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Simultaneous transplant nephrectomy and ipsilateral second graft retransplantation
SIMULTANEOUS TRANSPLANT NEPHRECTOMY
AND
IPSILATERAL SECOND GRAFT RETRANSPLANTATION E. N. SCOTT CLIFTON
SAMARA, M.D.
L. WHITESELL,
LEE A. HUTTON,
M.D.
M.D.
From the Department of Urology, Section of Renal Transplant Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
ABSTRACT-Six cases of simultaneous transplant nephrectomy and retransplantation in the ipsilateral iliac fossa are presented. All primary grafts were lost due to chronic rejection. Patients were followed from forty-one to one hundred months after the second graft transplant. The sources for all grafts were either living related donors or cadavers. Graft nephrectomy was performed through the previous lower quadrant incision; the arterial and venous stumps of the primary grafts were used when possible. In all cases continuity of the urinary tract was reestablished with a PolitanoLeadbetter ureteroneocystostomy. There appears to be no increased morbidity in any of these 6 cases, and the survival rate of the second graft is comparable to that of transplantation into the contralateral virginal fossa. Advantages of the simultaneous procedure are discussed.
Indications for nonfunctioning transplant nephrectomy have been well established in the literature.1-5 However, many patients with a nonfunctioning graft do not require transplant nephrectomy prior to retransplantation. Often a patient without medical or surgical indications for transplant nephrectomy is offered a second allograft. We herein describe our experience with simultaneous transplant nephrectomy and second graft retransplantation into the ipsilateral iliac fossa. Material and Methods A total of 172 renal transplants were performed at this institution between September, 1976, and December, 1984. Six patients underwent simultaneous transplant nephrectomy with second graft retransplantation into the ipsilateral iliac fossa. Patient age ranged from eleven to forty-seven years. Table I lists the cause of the original end-stage renal disease. In all cases, the first graft was lost due to chronic rejection.
134
TABLE I. Primary cause of renal failure
Patient
Original Cause of Renal Failure
MY DM MS AA FG RC
Chronic pyelonephritis Chronic pyelonephritis Chronic glomerulonephritis Chronic glomerulonephritis Chronic pyelonephritis Alport syndrome
The time interval between the first and second graft transplantations ranged from twentythree to seventy-one months. Sources for the first and second grafts were either living related or cadaver donors (Table II). Immunologic criteria used for donor selection for all transplants included HLA typing and crossmatching to exclude the presence of circulating preformed antibodies. Mixed lymphocyte culture (MLC) tests were performed when a living related donor was used.
UROLOGY
/ FEBRUARY1987 / VOLUMEXXIX,NUMBER2
TABLE
II.
Graft source -Graft 1st
Patient
Source 2nd
LR C C LR C C
MY DM MS AA FG RC
LR C LR C C LR
KEY: LR = living related; C = cadaver.
Graft nephrectomy was performed through the previous lower quadrant incision in the usual manner. The stump of the hypogastric artery and previous external iliac venotomy were dissected free and used when possible for retransplantation. Three of six grafts were implanted using an end-to-side arterial anastomosis with the iliac artery, and all venous continuity was established via an end-to-side anastomosis into the iliac vein. The continuity of the urinary tract was reestablished with a standard Politano-Leadbetter ureteroneocystostomy. The immediate postoperative management, as well as the immunosuppressive maintenance regimen, did not differ from those applied with the first transplant. Results The 6 cases of simultaneous transplant nephrectomy and retransplantation in the ipsilateral iliac fossa are summarized in Table III. These patients have been followed from fortyone to one hundred months postoperatively. Chronic rejection occurred in 1 patient and one graft was lost due to poor medical compliance, which resulted in irreversible acute rejection. A late surgical complication of renal artery stenoTABLE
Pt.
Time Since 2nd Graft (MO.)
MY
53
DM
84
MS
80
AA
100
FG RC
41 43
III.
i
FEBRUARY
1987
Comment The standard procedure for retransplantation in patients with a nonfunctioning in situ graft has been to place the new graft into the contralateral iliac fossa. This approach has been chosen chiefly for the advantage of operating in a virgin area. Our experience with simultaneous transplant nephrectomy and ipsilateral retransplantation demonstrates that this procedure, while requiring more meticulous dissection, is technically feasible and places neither the patient nor the second graft at increased risk. We believe that there are numerous advantages to the simultaneous procedure. These include: (1) Avoidance of the additional operation of graft nephrectomy with its potential risks and morbidity should it later be indicated. (2) Avoidance of the problem of sexual impotence in men receiving a second renal transplant into the contralateral iliac fossa. This complication has been reported to range from 30 to 100 per cent.6m7Simultaneous transplant nephrectomy in retransplantation spares the contralateral hypogastric artery and avoids the possibility of vasculogenic impotence. (3) Graft survival does not appear to be hindered by the simultaneous procedure. (4) This procedure does not appear to involve greater risk than either a transplant or transplant nephrectomy alone. (5) The combined procedure appears to be cost-effective when compared with
Current patient status
Late Complications Since 2nd Graft
Last BUN
Acute and chronic rejection, viral syndromes CMV, renovascular hypertension Diastolic hypertension, viral syndromes Poor medication compliance, psychotic/suicidal, chronic rejection CMV, chronic rejection None
17
1.0
. .
