Nghiên cứu đặc điểm kỹ thuật và đánh giá kết quả phẫu thuật ghép thận lấy từ người cho sống tại bệnh viện việt đức tt tiếng anh

MINISTRY OF EDUCATION AND TRAININGMINISTRY OF DEFENCE

MILITARY MEDICAL UNIVERSITY
===========

DO NGOC SON

RESEARCH ON TECHNICAL CHARACTERISTICS
AND RESULTS OF LIVING-DONOR KIDNEY
TRANSPLANTION AT VIETDUC UNIVERSITY
HOSPITAL
Speciality: SURGERY
Code: 9720104

PhD. THESIS ABSTRACT

HA NOI– 2019


THIS WORK WAS COMPLETED
AT VIETNAM MILITARY MEDICAL UNIVERSITY

Scientific Supervisors:
1. Assoc.Prof. PhD. Nguyen Tien Quyet
2. Assoc.Prof. PhD. Hoang Long

Reviewer 1: Prof. PhD. Nguyen Thanh Liem
Reviewer 2: Assoc.Prof. PhD. Le Viet Thang
Reviewer 3: Assoc.Prof. PhD. Le Dinh Khanh

The thesis is presented at the Council of Vietnam Military Medical

University at: h(date) / (month)/2019

The thesis can be founded at:
1. Vietnam National Library
2. Library of Military Medical University
3. Library of Viet Duc University Hospital
LIST OF WORKS PUBLISHING RESULTS OF THESIS


1. Do Ngoc Son, Hoang Long, Vu Nguyen Khai Ca and Nguyen
Tien Quyet (2018). Ureterovesical reimplantation in renal
transplantation from living donor at Viet Duc Hospital. Vietnam
Journal of Medicine, Issue 2 November, 33-36.
2. Do Ngoc Son, Nguyen Tien Quyet, Hoang Long (2018).
Surgical results of living-donor kidney transplantation of Viet
Duc hospital. Vietnam Journal of Medicine, Issue 2 November,
1-4.
3. Do Ngoc Son, Hoang Long, Vu Nguyen Khai Ca và Nguyen
Tien

Quyet

(2018).

Surgical

results

of

ureterovesical

reimplantation in renal transplantation from living donor at Viet
Duc Hospital. Journal of Military Pharmaco-Medicine,Vol
43,N0 9, December, 158-162.


1
INTRODUCTION
1. The neccessary of the subject
Renal transplantation from living donors has become routine
surgery in many hospitals across the country with the technical
process agreed by the Ministry of Health since 2006. However,no
studies have yet evaluated kidney transplant results in case of the
renal artery anastomosed end-to-side with recipient’s iliac artery
(external or common iliac).
In addition, transplant centers tend to perform laparoscopic donor
nephrectomy, so the number of donor kidney with short vein is
increasing (especially the right kidney). A simple solution can be
used when kidney transplant in in the right iliac fossa, even when the
short vein, reducing the rate of renal transplant vascular plasty
without increasing complications is inverted kidney transplant. The
reports all over the world recognize the advantages of this technique,
but in Vietnam there are no topics to study the “inverted kidney
transplant” in kidney transplantation.
To evaluated the result of living donor kidney transplant with
end-to-side arteries anastomosis and applying inverted kidney
transplant technique in right iliac fossa, we performed the study:
“Research on the technical characteristics and the results of
living-donors kidney transplant at Viet Duc University Hospital”,

with objectives:
1. Research on technical characteristics of kidney transplant
surgery from living donor at VietDuc University Hospital.
2. Evaluate the result of living-donor kidney transplant at VietDuc
University Hospital.


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2. The new main scientific contributions of the thesis
The thesis is the first study which evaluate the result of livingdonor kidney transplant with inverted kidney transplant technique
and end-to-side arteries anastomosis between renal artery and
recipient’s iliac artery (external or common iliac).
From the result of this study may open a new direction for kidney
transplantation techniques: it is possible to apply inverted kidney
transplant in case right kidney transplants in the right iliac fossa or
left kidney transplants in the left iliac fossa .
3. Structure of the thesis
The thesis consists of 145 pages (introduction 3 pages, overview
38 pages, subjects and methods 25 pages, results 38 pages, dicussion
38 pages, Conclusion 2 pages, and Recommendation 1 page); with 42
tables, 28 images, 22 graphs and 17 figure. The thesis also used 130
references, 31 refs. in Vietnamsese and 99 refs. in English.
CHAPTER 1
OVERVIEW
1.1. The brief history of kidney transplant
On April 23, 1954, in Boston, Joseph E. Murray et al.
successfully performed kidney transplants foridentical twins and
survived for 8 years. After that, kidney transplantation has been
widely developed worldwide.
In Vietnam, the first successfully kidney transplant from a living

