Transplant Nephrectomy (Failed Allograft)
Failed renal allograft, [right / left] iliac fossa: [chronic rejection / primary non-function / renal vein thrombosis / chronic allograft nephropathy / graft intolerance syndrome / recurrent disease / chronic allograft infection]
Same
Transplant nephrectomy, [right / left] iliac fossa, [intracapsular / extracapsular] technique
[***, MD/DO]
[Fellow/Resident name]
General endotracheal
Patient presents with failed renal allograft secondary to [chronic rejection / primary non-function / thrombosis / recurrent disease], transplanted [date]. Currently on [hemodialysis / peritoneal dialysis]. [Symptomatic allograft: fevers, pain, hematuria / Asymptomatic but immunosuppression withdrawn.] Decision made to proceed with allograft nephrectomy. Risks including bleeding from collateral vessels and scarred dissection plane, ureteral injury, vascular injury, infection, and prolonged operative time discussed. Consent obtained.
Failed allograft [small and fibrotic / enlarged and necrotic / phlegmonous]. Dissection plane [relatively straightforward / densely scarred / required intracapsular technique due to adherent retroperitoneal fibrosis]. Hilar vessels [easily controlled / required careful dissection from scarred retroperitoneum].
The patient was positioned supine. The prior [right / left] iliac fossa transplant incision was reopened [/ extended]. Retroperitoneal dissection was carried down to the allograft.
[INTRACAPSULAR TECHNIQUE:] The renal capsule was incised and the kidney removed intracapsularly, leaving the capsule and perirenal scar tissue in place. The renal artery and vein stumps were identified within the capsule, suture-ligated with [0-silk / 2-0 Prolene], and divided.
[EXTRACAPSULAR TECHNIQUE:] The kidney was dissected free in the extracapsular plane. Dense adhesions [encountered and carefully lysed]. The renal artery was controlled and divided using [suture ligation with 2-0 Prolene / 0-silk tie with transfixing Prolene stitch / vascular stapler], given the short anastomotic stump under iliac arterial pressure. The renal vein was similarly suture-ligated with [2-0 Prolene] and divided. The ureter was dissected as distally as safely feasible, ligated, and divided.
The allograft was removed and sent to pathology. Hemostasis confirmed. The wound was irrigated copiously. [A closed-suction drain was placed.] Fascia closed with running [0-PDS]. Skin closed with staples. Patient tolerated the procedure well.
None
Failed allograft to pathology
[X] mL
[Closed-suction drain / None]
Patient taken to recovery in stable condition. Admitted for monitoring.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Failed renal allograft, [right / left] iliac fossa: [chronic rejection / primary non-function / thrombosis]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Transplant nephrectomy, [right / left] iliac fossa, [intracapsular / extracapsular] technique
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with failed renal allograft secondary to *** (transplanted ***). Currently on hemodialysis. [Symptomatic: fevers, allograft pain, hematuria.] Risks including hemorrhage from scarred dissection plane, vascular injury, and prolonged dissection discussed. Informed consent obtained.
FINDINGS: Failed allograft [small and fibrotic / enlarged / necrotic]. Dissection [straightforward / densely scarred; intracapsular technique required]. Hilar vessels identified and controlled.
DESCRIPTION OF PROCEDURE:
Patient supine. Prior [right / left] iliac fossa incision reopened. Retroperitoneum entered. [INTRACAPSULAR: Capsule incised; kidney removed intracapsularly; renal artery and vein stumps suture-ligated within capsule.] [EXTRACAPSULAR: Kidney freed in extracapsular plane; adhesions lysed; renal artery doubly ligated and divided; renal vein suture-ligated and divided; ureter ligated and divided.] Allograft removed and sent to pathology. Hemostasis confirmed. Wound irrigated. [Drain placed.] Fascia closed with 0-PDS; skin with staples. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Failed allograft to pathology
COMPLICATIONS: None
DRAINS: [Closed-suction drain / None]
DISPOSITION: Patient to recovery. Admitted for monitoring.
Signed: .ME, .MYDEGREE
.TODAYVariants
Early nephrectomy (within 90-day global, related unplanned return-to-the-operating-room reporting)
Document complication necessitating return to OR. Payment is reduced.
Concurrent re-transplant
Place new allograft in the contralateral iliac fossa whenever feasible to avoid the scarred ipsilateral field. Document each procedure with separate operative times. If ipsilateral retransplant is required (prior bilateral transplants, vascular constraints), document rationale and expect increased blood loss and operative time.
Charting Tips
- Document indication for nephrectomy (chronic rejection, primary non-function, infection, thrombosis)
- State technique (intracapsular vs. extracapsular) and rationale
- Note extent of adhesions/scarring encountered and management
- Document hilar vessel control technique (suture ligation vs. stapled division)
- If within 90-day global of original transplant, related unplanned return-to-the-operating-room reporting is required. Flag for billing team.
Documentation & Reimbursement Considerations
- Report Transplant Nephrectomy (Failed Allograft) as the primary service when it is the definitive operation performed.
- The primary service applies whether the nephrectomy is performed for chronic rejection, primary non-function, infection, or thrombosis. Document the indication clearly.
- This significantly reduces payment. Document the complication that necessitated early return.
- Place the new allograft in the contralateral iliac fossa whenever feasible to avoid the densely scarred ipsilateral field, and document both procedures with individual operative times.
- Intracapsular vs. extracapsular dissection technique affects operative complexity and blood loss but does not change the reporting options. Document technique used and rationale. Intracapsular is faster and less bloody; extracapsular is required for infection or to clear the field for re-transplant.
- New problems or unrelated procedures outside this scope are separately reportable.
- Reserve increased-service reporting for truly exceptional cases (frozen pelvis, iliac vessel injury requiring reconstruction, hemorrhage requiring transfusion) with contemporaneous documentation of extra operative time and specific complexity.