Surgical Techniques of Kidney Transplantation

11

Surgical Techniques of Kidney Transplantation CHRISTOPHER J.E. WATSON, PETER J. FRIEND and LORNA P. MARSON

CHAPTER OUTLINE

Preparation of Recipient Preparation of Kidney Site Incision Preparation of Operative Bed Revascularization Arterial Anastomosis External Iliac Artery Internal Iliac Artery Venous Anastomosis Reperfusion of the Kidney Reconstruction of the Urinary Tract Ureteroneocystostomy (Anastomosis of the Transplant Ureter Directly to the Bladder) Transvesical Ureteroneocystostomy Extravesical Ureteroneocystostomy Parallel Incision Ureteroneocystostomy

Kidney transplantation is a major surgical procedure that involves both vascular and ureteric anastomoses, and it is usually performed by a dedicated transplant surgeon, although in the past it was performed predominantly by urologists or vascular surgeons. Most recipients are already established on dialysis, although some may avoid dialysis by having the transplant preemptively, and many consider this the gold standard treatment. Preemptive transplantation confers a modest benefit over transplantation after the start of dialysis, but not if the duration of dialysis is less than a year. There are concerns about equity of access to preemptive transplants, as it tends to disadvantage individuals who are less educated and from lower socioeconomic groups. In addition there is a suggestion that patients transplanted preemptively may have lower adherence to immunosuppression.1–3 Preemptive transplantation is particularly advantageous in children.4,5 Renal transplant recipients are frequently elderly, with other comorbidity (e.g., diabetes, cardiovascular disease, obesity), which increases the surgical and anesthetic challenges. In addition most have impaired platelet function through a combination of uremia and antiplatelet therapy (aspirin or clopidogrel), and some will be on warfarin for previous thromboembolic disease or prosthetic heart valves. Thus this group of patients carries a relatively high operative risk.

Double Ureters Augmented Bladder Pyelopyelostomy Pyeloureterostomy and Ureteroureterostomy Pyelovesicostomy Ureteroenterostomy Ureteric Stents Management of Catheter and Stent Closure Pediatric Recipient Pediatric Donor Double Kidney Transplant Transplant Nephrectomy

Preparation of Recipient The general preparation and selection of recipients for transplantation is discussed in Chapter 4. Potential kidney transplant recipients are carefully assessed before being placed on the waiting list. Medical and surgical risk factors will have been identified and evaluated, and periodically reassessed while waiting. On admission for transplantation, a further careful history and physical examination are required to ensure that there is no immediate contraindication to major surgery. For example, have there been changes since the patient was last assessed? Particular attention should be paid to the patient’s fluid and electrolyte status. In addition a history of recent sensitizing events should be elicited (blood transfusions, immunosuppression withdrawal in someone awaiting a retransplant). These should be brought to the attention of the histocompatibility laboratory. The patient may require dialysis before going to surgery because of fluid overload or a high serum potassium concentration; this will depend on the nature of dialysis and when this was last carried out. Potassium often rises as a consequence of anesthesia, blood transfusion, and reperfusion of the kidney; it is essential to ensure that the patient has a normal serum potassium pretransplant. It is much easier and safer to dialyze a patient before transplant than immediately posttransplant. 157

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The potential risks of a renal transplantation should be discussed with patients at the time of listing and must include general risks of surgery and specific risks of the procedure. These risks include technical complications such as arterial or venous thrombosis, bleeding or urinary complications, risk of delayed graft function (which can occur in up to 50% deceased donor kidney transplants), and of acute rejection. Careful explanation of the possible requirement for biopsy should be given. The need for immunosuppression, with its attendant drug-specific and immunosuppression-associated side effects, should also be discussed at the time of listing. Any recipient choices as to the nature of donors considered acceptable or not acceptable should be recorded (e.g., donors with a history of cancer or high risk behavior for hepatitis or HIV). At the time of admission for transplant, specific risks pertaining to the donor should be discussed with the patient where appropriate. Informed consent to proceed can then be obtained. Immunosuppression may be commenced before the patient goes to surgery. Although there is no hard evidence that preoperative immunosuppression is necessary, many centers prefer a loading dose of a calcineurin inhibitor or antimetabolite to ensure a better blood level in the first hours posttransplant. Induction agents (most typically basiliximab) are also started preoperatively. Where the recipient is receiving an antibody-incompatible graft (typically from a living donor), he or she will usually have received several days of preoperative immunosuppression in addition to undergoing antibody removal. Prophylaxis against deep vein thrombosis and pulmonary embolus should be undertaken with low dose molecular weight heparin according to hospital protocol, thromboembolic deterrent (TED) stockings, and perioperative intermittent calf compression. Although the transplant operation is a clean one, the patient will be immunosuppressed and is at high risk for wound infection. In addition it is possible for the deceased donor kidney to be contaminated during retrieval or for there to be a urinary tract infection as a consequence of the donor having a urethral catheter while on the intensive care unit before death. Infection in the vicinity of the vascular anastomosis may result in secondary hemorrhage, which is an uncommon but catastrophic complication, resulting in loss of the kidney, compromise of distal circulation, and significant mortality. Prophylactic antimicrobial therapy, with a spectrum to cover common skin organisms as well as possible urinary tract contaminants, has been shown to reduce the risk of developing sepsis with bacteremia and for developing bactiuria6; a single dose may be sufficient.7 Antimicrobial cover may also be required if the donor was known to be infected, such as donors dying from meningococcal meningitis; the advice of a specialist in microbiology is valuable in these situations. Consideration must be given at this stage to the cold ischemia time, which should be minimized. Prolonged cold ischemia is associated with increased rates of delayed graft function and worse long-term outcomes, particularly in transplants from donors after circulatory death.8 Logistical factors such as preoperative dialysis and the need for a prospective crossmatch, contribute significantly to cold ischemic times.9

After induction of anesthesia, a central venous catheter (CVC) may be inserted into the internal jugular vein (preferably under ultrasound guidance) to allow central venous pressure monitoring to ensure optimal fluid replacement and postoperative dialysis, although in some centers, the use of CVC may be reserved for those patients who will receive antithymocyte globulin (ATG) induction. In patients without hemodialysis access the selected catheter should enable postoperative hemodialysis if required. Subclavian vein cannulation should be avoided if possible because of the risk of causing subclavian venous stenosis, which would prejudice future upper-limb vascular access when the kidney has failed. Other aspects of the induction of anesthesia and monitoring during the operative procedure are discussed in Chapter 13. Once the patient is anesthetized, a urinary balloon catheter is inserted aseptically into the recipient’s bladder (see later). The skin should be prepared carefully in the operating room; body hair is removed and the skin of the abdominal wall prepared with an antimicrobial agent, typically chlorhexidine gluconate in alcohol.10 It is wise to prepare the entire abdomen from nipples to midthighs, especially in a recipient with vascular disease, because occasionally the original incision may need to be extended or abandoned and the opposite iliac fossa opened, or saphenous vein harvested to manage a vascular problem. Immediately before surgery, the World Health Organization (WHO) surgical safety check should be undertaken, giving additional consideration to checking blood group compatibility of donor and recipient and confirming the HLA crossmatch status. It is also important to ensure that the correct donor kidney is in the operating room. 

