Experiences and Outcomes of Inverted Kidney Transplantation From a Single Vietnamese Institute

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Aim To describe the technical characteristics, indications and evaluate the outcomes of inverted kidney transplantation. Methods Retrospective study from January 2016 to December 2023, included 74 patients who underwent inverted kidney transplantation with 72 cases of right kidney transplant into the right iliac fossa and 2 cases of left kidney transplant into the left iliac fossa performed in Viet Duc University Hospital. Results 63 cases in stage 1 (ipsilateral kidney transplant), all kidney graft were transplanted on the same side and 11 cases in stage 2 in which the kidney transplant was performed in some special cases such as recipients with severe atherosclerotic iliac arteries or incompatibility between the arteries and venous. There was 1 case (1.4%) of graft renal artery pseudoaneurysm and 5 cases (6.8%) of ureteral stenosis at the ureter-bladder junction. There was 1 case of graft loss due to chronic graft rejection – immunosuppression inadherence requiring retransplantation after 2 years. 98.6% of cases had normal kidney function when discharged and remained stable until the latest follow-up. Conclusion Inverted kidney transplantation is a simple, safe and effective technique and could be a feasible solution for atherosclerotic patients. inverted kidney transplantation upside-down kidney transplantation severe atherosclerosis outcomes Figures Figure 1 Figure 2 Figure 3 Figure 4 1. INTRODUCTION Kidney transplant (KT) has been widely recognized as the most effective treatment regarding long-term survival outcomes in end-stage renal disease, with 10-year graft survival of living donor KT of 70% [ 1 ]. KT has been applied in Vietnam since 1992 and approximately 6000 cases has been conducted up to 03/2022. KT has been implemented in Viet Duc University hospital since August 2000. To date, nearly 2000 cases kidney transplants have been performed, mainly from living donor. Our main priority is to protect the donor, thus the the kidney with better function was reserved for the donor. In living-donor kidney transplantation, dealing with short grafted renal veins (RV), mainly occurs in the right graft is still a challenge because anastomosis tension could easily lead to tearing and bleeding [ 2 ]. Firstly, we used the ipsilateral strategy, in which the right kidney is placed in the right iliac fossa and the left graft is placed in the left iliac fossa. Inverted technique, which shorten the distance to the external iliac vein and reduce the risk for RV anastomosis has been applied. In this technique, the direction of the graft’s ureter is reversed upward (towards the head), thus ureter rotation was also performed to prevent the risk of twist and kinking. Over time, we performed many other methods, such as external iliac vein transposition by ligation of internal iliac vein branches, renal hilum dissection, RV reconstruction using cryopreserved iliac vein or accompanying gonadal vein and the ipsilateral strategy was limited [ 3 ]. We also found that it is practical for some specific circumstances, such as severe atherosclerotic iliac arteries, angulation caused by early division and long renal artery. Thus, this study was conducted to determine the indication, evaluate the efficacy of inverted kidney transplantation and our experiences in this field. 2. MATERIALS AND METHODS - Study population: Patients who underwent inverted kidney transplantation in Viet Duc University hospital from 01/2016 to 12/2023, and has been follow-up in our hospital after the KT. Our study was approved by the Institutional Ethical Review Board (No 01.2024.NCVĐ). - Study design: The study was conducted retrospectively, in which the patients were divided into 2 groups + 1 st period: from January 2016 to December 2019. Inverted kidney transplant was routinely performed for ipsilateral kidney transplant (right kidney transplant into the right iliac fossa or left kidney transplant into the left iliac fossa). + 2 nd period: from January 2020 to December 2023. The technique was not routinely performed, only applied in some special cases (severe proximal external iliac atherosclerosis, long renal artery (mainly >4cm) which might cause kinking) - Data collection, outcomes and definitions: Baseline characteristics (Age, gender, BMI), recipient’s medical history: hemodialysis (if yes, duration of hemodialysis), history of previous kidney transplant, cardiovascular diseases, renal vessels – number and diameter, presence of iliac atherosclerosis; Technical characteristics: type of reconstruction in multiple vessels (one single orifice or seperated implantation), iliac vessel atherosclerosis, indication, cold ischemia time (from insertion of preservation solution until the kidney is placed in the iliac fossa for transplantation), warm ischemia time (when the kidney is placed in the iliac fossa until it is reperfused), vessel reconstruction time, operation time, waiting time of urine secretion after reperfusion. Outcomes variables include: Postoperative kidney function: Creatinine concentration, estimated glomerular filtration rate (eGFR) in the long-term follow-up. Complications: ureter stricture, vascular complications: bleeding, pseudoaneurysm, thrombosis, medical complications: acute allograft rejection, acute pancreatitis..., days of hospital stay, graft loss… - Surgical technique of ureteral rotation for ureteroneocystostomy in inverted kidney transplant: The avascular space attached to the lower pole was meticulously dissected to avoid excessive invasion of the golden triangle in the hilar area, from the lower pole of the kidney to the renal hilum. This procedure was ensured not to damage the blood vessels supplying the graft’s ureter (Figure 1) - Data analysis: The data were expressed by percentage for qualitative variables and mean ± SD for quantitative variables. Survival was analyzed using the Kaplan-Meier method. P values < 0.05 were considered as statistically significant. The data was collected and analyzed using IBM SPSS 20.0 software. 3. RESULTS Baseline characteristics During the study period, we collected a total of 74 cases of inverted kidney transplant. Of which, 63 cases were in stage 1, the remaining 11 cases were in stage 2. The data was shown below (Table 1 ). Over 77% has been underwent hemodialysis, only 2 patients (2.7%) was 2nd kidney transplant. Inverted kidney transplant was performed mostly in the way of right kidney into the right iliac fossa (97.3%). 