donor was conducted in 1992 at 103 Military Hospital. VietDuc
Hospital conducted kidney transplants from living donor since 2000
and now this operation becomes routine surgery.
1.2. Anatomy related to kidney transplant
1.2.1. Renal anatomy related to kidney transplant
A kidney consists of 2 planes, 2 poles, 2 edges and a hilum; with
12cm in length, 6 cm in width and 3cm thickness on average.


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Normally, there are 1 artery, 1 vein in renal hilum.
The renal veinis located in front of the artery. A kidney may have
1 or more arteries or veins. The veins are interlocked, so they can be
ligated at the root without serious problems. The length of renal vein
affects the choice of right of left donor nephrectomy, graft position
and suture techniques of the authors worldwide.
The ureter drains urine from the kidney to the bladder. The ureter
is only supllied by branch of renal artery.
1.2.2. Iliac vessels
The common iliac artery separates from the abdominal aorta to
the lower part, dividing into the external and internal iliac arteries.
The internal iliac artery may beligated the whole or its branches
on one or both sides, but the pelvic organs do not become necrotic.
External iliac arteries go from deep to shallow and often do not
have large lateral branches, so easy disclosure.
The right common iliac vein separates from inferior vena cava,
goes down and lies behind and internal of common iliac artery. It
divides into 1 or more internal iliac veins and goes parallel
posteriorly of external iliac artery. Therefore, surgeons often prefer to
choose a left graft into the right pelvis and vice versa.

1.3. Kidney transplant techniques
1.3.1. The kidney transpant incision and the natural compatibility
of vessels in graft position
1.3.1.1. The incision
Gibson incision often used in kidney transplantation.
1.3.1.2. Graft placement
There are 3 trends: taking the kidneys on any side, then grafting
into the opposite iliac fossa, or grafting into the same iliac fossa side,
or grafting all into the right iliac fossa. Some authors choose a low


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back position to place a graft in kidney transplantation for children or
for the third transplant.
1.3.2. Kidney transplantation technique
1.3.2.1. Graft preparation
Vascular plasty for graft arteries or veins in case of the variable
number of graft vessel: making 2 arteries into 1 main artery ‘gun
type’ when they are equivalent in diameter, or plant the pole artery
into main artery. It is possible to leave 2 arteries without plasty.
Grafts with many veins also treat similarly many arteries.
Graft ureter assessment: vessels, length and integrity of graft ureter.
1.3.2.2. Steps of procedure
- Step 1: General anesthesia
- Step 2: Skin incision, prepare graft hole
- Step 3: Graft placement
- Step 4: Vascular anastomosis
o Renal vein: end-to-side with external or common iliac vein
o Renal artery: end-to-side with external or common iliac artery
Renal with 2 arteries:

 Making 2 end-to-side anastomoses to external iliac artery;
or 1 anastomosis with external iliac artery, 1 anastomosis
with common iliac artery.
 Making 1 end-to-end anastomosis to internal iliac artery, and 1
end-to-side anastomosis with external or common iliac artery.
- Step 5: Loosening vascular clamp, evaluating the graft,
vascular anastomoses, ureter.
- Step 6: Reimplanting the graft ureter into bladder wall
+ Lich – Gregoir procedure
+ Politano – Leadbetter procedure
+ Others techniques.


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1.4. Complications of kidney transplant
1.4.1. Intra-operative complications
- Intra-operative bledding: identify the reason and resolve.
- Curvature, or kinking of anastomoses: re-suture.
1.4.2. Surgical complications of kidney transplant
1.4.2.1. Vascular complications
- Bledding, peri-graft hematomas.
- Vascular thromboses: the first graft-loss reason.
+ Renal vein thrombosis: Renal vein occlusion due to thrombosis
soon after transplantation is rarely seen and often involves technical
problems.
+ Spontaneous arterial thrombosis is rare.
Technically, there are three main causes of arterial thrombosis:
arterial injuries when nephrectomy, injuries of vascular endothelium,
or kinking/folding graft artery.
- Arterial stenosis:the most common postoperative complication.

