BACKGROUND:Allograft nephrectomy (AN) is a rare but morbid procedure required after graft failure or neoplasia. We systematically reviewed current knowledge on AN surgical techniques, complications, and alternatives. PATIENTS AND METHODS:Undertaken to inform the French Association of Urology guidelines on allograft nephrectomy, this review was reported following PRISMA guidelines. PubMed/MEDLINE was searched (January 2000-March 2024) for studies of patients with non-functional first kidney transplants requiring AN or alternative strategies. Case reports, editorials, and non-systematic reviews were excluded. RESULTS:AN is predominantly performed via an open extraperitoneal approach. For non-functional grafts, consensus is lacking regarding subcapsular versus extracapsular techniques. However, the subcapsular approach reduces operative time, bleeding, and intraoperative complications, though overall morbidity data remain conflicting. The surgical approach does not impact alloimmunization. Regarding arterial embolization, protocols are not standardized. Yet, it achieves >80% success with lower mortality and morbidity than AN. Its main complication is post-embolization syndrome, potentially leading to secondary AN. Embolization prior to AN effectively reduces intraoperative bleeding and operative time. CONCLUSION:The extraperitoneal subcapsular approach appears to be the safest surgical option. Arterial embolization is a valuable alternative or adjuvant strategy to AN in managing graft intolerance syndrome after graft failure.

BACKGROUND AND OBJECTIVE:The nutcracker syndrome is a rare condition that occurs in young patients and can cause severe flank pain. The available surgical techniques often carry a risk of complications or morbidity. This study aims to describe robotic-assisted kidney autotransplantation for nutcracker syndrome and show its efficacy and safety. METHODS AND SURGICAL PROCEDURE:A retrospective study of all patients managed in our center by robotic-assisted kidney autotransplantation for symptomatic nutcracker syndrome was carried out. Patient demographics, operative time, hospitalization time, complications, management of postoperative pain, and patient-reported outcome measures (PROMs) were assessed. KEY FINDINGS AND LIMITATIONS:Thirty-four patients (30 female and four male) underwent surgery between January 2015 and December 2024, with a median age of 35 (Q1-Q3: 27-43) yr and a median body mass index of 20 kg/m2. The median operative time was 314 (Q1-Q3: 265-350) min, and the median hospital stay was 3 d. One procedure was converted to open surgery. Seven patients (21%) experienced complications within 3 mo, including five minor (Clavien-Dindo grade <3) and two major (Clavien-Dindo ≥3) complications, one of which required a nephrectomy. The median follow-up was 15 (Q1-Q3: 6-30) mo. PROMs were available for 29 patients. Nine patients (31%) reported complete symptom relief, 17 (59%) partial improvement, and three (10%) partial worsening of their symptoms. CONCLUSIONS AND CLINICAL IMPLICATIONS:Robotic-assisted kidney autotransplantation can be a therapeutic option for the treatment of nutcracker syndrome, but it should be performed in an expert center for transplantation and robotic surgery. Further studies and long-term follow-up are needed.

Early (<14 days) renal transplant vein thrombosis posttransplant (eRVTPT) is a rare but threatening complication. We aimed to assess eRVTPT management and the rate of functional renal transplantation. Of 11,172 adult patients who had undergone transplantation between 01/1997 and 12/2020 at 6 French centres, we identified 176 patients with eRVTPT (1.6%): 16 intraoperative (Group 1, G1) and 160 postoperative (Group 2, G2). All but one patient received surgical management. Patients in group G2 had at least one imaging test for diagnostic confirmation (N = 157, 98%). During the operative management of the G2 group, transplantectomy for graft necrosis was performed immediately in 59.1% of cases. In both groups, either of two techniques was preferred, namely, thrombectomy by renal venotomy or thrombectomy + venous anastomosis repair, with no difference in the functional graft rate (FGR) at hospital discharge (p = NS). The FGR was 62.5% in G1 and 8.1% in G2 (p < 0.001). Numerous complications occurred during the initial hospitalization: 38 patients had a postoperative infection (21.6%), 5 experienced haemorrhagic shock (2.8%), 29 exhibited a haematoma (16.5%), and 97 (55.1%) received a blood transfusion. Five patients died (2.8%). Our study confirms the very poor prognosis of early renal graft venous thrombosis.

