Kidney autotransplantation with an open midline approach is an established technique used to manage complex urological and renovascular pathology. First reported as early as 1963 it is a method of preserving renal function in a range of pathologies including ureteric injuries, ureteric strictures, haematuria loin pain syndrome, complex nephrolithiasis, intrarenal aneurysm, tumours of the kidney and ureter and retroperitoneal fibrosis. This technique is valuable when the contralateral kidney is poorly functioning. In the literature there are a range of different methods described for performing this procedure. Early reports describe an open intraperitoneal approach which was then largely replaced by a laparoscopic approach or open flank incision to perform a nephrectomy. The literature does not describe an extraperitoneal midline approach in order to perform a kidney autotransplant surgery. However, extraperitoneal approaches to access the retroperitoneal space is well documented. The benefits of this approach are that it allows excellent exposure to retroperitoneal structures whilst avoiding a flank incision or intraperitoneal complications.

A midline laparotomy incision was performed. The rectus sheath was divided followed by cranial and caudal extension of this entry. The pre-peritoneal space was developed to reach the lateroconal fascia. The peritoneal sac was retracted superomedially to expose gerotas fascia. A simple nephrectomy was performed. First, the left ureter was divided with a good amount of healthy proximal ureter left intact. The renal hilum was left intact. A right rutherford morrison incision was performed followed by dissection to expose the external iliac artery and vein. The renal hilum was dissected and the arterial lumen flushed with heparinised saline. The renal artery was anastomosed to the external iliac artery and the renal vein was anastomosed to the external iliac vein in a continuous end to side fashion. The transplanted kidney was then reperfused and tested with ultrasound dopplers. The proximal ureter was trimmed extracorporeally to an ideal length to be anastomosed to the bladder dome. The bladder dome was incised medially to the graft site and a 4.8fr JJ ureteric stent was placed from inside the bladder through the transplanted ureter. The ureter was anastomosed to the bladder dome over the ureteric stent.

 

An extraperitoneal approach to a nephrectomy is an effective way of exposing retroperitoneal structures.