- Chyle leakage, orchyle cyst: common in obesity, diabetes and
wound infection.
1.4.2.2. Urologic complications
- Urine leakage: technical failure or ureteral necrosis.
- Utereal obstruction or stenosis: due to extruding from outside,
lack of blood support, or uretero-vesical junction stricture.
- Ureteovesical reflux: the most common risk causing recurrent
urinary tract infection.
1.4.3. Medical complications
Internal medically, many factors can affect graft function.
Hyperacute graft rejection, acute rejection are the leading causes of
graft function decline in early stage. Exclusion should be performed
due to surgical techniques to provide timely and appropriate


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treatment. Graft biopsy is the gold standard to determine the medical
condition.
1.4.4. Some factors affect long-term graft function
Some studies have reported: factors such as HLA match, donor
age, duration of graft cold ischemia are factors that have been
confirmed to affect the results of kidney transplant.
Obesity increases the rate of delayedgraft function causing
patients to need dialysis in the first week after surgery, wound
infection and prolonged hospital stay.
CHAPTER 2
SUBJECTSANDMETHODS
2.1. Subjects
2.1.1. Subjects
Including 101 patient with end-stage kidney diseases, who were

indicated for kidney transplant from living-donor at VietDuc
University Hospital, from January 2011 to December 2013.
2.1.2. Criteria of exclusion
- The transplant operation is not in duration of study.
- It is not enough following time.
- It is not enough information and documents to data analysis.
2.2. Methods
2.2.1. Design of study
The descriptive longitudinal serial-cases study.
The subjects were divided into two groups: inverted kidney
transplant group and non- inverted kidney transplant group.
Perform inverted kidney transplant in case:
+ Right kidney donor transplants into the right iliac fossa
+ Left kidney donor have abnormalities in front of the arteries and
renal vein, making it difficult to anastomosis renal veins to external iliac
vein and kidney arteris to external or common iliac artery.


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2.2.2. Sample size
Non-probability samplign (101 cases).
2.2.3. Research content
The data was collected from couples of donor and recipientwho
were registered for kidney transplantation at Viet Duc hospital, with
all the selection criteria prescribed by the Ministry of Health and
according to the pre-set dossier format.
2.2.3.1. The common characteristics of recipients
- Demographic, chronic diseases (diabetes, hypertension…),
viral infetion (Hepatitis B/C virus…).
- Blood test: cell counts, biochemical analysis (ure, creatinin).

- Cystography,bladder volume calculation.
- Time of dialysis until before surgery.
- Blood group matching, HLA matching.
2.2.3.2. Graft characteristics
* Side of graft: right or left.
Selection of donorgraft based on assessment of renal function on
renal scintigraphy given. They all chose to take kidneys with less
function to transplant, keeping better kidneys for donor.
* Graft characteristics after irrigation.
The grafts after being taken from the donor irrigated with 1 litre
of cold Custodiol solution. After irrigating, record the characteristics:
shape, artery, vein and ureter.
2.2.3.3. Evaluation of graft after irrigation
- Good: Kidney is milk white, quite firmly; there is no injuries of
artery or vein, integrity of surrounding fat and vessels of ureter.
- Not good: There are injuries: lanceration, contusion or
hematoma of graft parenchymal, artery or vein.
2.2.3.4. Process of kidney transplant
- Patientposition: supine.


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- Graft placement: right iliac fossa.
- Skin incision: Gibson incision.
- Presenting right iliac fossa, assessing recipient’s vessels:
conventional anatomy or variant, number, size…; taking care not to
damage lymphatic vessel along with iliac vessels (assesment of all:
common/external/internal iliac vessel).
- Graft placement:
. Right kidney: Upside down (inverted kidney transplant).

. Left kidney: non- inverted kidney transplant.
- Vessels suturing: suture vein first, and the artery.
- Graft revascularization: loosening of vein clamp first and then
artery clamp.
- Ureter reimplantation: we use modified Lich-Gregoir
extravesical procedure with JJ-stent.
- Evaluate of graft condition after revascularizing:
o Good: Renal vessels are distended, no stricture, no zigzag, no
bleeding at anastomoses. Kidney is firmly, pink and excreting the urine.
o Not good:
+ Vessels anastomoses are not distended, or bleeding, or stricture
due to kinking or folding.
+ Kidney is soft, purple.
+ Kidney is firmly, pink but there are some areas with contusion,
ischemia, subcapsule hematomas…
+ Kidney is not firmly.
+ There is no excretion of urine, or slow down.
- Evaluate of renal function after revascularizing, blood support
and excretion of urine:
+ Kidney excretes urine during 60 sec (1 minute) after revascularizing:
early excretion.


