What does kidney transplant surgery involve? 

Kidney transplant surgery is a major operation that usually takes between three and four hours. During the procedure, a healthy kidney from a donor is placed into your lower abdomen and connected to your blood vessels and bladder. Unlike many other organ surgeries, your original kidneys are typically left in place unless they are causing specific medical issues like infection or high blood pressure. In the UK, this is a highly coordinated procedure performed by a specialist surgical team under general anaesthetic. 

The goal of the surgery is to restore kidney function, allowing you to live a life free from dialysis. While it is a complex procedure, it is also a well-established one with high success rates. The surgery involves not just the physical implantation of the organ, but also the careful management of your immune system to ensure your body accepts the new kidney. 

What We Will Discuss in This Article 

• Pre-operative preparations and getting ready for theatre 

• The step-by-step surgical process of implanting the donor kidney 

• Where exactly the new kidney is placed and why 

• The connection of blood vessels and the urinary tract 

• Immediate post-operative care and the role of ‘lines’ and catheters 

• What happens in the first few hours of recovery 

Pre-operative preparation and anaesthesia 

The process begins even before you reach the operating theatre. If you are receiving a deceased donor kidney, you will be called to the hospital at short notice. Upon arrival, you will undergo final blood tests and a physical exam to ensure you are fit for surgery. For a living donor transplant, the date is scheduled in advance. You will be given medications, including initial doses of immunosuppressants, to prepare your immune system. 

The surgery is performed under general anaesthetic. Once you are unconscious, the anaesthetist will place several ‘lines’ into your veins to monitor your blood pressure and administer fluids. A urinary catheter will also be inserted into your bladder to help the surgical team monitor how quickly the new kidney starts producing urine during and after the operation. 

The surgical steps of implantation 

Once you are positioned on the operating table, the surgeon makes a curved incision in your lower abdomen, usually just above the groin. This area is chosen because it provides easy access to the large blood vessels and is close to your bladder. 

The surgical procedure follows a specific sequence: 

• Vascular Connection: The surgeon identifies the iliac artery and iliac vein. The donor kidney’s renal vein is sewn to your iliac vein, and the donor kidney’s renal artery is sewn to your iliac artery. 

• Reperfusion: Once the connections are secure, the clamps are removed. This is a critical moment where blood begins to flow through the new kidney. Often, the kidney will turn pink immediately. 

• Ureteral Connection: The ureter (the tube that carries urine) from the donor kidney is then connected to your bladder. 

• Stent Placement: A small, flexible plastic tube called a ‘ureteric stent’ is often placed inside the ureter to keep it open while it heals. This is usually removed a few weeks later. 

Comparing Surgical Features: Deceased vs. Living Donor 

The following table highlights some of the practical differences during the surgical episode: 

Feature	Deceased Donor Surgery	Living Donor Surgery
Scheduling	Emergency (day or night)	Planned and scheduled
Organ Travel	May travel long distances	Usually in the same building
Ischaemia Time	Longer (organ ‘on ice’)	Very short
Immediate Function	May take days to ‘wake up’	Usually works immediately
Hospital Stay	Typically 7 to 10 days	Typically 5 to 7 days
Dialysis Requirement	May need temporary sessions	Rarely needed post-op

 

Why are the original kidneys left in place? 

A common question is why the original ‘native’ kidneys are not removed. The primary cause is safety; removing the original kidneys is an additional, unnecessary surgical risk. Unless your own kidneys are causing problems such as being very large (in polycystic kidney disease), causing severe high blood pressure, or being a source of chronic infection they are left exactly where they are. 

This means that after a transplant, most recipients have three kidneys. The original kidneys may eventually shrink, but they rarely interfere with the new organ. The new kidney is placed in the lower abdomen because it is protected by the pelvic bone and is much easier for doctors to monitor if needed later. 

Triggers for immediate post-operative monitoring 

When you wake up in the recovery room, your clinical team will be watching for several key triggers. The most important is urine output. A healthy living donor kidney often triggers immediate urine production. If the kidney is from a deceased donor, it may have ‘delayed graft function’, where it stays ‘sleepy’ for a few days. If this happens, you might need a few sessions of dialysis while the kidney recovers. 

Pain management is another immediate priority. While you will be sore around the incision, you will have regular strong painkillers. The ‘lines’ in your neck and hand will stay in for a few days to ensure you remain well-hydrated. The team will also trigger early mobility, encouraging you to sit up within 24 hours to prevent blood clots and help your bowels start working again. 

Differentiation: Standard vs. Laparoscopic Surgery 

It is important to differentiate between the surgery for the recipient and the surgery for the donor. In the UK, living donors almost always have their kidney removed using ‘keyhole’ (laparoscopic) surgery, which allows for a faster recovery. However, the recipient’s surgery is an ‘open’ procedure because of the complex nature of sewing the blood vessels together. 

This differentiation ensures the best outcome for both parties. The recipient needs a larger incision to allow the surgeon enough space to work on the delicate vascular joins. While the scar will be visible, it usually fades significantly over time and is located low enough to be covered by clothing. 

Summary 

Kidney transplant surgery involves placing a healthy kidney in the lower abdomen and connecting it to the iliac blood vessels and the bladder. Most recipients keep their original kidneys and spend about a week in the hospital. The process is highly coordinated to ensure the new kidney is monitored closely from the moment blood begins to flow through it. 

Authority Snapshot 

This article was developed based on UK clinical standards for renal care. Dr. Stefan Brincat is a Consultant Nephrologist at St George’s University Hospital NHS Foundation Trust in London. He has extensive experience in managing acute and chronic kidney disease, with a focus on the long-term management of renal failure and transplant recipient care. His work involves coordinating with transplant surgeons to ensure patients are fully prepared for the surgical process.