**8. Urinary reconstruction**

After completing the reperfusion stage usually the urine flow is started. Sometimes, especially in case of deceased donors or when the nephrectomy has been performed with difficulty in the living donors, the urine flow will be delayed. If the color and contour of the graft look good and the arterial and venous flow is good with a well-palpable thrill in the hilum, the surgeon should proceed to urinary reconstruction.

First of all the urinary bladder should be filled with sterile normal saline serum through previously installed urinary catheter. Some surgeons add 10ml/lit povidone iodine and 80 mg/ lit Gentamicin or 500 mg/lit Amikacin to the irrigation fluid for better sterility of the bladder (Salehipour M, et al, 2010) [13] but its effect is controversial. The kidney should be positioned in its final expected place to prevent the tension on the remained ureter before cutting the excess length of the ureter. It's better to use the smallest possible length of the ureter to reduce future ischemic complications. If this step is forgotten the final length of ureter may be shorter than expected and this will result in kinking of the vasculature and changing the location of the kidney from its ideal position.

The surgeon has many options for urinary reconstruction: ureteroneocystostomy, ureter‐ oureterostomy, pyeloureterostomy, and pyelocystostomy or even ureteroenterostomy to an ileal conduit or Koch (Manassero F, et al, 2011) [14] or pyelopyelostomy in case of or‐ thotopic kidney transplantation or complicated case (Wagner M, et al, 1994) [15]. The type of reconstruction depends on the position of the graft, the length, condition and number of the donor ureter(s), the condition of the recipient's bladder or bladder substi‐ tute (including its capacity and continence), previous operations on the recipient bladder or ureter (and its antireflux condition). The anastomosis should be done by absorbable sutures, usually polydioxanone sutures. Because of the risk of infection, use of any types of stents, such as double J stents or newer antireflux stents are controversial (Parapiboon W, et al, 2012) [16], but we use it in our center and remove it after 3 weeks. At least 4 techniques and their modifications are discussed in the literature for ureteroneocystosto‐ my (Kayler L, et al, 2010) [17]. Prevention of leakage, stricture and reflux is the final goal of all of these techniques. The two most common types are transvesical or Leadbetter-Po‐ litano (LP) technique and the extravesical or modified Lich-Gregoir (LG) technique. We use and recommend the second technique because it needs fewer dissections and use on‐ ly one small cystostomy incision (comparing with 2 large cystostomy incision needs for LP technique) with comparable antireflux characteristics and fewer complications. The LG technique can be performed in a very shorter time. After distending the bladder, the detrusor muscle dissected bluntly in the dome of the bladder approximately for a length of 3 cm till the mucosa bulges out. The ureter shortened to its ideal length and spatulat‐ ed for a length of 2 cm in its anti-mesoureteral direction and then the bladder mucosa incised. Anastomosis is started near the heel of the spatulated ureter 2-3 mm in the op‐ posite direction of the corner of the ureter. In this manner, the tie is placed outside and with some distance from the corner. The mucosa of the bladder is then sutured to the ureteral end with simple continuous sutures. After completing the anastomosis, an ab‐ sorbable suture is used for approximating the detrusor muscle to close over the anasto‐ mosis and creating a small submucosal tunnel for its antireflux mechanism. The LP techniques and the two other extravesical techniques are better described in the literature (Kayler L, et al, 2010) [17]. In the LP technique, a large anterior cystostomy is done for visualization of the bladder interior and the ureter is transferred through another small posterior cystostomy and then through the mucosa and after anchoring the distal end to the mucosa, the bladder is closed in 2 layers with absorbable sutures. Another extravesi‐ cal technique is the single or double U-stitch technique. In these techniques after open‐ ing the submucosal tunnel by creating by dissection of detrusor muscle and incising the bladder mucosa only 1 U-stitch (Shanfield, 1972) [18] at the toe or 2 U-stitch (MacKinnon et al, 1968) [19] at the toe and heel of the trimmed ureter is used for anchoring the ure‐ ter to bladder mucosa and then the detrussor muscle closed as the same manner of the LG technique.