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+ Kidney excretes urine in 1 minute or moreafter revascularizing: late
excretion.
+ No urine until the operation is done.
- Intra-operative complications:
+ Bleeding: from vessels of right iliac fossa, suturing.
+ Vessel thromboses: causing graft vessels obstruction; retaking

out the graft, thrombectomy, reirrigating and re-suturing the vessels.
- Treatment and follow-up.
+ Immunosuppresive agents.
+ Follow-up.
- Follow-up just after surgery, day 1, day 3 and discharge.
+ General conditionand wound.
+ Urine 24 hour, time of catheterization.
+ Drainage: output 24h and time of drainage.
+ Blood test:ure (mmol/l) andcreatinin (µmol/l)
+ Doppler ultrasonud, evaluate some graft characteristics:
vascularization, artery, vein, RI index, pelvis and ureter, fluid
surrounding graft in 2 or 3 day after surgery.
+ Hospital stay is counted from day of transplant to discharge.
- Criteria of discharge: general condition is stable,healed wound,
normal urination, renal function is normal or towards to normal
according to ure and creatinin index.
- Re-examine 1 per week.
2.2.3.5. Longterm followup (after discharge)
JJ-stent is removed 1 month after surgery.
Re-examine: renal function (ure, creatinin), graft ultrasound 1-36-12 months after surgery. It is possible to take Doppler ultrasound
for graft vascular, multi-slide CT-Scan, graft biopsy… in selected
cases with doubt of complications.


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2.3. Data analysis
Data is analyzed by STATA 12.0 software.
2.4. Ethics in research
We strictly adhere to the law on organ transplants from the
National Assembly, the Government and the Ministry of Health. The

research proposal was approved by the Military Medical Science
Council. The technical process of transplantation is approved by Viet
Duc Hospital.
CHAPTER 3
RESULTS
3.1. General characteristics
In 101 patients underwent living donor kidney transplant:
57/101 patients with inverted kidney transplant and 44/101 patients
with non-inverted kidney transplant. Mean age was 36.9 ± 11.0 years
old. Male to female ratio was 2/1 with 68.3% males and 31.7%
females. There was 37/101 patients (36.6%) with end-stage renal
failure due to renal diseases. Co-morbidity was hypertension
(44.6%). Time of hemodialysis prior to transplant was 2.2 ± 2.0
years, and there was no difference between inverted kidney transplant
group and non-inverted kidney transplant group.
The rate of living donors who were not family member was
79.2%; 96% in same blood type in which 49.5% O blood type. HLA
compatibility: 75.2% in class I, 55.4% in class II, 49.5%
compatibility in both 2 class. BMI index was 68.3%. Recipient
vesical capacity was 171.5 ± 69.5 ml (normal range ≥ 100ml in
83.2% pts, low capacity<100ml in 16.8%).
3.2. Technical aspects
Graph 3.4: The rate of right donor nephectomy was higher than
left donor nephectomy (56.4% and 43.6%, respectively).


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3.2.1. Size of graft
Table 3.11. Mean length of graft in inverted kidney transplant
group and non-inverted kidney transplant group were 10.9 ± 0.7 (cm)

and 10.9 ± 0.8 (cm), respectively. There was no difference in length,
width and thickness of graft between 2 groups (p>0.05).
3.2.2. Graft ureter andvascular characteristics
Table 3.12 and 3.13: 3.7% grafts with 2 veins and 17.8% grafts
with 2 arteries, no difference between inverted kidney transplant
group and non-inverted kidney transplant group (p>0.05)
Table 3.14: the length of graft vein in inverted kidneys was
shorter than in non-inverted group significantly (p<0.001).
Table 3.16: All graft ureters were long enough to reimplante.
There was no difference in length and diameter of graft ureter
between inverted kidney transplant group and non-inverted kidney
transplant group (p>0.05).
3.2.3. Assessment of graft after irrigation
Table 3.16: good grafts were dominated with 96%. There were 4
graft not in good condition, but they were not so bad that could not be
transplanted. Also there was no difference in graft condition (good or
not good) between inverted kidney transplant group and non-inverted
kidney transplant group (p > 0.05).
3.2.3. Additional vascular plastic techniques after irrigation
Table 3.17: grafts with 2 arteries, no plasty in 13/18 recipients
(72.2%), vascularreconstruction into 1 trunk (‘pantalon type’) in 5/18
recipients (27.8%). There was no venous reconstruction.
Table 3.18: We did not use vascular disposition technique in
91.1% of cases, ligation of branchs of internal iliac vein in 7 cases
(6.9%), vascular disposition in 1 case (1%), 1 case was underwent
both 2 techniques.


