Supervisor - Professor Marc-Olivier Timsit
Hopital Necker, Université Paris Descartes, Paris, France.
I recently completed a fellowship at the world famous Necker Hospital in Paris where the world’s first living donor renal transplant was performed in 1952, two years before the infamous Herrick twin transplant was performed at the Brigham Hospital, Boston, USA. The Necker Institute remains Paris’ largest renal transplant centre with more than 200 transplants being performed annually. I chose to apply for a fellowship at this prestigious unit for several reasons, firstly due to their longstanding international reputation as a centre of excellence in renal transplantation and urology. Secondly due to their leading research and innovation and finally due to my longstanding interest in the French healthcare system. Thanks to the Urology Foundation Longer Term Fellowship Award I was able to spend six months immersing myself in transplant urology whilst building collaborative relationships with not only the Necker, but other prestigious transplant centres in France and Europe.
Transplant urology as a specialty remains niche in the UK where more than 95% of renal transplant surgeons are general surgeons. In France however, at least 95% of renal transplant surgeons are urologists. As a urologist, this was another reason why the Necker was the perfect place to complete my fellowship. From a clinical perspective, I was involved in all aspects of transplantation including ward rounds, transplant assessment clinics, surgery (both living donor, deceased donor and organ retrieval), post-operative care, morbidity and mortality meetings, radiology meetings and daily collaboration with the nephrology team. I was involved in over 60 renal transplants and also travelled to different hospital in Paris to assist with organ retrieval. Not only did I learn new surgical techniques but I also learned ways to improve the patient journey for those undergoing transplantation.
With regards to surgical techniques, I learned to perform the ‘Necker technique’ of transplanting kidneys. This specifically involves joining the donor ureter (tube which drains urine from the kidney to the bladder) to the recipient ureter and is a technique which I became confident to perform. Most centres, including all those in the UK, perform a technique whereby the donor ureter is connected directly to the bladder. The disadvantage of this latter technique is reflux of urine (urine flows backwards) into the kidney transplant which may cause problems including kidney infections. Learning new techniques increases the armamentarium of alternatives available when surgical options may be limited. For example, if a donor ureter is unsuitable, this new technique has the potential to salvage a potential transplant which may have otherwise been rendered untransplantable. Additionally the technique may be employed to treat transplant recipients with ureteric strictures (scars), those which are untreatable by conventional methods.
The patient journey can be improved by the early removal of transplant ureteric stents. This can be done at the bedside, under local anaesthetic using disposable instruments, as performed at the Necker. I was exposed to novel methods of stent removal including the use of stents which can be removed magnetically. The early removal of stents has been proven to reduce the risk of urinary tract infections which are often problematic in transplant recipients. All patients, with the exception of identical twins, require medications to suppress their immune system as part of their treatment to prevent ‘rejection’ of the donor organ and this in turn renders them susceptible to infections.
During my fellowship I also took the opportunity to compare the training between UK and Necker transplant surgeons. This resulted in the publication of a poster presentation at the British Transplant Society meeting ‘Training in Renal Transplant – the French Experience’. The training is significantly shorter in France but despite this, they produce excellent independent surgeons, who are adept at a wide range of urological surgical interventions alongside renal transplantation. Their training is much more focused than that in the UK and of course there are advantages and disadvantages of both systems.
In summary, the Necker Institute is one of France’s leading transplant urology units and is at the cutting edge of innovation and research. It was an honour to have the opportunity to spend six months learning new techniques and collaborating with an internationally renowned team of experts. I remain indebted both to the Urology Foundation for facilitating this experience and also to the team at the Necker, in particular Professors Mejean and Timsit, who welcomed me and treated me as part of their team.
