Year : 2002 | Volume
: 13 | Issue : 4 | Page : 451--459
Surgical Aspects of Renal Transplantation: Contributions to Solutions for Complex Problems
Department of Urology, Christian Medical College & Hospital, Vellore, Tamilnadu, India
Department of Urology Unit II, Christian Medical College & Hospital, Vellore-632 004, Tamilnadu
The first successful human renal transplantation was done in 1954 at Boston and many viewed this as a technical success. Since the allograft was from an identical twin, the problem of immunosuppression was overcome and other lessons learnt from the procedure has come a long way to establish renal transplantation as the preferred treatment of choice for patients with end stage renal disease (ESRD). While the surgical technique has changed little, what has evolved over the last 50 years, has been the explosion in immunosuppression, the improvement in anesthetic techniques, imaging modalities and diagnostic techniques. This has made it possible for many patients to be accepted for transplantation who were earlier not considered fit for the procedure. Further understanding of bladder function and reconstructive surgical techniques of lower urinary abnormalities both congenital and acquired, which could lead to ESRD, has widened the patient base for renal transplantation. This article aims to discuss some of these issues.
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Gopalakrishnan G. Surgical Aspects of Renal Transplantation: Contributions to Solutions for Complex Problems.Saudi J Kidney Dis Transpl 2002;13:451-459
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Gopalakrishnan G. Surgical Aspects of Renal Transplantation: Contributions to Solutions for Complex Problems. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2019 Dec 16 ];13:451-459
Available from: http://www.sjkdt.org/text.asp?2002/13/4/451/33097
Since the first successful renal transplantation, surgical techniques have steadily improved and made it possible for most patients with ESRD to undergo renal transplantation. When compared to maintenance hemodialysis, renal transplantation is preferred by most patients with ESRD as it is more cost effective, allows for a normal life style and reduces the risk of mortality from dialysis related complications. Survival rates for renal transplantation have improved over the last two decades.
The urologist/renal transplant surgeon has the following roles in the treatment of patients with ESRD: dialysis access surgery, urinary tract evaluation, urinary tract preparation prior to transplantation, donor nephrectomy and renal transplantation, urinary tract reconstruction at the time of transplantation and diagnosis and treatment of genitourinary complications after transplantation.
Selection Criteria for Transplantation
During the initial period of transplantation very rigid criteria of patient selection were employed. During the seventies, lower mortality rates allowed us to relax the criteria for accepting patients for transplantation. The availability of cyclosporin since 1983 has resulted in further relaxation of the criteria for accepting patients for transplantation.
Today only few conditions would exclude patients from undergoing transplantation. These include: active malignancy, acute infections and all chronic infections should be treated prior to transplantation. Patients who are HIV positive and those with conditions like primary oxalosis need to be considered for transplantation with extreme caution.
Urinary Tract Evaluation
Pre-transplant urological evaluation is indicated to determine the suitability of the bladder and the lower urinary tract or its substitute for urinary tract reconstruction with or without pre-transplant nephrectomy. It was earlier believed that an abnormal lower urinary tract placed the recipient at an increased risk post transplant. There was an initial reluctance to offer renal transplantation to these patients despite sporadic successful reports,  which suggested that an abnormal lower urinary tract poses no contraindication to renal transplantation. Urological evaluation includes history for urologic disease (such as voiding dysfunction, passage of stones, urinary infection, vesico-ureteric reflux (VUR), previous urinary tract surgery and sexual dysfunction), urinalysis and culture, ultrasound imaging of the kidneys and bladder (including a post-void residual urine estimation) and other imaging techniques if needed. A history of valvular obstruction or voiding dysfunction would dictate the need for carrying out a micturating cystourethrogram and urodynamic studies. The common causes of lower tract abnormalities that may end-up requiring renal transplantation are neglected posterior urethral valves, neuropathic bladder and VUR.