Background:Renal transplantation is facing a shortage of grafts. En bloc kidney transplantation (EBKT) from pediatric donors could increase the number of available grafts.Objective:To describe the surgical technique as well as the long-term functional and morphological results of EBKT.Design setting and participants:We performed a retrospective study of all the EBKT procedures performed in Lyon between 2002 and 2020. Electronic medical records were checked with an analysis of demographics, and peri- and postoperative results.Outcome measurements and statistical analysis:A descriptive analysis of donor and recipient characteristics, perioperative data, complications, and renal function was performed.Results and limitations:Between 2002 and 2020, 21 EBKT procedures were performed. Donors had a mean weight of 8.6 kg and a mean age of 12 mo, with a mean cold ischemia time of 11 h and 30 min. Receivers had a mean age of 30 yr and a body mass index of 20. The mean follow-up time was 62 mo, with patient survival of 100% and graft survival of 95%. There were 13 reinterventions comprising one early unilateral transplantectomy for thrombosis. Renal function was excellent, and the morphological findings described an important growth in size in the first 2 yr before attaining the adult size. This study's limitations include its retrospective nature and a small number of participants.Conclusions:The present study reports excellent results with EBKT and supports the pursuit and spread of this technique.Patient summary:In this report, we describe the technique and results of en bloc kidney transplantation. We found that results are excellent for renal function and patient survival. We conclude that en bloc kidney transplantation should be considered to increase the number of grafts.

OBJECTIVE:To analyze de novo graft carcinoma characteristics from our updated national multicentric retrospective cohort. METHODS:Thirty-two transplant centers have retrospectively completed the database. This database concerns all kidney graft tumors including urothelial, and others type but excludes renal lymphomas over 31 years. RESULTS:One hundred and fifty twokidney graft carcinomas were diagnosed in functional grafts. Among them 130 tumors were Renal Cell Carcinomas. The calculated incidence was 0.18%. Median age of the allograft at diagnosis was 45.4 years old. The median time between transplantation and diagnosis was 147.1 months. 60 tumors were papillary carcinomas and 64 were clear cell carcinomas. Median tumor size was 25 mm. 18, 64, 21 and 1 tumors were respectively Fuhrman grade 1, 2, 3 and 4. Nephron sparing surgery (NSS) was performed on 68 (52.3%) recipients. Ablative therapy was performed in 23 cases (17.7%). Specific survival rate was 96.8%. CONCLUSION:This study confirmed that renal graft carcinomas are a different entity: with a younger age of diagnosis; a lower stage at diagnosis; a higher incidence of papillary subtypes.

INTRODUCTION:In the setting of kidney transplantation (KT), we assessed the efficacy of desensitization and compared the survival of desensitized patients (HLA-incompatible KT) with similarly sensitized patients receiving HLA-compatible KT or sensitized patients still on a waiting list after adjusting for the usually unaccounted immortal time bias.METHODS:All patients in a French KT center on the waiting list between August 1994 and December 2019 with a high level of sensitization (panel-reactive antibodies [PRAs] ≥80%) were included. The primary outcome was all-cause mortality. A time-varying covariate Cox survival model was used to account for the immortal time bias. A landmark analysis was used as a sensitivity analysis.RESULTS:During the study period, 326 patients with high PRAs were followed, among which 147 (45%) remained on the waiting list at the time of last follow-up and 179 benefited from a KT. Thirty-six patients were desensitized, of which 30 received a kidney transplant, including eight deceased kidney donors. There were no differences in mortality rates between desensitized KT patients, nondesensitized KT patients, and waitlisted patients after adjusting for immortal time bias (hazard ratio [HR] = 0.48, P = 0.22). Death-censored graft survival was similar between desensitized and nondesensitized KT patients (HR = 0.92, P = 0.88 adjusting for donor age >65 years, donor status, and time on the waiting list). Mean estimated glomerular filtration rate at 1 year post-KT was similar for desensitized KT patients (53.3 ± 21 vs. 53.6 ± 21 ml/min per 1.73 m2 for nondesensitized patients; P = 0.95).CONCLUSIONS:HLA-desensitization was effective for highly sensitized patients and gave access to KT without detrimental effects on patient or graft survival rates.

