Recipient kidney transplantation into the iliac fossa

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Who: the recipient and the match End-stage kidney disease, on dialysis or approaching it with an eGFR under about 15, in a patient fit for a general anaesthetic and lifelong immunosuppression, assessed for cardiac disease, malignancy, infection, the iliac vessels on imaging where there is calcification, and a lower urinary tract that stores and empties. Blood group compatible or a planned incompatible programme, HLA typed, and a negative crossmatch on the day. A living donor kidney is scheduled; a deceased donor kidney arrives at any hour after brain death or circulatory death, with its cold ischaemia time on the clock, and the recipient is called in, dialysed if the potassium is high, consented and cross-matched while the kidney is on the bench. Induction immunosuppression is given before the clamps go on.
2. The kidney on the bench In ice, in a bowl of cold perfusion solution, the kidney is prepared: the perinephric fat removed from the capsule except at the lower pole and the hilum, where the fat between the lower pole, the renal pelvis and the ureter, the golden triangle, is left untouched because it carries the whole blood supply of the transplant ureter from the renal artery. The renal vein is cleared and, on a right kidney from a deceased donor, lengthened with a cuff of vena cava; the artery is identified on its Carrel patch of aorta, any accessory artery joined to the main or kept on the patch, and small branches ligated. The kidney is flushed and checked for leaks and for any lump, and the ureter is kept long and left alone.
   where it bites: the transplant ureter has one blood supply, from the renal artery through the hilar and periureteric fat; the golden triangle is never dissected.
3. The Gibson incision and the extraperitoneal space The right iliac fossa for a first transplant, because the external iliac vein is longer and more superficial on the right; the left for a second, or where the right vessels are diseased. A curved Gibson incision from two fingers above the anterior superior iliac spine to the midline above the pubis, through the external oblique, internal oblique and transversus, the inferior epigastric vessels divided between ties, the round ligament divided in a woman and the spermatic cord preserved and retracted medially in a man. The peritoneum is swept medially with the fingers and a self-retaining retractor holds it, so that the kidney will sit extraperitoneally on the psoas and iliacus with the peritoneum medial to it.
4. The external iliac vessels The external iliac artery and vein are exposed from the bifurcation to the inguinal ligament, the lymphatics that cross them ligated or clipped rather than coagulated, because divided lymph makes a lymphocele that compresses the vein and the ureter. The vein is mobilised first, its tributaries ligated, until a segment long enough for a side clamp is free; the internal iliac artery is identified in case it is needed end to end. The artery is palpated for plaque and a soft segment chosen for the anastomosis. Systemic heparin is given by unit protocol before the clamps go on, and the position of the kidney is rehearsed so that the vessels lie without kinking when it is finally placed.
5. The venous anastomosis The kidney comes to the field wrapped in ice slush, held by the assistant; the anastomosis time is the second warm ischaemia and is kept to about thirty minutes. Side-biting clamps on the external iliac vein, a venotomy the length of the renal vein, flushed with heparinised saline. The renal vein is joined end to side with 5-0 or 6-0 Prolene, two stay sutures at the apices and a running suture down each wall from inside then outside, the kidney orientated so that when it lies in the fossa the vein is not twisted or stretched. The clamps stay on. A vein that is too short on a right kidney has been lengthened on the bench with cava, not stretched here.
6. The arterial anastomosis The external iliac artery is clamped proximally and distally, an arteriotomy made with a blade and enlarged with a punch to a circle, and the renal artery on its Carrel patch joined end to side with 6-0 Prolene, running, the patch sewn to the arteriotomy with the same care at the heel and the toe where the stenosis will form if a bite is too big. A living donor artery has no patch and is spatulated. An end-to-end anastomosis to the internal iliac artery with interrupted sutures is the alternative for a short artery or a diseased external iliac. The clamps are prepared for release in order: distal artery, proximal artery, vein.
   where it bites: a bite too large at the heel or the toe of the arterial anastomosis is a stenosis; the arteriotomy is a punched circle, not a slit.
7. Reperfusion The venous clamps come off first, then the distal arterial clamp, then the proximal, and the kidney is watched: it should pink evenly and become firm within a minute, and urine may appear at the ureter within minutes in a living donor kidney. The anaesthetist has the patient filled, with the central venous pressure and the blood pressure kept up, mannitol or furosemide given by protocol, and the potassium and acidosis of the flushed preservation solution watched. Bleeding points at the hilum and the anastomoses are taken with fine sutures under vision, not diathermy near the vessels. A kidney that stays blue and soft has a problem with inflow or outflow that is found now: a kinked vein, a twisted artery, a clamp injury or an intimal flap.
   where it bites: a graft that does not pink and firm up on release is a vascular problem to be fixed at once; a kidney left blue is a kidney lost.
8. The ureter: Lich-Gregoir over a stent The bladder is filled with saline through the catheter so that the dome and the anterolateral wall rise into the wound. The ureter is cut to the shortest length that reaches without tension, keeping the periureteric fat, and spatulated. A two to three centimetre incision through the detrusor to the mucosa on the anterolateral wall, the mucosa freed on each side and opened at the distal end, and the ureter sewn to the mucosa with interrupted or running 5-0 or 6-0 PDS or Monocryl over a JJ stent passed to the renal pelvis. The detrusor is closed over the ureter with two or three interrupted sutures to make a tunnel that prevents reflux, without constricting it. The stent comes out at four to six weeks.
   where it bites: a long ureter is a distal end far from its only blood supply; the ureter is cut short, and the distal centimetre is the part that necroses.
9. Closure and the first night The kidney is placed in the fossa with the vessels lying without kink, checked once more for perfusion and for bleeding, and a drain left beside it. The muscles are closed in layers with looped PDS so that the graft is not compressed, and the skin closed. The first night is hourly urine output with fluid replaced millilitre for millilitre, potassium and haemoglobin checked, the catheter kept draining, and a duplex ultrasound within the first day or immediately if the urine stops. Anuria in a kidney that was passing urine is a catheter problem, a vascular problem or a leak, in that order of speed, and the duplex is done that hour. Immunosuppression continues, and the first creatinine tells whether the kidney is working or is delayed.

Complications and immediate saves

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FRCS viva questions

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Evidence and guidance