Combined antegrade-retrograde cystourethroscopic rendezvous procedure for the management of a severe urethral stricture during kidney transplantation: A case report.

INTRODUCTION: External bladder drainage with an indwelling transurethral catheter is standard during kidney transplant. Difficult Foley catheter placement is a frequent problem and one of the most common reasons for intraoperative urology consults. Suprapubic catheters are usually placed if retrograde urologic instrumentation options fail to cross the urethral obstruction. We report an alternative option with an antegrade-retrograde endoscopic approach. PRESENTATION OF CASE: This case illustrates a urethral rendezvous procedure applied successfully to traverse an occult mid-urethral stricture for Foley catheter placement during kidney transplantation in a 69-year-old diabetic man with end-stage renal disease and anuria. DISCUSSION: The combined antegrade-retrograde rendezvous techniques have largely been described in the treatment of complex ureteric strictures more so than urethral strictures. This technique has not been described in the setting of a complex urethral stricture encountered during kidney transplantation. After utilization of the urinary tract rendezvous technique during kidney transplantation, our patient experienced an uneventful post-operative course with excellent renal allograft function. CONCLUSION: The combined antegrade-retrograde urinary tract rendezvous technique is a feasible and safe technique that can help manage occult severe urethral strictures found at the time of kidney transplantation instead of suprapubic catheter placement when retrograde urologic instrumentation options fail to cross the obstruction.

Local Anesthetic Systemic Toxicity During Transversus Abdominis Plane Block With Liposomal Bupivacaine.

Local anesthetic systemic toxicity (LAST) is a rare but potentially fatal outcome associated with local anesthetic administration. Liposomal bupivacaine (LB; EXPAREL®) is a widely used local anesthetic with extended-release and liposomal formulation that carries an improved cardiac and central nervous system safety profile. However, there is limited data regarding LAST associated with liposomal bupivacaine. Here is described a case of local anesthetic systemic toxicity in a 68-year-old male who presented with obstructing sigmoid adenocarcinoma and underwent open sigmoidectomy with end descending colostomy. The operation was complicated by LAST following transversus abdominis plane block injection with liposomal bupivacaine resulting in cardiac arrest. Return of spontaneous circulation was achieved following advanced cardiac life support and infusion of 20% I.V. fat emulsion. Given the widespread use of local anesthetics, providers must be aware of the pathophysiology, diagnosis, and immediate treatment of LAST.

"Triple V-Plasty": Creation of a Single Orifice for Three Renal Arteries in Live-Donor Transplantation.

BACKGROUND: Donor renovascular anatomic variations can hinder renal transplantation (RT), especially from live donors. Back-table vascular reconstruction can be effective in the use of renal allografts with multiple renal arteries (RAs), helping to expand the pool of live donors. SURGICAL TECHNIQUE: Sequential V-plasty of 3 donor RAs using fine, non-absorbable, monofilament (7-0 or 8-0 polypropylene) suture in an uninterrupted fashion successfully enabled the creation of a single, wide ostium for anastomosis with the target inflow recipient artery. RESULTS: Creation of a single ostium for 3 RAs was successfully performed on a 31-year-old man during a live-donor left RT, resulting in good inflow and outflow with arterial and venous anastomoses, respectively, at graft implantation. Excellent postoperative allograft perfusion was achieved, and the patient continued to have normal allograft function at >1 year post-transplantation. CONCLUSIONS: Novel ex vivo renovascular reconstruction potentiates expansion of live-donor RT successfully despite variant renovascular anatomy.

Modified Mercedes Single Incision for Combined Liver Kidney Transplant: A Case Series Report.

BACKGROUND: The traditional approach in combined liver-kidney transplantation involves 2 separate and sequential incisions. We describe a modification of the standard Mercedes incision that allows a single-incision operation while providing and maintaining adequate exposure to enable safe dual-allograft transplantation. METHODS: Modification of the standard Mercedes incision includes bilateral, subcostal, muscle splitting incision 4 fingerbreadths below the rib edge with a midline, cephalad incision and inferior ± medial ipsilateral extension on the side of intended iliac fossa laterality for renovascular and ureteroneocystostomy anastomosis. RESULTS: Five consecutive patients (3 women/2 men; mean age, 49 years; median body mass index, 29.8 kg/m2) underwent combined liver-kidney transplantation for end-stage liver disease and progressive hepatorenal syndrome via a modified Mercedes single-incision approach (at a median Model for End-stage Liver Disease of 37) without an additional kidney transplant incision, extraperitoneal exposure, or addition of wound retractors. Two out of the 5 patients experienced postoperative wound complications, including 1 with delayed wound healing and 1 with superficial dehiscence. All patients have normal dual-allograft function at or beyond 6 months posttransplantation. CONCLUSIONS: The modified Mercedes single-incision technique is safe and feasible. Lowering the subcostal incisions with unilateral, inferomedial extension allows adequate visualization of the lower abdominopelvic area without compromising exposure of the upper abdomen for both renal and liver allograft implantation. Further studies are needed to prove the theoretical benefits of this technique.

A Modified Single Mercedes Incision Surgical Technique for Simultaneous Liver Kidney Transplant: A Case Series Report.

BACKGROUND: The traditional approach in simultaneous liver-kidney transplantation (SLKT) involves two separate and sequential incisions. We describe modification of the classic Mercedes incision which limits the operation to a single incision yet provides and maintains adequate exposure enabling safe dual-allograft transplantation. METHODS: Modification of the standard Mercedes incision includes bilateral, subcostal, muscle splitting incision 4-finger-breadths below the rib-edge with a midline, cephalad incision, and inferior±medial, ipsilateral extension on the side of intended iliac fossa laterality for renovascular and ureteroneocystostomy anastomosis. RESULTS: Five consecutive patients (3 women/2 men; mean age, 49 years; median BMI, 29.8 kg/m2) underwent SLKT for end-stage liver disease and progressive hepatorenal syndrome via modified Mercedes incision approach (at a median MELD of 37) without an additional kidney transplant incision, extraperitoneal exposure, or addition of wound retractors. Two out of the five patients experienced post-op wound complications, including one with delayed wound healing and superficial dehiscence in a diabetic patient. All patients have normal dual-allograft function with four out of five beyond six months and one at two months post-transplantation. CONCLUSION: Modified Mercedes incision technique is safe and feasible. Lowering the subcostal incisions with unilateral, inferomedial extension allows adequate visualization of the lower abdominopelvic area without compromising exposure of the upper abdomen for both renal and liver allograft implantation, respectively. Further studies are needed to prove the theoretical benefits of this technique.

Triple V-plasty: Novel Renovascular Reconstruction Technique in Live-Donor Transplantation.

INTRODUCTION: Donor renovascular anomalies, including multiplicity, length and caliber of blood vessels, could hinder renal transplantation, especially from live-donors. However, meticulous back-bench vascular reconstruction ascertaining orientation and patency of individual vessels can be effective in utilization of renal grafts with multiple renal arteries, helping to expand the pool of live-donors. SURGICAL TECHNIQUE: Sequential v-plasty of individual donor renal arteries using fine, non-absorbable, monofilament (7-0 or 8-0 Prolene) suture in an uninterrupted fashion enables creation of a single, wide ostium for anastomosis with the target, inflow recipient (usually external or common iliac) artery. Additionally, entwined donor hilar renovasculature may necessitate incisional separation and re-anastomosis of a bifid vein for proper renovascular orientation following graft implantation in the recipient. CONCLUSION: Application of never-before described ex vivo renovascular reconstruction led to live-donor renal transplantation between two pairs of donor-recipient through the National Kidney Registry with successful long-term outcomes.