Selective pre-transplant nephrectomy: indications and perioperative management.

From May 1977 to June 1983, 198 patients were accepted as candidates for renal transplantation at our university. We review our experience with 14 consecutive patients who underwent selective pre-transplant nephrectomy during this interval. Indications for this procedure included recurrent or chronic pyelonephritis, structural abnormalities of the urinary tract predisposing the patient to infection, malignant or renin-dependent hypertension, Goodpasture's disease, certain cases of rapidly progressive glomerulonephritis and selected patients with polycystic kidneys. All patients underwent dialysis 1 day preoperatively. Perioperative fluid losses were measured carefully with prompt and vigorous replacement therapy. Patients received an average of 5,890 cc fluid replacement before postoperative dialysis. All patients underwent dialysis within 29 hours postoperatively. There were no postoperative deaths and 8 complications. Selective pre-transplant nephrectomy has spared 93 per cent of potential renal transplant candidates from a major surgical procedure. No patient has required removal of the original kidneys during the post-transplant period. Our experience has shown that the reluctance to hydrate these patients is unwarranted and that prompt postoperative dialysis, if required, is safe. Since some end stage kidneys are physiologically active and the associated surgical risk is high, pre-transplant nephrectomy should be performed only in carefully selected patients. In contrast to previous reports, which advocated minimal fluid administration and delayed postoperative dialysis, our recent experience indicates that vigorous fluid replacement therapy, carefully monitored with serial vital signs, weights, serum electrolytes and central venous pressure readings, will avert many of the complications encountered previously.

Anterior transperitoneal approach for treatment of urolithiasis.

An anterior transperitoneal incision was used to remove stones from 20 kidneys in 18 patients (2 bilateral). Our experience with 35 kidneys operated upon by this method (15 previously reported) has been favorable. Use of percutaneous nephropyelostomy tubes to drain obstructed kidneys in septic patients has permitted all procedures to be done under non-emergency conditions. Careful alignment of x-ray equipment and adjustment of exposure technique in the operating room before induction of anesthesia result in consistently good quality preoperative and intraoperative roentgenograms. The transperitoneal approach has afforded good access to the anterior portion of the renal pelvis even in those patients who have had previous operations on the kidney by the flank approach. Additional intra-abdominal procedures done at the same operation have included urinary diversion by ileal loop, revision of previous ileal loop, ureterolithotomy, pyeloureteroplasty, partial nephrectomy, cholecystectomy and appendectomy. The procedures done with the patients in the supine position have been well tolerated even in patients with serious coincident medical diseases.

Anterior transperitoneal approach for removal of renal stones.

An anterior transperitoneal approach was used for removal of stones from 15 kidneys in 13 patients. Exposure of the anterior portion of the pelvis was readily accomplished making excellent exposure of the interior of the kidney possible. Minimal urinary drainage was noted postoperatively. The operative procedures done with the patients in the supine position were well tolerated.

A regional anesthetic approach for renal transplantation.

After consideration of surgical demands and patient condition, regional anesthesia is preferred for renal transplantation at the University of Rochester Medical Center. Of 75 consecutive cases, 64 were successfully managed with single high-dose spinal anesthesia (10 to 20 mg tetracaine, mean 16.5 mg). The technic avoids untoward effects of neuromuscular blocking drugs, iatrogenic pulmonary infection from anesthetic equipment, and problems with potent general and anesthetics. Patients are made comfortable by judicious low-dose sedation. Cardiovascular instability and blood loss are not troublesome. There have been no permanent neurologic sequelae or postspinal headaches. The authors believe this technic produces minimal biochemical and physiologic derangement for renal transplantation in the patient with chronic renal failure.

Cadaver donor nephrectomy.

Optimal preservation of renal and ureteral structure and function is attempted by maintenance of renal circulation during heart-beating cadaver nephrectomy. Modifications of Ackermann's en bloc procedure for removal of cadaver kidneys are suggested to adapt this procedure to the heart-beating cadaver situation.