Investigation of a method for long-term preservation of the vascular allograft.

BACKGROUND/OBJECTIVE: During multiple organ procurement, blood vessels are routinely retrieved and stored in University of Wisconsin solution and then discarded after two weeks, if not used at organ transplantation owing to lack of a method for long-term preservation. Therefore, the aim of this study is to investigate a method for long-term preservation of vascular allografts in ethanol. METHODS: Aorta and vena cava allografts were retrieved and stored in 75% ethanol solution for 12 months at 4°C. Four pigs were divided into two groups. A segment of aorta was excised and replaced by insertion of preserved aorta graft (Group A) or vena cava graft (Group V). The pigs were observed for six weeks. A laparotomy was performed and the vascular graft was harvested for histopathology followed by euthanasia at the end of study. RESULTS: Three pigs recovered uneventfully, while one pig died from venous graft rupture in the third week after surgery. There was no aneurysmal formation or thrombosis in the grafts. Some calcification was seen over aorta allograft. On histopathology, the elastic pattern was almost normal, although the endothelial cells degenerated after preservation. After implantation, the formation of the endothelium cell-like layer was seen in both aorta and vena cava allografts. CONCLUSION: Vascular allografts were functional after preservation for 12 months. The vena cava grafts had much less wall calcification than the aorta grafts. Further studies are necessary to investigate vascular graft remodelling with a longer observation period after implantation.

Long-Term Outcomes of the Flixene Vascular Graft Used for Haemodialysis.

Introduction The Flixene™ vascular graft (Maquet-Atrium Medical, Hudson, NH) has emerged as a new generation synthetic graft, which allows for early needling for haemodialysis. Most studies have shown satisfactory early results. The aim of this study is to report on long-term outcomes of the Flixene graft over eight years in a cohort of patients. Methods From February 2011 to September 2019, 61 patients had 64 arteriovenous graft fistulas (AVGs) by using the Flixene grafts. The median patient age was 67 years; the male to female ratio was 30:31. Diabetes was the reason for the majority of kidney failures (57%). The configuration of the grafts used was mostly upper arm straight AVG. The primary patency rate, secondary patency rate, and surgical complications were assessed. Results In a median follow-up of three years (interquartile range (IQR): 2 - 6), 36 of the AVGs required a fistulogram. Venous side stenosis was the most common cause of high venous pressure or AVG occlusion in 97%. The one-year primary patency rate was 30%. The secondary patency rate was 94.8%, 83.7%, and 77.7% at one, three, and five years, respectively. The longest functional AVG was observed for up to seven years. Conclusions This study has shown satisfactory long-term results of the Flixene graft used for hemodialysis. The Flixene graft could be needled within 72 hours without increased complications, which allows the creation of an AVG under an emergency setting to avoid the placement of a central venous catheter (CVC). This strategy should be advocated in future clinical practice.

Outcomes of Early Simultaneous Removal of Ureteric Stent With Indwelling Urethral Catheter After Kidney Transplant in Pediatric Recipients: A 10-Year Review.

OBJECTIVES: A ureteric stent is routinely placed to minimize urological complications during kidney transplant. However, some complications may occur in association with the ureteric stent, such as urinary tract infections, and the optimal duration for stent placement is unclear. We reviewed the outcomes following early simultaneous removal of the ureteric stent with the urethral catheter in pediatric kidney transplant recipients. MATERIALS AND METHODS: We reviewed all kidney transplants from January 2009 to January 2019. The data we collated included demographics, donor and recipient characteristics, and perioperative details, including urological complications, stent-related complications, and kidney graft function. The financial cost of late stent removal was calculated. The early stent removal group was defined as 5 days, and the late removal group was about 4 to 6 weeks. The median follow-up time was 60 months (interquartile range, 31.5-91 months). RESULTS: There were 32 transplants in 31 patients during the study period (early vs late group = 23:9). No urine leak occurred in either group. One patient in the early group developed distal ureteric stenosis, and this condition was managed with interventional balloon dilatation. The median time for stent removal was 6 days in the early group and 39 days in the late group. There were 5 episodes of symptomatic urinary tract infections in 3 patients in the early group and 10 episodes of symptomatic urinary tract infections in 3 patients in the late group. The mean estimated glomerular filtration rate at 12 months was comparable between the 2 groups (84 ± 54 vs 64 ± 21 L/min/1.73 m²; P = .3). The average cost for each early removal was A$772.65 compared with the late group. CONCLUSIONS: Early simultaneous removal of the ureteric stent with the urethral catheter in pediatric kidney transplant recipients is feasible, safe, and cost-effective.

