Renal transplantation remains the best mode of renal replacement therapy for the patients suffering from end stage of renal disease. Allograft survivals from 10 years vary from 46% for deceased donor to 58% for living donor transplants. Luckily, an improvement in immunosuppression leads to declining rates of graft failure from acute humoral and cellular rejection. Graft loss from interstitial fibrosis and tubular atrophy, still remains ever difficult and 10 year graft failure rates has not changed over the last decade. When the grafts fail, indications for surgical elimination of the late rejecting graft includes development of acute on chronic rejection, graft malignancy, infection and the desire to wean immunosuppression.
INTRACAPSULAR ALLOGRAFT NEPHRECTOMY:
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Intracapsular allograft nephrectomy (ICAN) facilitates the detection of the graft and that will provide reliable access to the renal hilum for secure vascular control. One main disadvantage of ICAN is a superior amount of donor tissue (capsule and urothelium) might be left in situ versus extracapsular allograft nephrectomy (ECAN), and this can leads to increase in allo-sensitization of the patient and compromise the probable for re-transplantation.
EXTRACAPSULAR ALLOGRAFT NEPHRECTOMY
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Initially the previous skin was cut and opened, and then the graft was identified. A capsulotomy was done and the plane in between the renal capsule and parenchyma developed by finger dissection till the hilum was identified.
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At this stage, a vascular clamp was taken to secure the entire hilum. The perseverance of a robust femoral pulse was set by palpation after every stage of the procedure, and the graft was excised above the clamp.
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The hilum was protected by a running continuous horizontal mattress 2.0 prolene suture instantly below the clamp, and releasing of the clamp was done.
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A second running continuous suture is used to support the initial layer
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An ECAN was done after entering the retroperitoneal space from the old transplant incision. The whole kidney was dissected out with total isolation of the ureter and the renal artery and vein.
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These vascular structures are individually ligated and with heavy 0.0 or 1.0 silk sutures they need to divide.
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The ureter is dissected out from the bladder and ligated with vicryl ties and separated instantly
above its insertion into the bladder.