Preparation of Kidney The preparation of the deceased donor kidney should be done in advance of the transplant procedure in case some anomaly (for example, a previously unrecognized tumor) is present that would preclude transplantation, or damage is found that requires repair. Good preparation will ensure an adequate length of vessels with good hemostasis at the time of reperfusion, both in living and deceased donor kidneys. A varying degree of dissection of the kidney is required when the kidney is removed from cold storage. In the case of a deceased donor kidney removed as part of an en bloc procedure, considerable dissection needs to be performed, and this should be done carefully and with a good light on a back table with the kidney in a bowl of ice slush. The kidney should be oriented as it is in the body. The renal vein should be picked up and dissected toward the kidney, dividing small tributaries, and ligating and dividing the gonadal and adrenal veins. Dissection should not continue close to the renal pelvis. If there is more than one renal vein, smaller veins can be ligated, assuming that there is one large renal vein. If two renal veins are of equal size and are not arising from a single caval patch, there is a risk of subsequent venous infarction if one vein is ligated; it is preferable to implant both veins separately or to join the veins to form a common trunk for a single anastomosis. A short right renal vein can be extended with donor inferior vena cava or external iliac vein.

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Once the venous preparation is complete, the renal vein may then be folded over the kidney and the artery dissected out from adherent fat. Care must be taken to define the arterial anatomy, ensuring that no polar arteries are damaged in the process. In particular, the right renal artery typically gives a branch to the adrenal which may occasionally pass on to supply the upper pole of the kidney. The ureter can now be dissected free, with care not to divide the tissue between the ureter and lower pole of kidney (the so-called golden triangle, see Chapter 29) and to retain a small amount of tissue around the ureter to preserve its blood supply. Once the kidney has been prepared, the perinephric fat can be removed. The kidney may then be flushed with 100 to 200 ml of kidney perfusion fluid, as this may remove products of metabolism and allows detection of defects in the artery or vein, which should be repaired at this stage. 

Site Although traditionally the right iliac fossa was used for implantation of the kidney,11–15 in reality there is little to choose between sides. It has been suggested that the left kidney is best placed in the right iliac fossa and the right kidney in the left iliac fossa, an approach that places the pelvis and ureter medially to facilitate future ureteric reconstruction, should it be required. In contrast, placing the deceased donor kidney on the ipsilateral side with anastomoses to the external iliac vessels avoids crossing the renal artery and vein, and may be facilitated by the use of a subrectus pouch (see later); similarly, live donor kidneys implanted using the internal iliac artery may be placed contralaterally to avoid vessels crossing. In general, however, it is reasonable to use either iliac fossa for placement of the kidney. Other factors which may dictate the optimal site of placement include the existence of previous abdominal incisions, particularly if placement of a transplant incision would result in devitalizing an area of abdominal wall. Previous venous thrombosis in one leg is an indication to use the opposite side lest the thrombus has obliterated the ipsilateral iliac veins. A history of femoral vein cannulation is also a relative contraindication to use that side for fear of iliac venous thrombosis or partial thrombosis. If a colostomy or ileostomy were emerging from one side of the abdomen, the contralateral side would usually be chosen, although it would be preferable to use the same side as an ileal conduit (urostomy) to facilitate ureteric implantation. The presence of large polycystic kidneys may dictate which side is chosen, as there may only be room to implant a kidney on one side. Occasionally the polycystic kidneys are too large to permit placement of a transplant. Such a situation should be picked up as part of the assessment process and one or both polycystic kidneys should be removed before the patient is activated on the transplant list. Polycystic nephrectomy is best done either laparoscopically or through a midline incision; a transverse incision is contraindicated to avoid later concerns regarding skin viability when performing the transplant incision. In children, in whom the vascular anastomoses of the renal vessels may be to the aorta and vena cava because of the size of the kidney, the right side is preferred because the kidney is placed behind the cecum and ascending colon.

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Where combined pancreas and kidney transplantation is performed via a vertical midline transperitoneal approach, the pancreas is usually placed in the right iliac fossa and the kidney in the left iliac fossa. To prevent torsion of the renal pedicle, the kidney is best placed in the retroperitoneal space, which is accessed by inserting an index finger into the prevesical space just lateral to the midline and developing the plane laterally.16 

Incision There are two common incisions used to expose the external iliac vessels and bladder. The oblique Rutherford Morison or curvilinear incision is made in the right or left lower quadrant of the abdomen beginning almost in the midline 2 cm above the pubic tubercle and curving upward and 2 cm parallel to the inguinal ligament and ending just above the anterior superior iliac spine of the iliac crest. Caution is taken to avoid the lateral cutaneous nerve of the thigh, which emerges through external oblique 1 cm medial to the anterior superior iliac spine. In a child or small adult, this incision can be carried up to the costal margin to increase exposure.17 The external oblique muscle and fascia are divided in the line of the incision and split to the lateral extent of the wound. This incision is carried medially on to the rectus sheath to permit retraction or division of part of the rectus muscle for later exposure of the bladder. To expose the peritoneum, the internal oblique and transverse muscles are divided with cautery in the line of the incision. The Alexandre or pararectal incision is slightly more vertical than that of Rutherford Morison. It starts 2 cm above the pubic symphysis and passes laterally and cranially along the edge of the rectus sheath, two finger breadths medial to the anterior superior iliac spine. The confluence of the oblique abdominal muscles just lateral to the rectus sheath (the Spigelian fascia) is divided to expose peritoneum beneath. Once the peritoneum is exposed, the inferior epigastric vessels may be ligated and divided to improve access, but if there are multiple renal arteries, the inferior epigastric vessels should be preserved in the first instance in case the inferior epigastric artery is required for anastomosis to a lower polar renal artery. It may also be wise to preserve the vascular supply to the rectus muscle if the muscle has been divided in previous surgery, for example, during a subcostal incision to remove an ipsilateral kidney, gallbladder, or spleen. Although division of the spermatic cord was advocated in early descriptions of the procedure and was common practice for many years, it should not be done and is rarely required for adequate exposure. The spermatic cord may be freed laterally, which allows it to be retracted medially. In females the round ligament can be divided between ligatures. 