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3.3. Surgical results of living donor kidney transplant

3.3.1. Comments on incision, graft placement and vascular
anastomosis.
Table 3.19 and 3.20: Right Gibson incision was used in 100% of
cases, also the grafts were placed in right iliac fossa. There were
57/101 patients (56.4%) with inverted kidney transplant and 44/101
patients with non-inverted kidney transplant (43.6%); 98.2% inverted
kidney transplant was the right kidney.
Table 3.21: in grafts with 1 vein, the end-to-side anastomosis
with recipient’s external iliac vein was made in 97.9%, and with
common external iliac vein in 2.1%. In all 4 grafts with 2 veins, the
separated venous anastomoses was made with external iliac vein.
Table 3.22: In 96.4% grafts with 1 artery, the end-to-side
anastomoses were made with recipient’s external iliac artery; the
rates in inverted kidney transplant and non-inverted kidney transplant
were 97.4% and 95.6%, respectively. In 83.3% grafts with 2 arteries,
2 separated anastomoses were made with external iliac artery; in the
rest 16.7%, 1 anastomosis was made with external iliac artery and
another with common iliac artery.
Table 3.23 and 3.24: Mean time of veinous anastomosis was
14.9 ± 5.5 mins and 14.4 ± 5.1 mins for arterial anastomosis. There
was no statistical difference in the time for arterial or venous
anastomosis between inverted kidney transplant group and noninverted kidney transplant group (p > 0.05).
Table 3.25: Mean time of ureter reimplantation was 24 ±7.9 mins,
and there was no statistical difference between inverted and non-inverted
kidney transplant, as well as no correlation with bladder capacity.
3.3.2. Results of revascularization
Table 3.26 and 3.27: Nearly all the graft’s artery and vein were
in good condition after revascularization (99%). Therefore, inverting
kidney did not impact on graft blood circulation.

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Table 3.28: 100% graft’s ureters werein good condition.
Table 3.29: Warm ischemia time in grafts with 2 arteries or 2
veins were longer significantly than in grafts with 1 artery or 1 vein,
with p = 0.0025 and p = 0.002, respectively. But there was no
difference in warm ischemia time between inverted and non-inverted
kidney transplant with p = 0.379 > 0.05.
Table 3.30: there was a statistical difference in cold ischemia
time between grafts with 1 artery and 2 arteries group (p = 0.0094);
but it was equivalent in 2 groups: grafts with 1 vein and 2 veins (p =
0.2066). There was no difference in cold ischemia time between
inverted and non-inverted kidney transplant with p = 0.3048.
Table 3.31: Mean duration of transplant surgery was 148 ± 30
mins and there was no difference between inverted and non-inverted
kidney transplant with p > 0.05. Mean operation time of grafts with 2
arteries group was statistical longer than of grafts with 1 artery (p =
0.0085 < 0.05)
3.4. Graft follow-up
3.4.1. Early stage
Graph 3.6 and table 3.32: After revascularized, all the grafts
excreted urine in time of surgery, in which 90/101 cases (89,1%) had
urine excretion under 1 mins, 11/101 cases (10,9%) had urine
excretion slower 1 mins. There was no difference in urine excretion
time between inverted and non-inverted kidney transplant with p =
0.136 > 0.05.
Graph 3.7: Intra-operative complications ocurred in 3/101 cases
(acounted for 3%)
Table 3.33. 99/101 cases (98%) with graft in good condition and
no difference in graft condition between inverted and non-inverted

kidney transplant (p > 0.05).


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3.4.2. Some indexes inpost-operative period
Table 3.34, Graph 3.8: total amount of urine in first 24 hours
was 14.1 ± 4.2 litre, andthere was no difference between inverted and
non-inverted kidney transplant (p > 0.05). Urine volume decreased
gradually until discharge.
Table 3.35, 3.37, Graph 3.9 and 3.10: ure and creatinine
concentration decreased gradually from the first day after surgery to
discharge, and there was no difference between inverted and noninverted kidney transplant. However, at the time of discharge, 4 grafts
were not in good condition (4%), in which 1 graft loss due to
rejection.
Graph 3.11: Doppler ultrasound revealed the normal vascular
circulationin all grafts (100%); RI of graft’s parenchymal was in
normal range in 94,1%.
Table 3.38: time of drainage operation field was 7.6 ± 2.2 days,
time of urethral catheter was 5.4 ± 1.2 days and post-transplant
hospital stay was 12.1 ± 5.5 days.
Graph 3.12: The rate of early post-operative complication was
4.9%: bleeding in 2 cases (2.0%), peri-graft fluid collection in 2 cases
(2.0%), wound infection in 1 case (1,0%); 1 graftin doubt of arterial
stenosis but the graft’s function improved postoperatively, and no
stenosion Doppler ultrasoud at discharge.
3.4.3. Long-term results
Table 3.40: ureter stricture developed in 1 case after JJ-stent
removed (1%), there was no difference in ureter stricture between
inverted and non-inverted kidney transplant group (p > 0.05).
Graph 3.14 to graph 3.20 and table 3.42: there was no difference

