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BRAIN ATTACK:

Orthotopic Kidney Transplantation

By Dr. Anant Kumar in Urology

Mar 16 , 2023 | 2 min read

Kidney Failure (ESRD) is a common problem worldwide and in India. It is often associated with comorbid conditions such as diabetes, ischemic heart disease and hypertension. Kidney transplants have played an important role in the last six decades. Dr Joseph Murray performed the first successful kidney transplant between two identical twins in 1954 in Boston.

A renal transplant is considered the treatment of choice for patients with end-stage renal disease (ESRD) due to its superior short- and long-term survival benefits and very good quality of life. In addition, with the constant evolution of immunosuppressive therapy, and the improvement of the surgical technique, the list of contraindications has decreased. Consequently, many patients are ongoing for second, third and even fourth kidney transplants. A common trend for kidney transplants in our country is an increasing acceptance of older patients with associated comorbidity.

The standard surgical technique for kidney transplantation is to place the kidney in the extraperitoneal space of the lower abdomen with renal vein anastomosed to the external iliac vein and renal artery anastomosed to the internal or external iliac artery.

However, in certain circumstances, such as occlusion/atherosclerosis of the aortoiliac vessels or severe adhesions due to repeated previous pelvic surgery or both iliac fossae have already been used in previous transplantations, the kidney graft can be transplanted at the original location or immediately next to the native kidney. This is called an orthotopic kidney transplant (OKT). 

OKT was first described by Gil-Vernet et al. in 1978, and large series of OKT has demonstrated equivalent patient and graft long-term survival compared with heterotopic kidney transplant at the iliac fossa.

OKT is not commonly practiced in most transplant centres as it is technically more challenging. However, it should be considered in the following conditions:

  • Poor quality or occlusive iliac vessel disease
  • Multiple previous pelvic surgeries and extensive adhesions
  • Previous transplants in both fossae
  • Kidney transplant in small children
  • Contact sports players such as football/rugby

Surgical Techniques

This technique requires more surgical skills compared to the heterotopic kidney transplant; hence, currently, only a few centres worldwide have performed such an operation. OKT can be performed either at the left or right renal fossa through a flank or midline incision.

However, the left side is preferred. Nephrectomy is performed first with preservation of the longer renal vein, and often, the renal artery is atretic (does not have an opening) or diseased due to the original disease. The ureter is divided at a level superior to the pelvis ureter junction. If the renal artery is not suitable, the aorta, splenic or a branch of the hepatic artery is used for revascularisation.

The urinary tract is reconstructed by the renal pelvis to the native ureter over a ureteric stent.

We have performed 3 orthotopic kidney transplants in the last 5 years. All three are doing well in follow-up. One patient had very bad aorta and iliac vessels. The second patient had multiple vascular and pelvic surgery, and the third was the third transplant.

In summary, this technique is a complex one, and the native renal artery usually is atrophic and does not have enough flow to be used for revascularization. The urinary tract has to be carefully dissected for successful urinary drainage.

All such patients who undergo a renal transplantation must have their vascular anatomy evaluated by CT angio to confirm the possibility of performing a heterotopic transplant.