Preparation of Operative Bed After exposure of the transversalis fascia and peritoneum, the transversalis fascia is divided, and the peritoneum is reflected upward and medially to expose the psoas muscle

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and the iliac vessels. This is best done in a caudal to cranial direction. At this stage, a self-retaining retractor is inserted to provide good exposure while allowing the assistant to have both hands free to assist with the anastomosis. Dissection proceeds in the first instance to expose the external, common, and/or internal iliac arteries, depending on circumstance: the external iliac artery is the site of first preference if there is a healthy Carrel patch on the donor renal artery; the internal iliac artery may be considered if not, and the common iliac artery if it is a second transplant or if there is significant arterial disease affecting the external iliac vessels. Considerations in children are discussed later. The lymphatics that course along the vessels are preserved where possible and separated from the artery without division. It has been suggested that lymphatics should be ligated and not cauterized when being divided, because this is said to prevent the later occurrence of a lymphocele, although what evidence there is does not support that suggestion (see Chapter 28).18 The surgeon must be careful not to mistake the genitofemoral nerve for a lymph vessel. It lies on the medial edge of the psoas muscle, and a branch may cross the distal external iliac artery. If the internal iliac artery is to be used, it is important to mobilize a length of the common and external iliac arteries so that the internal iliac artery can be rotated laterally without kinking at its origin and so that the vascular clamps can be applied to the common and external iliac arteries when the internal iliac artery is short. Care is taken to inspect the origin of the internal iliac artery, if this is to be used, for any evidence of atheroma and, similarly, any atheromatous disease in the common or external iliac artery should be noted. If there are two or more renal arteries not on a Carrel patch of aorta, the dissection of the internal iliac artery is extended distally to expose the initial branches of the internal iliac artery, which may be suitable for anastomosis to individual renal arteries. This can be done either in situ, or the bifurcation of the internal iliac removed and a back table anastomosis of the two renal arteries onto the divisions of the internal iliac artery performed, before the kidney is implanted using the resected portion of recipient internal iliac as an interposition graft.19 Having completed the exposure of the appropriate iliac arteries, dissection of the external iliac vein is performed (Fig. 11.1). If a left kidney with a long renal vein is available, dissection of the external iliac vein alone generally allows a satisfactory anastomosis without tension. Uncommonly, if the kidney has a very short renal vein, such as with a right kidney or occasionally a left kidney whose vein has been shortened, or if the recipient is obese, the internal iliac vein and usually one or two gluteal veins can be ligated and divided. This technique allows the common and external iliac veins to be brought well up into the wound, particularly if the internal iliac artery is divided, and this facilitates the performance of a tension-free anastomosis. However, division of the internal iliac and gluteal veins is not without risk, because slippage of the ligature may result in hemorrhage that is difficult to control. Alternative means of managing short renal veins are preferred, including use of the parachute technique for venous anastomosis, a more distal placement on the external iliac vein, or use of a segment of donor inferior vena cava to lengthen the renal vein. Temporary placement of the cold kidney graft into the wound assists in the selection of the sites for anastomosis on the recipient artery and vein. 

Fig. 11.1  Iliac vessels dissected free.

Revascularization Anomalies of the renal artery or vein are common, amounting to 30% deceased donor kidneys retrieved.20 In living donation, whereas kidneys are selected preferentially to have a single artery, multiple arteries are common. Because the renal arterial inflow comprises end arteries with no intrarenal communication, all arteries need to be perfused, but particularly the lower-pole artery, because it is likely to give rise to the ureteric blood supply. If multiple arteries are present and separate (i.e., not on a common Carrel patch), there are several surgical techniques that can be used: The vessels can be spatulated together to form a common trunk (Fig. 11.2),17 the internal iliac artery can be removed from the recipient and its branches used to anastomose to the renal arteries on the back table,19 a smaller artery may be anastomosed end-to-side to the larger main renal artery, a small accessory artery can be anastomosed to the inferior epigastric artery, or the renal arteries can be implanted separately into the external iliac artery. A small upper polar artery, if thought to be too small to anastomose safely to the major renal artery, may be ligated, provided that it supplies less than one-eighth of the kidney (this should be evident on perfusion of the kidney after removal). A deceased donor kidney usually has a renal artery or arteries arising from a single aortic patch, and this patch should be trimmed to an appropriate size and used for anastomosis to the external iliac artery. If two renal arteries are widely separated on the aortic patch, the patch may be divided to allow separate implantation into the external iliac artery, or the two separate patches joined together to form a shorter patch, or one may be implanted end-to-side to the external iliac artery and the other to the internal iliac artery, or both may be implanted to separate branches of the internal iliac artery.

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End-to-end

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End-to-side

Internal Iliac Artery

Two renal arteries on a patch

Two renal arteries separate anastomoses Ligated trunks of artery CIA

Fig. 11.3  Anastomosis of two renal arteries to the external iliac artery. (From Lee HM. Surgical techniques of renal transplantation. In: Morris PJ, editor. Kidney transplantation. London: Academic Press/Grune & Stratton; 1979. p.149.)

EA

A

the side of the glove.22 This technique not only keeps the kidney cool during the anastomosis, but also facilitates handling of the kidney.

B

Two arteries joined as a pantaloon

Interposition y-graft of native internal iliac artery

Fig. 11.2  Variations of renal artery anastomoses. (From Lee HM. Surgical techniques in renal transplantation. In: Morris PJ, ed. Kidney Transplantation. London: Academic Press/Grune & Stratton; 1979. p.150.)

Before making the arteriotomy or venotomy, the surgeon should mentally visualize the kidney in situ in its final resting place, as well as picturing the course that the renal artery and vein would take to ensure the optimal site for the anastomosis. Where the renal artery is much longer than the vein, it may either be electively anastomosed on the internal iliac artery or, more simply, the artery can be anastomosed to the external iliac artery but the kidney placed in a subrectus pouch fashioned by dissecting the peritoneum from the underside of the rectus muscle.21 In such a position, the longer artery tends to run a smooth course. When the kidney has been prepared and is ready for implantation, the vessels are now ready for clamping. Heparin may be administered in a modest dose (e.g., 30–60 IU/kg), although many surgeons simply cross-clamp the recipient vessels without heparinization in patients already on dialysis. The kidney should be kept cold during the implantation phase. This may be achieved in a number of ways, such as wrapping in a surgical gauze swab filled with crushed frozen saline. Another technique uses a surgical glove to contain the kidney together with crushed ice, the vessels being brought out through a small cut in

ARTERIAL ANASTOMOSIS External Iliac Artery An end-to-side anastomosis of the renal artery to the external iliac artery (or common iliac artery) usually is performed using an appropriately trimmed cuff of aorta attached to the renal artery (the Carrel patch) (Fig. 11.3). Vascular clamps are applied to the external iliac artery proximally and distally if an end-to-side anastomosis is to be performed, with care taken to avoid clamping diseased segments of artery wherever possible. An arteriotomy appropriately placed is performed in the external iliac artery, and the lumen is flushed out again with heparinized saline; where the donor artery has no Carrel aortic patch, a hole punch is used to create a suitably sized hole for anastomosis. The anastomosis is done with a continuous 5-0 or 6-0 monofilament vascular suture (see Fig. 11.2),17 although an interrupted technique may be necessary where no Carrel patch exists. In older patients and those who have been on dialysis some time, the intima may be calcified and may be easily displaced from the wall of the artery. Particular care should be taken to ensure that all the intima on the recipient artery is secured back in position during the anastomosis to prevent a dissection propagating along the distal artery on reperfusion. In very severe cases of calcification of the recipient artery, it may be necessary to carry out a formal endarterectomy of the iliac artery, with the distal intima stitched in place to prevent formation of a flap and subsequent dissection. 

