| INTRODUC TI ONKidney paired donation (KPD) has seen consistent growth over the last 2 decades. 1 Although some single-center systems have seen modest growth, 2,3 regional and national systems currently account for the majority of KPD transplants in the United States. 4,5 These cooperative networks require a great deal of trust between different teams of surgeons, nephrologists, nurses, donor advocates, social workers, and living donor coordinators responsible for the preoperative evaluation of donors, as well as kidney quality resulting from the performance of the donor nephrectomy. Although deceased donor kidneys are routinely procured by remote centers, living donor organs are produced by a program's own surgeons; this was especially true prior to the establishment of large KPD systems. 6 Programs depend upon cooperation between transplant centers and teams, and necessitate trust in the quality of donor procurements at other centers. As evidenced in a recent debate at the 2019 ASTS Winter Cooperative kidney paired donation (KPD) networks account for an increasing proportion of all living donor kidney transplants in the United States. There are sparse data on the rate of primary nonfunction (PNF) losses and their consequences within KPD networks. We studied National Kidney Registry (NKR) transplants (February 14, 2009 to December 31, 2017) and quantified PNF, graft loss within 30 days of transplantation, and graft losses in the first-year posttransplant and assessed potential risk factors. Of 2364 transplants, there were 38 grafts (1.6%) lost within the first year, 13 (0.5%) with PNF. When compared to functioning grafts, there were no clinically significant differences in blood type compatibility, degree of HLA mismatch, number of veins/arteries, cold ischemia, and travel times. Of 13 PNF cases, 2 were due to early venous thrombosis, 2 to arterial thrombosis, and 2 to failure of desensitization and development of antibody-mediated rejection (AMR). Given the low rate of PNF, the NKR created a policy to allocate chain-end kidneys to recipients with PNF following event review and attributable to surgical issues of donor nephrectomy. It is expected that demonstration of low incidence of poor early graft outcomes and the presence of a "safety net" would further encourage program participation in national KPD. K E Y W O R D S clinical research/practice, donors and donation: living, graft survival, kidney transplantation/ nephrology, kidney transplantation: living donor, primary nonfunction 1394 | VERBESEY Et al.Other," there is still a tendency for many centers to only want to rely on their own surgeons.Participation in national exchange programs challenges this preference. Medium-and long-term graft survival for these transplants are high, which is expected of living donor kidney transplantation (LDKT) even in the context of longer KPD cold ischemic times. 4,7,8 However, scarce data exist on primary nonfunction (PNF, or loss within 30 days of transplant), other early graft failures, and surgical complications th...

radiation applied to the small bowel. Commonly utilized radiation spacers focus on reduction of the doses applied to the rectum, however the morbidity of small bowel radiation is significantly higher than that of the rectum. Surgical spacers and mesh retention placement have been utilized previously in reports with other pelvic cancers. We present a robot-assisted surgical technique for overcoming the challenges of a patient with two prior pelvic surgeries and small bowel in the radiation target.METHODS: A 72-year-old male required treatment of his biochemical recurrent prostate cancer. In 2006 this patient presented with a PSA of 5.74, Gleason 3þ3 prostate cancer. He underwent a robot-assisted laparoscopic radical prostatectomy for pT2a disease. In 2008, the patient was found to have muscle invasive high grade papillary urothelial carcinoma and underwent robot-assisted cystectomy and ileal conduit with final pathology pT2bN0 disease. In 2017 he had biochemical recurrence of his prostate cancer with a PSA of 0.30. Pelvic CT showed small bowel deep into his prostatic bed behind the pubic bone. A robot-assisted lysis of adhesions and placement of a PMT corporation tissue expander in the prostatic fossa was performed. Three robotic ports and one assistant port were utilized. The sigmoid and small bowel were displaced during lysis of adhesions. The tissue expander was passed through the midline trocar site deflated and inflated after entry into the abdomen. This was filled with 330 cc of saline. The tissue expander was secured with proline sutures in a dependent position. The patient subsequently underwent IRMT of 66 Gray to the prostatic fossa. Eleven days after IMRT the patient underwent successful laparoscopic removal of the tissue expander.RESULTS: The patient tolerated IMRT without any complications. There were no gastrointestinal complaints following radiation therapy.CONCLUSIONS: Robotic placement of a tissue expander in patients who have undergone multiple pelvic surgeries is a feasible procedure that can reduce the morbidity associated with pelvic radiation.

This review article provides ethical guidance for determining which kinds of financial benefits provided to living organ donors are ethically appropriate. It does so by way of ethical analysis of a policy case study: the National Kidney Registry (NKR) has implemented a donor insurance program to all its living donors. Is such a policy ethically supportable, or is it an unethical practice? The article proceeds as follows. First, a framework for grounding the ethical commitments of transplant programs is defended. It is argued that this framework can be accepted by all who work in transplant medicine, regardless of differences in ethical theory preference or background. Second, from this framework two ethical principles are formulated. (1) Living donors should, as far as possible, not be worse off for donating. (2) Disincentives towards donation should be removed as much as possible. Third, issues with unethical incentives are explored: undue inducement, commodification of the body, potential decreased organ donation rates, and potential exploitation of vulnerable populations. Lastly, these ethical considerations are applied to the policy change at the NKR, showing that the NKR policy change appears to be ethically supportable. Financial benefits provided to donors are ethically sound if they are in keeping with principles (1) and (2), and do not cause undue inducement, commodification, decreased organ donation, or exploitation. It is ethically appropriate for transplant programs to institute as well as study such programs with the goal of serving the welfare and interests of patients, donors, and the general public.

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