Serial renal transplant surgery: technical reflections concerning third transplants.

From 1972 to 1993, we carried out 803 consecutive renal transplants including 8 third transplants. Exclusively cadaveric, these third renal transplants were implanted by intraperitoneal approach in right iliac position, without previous homolateral transplantectomy in 5 cases. The arterial anastomoses were common (7) or external iliac and hypogastric (1), and the venous anastomoses external (1) and common iliac (3), or inferior vena cava (4). Restoration of urinary continuity was by ureteronecystostomy (Politano-Leadbetter = 4, Grégoir-Lich = 3) or ureteroureteric anastomosis (1). The level of HLA compatibility varied from 2 to 5 identities (mean 3.1) and 4 of the 7 patients explored were hyperimmunized with lymphocytotoxic antibody levels > or = 80%. With the exception of the first of these third transplants, the immunosuppressive protocol associated azathioprine, prednisolone, antilymphocytic serum and cyclosporin. Postoperative sequels were marked by 3 vascular rejections and 1 death from hyperkalemia. Moreover, 1 urinary fistula on ureteroureteric anastomosis settled after percutaneous nephrostomy and placing of an uteric stent endoprosthesis. With a postoperative follow-up of 8-32 months (mean 24), 5 of the transplanted patients (62.5%) have a functional renal transplant with a serum creatinine from 120 to 180 microM/l (mean 140). This brief series, whose failures are exclusively immunological, reveals the remarkable technical reliability for these third renal transplants in right iliac implantation, by median transabdominal approach and above a former transplant site.