Proposer des recommandations pour la prise en charge des calculs urinaires chez le donneur ou le receveur d’un transplant rénal. Une revue d’approche systématique de la littérature (Medline) a été conduite par le CTAFU concernant l’épidémiologie, le diagnostic et le traitement des calculs urinaires chez le donneur ou le receveur d’un transplant rénal. La prévalence des calculs urinaires est inconnue chez les donneurs décédés mais peut atteindre 9,3 % chez les donneurs vivants dans les pays industrialisés. Chez tous types de donneurs de reins, hormis ceux de la catégorie 2 de Maastricht, le diagnostic repose sur la tomodensitométrie faisant partie du bilan avant tout prélèvement d’organes en France. Aucune étude n’a comparé les stratégies de traitements envisageables en cas de calcul détecté chez le donneur : l’uretéroscopie ou la lithotripsie extracorporelle chez le donneur vivant avant prélèvement, un traitement ex vivo (pyélotomie ou uretéroscopie), une uretéroscopie chez le receveur après transplantation, une surveillance en cas de petit calcul. Les calculs de novo chez le receveur impliquent un processus de lithogenèse à identifier et traiter pour éviter les récidives. Le contexte de rein unique fonctionnel fait toute la gravité de la pathologie lithiasique. Le diagnostic est en général fait au décours d’un bilan pour altération de la fonction rénale, d’une hématurie ou d’un sepsis. L’échographie détecte la dilatation des cavités pyélocalicielles, le scanner précise la topographie et la taille du calcul. Il n’existe aucune étude prospective comparative évaluant les techniques de traitement d’un calcul chez un transplanté rénal qui sont identiques à celles de la population générale. Ces recommandations françaises doivent contribuer à améliorer la prise en charge des calculs urinaires chez le patient donneur ou receveur d’un transplant rénal. To define guidelines for the management of kidney stones in kidney transplant (KTx) donor or recipients. Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU to report kidney stone epidemiology, diagnosis and management in KTx donors and recipients with the corresponding level of evidence. Prevalence of kidney stones in deceased donor is unknown but reaches 9.3% in living donors in industrialized countries. Except in Maastrich 2 donors, diagnosis is done on systematic pre-donation CT scan according to standard french procedure. No prospective study has compared therapeutic strategies available for the management of kidney stones in KTx donor: ureteroscopy or an extra corporeal lithotripsy in case of living donor prior to donation, ex vivo approach (pyelotomy or ureteroscopy), ureterocopy in the KTx recipient or surveillance. De novo kidney stones result from a lithogenesis process to be identified and treated in order to avoid recurrences. The context of solitary functional kidney renders the prevention of recurrence of great importance. Diagnosis is suspected when identification of a renal graft dysfunction, hematuria or urinary tract infection with renal pelvis dilatation. Stone size and location are determined by computed tomography. There are no prospective, controlled studies on kidney stone management in the KTx. The therapeutic strategies are similar to standard management in general population. These French recommendations should contribute to improve kidney stones management in KTx donor and recipients.

Background. The 2 main objectives regarding living kidney transplant are to provide optimal graft function and to ensure the safety of donation. Our study hypothesized that the glomerular filtration rate of a single kidney (skGFR), when transplanted, might predict graft function and that the skGFR of the remaining kidney could predict donor functional gain. Methods. A prospective monocentric study was conducted at Grenoble-Alpes University Hospital. Twenty couples of donors and recipients were included. Dimercaptosuccinic acid renal scintigraphy and Cr-51-ethylene-diamine tetra-acetic acid clearance were evaluated predonation to calculate skGFR. All patients had renal function according to Cr-51-ethylene-diamine tetra-acetic acid clearance at 1 year post transplant to assess graft function and donor functional gain. All donors had normal renal function predonation. Results. At 1 year post transplant, median glomerular filtration rate of the graft was 50 mL/min/1.73 m(2) (range, 46-56 mL/min/1.73 m(2)) and donor median glomerular filtration rate was 59 mL/min/1.73 m(2) (range, 55-74 mL/min/1.73 m(2)). Median functional gain was 20 mL/min/1.73 m(2) (range, 12-22 mL/min/1.73 m(2)). No statistical correlation was found between skGFR of the transplanted kidney and graft function at 1 year (R-2 = 0.096, P = .7). For the donor, functional gain was not associated with predonation skGFR of the remaining kidney (R-2 = 0.17, P = .5). A statistical difference was found between donor functional gain (18 [SD, 10] mL/min) and recipient gain (delta between skGFR before and after transplant, 7 [SD, 16] mL/min; P = .02). Conclusion. Predonation skGFR of the transplanted kidney had no influence on renal allograft function at 1 year post transplant. Similarly, there was no association between measured skGFR of the remaining kidney and donor functional gain at 1 year.