7 cases related to complicated atherosclerotic iliac vessels. Conventional 1 renal artery accounted for 70.2%. We mostly performed the reconstruction of 1 single orifice if there were more than 2 arteries. 1 case had 3 renal veins, we ligated 1 small vein, the remaining 2 veins were reconstructed to form a common trunk. Operative characteristics The warm ischemia time was 38.6 ± 10 mins, urine secretion was seen after the reperfusion a mean of 2 mins. The average operation time was 192.8 minutes. The mean arterial reconstruction time was 15.1 ± 5.7 minutes, with the longer time in stage 2 as the vessels take more caution. Creatinin concentration returned to normal mostly after 3–5 days. Complications: Most complications occur in stage 1: There was 1 (1.3%) case of pseudoaneurysm of the single orifice, requiring re-operation. Acute graft rejection was observed in 1 case (1.4%) and 1 case (1.4%) of acute pancreatitis due to immunosuppression drugs, all were medically treated. Ureter stricture was the main complication (6.8%). The average hospital stay in Stage 1 and 2 were 16 ± 12.5 and 14 ± 1.3 days, respectively. Long-term outcomes: The mean 3-year eGFR was 79.0 ± 20.4 ml/mins. Only one patient (1.4%) suffered chronic graft rejection due to non-compliance, requiring retransplantation after 2 years. The 3 year graft survival was 98.6%. 4. DISCUSSION The site to place a kidney graft depends mainly on the vascular condition as well as the surgeon’s perspective. However, the right iliac fossa seems to be preferred most. Firstly, right iliac fossa is shallower than the left side, the iliac vein is horizontal and proximal, which facilitates the operation. During post-transplant follow-up, it will be more convenient for ultrasound check-up and kidney biopsy if needed [ 4 ]. Inverted kidney transplant means that the direction of the renal pelvis - ureter is reversed towards the head, so it is common that the right kidney is transplanted into the right iliac fossa or left kidney in the left iliac fossa. The main advantages of this technique is the renal vein is reversed to place behind the renal artery, compatible with the recipient's iliac vessels. Therefore, the first significant advantage of this technique is its application in cases of kidney transplantation with short renal veins. Siforoosh reported 32 cases of laparoscopic right nephrectomy with short renal vein (1.5cm), and inverted KT was applied, showing favorable outcomes [ 5 ]. By 2016, Siforoosh reviewed 79 cases of reverse polar kidney transplant and concluded that inverted KT was an easy, safe method which reduces the need for lengthening short renal vein [ 6 ]. The indications were shown in Table 2 . The indication was temporarily divided into 2 stages. Phase 1 is the stage where we routinely transplant the right kidney into the right iliac fossa for right renal vein. However, many methods has been published to handle this circumstance, such as the renal vein transposition, internal iliac vein branch ligation or renal vein lengthening [ 3 ]... From that time, KT was performed routinely in the right iliac fossa, and the indication for inverted KT changed to severe iliac atherosclerosis. The cause of calcification was triggered by diabetes, lipidemia, uremia, oxidative stress, hepatitis C…[ 7 ] Performing the arterial anastomosis in sclerotic area is a hazardous approach, might result in graft loss. Inverted KT could help change the place for arterial implantation, avoidance of replacing the damaged iliac artery segment, reduce the risk of thrombosis and atherosclerotic plaque rupture (Fig. 2). In stage 2, inverted KT is not routinely performed. We encountered cases where the renal artery divides early and is long, while the renal vein is short. If the kidney transplant is not inverted, vessel reconstruction (lengthening the renal vein or shortening the renal artery…) might be needed, otherwise angulation of the artery could occur. We presented a case in which the right kidney graft had 1 long artery with a common trunk, early branching, combined with a short renal vein, while the external iliac artery is superficial. Two options were feasible, removing the common trunk and performing 2 seperated arterial anastomosis or inverted KT; and we decided to perform the later technique (Fig. 3 ). 54.5% of the patients in stage II had severe iliac atherosclerosis. Otherwise, the plaque might rupture, cause obstruction and iliac artery replacement was needed. Inverted KT might be a good option for these circumstances, which also reduce the risk, surgical time, and maximize graft survival. In our center, after being harvested, the transplanted kidney is immediately perfused with storage solution before transplanting into the recipient. The cold ischemic time remained below 2 hours, meet the standard (less than 8 hours) according to J Nath's study [ 8 ]. Regarding early kidney function assessment, we used blood creatinine concentration and Doppler ultrasound. Creatinine concentration decreased immediately significantly after transplantation and stabilized from day 5 after transplantation with the average level of 138 ± 56 µmol/l and returned to normal when discharged from the hospital. After the average follow-up of 56 ± 26 months, only 1 case with graft loss due to inadherence to treatment requiring retransplantation after 2 years, 1.4% had acute rejection, 1.4% had artery pseudoaneurysm, requiring re-operation. The data was similar to other studies of inverted kidney transplantation [ 5 , 9 , 10 ]. The eGFR after 3 years remained at a good level compared to conventional KT. In theory, the blood supply of the ureters, the renal pelvis and the upper part of the ureter are fed by branches of the renal artery and from the testicular artery (in men) or ovarian artery (in women). The lower part of the ureter is fed by common iliac artery’s branches. The pelvic ureter is supplied from the inferior vesical artery, sometimes branches of the middle rectal artery 9 . In kidney transplantation, the grafted kidney is perfused by the renal artery only. To preserve the perfusion of the ureter, we must respect the golden triangle formed by angle of inferior vena cava and renal vein, renal hilum and the lower pole [ 11 , 12 ]. Krol showed that about 70% of cases of distal ureteral necrosis are due to damage to this triangle [ 13 ]. In our study, there were no cases of ureteral perforation or necrosis. 