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Microvascular damage is the main cause of delayed graft function (DGF) after kidney transplant. Assessing its extent may be helpful in predicting DGF to achieve better postoperative management, especially in terms of an immunosuppressive regimen. Our aim was to explore the capability of intraoperative indocyanine green (ICG) angiography to examine the microvasculature of the kidney.We conducted a prospective cohort study on 37 kidney transplant recipients in a high-volume kidney transplant center. During surgery, after graft implant, an ICG angiography was performed through a high-definition Storz camera system (Karl Storz GmbH, Tuttlingen, Germany) with successive quantitative assessment of fluorescence using Icy bioimage analysis.All transplanted kidneys that showed immediate recovery of their function had a fluorescent intensity ≥49.953 with a mean of 96.930 ± 21. The fluorescence intensity for kidneys that showed a delayed recovery of their function never exceeded 55.648, and the mean was 37.718 ± 13. The difference between the 2 groups was statistically significant with a P value.001. The only kidney that never recovered showed a fluorescence intensity consistently25.220, the lowest detected.This study demonstrates that intraoperative ICG angiography may be used to assess the microvasculature of the graft. A statistically significant difference in terms of fluorescent intensity can be highlighted between kidneys that immediately recover their function and those with delayed recovery. Further larger studies are needed to confirm the capability of the technique to predict DGF to optimize the transplanted patients' management.

Aortoiliac occlusive disease (AOD) is a great threat for kidney transplantation (KT). Here we report the case of an aortoiliac bypass, performed simultaneously with renal transplantation using venous grafts obtained from the deceased donor. The recipient was a 68-year-old woman with significant stenosis of the aortoiliac axis. We performed an aortobisiliac bypass using donor’s femoral veins because presence of methicillin-resistant Staphylococcus aureus was detected on donor hemoculture and contraindicated a prosthetic implant on the recipient. KT was then carried out using standard technique. Operative time amounted to 330 minutes and cold ischemia time of the renal graft was 900 minutes. Delayed graft function was observed until postoperative day 12, but the patient showed a good urine output and a serum creatinine of 2.1 mg/dL at discharge. AOD is not an absolute contraindication to renal transplantation, and simultaneous surgical repair of aortoiliac lesions with KT seems feasible. The patient’s return to function after initial delayed graft function suggests that such interventions may allow transplantation to be offered to those patients who otherwise may be excluded for severe vascular comorbidities. Homologous vascular grafts are an excellent choice because prosthetic vascular replacement during immunosuppression must be avoided as long as possible, especially in patients with coexisting infective risk.

Background Many surgical procedures can produce persistent lymphorrhea, lymphoceles, and lymphedema after lymph node and lymph vessel damage. Appropriate visualization of the lymphatic system is challenging. Indocyanine green (ICG) is a well-known nontoxic dye for lymphatic flow evaluation. ICG fluorescence-guided lymphography has emerged as a promising technique for intraoperative lymphatic mapping. Objective Our goal was to develop a high spatial resolution, real-time intraoperative imaging technique to avoid or recognize early deep lymphatic vessel damage. Methods We intraoperatively performed ICG fluorescence-guided lymphography during a kidney transplant. ICG was injected in the subcutaneous tissue of the patient's groin in the Scarpa's triangle. A dedicated laparoscopic high-definition camera system was used. Results Soon after ICG injection, the lymphatic vessels were identified in the abdominal retroperitoneal compartment as fluorescent linear structures running side by side to the iliac vessels. Surgical dissection was therefore performed, avoiding iatrogenic damage to major lymphatic structures. Another ICG injection at the end of the procedure confirmed that the lymphatic vessels were intact without lymph spread. Conclusions Intraoperative lymphatic mapping with an ICG fluorescence-sensitive camera system is a safe and feasible procedure. ICG real-time fluorescence lymphography can be used to avoid or recognize early deep lymphatic vessel damage and reduce postoperative complications related to the lymphatic system.

Introduction Indocyanine green (ICG) fluorescence imaging system is a now a consolidated complementary technique for several surgical fields. The development of post-transplant lymphocele following lymph spread could affect kidney function; between therapeutic options, the literature reports a 12% overall conversion rate from laparoscopic to open surgery with a major risk of damaging the urinary tract. Objective The goal of the present study was to demonstrate that intraoperative ICG fluorescent imaging is a safe technique that can be used in laparoscopy establishing the exact location of the lymphocele and reducing intraoperative risks. Method Fifty milligrams of ICG dissolved in 20 mL of saline solution was injected via percutaneous drainage placed into the lymphocele to decompress transplanted kidneys 2 weeks before a laparoscopic lymphocele marsupialization procedure. Results During the first exploratory laparoscopy, in the flank and right iliac fossa, near the 2 renal grafts, fluorescence was identified in 3 raised areas that were the internal side of the lymphocele lobes. The lymphocele wall was dissected and 300 mL of serous fluid was aspirated after puncturing. A 5 cm breach was then made in the cyst wall using the Ultracision harmonic scalpel (Ethicon US). Afterwards, a pedicle of the omentum in the lymphocele core was interfered with and fixed by 2 stitches. Conclusions Laparoscopic surgery seems to be the preferred surgical option for the treatment of primary symptomatic lymphocele after kidney transplantation. Intraoperative ICG fluorescent imaging is a safe technique to establish the exact location of the lymphocele and reduces the risk of damaging urinary structures during surgery.