Bench Surgery With Renal Autotransplantation for Angiomyolipoma of Renal Sinus J. Zhenga, Z. Zhoua, Z. Chena, Q. Fanga, H. Liub, F. Zhub, and J. Pana,* a Urological Surgery Research Institute, Southwest Hospital, Third Military Medical University, Chongqing, China; and bDepartment of Nephrology, Southwest Hospital, Third Military Medical University, Chongqing, China
ABSTRACT Background. The treatment of angiomyolipomas (AML) of the renal sinus is challenging and often requires nephrectomy. In this study, we report on 5 patients who underwent extracorporeal AML resection and subsequent renal autotransplantation (RA) for renal sinus AML. Methods. As of May 2013, 5 patients had undergone extracorporeal AML resection and RA for renal sinus AML at our institute. Separation of the AML in renal sinus is performed by combined sharp and blunt dissection. Tissue between AML and renal sinus is ligated where blood vessels cannot be excluded. When complicated with AML of the renal parenchyma, the AMLs were resected using ultrasound guidance. Results. Renal nuclear scan showed that kidney grafts were perfused uniformly without evidence of segmental infarction at day 7 posttransplantation in all patients. No significant deterioration in renal function and tumor recurrence was noted over a median follow-up of 3 months (range: 1 to 6 months). All patients presented with normal blood pressure values. No intraoperative complications occurred. Conclusions. Bench surgery and subsequent RA method, due to its advantage of kidney preservation, is a valuable option for renal sinus AML treatment.
R
ENAL angiomyolipomas (RAMLs) are benign but progressive tumors consisting of smooth muscle, fat, and vascular elements, partly associated with the tuberous sclerosis complex. RAML most often originates in the renal parenchyma; however, it can occasionally occur in the renal sinus as well [1]. Given the benign nature of AML and the fact that AMLs in tuberous sclerosis (TS) are often multiple, bilateral, and affect an early age group, it is important that AML of the renal sinus is resected completely and the kidney is preserved [1]. However, according to previous reports, almost all AMLs of the renal sinus were treated by nephrectomy [2], except in 1 case in which the renal sinus AML was removed by blunt dissection [3]. Renal autotransplantation (RA), the relocation of a renal unit within the body, was first described by Hardy in 1963 for high ureteric injury [4]. Since that first performance, RA has been used successfully in the treatment of ureteric length deficiencies, loin-pain syndrome, renovascular disease, and renal tumors [5e7]. In this study, for the first time, we
present our initial experience of renal sinus AML treatment by extracorporeal AML resection and subsequent RA. METHODS As of May 2013, 5 patients had undergone extracorporeal AML resection and RA for renal sinus AML at our institute. The patients’ medical records were reviewed retrospectively. Our study was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. Median patient age was 36 years (range: 23 to 59 years); tumor size was 6.2 cm (range: 4.3 to 8.1 cm) (Table 1). All patients were diagnosed as renal sinus AML by computed tomography (CT) (Fig 1) and magnetic resonance imaging before surgery. All 5 patients’ preoperative renal nuclear scans by ECT test showed 2 kidneys with normal glomerular filtration rate.
*Address correspondence to Jinhong Pan, MD, PhD, Urological Surgery Research Institute, Southwest Hospital, Third Military Medical University, Gao Tanyan Road 30, Chongqing 400038, China. E-mail: [email protected]
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2014.01.015
Transplantation Proceedings, 46, 1281e1285 (2014)
1281
1282
ZHENG, ZHOU, CHEN ET AL
Table 1. Demographics, Perioperative Data, and Follow-Up Data of the Patients Parameters
Median (range) or N (%)
No. of patients Age, y, median (range) Sex, male:female, n Body mass index, kg/m2, median (range) ASA score 1; 2, n (%) Side, left; right Multiple tumors, n (%)* Pathologic tumor size, cm, median (range) Operative time, min, median (range) Cold ischemia time, min, median (range) Blood loss, mL, median (range) Complications, n (%)* Hospital stay, d, median (range) Preoperative GFR, mL/min per 1.73 m2 Preoperative Scr, mg/dL Postoperative GFR, mL/min per 1.73 m2 Postoperative Scr, mg/dL Follow-up, mos, median (range) Tumor recurrence
5 36 (23e59) 2:3 20.7 (19.6e22.2) 3 (60); 2 (40) 2; 3 1 (20) 6.2 (4.3e8.1) 452 (397e514) 213 (173e286) 350 (250e600) 1 (20) 9 (9e10) 50.6 (40.2e58.6) 0.9 (0.7e1.5) 46.8 (32.7e60.3) 1.0 (0.6e1.7) 3 (1e6) 0
Abbreviations: ASA, American Society Anesthesiologists; GFR, glomerular filtration rate; SCr, serum creatinine. *Postoperative urinary tract infection (Clavien grade 1).
