**4.3 Surgical steps**

As described in all transperitoneal approaches, we start by taking the colon off the kidney medially along the Toldt's fascia from the iliac vessels up to the colonic angle (splenic flexure on the left and hepatic flexure on the right). Gerota's fascia is left intact on the kidney (**Figure 5**). The lateral and parietal attachments of the kidney are left in place to prevent the kidney from slipping down and disturbing later the hilar dissection. We use from the start a LigaSure™ Maryland 5 mm (Covidien) sealing device. We then dissect and isolate the ureter inferiorly down to the iliac vessels with identification of the psoas muscle and the genital vessels. All periureteral and inferior renal pole fat must be well preserved to keep a wellvascularized ureter (**Figure 6**). Avoid any injury to the genitofemoral nerve and try to keep the psoas fascia in place. The gonadal vein can be divided proximally and distally and kept with the ureter in order to protect ureteric vascularity. This is thought to be the cause of postoperative ipsilateral orchialgia, which occurs in 6.2–9.6% of male donors [40, 41]. Large studies, however, have demonstrated that leaving the gonadal vein in situ does not lead to increased ureteric complications in the transplant recipient [42] and prevents orchialgia [40, 43].