6.8% had ureteral stenosis requiring dilatation and reconstruction, which is higher to the Gyawali’s study (4.3%) [ 10 ]. There were 4 cases of ureteral fistula (5%) and 2 cases of ureteral stenosis at the ureteral-bladder insertion site (2.5%). The overall ureteral complication rate was comparable to conventional KT (2.9–12.5%) [ 14 , 15 ]. There was 1 case in which the renal pelvis-ureter angle was bended. After this experience, we rotate the ureter inwardly, the golden triangle attached to the lower renal pole was dissected. In general, our overall ureteral complications were acceptable. We also did not encounter any cases of proximal ureteral stenosis. Therefore, this technique not only avoids golden triangle damage, but also keep the ureter’s direction intact. To the best of my knowledge, this is one of the first studies provide the indication for inverted KT and provide the long-term outcomes of this study group. Further study with larger sample size and long-term follow-up might be needed to prove this efficacy. 5. CONCLUSION Inverted kidney transplantation is a technique that can be performed simply, safely and effectively. It can be applied in specific cases, especially when the recipients with severe iliac atherosclerosis or when the risk of angulation, twisting or common trunk removal due to the discrepancy of the arterial and venous anastomosis. Declarations Acknowledgements: None Author contribution: Hung DD: perform the operation, write the manuscript; Khai NV: perform and assist the operation, design the research, do the follow-up; Dang DH: design the research, do the follow-up; Tuan H: assist the operation, collect the data; Ngoc NB: analyze the data; Son DN: write and revise the manuscript,. All authors have discussed the results together and contributed to the final manuscript. Institutional review board statement: This study was approved by the Institutional Ethical Review Board (No 01.2024.NCVĐ). Informed consent statement: The need for patient consent was waived due to the retrospective nature of the study Conflict-of-interest statement : The authors declare that they have no conflicts of interest Funding : The authors declare no funding for this study. Provenance and peer review : Not commissioned, externally peer reviewed. References Long-term kidney transplant graft survival—Making progress when most needed. American Journal of Transplantation, 2021. 21(8): pp. 2824–2832 Tran S, Du NTT (2018) Long-term Follow-up after Short Renal Vein Repair Procedure in Kidney Transplantation. Transplantation, 102 Viet KN et al (2024) Efficacy of lengthening right renal veins using accompanying gonadal veins in living donor kidney transplantation. World J Urol 42(1):407 Doria C, Margetich L (2018) Recipient Kidney Transplantation Surgery , in Contemporary Kidney Transplantation , C.G.B. Ramirez and J. McCauley, Editors. Springer International Publishing: Cham. pp. 91–100 Simforoosh N et al (2007) Right laparoscopic donor nephrectomy and the use of inverted kidney transplantation: an alternative technique. BJU Int 100(6):1347–1350 Simforoosh N et al (2016) Long-Term Follow-up After Right Laparoscopic Donor Nephrectomy and Inverted Kidney Transplant. Exp Clin Transpl 14(1):27–31 Garcia LE et al (2019) Arterial reconstruction with donor iliac vessels during kidney transplantation in a patient with severe atherosclerosis. J Vasc Surg Cases Innov Tech 5(4):443–446 Nath J et al (2016) Effect of cold ischaemia time on outcome after living donor renal transplantation. Br J Surg 103(9):1230–1236 Bueno Jimenez A et al (2021) Upside-down kidney placement: An alternative in pediatric renal transplantation. J Pediatr Surg 56(8):1417–1420 Gyawali P et al (2019) Upside-down kidney transplantation using single-suture single-knot technique. Indian J Transplantation 13:264 Elsayed S (2020) Early urological complications post kidney transplant. Urol Nephrol Open Access J 8:1–4 Slagt IK et al (2014) Independent risk factors for urological complications after deceased donor kidney transplantation. PLoS ONE 9(3):e91211 Król R et al (2006) Surgical treatment of urological complications after kidney transplantation. Transpl Proc 38(1):127–130 Mundy AR et al (1981) The urological complications of 1000 renal transplants. Br J Urol 53(5):397–402 Göğüs C et al (2002) Urological complications in renal transplantation: long-term follow-up of the Woodruff ureteroneocystostomy procedure in 433 patients. Urol Int 69(2):99–101 Tables Table 1 Demographics and previous medical history Characteristics Stage 1 (n = 63) Stage 2 (n = 11) Total Age (mean ± SD (min-max)) 40.7 ± 11.3 (17–70) 46.3 ± 13.5 (27–65) 41.4 ± 11.8 (17–70) Male:female 1.86:1 1.75:1 1.85:1 BMI (mean ± SD (min-max)) 20.8 ± 5.7 (14.7–29.2) 22.0 ± 1.6 (19.6–24) 21.0 ± 2.7 (14.7–29) History of cardiovascular diseases (%) - Heart valve replacement - Coronary artery stenosis - Coronary angioplasty - Stroke 1.6 4.8 1.6 3.2 0 18.2 9.1 0 1.4 6.8 2.7 2.7 Hemodialysis (%) 76.6 81.8 77.3 Duration of hemodialysis (months) 11.4 ± 23.5 7.3 ± 5.3 10.8 ± 21.7 Second kidney transplant (%) 3.2 0 2.7 Table 2 Graft characteristics and intraoperative outcomes Characteristics Stage 1 (n = 63) Stage 2 (n = 11) Total Renal vein length (cm) 2.0 ± 0.7 (1–4) 2.3 ± 0.5 (1.5-3) 2.0 ± 0.7 (1–4) Severe iliac atherosclerosis (%) 0 54.5 9.3 Site of implantation and graft (%) - Right iliac fossa and right kidney - Left iliac fossa and left kidney 96.8 3.2 100 0 97.3 2.7 Indication for inverted KT (%) - Short renal vein - Upper iliac atherosclerosis - Risk of kinking (early branching/long artery (3–5 cm)) 100 0 0 0 54.5 45.5 85.1 8.1 6.8 No. of renal artery and reconstruction (%) - 1 artery - 2 arteries o Common orifice o Seperated - 3 arteries in common orifice - 4 arteries in common orifice 71.4 14.3 9.5 1.6 3.2 63.6 27.3 9.1 0 0 70.2 16.2 9.5 1.4 2.7 No. of renal vein - 1 vein - 2 veins o Common orifice o Seperated - 3 veins (ligation of small one, reconstruction the others) 92.2 6.4 1.4 0 90.9 0 0 9.1 91.9 5.3 1.4 1.4 Cold ischemic time < 2 hours (%) 100 100 100 Warm ischemic time (mins) 38.3 ± 10.0 (22–75) 42.8 ± 11.6 (31–55) 38.6 ± 10 (22–75) Arterial reconstruction time (mins) 15.1 ± 5.7 (7–33) 15.8 ± 2.2 (14–19) 15.1 ± 5.7 (7–33) Venous reconstruction time (mins) 13.4 ± 4.7 (1–26) 22.5 ± 9.0 (14–34) 12.9 ± 2.2 (9–15) Waiting time of urine secretion after reperfusion (mins) 2.3 ± 1.7 (1–5) 2 ± 2 (1–5) 2.3 ± 1.7 (1–5) Operation time (mins) 194.7 ± 57.8 (110–360) 170 ± 35.6 (130–200) 192.8 ± 56.6 (110–360) Complications (%) - Acute pancreatitis - Acute rejection - Graft loss - Ureter stenosis 1.6 1.6 1.6 