Long-term outcome of kidney transplant by using restored kidney grafts after tumour ex vivo excision - a prospective study.

The aim of this study is to report long-term outcomes of kidney transplantation by using the kidney graft after a small tumour ex vivo excision. A structured programme was established to use the restored kidney graft from urological referral after radical nephrectomy. The criteria were defined as tumour size ≤3 cm, margin clear on frozen section and recipients aged ≥60 years or those on the urgent list for transplantation as a result of imminent lack of dialysis access. The recipients were followed up regularly for surveillance of tumour recurrence. Between February 2007 and February 2018, 28 recipients had kidney transplantation by using the restored kidney grafts. The tumour size was 2.6 ± 0.7 cm. The follow-up was median 7 years without evidence of tumour recurrence. The patient and graft survival was satisfactory. Kidney transplantation by using restored kidneys after a small tumour excision is a novel source for selected recipients. The long-term patient and graft survival is satisfactory. Although there is a risk of tumour recurrence, it is rare event. Together with literature review, we would support use of kidney graft after a small tumour excision for selected recipients.

Weekend effect on early allograft outcome after kidney transplantation- a multi-centre cohort study.

Weekend surgery may be associated with a higher risk of early complications, but the effect of the timing of kidney transplant surgery on early allograft outcome remains uncertain. The aim of this study is to evaluate whether the association between weekend transplant surgery and allograft failure was modified by prevalent vascular disease. Using data from the Australia and New Zealand Dialysis and Transplant registry, we examined the association between weekend status and 90-day and 1-year allograft failure in deceased donor transplant recipients between 1994-2012. Two-way interaction between vascular disease and weekend status was examined. Of 6622 recipients, 1868 (28.2%) received transplants during weekends. Compared with weekday transplants, weekend transplants were associated with an adjusted hazard ratio (HR) for 90-day and 1-year allograft failure of 0.99 (0.78-1.25; P = 0.917) and 0.93 (0.76-1.13, P = 0.468), respectively. There was a significant interaction between prevalent vascular disease and weekend status for 90-day allograft failure (Pinteraction = 0.008) but not at 1-year, such that patients with vascular disease were more likely to experience 90-day allograft failure if transplanted on weekend (versus weekdays), particularly failures secondary to vascular complications. Timing of transplantation does not impact on allograft outcome, although those with vascular disease may benefit from more intensive post-transplant follow-up for potential vascular complications.

Multiple refinements to the anaesthetic protocol for laparoscopic orthotopic kidney auto-transplantation in a pig model.

Fifty-four pigs ( Sus scrofa, Large White cross) from a commercial pig farm were anaesthetised over a six-year period from October 2011. The procedural stages included initial instrumentation for intra-operative monitoring, laparoscopic nephrectomy, preparation of the kidney graft, orthotopic auto-transplantation by either a laparoscopic approach or an open surgical approach, and ligation of the contralateral ureter. During the evolution and establishment of this pig model multiple refinements were introduced: (1) a heat pad was changed to a circulating warm air blanket; (2) routine administration of anticholinesterase and antimuscarinic drugs for reversal of neuromuscular blockade; (3) a technique for urethral catheterisation was developed; (4) ultrasound guidance for placement of a central venous line was learned; (5) intravenous infusions of morphine and ketamine were instituted for a more stable and balanced anaesthetic protocol; and (6) post-operative monitoring was performed by two technical staff for at least the first six hours after extubation of the trachea. The combination of refinements to the anaesthesia protocol for laparoscopic orthotopic kidney auto-transplantation over the first 54 pigs has translated to improved outcomes. This conclusion is entirely subjective as accurate measurement of the impact of each refinement is impossible. Nevertheless, refinement is a continuous process and should be applied to the entire range of procedures involved in animal use for scientific purposes.

