Editing Renal Transplant (section)

== Kidney transplant operation ==

* '''Donation'''
** '''Most laparoscopic donor nephrectomies are left sided (because of the longer left renal vein)'''
** '''The ureter is mobilized to the point at which it crosses the iliac vessels. It is unnecessary to include the gonadal vein with the ureter, and the gonadal artery should also be left intact for the donor when possible'''
** '''Hem-o-lock clips are contraindicated in laparoscopic donor nephrectomies because they have been associated with living-donor deaths when used to seal the aortic side of the donor renal artery'''.
* '''Allograft preparation'''
** Branches that drain into the renal vein, such as the left adrenal vein, should be ligated
** Fatty tissue close to the renal hilum should be ligated, because this tissue often contains lymphatic channels that may otherwise contribute to a postoperative lymphocele.
** '''The best solution for preservation of all abdominal organs is University of Wisconsin (UW) solution'''
** '''The quality of early graft function is directly correlated with cold ischemia time'''
* Recipient operation
** Ideally, the kidney is transplanted extraperitoneally with the vascular anastomosis to the right external iliac artery and veiniliac.
*** The extraperitoneal approach minimizes potential bowel complications and postoperative ileus
*** The transplant is usually to the right iliac fossa so that the ureter is medial
** The central venous pressure should be maintained between 10-15 cm H2O with IV crystalloid and colloid solutions to achieve a mean arterial pressure ideally > 80 mm Hg
** A bladder irrigant, preferably a broad-spectrum antimicrobial solution such as bacitracin or neomycin–polymyxin B, is used
** The '''inferior epigastric vessels (deep to tranversalis fascia)''' can usually be gently retracted, but they may be divided if surgical exposure is compromised. Similarly, the round ligament may be preserved in females. The spermatic cord is identified in men as it travels inferiorly exiting the peritoneum and is carefully preserved.
** Lymphatic tissue overlying the vessels should be ligated or sealed with electrocautery. Care is taken to avoid injury of the genitofemoral nerve that lies anterior to the psoas muscle just lateral to the external iliac artery.
** '''The venous anastomosis is generally performed first to limit ischemia to the leg'''
** '''Before reperfusion, an IV bolus of furosemide and mannitol may be administered to facilitate diuresis and act as a free-radical scavenger.'''
** Urinary tract reconstruction is usually by antireflux ureteroneocystostomy
** The routine use of a ureteral stent for all cases of renal transplantation has been shown to reduce the incidence of ureteral complications