in ure and creatinine concentration between inverted and noninverted kidney transplant group in long-term follow-up.


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Graph Kaplan-Meier 3.21 showed the rate of good graft
function by the time: 91% of grafts survived 5 years after
transplantation, and the rate of good function grafts was over 80% 8
years after surgery.
CHAPTER4
DISCUSSION
4.1. Recipients’ charateristics
Mean age was 36.9 ±11 years old, male/female ratio was 2/1,
there was no difference between inverted and non-inverted kidney
transplant group. Researches of J.M. Gloor et al, of Bayat and et al
showed that the average recipient’s age was higher than our study.
The incidence of kidney disease leading to chronic renal failure is
36.6%. This result was lower than that of some authors such as
Robert P. Pauly (2009) and Haririan (2009).
Patients with hemodialysis less than 2 years accounted for
61.4%, only 2.0% had not been treated by hemodialysis. Robert P.
Paly et al (2009) showed that the rate of patients without dialysis was
14.1%, and dialysis less than 2 years accounted for 48%.
Patients with the same blood group accounted for 96.0%,
unrelated donors accounted for 20.8% and there was no difference
between the two groups of inverted and non-inverted kidney
transplant. Study of John R.Montgomery et al (2012) showed that
there was 40% of unrelated donors. There was a similarity between
our study and other studies on blood groups.
Our research showed that the 1 st class HLA compatibility
accounted for 75.2%, the 2 nd class compatibility accounted for 55.4%,

and the compatibility of both classes accounted for 49.5%.
In our study, the majority of recipients had normal BMI (68.3%).
Recipients with BMI <18.5 accounted for 26.7%, BMI> 25


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accounted for a very low rate of 5.0%. Meanwhile, the results in the
world showed that the proportion of patients with BMI over 25 is
much higher than the results in our study.
4.2. Evaluate the technique of living donor kidney transplant
4.2.1. Choose the side of kidney nephrectomy from the donor and side
of iliac fossa to transplant.
4.2.1.1. Choose the side of kidney nephrectomy
In the study, we chose to take a less functional kidney. The rate
of right kidney was higher than left kidney, 56.4% and 43.6%,
respectively. This rate is different from previous reports with a very
high rate of left kidney nephrectomy to transplant: Tran Ngoc Sinh et
al (2012) 74.26% left kidney, Du Thi Ngoc Thu 75.12% left kidney
and Nguyen Truong Giang et al (2012) 100% taking left kidney.
4.2.1.2. Choose the pelvis to transplant the graft
Nguyen Thi Anh Huong (2008) summarized and made the
judgment: there are three position options for conducting kidney
transplant surgery related to the kidneys.
- Taking kidneys on any side, then transplant into the same side
iliac fossa.
- Taking kidneys on any side, but always choose to transplant into
the right iliac fossa.
- Taking kidneys on any side, then grafting into the opposite iliac
fossa (taking the right kidney to transplant into the left iliac
fossa and vice versa).

However, authors like to take the left kidney and graft into the
right iliac fossa by many favorable factors.
Kidney transplantation in the right iliac fossa have outstanding
advantages compared to the left:


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+ The technique of transplantation is more advantageous
because the right iliac vein is more shallow and horizontal than the
left, so the exposure will be easier and faster than the left.
+ More advantageous for vascular disposition technique because
the vein tends to be right deviation.
+ More advantageous for graft examination or graft biopsy.
Therefore, authors often tend to transplant grafts into the right
iliac fossa. My research also followed this trend so 100% of our
patients received kidney transplants into the right iliac fossa.
4.2.2.Evaluation of the graft, vascular plasty and ureter.
4.2.2.1. Evaluation of the graft
There was no difference in graft size between inverted and noninverted kidney transplant group.
4.2.2.2. Evaluation of the ureter
In kidney transplant surgery, only renal artery is the main source
of blood supply for ureter. Research of Liselottes et al (2015) has
shown that there was no relationship between length of ureter and
complications after kidney transplant surgery.
According to Cranston et al. (2001), when a kidney transplant
suregery is performed, the ‘golden triangle’ (between the vena cava
and the renal vein, the renal sinuses and the lower pole) must be
respected. In this study, we always paid attention to respect this
"golden triangle". Dissection of ureter and pelvis follows the lower of
the kidney pole to the hilum in case of reversing the urinary tract