Feasibility of Laparoscopic Combined Para-Orthotopic Pancreas and Orthotopic Kidney Transplantation: Initial Research with a Pig Model.

BACKGROUND The aim of this study was to investigate the feasibility of laparoscopic combined para-orthotopic pancreas and orthotopic kidney transplantation in a pig model. MATERIAL AND METHODS Twelve white female pigs, (4-5 months old, weight range 40-45 kg) were used as donors and recipients, and 6 laparoscopic-combined pancreas and kidney transplantations were performed. After bilateral nephrectomy, the pancreatic artery and vein were anastomosed to the right renal artery and vein, respectively, and the pancreatic fluid was diverted to the duodenum or jejunum. The renal artery and vein were anastomosed to the left renal artery and vein, respectively. The ureter (or kidney pelvis) was anastomosed to the left native ureter (or kidney pelvis). The data of the operations were recorded, and grafts were inspected at autopsy. RESULTS Four of the 6 recipient pigs underwent the entire procedure. The duodenum-to-duodenum anastomosis was unfinished in 1 case, and both the duodenum-to-duodenum and renal pelvis-to-pelvis anastomoses were left unperformed in another case. The mean recipient operative time was 429±43 minutes. The mean venous and arterial anastomotic times were 69±15 minutes and 37±18 minutes, respectively, for pancreas transplantation and 56±09 minutes and 42±06 minutes, respectively, for kidney transplantation. The time for renal pelvis-to-pelvis anastomosis was 56±13 minutes and for duodenum-to-duodenum anastomosis was 90±13 minutes. The mean blood loss for recipient pigs was 98±35 mL. An immediate viable blood supply was seen in the 4 pancreatic grafts and in the 5 kidney grafts during the operation by the appearance of a bright red color after revascularization. Five pancreatic grafts had autopsy-proven reliable artery anastomoses and 4 reliable vein anastomoses. All 6 kidney grafts had autopsy-proven reliable artery anastomoses; however, 1 had a vein anastomotic stricture. CONCLUSIONS Our study showed that laparoscopic-combined para-orthotopic pancreas and orthotopic kidney transplantation in pigs is surgically possible.

Outcomes of Kidney Transplantation by Using the Technique of Renal Artery Anastomosis First.

Introduction The surgical technique for kidney transplantation has been well established: the renal vein is anastomosed first, followed by renal artery anastomosis. Alternatively, the renal artery can be anastomosed first and then the renal vein for kidney transplantation. However, there is a lack of data on the outcomes of kidney transplantation by using this alternative approach. The objective of this paper was to review the outcomes of kidney transplant by using this approach. Methods A review of 205 consecutive kidney transplants was conducted. All kidney transplants were performed by doing renal artery anastomosis first and then the renal vein. Data were collected, including vascular/urological complications and kidney graft function. Results All transplants were performed successfully with no occurrence of renal artery/vein thrombosis and urine leakage. There were five cases of renal artery stenosis that were managed with endovascular intervention. There was no recurrence on follow-up. One ureteric stenosis required surgical reconstruction. Conclusions This alternative vascular anastomotic technique is efficient and safe. It avoids flip-flopping the kidney graft during the vessel anastomoses and may be more practical in minimally invasive surgery for a kidney transplant due to the space constraint.

Establishment of laparoscopic live donor nephrectomy in a porcine model: techniques and outcomes in 44 pigs.

