Complex Renal Artery Aneurysm Managed with Hand-Assisted Laparoscopic Nephrectomy, Ex Vivo Repair, and Autotransplantation Benjamin J. King, Georg Steinthorsson, and Antonio Di Carlo, Burlington, Vermont
A 58-year-old woman had an incidentally found complex right renal artery aneurysm (RAA) during a clinical work-up for diverticulitis. The aneurysm measured 2.5 cm in diameter and was located at the right renal artery bifurcation. She was hospitalized and underwent handassisted laparoscopic nephrectomy with ex vivo repair of the RAA and autotransplantation into the right iliac fossa. The same incision was used to remove the kidney from the retroperitoneum as was used to transplant into the right lower quadrant. She tolerated the procedure well. Her postoperative course was uncomplicated. Hand-assisted laparoscopic nephrectomy with ex vivo repair of a complicated RAA and autotransplantation is feasible and safe.
Renal artery aneurysm (RAA) is a rare vascular lesion with an incidence of 0.15e1% in the general population.1 Indications for treatment include pain, a lesion diameter of >2.5 cm, renovascular hypertension, hematuria, intrarenal thromboemboli, interval enlargement, and lesions in women of childbearing age. Endovascular repair of RAAs is a minimally invasive technique for repair, but this cannot be performed in all cases because of the size and location of the aneurysm and the presence or absence of a neck.2,3 In the 1960s, ex situ repair of a RAA was described, and more recently, laparoscopic nephrectomy with autotransplantation has been described.4,5 In this study, we performed hand-assisted laparoscopic nephrectomy with autotransplantation into the iliac fossa using the same
Department of Urology, University of Vermont, Burlington, VT. Correspondence to: Benjamin J. King, MD, Department of Urology, University of Vermont, Fletcher House 301, 111 Colchester Avenue, Burlington, VT 05401, USA; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1036.e9–1036.e13 http://dx.doi.org/10.1016/j.avsg.2013.08.015 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: June 10, 2013; manuscript accepted: August 11, 2013; published online: December 9, 2013.
incision used to remove the kidney from the retroperitoneum.
CASE REPORT A 58-year-old woman presented to the emergency department because of pain in the left lower quadrant of her abdomen. A computed tomography (CT) scan was performed to rule out diverticulitis, and an incidental right renal artery aneurysm (RAA) was found and measured to be 2.5 cm in diameter. Her medical history was significant for hypertension. The patient was referred to an interventional radiologist, and a CT angiography scan was performed that revealed a complex 2.5-cm right RAA at the bifurcation of the right renal artery (Fig. 1A). The CT angiography scan was also used to assess the right common iliac vessels to verify their patency and the lack of extensive calcifications that, if present, would make the anastomosis difficult. Three-dimensional reconstruction revealed a complex, broad-based, saccular aneurysm (Fig. 1B). Endovascular repair was discussed but was felt to not be feasible given the location of the aneurysm; in situ repair also was not possible because of the location of the aneurysm and presumed limited surgical access for reconstruction. Nephrectomy was also discussed with the patient, but the surgery team and the patient decided to make every attempt to spare both kidneys because of her history of hypertension and a renogram revealing 1036.e9
1036.e10 Case reports
Annals of Vascular Surgery
Fig. 1. The aneurysm shown on CT angiogram (A) preoperatively. Three dimensional reconstruction, superior view of right RAA (B). A, aorta; RA, renal artery.
