Laparoscopic Transplant Nephrectomy Using a Combination of Intracapsular and Extracapsular Approaches for Graft Intolerance Syndrome in Failed Renal Allografts

Introduction: Transplant nephrectomy for graft intolerance syndrome is technically challenging because severe perirenal adhesions increase bleeding risk. Despite the increasing adoption of minimally invasive techniques, optimal laparoscopic strategies remain limited. Case Presentation: A 49-year-old man developed pembrolizumab-induced graft intolerance syndrome (GIS) following surgery for native renal cell carcinoma. To enable safe continuation of immunotherapy, laparoscopic transplant nephrectomy was performed. Despite severe adhesions, a combined intracapsular and extracapsular approach enabled safe graft removal. Multiple feeding vessels were divided using a vessel-sealing device and soft coagulation, while avoiding extensive hilar dissection. Postoperative computed tomography confirmed complete resection of the allograph, with no radiologically evident residual tissue or postoperative complications. Conclusion: This hybrid laparoscopic approach is a safe, minimally invasive option for managing GIS with severe adhesions.