7.9 0 0 0 10.3 0 1.4 1.4 1.4 6.8 Post-op creatinine - Day 1 - Day 3 - Day 5 - Day 7 - Discharge 666 ± 332 350 ± 273 197 ± 143 150 ± 122 115 ± 25 388 ± 233 153 ± 70 127 ± 49 113 ± 15 105 ± 12 627 ± 333 322 ± 264 138 ± 56 111 ± 45 103 ± 25 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Nov, 2024 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 15 Sep, 2024 Reviews received at journal 10 Sep, 2024 Reviews received at journal 01 Sep, 2024 Reviewers agreed at journal 18 Aug, 2024 Reviewers agreed at journal 17 Aug, 2024 Reviewers invited by journal 17 Aug, 2024 Editor assigned by journal 11 Aug, 2024 Submission checks completed at journal 05 Aug, 2024 First submitted to journal 24 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4795876","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":345136037,"identity":"062e00ca-912a-48c9-a56b-f530f9f6ef1b","order_by":0,"name":"Hung Duong Duc","email":"","orcid":"","institution":"Cardiovascular and Thoracic Center, Viet Duc University hospital","correspondingAuthor":false,"prefix":"","firstName":"Hung","middleName":"Duong","lastName":"Duc","suffix":""},{"id":345136039,"identity":"7a860751-aa7e-46b9-8a2d-7e4235bd2ce7","order_by":1,"name":"Khai Ninh 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INTRODUCTION","content":"\u003cp\u003eKidney transplant (KT) has been widely recognized as the most effective treatment regarding long-term survival outcomes in end-stage renal disease, with 10-year graft survival of living donor KT of 70% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. KT has been applied in Vietnam since 1992 and approximately 6000 cases has been conducted up to 03/2022. KT has been implemented in Viet Duc University hospital since August 2000. To date, nearly 2000 cases kidney transplants have been performed, mainly from living donor. Our main priority is to protect the donor, thus the the kidney with better function was reserved for the donor.\u003c/p\u003e \u003cp\u003eIn living-donor kidney transplantation, dealing with short grafted renal veins (RV), mainly occurs in the right graft is still a challenge because anastomosis tension could easily lead to tearing and bleeding [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Firstly, we used the ipsilateral strategy, in which the right kidney is placed in the right iliac fossa and the left graft is placed in the left iliac fossa. Inverted technique, which shorten the distance to the external iliac vein and reduce the risk for RV anastomosis has been applied. In this technique, the direction of the graft\u0026rsquo;s ureter is reversed upward (towards the head), thus ureter rotation was also performed to prevent the risk of twist and kinking.\u003c/p\u003e \u003cp\u003eOver time, we performed many other methods, such as external iliac vein transposition by ligation of internal iliac vein branches, renal hilum dissection, RV reconstruction using cryopreserved iliac vein or accompanying gonadal vein and the ipsilateral strategy was limited [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. We also found that it is practical for some specific circumstances, such as severe atherosclerotic iliac arteries, angulation caused by early division and long renal artery. Thus, this study was conducted to determine the indication, evaluate the efficacy of inverted kidney transplantation and our experiences in this field.\u003c/p\u003e"},{"header":"2. MATERIALS AND METHODS","content":"\u003cp\u003e- Study population: Patients who underwent inverted kidney transplantation in Viet Duc University hospital from 01/2016 to 12/2023, and has been follow-up in our hospital after the KT. Our study was approved by the Institutional Ethical Review Board (No 01.2024.NCVĐ).\u003c/p\u003e\n\u003cp\u003e- \u0026nbsp;Study design: The study was conducted retrospectively, in which the patients were divided into 2 groups\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e+ 1\u003csup\u003est\u003c/sup\u003e period: from January 2016 to December 2019. Inverted kidney transplant was routinely performed for ipsilateral kidney transplant (right kidney transplant into the right iliac fossa or left kidney transplant into the left iliac fossa).\u003c/p\u003e\n\u003cp\u003e+ 2\u003csup\u003end\u003c/sup\u003e period: from January 2020 to December 2023. The technique was not routinely performed, only applied in some special cases (severe proximal external iliac atherosclerosis, long renal artery (mainly \u0026gt;4cm) which might cause kinking)\u003c/p\u003e\n\u003cp\u003e- Data collection, outcomes and definitions: Baseline characteristics (Age, gender, BMI), recipient\u0026rsquo;s medical history: hemodialysis (if yes, duration of hemodialysis), history of previous kidney transplant, cardiovascular diseases, renal vessels \u0026ndash; number and diameter, presence of iliac atherosclerosis; Technical characteristics: type of reconstruction in multiple vessels (one single orifice or seperated implantation), iliac vessel atherosclerosis, indication, cold ischemia time (from insertion of preservation solution until the kidney is placed in the iliac fossa for transplantation), warm ischemia time (when the kidney is placed in the iliac fossa until it is reperfused), vessel reconstruction time, operation time, waiting time of urine secretion after reperfusion. Outcomes variables include: Postoperative kidney function: Creatinine concentration, estimated glomerular filtration rate (eGFR) in the long-term follow-up. Complications: ureter stricture, vascular complications: bleeding, pseudoaneurysm, thrombosis, medical complications: acute allograft rejection, acute pancreatitis..., days of hospital stay, graft loss\u0026hellip;\u003c/p\u003e\n\u003cp\u003e- Surgical technique of ureteral rotation for ureteroneocystostomy in inverted kidney transplant: The avascular space attached to the lower pole was meticulously dissected to avoid excessive invasion of the golden triangle in the hilar area, from the lower pole of the kidney to the renal hilum. This procedure was ensured not to damage the blood vessels supplying the graft\u0026rsquo;s ureter (Figure 1)\u003c/p\u003e\n\u003cp\u003e- \u0026nbsp; Data analysis: The data were expressed by percentage for qualitative variables and mean \u0026plusmn; SD for quantitative variables. Survival was analyzed using the Kaplan-Meier method. P values \u0026lt; 0.05 were considered as statistically significant. The data was collected and analyzed using IBM SPSS 20.0 software.