BACKGROUND: Laparoscopic live donor nephrectomy has replaced open donor nephrectomy in most patients due to numerous benefits. A live animal model is required to equip surgeons with the necessary skills to perform such a procedure with minimal risk of complications. The aim of this study was to establish the technique for laparoscopic live donor nephrectomy in a porcine (Sus scrofa) model. MATERIALS AND METHODS: This study was approved by the Animal Ethics Committee of the university. Forty-four pigs underwent laparoscopic live donor nephrectomy. The left kidney was removed with a standardized four-port technique, with a small suprapubic incision to facilitate kidney delivery. RESULTS: All 44 procedures were performed successfully, with no intraoperative complications or conversion to open surgery. There was no apparent damage to any of the kidney grafts. The mean surgical time was 118.3 (±20.7) minutes. There was a small, but statistically insignificant, decrease in surgical time throughout the duration of the study. Several subjects had minor variations in the anatomy of the renal vasculature. CONCLUSIONS: This series has developed and proven a training model for laparoscopic donor nephrectomy in pigs. This training model will allow surgeons to develop laparoscopic proficiency in a live donor, to be used in conjunction with human cadaveric training.

A Proposed Classification System and Therapeutic Strategy for Chyle Leak After Laparoscopic Living-Donor Nephrectomy: A Single-Center Experience and Review of the Literature.

OBJECTIVES: Chyle leak or chylous ascites remains a rare complication after laparoscopic living-donor nephrectomy. Its cause and management have not been well elucidated in the literature. Thus, the aim of this study was to review the incidence of chyle leak/chylous ascites after laparoscopic living-donor nephrectomy in our institute and in the literature to propose a classification system with its associated treatment strategy. MATERILAS AND METHODS: In this retrospective review of laparoscopic living-donor nephrectomy patients from January 2005 to April 2016, we identified patients with chyle leak/chylous ascites along with the care performed. A proposed classification system based on our experience and literature is described. RESULTS: Chylous leak developed in 4 donors (2.25%). Of the 4 donors, 3 were treated nonoperatively with diet modification and subcutaneous octreotide injection. One patient required surgical intervention after not responding to second-line therapy with total parenteral nutrition. CONCLUSIONS: Chyle leak/chylous ascites after laparoscopic living-donor nephrectomy is rare, but a delayed diagnosis may lead to morbidity secondary to malnutrition and immunosuppression. Meticulous surgical dissection is essential to seal the lymphatic tubes during laparoscopic living-donor nephrectomy. The proposed classification system provides a practical and tailored guide to management based on the drainage volume of chyle leak and a guide to the earlier identification of refractory cases.

Transition from laparoscopic to retroperitoneoscopic approach for live donor nephrectomy.

BACKGROUND: Laparoscopic donor nephrectomy has become the standard of care due to multiple benefits. Currently, there are various techniques employed with two different approaches: transperitoneal (TLDN) or retroperitoneoscopic (RLDN) approach. There is a lack of data to determine which technique is superior, although the RLDN offers an anatomical advantage by avoidance of manipulation of the intraperitoneal organs. The aims of this study were to explore the merits of RLDN to TLDN and assess the learning curve of transition from TLDN to RLDN. METHODS: From January 2010 to February 2017, 106 live donor nephrectomies were performed: 56 by TLDN and 50 by RLDN. Data on patient demographics, perioperative parameters, analgesic consumption, pain scores, and kidney graft function were collected and analysed. Data were compared with a Student's t test or Mann-Whitney test. A CUSUM analysis was performed to investigate the learning curve. RESULTS: All live donor nephrectomies were successful with no conversion to open surgery. There was no blood transfusion, readmission, or mortality. No postoperative complications were graded over Clavien II. Kidney function was comparable in both groups. The follow-up period ranged from 3 to 78 months. CONCLUSION: Retroperitoneoscopic live donor nephrectomy is a safe approach with comparable results to TLDN. RLDN has an anatomical advantage as it avoids manipulating the intraperitoneal organs and retains a virgin abdomen and hence translates to a lower perioperative complication risk.

Horner Syndrome in 2 Pigs (Sus scrofa) after Vascular Grafting of the Carotid Artery and Jugular Vein.