envisioned as dissection according to the edge of the "golden
triangle" that the authors mentioned should be respected. This
movement will not damage the blood vessels that keep the ureters
separated from the renal artery, which will only work to move the
triangle so that the urinary excretion line is not kinked when the
kidney is inverted.


18
Our ureter size was similar to other studies. Of course, the
length of the graft's ureter is shorter than the length of the normal
ureter due to the need to reveal and take the ureter to theposition of
crossing anteriorly pelvic arteries.
4.2.3. Inverted kidney transplant technique
In placing the grafts into the iliac fossa, we always prioritized
the implementation of vascular anastomoses. If the left kidney
transplant into the right iliac fossa, just flip the kidneys, if the right
kidney transplant into the right iliac fossa, in addition to the flip the
need to reverse the pole (inverted kidney transplant technique), the
graft can be compatible with blood vessels in coronal plane.
However, in case of inverted kidney transplant, the pathway of
the ureteropelvic junction and ureter are upwards. Allen (2014)
mentions this problem after performing arterial and venous anasomoses.
At that time, it is possible to retake out the graft, irrigate and retransplant that the ureter is downward. But many authors consent that:
release the renal pelvis and the renal ureter down to the bladder.
Because of all the outstanding advantages of the inverted kidney
transplants described above, we have applied this technique in most
right kidney (98.2%) transplant into the right iliac fossa.
The inverted kidney transplant had very good results: there is no
vascular complication and we completely managed the reverse ureter

which is considered the only disadvantage of the technique. In no
case, the upper third ureteral stenosis was folded or kinked due to
ureteropelvic reversal, no cases of ureteral necrosis due to injury of
ureteral vessels separated from the renal artery. Only 1 case had a
stricture of neo ureteral orifice after JJ-stent removed 1 month (1%).
Thus, we did not found any difference in urinary complications in
inverted and non-inverted kidney transplant groups.


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In 2016, Simforooth summed up 79 cases of right kidney
transplants and identified the inverted kidney transplant as an easy,
safe method and reduced the need for prolonged graft’s vein. Ramesh
S. et al (2019) performed the inverted technique in 6/50 (12%)
kidney transplants in children from brain-dead donor and also found
no difference in the rate of complications after surgery between
inverted and non-inverted groups. The author also identified the
inverted kidney transplant as a feasible surgical technique to
compensate for graft’s anatomical variants or short veins.
4.2.4. Vascular plasty techniques
4.2.4.1. Graft’s arterial plasty technique
In this study, there were 18 cases of grafts with 2 arteries
(17.82%), 13 cases without plasty accounted for 72.2%; 27.8% were
reformed into 1 artery (2 cases of ‘pantalon’ shape, 3 cases of sideconnected small artery with main trunk). Antonopoulos (2014)
sutured 2 arteries into 1 artery in 77/98 cases of grafts with many
arteries, accounted for 78.57%. This rate is higher than our research.
According to Allen (2014), although making 2 separated anastomoses
takes longer time, he does not like to connect the renal arteries before
transplanting to avoid the risk of arterial thrombosis.
4.2.4.2. Graft’s venous plasty technique

The management of graft’s multiple veinsis similar to of
multiple arteries. In this study, there were 4 grafts with 2 veins of the
same size, so they did not reshaped and kept 2 anastomoses.
Evaluating kidneys in preparation for grafting according to the
criteria, good kidney accounted for 96.0%. In case the graftwas taken
from the right, due to inverted technique when transplanting, we
released the renal pelvis and ureter to avoid kinking urinary tract. The


