Objectives: The objective of this study was to investigate the long-term outcomes of inverted kidney transplant, an alternative easy and safe technique to overcome difficulties associated with short right renal vein anastomosis after laparoscopic donor nephrectomy.

Materials and Methods: Seventy-nine laparoscopic donor nephrectomies and intentionally inverted renal transplants were performed between 2004 and 2009. For these transplants, the renal artery was ligated by Hem-o-lok (Weck Surgical Instruments, Teleflex Medical, Durham, NC, USA) and titanium clips, and the vein was closed with 2 Hem-o-lok clips, resulting in a short renal vein. By inverting the recovered kidney to the ipsilateral pelvic side of he recipient, the short renal vein is placed posterior and adjacent to the external iliac vein; this made an easy and safe short renal vein anastomosis possible.

Results: All donor nephrectomies were completed laparoscopically, and no conversion to open surgery was required. The mean warm and cold ischemic times were 7.3 minutes (range, 3.2-17.5 min) and 37.5 minutes (range, 14.2-88 min). Only 6 patients (7.6%) had delayed graft function. At 5 years after transplant, patients showed excellent graft function, with mean serum creatinine level of 1.46 mg/dL and graft survival of 93.7%. There were no occurrences of vascular thrombosis or acute rejection. However, 5 years after transplant, 4 patients had died, with 3 patients still having functional transplanted kidneys and 1 patient experiencing graft rejection 1 month before death.

Conclusions: Inverted kidney transplant is an easy and safe method to overcome the complications associated with short right renal vein anastomosis after laparoscopic donor nephrectomy. This simple modification might obviate the need to elongate a short renal vein.

Key words :

From the Shahid Labbafinejad Medical Center, Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Acknowledgements: The authors declare that they have no sources of funding

Introduction

The first successful human laparoscopic donor nephrectomy was performed in 1995.¹ Today, it is believed that morbidity with laparoscopic donor nephrectomy is less than with open donor nephrectomy and that long-term graft function is the same with either procedure.^2-4 In the first randomized clinical trial comparing these procedures, Simforoosh and associates showed that laparoscopic donor nephrectomy gave both better donor satisfaction and less morbidity than open donor nephrectomy, although graft outcomes were equivalent.^5,6

Right donor nephrectomy, especially when conducted laparoscopically, has not been accepted by most transplant surgeons because of the consequent short right renal vein and the possible increased incidence of venous thrombosis and other surgical complications.^7,8 However, apart from difficulties because of short right renal vein anastomosis, some previous studies have reported that there are no significant differences in graft outcomes between left and right kidney recipients and whether open donor nephrectomy or live laparoscopic donor nephrectomy is performed.^9-13 Therefore, it is suggested that the less functional kidney (left or right) should be selected for donor nephrectomy regardless of anatomic side.^12,14

It should be noted that the right pelvic cavity is preferred to the left for kidney transplant because the iliac vein is located deeper in the left side; furthermore, the sigmoid colon in the left cavity might also interfere with anastomosis of a short right renal vein.

This prospective study presents the long-term results of a previously reported novel approach to right donor kidney transplant and the inherent complications of a short renal vein in which the recovered kidney was intentionally transplanted inverted (upside down) in the right iliac fossa.¹⁵

Materials and Methods

Between March 2004 and November 2009, our center performed 79 inverted kidney transplants. Kidney donors who met our routine selection criteria, as described previously,⁵ were admitted 1 day before surgery. All donors underwent scheduled laboratory analyses and imaging evaluations. From our 79 donors, 62 donors had multiple left renal arteries and 17 donors were eligible female donors of childbearing age.

Right laparoscopic donor nephrectomy was achieved with a transperitoneal approach using 4 or 5 ports (one 5-mm port for liver retraction was sometimes needed). The right renal artery was mobilized to the lateral border of the inferior vena cava, whereas the right renal vein was dissected down to its root from the inferior vena cava to have the largest possible length of vein for anastomosis. Double ligation of the renal artery was achieved with 1 Hem-o-lock clip (Weck; Telefex Medical, Research Triangle Park, NC, USA) and 1 medium-large titanium clip. The renal vein was closed by 2 Hem-o-lok clips, and the use of the Endo-GIA Stapler (ENDO GIA Universal; Johnson & Johnson, New Brunswick, NJ, USA) was not required. The divided kidney was delivered through a transverse suprapubic incision (Pfannenstiel incision).