The term Horner syndrome refers to the clinical presentation of oculosympathoparesis, comprising miosis, ptosis, and facial anhydrosis. To date, there are 2 reports of postoperative Horner syndrome in pigs. In this species the cervical sympathetic chain and cranial cervical sympathetic ganglion are consistently within the carotid artery sheath. This case study describes the sudden onset of Horner syndrome in 2 pigs, from a study cohort of 8, after the placement of a vascular graft between the carotid artery and external jugular vein. Anesthesia and surgery was uneventful in all the pigs in the study, but 2 pigs demonstrated clinical signs including ptosis, enophthalmos and prolapse of the nictitating membrane immediately after recovery from anesthesia. Horner syndrome was diagnosed in light of the clinical signs. These clinical signs persisted throughout the 2-mo study period and did not appear to improve or deteriorate in that time. Gross examination of the surgery site at the end of the study did not reveal an obvious lesion in the carotid artery sheath. The risk of Horner syndrome after surgery involving the carotid artery in pigs had not been reported prior to this study. Without specific measures to protect the cervical sympathetic ganglion during surgery, the incidence of postoperative Horner syndrome was 25% in our population of pigs. Although the welfare implications of this syndrome are minimal, concerted effort to avoid intraoperative damage to the cervical ganglion is essential for future work.

A comparative study on the efficacy of a retrograde perfusion technique and an antegrade perfusion technique for donor kidney recovery in transplantation in pigs.

BACKGROUND: Donor organ shortage is a significant problem in kidney transplantation. Improvement of perfusion techniques can increase the number of available organs. The aim of this study is to investigate the efficiency and safety of retrograde perfusion (RP) of kidney grafts during organ recovery after transplantation in pigs. METHODS: Ten pigs were divided into two groups, six in the study group for the RP technique and four in the control group for standard antegrade perfusion (AP). The left kidney was removed and perfused by the RP or AP method according to the study group. The perfused left kidney was auto-transplanted to the right groin location. The right kidney was removed and perfused in the same manner and then stored at 4 °C for 24 h prior to histopathological analysis. Data in both groups were observed and recorded. RESULTS: All kidneys perfused by both the RP and AP methods were satisfactory in appearance. All grafts showed diuresis from the first postoperative day onward. On postoperative day 7, the mean serum creatinine (Scr) and blood urea nitrogen (BUN) levels were 174 ± 9.7 ìmol/L and 27.7 ± 2.5 mg/dL in the RP group, and they were 168 ± 13.7 ìmol/L and 26.5 ± 4.3 mg/dL, respectively, in the AP group (p = 0.483 for Scr and p = 0.646 for BUN). The mean peak Scr levels in the RP group (570 ìmol/L) and the AP group (530 ìmol/L) were similar. All pigs survived with adequate renal function throughout the study period. There was minimal interstitial and tubular edema, and there was endothelial cell swelling in some specimens before revascularization in both groups. At postoperative day 7, the auto-transplanted kidneys showed normal glomerular and tubular structure with little interstitial edema and inflammatory cell infiltration in the grafts. No differences were identified between the two groups. Under electron microscopy, the tubular epithelial cells, glomeruli, and glomerular capillary endothelium of the grafts appeared normal in both groups after 24 h in cold storage. CONCLUSIONS: Kidney grafts in pigs perfused by RP had normal function after transplantation compared with the AP control group. Therefore,retrograde perfusion is potentially an efficient, safe kidney perfusion method for organ recovery.

Evaluation of Three-Dimensional Versus Conventional Laparoscopy for Kidney Transplant Procedures in a Human Cadaveric Model.