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maximum conservation tissues around the ureter and renal pelvis is
important to avoid urologic complications after transplantation.
4.2.4.3. Vascular disposition technique
Level 1: lengthenvein by dissection renal hilum. Level 2:
assessment of arteries, veins with interdependent compression, so the
vessels must be displaced. Level 3: cut the recipient’s internal iliac
vein to mobile the external iliac vein, and then make the vein
disposition to the right outside of common and external iliac arteries.
Christopher J.E. Watson and Peter J. Friend (2014), and Barry (2000)
also mentioned the technique of ligating internal iliac vein in order to
mobile the external vein in kidney transplantation.
Unlike the study by Du Thi Ngoc Thu, we only performed
vascular disposition at level 3 when applying the inverted technique
but the graft’s veins were still not long enough. The inverted
technique maked the coronal plane of graft’s arteries and veins closer
to the recipient’iliac vessels, so there was no need of level 1 and 2
vascular disposition.
There were 91.1% of cases not need vascular disposition, 9/101
cases (8.9%) of level 3 disposition and all of these were inverted
kidney transplantbut the graft’s veins still stretch when anastomosed.

The rate of vascular disposition in our study was many times lower
than that of Du Thi Ngoc Thu's study, maybe part of the reason was
that the number of patients in this study was less and we carried out
open living-donor nephrectomy. In order to have confirmation, more
research is needed with larger samples.
4.3. Evaluation of living donor kidney transplantation
4.3.1. Intra-operative and post-operative assessement
4.3.1.1. Graft evaluation after revascularization
After revascularization, 98.0% of grafts achieved good results.
The study of Tran Ngoc Sinh et al (2012) performed 202 cases of


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kidney transplantation from live donors at Cho Ray hospital from
1992 to 2010 for 99.5% success rate (201/202 cases).
4.3.1.2. Graft’s warm ischemia
The average warm ischemia time for the 2 groups inverted and
non-inverted kidney were 35.1 ± 9.5 minutes and 33.5 ± 8.8 minutes,
respectively. However, this difference is not statistically significant
with p = 0.379> 0.05. Thus, the time for vessels anastomoses in
inverted and non-inverted groups were the same in our study.
4.3.1.3. Time of operation
The duration of surgery was 148.0 ± 30 minutes. There was a
statistically significant difference between mean time in the grafts
with 2 arteries and the grafts with 1 artery with p = 0.0085, because
the 2-artery grafts with 13/18 cases (72.2%) performed 2 separate
anastomoses with iliac arteries so the time was longer. Comparing the
average time between inverted and non-inverted group, there was no
significant difference with p> 0.05.
4.3.1.4. Intra-operative complications

Intra-operative complications occurred in 3 cases (3.0%): 1 graft
with folded long artery, 1 graft with kinked vein, 1 case of bleeding
from skin incision of drainage which resutured. In the study of Le
Nguyen Vu (2014) on kidney transplantation from brain-dead donors,
there was intra-operative bleeding in 2/38 cases (5.16%).
4.3.2. Evaluation of kidney transplantation in early stage
4.3.2.1. Excretion of urine for days just after surgery
The volume of first 24-hour urine was 14.1 ± 4.2 liters. The 24hour urine volume tended to decrease gradually to the day of
discharge in both inverted and non-inverted group. At time of
discharge, urine volume was 3.2 ± 0.8 liters. This result was similar


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to that of Le Nguyen Vu’s study (2014) in 38 patients who received
kidney transplantation from 20 brain-death donors.
4.3.2.3. Post-transplant hospital stay
The period of post-operative hospital stay in our study was 12.1
± 5.5 days, longer than that of Hoang Khac Chuan (2016) was 10
days, or Karim Marzouk's research ( 2013) was 9 days.
4.3.2.4. Post-operative complications
Early post-operative complications were in 6/101 cases
(4.9%)lower than in the study of F. Reyna-Sepulveda (2017) 12.7%.
Besides, there was bleeding in 2 cases (2.0%), peri-graft fluid
collection in 2 cases (2.0%).
In our study, wound infection was in 1 case (1%); 1 graft in
doubt of arterial stenosis but the graft’s function improved postoperatively, and no stenosis on Doppler ultrasoud at discharge; 1
graft loss due to rejection.
4.3.3. Long-term post-transplant evaluation
Only 1 case had a stricture of neo ureteral orifice after JJ-stent
removed 1 month (1%), but we found it not related to the inverted

technique.Thus, inverted kidney transplant technique does not
increase urologic complications after transplantation as identified by
some authors in the world.
Until now, the recipients continue to be follow-up at Viet Duc
hospital. By the end of 2018, 91% of grafts survived 5 years after
transplantation, and the rate of good function grafts was over 80% at
8 years after surgery.
The research results showed that living donor kidney transplant
is a good treatment option for patients with chronic renal failure.
Performing end-to-side anastomosis between kidney artery and iliac
artery, and applying inverted kidney transplant technique in case of