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Internal Iliac Artery The internal iliac artery should not be used for anastomosis if the contralateral internal iliac artery has already been used for a previous transplant or if the contralateral limb relies on collaterals from the ipsilateral internal iliac for its perfusion (for example, where the contralateral common iliac artery is occluded). If the internal iliac artery is to be used, its distal branches are ligated. A vascular clamp is applied to the internal iliac artery close to its origin (to reduce the chances of clot forming in the occluded stump) or to both the common and external iliac arteries. The internal iliac artery is then divided close to or at the bifurcation maximizing its length, and the lumen is flushed out with heparinized saline. The internal iliac artery is anastomosed end-to-end to the renal artery with 5-0 or 6-0 monofilament vascular suture using a three-point anastomosis technique, as described by Carrel in 1902,23 or a two-point anastomosis (Fig. 11.4)17; alternatively, the parachute technique may be used, only tying the sutures after first placing all the sutures individually. If there is a disparity between the renal artery and the internal iliac artery, the renal artery being considerably smaller in diameter, the renal artery may be spatulated along one side to broaden the anastomosis. If one side of the renal artery is spatulated, care should be taken to place the spatulation of the renal artery appropriately, taking into consideration the final curve of the internal iliac artery and the renal artery to avoid kinking when the kidney is placed in its final position.17 If both arteries are small, the anastomosis should be performed with interrupted sutures to allow for expansion. In a child or a small adult with small arteries, the whole anastomosis should be performed with interrupted sutures. 

VENOUS ANASTOMOSIS The renal vein is anastomosed end-to-side, usually to the external iliac vein. The external iliac vein is clamped

proximally and distally with vascular clamps or a Satinsky side clamp is used. The venotomy is flushed out with heparinized saline. Where possible the site of venotomy should be proximal or distal to a valve, and if a valve is present at the site of the venotomy, it should be removed carefully. The anastomosis is fashioned using a continuous 5-0 monofilament vascular suture, with the initial sutures placed at either end of the venotomy (Fig. 11.5).17 A useful aid when doing the venous anastomosis is to place an anchor suture at the midpoint of the lateral wall, which allows the external iliac vein and the renal vein on the lateral side of the anastomosis to be drawn clear of the medial wall of the anastomosis (Fig. 11.6). This technique reduces the risk of the back wall being caught up in the suture while the medial wall is being sutured. An alternative, and one suited to larger patients, is to use the parachute technique, placing several sutures at the cranial aspect of the medial suture line before parachuting the anastomosis down. This has the benefit of distributing the tension over a wider area of vein, so there is less likelihood of the suture pulling out. The renal vein is usually anastomosed to the external iliac vein medial to the external iliac artery, although on occasion it may be lateral to the artery. Wherever the anastomosis is positioned, it is important to ensure that the renal vein is under no tension, and care should be taken that the vein is not twisted before starting the anastomosis. When a small child receives an adult kidney, it is sometimes necessary to shorten the renal vein to prevent kinking, especially when the vein is anastomosed to the inferior vena cava. If the venous anastomosis is fashioned before the arterial anastomosis (such as when the external iliac artery is to be used), it may be desirable to remove the venous clamps to permit return of blood from the leg, so shortening the duration of venous stasis. This is best achieved by placing a separate fine bulldog clamp close to the anastomosis on the renal vein before removing the iliac vein clamps, so preventing reflux of

Fig. 11.4  Internal iliac (hypogastric) artery ligated and divided, the lumen flushed with heparinized saline. (From Lee HM. Surgical techniques of renal transplantation. In: Morris PJ, editor. Kidney transplantation. London: Academic Press/Grune & Stratton; 1979. p.148.)

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blood into the kidney. It is important that the bulldog clamp is not traumatic to the vein, and does not slip off the vein— two clamps are often better than one to ensure the latter. This maneuver also allows any bleeding from the venous anastomosis to be managed before the kidney is revascularized. The question of whether the arterial anastomosis or the venous anastomosis should be done first depends on the final position of the kidney and the ease with which the second anastomosis may or may not be done. If the renal artery is to be anastomosed end-to-side to the external iliac artery (usually with a Carrel patch of aorta), it is preferable to do the venous anastomosis first, then the end-to-side arterial anastomosis can be positioned correctly. If the renal artery is to be anastomosed to the internal iliac artery, the arterial anastomosis may be done first because this enables the renal vein to be positioned appropriately. 

REPERFUSION OF THE KIDNEY Vascular clamps are removed sequentially, starting either with the venous clamps (proximal first then distal), or the arterial clamps (distal first then proximal), depending on surgeon preference. Once the kidney is reperfused, attention should be paid to controlling significant bleeding points on the anastomoses and ligating any tributaries that were missed during the back table preparation. The quality of reperfusion is variable. Live donor kidneys and kidneys that have been subject to machine preservation reperfuse evenly and become pink very quickly. Deceased donor kidneys, particularly those with prolonged cold ischemia or those donated after circulatory death, tend to be patchy for some time. Although this usually resolves over time, it is important to ensure the following:    All the clamps have been removed. The artery is not twisted. □  The recipient has a good blood pressure. □  □ 

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There is no intimal dissection of the proximal recipient artery or the donor renal artery, the latter being a consequence of traction in the donor or extreme donor hypertension during coning.

□ 

  

Finally, if concern still exists, the Hume test can be reassuring. When the renal vein is occluded between finger and thumb, the kidney should swell and throb. When the vein is released the kidney palpably softens as the turgor goes. 

Reconstruction of the Urinary Tract Once the kidney is perfused with recipient blood and hemostasis has been secured, reconstruction of the urinary tract is carried out. Transplantation of the left kidney into the right iliac fossa and the right kidney into the left iliac fossa reverses the normal anterior-to-posterior relationship of the vein, artery, and collecting system and positions the renal pelvis and ureter of the kidney transplant so that they are the most medial and superficial of the hilar structures.13 This positioning simplifies primary (and secondary) urinary tract reconstruction if pyeloureterostomy, ureteroureterostomy, or pyelovesicostomy need to be done. The factors that determine the type of urinary tract reconstruction are the length and condition of the donor ureter, the condition of the recipient’s bladder or bladder substitute, the condition of the recipient’s ureter, and the familiarity of the surgeon with the technique. Suture material is an individual choice. Although urinary tract reconstruction with nonabsorbable sutures has been described,24,25 it leaves the recipient with the risk of stone formation. Modern synthetic absorbable monofilament sutures (e.g., polyglyconate and polydioxanone) have characteristics suitable for the immunocompromised kidney transplant recipient in whom delayed wound healing is possible.

URETERONEOCYSTOSTOMY (ANASTOMOSIS OF THE TRANSPLANT URETER DIRECTLY TO THE BLADDER) This is the usual form of urinary tract reconstruction. Its advantages are as follows:    It can be performed regardless of the quality or presence of the recipient ureter. □  It is several centimeters away from the vascular anastomoses. □  The native ureter remains untouched and therefore available for the future management of ureteric complications. □  Native nephrectomy is unnecessary. □ 

  

Fig. 11.5  Vein anastomosis with triangular stay sutures in place. (From Lee HM. Surgical techniques of renal transplantation. In: Morris PJ, editor. Kidney transplantation. London: Academic Press/Grune & Stratton; 1979. p.151.)