OBJECTIVES: There are increased reports that kidney transplant can be performed by laparoscopic surgery. The further development of this technique could revolutionize human kidney transplant surgery. However, laparoscopic kidney transplant demands a high level of skill for vascular anastomoses. The emerging technology of the three-dimensional, high-definition laparoscopic system may facilitate the application of this technique. Therefore, in this study, we evaluated this system in performing kidney transplant surgery versus the two-dimensional laparoscopic system. MATERIALS AND METHODS: Four fresh-frozen human cadavers were used in this study, with 2 for the 3-dimensional and 2 for the 2-dimensional system. Kidneys were retrieved by using the retroperitoneoscopic technique for living donor nephrectomy from the same cadaver. The kidney graft was transplanted at the right iliac fossa using a laparoscopic technique by extraperitoneal approach. The procedure was recorded, and the vessel anastomotic time was analyzed. RESULTS: Kidney transplant procedures were conducted successfully in the 3-dimensional, high-definition and the 2-dimensional groups. We recorded no significant differences in terms of vessel anastomotic time between the 2 groups. The total surgery time was shorter in the 3-dimensional, high-definition group than in the 2-dimensional group (P = .02). CONCLUSIONS: This pilot study reinforces that kidney transplant with either the 3-dimensional, high-definition or 2-dimensional laparoscopy is feasible in a human cadaveric model. The operation was the same as open kidney transplant, but the procedure was performed by a laparoscopic approach with a smaller incision.

Determining the Superior Technique for Living-donor Nephrectomy: the Laparoscopic Intraperitoneal Versus the Retroperitoneoscopic Approach.

OBJECTIVES: Laparoscopic living-donor nephrectomy is now widely used because of its many beneficial features. Currently, there are 2 major techniques: the laparoscopic intraperitoneal approach and the retroperitoneoscopic approach. There is no evidence to support one particular approach over another. Therefore, in this study, we conducted a systematic literature review with the aim of defining which technique is superior. MATERIALS AND METHODS: The Embase, PubMed, and Cochrane literature databases were searched for English language articles published between January 1994 and January 2013 using the terms "laparoscopic donor nephrectomy," "retroperitoneoscopic donor nephrectomy," and "live donor nephrectomy." A meta-analysis was undertaken, and I(2) statistical analyses were used to describe the percentage of variation across studies due to heterogeneity rather than chance. RESULTS: With the use of our selection criteria, 55 papers on the laparoscopic intraperitoneal approach and 6 papers on the retroperitoneoscopic approach were included in this study. We found significantly lower transfusion rate, fewer patients with delayed graft functions, less vessel injuries, and less conversion to open surgical procedure with the retroperitoneoscopic approach than with the laparoscopic intraperitoneal approach. CONCLUSIONS: From this review, a high degree of study heterogeneity was identified, suggesting an urgent need for consistency in reporting laparoscopic living-donor nephrectomy. Results of the meta-analyses may define a better technique for the future. The retroperitoneoscopic approach may be better than the laparoscopic intraperitoneal approach with fewer complications and fewer patients with delayed graft function. Further study of laparoscopic living-donor nephrectomy is recommended to define a standard and thus to minimize the surgical morbidities.

A human cadaver model for laparoscopic kidney transplant.

OBJECTIVES: To evaluate the technique of laparoscopic kidney transplant and demonstrate the feasibility of this procedure by an extraperitoneal approach. MATERIALS AND METHODS: The procedure was performed on 2 human cadavers. Retroperitoneal endoscopic left nephrectomy was performed. An extraperitoneal space was established by inflation of a balloon dilator. The external iliac artery and vein were exposed. A Pfannenstiel incision (6 cm) was made and a hand-access device was used. The renal artery was anastomosed to the external iliac artery (end-to-side anastomosis); the renal vein was anastomosed to the external iliac vein (end-to-side anastomosis). The ureter was anastomosed to the bladder with an extravesical tunnelling technique. RESULTS: The donor kidney grafts were obtained successfully. The preparation of the external iliac artery and vein was satisfactory. The entire procedure for the renal artery, renal vein, and ureteral anastomoses was performed with laparoscopic technique without any difficulty. CONCLUSIONS: The present model on human cadavers may provide a feasible approach for training surgeons to perform human laparoscopic kidney transplant. The present technique may be applied to clinical human kidney transplant.

Laparoscopic surgery for kidney orthotopic transplant in the pig model.