After the kidney was immersed in ice slush, irrigation was started with 250 mL of washing liquid. The irrigated hypothermic kidney was then immediately transferred to the prepared ipsilateral pelvic cavity of the recipient, located in an operating room next door, with no bench dissection of the renal pedicle. Adequate mobilization of the right internal and common iliac arteries and external iliac vein of the recipient was achieved before the recovered kidney was placed upside down intentionally within the right iliac fossa.

Inversion of the right donor kidney allows the short right renal vein to lie posterior and stay closer to the recipient’s external right iliac vein, making anastomosis much easier and faster with no need of any further procedures for right renal vein extension or extensive mobilization of the recipient’s external iliac vein by ligating its branches. The renal artery was then anastomosed to the internal or common iliac artery as per usual practice. A modified Lich-Gregoir technique was used to reimplant the donor ureter in 74 recipients, whereas the remaining 5 recipients required anastomosis to the ipsilateral native ureter over a 4.8 F ureteral catheter. Doppler ultrasonography and nuclear scans of the transplanted kidney were performed if there was any indication of graft malfunction.

For our study, demographic data of donors and recipients, including sex, age, body mass index, date of transplant, and surgical variables, including type of right donor nephrectomy (laparoscopy or converted to open nephrectomy), warm ischemia time (from moment of donor artery clamping to start of cold irrigation and cooling of graft), cold ischemia time (from moment of cooling of graft to finishing anastomosis and graft reperfusion in the recipient), immediate complications (acute graft rejection, graft artery or vein thrombosis), postoperative long-term complications, blood transfusion, and retransplant, were analyzed.

Early and late graft function was estimated with the use of serum creatinine levels 1 week and 3 months after surgery. Long-term graft function (creatinine levels each year for 5 years) and graft and patient survival outcomes were assessed. Delayed graft function was defined as serum creatinine levels greater than 3.5 mg/dL after the third day of transplant.

Results

Characteristics and surgical outcomes of 79 donors and 79 recipients are presented in Table 1. All planned live right laparoscopic donor nephrectomy were completed without any conversion to open surgery or need of reoperations. Right donated kidneys were anastomosed upside down to the right pelvic vessels of recipients (right side to right side).

Seven kidneys (9%) were from first-degree related donors, and 72 kidneys (91%) were from unrelated donors. Mean duration of warm ischemia was 7.3 minutes (range, 3.2-17.5 min), and mean duration of cold ischemia was 37.5 minutes (range, 14.2-88 min). Serum creatinine levels of recipients before and after transplant and levels during 5 years of follow-up are shown in Table 2. Six patients (7.6%) showed delayed graft function but with no need for dialysis.

Our patients showed no early postoperative complications, such as arterial or venous thrombosis, and no acute graft rejections. However, 8 recipients (10%) experienced long-term complications: 4 patients had ureteral fistulas, with 1 resolved with conservative treatment and 3 requiring surgical intervention; 2 patients had ureteral stenosis, requiring repeat ureteroneocystostomy anastomosis (modified Lich-Gregoir method); and 2 patients presented with recurrent large lymphoceles, which, after attempts with percutaneous drainage, required open lymphocele drainage with opening of the peritoneal window.

Although 6 recipients (7.6%) received post­operative blood transfusions, no donor transfusion during surgery was required and no instances of vascular clip malfunction on the major vessels were observed.

Long-term graft survival was 93.7%. Five graft rejections occurred between 1 and 54 months after transplant; however, only 2 subcapsular graft nephrectomies were performed for gross hematuria, intractable pain, or prolonged fever. During our 5-year follow-up, 4 recipients (5%) died; 3 of these recipients had functioning kidneys, but 1 patient (50-y-old male) had graft rejection 1 month before death.

