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INDICATIONS

This procedure is for patients with end-stage chronic kidney disease with a glomerular filtration rate 20 mL/min or less who possess adequate cardiopulmonary reserve to undergo surgery. In addition, patients cannot have an active infection or malignancy that would be exacerbated after the transplant because of the necessity of ongoing immunosuppression therapy following engraftment.

PREOPERATIVE PREPARATION

Candidates are evaluated prior to transplantation for suitability based on the above-mentioned indications as well as other psychosocial factors. Candidates found to have preexisting comorbidities receive additional evaluation and testing at this time as needed to aid in determining suitability. Once a candidate has been deemed suitable, he or she is ready for transplantation with a living-donor kidney, if available, or listed for a deceased-donor kidney.

Intravenous access is obtained prior to administration of general anesthesia and endotracheal intubation. Central venous access is needed in patients with poor peripheral access. Antibiotics are administered intravenously within 1 hour of procedure commencement. Following intubation, a urinary catheter is placed, and the bladder is irrigated with antibiotic-containing saline. If the patient is oliguric or anuric, saline is left in the bladder after irrigation to distend it, aiding intraoperative identification. The Foley drainage bag is clamped to keep the bladder distended until the neoureterocystostomy is performed. An oral gastric tube is placed and kept on suction to evacuate and decompress the stomach. Deep venous thrombosis prophylaxis should be employed.

ANESTHESIA

General and endotracheal anesthesia is required.

POSITION

Patients are placed in the supine position. The legs are secured to the table with a strap with slight laxity. The lower extremities should be exposed enough to allow surgical access to the infrainguinal femoral vessels for the rare patient in whom arterial reconstruction is necessary. The ipsilateral femoral artery is palpated to verify iliac artery patency. If the patient has a peritoneal dialysis catheter, every attempt should be made to position and drape it out of the surgical field. Removal of the peritoneal dialysis catheter at the end of the transplant procedure may be considered based on surgeon preference as well as the function of the transplanted kidney.

OPERATIVE PREPARATION

Hair overlying the surgical field is removed with hair clippers. The abdomen is prepped from the midaxillary line on the side chosen for implantation to well beyond the midline or, if desired, to the opposite midaxillary line. Caudally, the abdomen is prepped below the symphysis pubis, and this includes the femoral region on the implantation side. The prep extends cephalad to at least 5 cm above the umbilicus. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE

The straight or curvilinear skin incision is made on the left or right ...

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