title: [Surgical aspects in the third and fourth kidney retransplant].
abstract: OBJECTIVE
  A quarter of patients waiting for kidney transplantation are patients with previous graft failure. Outcome of first and second renal transplant make these the gold standard for end renal stage disease, but this is not so clear in the case of third and further renal transplant, especially at the time of organ shortage. We revise our experience in patients with three or more kidney transplants focusing on surgical aspects and graft outcome.
  
  
  METHODS
  1364 renal transplants have been carried out in our centre since 1975 until December 2003. We have retrospectively revised the 34 patients with three renal transplants and the 5 with four. We analyse the surgical technique, surgical complications and graft outcome.
  
  
  RESULTS
  Mean age was 42 years (21-65). Average mismatches between donor and recipient was 3.2. All kidneys, but one case of living donor, were harvested from cadaver donors, mostly in multiple organ-procurement. Average time from the last renal transplant was 5 years (3 days-17 years) and from the last transplant carried out in the iliac fossa reused until the new transplant was 9 years (3 days- 17.5 years). All implants were performed through an iterative lumboliliac incision (25 on the right side, 11 on the left one and in 3 cases where side was not registered). Mean average duration of the procedure was 166 minutes (100-300). Nephrectomy of previous graft at the moment of the implant was carried out in 13 patients (33%). Vascular anastomosis was made on the common iliac vessels (50%) or on the external ones (50%) in end to side way, Ureteroneocystostomy was performed in an extravesical way except in 1 patient with cutaneous diversion. Vascular complications were 4 haemorrages (1 patient died), 3 venous and 2 arterial thrombosis. We had an abscess secondary to intestinal fistulae. Other surgical complications were 4 lymphoceles, three of them needed surgical treatment, and one perirenal haematoma treated in a conservative way. No urological complications were seen. In total 6 grafts (15%) were lost due to surgical complications. Graft actuarial survival rate at 1 year was 65%, 40% at 5 and 28% at 10 years.
  
  
  CONCLUSIONS
  Three and four renal transplant survival rates are shorter than first and second ones. Iterative access through lumboiliac incision is associated with a higher vascular complication rate, probably in these patients a transperitoneal access would be better. Multicentric studies with higher numbers of patients are needed to define more clearly which patients would benefit from multiple kidney retransplants.
authors.affiliation: Servicio de Urología, Hospital Universitario Marqués de Valdecilla, Santander. jlgb@ono.com
authors.forename: J L
authors.initials: JL
authors.lastname: Gutiérrez Baños
authors.forename: E
authors.initials: E
authors.lastname: Rodrigo Calabia
authors.forename: M H
authors.initials: MH
authors.lastname: Rebollo Rodrigo
authors.forename: J A
authors.initials: JA
authors.lastname: Portillo Martín
authors.forename: A
authors.initials: A
authors.lastname: Roca Edreira
authors.forename: M A
authors.initials: MA
authors.lastname: Gómez Correas
authors.forename: J
authors.initials: J
authors.lastname: Ignacio del Valle Schaan
authors.forename: C
authors.initials: C
authors.lastname: Aguilera Tubet
authors.forename: F
authors.initials: F
authors.lastname: Ruiz Izquierdo
authors.forename: R
authors.initials: R
authors.lastname: Ballestero Diego
authors.forename: B
authors.initials: B
authors.lastname: Martín García
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D016030:Kidney Transplantation / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome