Novel Approaches to Kidney Transplantation R.B. Khauli T HE SURGICAL APPROACHES to renal transplan- tation have been summarized in a prior report. 1 Currently, four transplant surgical procedures are per- formed (Figs 1A to D): (1) pelvic (basic) approach, (2) the lower abdominal approach, (3) the orthotopic (lumbar) approach, and (4) the pediatric en bloc transplantation. The most commonly used approach is the standard pelvic ap- proach with retroperitoneal placement of the kidney. How- ever, the surgeon must be familiar with the other ap- proaches, which are useful in special situations like retransplantation and severe atherosclerosis of the iliac vessels. We herein report on our experience with the surgical approaches to transplantation. METHODS Pelvic (Basic) Renal Transplantation This most commonly used approach consists of placing the kidney in the iliac fossa and is applicable to the majority of recipients of primary and secondary grafts (Fig 1A). A curvilinear incision is made in the right lower quadrant (or left in retransplants) and taken from the midline above the symphysis pubis, to a point three fingerbreadths medial to the anterosuperior iliac spine. Alterna- tively, the J-incision, with the upper limb placed more medially, is carried out parallel to the linea semilunaris. The retroperitoneal space is exposed with a Bookwalter retractor. Inspection of the kidney anatomy at this point helps in the decision-making process of which artery to utilize for implantation (hypogastric or external iliac). We prefer the former if surgically feasible. Multiple renal arteries, or the use of common Carrel patches of two arteries in CAD transplantation, preclude the use of the hypogastric artery for revascularization. In cases of bench repair of two equivalent arteries to produce a common ostium, the hypogastric artery could be utilized for revascularization as shown in Fig 1E. The hypogas- tric or external iliac and external iliac vein are carefully mobilized ligating all overlying lymphatics. The hypogastric artery is prepared by endarterectomy and flushed with dilute heparin (10,000 units/50 mL), and a venotomy is performed in the external iliac vein. The venous anastomosis is performed first, running the renal vein end-to-side to the external iliac vein using continuous 5-0 prolene. The arterial anastomosis is performed, end-to-end, between renal artery and hypogastric ar- tery, and end-to-side to external iliac artery if hypogastric is diseased, using running 6-0 prolene. Contraindications to using the hypogastric artery are severe involvement with atherosclerotic disease, significant discrepancy in size compared to the renal artery, presence of multiple donor arteries on a Carrell patch, and prior transplant using contralateral hypogastric artery for fear of erectile dysfunction. In case of use of common or external iliac artery, the artery is prepared by a longitudinal arteriotomy and appropriate excision of arterial wall as needed, and running 6-0 prolene between the arterial stump and the recipient artery. During vascu- lar anastomosis the kidney is kept cold by continuous topical irrigation with ice-cold saline, and the vascular anastomosis is limited to 30 minutes. On reperfusion, the CVP is kept above 10 cm H 2 O by appropriate colloid and crystalloid infusion. Lower Abdominal Transplant This approach has been described by Belzer 2 and is particularly useful when using the right kidney with a short renal vein or performing retransplants (Fig 1A). The technique depends on good exposure of the right common iliac vessels, aortic bifurcation, and inferior vena cava through a midline or J-incision that is slightly higher in position than the standard pelvic approach. The anasto- mosis is performed to the vena cava and common iliac artery, avoiding the use of vascular segments that have been involved by prior dissections and perivascular fibrosis. The approach is also advantageous in patients with atherosclerosis of the external iliac and hypogastric circulation, sparing the right common iliac, and in patients with extensive venous disease in the pelvis, sparing the vena cava, like retroperitoneal fibrosis. Orthotopic (Lumbar) Transplantation Orthotopic transplantation (Fig 1C) was described by Gil-Vernet et al. 3 for patients with prior failed transplants or severely diseased pelvis prohibiting the use of the iliac circulation. The technique utilizes the native vasculature and renal pelvis of the left kidney, which are preserved when performing a left nephrectomy, and the graft is placed in the lumbar fossa via a flank approach. The venous anastomosis of the native vein to transplant renal vein is performed end-to-end; the arterial anastomosis of the renal artery to the native splenic artery is performed end-to-end (aorto-renal revas- cularization in case of diseased splenic artery). The technique is useful in patients with abnormal venous circulation like pelvic resections or pelvic deep vein thrombosis. Also, patients with From the American University of Beirut Medical Center, Beirut, Lebanon and University of Massachusetts-Memorial Medical Systems, Worcester, Massachusetts, USA. Supported partially by the UMMC Transplantation Fund 6-31676. Figures reproduced with permission from Urologic Clinics of North America Volume 21 (2)May 1994:321. Address reprint requests to Raja B. Khauli, MD, FACS, Pro- fessor and Head, Division of Urology, and Director, Renal Transplantation Unit, AUBMC, Professor of Surgery (Adjunct) University of Massachusetts Memorial Healthcare, Worcester, MA, AUBMC, 850 Third Ave, 18th floor, New York, NY 10022. 0041-1345/01/$–see front matter © 2001 by Elsevier Science Inc. PII S0041-1345(01)02141-8 655 Avenue of the Americas, New York, NY 10010 2670 Transplantation Proceedings, 33, 2670–2672 (2001)