• The renal allograft is implanted in the extraperitoneal iliac fossa through a curved oblique incision either in the right or left lower abdominal quadrant.
• The sequence of vascular anastomosis involves end-to-side anastomosis of the renal vein to the external iliac vein.
• This is followed by the arterial anastomosis that joins the end of the renal transplant artery (often with a Carrel patch of cadaver donor aorta) to the side of the external iliac artery.
• The internal iliac artery can be used, but there are frequently extensive arteriosclerotic changes in diabetic recipients. Distal ligation of the internal iliac artery may also contribute to impotence.
• The genitourinary tract continuity is established with an extravesical ureteroneocystostomy (modified Lich technique). With this extravesical approach, the spatulated end of the transplant ureter is sewn to the bladder mucosa after incision of the detrusor muscle.
• The detrusor muscle is then reunited to buttress the anastomosis and create an antireflux valve.
• Nephroureteric internal stents are usually not utilized.
• Older techniques for GU continuity include the Leadbetter-Politano and ureteropyelostomy using the native ureter.
• If the patient has been anuric or oliguric for several years, the bladder may be contracted and noncompliant.
• Bladder augmentation using a segment of intestine is then warranted, a procedure which is uniformly completed prior to transplantation.
• An alternative to augmentation is "stretching" the bladder with a regimen of bladder filling using incrementally larger volumes over time.
• If the bladder urodynamics are markedly abnormal, the bladder may be used as a reservoir and intermittent self-catheterization instituted after transplantation. This meets with better patient satisfaction and fewer complications than diversion.

References

Calligaro P, Modern Management of Renovascular Hypertension and Renal Salvage, Williams & Wilkins, 1996.

Dean RH, Krueger TC, Whiteneck JM, et al: Operative management of renovascular hypertension: Results after a follow-up of fifteen to twenty-three years. J Vasc Surg 1:234-422, 1984.

Galanski M, Prokop M, Chavan A, et al: Renal artery stenosis: Sprial CT angiography. Radiology 189:185-192, 1993.

Martin LG, Price RB, Casarella WJ, et al: Percutaneous angioplasty in the clinical management of renovascular hypertension: Initial and long term results. Radiology 155:629, 1985.

Meier GH, Sumpio B, Black HR, Gusberg RJ; Captopril renal scintography. An advance in the detection and treatment of renovascular hypertension. J Vasc Surg 11:770-777, 1990.

Prince MR, Narasimham DL, Stanley JC, et al: Breath-hold gadolinium-enhanced MR angiography of the abdominal aorta and its major branches. Radiology 197:785, 1995.

Raynaud AC, Beyssen BM, Turmel-Rodrigues LE, et al. Renal artery stent placement: Immediate and midterm technical and clinical results. JVIR 5:849, 1994.

Strandnesss DE. Duplex scanning in diagnosis of renovascular hypertension. Surg Clin North Am 70:109-117, 1990.

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