Discussion

Use of laparoscopic donor nephrectomy for recovery of donor kidneys has increasingly become the method of interest, especially in high-volume renal transplant centers. This may be because of advantages reported for laparoscopic donor nephrectomy with equal graft outcomes as open donor nephrectomy.^2-4

One of the limitations of laparoscopic donor nephrectomy is the short right renal vein when recovery of the right kidney is needed. This can reduce the number of kidney donations, especially when conditions dictate the need for right donor nephrectomy. These conditions include female donors of childbearing age (because hydronephrosis and pyelonephritis of pregnancy occur predominantly in this side), when left complex vascular anatomy is present, or if there is a cyst in the right kidney or the right kidney is smaller or anomalous.¹⁶

Different techniques have been attempted to overcome the difficulties with short right renal vein anastomosis. These techniques have included mobilization of the recipient’s common and external iliac vein,¹⁷ donor vein elongation using a donor gonadal vein^18-19 or donor inferior vena cava,^7,20 use of a polytetrafluoroethylene graft,²¹ or use of the recipient’s saphenous or superficial femoral vein.²²

Rosenblatt and associates²³ performed right renal vein extension with recipient’s left renal vein after laparoscopic right donor nephrectomy. Lind and associates¹⁷ performed a recipient iliac vein mobilization in 67 donors with complete right laparoscopic donor nephrectomy to overcome the difficulties in short right renal vein anastomosis. However, delayed graft function seemed to be increased in this series, with 1 occurrence of arterial thrombosis.

In a study by Mandal and associates,⁷ com­plications encountered with a short right renal vein were in general overcome by extensive renal vein mobilization and division parallel to the donor’s vena cava after drawing a small portion of the caval vein in to the stapler to increase right renal vein length. Although this method was confirmed by Lind and associates⁸ and others,^20,24 the safety of the donor may have been endangered because a part of the donor inferior vena cava is taken (although small). The upside-down placement of a recovered kidney for anastomosis of a short right renal vein is easier because of the posterior positioning of the right renal vein; it is also quicker and safer because there is no need for donor inferior vena cava invasion or recipient iliac vein invasion.¹⁶ In 1972, Hamburger and associates²⁵ reported inverted right kidney transplant procedures with no serious complications. The study stated that the right renal vein is short and lies anteriorly, and placement of the graft in an upside-down position allows for more convenient vascular anastomosis.

In a review of 1270 renal transplants over 23 years, Webb and associates²⁶ found 4 cases of accidental inverted kidney placement. Outcomes of all 4 kidneys showed acceptable function. Diner and associates²⁷ also reported 4 cases of inverted kidney transplant to make a tension-free vascular anas­tomosis with no adverse effects.

To our knowledge, our study presents the largest long-term follow-up of planned inverted kidney transplant. This technique has a number of advantages. Inversion of the graft allows the kidney to lie higher in the pelvis, so vascular anastomosis of a kidney with a short vein, especially in obese patients or patients with a deep pelvis, is technically easier, faster, and safer. Unlike other successful reports for right laparoscopic donor nephrectomy,^8,17 the use of an upside-down kidney position results in no need to ligate branches of external iliac vein, providing better graft venous drainage and therefore preventing venous thrombosis.

In our patients, clips were used instead of vascular stapler in lymph node dissection, and the kidney was hand extracted from a suprapubic transverse incision (Pfannenstiel incision). This made our pure laparoscopic technique safe, cost effective, and fast.⁶ We recently reported the safety of Hem-o-Lok and titanium clips for renal artery and vein ligation in 1834 nephrectomies.²⁸ This method of vascular control has become popular in European and Asian countries but not in the United States due to a US Food and Drug Administration warning.^29,30

In conclusion, difficulties with short right renal vein anastomosis obtained by laparoscopic donor nephrectomy can be safely overcome by inverted kidney placement to the ipsilateral side of the recipient’s iliac fossa, where an easier, faster, and safer tension-free vascular anastomosis is possible, with no increased cold ischemic time, no increased risk of vascular and other complications, and no increased graft morbidity in short- and long-term follow-up.

Conclusions

Inverted kidney transplant is an easy and safe method to overcome the complications associated with short right renal vein anastomosis after laparoscopic donor nephrectomy. In this situation, like laparoscopic donor nephrectomy, it has become the method of choice at our center. This simple modification might obviate the need for short renal vein elongation using the donor’s inferior vena cava, other veins from the recipient, or synthetic graft or excessive iliac vein mobilization, which could be challenging for most transplant surgeons.

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