Dear Editor:

The reduced length of the right renal vein (RRV) represents a technical challenge in kidney transplantation. Here, we have described how we perform the retrieval procedure in order to lengthen the RRV with the contiguous inferior vena cava (IVC) in deceased donor kidney transplantation.

We have read the article entitled “Surgical Stapler for Right Renal Vein Elongation Using the Inferior Vena Cava in Kidney Transplant” by Di Cocco and associates,¹ which was published in Experimental and Clinical Transplantation. We want to congratulate the authors for their successful work and make some contributions.

Right kidney transplant with RRV anastomosis represents a technical challenge due to its anatomical characteristics. The shortness of the RRV compared with the contralateral vein can cause trouble to surgeons because of a reduced surgical operative area, which hinders the safe allocation of the transplanted kidney in the iliac fossa. Therefore, to overcome this technical limit, various solutions for RRV elongation have been identified over the years.^2,3 The caval patch through the use of a linear stapler in bench surgery, after “en bloc” kidney procurement, as presented by Di Cocco and associates,¹ shows a master example of it. After an en bloc resection of the kidneys from the donor, and subsequent separation of the organs at the back table, the authors took the left renal vein (LRV) approximately 3 to 4 mm away from the IVC. The right kidney can then be retrieved along with the IVC, from which a conduit is subsequently constructed to elongate the RRV by stapling proximally and distally across the IVC with the use of the vascular stapler.

Similarly, Santangelo and colleagues have described how they created the “cava conduit” during procurement. In particular, they described closing the superior edge of the IVC and the ostium of the LRV with continuous sutures, checking for leaks in the suture line during Celsior perfusion by closing the IVC with a bulldog clamp and subsequently proceeding with the standard retrieval technique.⁴ Both groups of authors^1,4 found no vascular complications in kidney transplantations performed with the elongated RRV.

Here, we describe a technique that can be seen as a union of these 2 methods. In recent years, we have adopted a technical variant according to which we divide the kidneys “in situ” at the time of procurement. With the use of a vascular linear stapler (Covidien DST Series TA linear stapler, 30 mm), the IVC is sutured about 3 to 4 mm above the entrance of the renal veins (Figure 1). With the same stapler, the LRV is also sutured close to its entrance into the IVC (Figure 2). The IVC is sectioned with cold scissors, immediately above the staple line and right above the iliac bifurcation. The LRV is cut, leaving the staple line on the caval side. Any defects on the staple line are fixed with detached Prolene stiches at the back table or in vivo during transplant. In 20 cases performed with this technique, we have not detected any early or late vascular complications.

Compared with the procedures described by Di Cocco and Santangelo and colleagues, our technique provides the following advantages. First, it reduces the length of time of the back-table graft preparation. Second, our procedure allows us to maintain a major length of the RRV-IVC complex (Figure 3), with particular usefulness as a safer procedure in obese patients undergoing kidney transplant. This technique of “in situ” division of the 2 kidneys during the procurement procedure with the use of a linear stapler also represents a suitable technique for surgeons in training, such as those who most frequently perform the organ procurement procedures at our center. It allows us to reduce imperfections of the RRV due to its inaccurate sections from the vena cava. These imperfections may require difficult suturing during bench surgery with possible repercussions on vascular dynamics.

References:

1. Di Cocco P, Kandilis A, Rajagopal P, Herbert P, Hassen Y, Hakim N. Surgical stapler for right renal vein elongation using the inferior vena cava in kidney transplant. Exp Clin Transplant. 2016;14(5):564-566. doi:10.6002/ect.2014.0142
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2. Baptista-Silva JC, Medina-Pestana JO, Verissimo MJ, Castro MJ, Demuner MS, Signorelli MF. Right renal vein elongation with the inferior vena cava for cadaveric kidney transplants. An old neglected surgical approach. Int Braz J Urol. 2005;31(6):519-525; discussion 525. doi:10.1590/s1677-55382005000600002
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3. Arango O, Lorente JA, Bielsa O, et al. [Elongation of the right renal vein in 120 consecutive transplant patients. A comparative analysis]. Actas Urol Esp. 2013;37(3):135-141. doi:10.1016/j.acuro.2012.03.009
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4. Santangelo M, Spinosa G, Grassia S, et al. In situ elongation patch in right kidney transplantation. Transplant Proc. 2008;40(6):1871-1872. doi:10.1016/j.transproceed.2008.05.019
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