Vesicoureteric reflux is the commonest lower tract anomaly seen in potential recipients and an incidence of 47% was reported by Cairns.  Pre-transplant bilateral nephroureterectomy is rarely indicated in our experience unless there is definite evidence of symptomatic urinary infections especially with resistant bacteria. Our data  showed that patients with VUR had a slightly increased incidence of urinary infection post transplant and that was seen mostly in the first six months; all of them benefited from low dose antibiotics. It should be remembered that pre-transplant nephroureterectomy does place the patient at an increased risk of fluid overload and anemia in addition to the morbidity of the procedure. In some situations, in order to avoid the morbidity of surgery, VUR may be corrected using submucosal injection of teflon, with benefit of correction estimated to be up to 65%.  It should seem reasonable to use contigen or macroplastique also in these situations.
If voiding dysfunction has resulted in ESRD, then the main question that needs to be addressed is whether the bladder can be made suitable for drainage of the renal allograft. Ideally, the urinary bladder should be a low-pressure reservoir with good volume, normal compliance and free of infection. Many patients with abnormal bladders may not be able to void and would need to resort to clean intermittent self-catheterization. Some patients with neurovesical dysfunction have already been used to this technique prior to transplantation and are able to restart this after the transplant surgery. Those patients who had not been exposed to this technique would need to be educated about this prior to transplantation. This is feasible in transplant recipients; results are encouraging and it appears that the anxiety about systemic infection is unfounded.  Results show that 52% of such patients have asymptomatic infection and 22% experience symptomatic infections.
If an ileal conduit is needed, then this should be constructed 4-6 weeks prior to transplantation. Sometimes the bladder might require modulation to improve compliance and capacity. In such situations, augmentation with bowel substitution or autoaugmentation would need to be performed. A fictionalized augmentation is preferable to a dry bladder. In case the urine output is low pre-transplant, then the augmented segment would need to be cycled with washing in order to prevent mucous plugs from blocking the outlet. It should be our aim to provide, if possible, a urothelial lined augmentation and this direction a ureterocystoplasty, whenever possible, should be attempted. It is therefore necessary to preserve all non-functioning kidneys with dilated ureters in order to achieve this goal.
Rarely, a cutaneous ureterostomy would need to be done as the modality of diversion using the allograft ureter. This could happen if the patient refuses to perform selfcatheterization. This is likely in unmarried females of certain faiths who feel that selfcatheterization could pose a problem with virginity. In case ureterostomy is performed then this could either be an end ureterostomy or, as suggested by Amin,  a loop ureterostomy. Needless to say that all patients with abnormal bladders who have been transplanted need to be on rigorous and close follow up. The slightest doubt of obstruction should be proved and corrected. At the present, the relative small number of cases of bladder augmentation or substitution reported in literature does not allow for meaningful long-term results to be assessed.
The need to perform pre-transplant transurethral resection of the prostate to relieve bladder outflow obstruction is low in our experience. It should be possible to manage these patients with alpha-blockers till the transplant is over. Transurethral prostatectomy is best performed in a patient with good urine output and this can be done 4-6 weeks after transplantation.
Surgical Techniques of Donor and Recipient Operations
Donor nephrectomy (cadaver)
The technique of cadaver organ retrieval is well established and standardized in all centers. The use of perfusion solutions with intracellular composition enables most kidneys to produce urine output very soon after release of vascular clamps in the recipients. A prospectively randomized study of cadaveric kidney grafts perfused with either University of Wisconsin solution or Euro-Collins showed that the former resulted in significantly lower postoperative dialysis rate and a 6% higher one year graft survival when compared to kidneys perfused with Euro-Collins solution. 
Donor Nephrectomy (live)
Two aspects of live donor nephrectomy have made this operation more attractive and acceptable. Firstly, with regard to evaluation, spiral CT angiography has virtually replaced the conventional digital subtraction angiography to map the arterial pattern of the donor kidney. At our centre, this is the standard practice.  Not only is the procedure non-invasive and rapid but also serves to pick up unsuspected pathology within the abdominal cavity. The 3-D reconstructed images serve to provide a clear anatomical outline of the kidneys and its vasculature. It also helps to identify venous anomalies and this is of immense value when doing laparoscopic donor nephrectomy.
The second aspect of live donor nephrectomy has been the introduction of laparoscopic surgery in carrying out this operation. Since the first live donor laparoscopic nephrectomy was done in 1995 at the Johns Hopkins Bayview Centre, the technique has evolved and it is likely that very soon it will become the new standard donor operation. Since the procedure was initiated various surgical modifications have simultaneously taken place. The total operative time has been shortened with experience, while the use of the hand-assisted devices has reduced the time even further while adding to the overall increase in the cost of the operation. Complications that are not uncommon with the open donor nephrectomy such as pneumothorax, incisional hernia and wound discomfort are virtually nonexistent with the laparoscopic procedure. 
