Kidney Autotransplantation and Orthotopic Kidney Transplantation: Two Different Approaches for Complex Cases

Abstract

Introduction. Transplantation surgery teams often have to face complex cases. In certain circumstances, such as occlusion of the iliac vessels or prior pelvic surgery, heterotopic kidney transplantation may not be feasible and orthotopic kidney transplantation (OKT) could be a good alternative. Kidney autotransplantation (KAT) has been described as a potential treatment for complex renovascular, ureteral, or neoplastic conditions. There are scarce data regarding the complications and outcomes of these procedures; therefore, we present our experience. Materials and Methods. We retrospectively analysed the medical records of both 21 patients who had received OKT and 19 patients who underwent KAT between 1993 and 2020. We collected demographic features and data regarding surgical technique, complications, and graft outcomes. Kidney graft survival was calculated using Kaplan–Meier survival analysis. Results. Regarding OKT, in 15 (71.43%) cases, it was the first kidney transplantation. The most common indication was the unsuitable iliac region due to vascular abnormalities (57.14%). The early postoperative complication rate was high (66.67%), with 23.81% of Clavien grade 3b complications. During the follow-up period (mean 5.76 -SD 6.15- years), we detected 9 (42.85%) graft losses. At 1 year, the survival rate was 84.9%. Concerning KAT, the most frequent indication was ureteral pathology (52.63%), followed by vascular lesions (42.11%). The overall early complication rate was 42.11%. During the follow-up period (mean of 4.47 years), 4 (15.79%) graft losses were reported. Conclusions. Although OKT and KAT have high complication rates, these techniques can be considered as two valuable approaches for complex cases, in the absence of other therapeutic options.

Graft survival and postoperative complications following orthotopic renal transplantation

“…Further, a total of 90 articles were excluded as per the study policy, and only 10 studies met the inclusion criteria (Figure 1). Full‐text reviews were performed on ten articles comprising 269 patients for this narrative review 1,2,5–12 …”

“…However, this review should be criticized for not specifying how many years the overall patient and graft survival rates have been. Further, this systematic review included only four papers published before 2014 whereas five more recent articles published in 2016 and later were added to our narrative review, 1,7–9 and similar survival rates at the postoperative 1st year were observed when compared to the previous studies 2,11 …”

“…Thus, a rise in both surgically and immunologically complex renal transplantations. Regarding secondary or tertiary renal transplantation, in challenging cases that are not feasible for HRT, ORT may be a useful approach to consider with promising graft outcomes in the lack of another surgical option despite a relatively high complication rate 7 . According to the proponents of this technique, ORT may simplify a subsequent third transplantation attempt when needed 5 .…”

“…Regarding secondary or tertiary renal transplantation, in challenging cases that are not feasible for HRT, ORT may be a useful approach to consider with promising graft outcomes in the lack of another surgical option despite a relatively high complication rate. 7 According to the proponents of this technique, ORT may simplify a subsequent third transplantation attempt when needed. 5 Additionally, it preserves the upper urinary tract with its normal physiology since the graft is placed in the relatively normal anatomical position.…”

Indications for and results of renal autotransplantation

“…Extensive ureteral stricture disease is often a sequela of inflammatory disorders like Crohn's disease, ureteral trauma, and iatrogenic injury [20,[47][48][49][50][51]. The 2022 European Association of Urology Guidelines on Urological Trauma state that RA is an alternative in patients with extensive ureteral loss, multiple attempts at ureteral repair, or who would not be candidates for other forms of ureteral reconstruction (Fig.…”