20
1.5
. .
10
0.6
.
KEY: BUN = blood urea nitrogen; Cr = creatinine; CMV
UROLOGY
sis, with subsequent renal hypertension, was encountered in 1 patient with a repeat end-toend arterial anastomosis. The stenosis was diagnosed two years postretransplantation and was surgically repaired. This patient currently has normal renal function and is normotensive.
Last Cr
Dialysis Resumed
97
23
3 x week
87 14
14 1.0
3 x week . .
= cytomegalovirus.
/ VOLUME XXIX, NUMBER 2
135
a transplant nephrectomy and retransplantation done as separate procedures. University of Oklahoma Health Sciences Center Section of Renal Transplant Surgery 920 Stanton L. Young Blvd., 5 SP 320 Oklahoma City, Oklahoma 73190 (DR. SAMARA) References 1. Silberman H, F&gibbons TJ, Butler J, and Berne TV: Renal allografts retained in situ after failure, Arch Surg 115: 42 (1980).
136
2. Gustafsson A, et al: The fate of failed renal homografts retained after retransplantation, Surg Gynecol Obstet 137: 40 (1973). 3. MacLean LD, MacKinnon KG, Inglis FG, and Dossetor JB: When should renal alloerafts be removed? Arch Sure 99: 269 (1969). 4. Palleschi J, Novick AC, Braun WE, and Magnusson MO: Vascular complications of renal transplantation, Urology 16: 61 (1980). 5. Dabhoiwala NF, et al: Conservative surgical management of urological complications after cadaveric renal transplantation, J Urol 120: 290 (1978). 6. Gittes RF, and Waters WB: Sexual impotence: the overlooked complication of a second renal transplant, ibid 121: 719 (1979). 7. Burns JR, et al: Vascular-induced erectile impotence in renal transplant recipients, ibid 121: 721 (1979).
UROLOGY
/
FEBRUARY
1987
i
VOLUME
XXIX,
NUMBER
2
AND
IPSILATERAL SECOND GRAFT RETRANSPLANTATION E. N. SCOTT CLIFTON
SAMARA, M.D.
L. WHITESELL,
LEE A. HUTTON,
M.D.
M.D.
From the Department of Urology, Section of Renal Transplant Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
ABSTRACT-Six cases of simultaneous transplant nephrectomy and retransplantation in the ipsilateral iliac fossa are presented. All primary grafts were lost due to chronic rejection. Patients were followed from forty-one to one hundred months after the second graft transplant. The sources for all grafts were either living related donors or cadavers. Graft nephrectomy was performed through the previous lower quadrant incision; the arterial and venous stumps of the primary grafts were used when possible. In all cases continuity of the urinary tract was reestablished with a PolitanoLeadbetter ureteroneocystostomy. There appears to be no increased morbidity in any of these 6 cases, and the survival rate of the second graft is comparable to that of transplantation into the contralateral virginal fossa. Advantages of the simultaneous procedure are discussed.
Indications for nonfunctioning transplant nephrectomy have been well established in the literature.1-5 However, many patients with a nonfunctioning graft do not require transplant nephrectomy prior to retransplantation. Often a patient without medical or surgical indications for transplant nephrectomy is offered a second allograft. We herein describe our experience with simultaneous transplant nephrectomy and second graft retransplantation into the ipsilateral iliac fossa. Material and Methods A total of 172 renal transplants were performed at this institution between September, 1976, and December, 1984. Six patients underwent simultaneous transplant nephrectomy with second graft retransplantation into the ipsilateral iliac fossa. Patient age ranged from eleven to forty-seven years. Table I lists the cause of the original end-stage renal disease. In all cases, the first graft was lost due to chronic rejection.
134
TABLE I. Primary cause of renal failure
Patient
Original Cause of Renal Failure
MY DM MS AA FG RC
Chronic pyelonephritis Chronic pyelonephritis Chronic glomerulonephritis Chronic glomerulonephritis Chronic pyelonephritis Alport syndrome
The time interval between the first and second graft transplantations ranged from twentythree to seventy-one months. Sources for the first and second grafts were either living related or cadaver donors (Table II). Immunologic criteria used for donor selection for all transplants included HLA typing and crossmatching to exclude the presence of circulating preformed antibodies. Mixed lymphocyte culture (MLC) tests were performed when a living related donor was used.
