Abstract
The authors are to be congratulated for their 23 ex-vivo ureteroscopic stone extractions at the time of live donor nephrectomy. Although the number of cases is small, this seems to be the largest series published to date. Because the authors recorded no complications, they may conclude that the risk to the graft is minimal. Data regarding the outcome of this procedure are, however, sparse, and we think, therefore, that any adverse event ought to be reported, as in this 35-year-old patient who received her father's right kidney at our institution.
Immediately after laparoscopic harvesting, a rigid ureteroscope was introduced into the ureteral stump to remove an 8-mm lithiasis from the uppermost calix. The stone was impacted in a narrow mouth caliceal diverticulum and could be retrieved in a basket only after mechanical fragmentation. The kidney was then transplanted in a standard fashion: Revascularization at the release of clamps was unsatisfactory, and the arterial anastomosis was therefore redone. Vascularization improved temporarily, but the graft had to be explanted eventually because of acute ischemia: The arterial anastomosis was widely patent, but a major intimal flap in the hilum, next to the renal pelvis, explained the failure. The patient subsequently underwent a successful retransplantation from a “good samaritan” donor.
To the best of our knowledge, this complication of ex-vivo ureteroscopic stone extraction has not been described. The most likely explanation is that the instrumental manipulations within the renal pelvis resulted in an injury of the neighboring artery and that use of a flexible endoscope might have been softer. A less likely explanation is that the arterial injury may have occurred during the donor nephrectomy. We conclude that whenever the ex-vivo endoscopy does not appear technically straightforward, close observation post-transplant or extraction by pyelotomy may be preferable, depending on the clinical context. 2