\u003c/p\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eBaseline characteristics\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eDuring the study period, we collected a total of 74 cases of inverted kidney transplant. Of which, 63 cases were in stage 1, the remaining 11 cases were in stage 2. The data was shown below (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOver 77% has been underwent hemodialysis, only 2 patients (2.7%) was 2nd kidney transplant. Inverted kidney transplant was performed mostly in the way of right kidney into the right iliac fossa (97.3%). 7 cases related to complicated atherosclerotic iliac vessels. Conventional 1 renal artery accounted for 70.2%. We mostly performed the reconstruction of 1 single orifice if there were more than 2 arteries. 1 case had 3 renal veins, we ligated 1 small vein, the remaining 2 veins were reconstructed to form a common trunk.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eOperative characteristics\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe warm ischemia time was 38.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10 mins, urine secretion was seen after the reperfusion a mean of 2 mins. The average operation time was 192.8 minutes. The mean arterial reconstruction time was 15.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7 minutes, with the longer time in stage 2 as the vessels take more caution. Creatinin concentration returned to normal mostly after 3\u0026ndash;5 days. Complications: Most complications occur in stage 1: There was 1 (1.3%) case of pseudoaneurysm of the single orifice, requiring re-operation. Acute graft rejection was observed in 1 case (1.4%) and 1 case (1.4%) of acute pancreatitis due to immunosuppression drugs, all were medically treated. Ureter stricture was the main complication (6.8%). The average hospital stay in Stage 1 and 2 were 16\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5 and 14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 days, respectively.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLong-term outcomes:\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe mean 3-year eGFR was 79.0\u0026thinsp;\u0026plusmn;\u0026thinsp;20.4 ml/mins. Only one patient (1.4%) suffered chronic graft rejection due to non-compliance, requiring retransplantation after 2 years. The 3 year graft survival was 98.6%.\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eThe site to place a kidney graft depends mainly on the vascular condition as well as the surgeon\u0026rsquo;s perspective. However, the right iliac fossa seems to be preferred most. Firstly, right iliac fossa is shallower than the left side, the iliac vein is horizontal and proximal, which facilitates the operation. During post-transplant follow-up, it will be more convenient for ultrasound check-up and kidney biopsy if needed [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInverted kidney transplant means that the direction of the renal pelvis - ureter is reversed towards the head, so it is common that the right kidney is transplanted into the right iliac fossa or left kidney in the left iliac fossa. The main advantages of this technique is the renal vein is reversed to place behind the renal artery, compatible with the recipient's iliac vessels. Therefore, the first significant advantage of this technique is its application in cases of kidney transplantation with short renal veins. Siforoosh reported 32 cases of laparoscopic right nephrectomy with short renal vein (1.5cm), and inverted KT was applied, showing favorable outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. By 2016, Siforoosh reviewed 79 cases of reverse polar kidney transplant and concluded that inverted KT was an easy, safe method which reduces the need for lengthening short renal vein [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe indications were shown in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The indication was temporarily divided into 2 stages. Phase 1 is the stage where we routinely transplant the right kidney into the right iliac fossa for right renal vein. However, many methods has been published to handle this circumstance, such as the renal vein transposition, internal iliac vein branch ligation or renal vein lengthening [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]... From that time, KT was performed routinely in the right iliac fossa, and the indication for inverted KT changed to severe iliac atherosclerosis. The cause of calcification was triggered by diabetes, lipidemia, uremia, oxidative stress, hepatitis C\u0026hellip;[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Performing the arterial anastomosis in sclerotic area is a hazardous approach, might result in graft loss. Inverted KT could help change the place for arterial implantation, avoidance of replacing the damaged iliac artery segment, reduce the risk of thrombosis and atherosclerotic plaque rupture (Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eIn stage 2, inverted KT is not routinely performed. We encountered cases where the renal artery divides early and is long, while the renal vein is short. If the kidney transplant is not inverted, vessel reconstruction (lengthening the renal vein or shortening the renal artery\u0026hellip;) might be needed, otherwise angulation of the artery could occur. We presented a case in which the right kidney graft had 1 long artery with a common trunk, early branching, combined with a short renal vein, while the external iliac artery is superficial. Two options were feasible, removing the common trunk and performing 2 seperated arterial anastomosis or inverted KT; and we decided to perform the later technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e3\u003c/span\u003e). 54.5% of the patients in stage II had severe iliac atherosclerosis. Otherwise, the plaque might rupture, cause obstruction and iliac artery replacement was needed. Inverted KT might be a good option for these circumstances, which also reduce the risk, surgical time, and maximize graft survival. In our center, after being harvested, the transplanted kidney is immediately perfused with storage solution before transplanting into the recipient. The cold ischemic time remained below 2 hours, meet the standard (less than 8 hours) according to J Nath's study [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eRegarding early kidney function assessment, we used blood creatinine concentration and Doppler ultrasound. Creatinine concentration decreased immediately significantly after transplantation and stabilized from day 5 after transplantation with the average level of 138\u0026thinsp;\u0026plusmn;\u0026thinsp;56 \u0026micro;mol/l and returned to normal when discharged from the hospital. After the average follow-up of 56\u0026thinsp;\u0026plusmn;\u0026thinsp;26 months, only 1 case with graft loss due to inadherence to treatment requiring retransplantation after 2 years, 1.4% had acute rejection, 1.4% had artery pseudoaneurysm, requiring re-operation. The data was similar to other studies of inverted kidney transplantation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The eGFR after 3 years remained at a good level compared to conventional KT.