Fig 1 - uploaded by Ernest Pang Chan
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Diagrams for orthotopic kidney transplants (OKT) performed in current series. (A) Case 1 OKT with left donor kidney. (B) Case 2 OKT with right donor kidney; ureteral anastomoses to ileal conduit. (C) Case 3 OKT with right donor kidney.
Contexts in source publication
Context 1
... age of donor was 43 years; all were standard criteria donors. Technical aspects of OKTs are listed in Table 2. Diagrams of arterial, venous, and urinary anastomoses are found in Figure 1. No patients experienced graft rejection. ...
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Citations
... Other anastomoses have also been reported: end-to-side anastomosis to the aorta 2-7 and anastomosis to the inferior mesenteric artery 2 or common iliac artery. 8 We consider uretero-ureteral anastomosis to be technically simple and easy. Moreover, if urine leakage develops, subsequent complications can be avoided by separation between the ureteroureteral anastomosis and the vascular anastomotic site. ...
Introduction
Orthotopic kidney transplantation is an option when heterotopic kidney transplantation into the iliac fossa is inappropriate. We report a case of orthotopic kidney transplantation following stenting of both external iliac arteries to treat arteriosclerosis obliterans.
Case presentation
A 56‐year‐old woman on hemodialysis for end‐stage kidney disease underwent living‐donor kidney transplantation. Desensitization therapy was administered because of her history of sensitization by pregnancy. Stents had been placed previously in both external iliac arteries. The left kidney was removed via an oblique lumbar incision. The two graft arteries were conjoined and anastomosed to the native renal artery end‐to‐end. The urinary tract was reconstructed by uretero‐ureterostomy with ureteral stent placement. Renal function improved promptly after surgery.
Conclusion
Preoperative imaging of vascular anatomy is important for successful orthotopic kidney transplantation in patients who have previously undergone stenting of both external iliac arteries for arteriosclerosis obliterans.
... Other conditions, like inferior vena cava (IVC) thrombosis, agenesia, or stenosis, could require OKT. Chan et al. have published a series of 3 cases of OKT in this scenario [12]. ...
Introduction:
Transplantation surgery teams often have to face complex cases. In certain circumstances, such as occlusion of the iliac vessels or prior pelvic surgery, heterotopic kidney transplantation may not be feasible and orthotopic kidney transplantation (OKT) could be a good alternative. Kidney autotransplantation (KAT) has been described as a potential treatment for complex renovascular, ureteral, or neoplastic conditions. There are scarce data regarding the complications and outcomes of these procedures; therefore, we present our experience.
Materials and methods:
We retrospectively analysed the medical records of both 21 patients who had received OKT and 19 patients who underwent KAT between 1993 and 2020. We collected demographic features and data regarding surgical technique, complications, and graft outcomes. Kidney graft survival was calculated using Kaplan-Meier survival analysis.
Results:
Regarding OKT, in 15 (71.43%) cases, it was the first kidney transplantation. The most common indication was the unsuitable iliac region due to vascular abnormalities (57.14%). The early postoperative complication rate was high (66.67%), with 23.81% of Clavien grade 3b complications. During the follow-up period (mean 5.76 -SD 6.15- years), we detected 9 (42.85%) graft losses. At 1 year, the survival rate was 84.9%. Concerning KAT, the most frequent indication was ureteral pathology (52.63%), followed by vascular lesions (42.11%). The overall early complication rate was 42.11%. During the follow-up period (mean of 4.47 years), 4 (15.79%) graft losses were reported.
Conclusions:
Although OKT and KAT have high complication rates, these techniques can be considered as two valuable approaches for complex cases, in the absence of other therapeutic options.
... Rodrigues et al. described four cases (two young people and two older than 60 years old) with severe atherosclerosis [25]. Furthermore, Chan et al. showed three patients (two young and one older than 60 years old) with inferior vena cava (IVC) thrombosis or stenosis [26]. On the other side, Novotny et al. described a patient with a papillary renal cell carcinoma recurrence who underwent radical nephrectomy, along with an OKT [27]. ...
Purpose
To determine graft and patient survival and adverse events in patients who undergo orthotopic kidney transplantation.
Methods
We performed a systematic review and meta-analysis. We search in Medline, Embase, and Central from inception to nowadays. We included observational studies with patients who undergo orthotopic kidney transplantation. The primary outcomes were overall patient and graft survival. We pooled the information in a frequency meta-analysis with a 95% CI. We analyzed bias with the STROBE statement.