In the developing world, where patient care is by and large not covered by health insurance, the cost of these procedures can be prohibitive. While most of these newer surgical techniques are learned readily and quite efficiently by most surgeons, the cost factor would need to be borne in mind. When laparoscopic donor nephrectomy was introduced there was skepticism whether the kidney would be functionally intact and also if it would have any deleterious effect on the outcome of the recipient operation. Of concern is the effect that pneumoperitoneum has on renal blood flow and function. While this can be overcome with volume overloading, it was also felt that the kidney could be exposed to ischemia and also render it more allogenic. These fears have not been borne out by both animal and human studies till date. Finally, the advent of laparoscopic donor nephrectomy has made organ donation from live related individuals more forthcoming at least in the developed nations of the world. In the developing world, the major source of organs has been the live related/unrelated donor and the major bottleneck to offering this facility to larger numbers of the population has been the prohibitive cost by living standards of the majority.
Asystolic cadaver donors (non-heart beating)
Cadavers presenting after sudden cardiac arrest are another source of expanding the donor pool and good results can be obtained by this technique. It is essential to ensure a rapid and effective cooling of the kidneys once irretrievable cardiac arrest has been diagnosed. The cooling is done in the emergency or in the ward. Asystolic donors are declared dead by cardiac-arrest criteria. Once death has been certified, the transplant team restarts cardiac massage and ventilation while pending introduction of catheters for cooling the kidneys. Using this source increases the donor pool by about 25% with acceptable results. Delayed graft function is usual and ultimate graft function in these kidneys is about 10% less than kidneys obtained by brain-dead criteria using beating heart donors.  Some transplant centers have established protocols for retrieval of such kidneys. The maximum use of such kidneys is from Japan in view of the fact that their cadaver program is limited to the use of such kidneys. Five year graft function of 72% compares favorably with data from the Western world using heart beating donors.  It should be kept in mind that such kidneys are usually sourced from intensive care units and show a poorer prognosis than kidneys from the emergency rooms.  Acute tubular necrosis in kidneys from non-heart beating donors is a reason for delayed graft function and confounds the post-operative period of such transplants when rejection episodes and cyclosporin toxicity could add to worsening renal function.
Surgical Complications of Renal Transplantation
Surgical complications associated with renal transplantation can be considered under the following headings: vascular, fluid collections and urological.
While the technique of vascular anastomosis is well standardized, careful placement of sutures, ensuring that an intimal flap is not lifted especially in diseased vessels, and the use of optical magnification helps in reducing the incidence of arterial thrombosis and ensuring a good outcome. With regard to the venous anastomosis, a wide anastomosis with a stretched open renal vein will reduce the risk of venous thrombosis. The advent of cyclosporine appears to have increased the incidence of post-operative, especially venous thrombosis. [, The failure of a graft to produce urine could be due to arterial thrombosis and this is especially so in living donor transplantation. In many patients the situation is not salvageable and graft loss is inevitable. Isotope scans are useful and serve to establish the diagnosis by the classical "white-out" effect. This sign is however to be treated with some degree of caution in a cadaver transplant because it has been reported that such kidneys might function and a Doppler is a more reliable in diagnosing graft arterial thrombosis.
Fluid collections after transplant
The advent of ultrasound has shown fluid collections around renal allografts in the region of about 10-50%. 15 Most lymphocoeles produce symptoms when they are more than 3 cm in size and when they contain more than 100 ml of fluid. The peak incidence is usually around 6 weeks following transplant but lymphocoeles have been reported as late as 8 years after transplant.  The most common presentation is ipsilateral painless swelling of the leg, perigraft swelling and fever due to secondary infection. Treatment in most situations is conservative. However, if deemed necessary, a single aspiration and injection of sclerosant is often useful. Agents like tetracycline have not proven useful. If ultrasound shows presence of infection then external drainage is preferable. Instilling povidone-iodine along with external drainage has shown a response rate of less than 11%. Surgical fenestration is the most definitive procedure and involves draining the fluid collection into the peritoneal cavity. In order to make the procedure more effective the fenestrated edges are sutured and omentum is mobilized and plugged into the area to facilitate drainage. Currently the procedure of choice is laparoscopic drainage into the peritoneal cavity.
