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Year : 2019  |  Volume : 13  |  Issue : 4  |  Page : 264-266

Upside-down kidney transplantation using single-suture single-knot technique

Department of Urology and Kidney Transplant Surgery, TU Teaching Hospital, Kathmandu, Nepal

Date of Submission13-Jun-2019
Date of Acceptance03-Nov-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Prof. Prem Gyawali
Department of Urology and Kidney Transplant Surgery, TU Teaching Hospital, Kathmandu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_18_19

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Aim: The aim of the study was to evaluate the outcomes of upside-down transplanted kidney with single-suture single-knot technique.Methods: From August 2013 till date, a total of 299 living-related kidney transplantations were done in the Department of Urology and Kidney Transplantation Surgery TU Teaching Hospital and Grande International Hospital, Kathmandu, Nepal. Out of them, 71 upside-down kidney transplantations were performed using single-suture single-knot technique. In this study, their overall outcome is evaluated. Results: Our study showed no difference in the overall outcome between upside-down and standard kidney transplantation and even less blood transfusion rate in upside-down group. Conclusion: There should be no hesitation to perform the upside-down kidney transplantation.

Keywords: Complications, single-suture single knot, upside-down kidney transplantation

How to cite this article:
Gyawali P, Poudyal S, Chapagain S, Luitel B, Chalise P, Sharma U. Upside-down kidney transplantation using single-suture single-knot technique. Indian J Transplant 2019;13:264-6

How to cite this URL:
Gyawali P, Poudyal S, Chapagain S, Luitel B, Chalise P, Sharma U. Upside-down kidney transplantation using single-suture single-knot technique. Indian J Transplant [serial online] 2019 [cited 2020 Sep 28];13:264-6. Available from: http://www.ijtonline.in/text.asp?2019/13/4/264/274600

  Introduction Top

Kidney transplantation is the best option for patients with end-stage renal disease. Although the first successful kidney transplantation was performed between identical twins in 1954, its number is in rise every year. According to global observatory for 2016 and transplantation 135,860 solid organ were estimated for transplantation and out of them 40.2% was living kidney transplant.[1] During transplantation, all graft kidneys are anastomosed with contralateral iliac vessels to insure that the renal pelvis and ureter are anterior, in the event that future surgery is necessary for surgical correction.[2] Very few articles are published about kidney transplantation on the ipsilateral side.[3],[4],[5] Kidney transplantation is a very delicate procedure with a very little window for error. Perfection in surgical technique and shortest possible warm ischemia time predicts the long-term outcome of the surgery. Despite improved surgical technique and better immunosuppressive drugs and technology, complications do occur and if not treated promptly may lead to catastrophic consequences. In this study, our aim is to evaluate the outcome of upside-down kidney transplantation.

  Methods Top

In our institutions till 2013, all donor kidneys were transplanted in its contralateral side (right donor kidney on the left and left donor kidney on the right iliac vessels), and two-point anastomosis technique was used with 6/0 polypropylene suture. However, August 2013 onward, first transplantations to the recipient were performed only on the right iliac vessels, regardless of donor side. Right donor kidneys were transplanted in the right side with upside-down position. All donor kidneys were placed in its desirable position on the right iliac fossa only then after vessels and ureter were anastomosed. Only one anchor suture was taken in the mid part of the recipient's vessel, and anastomosis was started from its proximal part using 6/0 double-arm polypropylene suture in a continuous fashion. The posterior wall was stitched first with one arm and the anterior wall with another arm of a suture. Single knot of the suture was made at its distal end only after releasing the vascular clamp. Ureteroneocystostomy was performed by the modified Lich-Gregoir technique with 5/0 polyglactin suture. In the past 11 years (from August 2008 to April 2019), 698 living-related kidney transplantations were done in Tribhuvan University Teaching Hospital, Kathmandu, and Grande International Hospital, Dhapasi, Kathmandu, Nepal. From 2013 onward, we have started upside-down kidney transplantation. In this period, a total of 299 renal transplantations were performed and were grouped into Standard (Group I – right kidney on the left and the left kidney on the right iliac vessels) and Upside down (Group II – the right kidney on the right iliac vessels) and were enrolled for the study. Their demographic baseline, postoperative graft function, surgical complications, and overall surgical outcome were studied. Statistical analysis was done using (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp). The associations between the categorical variables were studied through the Chi-square test or the Fisher's exact test. Independent t-test was applied for the continuous variables if the data satisfied the assumption of normal distribution; Substantially deviated data were analysed by Mann-Whitney U test.

The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity. The study has been approved by Institutional ethics committee ofInstitute of Medicine Tribhuvandas University Nepal IEC 250(6-11) E2-076/77.