The donor nephrectomy was performed routinely by laparoscopic surgery. The kidney graft was perfused immediately with hypertonic citrate adenine solution through the renal artery. Separation of the AML in the renal sinus was performed by combined sharp and blunt dissection (Fig 2A). Tissue between the AML and renal sinus was ligated where blood vessels could not be excluded (Fig 2B). When complicated with AMLs of renal parenchyma, the AMLs were resected using ultrasound guidance. First, an ultrasound probe was attached to the kidney to confirm the locations of AMLs (Fig 2C), and then the AMLs were resected by an enucleation and aspiration
Fig 1. (A, B) CT showing AML in renal sinus. The AML was composed primarily of fat, but also contained some soft tissue septations (arrow) (A). Note left renal artery (arrowhead) and left renal vein (arrow) draped over the AML (B). (C, D) AMLs in upper pole (arrow) (C) and middle pole (arrows) (D) of renal parenchyma revealed by CT. Abbreviations: AML, angiomyolipoma; CT, computed tomography.
procedure (Fig 2D) as previously described [8]. The renal artery (arrowhead) was then perfused with hypertonic citrate adenine solution by a tube (Fig 2E). Locations where solution weeped from the renal sinus were considered as suspicious bleeding points and were oversewn with 5-0 PDS sutures (Fig 2F). Before RA was performed, hemostatic yarn and absorbable gelatin sponge were filled and oversewn into the cavity of the renal sinus. The kidney grafts were transplanted into the iliac fossa, the renal vein was anastomosed to the side of external iliac vein, and the renal artery was anastomosed end-to-end to the internal iliac artery. After the kidney grafts were reperfused rapidly and uniformly, urine output was observed on the operating table (Fig 3). The ureteroneocystostomy was performed using 5/0 polydioxanone suture with a ureteric stent placed in situ.
Statistical Analysis All analyses were performed using SPSS software (Statistical Package for the Social Sciences, version 20.0; SPSS, Evanston, Illinois, USA). Numerical variables were compared using Student t test. A P value
ABSTRACT Background. The treatment of angiomyolipomas (AML) of the renal sinus is challenging and often requires nephrectomy. In this study, we report on 5 patients who underwent extracorporeal AML resection and subsequent renal autotransplantation (RA) for renal sinus AML. Methods. As of May 2013, 5 patients had undergone extracorporeal AML resection and RA for renal sinus AML at our institute. Separation of the AML in renal sinus is performed by combined sharp and blunt dissection. Tissue between AML and renal sinus is ligated where blood vessels cannot be excluded. When complicated with AML of the renal parenchyma, the AMLs were resected using ultrasound guidance. Results. Renal nuclear scan showed that kidney grafts were perfused uniformly without evidence of segmental infarction at day 7 posttransplantation in all patients. No significant deterioration in renal function and tumor recurrence was noted over a median follow-up of 3 months (range: 1 to 6 months). All patients presented with normal blood pressure values. No intraoperative complications occurred. Conclusions. Bench surgery and subsequent RA method, due to its advantage of kidney preservation, is a valuable option for renal sinus AML treatment.
R
ENAL angiomyolipomas (RAMLs) are benign but progressive tumors consisting of smooth muscle, fat, and vascular elements, partly associated with the tuberous sclerosis complex. RAML most often originates in the renal parenchyma; however, it can occasionally occur in the renal sinus as well [1]. Given the benign nature of AML and the fact that AMLs in tuberous sclerosis (TS) are often multiple, bilateral, and affect an early age group, it is important that AML of the renal sinus is resected completely and the kidney is preserved [1]. However, according to previous reports, almost all AMLs of the renal sinus were treated by nephrectomy [2], except in 1 case in which the renal sinus AML was removed by blunt dissection [3]. Renal autotransplantation (RA), the relocation of a renal unit within the body, was first described by Hardy in 1963 for high ureteric injury [4]. Since that first performance, RA has been used successfully in the treatment of ureteric length deficiencies, loin-pain syndrome, renovascular disease, and renal tumors [5e7]. In this study, for the first time, we
present our initial experience of renal sinus AML treatment by extracorporeal AML resection and subsequent RA. METHODS As of May 2013, 5 patients had undergone extracorporeal AML resection and RA for renal sinus AML at our institute. The patients’ medical records were reviewed retrospectively. Our study was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. Median patient age was 36 years (range: 23 to 59 years); tumor size was 6.2 cm (range: 4.3 to 8.1 cm) (Table 1). All patients were diagnosed as renal sinus AML by computed tomography (CT) (Fig 1) and magnetic resonance imaging before surgery. All 5 patients’ preoperative renal nuclear scans by ECT test showed 2 kidneys with normal glomerular filtration rate.