The goal is to anastomose the ureter to the mucosa of the bladder, with the distal ureter surrounded in a 2- to 3-cm tunnel so that, when the bladder contracts, there is a valve mechanism to prevent reflux of urine up the ureter.26–28 The efficiency of this antireflux mechanism is variable. The urinary catheter is connected to a Y connector with a bag filled with saline and an antibiotic and/or methylene blue dye on one line and a urinary collection bag on

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Kidney Transplantation: Principles and Practice

A

B Fig. 11.6  Color photo of (A) preparation of external iliac vein and (B) venous anastomosis.

Fig. 11.7  Y-tube system for rinsing, filling, and draining bladder or bladder substitute. (From Kostra JW. Kidney transplantation. In: Kremer B, Broelsch CE, Henne-Bruns D, editors. Atlas of liver, pancreas, and kidney transplantation. Stuttgart: Georg Thieme Verlag; 1994. p.128.)

the other (Fig. 11.7).29 The use of an antibiotic in the solution reduces the risk of postoperative urinary infection,30,31 whereas the dye reassures the surgeon it is the bladder that has been opened and not another viscus. With this system, the bladder can be filled, drained, and, if necessary, refilled during the procedure. It is especially helpful when the bladder is difficult to identify because of pelvic scar tissue, recipient obesity, or reduced capacity. After initially accommodating a small volume, the defunctioned bladder often accepts more fluid 1 or 2 hours into the transplantation procedure.32 

Transvesical Ureteroneocystostomy The traditional technique for transvesical ureteroneocystostomy is similar to that described by Merrill and colleagues13 in the first successful kidney transplant from a twin (Fig. 11.8). The dome of the bladder is identified, and stay sutures or Babcock clamps are placed on either side

of a proposed vertical midline incision. The urinary bladder is drained, and an incision is made through all layers of the anterior bladder wall. A retractor is placed into the dome of the bladder to expose the trigone. A point clear of the native ureter is selected, and a transverse incision is made in the mucosa. A submucosal tunnel is created with a right-angle clamp or small scissors for about 2 cm. The clamp or scissors is pushed through the bladder from inside to outside, and the muscular opening is enlarged to accept the kidney transplant ureter. The ureter is drawn into the bladder, where it is transected at a length that prevents tension or redundancy. The cut end of the ureter is incised for 3 to 5 mm and approximated to the bladder mucosa with fine absorbable sutures. The inferior suture includes the bladder muscle to fix the ureter distally and to prevent its movement in the submucosal tunnel. The retractor is removed, and the cystotomy is closed with a single or double layer of 3-0 absorbable suture. The bladder can be refilled to check for leakage, and points of leakage can be repaired with interrupted sutures. Some surgeons use two bladder mucosal incisions about 2 cm apart33; when this technique is used, the proximal bladder mucosal incision is closed with a fine absorbable suture. 

Extravesical Ureteroneocystostomy This is the most common technique used. Although not producing such a “physiologic” antireflux mechanism as the transvesical method, extravesical techniques are faster, do not require a separate cystotomy, and require less ureteric length, are associated with fewer urinary tract infections, leaks, and less hematuria than intravesical techniques (Fig. 11.9).34,35 Extravesical techniques are based on the procedure described by Lich and colleagues.26 Extravesical ureteroneocystostomy was adapted for renal transplantation by Woodruff in 1962,36 and it is well illustrated by Konnak and colleagues (see Fig. 11.9).37 A subsequent modification was the addition of a stitch to anchor the toe of the spatulated ureter to the bladder to prevent proximal slippage of the ureter in the submucosal tunnel with loss of the antireflux valve and disruption of the ureteric anastomosis.38,39 A double-pigtail (double-J) ureteric stent reduces the incidence of leak and stenosis40–42 and is widely used. This is passed retrograde up the donor ureter, after first cutting the ureter to a suitable length and spatulating its

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Fig. 11.8  (A–D) Transvesical ureteroneocystostomy. (From Lee DM. Surgical techniques of renal transplantation. In: Morris PJ, editor. Kidney transplantation. London: Academic Press/Grune & Stratton; 1979. p.153.)

end. The bladder is distended with an antibiotic/dye solution through the urethral catheter. The lateral surface of the bladder is cleared of fat and the peritoneal reflection, a retractor is placed medially, another is placed inferolaterally, and a third retractor is placed cephalomedially to hold the peritoneum and its contents out of the way. Some authors recommend placing the ureter under the spermatic cord or round ligament, believing that this prevents posttransplant ureteric obstruction. A longitudinal oblique incision is made for approximately 2 cm until the bladder mucosa bulges into the incision. The bladder is partially drained via the urethral catheter, and the mucosa is dissected away from the muscularis on both sides to facilitate later creation of a submucosal tunnel for the ureter. The bladder mucosa is incised and 5-0 monofilament absorbable sutures (e.g., polydioxanone) placed through both ends of the incision. The ureter is brought up to the

wound, and the mucosal sutures passed through the toe and heel of the spatulated end, and the ureter parachuted on to the bladder. The ureter is then anastomosed to the bladder mucosa with running sutures between the ureter and the mucosa of the bladder; some surgeons take a small amount of bladder muscle in the suture, whereas others suture to mucosa alone. Some authors recommend specifically anchoring the toe of the ureter with a horizontal or vertical mattress suture placed in the toe of the ureter and passed submucosally through the seromuscular layer of the bladder and tied about 5 mm distal to the cystotomy (Fig. 11.10). When handling the ureter and bladder, care should be taken to avoid crushing the delicate mucosa with forceps. Once the ureteric anastomosis is complete, the seromuscular layer is closed over the ureter with interrupted absorbable sutures, care being taken to avoid narrowing the ureter in the process. 

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Parallel Incision Ureteroneocystostomy A variant of the extravesical ureteroneocystostomy is the parallel incision ureteroneocystostomy.43 It involves two parallel vertical incisions in the bladder muscle some 2 cm apart. The ureter is tunneled submucosally through the lateral incision and out of the medial one. The ureter is then cut, spatulated, the bladder mucosa opened at the site of the medial incision, and the heel of the ureter sutured to the mucosa while the toe is sutured to both mucosa and muscle wall (Fig. 11.11). The muscle is then closed over the both incisions with an absorbable suture.44 

DOUBLE URETERS

Fig. 11.9  (A–C) Extravesical ureteroneocystostomy. (From Konnak JW, Herwig KR, Turcotte JG. External ureteroneocystostomy in renal transplantation. J Urol 1972;108:380.)

Double ureters can be managed simply by trimming them to appropriate length, spatulating them, and either anastomosing the medial edges together with a continuous or interrupted fine absorbable suture (Fig. 11.12)45,46 or joining them, one on top of the other, with a single stitch from the toe of the upper one to the heel of the lower one.47 The conjoined ureters can be treated as a single ureter by any of the previously described ureteroneocystostomy techniques. The submucosal tunnel needs to be made a bit wider. The alternative approach is to use a separate ureteroneocystostomy for each of the ureters.48 These same techniques can be used for the en bloc transplantation of pediatric kidneys or the transplantation of two adult kidneys, stacked one on top of the other,49 into one recipient. Fjeldborg and Kim50 described a pyeloureteric anastomosis for a kidney with double ureters in which both renal pelves are joined after dividing the ureters at their ureteropelvic junctions and suturing the posterior walls together, leaving the anterior halves for anastomosis with the recipient ureter (Fig. 11.13).50 If both ureters have been stented it is important to ensure that both stents are subsequently removed. 

