Ureter Preparation in Kidney Transplantation
For living donor kidneys, preserve the distal periureteral fatty tissue and keep the ureter with its surrounding fat intact during procurement to maintain blood supply and prevent ischemic complications. 1
Key Principles of Ureteral Preparation
Living Donor Nephrectomy
Preserve periureteral tissue: The native ureter should be prepared with careful preservation of the distal periureteral fatty tissue during donor nephrectomy, as this tissue contains the critical blood supply to the ureter 1
Gonadal vein handling: Keeping the ureter with the gonadal vein in the specimen is a common practice during laparoscopic donor nephrectomy, though evidence suggests this may not be strictly necessary 2
- However, one large series of 800 laparoscopic donor nephrectomies found only 1 case (0.125%) of ureteral stricture when the gonadal vein was NOT preserved with the specimen, suggesting gonadal vein preservation is not mandatory 3
- The decision to preserve or divide the gonadal vein can be made based on surgical preference and anatomy 2, 3
Critical Technical Considerations
Avoid excessive ureteral dissection: Ischemia is the major contributing factor to urologic complications after renal transplantation, making preservation of periureteral blood supply paramount 1
Vascular anatomy variations: Preparation technique must account for variations in vascular anatomy, as renal artery multiplicity may increase the risk of ureteral complications 4
- In one series, 3 of 5 patients (60%) with ureteral complications had received kidneys with more than one renal artery 4
Deceased Donor Considerations
Timing matters: For deceased donor kidney procurement, the kidney extraction time (from flush/cross-clamp until nephrectomy and placement in hypothermic solution) should be ≤ 60 minutes to minimize warm ischemic injury 5
Standard preservation: Deceased donor kidneys require cold preservation solution flush and ice storage, but the ureteral preparation principles remain the same—preserve periureteral tissue 6
Common Pitfalls to Avoid
Over-dissection of the ureter: Stripping the ureter of its periureteral fat and blood supply leads to ischemia and subsequent stricture or leak 1
Inadequate length: While preserving blood supply, ensure adequate ureteral length for tension-free anastomosis
Ignoring multiple arteries: Be especially cautious with ureteral handling when multiple renal arteries are present, as these cases carry higher complication risk 4