**3. Implantation site**

So many factors impact the surgeon's decision on which site he could implant the kidney graft (table 2). These factors include: the graft size comparing with the recipient, the size, length and number of graft arteries, veins and/or ureters, previous surgeries (for example previous failed kidney transplantation, previous pelvic exploration for bladder reconstruction or anti-reflux surgeries), associated abdominal organ (liver, pancreas or small bowel) transplantation, lateral‐ ity of the donor kidney (left or right), anomalies of the donor graft (horseshoe kidney, double pelvis, double ureter, etc.), and at last the number of kidney grafts (double kidney from a pedia‐ tric or old age or marginal donor). Traditionally the right iliac fossa is the standard fossa for a kidney transplantation procedure and the left iliac fossa is the preferred site for simultaneous kidney-pancreas transplantation. In the pediatric recipient when the graft is larger than usual we should use the main abdominal fossa for implantation. The most important limiting factor for each of these procedures is the length of the renal vein and also the length of the donor ureter and mobility of the recipient urinary bladder. In most instances when the recipient internal iliac artery is used as the arterial inflow, it provides a good length for mobilization and would not be a limiting factor. The right iliac fossa is the preferred site because of the more superficial posi‐ tion of the external iliac vein. The deep branches of the iliac vein can be suture ligated and cut if more superficialization is needed. If the recipient ureter is not diseased it can be used for urinary outflow reconstruction if the donor ureter is short.


**Table 2.** Factors influencing the choice of implantation site