The kidney should be firm and well-perfused after 1-2 minutes and urine flow usually starts after that. If the graft is flaccid and the patient's blood pressure is good, arterial kinking is the first differential diagnosis. This usually is resolved by repositioning of the graft. Also the surgeon could transiently clamp the renal vein or the distal part of the external iliac artery. If

After completing the reperfusion stage usually the urine flow is started. Sometimes, especially in case of deceased donors or when the nephrectomy has been performed with difficulty in the living donors, the urine flow will be delayed. If the color and contour of the graft look good and the arterial and venous flow is good with a well-palpable thrill in the hilum, the surgeon

First of all the urinary bladder should be filled with sterile normal saline serum through previously installed urinary catheter. Some surgeons add 10ml/lit povidone iodine and 80 mg/ lit Gentamicin or 500 mg/lit Amikacin to the irrigation fluid for better sterility of the bladder (Salehipour M, et al, 2010) [13] but its effect is controversial. The kidney should be positioned in its final expected place to prevent the tension on the remained ureter before cutting the excess length of the ureter. It's better to use the smallest possible length of the ureter to reduce future ischemic complications. If this step is forgotten the final length of ureter may be shorter than expected and this will result in kinking of the vasculature and changing the location of

The surgeon has many options for urinary reconstruction: ureteroneocystostomy, ureter‐ oureterostomy, pyeloureterostomy, and pyelocystostomy or even ureteroenterostomy to an ileal conduit or Koch (Manassero F, et al, 2011) [14] or pyelopyelostomy in case of or‐ thotopic kidney transplantation or complicated case (Wagner M, et al, 1994) [15]. The type of reconstruction depends on the position of the graft, the length, condition and number of the donor ureter(s), the condition of the recipient's bladder or bladder substi‐ tute (including its capacity and continence), previous operations on the recipient bladder or ureter (and its antireflux condition). The anastomosis should be done by absorbable sutures, usually polydioxanone sutures. Because of the risk of infection, use of any types of stents, such as double J stents or newer antireflux stents are controversial (Parapiboon W, et al, 2012) [16], but we use it in our center and remove it after 3 weeks. At least 4 techniques and their modifications are discussed in the literature for ureteroneocystosto‐ my (Kayler L, et al, 2010) [17]. Prevention of leakage, stricture and reflux is the final goal of all of these techniques. The two most common types are transvesical or Leadbetter-Po‐ litano (LP) technique and the extravesical or modified Lich-Gregoir (LG) technique. We use and recommend the second technique because it needs fewer dissections and use on‐ ly one small cystostomy incision (comparing with 2 large cystostomy incision needs for LP technique) with comparable antireflux characteristics and fewer complications. The LG technique can be performed in a very shorter time. After distending the bladder, the

not, thrombosis must be considered and ruled out as soon as possible.

**8. Urinary reconstruction**

should proceed to urinary reconstruction.

180 Current Issues and Future Direction in Kidney Transplantation

the kidney from its ideal position.

Another extravesical technique uses two parallel incisions in the detrusor muscle, first posterior for transferring the ureter in a submucosal tunnel and the second incision for anastomosis of the ureter to the ureteral mucosa (Barry JM, 1983) [20]. In the last technique, the ureter is anastomosed to the bladder full-thickness wall without any antireflux mechanism (Starzl, et al, 1989) [21]. In our opinion, the surgeon should be familiar with all of these methods and use them as needed, but we have the most experience with the modified LG technique without any major urologic complication (Davari HR, et al, 2006) [22].

When the graft ureter is short, ischemic, or denuded, the surgeon should use the native ureters for ureteroureterostomy or pyeloureterostomy if they are completely in a healthy condition (no stricture, no infection, no dilation or no reflux) or decide to perform a pyeloneocystostomy. This should be done with extreme caution to prevent kinking or pressure on the graft vascu‐ lature or repositioning of the graft. A Boari flap or psoas hitch is often necessary in all cases.

In case of previous bladder surgery such as antireflux surgeries or cystoplasty or bladder augmentation, it's very important that the site of final urinary reconstruction is fully depicted before proceeding with vascular anastomosis, or even before proceeding with nephrectomy in the living donor. Also the blood supply of the tissues used for augmentation should be considered. Creating a submucosal flap in the augmented bladder may results in ischemia of the tissues used for augmentation and if possible it's better to use the native bladder area for ureteral anastomosis.

In case of double or multiple ureters (such as horseshoe kidneys or en bloc transplantation of two kidneys), the ureters can be anastomosed separately to the bladder, or one to the bladder and the shorter ones to the native ureter. Another option is anastomosis of the ureters to each other and then anastomosis of the conjoined ureter to the bladder. In our opinion using separate anastomoses (if possible) reduces the future complications.

**References**

74-8.

653-5.

Urol. 2007 Jul;23(3):265-9.

Clin Transplant. 2003 Oct;17(5):484.

Gynecol Obstet. 1984 Aug;159(2):164-5.

Technol Res 2:113. doi:10.4172/2161-0991.1000113

Future Directions. Am J Transplant. 2012 Jul 23.

literature. Transplant Proc. 2011 Sep;43(7):2820-6. Review.

Mt Sinai J Med. 2012 May-Jun;79(3):303-4.

2011 Sep;43(7):2584-6.

transplantation. Int Urol Nephrol. 2008;40(2):283-7.

[1] Dolińska B, Ostróżka-Cieślik A, Caban A, Cierpka L, Ryszka F. Comparing the effect of Biolasol® and HTK solutions on maintaining proper homeostasis, indicating the kidney storage efficiency prior to transplantation. Ann Transplant. 2012 Jun 29;17(2):

Kidney Transplantation Techniques http://dx.doi.org/10.5772/54829 183

[2] Prasad GS, Ninan CN, Devasia A, Gnanaraj L, Kekre NS, Gopalakrishnan G.: Is Euro-Collins better than ringer lactate in live related donor renal transplantation? Indian J

[3] El-Sherbiny M, Abou-Elela A, Morsy A, Salah M, Foda A. The use of the inferior epigastric artery for accessory lower polar artery revascularization in live donor renal

[4] Nghiem DD, Choi SS. Eversion endarterectomy of the cadaver donor renal artery: a method to increase the use of elderly donor kidney allografts. J Urol. 1992 Mar;147(3):

[5] Sharma A, King AL, Lee HM, Posner MP. Saphenous vein graft aneurysm after renal

[6] Webb J, Soomro N, Jaques B, Manas D, Talbot D. The upside down transplant kidney.

[7] Starzl TE, Iwatsuki S, Shaw BW Jr. A growth factor in fine vascular anastomoses. Surg

[8] Zomorrodi A, Kakei F, Farshi A, Zomorrodi S (2012) Is Placing an Expansion Space at the Anastomosing Site of the Vessel for Prevention of Pursiness, Safe? J Transplant

[9] Nadim MK, Sung RS, Davis CL, Andreoni KA, Biggins SW, Danovitch GM, Feng S, Friedewald JJ, Hong JC, Kellum JA, Kim WR, Lake JR, Melton LB, Pomfret EA, Saab S, Genyk YS Simultaneous Liver-Kidney Transplantation Summit: Current State and

[10] Florman S, Kim-Schluger L. Organ transplantation update, part II: heart and kidney.

[11] Rana RK, Ghandehari S, Falk JA, Simsir SA, Ghaly AS, Cheng W, Cohen JL, Peng A, Czer LS, Schwarz ER, Chaux GE. Successful combined heart-bilateral lung-kidney transplantation from a same donor to treat severe hypertrophic cardiomyopathy with secondary pulmonary hypertension and renal failure: case report and review of the

[12] Sageshima J, Ciancio G, Uchida K, Romano A, Acun Z, Chen L, Burke GW 3rd. Absorbable cyanoacrylate surgical sealant in kidney transplantation. Transplant Proc.

transplantation: a case report. Transplantation. 2010 May 15;89(9):1162-3.