BACKGROUND AND OBJECTIVES: Laparoscopic surgery has rapidly expanded in surgical practice with well-accepted benefits of minimal incision, less analgesia, better cosmetics, and quick recovery. The surgical technique for kidney transplantation has remained unchanged since the first successful kidney transplant in the 1950s. Over the past decade, there were only a few case reports of kidney transplantation by laparoscopic or robotic surgery. Therefore, the aim of this study is to develop a laparoscopic technique for kidney transplantation at the region of the native kidney. METHODS: After initial development of the laparoscopic technique for kidney transplant in cadaveric pigs, 5 live pigs (Sus scrofa, weighing 45-50 kg) underwent laparoscopic kidney transplant under general anesthesia. First, laparoscopic donor nephrectomy was performed, and then the kidney was perfused and preserved with cold Ross solution. The orthotopic auto-transplant was subsequently performed using the laparoscopic technique. The blood flow of the kidney graft was assessed using Doppler ultrasonography, and urine output was monitored. RESULTS: The laparoscopic kidney transplant was successful in 4 live pigs. Immediate urine output was observed in 3 pigs. The blood flow in the kidney was adequate, as determined using Doppler ultrasonography. CONCLUSION: It has been shown that laparoscopic kidney orthotopic transplant is feasible and safe in the pig model. Immediate kidney graft function can be achieved. A further study will be considered to identify the potential surgical morbidity and mortality after recovery in a pig model before translating the technique to clinical human kidney transplantation.

Laparoscopic surgery for orthotopic kidney transplant in the pig model.

BACKGROUND: Laparoscopic surgery has become the preferred approach in surgical practice due to multiple benefits. Over the last decade, kidney transplant by laparoscopic or robotic techniques have been explored. The aim of this study is to establish a new laparoscopic technique for kidney orthotopic transplant. MATERIALS AND METHODS: The study was approved by the Animal Ethics Committee of the University. Ten live female pigs (Sus scrofa), weighing 45-50 kg, underwent laparoscopic kidney orthotopic transplant on left side under general anesthesia, and the opposite right kidney was defunctioned by complete ligation of the ureter at the same time. RESULTS: The vital signs of all pigs were stable during the surgery and postoperative period. There were no intraoperative complications and no conversion to open surgery. The laparoscopic kidney transplant was successful in seven of 10 pigs. Seven pigs were observed up to 4 wk as planned in the study. DISCUSSION: To our knowledge, this is the first study of laparoscopic kidney orthotopic transplant in pig model with satisfactory immediate graft function. It was demonstrated that laparoscopic kidney transplant is a feasible, reliable, and safe procedure. However, it is a very demanding technique. Adequate training is mandatory for performing laparoscopic kidney transplant. This study could be used as a training model for surgeons who wish to perform human laparoscopic kidney transplant in the future.

Classification of ureteral stenosis and associated strategy for treatment after kidney transplant.

OBJECTIVES: Ureteral stenosis is a common complication after a kidney transplant. Treatment for ureteral stenosis ranges from interventional procedures to open surgery. The aim of this study is to present classification for ureteral stenosis and recommend the targeted strategy for effective treatment. MATERIALS AND METHODS: Twelve cases of ureteral stenosis were diagnosed among 193 kidney transplants, of which 91 were from a live donor and 102 from a deceased donor. The mean age was 46.22 ± 13.23 years. The diagnosis of ureteral stenosis includes serum creatinine elevation, hydronephrosis, and presence of stricture on a pyelogram. The criterion for classification is based on the severity of stricture. RESULTS: One of ureteral stenoses was classified as grade 1, six were grade 2, and five were grade 3. Of 12 cases, 10 were live-donor kidney transplant, 4 had lymphocele, and 2 had a hematoma after transplant. The corresponding strategy for each grade of ureteral stenosis is as follows: grade 1, ureteral stent reinsertion; grade 2, cutting balloon dilatation or endoscopic incision of stenosis; grade 3, open surgery urinary tract reconstruction. All cases were successfully treated using these strategies. CONCLUSIONS: This classification of ureteral stenosis provides guidance for effective management and avoids unnecessary procedures. In this series, ureteral stenosis was significantly associated with a live donor and surgical complications.