AUGMENTED BLADDER In patients with congenital bladder abnormalities, the bladder may have been augmented as part of previous treatment or in preparation for transplantation. It is important to know the anatomy and blood supply of an augmentation patch so as not to interfere with it during the kidney transplant procedure. Ideally the ureter should be anastomosed to the bladder itself, with a submucosal tunnel for ureteroneocystostomy. Where ileum or cecum has been used, and is the most readily accessible component of the reconstructed bladder, the donor ureter may be anastomosed without a tunnel, and the anastomosis managed in a similar fashion used for an ileal conduit. Ureteric stents are usually used. 

PYELOPYELOSTOMY Fig. 11.10  One or two mattress sutures to anchor toe of transplant ureter to full-thickness bladder. This prevents ureteric slippage in the submucosal tunnel. (From Hinman Jr F. Ureteral reconstruction and excision. In: Hinman Jr F, editor. Atlas of urologic surgery. 2nd ed. Philadelphia: WB Saunders; 1998. p.799.)

Pyelopyelostomy has been used for orthotopic kidney transplantation, usually in the left flank.51 The native kidney is removed, and the kidney transplant is revascularized with the native renal artery or the splenic artery and the native renal vein. The proximal ureter and renal

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A

B

C

D

167

Fig. 11.11  (A–D) Parallel incision ureteroneocystostomy. (From Knechtle S. Ureteroneocystostomy for renal transplantation. J Am Coll Surg 1999;188(6):707–9.)

pelvis of the kidney transplant are opened medially, and the native renal pelvis is anastomosed to the kidney transplant renal pelvis with a running fine absorbable suture. After completion of one wall, a double-pigtail ureteric stent is passed with or over a guidewire through the native ureter into the bladder, and the wire is withdrawn to allow the distal end to curl within the bladder. Its position in the bladder is confirmed by reflux of bladder irrigant up the stent. The proximal coil is placed in the renal pelvis of the kidney transplant, and the remaining half of the suture line is completed. Compared with ureteroneocystostomy, an advantage of urinary tract reconstruction with the native renal pelvis or ureter is the ease with which subsequent retrograde pyelography, stent placement, or ureteroscopy can be accomplished through the normally positioned ureteric orifice. 

Fig. 11.12  Management of double ureters to make them into a single ureteric orifice.

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Fig. 11.13  Management of double ureters by pyelopyelostomy followed by conjoined pyeloureterostomy. (From Fjeldborg O, Kim CH. Double ureters in renal transplantation. J Urol 1972;108:377.)

PYELOURETEROSTOMY AND URETEROURETEROSTOMY Pyeloureterostomy and ureteroureterostomy usually are done: (1) when the transplant ureter’s blood supply seems to be compromised, (2) when the urinary bladder is difficult to identify because of pelvic scar, (3) when the bladder does not distend enough for a ureteroneocystostomy, or (4) as a result of surgeon preference.52–54 The techniques for ureteropyelostomy and ureteroureterostomy are similar (Fig. 11.14). The posterior, or back wall, anastomosis is completed between the kidney transplant pelvis or ureter and the side or to the spatulated end of the native ureter; a double-pigtail ureteric stent is placed, and the anterior suture line is completed. The proximal native ureter is managed by the following:    Leaving the native kidney in situ and using the side of the native ureter for the anastomosis □  Ipsilateral nephrectomy and proximal ureterectomy □  Ligation of the proximal ureter with the obstructed native kidney left in situ55,56 □ 

  

The native ureter should not be ligated in the presence of urinary tract sepsis (when a pyonephrosis of the native kidney may ensue) or where the recipient has previously undergone ureteric reimplantation to treat reflux disease (in which case the blood supply to the ureter may be severely compromised). By leaving the native ureter in continuity with its kidney, and anastomosing the pelvis or ureter of the renal transplant to the side of the native ureter, a good blood supply to the native ureter is guaranteed without the risk of an obstructed, hydronephrotic native

Fig. 11.14 Ureteropyelostomy and ureteroureterostomy. A doublepigtail stent is placed after the back wall suture line has been completed.

kidney. However, with the two caveats mentioned, ligation of the native ureter for ureteroureterostomy is normally uneventful. 

PYELOVESICOSTOMY Pyelovesicostomy has been described for urinary tract reconstruction when the native ureter and the renal transplant ureter are unsuitable or become so (Fig. 11.15).57–59 The bladder must reach the renal pelvis without tension. To achieve this the bladder may be mobilized and hitched to the psoas muscle or a bladder extension with a Boari flap may be needed.60 This technique may also be useful as a management of posttransplant ureteric stenosis. 

URETEROENTEROSTOMY Ureteroenterostomy into an intestinal conduit or an intestinal pouch is indicated where the bladder has been removed or is unusable.61,62 It is preferable to create the conduit before the transplant, at the time of listing if it has not been created previously. The conduit or pouch is washed with antiseptic before surgery commences. The ureteric

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MANAGEMENT OF CATHETER AND STENT The urinary bladder or reservoir catheter usually is removed on postoperative day 5. Some units test the urine at the bedside for nitrites and send for bacterial culture. If the urine is shown to be infected, an antibiotic is chosen based on sensitivity results and is prescribed for 10 to 14 days. Where the stent has been fixed to the urinary catheter it will come out as the catheter is withdrawn,64 otherwise the stent is removed at 6 weeks using flexible cystoscopy. Early stent removal has the advantage of reducing urinary tract infections while still reducing other complications.64,65 If a ureteric stent is in situ it should be removed if infection is present. Care should be taken to identify all patients with stents in situ lest one be forgotten. 

Closure

Fig. 11.15  Pyelovesicostomy. (From Firlit CF. Unique urinary diversions in transplantation. J Urol 1977;118:1043.)

anastomosis is done with the spatulated end of the ureter being anastomosed to the full thickness of the bowel wall. If it is difficult to identify the intestinal conduit or pouch because of surrounding intestines, the addition of methylene blue dye to the irrigant stains the conduit or pouch and may make it easier to find,63 or placing a finger in the lumen may help. This topic is discussed more completely in Chapter 12. 

