Back-Table Repair of Parenchymal and Collecting System Injury of a Living Donor Kidney

Living donor kidney transplantation provides superior outcomes compared with deceased donor transplantation, but unexpected allograft injury during donor nephrectomy can threaten graft viability. Reports describing back-table repair of iatrogenic donor kidney injuries are limited, particularly for full-thickness parenchymal defects involving the collecting system. We report a case of a 69-year-old male with end-stage renal disease secondary to type 2 diabetes mellitus and hypertension who underwent planned living-related kidney transplantation from his 43-year-old son. The donor underwent robotic-assisted left donor nephrectomy without an identified intraoperative complication. During back-table preparation, the allograft was found to have a large subcapsular hematoma and an approximately 2 cm parenchymal defect communicating with the calyces and renal pelvis. After clot evacuation and exposure of the injury, a three-layer repair was performed. The collecting system was closed with interrupted 6-0 polydioxanone sutures (PDS), the renal cortex and medulla were reapproximated with running 6-0 PDS, and the capsule was closed with running 6-0 Prolene with Surgicel as a pledget. The kidney was then implanted in the recipient's right iliac fossa using standard vascular anastomoses and ureteroneocystostomy over a double-J stent. A perinephric drain was placed. The recipient had immediate graft function without the need for renal replacement therapy. Drain output was minimal, and the drain was removed on postoperative day 15. This case demonstrates that a structured multilayer back-table repair can salvage a living donor kidney with full-thickness parenchymal and collecting system injury. Careful injury assessment, multilayer reapproximation, and capsular reinforcement may support successful transplantation.