Living donor nephrectomy is a high-stake procedure involving healthy individuals, therefore every effort should be made to define each patient’s individualized risk and improve potential donors’ information. The aim of this study was to evaluate the interest of the Mayo adhesive probability (MAP) score, an imaging-based score initially designed to estimate the risk of adherent perinephric fat in partial nephrectomy, to predict intra- and postoperative complications of living donor nephrectomy. We retrospectively reviewed the imaging, clinical, and follow-up data of 452 kidney donors who underwent laparoscopic donor nephrectomy in two academic centers. Imaging and follow-up data were available for 307 kidney donors, among which 44 (14%) had a high MAP score (≥ 3). Intraoperative difficulties were encountered in 50 patients (16%), including difficult dissection (n = 35) and bleeding (n = 17). Conversion to open surgery was required for 13 patients (4.2%). On multivariate analysis, a MAP score ≥ 3 was significantly associated with the risk of intraoperative difficulty [OR 14.12 (5.58–35.7), p < 0.001] or conversion to open surgery [OR 18.96 (3.42–105.14), p = 0.0042]. Postoperative complications were noted in 99 patients (32%), including 12 patients (3.9%) with Clavien–Dindo grade III–IV complications. On multivariate analysis, a high MAP score was also associated with the risk of postoperative complications [OR 2.55 (1.20–5.40), p = 0.01]. In this retrospective bicentric study, a high MAP score was associated with the risk of intra- and postoperative complications of laparoscopic donor nephrectomy. The MAP score appears of interest in the living donor evaluation process to help improve donors’ information and outcomes.

Objectives: Chronic antibody-mediated rejection is the main cause of late kidney graft loss. The presence of donor-specific antibodies in the serum is the main criterion for this diagnosis. Single antigen Luminex assays can identify donor-specific antibodies, and semiquantitative estimates of antibodies can be assessed using mean fluorescence intensity. Recent data have shown that patients whose donor-specific antibodies fix C3d have worse clinical outcomes, implying that C3d-specific Luminex assays may provide useful prognostic data. Materials and Methods: We compared C3d donorspecific antibodies with standard immunoglobulin G donor-specific antibody mean fluorescence intensities in a cohort of patients with de novo class II donorspecific antibodies and analyzed subsequent graft survival.The included kidney graft recipients received transplants between 2005 and 2015 and had developed de novo class II donor-specific antibodies. Serum was tested using the standard single antigen Luminex technique and the C3d-fixing antibody-detection system (Immucor, Herentals, Belgium). Results: In our patient cohort, 41/924 patients (4.4%) developed class II donor-specific antibodies, and 65 serum samples were analyzed (at baseline and followup). Among these samples, 43 (66%) were negative for C3d donor-specific antibodies. A mean fluorescence intensity threshold of 9000 in the single antigen Luminex assay discerned all negative (from positive) C3d donor-specific antibodies, even when all single-bead results were taken into account. Sixteen patients (39%) had poor outcomes (ie, either creatinine levels had doubled or they had lost their graft) over the median follow-up of 5 years. C3d results were significantly associated with graft survival (P = .04). We found a strong correlation between C3d-fixing antibody positivity and mean fluorescence intensity strength in the setting of de novo class II donor-specific antibodies. Conclusions: These results further reinforce the paradigm that the higher the mean fluorescence intensity, the more complement activation occurs. Routine C3d testing is thus unnecessary in this setting.

ABSTRACT Introduction Super-selective clamping of tumor-specific segmental arteries was developed to eliminate ischemia of the remnant kidney while limiting hemorrhage during partial nephrectomy. The objective is to evaluate the benefice of super-selective clamping on renal functional outcome, compared to early-unclamping of the renal artery. Materials and Methods From March 2015 to July 2016, data from 30 patients undergoing super-selective robot-assisted PN (RAPN) for a solitary tumor by a single surgeon were prospectively collected. Tumor devascularization was assessed using indocyanine green near-infrared fluorescence. A matched-pair analysis with a retrospective cohort undergoing early-unclamping was conducted, adjusting on tumor complexity and preoperative eGFR. Perioperative, oncologic and functional outcomes using DMSA-renal scintigraphy were assessed. Multivariate analysis was performed to identify predictors of postoperative renal function and de novo chronic kidney disease (CKD). Results Super-selective RAPN was successful in 23/30 patients (76.7%), 5 requiring secondary main artery clamping due to persistent tumor fluorescence. Matched-pair analysis showed similar operating time, blood loss, positives margins and complication rates. Super-selective clamping was associated with an improved eGFR variation at discharge (p=0.002), 1-month (p=0.01) and 6-month post-op (-2%vs-16% p=0.001). It also led to a better relative function on scintigraphy (46%vs40% p=0.04) and homolateral eGFR (p=0.04), and fewer upstaging to CKD stage ≥3 (p=0.03). On multivariate analysis, super-selective clamping was a predictor of postoperative renal function. Conclusion Super-selective RAPN leads to an improved preservation of renal function and a reduced risk of de novo CKD stage≥3, while keeping the benefit of main artery clamping on perioperative outcomes.