Many units obtain a biopsy specimen of the kidney routinely before closure of the wound (a “time zero biopsy”). This biopsy can be used to provide baseline histology to identify chronic changes and any unknown renal disease; it may also show evidence of ischemia/reperfusion injury or early antibody-mediated damage, but the time taken for these to manifest histologically is generally longer than the average transplant operation (see Chapter 26). Methods of closing the wound vary, but closure of all musculofascial layers with a nonabsorbable material such as nylon is preferred to avoid herniation. Skin closure with a subcuticular absorbable suture gives the best cosmetic result. Some surgeons prefer to drain the surgical bed to give early warning of bleeding or urinary leak, whereas others argue that the drain is a portal for entry of microorganisms. If drainage is performed it should be a closed system and drains should be removed at the earliest opportunity. The exit site of the drain should be cleaned and dressed daily until the drain is removed. The historical practice of capsulotomy of the transplanted kidney, where the renal capsule is carefully split along its convex border from pole to pole to minimize damage to the kidney as the parenchyma swelled in response to reperfusion injury is no longer performed.66,67 

URETERIC STENTS

Pediatric Recipient

Stents have been shown to reduce many of the urologic complications of ureteric anastomoses but are associated with an increased incidence of urinary tract infections.40–42 Indications for their selective use, where stenting is not routine practice, include edema; a thickened bladder; and when a pyelopyelostomy, pyeloureterostomy, or ureteroureterostomy have been performed; or when the ureter has been anastomosed to an intestinal conduit or pouch. The ideal length of the stent is determined by the estimated distance between the renal pelvis of the kidney graft and the bladder (or its substitute). A double-pigtail 5 French stent of 12 cm in length is generally suitable for an adult transplant kidney located in the iliac fossa and anastomosed to the native bladder. 

For older children, the transplant procedure is the same as for adults if their weight is more than 20 kg.5,68,69 The renal vessels are anastomosed end-to-side to the iliac vessels or to the aorta and vena cava.70 In smaller children (weight <20 kg), the right extraperitoneal space can be developed by extending the incision to the right costal margin,71 or a transperitoneal approach can be used.33 In the case of the latter, the abdomen is opened through the midline incision from the xyphoid to the pubis, and the retroperitoneum opened by incising the peritoneum lateral to the ascending colon, which is reflected medially. The terminal portion of the vena cava is dissected over 3 to 4 cm, ligating and dividing two to three lumbar veins posteriorly. The terminal aorta is also dissected free at its

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Fig. 11.16  Renal transplant in small children (<20 kg). (From Lee HM. Surgical techniques of renal transplantation. In: Morris PJ, editor. Kidney transplantation. London: Academic Press/Grune & Stratton; 1979. p.159.)

bifurcation, as is the right common iliac artery. A partial occluding clamp is used to isolate the vena cava and aorta, in preference to full mobilization of vena cava and aorta and cross-clamping. The renal vein is anastomosed to the vena cava first in an end-to-side technique with nonabsorbable monofilament vascular sutures (Fig. 11.16).17 The renal artery is then anastomosed to either the right common iliac artery or distal aorta in an end-to-side fashion using fine nonabsorbable monofilament vascular sutures. Occasionally a small aortic punch may be used to create a hole in the aorta to which the renal artery is anastomosed. This latter technique is said to reduce the chance of the renal artery lumen occluding if hypotension occurs. When the renal artery is anastomosed to the aorta it is usually brought in front of the vena cava, although on occasion it may lie best if passed behind the vena cava. Careful liaison with the anesthetist is required when clamping and declamping the vena cava and aorta, because the perfused kidney may remove a large part of the child’s circulating volume, resulting in dramatic hemodynamic changes. The ascending colon is placed back over the anterior surface of the kidney. No fixation is necessary. The ureter is brought down retroperitoneally crossing the common iliac artery at its midpoint and is implanted into the bladder as a ureteroneocystostomy. End-to-end arterial anastomoses in growing children should be done wholly or partially interrupted; for end- toside anastomoses, where there is a significant Carrel patch of donor vessel, continuous anastomoses may suffice. 

Pediatric Donor When a child’s kidney is used as a donor kidney for an adult or child recipient, the surgical technique is essentially the same as has been described. Because of the small size of the renal vessels, use of aortic and vena caval patches generally

is necessary. Interrupted sutures may be necessary for at least half the circumference of the anastomosis because the kidney will increase in size. When pediatric kidneys are very small, double kidneys may be transplanted en bloc into adults and bigger children.72–76 However there is increasing evidence that even kidneys from donors as small as 20 kg may be transplanted singly with good outcomes.77 For en bloc transplantation, both kidneys are removed with a segment of aorta and vena cava. The aorta and vena cava caudal to the renal vessels are removed and anastomosed to the aorta and vena cava cranial to the renal vessels, closing off the caudal aorta and cava of the donor. This technique allows the kidneys to be placed quite low over the iliac vessels and provides a short distance for the ureters to traverse to the bladder. Other techniques include simply oversewing the cranial ends of the aorta and vena cava, with anastomoses of the caudal ends of the aorta and vena cava end-to-side to the iliac vessels. Some surgeons advocate suturing the superior poles of the kidneys to the sides of the aorta to prevent torsion or kinking of renal vascular pedicles. Ureters are implanted to the bladder separately using the extravesical approach or are joined together to form a common funnel, as described earlier. Another technique is to remove segments of the recipient’s external iliac artery and vein and anastomose the tubular aorta and inferior vena cava into the defects. A fourth technique is to incise longitudinally the posterior aorta and inferior vena cava and anastomose these vascular patches to the iliac vessels. 

Double Kidney Transplant Less than optimal kidneys are increasingly being used for transplantation, accepting less than perfect function in the knowledge that this is, nonetheless, superior to life on dialysis.78–80 Some centers routinely biopsy older donor kidneys,81 and if the biopsy shows significant chronic changes then both donor kidneys are transplanted into one recipient, rather than transplanting one each into two separate recipients. Double kidney transplantation can be performed in two ways.82 Both kidneys can be transplanted on to the same side through an extended pararectal incision. The first kidney chosen should have the longest ureter, and is transplanted on to the common iliac artery and either the common iliac vein or vena cava; the second kidney is then implanted caudally onto the external iliac vessels. The ureters may be managed as described previously. It is important to transplant the cranial kidney first, because clamping the common iliac artery will remove the inflow to a kidney that has been transplanted to the external vessels below. The alternative method of transplantation is to implant kidneys bilaterally through separate incisions, one in each iliac fossa. 

Transplant Nephrectomy Removal of a graft that has undergone chronic rejection and has been in place for many months or years can be extremely difficult and should be performed by an