*Address correspondence to Jinhong Pan, MD, PhD, Urological Surgery Research Institute, Southwest Hospital, Third Military Medical University, Gao Tanyan Road 30, Chongqing 400038, China. E-mail: [email protected]
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2014.01.015
Transplantation Proceedings, 46, 1281e1285 (2014)
1281
1282
ZHENG, ZHOU, CHEN ET AL
Table 1. Demographics, Perioperative Data, and Follow-Up Data of the Patients Parameters
Median (range) or N (%)
No. of patients Age, y, median (range) Sex, male:female, n Body mass index, kg/m2, median (range) ASA score 1; 2, n (%) Side, left; right Multiple tumors, n (%)* Pathologic tumor size, cm, median (range) Operative time, min, median (range) Cold ischemia time, min, median (range) Blood loss, mL, median (range) Complications, n (%)* Hospital stay, d, median (range) Preoperative GFR, mL/min per 1.73 m2 Preoperative Scr, mg/dL Postoperative GFR, mL/min per 1.73 m2 Postoperative Scr, mg/dL Follow-up, mos, median (range) Tumor recurrence
5 36 (23e59) 2:3 20.7 (19.6e22.2) 3 (60); 2 (40) 2; 3 1 (20) 6.2 (4.3e8.1) 452 (397e514) 213 (173e286) 350 (250e600) 1 (20) 9 (9e10) 50.6 (40.2e58.6) 0.9 (0.7e1.5) 46.8 (32.7e60.3) 1.0 (0.6e1.7) 3 (1e6) 0
Abbreviations: ASA, American Society Anesthesiologists; GFR, glomerular filtration rate; SCr, serum creatinine. *Postoperative urinary tract infection (Clavien grade 1).
The donor nephrectomy was performed routinely by laparoscopic surgery. The kidney graft was perfused immediately with hypertonic citrate adenine solution through the renal artery. Separation of the AML in the renal sinus was performed by combined sharp and blunt dissection (Fig 2A). Tissue between the AML and renal sinus was ligated where blood vessels could not be excluded (Fig 2B). When complicated with AMLs of renal parenchyma, the AMLs were resected using ultrasound guidance. First, an ultrasound probe was attached to the kidney to confirm the locations of AMLs (Fig 2C), and then the AMLs were resected by an enucleation and aspiration
Fig 1. (A, B) CT showing AML in renal sinus. The AML was composed primarily of fat, but also contained some soft tissue septations (arrow) (A). Note left renal artery (arrowhead) and left renal vein (arrow) draped over the AML (B). (C, D) AMLs in upper pole (arrow) (C) and middle pole (arrows) (D) of renal parenchyma revealed by CT. Abbreviations: AML, angiomyolipoma; CT, computed tomography.
procedure (Fig 2D) as previously described [8]. The renal artery (arrowhead) was then perfused with hypertonic citrate adenine solution by a tube (Fig 2E). Locations where solution weeped from the renal sinus were considered as suspicious bleeding points and were oversewn with 5-0 PDS sutures (Fig 2F). Before RA was performed, hemostatic yarn and absorbable gelatin sponge were filled and oversewn into the cavity of the renal sinus. The kidney grafts were transplanted into the iliac fossa, the renal vein was anastomosed to the side of external iliac vein, and the renal artery was anastomosed end-to-end to the internal iliac artery. After the kidney grafts were reperfused rapidly and uniformly, urine output was observed on the operating table (Fig 3). The ureteroneocystostomy was performed using 5/0 polydioxanone suture with a ureteric stent placed in situ.
Statistical Analysis All analyses were performed using SPSS software (Statistical Package for the Social Sciences, version 20.0; SPSS, Evanston, Illinois, USA). Numerical variables were compared using Student t test. A P value
