*7.7.6 Kidneys*

Kidneys are the last organs that will be removed. They may be procured en-bloc in line with aorta and IVC when both of them are programmed to transplanted to one person (for example from a pediatric or marginal donor for an adult recipient, or when we encounter with a horseshoe kidney with multiple renal arteries and veins) or retrieved separately. For separation, IVC is transected transversely just above the renal vein origins and then incised longitudinally to explore for possible multiple renal veins. All renal veins should be separated with a common patch of IVC. Separation of renal veins should be done with caution not to injure the renal arteries which run posterior to veins especially accessory undefined renal arteries. Ureters (sometimes double or rarely multiple) are completely separated from the surrounding tissues and transected distally in the pelvic rim, but the window tissues between kidneys and ureters and also between the ureters and gonadal veins should remain intact to prevent ischemia and future contracture or anastomotic failure. Renal arteries are exposed by longitudinal incision of the aorta to find multiple branches from inside the aorta and retrieval with a common patch. Rarely an accessory branch may originate from the iliac arteries or the other side of the aorta. It is better not to jeopardize such branches but the kidney transplant team should be capable of back-table microvascular reconstruction of several arterial branches in such cases. Left adrenal vein is ligated and transected as well.

After complete separation of all arterial and venous branches, kidneys are retrieved by medial to lateral movement by the surgeon with extreme caution not to over-retract these branches and induce intimal rupture. Also rupture of renal capsule has to be prevented by using sharp dissections specially in older marginal donors. It is better to perform these dissections outside the perirenal fatty tissues to prevent such inadvertent injuries.
