CASE 38: Right Deceased Donor Kidney With Decapsulation, Parenchymal Injuries, Hydronephrosis, Ureteral Stricture, Hydroureter, Retained Stones, and Injured Unrecognized Inferior Pole Artery

Upon inspection in the back table prior to implantation, a deceased donor kidney was found to have multiple parenchymal lacerations (pink arrows) and decapsulation (orange arrows indicate the edge of the remnant capsule). The renal parenchymal injuries were repaired with resorbable (4-0 polydioxanone) sutures, encompassing beyond the depth of the laceration to avoid bleeding and urine leaks.

There was also marked hydronephrosis (purple arrows) and hydroureter (black arrows). Multiple stones (yellow arrows) were extracted from the distal dilated ureter.

Upon further examination, a stone was found to be impacted (pink arrow) in a strictured segment of the ureter.

The ureter was incised proximal to the impacted stone in order to remove it (arrow). The strictured segment of the ureter was inspected, and a decision made to resect it and perform an anastomosis of the donor renal pelvis to the recipient bladder.

An accessory renal artery (red arrow) to the lower pole (unrecognized at the time of procurement and transected with no aortic patch) was detected when preparing the vessels. Note the main renal artery (pink arrow) with the pump cannula (white arrow). Also visible is the renal vein (light blue arrow) and IVC (dark blue arrows, this was a right kidney).

Although we do not routinely reconstruct the right renal vein, given the complexity of this specific case, we decided to perform a reconstruction by closing the distal end of the attached IVC and trimming the proximal end (light blue arrows) for anastomosis with the recipient iliac vein. We also preserved two fat pads (purple arrows) for possible use as buttresses should one of the two arteries show some undesired curves/kinks.

This post-implantation and reperfusion view from the medial side of the incision shows: the transposed iliac vessels with the right external iliac vein (orange arrow) lateral to the right external iliac artery (white arrow), the renal vein (light blue arrow), the IVC reconstruction (dark blue arrow) anastomosed (black arrow) to the transposed right external vein (orange arrow), the main renal artery (green arrow), the accessory renal artery (yellow arrow) that has been anastomosed independently to the transposed right external iliac artery (white arrow), and the renal pelvis (purple arrow).

The repaired parenchymal lacerations show good hemostasis.

The kidney started to produce urine soon after reperfusion.