\u003c/p\u003e \u003cp\u003eIn theory, the blood supply of the ureters, the renal pelvis and the upper part of the ureter are fed by branches of the renal artery and from the testicular artery (in men) or ovarian artery (in women). The lower part of the ureter is fed by common iliac artery\u0026rsquo;s branches. The pelvic ureter is supplied from the inferior vesical artery, sometimes branches of the middle rectal artery \u003csup\u003e9\u003c/sup\u003e. In kidney transplantation, the grafted kidney is perfused by the renal artery only. To preserve the perfusion of the ureter, we must respect the golden triangle formed by angle of inferior vena cava and renal vein, renal hilum and the lower pole [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Krol showed that about 70% of cases of distal ureteral necrosis are due to damage to this triangle [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In our study, there were no cases of ureteral perforation or necrosis. 6.8% had ureteral stenosis requiring dilatation and reconstruction, which is higher to the Gyawali\u0026rsquo;s study (4.3%) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. There were 4 cases of ureteral fistula (5%) and 2 cases of ureteral stenosis at the ureteral-bladder insertion site (2.5%).\u003c/p\u003e \u003cp\u003eThe overall ureteral complication rate was comparable to conventional KT (2.9\u0026ndash;12.5%) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. There was 1 case in which the renal pelvis-ureter angle was bended. After this experience, we rotate the ureter inwardly, the golden triangle attached to the lower renal pole was dissected. In general, our overall ureteral complications were acceptable. We also did not encounter any cases of proximal ureteral stenosis. Therefore, this technique not only avoids golden triangle damage, but also keep the ureter\u0026rsquo;s direction intact.\u003c/p\u003e \u003cp\u003eTo the best of my knowledge, this is one of the first studies provide the indication for inverted KT and provide the long-term outcomes of this study group. Further study with larger sample size and long-term follow-up might be needed to prove this efficacy.\u003c/p\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003eInverted kidney transplantation is a technique that can be performed simply, safely and effectively. It can be applied in specific cases, especially when the recipients with severe iliac atherosclerosis or when the risk of angulation, twisting or common trunk removal due to the discrepancy of the arterial and venous anastomosis.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution:\u003c/strong\u003e Hung DD: perform the operation, write the manuscript; Khai NV: perform and assist the operation, design the research, do the follow-up; Dang DH: design the research, do the follow-up; Tuan H: assist the operation, collect the data; Ngoc NB: analyze the data; Son DN: write and revise the manuscript,. All authors have discussed the results together and contributed to the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional review board statement:\u0026nbsp;\u003c/strong\u003eThis study was approved by the Institutional Ethical Review Board (No 01.2024.NCVĐ).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent statement:\u0026nbsp;\u003c/strong\u003eThe need for patient consent was waived due to the retrospective nature of the study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict-of-interest statement\u003c/strong\u003e: The authors declare that they have no conflicts of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The authors declare no funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProvenance and peer review\u003c/strong\u003e: Not commissioned, externally peer reviewed.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eLong-term kidney transplant graft survival\u0026mdash;Making progress when most needed.\u003c/em\u003e American Journal of Transplantation, 2021. 21(8): pp. 2824\u0026ndash;2832\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTran S, Du NTT (2018) Long-term Follow-up after Short Renal Vein Repair Procedure in Kidney Transplantation. Transplantation, 102\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViet KN et al (2024) Efficacy of lengthening right renal veins using accompanying gonadal veins in living donor kidney transplantation. World J Urol 42(1):407\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoria C, Margetich L (2018) \u003cem\u003eRecipient Kidney Transplantation Surgery\u003c/em\u003e, in \u003cem\u003eContemporary Kidney Transplantation\u003c/em\u003e, C.G.B. Ramirez and J. McCauley, Editors. Springer International Publishing: Cham. pp. 91\u0026ndash;100\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimforoosh N et al (2007) Right laparoscopic donor nephrectomy and the use of inverted kidney transplantation: an alternative technique. BJU Int 100(6):1347\u0026ndash;1350\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimforoosh N et al (2016) Long-Term Follow-up After Right Laparoscopic Donor Nephrectomy and Inverted Kidney Transplant. Exp Clin Transpl 14(1):27\u0026ndash;31\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarcia LE et al (2019) Arterial reconstruction with donor iliac vessels during kidney transplantation in a patient with severe atherosclerosis. J Vasc Surg Cases Innov Tech 5(4):443\u0026ndash;446\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNath J et al (2016) Effect of cold ischaemia time on outcome after living donor renal transplantation. Br J Surg 103(9):1230\u0026ndash;1236\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBueno Jimenez A et al (2021) Upside-down kidney placement: An alternative in pediatric renal transplantation. J Pediatr Surg 56(8):1417\u0026ndash;1420\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGyawali P et al (2019) Upside-down