Living donor kidney transplantation involving a 69-year-old male recipient and his 43-year-old son as a donor featured the successful salvage of an allograft that sustained an unexpected 2 cm full-thickness parenchymal and collecting system injury during a robot-assisted left donor nephrectomy, according to a clinical case report published by the transplant team.
Robot-Assisted Donor Nephrectomy and Unexpected Allograft Injury
The 43-year-old donor underwent a robot-assisted left donor nephrectomy using a 10-cm Pfannenstiel incision and three 8-mm robotic ports, according to the surgical records. Preoperative CT angiography demonstrated symmetric renal volumes—209 cc for the right kidney and 210 cc for the left—with a single left renal artery, single renal vein, and single ureter. The left kidney was selected due to its less complex vascular anatomy compared to the right, which possessed an accessory lower-pole artery. The donor had a BMI of 26.56 kg/m² and a remote history of smoking. The allograft was flushed with approximately 700 mL of ice-cold preservation solution and showed uniform initial perfusion.
During subsequent back-table preparation in the recipient room, the transplant team identified a large subcapsular hematoma and an approximate 2 cm cortical defect communicating directly with the calyces and renal pelvis, according to the report. While the exact timing and mechanism remain undetermined, surgeons noted that an inadvertent instrument puncture outside the robotic field of view could have caused the defect. Accidental donor-kidney injury during living donor nephrectomy is uncommon, occurring in 1.2% of procedures in a contemporary series of 425 open operations cited by the authors.
Multilayer Back-Table Repair and Surgical Technique
To salvage the kidney, the surgical team executed a structured three-layer reconstruction after evacuating the adherent clot and excising a portion of the overlying capsule for visibility. First, the collecting system and involved calyces were closed using interrupted 6-0 polydioxanone sutures (PDS) to restore watertight integrity. Second, the renal cortex and medulla were reapproximated with running 6-0 PDS to obliterate dead space. Finally, the renal capsule was closed with running 6-0 Prolene and reinforced with Surgicel as a pledget for hemostasis.
Following the back-table reconstruction, the 69-year-old recipient—who had end-stage renal disease secondary to type 2 diabetes mellitus and hypertension, with a preoperative eGFR below 15 mL/min/1.73 m² and a serum creatinine of 7.14 mg/dL—underwent transplantation. Total operative time was 322 minutes, with a cold ischemia time of 117 minutes and a warm ischemia time of 28 minutes. Standard end-to-side vascular anastomoses and a Lich-Gregoir ureteroneocystostomy over a double-J stent were performed in the recipient’s right iliac fossa, alongside perinephric drain placement.
Postoperative Recovery and Immediate Graft Function
The recipient experienced immediate graft function without requiring postoperative renal replacement therapy, according to clinical follow-up data. Serum creatinine dropped to 1.69 mg/dL by postoperative day four at discharge and eventually reached a nadir of 0.70 mg/dL. Minimal drain output was recorded, and fluid creatinine testing confirmed the absence of a urinary leak. The patient developed a right gastrocnemius vein thrombosis during early outpatient follow-up, which was managed with apixaban.
By demonstrating that a Grade IV parenchymal defect involving the collecting system can be successfully repaired on the back table, this case provides a reproducible framework for managing intraoperative donor kidney trauma. The authors emphasize that meticulous layered renorrhaphy allows transplant centers to safely utilize injured living-donor grafts, maximizing organ preservation and patient outcomes.
Frequently Asked Questions
What caused the injury to the donor kidney?
The exact mechanism remains unconfirmed, but the surgical team noted that an inadvertent instrument puncture outside the direct robotic field of view during the donor nephrectomy is a suspected cause.
How was the 2 cm parenchymal defect repaired?
Surgeons performed a structured three-layer back-table repair: interrupted 6-0 PDS sutures closed the collecting system, running 6-0 PDS reapproximated the cortex and medulla, and running 6-0 Prolene with Surgicel secured the renal capsule.
Did the recipient experience delayed graft function?
No. The recipient achieved immediate graft function without needing dialysis, and serum creatinine decreased from a preoperative level of 7.14 mg/dL to a nadir of 0.70 mg/dL.
Is back-table repair common for living donor kidneys?
Such injuries are rare—occurring in roughly 1.2% of cases in major open series—and published reports detailing full-thickness collecting system repairs remain limited, though trauma renorrhaphy principles support the approach.
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