Allograft nephrectomy: Surgical aspects and alternatives

Allograft nephrectomy (AN) is a rare but morbid procedure required after graft failure or neoplasia. We systematically reviewed current knowledge on AN surgical techniques, complications, and alternatives.

Undertaken to inform the French Association of Urology guidelines on allograft nephrectomy, this review was reported following PRISMA guidelines. PubMed/MEDLINE was searched (January 2000-March 2024) for studies of patients with non-functional first kidney transplants requiring AN or alternative strategies. Case reports, editorials, and non-systematic reviews were excluded.

AN is predominantly performed via an open extraperitoneal approach. For non-functional grafts, consensus is lacking regarding subcapsular versus extracapsular techniques. However, the subcapsular approach reduces operative time, bleeding, and intraoperative complications, though overall morbidity data remain conflicting. The surgical approach does not impact alloimmunization. Regarding arterial embolization, protocols are not standardized. Yet, it achieves >80% success with lower mortality and morbidity than AN. Its main complication is post-embolization syndrome, potentially leading to secondary AN. Embolization prior to AN effectively reduces intraoperative bleeding and operative time.

The extraperitoneal subcapsular approach appears to be the safest surgical option. Arterial embolization is a valuable alternative or adjuvant strategy to AN in managing graft intolerance syndrome after graft failure.