**7. Declamping and reperfusion**

renal vein, then after completing the posterior layer, the excessive part should be repaired

In case of thrombosed or fibrotic external iliac vein (due to multiple previous femoral vein canulations or previous DVT) or severe atherosclerotic iliac arteries, the best approach is to use the abdominal major vasculature for renal transplantation. The surgeon may decide to use the common iliac artery or vein if spared from the disease or close the wound and explore the opposite iliac fossa if preoperative Investigations or intraoperative sonographywere negative for the same complication. In extreme cases when the IVC is also thrombosed or fibrotic, or when the infrarenal aorta also is atretic or severely atherosclerotic, using the splenic or native renal vein and artery may be an option, provided that the native ureters has a normal function

Another unusual case is the horseshoe kidney. Anomalous vasculature is the rule in these cases. Crossed fused or non-fused ectopic kidneys have the same problem. One option for approaching this type of anomaly is to incise the ismusth between the two conjoined kidneys and use each kidney for a separate recipient. The major problem is the resultant two grafts with so many arterial and venous branches and also short and multiple ureters. Because of shortage of donor organs most centers prefer this approach. But sometimes dividing the horseshoe kidney is so difficult and may results in damaging both kidneys. In these cases it's better to use the anomalous kidney as an individual graft and use the aorta and IVC as the arterial inflow and venous outflow of the graft. Such large size graft often could not be placed retroperitoneally and should be implanted in an intraperitoneal space. The same principle is applied to double kidney grafts from a pediatric or old age or more marginal donors such as donation after cardiac death (DCD) donors: transplanting each unit separately or using the aorta and IVC as the vascular conduits of the graft. Circumaortic or retroaortic renal veins are other problematic vascular anomalies that make the transplantation procedure more difficult. In experienced hands, these anomalies per se are not contraindication for donation even from

When a suspicious lesion is found on the kidney graft, it should be incised or excised and sent for frozen section pathologic investigation. Hemostasis could be done by sutures or argon beam coagulators, following the principles of any standard partial nephrectomy. Benign lesions should be removed completely and grafts with any non-benign pathology should be discarded. Solitary cysts are very common and if small, needs no investigation. There are many case reports in the literature about transplanting kidneys from deceased donors with adult polycystic kidney disease, without any short-term complications. These grafts should only be used when the donor kidney function is good and the recipient is fully aware of the donor disease. These cases are best suitable for sedentary recipients with a short life expectancy,

provided that no other contraindication such as HLA mismatch is found.

before starting the anterior layer, preferably by another suture line.

**6. Unusual situations**

178 Current Issues and Future Direction in Kidney Transplantation

and anatomy.

the living donors

After completing the vascular anastomoses, the opposite corner stay sutures remained untied until reperfusion. The recipient systolic blood pressure should be at least 120 mmHg and the central venous pressure between 10 to 14 cm H2O. The use of vasopressors such as dopamine for increasing the blood pressure is controversial. Immunosuppressant is best infused before declamping according to the protocols of each transplant ward. Some authors suggests some over-hydration, infusing Furosemide and Mannitol and correction of acid-base imbalance according to the last arterial blood gas base deficit before declamping to prevent the so called "reperfusion syndrome". Unlike liver or small bowel transplantation, in most cases reperfu‐ sion syndrome will not be a problematic issue, because the kidney graft is relatively small, except when using an adult kidney for a pediatric recipient or in cases of a long implantation time with complete aortic or common or external iliac artery clamping time. In such cases the cause of "reperfusion syndrome" is transient ischemia of the lower limbs. The anesthesiologist should prepare sodium bicarbonate, calcium gluconate, and insulin with 50% Glucose before declamping for managing this complication and obtain an arterial blood gas before and after the declamping for estimating the severity of acidosis and monitor the electrocardiogram for diagnosis of hyperkalemia.

Arterial declamping is done first and after complete filling of the graft, veins are also opened. In this phase brisk bleeding is a rule, especially when we applied "growth factors" to the last ties. Most of the bleeding will be stopped spontaneously after complete dilatation of the anastomotic lines. Small bleeding sites may be covered by small parts of any hemostatic agent such as Surgicel®, N-butyl cyanoacrylate glues, Tachosil® or similar agents (Sageshima J, et al, 2011) [13]. All the other larger bleeding sites should be transligated or repaired by fine Prolene® sutures especially near the hilum, but extreme caution should be paid not to include the delicate hilar arterial branches in the sutures.

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

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

Kidney Transplantation Techniques http://dx.doi.org/10.5772/54829 181

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

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

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

without any major urologic complication (Davari HR, et al, 2006) [22].

LG technique.

ureteral anastomosis.