UROLOGY
/ FEBRUARY1987 / VOLUMEXXIX,NUMBER2
TABLE
II.
Graft source -Graft 1st
Patient
Source 2nd
LR C C LR C C
MY DM MS AA FG RC
LR C LR C C LR
KEY: LR = living related; C = cadaver.
Graft nephrectomy was performed through the previous lower quadrant incision in the usual manner. The stump of the hypogastric artery and previous external iliac venotomy were dissected free and used when possible for retransplantation. Three of six grafts were implanted using an end-to-side arterial anastomosis with the iliac artery, and all venous continuity was established via an end-to-side anastomosis into the iliac vein. The continuity of the urinary tract was reestablished with a standard Politano-Leadbetter ureteroneocystostomy. The immediate postoperative management, as well as the immunosuppressive maintenance regimen, did not differ from those applied with the first transplant. Results The 6 cases of simultaneous transplant nephrectomy and retransplantation in the ipsilateral iliac fossa are summarized in Table III. These patients have been followed from fortyone to one hundred months postoperatively. Chronic rejection occurred in 1 patient and one graft was lost due to poor medical compliance, which resulted in irreversible acute rejection. A late surgical complication of renal artery stenoTABLE
Pt.
Time Since 2nd Graft (MO.)
MY
53
DM
84
MS
80
AA
100
FG RC
41 43
III.
i
FEBRUARY
1987
Comment The standard procedure for retransplantation in patients with a nonfunctioning in situ graft has been to place the new graft into the contralateral iliac fossa. This approach has been chosen chiefly for the advantage of operating in a virgin area. Our experience with simultaneous transplant nephrectomy and ipsilateral retransplantation demonstrates that this procedure, while requiring more meticulous dissection, is technically feasible and places neither the patient nor the second graft at increased risk. We believe that there are numerous advantages to the simultaneous procedure. These include: (1) Avoidance of the additional operation of graft nephrectomy with its potential risks and morbidity should it later be indicated. (2) Avoidance of the problem of sexual impotence in men receiving a second renal transplant into the contralateral iliac fossa. This complication has been reported to range from 30 to 100 per cent.6m7Simultaneous transplant nephrectomy in retransplantation spares the contralateral hypogastric artery and avoids the possibility of vasculogenic impotence. (3) Graft survival does not appear to be hindered by the simultaneous procedure. (4) This procedure does not appear to involve greater risk than either a transplant or transplant nephrectomy alone. (5) The combined procedure appears to be cost-effective when compared with
Current patient status
Late Complications Since 2nd Graft
Last BUN
Acute and chronic rejection, viral syndromes CMV, renovascular hypertension Diastolic hypertension, viral syndromes Poor medication compliance, psychotic/suicidal, chronic rejection CMV, chronic rejection None
17
1.0
. .
20
1.5
. .
10
0.6
.
KEY: BUN = blood urea nitrogen; Cr = creatinine; CMV
UROLOGY
sis, with subsequent renal hypertension, was encountered in 1 patient with a repeat end-toend arterial anastomosis. The stenosis was diagnosed two years postretransplantation and was surgically repaired. This patient currently has normal renal function and is normotensive.
Last Cr
Dialysis Resumed
97
23
3 x week
87 14
14 1.0
3 x week . .
= cytomegalovirus.
/ VOLUME XXIX, NUMBER 2
135
a transplant nephrectomy and retransplantation done as separate procedures. University of Oklahoma Health Sciences Center Section of Renal Transplant Surgery 920 Stanton L. Young Blvd., 5 SP 320 Oklahoma City, Oklahoma 73190 (DR. SAMARA) References 1. Silberman H, F&gibbons TJ, Butler J, and Berne TV: Renal allografts retained in situ after failure, Arch Surg 115: 42 (1980).
136
2. Gustafsson A, et al: The fate of failed renal homografts retained after retransplantation, Surg Gynecol Obstet 137: 40 (1973). 3. MacLean LD, MacKinnon KG, Inglis FG, and Dossetor JB: When should renal alloerafts be removed? Arch Sure 99: 269 (1969). 4. Palleschi J, Novick AC, Braun WE, and Magnusson MO: Vascular complications of renal transplantation, Urology 16: 61 (1980). 5. Dabhoiwala NF, et al: Conservative surgical management of urological complications after cadaveric renal transplantation, J Urol 120: 290 (1978). 6. Gittes RF, and Waters WB: Sexual impotence: the overlooked complication of a second renal transplant, ibid 121: 719 (1979). 7. Burns JR, et al: Vascular-induced erectile impotence in renal transplant recipients, ibid 121: 721 (1979).
UROLOGY
/
FEBRUARY
1987
i
VOLUME
XXIX,
NUMBER
2