11 • Surgical Techniques of Kidney Transplantation

experienced transplant surgeon. The usual approach for the transplant nephrectomy is through the original transplant incision. An abdominal incision may be preferred in small children, particularly if the implantation was performed intraabdominally. One may also use the abdominal approach to control the iliac vessels in case of a mycotic aneurysm or a perinephric abscess, where there is a risk of catastrophic hemorrhage. Prophylactic antibiotics should be given to cover skin and urinary pathogens, together with coverage of any other organism known to be prevalent. In the early postoperative period, removal of the transplant in toto is simple with easy identification of the renal pedicle structures. The donor vessels may be simply ligated, with the ligated stumps of donor vessels either left in situ in the recipient or removed. Leaving stumps runs the risk of thrombosis or hemorrhage as the immune system attacks the donor endothelium, although this is less likely the more time that has elapsed since transplantation. Alternatively, removal of the donor vessel stumps may necessitate vascular repair using an autologous saphenous vein patch to prevent narrowing of the native vessels. The long-standing transplanted kidney is most easily removed subcapsularly. After deepening the original incision the capsule is identified and incised. The kidney parenchyma is freed with blunt dissection all around the kidney in the plane within the capsule but outside the parenchyma. The vessels and ureter enter the capsule deep to the kidney, and it is usually necessary to incise the capsule around the hilum so as to isolate the vascular pedicle. Care should be taken to ensure that the native vessels, typically the external iliac artery and vein, are separate from the vascular pedicle and are not damaged. The pedicle is then mass-clamped with a Satinsky clamp and divided to remove the kidney. The vascular pedicle is oversewn with a monofilament vascular suture. The artery and the vein may be dissected and transfixed separately at this time, but this can be difficult and is usually unnecessary. Sometimes the segmental renal arteries and venous branches are ligated and divided as they appear during dissection within the renal hilar scar, obviating the need to control the pedicle. The ureter is usually readily identified and followed to the bladder, where it is excised with any defect in the bladder wall oversewn with an absorbable suture. Transplant nephrectomy, therefore, leaves a small amount of donor material in the patient—the site of the anastomosis. Although theoretically at risk of rejection, this does not, in reality, appear to cause a problem. If the wound is grossly contaminated or infected, it should be left open with packing, with secondary closure in mind.83,84 Closed suction drainage may be used, according to the surgeon’s preference.

References 1. Abramowicz D, Hazzan M, Maggiore U, et al. Does pre-emptive transplantation versus post start of dialysis transplantation with a kidney from a living donor improve outcomes after transplantation? A systematic literature review and position statement by the Descartes Working Group and ERBP. Nephrol Dial Transplant 2016;31(5):691–7. 2. Li B, Cairns JA, Robb ML, et  al. Predicting patient survival after deceased donor kidney transplantation using flexible parametric modelling. BMC Nephrol 2016;17(1):51. 3. Wu DA, Robb ML, Watson CJE, et al. Barriers to living donor kidney transplantation in the United Kingdom: a national observational study. Nephrol Dial Transplant 2017;32(5):890–900.

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4. Cole BR. The psychosocial implications of pre-emptive transplantation. Pediatr Nephrol 1991;5(1):158–61. 5. Fine RN, Korsch BM, Stiles Q, et  al. Renal homotransplantation in children. J Pediatr 1970;76(3):347–57. 6. Green H, Rahamimov R, Gafter U, et  al. Antibiotic prophylaxis for urinary tract infections in renal transplant recipients: a systematic review and meta-analysis. Transpl Infect Dis 2011;13(5):441–7. 7. Orlando G, Manzia TM, Sorge R, et al. One-shot versus multidose perioperative antibiotic prophylaxis after kidney transplantation: a randomized, controlled clinical trial. Surgery 2015;157(1):104–10. 8. Summers DM, Johnson RJ, Allen J, et al. Analysis of factors that affect outcome after transplantation of kidneys donated after cardiac death in the UK: a cohort study. Lancet 2010;376(9749):1303–11. 9. Shrestha S, Bradbury L, Boal M, et  al. Logistical factors influencing cold ischemia times in deceased donor kidney transplants. Transplantation 2016;100(2):422–8. 10. Darouiche RO, Wall MJ Jr, Itani KM, et  al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362(1):18–26. 11. Hume DM, Magee JH, Kauffman HM, et al. Renal homotransplantation in man in modified recipients. Ann Surg 1963;158:608–44. 12. Küss R, Teinturier J, Milliez P. Quelques essais de greffes du rein chez l’homme. Mem Acad Chir (Paris) 1951;77(22-24):755–64. 13. Merrill JP, Murray JE, Harrison JH, et al. Successful homotransplantation of the human kidney between identical twins. J Am Med Assoc 1956;160(4):277–82. 14. Michon L, Hamburger J, Oeconomos N, et al. Une tentative de transplantation rénale chez l’homme: aspects medicaux et abiologiques. Presse Med 1953;61(70):1419–23. 15. Starzl TE, Marchioro TL, Dickinson TC, et al. Technique of renal homotransplantation. Experience with 42 cases. Arch Surg 1964;89:87– 104. 16. West MS, Stevens RB, Metrakos P, et  al. Renal pedicle torsion after simultaneous kidney-­ pancreas transplantation. J Am Coll Surg 1998;187(1):80–7. 17. Lee H. Surgical techniques of renal transplantation. In: Morris P, editor. Kidney transplantation. London: Academic Press/Grune & Stratton; 1979. p. 145. 18. Farouk K, Afridi Z, Bano U, et  al. Electrocoagulation versus sutureligation of lymphatics in kidney transplant recipient surgery. J Postgrad Med Inst 2006;4:398–403. 19. Hiramitsu T, Futamura K, Okada M, et  al. Impact of arterial reconstruction with recipient’s own internal iliac artery for multiple graft arteries on living donor kidney transplantation: strobe study. Medicine (Baltimore) 2015;94(43):e1811. 20. Watson CJ, Harper SJ. Anatomical variation and its management in transplantation. Am J Transplant 2015;15(6):1459–71. 21. Wheatley TJ, Doughman TM, Veitch PS, et  al. Subrectus pouch for renal transplantation. Br J Surg 1996;83(3):419. 22. Roake JA, Toogood GJ, Cahill AP, et al. Reducing renal ischaemia during transplantation. Br J Surg 1991;78(1):121. 23. Carrel A. Le technique opératoire des anastomoses vasculaires et la transplantation des viscères. Lyon Med 1902;98:859–64. 24. Jaffers GJ, Cosimi AB, Delmonico FL, et al. Experience with pyeloureterostomy in renal transplantation. Ann Surg 1982;196(5):588–93. 25. McDonald JC, Landreneau MD, Hargroder DE, et al. External ureteroneocystostomy and ureteroureterostomy in renal transplantation. Ann Surg 1987;205(4):428–31. 26. Lich Jr R. Obstructive diseases of the urinary tract in children. J Ark Med Soc 1961;58:127–30. 27. Politano VA, Leadbetter WF. An operative technique for the correction of vesicoureteral reflux. J Urol 1958;79(6):932–41. 28. Stevens A, Marshall V. Reimplantation of the ureter into the bladder. Surg Gynecol Obstet 1943;77:585–94. 29. Kootstra G. Kidney transplantation. In: Kremer B, Broelsch C, HenneBruns D, editors. Atlas of liver, pancreas, and kidney transplantation. Stuttgart: Georg Thieme Verlag; 1994. p. 128. 30. Salehipour M, Salahi H, Fathikalajahi A, et  al. Is perioperative intravesically applied antibiotic solution effective in the prophylaxis of urinary tract infections after renal transplantation? Urol Int 2010;85(1):66–9. 31. Salmela K, Eklund B, Kyllonen L, et  al. The effect of intravesically applied antibiotic solution in the prophylaxis of infectious complications of renal transplantation. Transpl Int 1990;3(1):12–4. 32. Barry JM, Lemmers MJ, Meyer MM, et al. Cadaver kidney transplantation in patients more than 65 years old. World J Urol 1996;14(4):243–8.

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