Psoas Muscle Groove Technique: A Novel Solution for Venous Anastomosis in Kidney Transplantation With Challenging Iliac Anatomy.

OBJECTIVES

Venous anastomosis in kidney transplan-tation can be technically demanding in patients with deep iliac vein or bulky psoas muscle, increasing the risk of renal vein kinking, thrombosis, and prolonged ischemia times. This study prospectively evaluated the safety and efficacy of a novel surgical technique, psoas muscle groove creation, to address this specific challenge.

MATERIALS AND

METHODS

In this prospective case series, 20 consecutive living related kidney transplant recipients with preoperatively identified challenging venous anatomy (deep iliac vein, prominent psoas overhang) underwent venous anastomosis with the psoas groove technique between September 2017 and June 2025. The technique involved creating a shallow, hemostatic groove in the psoas major muscle by using limited electrocautery to accommodate the renal vein, preventing kinking and ensuring a tension-free course. Primary outcomes were venous anastomosis time and incidence of vascular complications. Secondary outcomes included cold ischemia time, operative duration, graft function, and 1-year patient and graft survival.

RESULTS

All 20 procedures were successfully completed without conversion to an alternative technique. Mean venous anastomosis time was 12 ± 4 minutes, and mean cold ischemia time was 25 ± 6 minutes. No cases of renal vein thrombosis, kinking, or other major vascular complications occurred. Immediate graft function was achieved in 95% of patients. At 1-year follow-up, graft survival was 96.4% and patient survival was 96.4%, with mean estimated glomerular filtration rate of 89 mL/min/1.73 m². Postoperative complications were infrequent and not related to the groove creation.

CONCLUSIONS

The psoas muscle groove technique is a safe, reproducible, and effective surgical innovation for managing challenging venous anastomosis during kidney transplant. By providing a protected channel for the renal vein, the technique facilitates a tension-free anastomosis, reduces operative and ischemia times, and prevents kinking, without adding procedural morbidity. This technique represents a valuable adjunct for transplant surgeons facing difficult iliac anatomy.