Urological complications are uncommon; the incidence varies between centers and is quoted as between 5% to 14%. Urological complications are responsible for deteriorating renal function due either to ureteric obstruction or fistula; the latter usually presenting as a fluid collection usually in the early post-operative period but even as late as six weeks after transplantation. Early complications are defined as those occurring three months before transplantation. Ureteral obstruction in the early post-operative period is due to technical causes, odema or blood clot or, rarely an unsuspected donor calculus. Late obstruction is due to ischemic stricture, calculus, tumour, fungus ball or even lymphocoele. The role of rejection in ureteral damage has not yet been proven.  The technique of ureteroneocystostomy does not also appear to play a role in either early or late urological complications.  What does appear to make a difference is the technique of harvesting the donor kidney and the ureteral dissection, be it a cadaver or live donor, done either by the open method or laparoscopically. Apart from preserving the adequate periureteral tissue, it is important not to violate the "golden triangle" bounded by the gonadal vein, lower pole of the kidney on the left and the lower border of the kidney and the lower border of the junction between the renal vein and the inferior vena cava on the right hand side.  In cases where there is an accessory lower polar artery, reanastomosis of this vessel is necessary to ensure blood supply to the ureter. The advent of laparoscopic donor nephrectomy did result in skeletonisation of the ureter and increase in the incidence of complications.  It is now recommended that donor dissection laparoscopically is begun and maintained medial to the gonadal vein; it is recommended that the entire sheet of tissue consisting of the gonadal vein and the ureter is lifted along with the lower pole of the kidney to facilitate exposure of the renal vein and artery.  With this technique, in a review of 100 consecutive cases at Johns Hopkins Medical Centre, the incidence of ureteral complications was reduced to 3%. To date no allograft has been lost due to ureteral complications in more than 280 live donor laparoscopic nephrectomies.
One of the issues that have risen as a spin off of endourology has been the use of double J stents on routine basis in transplant recipients by various centers. Centers using stents for both live and cadaver transplants claim a markedly reduced incidence of ureteral complications. Dominguez et al  compared two groups of patients who, after transplantation, were either stented or not stented. They concluded that routine stenting is not necessary in kidney transplantation in patients at low risk for urologic complications. Careful surgical technique with selected stenting of problematic anastomosis yields similar results.
Another issue, which has not yet been resolved, is that of vesicoureteric reflux into the transplant ureter. There is no strong evidence that reflux of sterile urine results in increased graft loss and hence, in most instances, conservative management is sufficient. Persistent infection with no other demonstrable pathology other than reflux would make one consider correction of reflux.
Laparoscopic Surgery in Renal Transplant Recipients
Laparoscopic surgery in the treatment of urological diseases has become the standard of care for many patients. While laparoscopic live donor nephrectomy was initiated only recently, the role of laparoscopic procedures in the management of conditions affecting prospective renal transplant recipients has been practiced some time earlier. Both ablative and reconstructive procedures in renal transplant recipients are now being done laparoscopically. While clinical and experimental data suggest that laparoscopy causes a transient and self limiting oliguria in the no transplant patient with normal renal function, there is no report of adverse effects on renal function in renal transplant recipients.  Laparoscopic deroofing and fenestration is an elegant procedure which allows for a shorter hospital stay, markedly reduced blood loss and shorter convalescence. The most common complication of the procedure is related to injury to the allograft ureter and bladder. One method described to avoid injury is to transcutaneously inject methylene blue into the lymphocoele cavity and thus identify the landmarks.  Ratner and colleagues  have described laparoscopic insertion of a small fibreoptic endoscope into the lymphocoele cavity to illuminate the cavity and help identify structures. Laparoscopic native kidney nephrectomy has been performed in renal transplant recipients but whether this is superior to the dorsal lumbotomy is debatable and a randomized comparison of the two procedures has not been done. It is claimed that pain is also fairly minimal with the lumbotomy. Recently laparoscopic nephrectomy has been extended to p 2 atients with adult polycystic kidney disease. 
