CHAPTER 77: Allograft Nephrectomy

GENERAL OBSERVATIONS

• In general, failed allografts are removed only when there is a specific indication for it.

• In the case of recent transplants, usual indications include necrosis of the organ with its associated urinary leaks, bleeding, and sepsis.

• In the case of long-standing transplants, indications include recurrent episodes of rejection, bleeding, pain, infections, tumors, need to place a new allograft in that specific space.

• Although considered as a simple procedure by many, allograft nephrectomies can be associated with major complications and should not be underestimated.

• Embolization of the transplant renal artery (as well as vein) by interventional radiology prior to the procedure can facilitate the intervention and make it safer.

RECENT TRANSPLANTS

• Recently transplanted kidneys that have failed (such as encountered in the setting of thromboses) are removed by reopening the incision, suture ligating and transecting the donor vessels, taking down the ureter anastomosis, and closing the bladder.

• We prefer to tie and transect the donor vessels as close as possible to the native vessels (ensuring that no stenoses are created) so to avoid having to reconstruct the recipient artery and vein.

• Leaving a very small amount of donor tissue has a negligible incidence of possible rejection.

LONG-STANDING TRANSPLANTS

• The approach can be open (most frequent, described below [Figures 77-1 through 77-6]) or laparoscopic.

• We usually obtain an imaging study (such as a CT scan with contrast) prior to the procedure to evaluate the kidney itself, associated blood vessels, and nearby structures such as overlying bowel.

• The previous incision is reopened, and the subcutaneous tissues and muscle overlying the allograft are transected.

• Care should be taken not to injure any intra-abdominal organs lying ventral to the kidney.

• Once the allograft is reached, we perform a subcapsular dissection to free the parenchyma and expose the area of the hilum.

• A clamp is placed in the hilar area, encompassing the renal transplant blood vessels and ureter.

• Care should be taken not to injure the recipient iliac vessels when placing this clamp. It can be helpful to verify that the femoral pulse is palpable distal to the clamp prior to proceeding with the next step.

• The kidney is removed by transecting in between the clamp and the renal parenchyma, leaving enough tissue to prevent the clamp from becoming loose.

• The hilar stump is oversewn with a back and forth horizontal mattress running suture of non-absorbable material (such as 2-0 monofilament polypropylene). We prefer to place the sutures in between clamp and recipient tissues. Unless a significant amount of renal parenchyma is left behind (something that should be avoided since it represents a foreign tissue), attempting to sew on top of the clamp usually results in small bites that can lead to bleeding or pseudoaneurysms. Care should be taken not to injure the underlying iliac vessels, as well as not to encase the clamp with the running suture.

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