Results
Of the 106 papers initially retrieved, four met the inclusion criteria. Vascular and urinary tract complications were reported in 19% and 15%, respectively. The overall patient survival was 92% 95%CI (88% to 95%), I2 = 0%, and the overall graft survival was 88% 95 CI (83% to 91%), I2 = 0%.
Conclusion
Our analysis showed a high survival rate in patients and kidney grafts after orthotopic kidney transplantation, with a similar complication rate compared to a heterotopic kidney transplant.
The iliac fossa is the most commonly used site to place the graft in renal transplantation in adults. However, iliac fossa may not be used in various conditions. Thus, orthotopic renal transplantation becomes a viable alternative for these selected patients. Given the technically challenging surgery and limited number of patients, data on the long‐term outcomes on this regard are scarce. This narrative review serves as an update on the clinical outcomes after orthotopic renal transplantation, focusing on overall recipient survival and renal graft survival, as well as postoperative complications. We found that studies to date showed a comparable survival rate in both recipients and renal grafts in the postoperative follow‐up period after orthotopic renal transplantation with a lower complication rate compared to the published data on heterotopic renal transplantation. The results of our review may encourage transplant centers to reevaluate their policies to consider orthotopic renal transplantation as an alternative technique in cases where heterotopic kidney transplantation is not possible.
Purpose of review:
Nowadays many ESRD patients awaiting kidney transplantation have known unsuitable iliac vessels for vascular anastomosis, due to severe atheromatosis, occupied iliac fossa, or other uncommon vascular abnormalities. In these cases, orthotopic kidney transplantation (OKT) could be the solution.
Recent findings:
Since the update on OKT published in 2010, no more large series have been reported. Some small series or case reports being described in the literature. The orthotopic position has shown good recipient and graft results with acceptable complication rate in selected patients. This technique permits the possibility of kidney transplantation, in patients unfit for heterotopic kidney transplantation (HKT), and consequently the avoidance of the dialysis treatment. In this paper, we review what is new in the literature, analyzing indications, technique, and results of this surgical approach.
Purpose of Review
To update the most relevant literature regarding complex cases during kidney transplant setting that recipient presents by himself, especially during implantation surgery due to vascular diseases and/or urinary tract anomalies.
Recent Findings
Increasing age of donors and recipients is leading to an increased complexity of kidney transplant implantation surgery. In addition, the high peripheral vascular disease prevalence worldwide increases difficulty of surgery and decreases long-term outcomes as well. Moreover, it also increases transplant morbidity and mortality, both overall and cardiovascular, and finally clearly decreases graft survival. However, dialysis alternative has even worse outcomes in terms of mortality, with a proportional risk of death 2.66 higher compared with transplanted patients. Aorto-iliac prosthesis and 3rd and 4th transplants in occupied iliac fossae do also represent a challenging situation with a clearly increased morbidity and mortality. In some of those particular conditions, orthotopic kidney transplant technique is an alternative with good functional and survival outcomes, but not exempt of complications.
Summary
Kidney transplant in vascular complex recipients has worse outcomes compared with conventional non-risky population. It remains a challenging surgical and medical procedure with higher morbidity and mortality, and decreased graft survival. However, dialysis mortality is still even greater and a transplant attempt might be justified. Orthotopic kidney transplant technique might play a role in selected patients with aorto-iliac unworkable segments or even in patients with special urinary tract conditions.
El trasplante renal es el mejor tratamiento para pacientes con enfermedad renal crónica terminal (ERCT). La complejidad, tanto médica como quirúrgica de los pacientes que se enlistan, es cada vez mayor y, por lo tanto, no siempre es posible realizar un trasplante renal heterotópico. Se presenta el caso de un paciente de 28 años que fue sometido a un trasplante renal ortotópico de donador vivo relacionado de manera exitosa, debido a agotamiento de accesos vasculares. Este caso se trató de un paciente joven con múltiples comorbilidades (catéteres, peritonitis, infecciones, trombosis femoral, estenosis de vena cava superior), lo cual dificultó la colocación de accesos vasculares y, finalmente, se tuvo que utilizar el acceso derecho que se estaba reservando para el trasplante, quedando finalmente el trasplante heterotópico como única opción viable, el cual se pudo realizar de manera exitosa. Palabras clave: Trasplante renal, ortotópico, donador vivo.