Placement of peritoneal dialysis catheters for ambulatory dialysis has also been performed laparoscopically. Complications related to the procedure, such as catheter malfunction due to omental entrapment, kinking, and adhesions can also be rectified via laparoscopic approaches.
The Marginal Kidney and the Marginal Donor
The shortage of human organs for transplantation has forced transplant surgeons to consider kidneys and patients with some abnormalities that would not cause alterations in patient well-being or affect graft function seriously, for possible transplantation. Such kidneys would be labeled as marginal, and some of the donors who have some medical morbidity would be called marginal.
Kidneys from Older Donors
It has been reported that there is a 10 ml/min decline of glomerular filtration rate (GFR) for every decade after the age of 30 years. The diminished graft survival of such kidneys from older donors is explained by this reduction in functional reserve of these kidneys. Despite clear-cut histological changes in the kidneys, the upper age of donors is still controversial. In a living donor program other co-morbid factors would make this an easy decision; but sometimes that too is difficult. Singh reviewed 24 living related transplants from donors over 60 years. The acturial graft survival at 1 year was 89% and 76% at 4 years. These recipients experience more episodes of rejection when compared to the patients from younger donors.
In order to offset the imbalance of reduced nephron mass in older kidneys, one of the techniques employed is to transplant double allografts i.e. both kidneys from the older donor into a single size-matched older recipient. The decision to perform dual transplant is not easy and certain criteria have been proposed to help make this decision. Such criteria are a terminal serum creatinine of 220 µmol/l (2.5 mg/dl), the donor age over 55 years and allograft biopsy showing 10% glomerulosclerosis vascular thickening and interstitial fibrosis. Donors more than 50 years if completely suitable can add to the total number of kidneys available for transplantation. To maximize outcome in such kidneys, they are preferably transplanted into similar recipients.
Kidneys with Anatomic Abnormalities
Kidneys with anatomic abnormalities are not a contraindication for transplantation provided no histological damage has occurred which in itself could have reduced the GFR. Conditions like pelviureteric junction obstruction and renovascular lesions can be corrected ex-vivo and reimplanted into the recipient with reasonably good graft function.
Less than Ideal Donors
Organs from less-than-ideal, brain-dead donors are capable of giving good results.
These include elderly diabetics and hypertensives with normal renal function.  Careful evaluation; including histological assessment of the removed organs is mandatory.
Abouna and co-workers  reported on the successful transplantation of cadaver kidneys from diabetic donors into non-diabetic recipients. They reported an apparent regression of diabetic nephropathy. It was agreed that carefully screened kidneys from diabetic cadaver donors should be considered for transplantation. The kidney should satisfy the following criteria: renal function should be normal with no proteinuria, no evidence of accelerated atherosclerosis and a stable course in the intensive care unit.
The ever-increasing number of patients with ESRD on dialysis and the lack of cadaver and live related donors, has placed tremendous demands on dialysis centers. This has resulted in trying to expand the donor pool and the previous sections have discussed some these issues. What has been condemned by the transplant committee seems to be surfacing again and that is the area of paid organ donation. While there is no doubt that this is being performed all over the world, it was interesting that a news item by Deborah Josefson from Omaha, Nebraska on the above subject was placed in the British Medical Journal.  The American Medical Association Council for Ethical and Judicial affairs ruled that financial incentives to encourage organ donation were not totally unethical and warranted further study. A 1992 telephone survey involving 1200 adults conducted by UNOS found that 48% favored some form of compensation to potential organ donors. The American Society of Transplant Surgeons also favors the issue of financial incentives and a congressional order introduced in May this year could allow a donor family $ 10,000 tax credit in exchange for donated organs.
While the surgical techniques of renal transplantation have changed little, what has evolved over the last 50 years has been an expansion of the recipient pool, this sharply contrasting with the paucity of organ donors. This has resulted in considering newer innovations in donor evaluation and operations while also using marginal kidneys/donors.
The encouraging graft survival rates with the currently available immunosuppression has helped made this possible but has still not helped to offset the imbalance between supply and demand. This scenario could force one to legislate incentives for organ donation from living donors.
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