kidney transplantation using single-suture single-knot technique. Indian J Transplantation 13:264\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElsayed S (2020) Early urological complications post kidney transplant. Urol Nephrol Open Access J 8:1\u0026ndash;4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlagt IK et al (2014) Independent risk factors for urological complications after deceased donor kidney transplantation. PLoS ONE 9(3):e91211\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKr\u0026oacute;l R et al (2006) Surgical treatment of urological complications after kidney transplantation. Transpl Proc 38(1):127\u0026ndash;130\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMundy AR et al (1981) The urological complications of 1000 renal transplants. Br J Urol 53(5):397\u0026ndash;402\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026ouml;ğ\u0026uuml;s C et al (2002) Urological complications in renal transplantation: long-term follow-up of the Woodruff ureteroneocystostomy procedure in 433 patients. Urol Int 69(2):99\u0026ndash;101\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics and previous medical history\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage 1\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStage 2\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (min-max))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u003c/p\u003e \u003cp\u003e(17\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e \u003cp\u003e(27\u0026ndash;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.8 (17\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale:female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.86:1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.75:1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.85:1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (min-max))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7 (14.7\u0026ndash;29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 (19.6\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 (14.7\u0026ndash;29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of cardiovascular diseases (%)\u003c/p\u003e \u003cp\u003e- Heart valve replacement\u003c/p\u003e \u003cp\u003e- Coronary artery stenosis\u003c/p\u003e \u003cp\u003e- Coronary angioplasty\u003c/p\u003e \u003cp\u003e- Stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003cp\u003e4.8\u003c/p\u003e \u003cp\u003e1.6\u003c/p\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e18.2\u003c/p\u003e \u003cp\u003e9.1\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003cp\u003e6.8\u003c/p\u003e \u003cp\u003e2.7\u003c/p\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemodialysis (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of hemodialysis (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.4\u0026thinsp;\u0026plusmn;\u0026thinsp;23.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.8\u0026thinsp;\u0026plusmn;\u0026thinsp;21.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecond kidney transplant (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGraft characteristics and intraoperative outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage 1\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStage 2\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal vein length (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003cp\u003e(1\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3 \u0026plusmn; 0.5\u003c/p\u003e \u003cp\u003e(1.5-3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003cp\u003e(1\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere iliac atherosclerosis (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite of implantation and graft (%)\u003c/p\u003e \u003cp\u003e- Right iliac fossa and right kidney\u003c/p\u003e \u003cp\u003e- Left iliac fossa and left kidney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.8\u003c/p\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97.3\u003c/p\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication for inverted KT (%)\u003c/p\u003e \u003cp\u003e- Short renal vein\u003c/p\u003e \u003cp\u003e- Upper iliac atherosclerosis\u003c/p\u003e \u003cp\u003e- Risk of kinking (early branching/long artery (3\u0026ndash;5 cm))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e54.5\u003c/p\u003e \u003cp\u003e45.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.1\u003c/p\u003e \u003cp\u003e8.1\u003c/p\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of renal artery and reconstruction (%)\u003c/p\u003e \u003cp\u003e- 1 artery\u003c/p\u003e \u003cp\u003e- 2 arteries\u003c/p\u003e \u003cp\u003eo Common orifice\u003c/p\u003e \u003cp\u003eo Seperated\u003c/p\u003e \u003cp\u003e- 3 arteries in common orifice\u003c/p\u003e \u003cp\u003e- 4 arteries in common orifice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003cp\u003e14.3\u003c/p\u003e \u003cp\u003e9.5\u003c/p\u003e \u003cp\u003e1.6\u003c/p\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.6\u003c/p\u003e \u003cp\u003e27.3\u003c/p\u003e \u003cp\u003e9.1\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.2\u003c/p\u003e \u003cp\u003e16.2\u003c/p\u003e \u003cp\u003e9.5\u003c/p\u003e \u003cp\u003e1.4\u003c/p\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of renal vein\u003c/p\u003e \u003cp\u003e- 1 vein\u003c/p\u003e \u003cp\u003e- 2 veins\u003c/p\u003e \u003cp\u003eo Common orifice\u003c/p\u003e \u003cp\u003eo Seperated\u003c/p\u003e \u003cp\u003e- 3 veins (ligation of small one, reconstruction the others)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.2\u003c/p\u003e \u003cp\u003e6.4\u003c/p\u003e \u003cp\u003e1.4\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.9\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.9\u003c/p\u003e \u003cp\u003e5.3\u003c/p\u003e \u003cp\u003e1.4\u003c/p\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCold ischemic time\u0026thinsp;\u0026lt;\u0026thinsp;2 hours (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWarm ischemic time (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e \u003cp\u003e(22\u0026ndash;75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6 (31\u0026ndash;55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10\u003c/p\u003e \u003cp\u003e(22\u0026ndash;75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArterial reconstruction time (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003cp\u003e(7\u0026ndash;33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003cp\u003e(14\u0026ndash;19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003cp\u003e(7\u0026ndash;33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenous reconstruction time (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003cp\u003e(1\u0026ndash;26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0\u003c/p\u003e \u003cp\u003e(14\u0026ndash;34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003cp\u003e(9\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWaiting time of urine secretion after reperfusion (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003cp\u003e(1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u003c/p\u003e \u003cp\u003e(1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003cp\u003e(1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e194.7\u0026thinsp;\u0026plusmn;\u0026thinsp;57.8 (110\u0026ndash;360)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e170\u0026thinsp;\u0026plusmn;\u0026thinsp;35.6 (130\u0026ndash;200)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e192.8\u0026thinsp;\u0026plusmn;\u0026thinsp;56.6 (110\u0026ndash;360)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications (%)\u003c/p\u003e \u003cp\u003e- Acute pancreatitis\u003c/p\u003e \u003cp\u003e- Acute rejection\u003c/p\u003e \u003cp\u003e- Graft loss\u003c/p\u003e \u003cp\u003e- Ureter stenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003cp\u003e1.6\u003c/p\u003e \u003cp\u003e1.6\u003c/p\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e10.3 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003cp\u003e1.4\u003c/p\u003e \u003cp\u003e1.4\u003c/p\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-op creatinine\u003c/p\u003e \u003cp\u003e- Day 1\u003c/p\u003e \u003cp\u003e- Day 3\u003c/p\u003e \u003cp\u003e- Day 5\u003c/p\u003e \u003cp\u003e- Day 7\u003c/p\u003e \u003cp\u003e- Discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e666\u0026thinsp;\u0026plusmn;\u0026thinsp;332\u003c/p\u003e \u003cp\u003e350\u0026thinsp;\u0026plusmn;\u0026thinsp;273\u003c/p\u003e \u003cp\u003e197\u0026thinsp;\u0026plusmn;\u0026thinsp;143\u003c/p\u003e \u003cp\u003e150\u0026thinsp;\u0026plusmn;\u0026thinsp;122\u003c/p\u003e \u003cp\u003e115\u0026thinsp;\u0026plusmn;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e388\u0026thinsp;\u0026plusmn;\u0026thinsp;233\u003c/p\u003e \u003cp\u003e153\u0026thinsp;\u0026plusmn;\u0026thinsp;70\u003c/p\u003e \u003cp\u003e127\u0026thinsp;\u0026plusmn;\u0026thinsp;49\u003c/p\u003e \u003cp\u003e113\u0026thinsp;\u0026plusmn;\u0026thinsp;15\u003c/p\u003e \u003cp\u003e105\u0026thinsp;\u0026plusmn;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e627\u0026thinsp;\u0026plusmn;\u0026thinsp;333\u003c/p\u003e \u003cp\u003e322\u0026thinsp;\u0026plusmn;\u0026thinsp;264\u003c/p\u003e \u003cp\u003e138\u0026thinsp;\u0026plusmn;\u0026thinsp;56\u003c/p\u003e \u003cp\u003e111\u0026thinsp;\u0026plusmn;\u0026thinsp;45\u003c/p\u003e \u003cp\u003e103\u0026thinsp;\u0026plusmn;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"inverted kidney transplantation, upside-down kidney transplantation, severe atherosclerosis, outcomes","lastPublishedDoi":"10.21203/rs.3.rs-4795876/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4795876/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInverted kidney transplant (KT) have been applied in many transplant centers, but the experiences and outcomes of this technique was limited.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eTo describe the technical characteristics, indications and evaluate the outcomes of inverted kidney transplantation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eRetrospective study from January 2016 to December 2023, included 74 patients who underwent inverted kidney transplantation with 72 cases of right kidney transplant into the right iliac fossa and 2 cases of left kidney transplant into the left iliac fossa performed in Viet Duc University Hospital.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e63 cases in stage 1 (ipsilateral kidney transplant), all kidney graft were transplanted on the same side and 11 cases in stage 2 in which the kidney transplant was performed in some special cases such as recipients with severe atherosclerotic iliac arteries or incompatibility between the arteries and venous. There was 1 case (1.4%) of graft renal artery pseudoaneurysm and 5 cases (6.8%) of ureteral stenosis at the ureter-bladder junction. There was 1 case of graft loss due to chronic graft rejection \u0026ndash; immunosuppression inadherence requiring retransplantation after 2 years. 98.6% of cases had normal kidney function when discharged and remained stable until the latest follow-up.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eInverted kidney transplantation is a simple, safe and effective technique and could be a feasible solution for atherosclerotic patients.\u003c/p\u003e","manuscriptTitle":"Experiences and Outcomes of Inverted Kidney Transplantation From a Single Vietnamese Institute","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-10 06:42:53","doi":"10.21203/rs.3.rs-4795876/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-16T03:33:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-10T22:22:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-02T00:17:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33675858513173782787577599640964398193","date":"2024-08-18T09:41:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284166875998698668733100966957774873353","date":"2024-08-17T11:35:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-17T09:14:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-12T03:27:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-05T14:41:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2024-07-24T13:46:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"23e4e004-cb5e-460f-bad7-338ec0f6662a","owner":[],"postedDate":"September 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T17:21:13+00:00","versionOfRecord":{"articleIdentity":"rs-4795876","link":"https://doi.org/10.1007/s00423-024-03544-0","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2024-11-26 15:58:24","publishedOnDateReadable":"November 26th, 2024"},"versionCreatedAt":"2024-09-10 06:42:53","video":"","vorDoi":"10.1007/s00423-024-03544-0","vorDoiUrl":"https://doi.org/10.1007/s00423-024-03544-0","workflowStages":[]},"version":"v1","identity":"rs-4795876","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4795876","identity":"rs-4795876","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}