaches that allow a surgically successful result using kidneys with major vascular abnormalities. No one technique has become pre-eminent. In our center we sought to do three things: (1) minimize the time taken for anastomosis; (2) maximize the capacity to use donor kidneys (regardless of the anatomic variations); (3) standardize technique. Achieving the last objective, while complying with the first two, enhances the familiarity with a single technique, facilitates teaching, and improves surgical results. In rationalizing our approach to the anastomoses in renal transplantation free use was *Supported Council.
340
by the Grant
MA-7870
from the Medical
Research
made of advances in the techniques of aortocoronary bypass surgery. In particular, bypass graft surgery has demonstrated unequivocally the success of the side-to-end anastomosis and its place in the anastomosis of vessels of markedly different caliber. We applied these concepts and exclusively used punch arteriotomies, running monofilament sutures and sideto-end anastomoses. Further consideration of the anatomy and the freedom allowed by our approach to the vascular anastomoses prompted us to adopt ipsilateral kidney placement as the ideal and the routine. Our experience with 34 kidneys is presented. Material and Methods In a five-year period, 6 kidneys from live donors and 28 cadaver kidneys were transplanted. The same vascular surgeon performed all the vascular anastomoses, and one of the three urologists performed the ureteric implantation. The outcome of patients in the program
UROLOGY
i
OCTOBER
1984
/ VOLUME
XXIV. NUMBER
4
Vascular anastomoses during kidney transplant. Note two separate holes in external iliac arteries; insert shows punch that was used.
FIGURE 1.
has been discussed in detail elsewhere.’ This group, defined by the particular technique of vascular anastomosis, suffered no demonstrable vascular problems to date. Two patients were hypertensive, 6 were in renal failure, and 3 had ureteric problems. Three patients died; 2 after myocardial infarctions and 1 after an episode of sepsis. In these patients, direct side-to-end anastomoses from the external iliac vessels to the donor vessels were used. A punch arteriotomy was employed in the external iliac artery (EIA). In most cases the kidney was placed in the ipsilateral iliac fossa. In recommending this approach a number of factors can be stressed: (1) The technique requires minimal dissection and minimal disruption of the native vascular bed; (2) side-to-end anastomosis using a punch arteriotomy (analogous to the proximal anastomoses in coronary artery surgery) is relatively safe in diseased vessels in comparison with end-to-end anastomosis; (3) multiple arteries and arteries of various sizes may all be anastomosed using the same technique; (4) it is readily adaptable to autotransplantation; (5) contralateral kidneys may be transplanted with nearly equal facility; and (6) the technique is fast and easily taught.
kidney hilum 90 degrees posteriorly about a longitudinal axis brings the RA into a lateral position. The RV will be medial, the ureter will continue to lie caudad, and the hilum will be posterior to the kidney. A donor kidney, therefore, may be placed in the ipsilateral iliac fossa and its vessels will lie naturally adjacent and perpendicular to the recipient vessels. This simple translocation facilitates the placement of one or more renal arteries along the exposed EIA. A single punch arteriotomy can be used for each renal artery. The renal veins will be similarly well placed and conventional stab venotomies, 1 for each donor vein, should be used. Technique of Vascular Anastomoses
The normal anatomy of the renal hilum places the renal artery (RA) posterior to the renal vein (RV). The recipient vessels lie with the EIA placed laterally and anteriorly to the external iliac vein (EIV). A simple rotation of the
A transplant incision is used for the exposure of the external iliac vessels and iliac fossa. The vessels are freed of overlying tissue and the donor kidney placed within the wound to assess the vascular relationships. It will be found that the natural location for the anastomoses is quite distal as the external iliac vessels curve anteriorly a few centimeters proximal to the take off of the deep circumflex iliac vessels. The EIV should be isolated and proximal and distal ties of umbilical tape placed as snares (Fig. 1 in a left iliac fossa). The EIA should then be clamped with two vascular clamps isolating the segment for anastomosis. No heparin is used. The EIV snares should be tightened and stab
UROLOGY
4
Rationale
/
OCTOBER
1984
/ VOLUME
XXIV. NUMBER
341
tion can also be accomplished simply with the side-to-end anastomosis although some distortion of the hilum will be inevitable. Using this technique dissection time and warm ischemic time have been markedly reduced. Comment
FIGURE 2.
Completion
of all anastomoses.
venotomies made, as determined by the configuration of the donor RVS, and extended with a Pott scissors. The donor kidney is then placed in the wound and held laterally. A “Kyper” stitch of 5-O Prolene is placed along the medial suture line of the venovenous anastomosis. The kidney is reflected medially, the stitch tightened down, and the lateral suture line inserted to complete the venovenous anastomosis. Using a no. 15 blade, stab arteriotomies are made opposite each donor RA and a 4-mm punch (Hancock aortic punch extracorporeal, 4 mm, Medical Specialties Inc., Anaheim, CA) is used to create the definitive orifices, one at a time, and the side-to-end arterial anastomoses are fashioned using “Kyper” stitches of 5-O Prolene (Fig. 2). The venous snares are loosened, and arterial flow is established secondarily. Ample mobility remains for rechecking the anastomoses. The procedure is finished by conventional ureteric re-implantation and wound closure. No drains are used. Multiple major renal veins may be handled using this technique. Contralateral implanta-
342
When other incompatibilities have been eliminated, potential anatomic vascular problems should not deter the surgeon from the transplantation of any kidney. Techniques have been described for managing combinations of short, multiple, and unequal caliber arteries.2-5 The problem presented by multiple vessels may be of particular concern in living donors.6.7 The continuing success of widely accepted techniques in coronary artery surgery can stand as a model for renal artery anastomosis. Arteries down to l-2 mm in size are amenable to direct side-to-end anastomosis using the EIA. In summary, renovascular anastomosis in transplantation may be simplified and made more rapid by the almost universal application of the technique of ipsilateral side-to-end anastomosis using the EIA and punch arteriotomies. Division Toronto,
of Cardiovascular Ontario,
Surgery 30 Bond Canada M5B lW8 (DR. SALERNO)
References 1. Ludwin D, et al: Results of renal transplantation in a small centre, Can Med Assoc J 126: 1420 (1982). 2. Starzl TE: Experience in Renal Transplantation, Philadelphia, WB Saunders, 1964, p 48. 3. Belzer FO, Schweizer RT, and Kountz SL: Management of multiple vessels in renal transplantation, Transplant Proc 4: 639 (1972). 4. Mendez R, et al: Management of multiple renal arteries in renal transplantation, Urology 3: 409 (1974). 5. Banowsky LH, et al: Renal transplantation. I. Use of donor organs with multiple vessels, ibid 4: 643 (1974). 6. Simmons RL, et al: Kidney transplantation from living donors with bilateral double renal arteries, Surgery 69: 201 (1971). 7. Merkel FK, rt al: Microvascular techniques for polar arter) reconstruction in kidney transplants, ibid 79: 253 (1976).
UROLOGY
i
OCTOBER
1984
/ VOLUME
XXIV, NUMBER
4