Kidney Transplant
End-stage renal disease: [diabetic nephropathy / FSGS / IgA nephropathy / hypertensive nephrosclerosis / polycystic kidney disease]
Same
Deceased donor [/ living donor] renal transplant, right [/ left] iliac fossa
[***, MD/DO]
[Fellow/Resident name]
General endotracheal
Patient presents with end-stage renal disease secondary to [etiology] on [hemodialysis / peritoneal dialysis] since [date]. [Preemptive transplant / living donor / deceased donor, PRA [X]%.] Cross-match [negative / virtual negative]. HLA mismatch [X]/6. CMV: donor [+/-], recipient [+/-]. Cold ischemia time [X] hours. Induction immunosuppression: [basiliximab / thymoglobulin]. Risks including delayed graft function, primary non-function, rejection, vascular thrombosis, ureteral leak, lymphocele, and death discussed. Consent obtained.
Kidney [appeared viable / showed [some mottling / excellent perfusion] on back table]. Bench preparation included [ligation of accessory vessels / double renal arteries anastomosed to Carrel patch / venous extension graft]. Cold ischemia time: [X] hours. Second warm ischemia (anastomosis) time: [X] minutes. On reperfusion, kidney [pinked immediately / had delayed reperfusion]. [Urine output noted intraoperatively / no immediate urine output, consistent with delayed graft function].
The patient was positioned supine. A [right / left] curvilinear iliac fossa (Gibson) incision was made. The external oblique, internal oblique, and transversalis fascia were divided. The retroperitoneal space was developed. The external iliac artery and vein were dissected free and controlled with vessel loops.
The kidney was brought to the field. The renal vein was anastomosed end-to-side to the external iliac vein using running [5-0 / 6-0 Prolene]. The renal artery was anastomosed end-to-side to the external iliac artery using running [5-0 / 6-0 Prolene]. Clamps were released with [immediate turgidity and color change / delayed reperfusion]. [Urine noted in the ureter within minutes of reperfusion / no immediate urine output.]
Ureteroneocystostomy was performed using the [Lich-Gregoir extravesical technique / Politano-Leadbetter intravesical technique]. [Lich-Gregoir: the detrusor was incised, the ureter was anastomosed to the urothelium with running [4-0 Vicryl], and the detrusor was reapproximated over the ureter creating an antireflux tunnel.] A [double-J ureteral stent / no stent] was placed.
Hemostasis confirmed. [A closed-suction drain was placed near the hilum.] Fascia closed with running PDS. Skin closed with staples. Patient tolerated the procedure well.
None
[Back-table tissue biopsy sent / None]
[X] mL
[Closed-suction Jackson-Pratt drain / None]
Patient taken to transplant ICU / floor in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: End-stage renal disease: [diabetic nephropathy / FSGS / IgA nephropathy / hypertensive nephrosclerosis / PKD]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Deceased donor [/ living donor] renal transplant, [right / left] iliac fossa
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with ESRD secondary to *** on [hemodialysis / peritoneal dialysis]. [Deceased donor / Living donor.] Cross-match negative. HLA mismatch ***. CMV D/R: ***. Cold ischemia time: *** hours. Induction immunosuppression: [basiliximab / thymoglobulin]. Risks including DGF, primary non-function, rejection, vascular thrombosis, ureteral leak, and lymphocele discussed. Informed consent obtained.
FINDINGS: Kidney appeared viable with [excellent / adequate] bench anatomy. [Double renal arteries / Carrel patch / Single artery.] Cold ischemia time: *** hours. Second warm ischemia (anastomosis) time: *** minutes. On reperfusion: [immediate turgidity and color change / delayed reperfusion]. [Urine output noted intraoperatively / no immediate urine output.]
DESCRIPTION OF PROCEDURE:
Patient supine. [Right / left] Gibson incision; retroperitoneal space developed; external iliac artery and vein dissected and controlled with vessel loops. Renal vein anastomosed end-to-side to external iliac vein with running 5-0 Prolene. Renal artery anastomosed end-to-side to external iliac artery with running 5-0 Prolene. Clamps released; excellent perfusion confirmed. Ureteroneocystostomy via Lich-Gregoir extravesical technique; [double-J ureteral stent placed]. Hemostasis confirmed. [JP drain placed at hilum.] Fascia closed with PDS; skin with staples. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [Back-table biopsy to pathology / None]
COMPLICATIONS: None
DRAINS: [JP drain / None]
DISPOSITION: Patient to transplant [ICU / floor] in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Living donor kidney transplant
Same implantation technique. Note shorter cold ischemia time and typically better graft quality. Document donor relationship. Back-table preparation may be simpler (single artery, shorter ureter).
Dual kidney transplant (marginal donors)
Both kidneys placed in same recipient, typically from older or marginal donors. Document dual implantation, individual anastomoses, and rationale for dual placement.
Transplant with recipient nephrectomy
Document indication for concurrent nephrectomy (infection, hypertension, massive polycystic kidneys). Performed through same Gibson incision or separate midline incision.
Charting Tips
- Document cold ischemia time (from cross-clamp to cold flush in the donor OR) and second warm ischemia time (from removal of the allograft from ice to reperfusion in the recipient OR; i.e., anastomosis time). Both are OPTN-required data elements. If deceased donor, note donor KDPI/KDRI. If machine-perfused, document pump parameters (flow, resistance, preservation solution).
- State number of renal arteries and veins and anastomotic technique for each
- Note reperfusion quality: immediate vs. delayed, color, turgidity, urine output
- Document ureteral stent use and planned removal date. Current evidence supports early removal at approximately 3 weeks (range 2-6 weeks); earlier removal (at or before 3 weeks) significantly reduces UTI risk (OR ~0.49 per meta-analysis) compared to later removal.
- Record drain placement location and output at end of case
- Induction immunosuppression agent should be in the operative note
Documentation & Reimbursement Considerations
- Report Kidney Transplant as the primary service when it is the definitive operation performed.
- What is NOT separately billable is the cadaveric donor nephrectomy itself (the applicable service) — that is covered through organ acquisition cost, not the physician fee schedule.
- These apply to back-table work (Carrel patch creation, multiple arteries anastomosed, venous extension grafts, ureteral reconstruction). Document all bench reconstruction explicitly.
- 90-day global period: biopsy of the transplanted kidney (report percutaneous renal biopsy), rejection workup visits, and Doppler surveillance are not separately billable surgical fees within 90 days but generate radiology/pathology fees independently.
- Immunosuppression management, biopsy interpretation, and nephrology co-management are physician E/M services billed independently by the respective providers and are not included in the surgical global.