Pre transplant nephrectomy , our experience in Prince Hussien Center of Urology and Organ transplantation By : Dr. Ghaith Gsous third year general surgery resident Supervisor : Dr.Muhanad Al-Naser Consultant of Urology

Objective  to review our experience in pre transplant nephrectomy and discuss the indications , causes and outcome for this procedure and compare it  with international literature.

Introduction Indications of nephrectomy Indications of kidney transplant Indications for native nephrectomy and transplant Types of native nephrectomy with transplant Our experince Comparing to international literature conclusion

Indications of nephrectomy Benign conditions : irreversable damaged kidney due to: chronic infection . obstruction . trauma . renal TB . renovascular hypertension . polycystic kidney disease . transplant . Malignant : renal cell carcinoma , chromophobe carcinoma

Indications of kidney transplant End stage renal disease due to : diabetes hypertension glomerulonephritis cystic kidney focal segmental glomerulosclerosis , etc .

Indications for native nephrectomy and transplant polycystic kidney disease ( most common ) . prevent recurrent Urinary tract infection pyelonephritis due to renal stones . vesicouretral reflux .

Types of native nephrectomy with transplant Native nephrectomy pre transplant Native nephrectomy and transplant in same session Native nephrectomy after transplant

Our experince Materials and Methods : -this prospective study carried out in Prince Hussien Center Of Urology and Organ Transplantation from 2010 to 2015 on 28 patients who underwent nephrectomy pretransplant for different causes .

Results : out of 28 patients there was : (18 patients) had nephrectomy pretransplant due to polycystic kidney disease .  (6 patients) had nephrectomy to prevent recurrent Urinary tract infection due to renal stones or to prevent pyelonephritis . (4 patients) due to vesicouretral reflux.

Specific points : All donors are living donor. Dialysis done 1 day before surgery 3 months the interval between native nephrectomy and transplant surgery Bilateral native nephrectomy done in 8 patients. Midline incision done for nephrectomy .

Dr.Mohannad Al-Naser Huge PCK

Complications 1-Splenic injury in one pateint , treated with splenectomy . 2-Bowel injury in one patient , treated by primary repair .

Comparing with international studies Common cause of native nephrectomy and transplant Timing of native nephrectomy according to transplant surgery Outcome and Conclusion

Common complaints with PCKD  St Thomas' Hospital(1988-2008 ) = 31 cases Renal Transplant Unit Central Manchester University Hospital (2003-2009)= 32 cases Prince Hussien center (2010-2015)= 16 cases Common complaints with PCKD UTI (14 pt) Pain (12 pt) Susp.tumor (3 pt) Hematuria (1 pt) No space (1 pt) Pain No space Hematuria Reccurnt infection No space(10 pt ) Pain (3 pt ) Hematuria (2 pt ) Infected cyst (1pt) Timing of native nephrectomy Pre transplant (10 pt) Post transplant (20 pt) In same session (1 pt) Pre transplant (20 pt) Post transplant (12 pt ) Pre transplant nephrectomy ( regardless the indication ) Outcome Mortality 3% Morbidity 65% Mortality (3pt , 2 in pre transplant group ) No mortality Splenic injury (1 pt ) Bowel injury (1pt ) Conclusion The timing of NN is variable and dictated by indication Post-transplant unilateral nephrectomy appears to be the safest approach

Conclusion PCKD is the most common cause of native nephrectomy and kidney transplant. Timing the native nephrectomy still controversial , our policy is Pre-Transplant nephrectomy in all cases , the international literature support the Post- Transplant nephrectomy . Our outcome and results the same with international centers .

Question for discussion What is the optimal time for native nephrectomy , is it Pre-Transplant , Post- Transplant or in one session ?

My opinion 1- the indication for native nephrectomy should be considered at first. 2- patient post-transplant will be on immunosuppressant medications and the surgery for native nephrectomy will increase risk of infection of rejection . 3- the cost will be less on hospital if the nephrectomy done with transplant in same session . 4- we don’t have to put the patient on risk of two major surgery .

Thank you