  Results Top

Out of 299 kidney transplantations, 228 grafts were placed on the contralateral side and 70 (23.7%) right donor kidneys on the right side of the recipient using upside-down position. In one case, even left donor kidney was placed in the right iliac vessels using upside-down position due to its complex vascular anatomy. The demographic and baseline characteristics of patients were comparable in both the groups, as illustrated in [Table 1]. Similarly, postoperative creatinine and surgical complications were not statistically significant between the two groups [Table 2]. Surgical complications even when categorized specifically as vascular and ureteric complications were comparable between the two groups. Graft nephrectomy was needed in one case of Group-I for ischemic graft due to the external iliac artery dissection, and the same case succumbed to death due to the graft loss, ventilator-associated pneumonia, and sepsis. Similarly, one mortality in Group-II was due to the Takayasu arteritis leading to poor graft perfusion with delayed graft function and sepsis because of ventilator-associated pneumonia.
Table 1: Demographic and baseline characteristics

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Table 2: Postoperative outcome

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  Discussion Top

While using two-point anastomosis technique (we named it as a hanging method), the graft kidney is placed in its position only after the completion of vascular anastomosis. During anastomosis, the kidney should be turned on the left and right to prevent the stitching of the opposite sidewall. In this scenario, not always graft lies perfectly in the iliac fossa. If attention is not applied, the posterior wall of the vessels can be taken on stitch during anastomosis as well as kinking of the vessels can be encountered. None of the cases in upside-down group had renal artery stenosis. In single-suture single-knot technique, the graft kidney is placed in its favorable position before anastomosis. Only one anchor suture away from the surgeon is placed at the middle of the recipients' vessels. Posterior wall anastomosis is done under direct vision with 6/0 polypropylene suture. A knot is approximated only after the release of clamps which prevents purse-string effect [Figure 1]. Modified Lich-Gregoir technique is used for the ureteroneocystostomy using 5/0 polyglactin. The logic of performing upside-down kidney transplantation is that the right iliac vein is more superficial than on its counterpart, so vessels' mobilization is easier.[3] Issue of short length of donor vessels can be solved more easily in upside-down renal transplantation with no increase in vascular complications.[4],[5],[6] Vascular complications during kidney transplantation are mostly due to technical errors. While performing upside-down kidney transplantation, arterial anastomosis lies distal to venous anastomosis which makes procedure more easier. In single-suture single-knot technique, both anterior and posterior arterial walls are visualized perfectly which almost eradicates the chances of stitching the opposite wall and significantly decreases anastomosis complications. Purse-string effect of the suture is eliminated by knotting after releasing the vascular clamp. All our transplant surgeons are right handed, so it is easier to them to perform transplantation on the right iliac vessels standing on the right side of the patient. Graft lies obliquely and parallel to the right iliac vessels, and pelvis–ureteric angle is more than 120°. Ureteral peristalsis persists even after transplantation and denervation of the ureter so if pelvis and ureter are facing obliquely; it does not cause urinary stasis.[7] Similar to our study, Ramesh S et al. did not find significant differences between postoperative complications between upright and inverted grafts.[3] In our study, three patients in Group-II developed ureteric strictures which required revision ureterocystoneostomy. The ureteric stricture was due to the skletonization of the ureter during harvesting, and nothing was related to the graft position. Simforoosh et al. in their study of 32 right laparoscopic donor nephrectomies with short renal vein underwent upside-down kidney transplantation, found two ureteric complications which were managed surgically.[4] Similarly, Webb et al. did not report ureteric complications in their four cases of upside-down renal transplantation.[5] Although literature is still scarce regarding upside-down renal transplantation, available few studies with limited number of cases have shown it to be comparable with standard technique of kidney transplantation. In our knowledge, this study is largest in number (n = 71) of upside-down kidney transplantation published in literature and also shows no difference in result between the two groups.
Figure 1: Vascular anastomosis during and after knotting the suture. The figure on the left shows the single suture single knot technique of end-to-side anastomosis between donor renal vein and recipient's right external iliac artery. The right figure shows the completed anastomosis

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  Conclusion Top

Our study shows upside-down kidney transplantation using single-suture single-knot technique is easy to perform for right donor nephrectomy with no increase in vascular and ureteric complications.

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Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Global Observatory Donation and Transplantation. World Health Organization; 2016. Available from: http://www.transplant-observatory.org. [Last accessed on 2019 Mar 15].  Back to cited text no. 1
Morris PJ, Knechtle SJ. Kidney Transplantations: Principles and Practice. 6th ed. Philadelphia PA:Saunders Elsevier Surgical Techniques of Renal Transplantation; 2008. p. 159.  Back to cited text no. 2
Kakaei F, Nikeghbalian S, Malekhosseini SA. Kidney transplantation techniques. In: Rath T, editor. Current Issues and Future Direction in Kidney Transplantation. London: IntechOpen; 2013.p. 2831.  Back to cited text no. 3
Ramesh S, Taylor K, Koyle MA, Lorenzo AJ. “Inverted” positioning of renal allograft during kidney transplantation in children and adolescents: A single-institution comparative analysis. Pediatr Transplant 2019;23:e13365.  Back to cited text no. 4
Simforoosh N, Aminsharifi A, Tabibi A, Fattahi M, Mahmoodi H, Tavakoli M, et al. Right laparoscopic donor nephrectomy and the use of inverted kidney transplantation: An alternative technique. BJU Int 2007;100:1347-50.  Back to cited text no. 5
Webb J, Soomro N, Jaques B, Manas D, Talbot D. The upside down transplant kidney. Clin Transplant 2003;17:484.  Back to cited text no. 6
Leung VY, Metreweli C. Ureteric jet in renal transplantation patient. Ultrasound Med Biol 2002;28:885-8.  Back to cited text no. 7


  [Figure 1]

  [Table 1], [Table 2]


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