INTRODUCTION:In the presence of severe aorto-iliac calcification, aortic bypass surgery can be mandatory to allow kidney transplantation. The aim of our study was to evaluate the safety and outcomes of this strategy among asymptomatic patients. MATERIALS AND METHODS:We retrospectively reviewed the files of all patients that had undergone vascular bypass surgery prior to kidney transplantation between November 2004 and March 2016. All patients undergoing aortic bypass surgery prior to kidney transplantation without any vascular-related symptoms were included. RESULTS:Twenty-one asymptomatic patients were included. Ten patients (48%) have not received a kidney transplant. Four patients died before kidney transplantation, including 2 deaths related to the bypass surgery (9.5%). Early post-operative morbidity involved 11 cases. Eleven patients (52%) were transplanted. Transplanted patients were significantly younger (median age 60 [56-61] vs 67 [60-72] years, P = .04) at the time of bypass and were less frequently treated for coronary heart disease (9% vs 50%, P = .06). CONCLUSION:Aortic bypass surgery performed prior to kidney transplantation among asymptomatic patients has significant mortality and morbidity rates. When transplantation is possible, the results are satisfying. Larger studies are required to define the selection criteria, such as age and coronary heart disease.

Purpose: The management of major renal trauma has shifted in the last decade in favor of a nonoperative approach. Our level 1 trauma center promotes this approach with the objective of renal function preservation. However, certain situations still require surgery. In this study we analyze predictors of surgery and long-term outcomes after conservative management.Materials and Methods: From January 2004 to March 2015 we prospectively collected data from all patients admitted to our institution for high grade blunt renal trauma (grades IV and V). Nonoperative management was considered successful when patients did not undergo surgical exploration, regardless of angioembolization or endoscopic treatment.Results: Of 306 patients with renal trauma 151 presented with major injuries, including 124 grade IV and 27 grade V. Nonoperative management was successful in 110 (89%) cases of grade IV and 14 (52%) cases of grade V lesions. Deceleration mechanism (p = 0.03), associated lesions (p = 0.001), percentage of devitalized parenchyma (p = 0.012), angioembolization (p < 0.001), hemodynamic instability (p < 0.001) and low hemoglobin (p = 0.001) were more frequent in patients treated surgically. On multivariate analysis grade (OR 7.36, p = 0.01) and hemodynamic instability (OR 4.18, p = 0.04) were the only independent predictors of surgical treatment. Long-term followup of preserved kidneys revealed a remaining 40% and 0% relative renal function after grade IV and V injuries, respectively. Only devascularized parenchyma greater than 25% predicted the decline of long-term renal function.Conclusions: Nonoperative management can and should be performed safely in cases of grade IV injuries whenever possible, with valuable long-term renal function. It can also be initiated in grade V cases. However, surgeons should consider nephrectomy with the onset of any suspicious symptoms.

Study Type – Therapy (outcomes) Level of Evidence 2b What's known on the subject? and What does the study add? High-grade renal trauma seems to be eligible for conservative management. Ureteric stent placement raises issues about its usefulness and its timing. Predictive factors of post-trauma function and surgery need to be known. Urinary extravasation is not associated with poor functional outcome. Ureteric stenting is needed only in case of sepsis and ureteric clot retention. The only independent predictor of long-term renal function is the importance of devascularised renal fragments. To predict the outcomes of a non-operative approach to managing urinary extravasation after blunt renal trauma. A prospective observational study was conducted between January 2004 and October 2011. First-line non-operative management was proposed for 99 patients presenting with a grade IV blunt renal injury according to the revised American Association for the Surgery of Trauma (AAST) classification. Among them, 72 patients presented with a urinary extravasation. Management and outcomes were recorded and compared between patients presenting and those who did not present with urinary leakage. Relative postoperative renal function was assessed 6 months after the trauma using dimercapto-succinic acid renal scintigraphy. Predictors of the need for endoscopic or surgical management and long-term renal function were evaluated on multivariate analysis. Among patients with urinary leakage, endoscopic ureteric stent placement and open surgery were required in 37% and 15%, respectively. On multivariate analysis, fever of >38.5 °C and ureteric clot obstruction were independent predictors of the need for ureteric stent placement. The only predictor of open surgery was the percentage of devitalised parenchyma. Long-term renal function loss was correlated to the percentage of devitalised parenchyma and associated visceral lesions. Urinary extravasation did not predict surgical intervention or long-term renal function loss. Urinary extravasation after blunt renal trauma can be successfully managed conservatively and does not predict long-term decreased renal function or surgery requirement. A devascularised parenchyma volume of >25% predicts a higher rate of surgery and poorer renal function.