that 44% of her renal function was derived from her right kidney. The patient agreed to ex vivo repair and autotransplantation after discussion with the multidisciplinary team. Surgery was performed under general anesthesia. One 5-mm and two 12-mm ports were placed (Fig. 2) after pneumoperitoneum was created with a Veress needle. The right renal artery and vein were identified and the kidney was mobilized from its attachments. At this point, a Gibson incision was made in the right iliac fossa (Fig. 2) and a GelPort (Applied Medical, Rancho Santa Margarita, CA) was introduced at this incision site. Using a handassisted technique, the renal artery, vein, and then ureter were stapled after being exposed. The ureter was transected distally with two-thirds of its length remaining attached to the kidney. We then delivered the kidney through the GelPort. The kidney was immediately perfused with cold Wisconsin solution for 15 min and placed in an ice slush. The vascular surgeon then began repair of the aneurysm while the patient was placed in the supine position in preparation for autotransplantation. The aneurysm was resected at the trifurcation of the 3 main branches leading into the kidney (Fig. 3A, B). After dissecting out the aneurysm, the vessels were reconstructed to create 1 continuous renal artery that divided into the appropriate vessels (Fig. 3C). Next, the kidney was autotransplanted into the right iliac fossa using the common iliac vein and artery in an end to side anastomosis (Fig. 4). After completing the anastomoses the side clamps were removed from the iliac vessels and the kidney immediately became pink. Ureterovesical anastomosis was performed with submucosal tunneling of the ureter to prevent reflux of urine. A double J ureteral stent was left in place. The cold ischemia time was approximately 140 min, with an overall case time of 6 hours. The patient was admitted to the surgical intensive care unit (SICU) immediately postsurgery to monitor her urine output and vital signs. She had an uncomplicated course in the SICU and was transferred to the regular surgical
floor on postoperative day (POD) 1. Her preoperative creatinine was 0.74 with a blood urea nitrogen (BUN) level of 16 mg/dL, and on POD 1 creatinine was normal at 0.63 with a BUN level of 16 mg/dL. Also on POD 1, duplex ultrasonography of the renal artery revealed normal right renal arterial flow. On POD 2, she had some nausea and an episode of vomiting that resolved with the return of bowel function. Her creatinine and BUN measurements remained normal; on discharge on POD 4, her creatinine level was 0.63 and her BUN measurement was 10 mg/dL. Immediately postoperatively, she was hypertensive (i.e., blood pressure of 160/66 mm Hg), which resolved within 4 hours, and she was normotensive on the date of discharge. Her vital signs otherwise remained normal throughout the duration of her hospital stay. Two weeks postoperatively, she underwent an additional right renal duplex ultrasonography scan that revealed a widely patent renal artery and vein with a normal kidney size in the right iliac fossa. Her ureteral stent was removed through the urethra without complication 5 weeks postsurgery. Six weeks postoperatively, she had healing abdominal surgical wounds, minimal pain, had returned to a regular diet with a creatinine level of 0.78 and a BUN measurement of 17 mg/dL, and she was normotensive.
DISCUSSION There are many options for the repair of renal artery aneurysms, and the treatment choice depends on the location of the renal artery and the size and complexity of the aneurysm. The first reported case of renal autotransplantation was in 1963 for ureteral disease, and the first reported case for repair of an RAA via an ex situ technique for renovascular hypertension was in 1967.4,6 Since that time, there
Vol. 28, No. 4, May 2014
Fig. 2. One 5mm port and two 12mm ports are shown. The Gibson incision is illustrated, and is typically made 2cm lateral to the anterior superior iliac spine and extending inferiomedial in a curvilinear fashion just above the inguinal ligament to the lateral border of the rectus sheath.
have been different techniques describing repair of RAAs, including stent graft placement, renal artery bypass, coil embolization, and nephrectomy.7,8 Coil embolization is a new, promising, and minimally invasive technique that has been reported in
Case reports 1036.e11
the literature, but its use is limited to saccular aneurysms with a narrow neck; in addition, long-term data on outcomes are not yet available.9 The indications for repair are variable in the literature, but the general consensus includes the following: a diameter of >2.0e2.5 cm, renovascular hypertension, hematuria, intrarenal thromboemboli, interval enlargement, and lesions in women of childbearing age.10e12 In our particular case, the aneurysm was 2.5 cm and the patient had a documented history of hypertension. The association of hypertension and RAA is described and documented, but the exact pathophysiology is unclear.11 Nephrectomy was considered in this case, but given her hypertension and normally functioning right kidney, this was considered a last resort. In situ repair can be performed unless the location and complexity of the aneurysm is not amenable to a narrow surgical field with a limited view. A warm ischemia time of
A 58-year-old woman had an incidentally found complex right renal artery aneurysm (RAA) during a clinical work-up for diverticulitis. The aneurysm measured 2.5 cm in diameter and was located at the right renal artery bifurcation. She was hospitalized and underwent handassisted laparoscopic nephrectomy with ex vivo repair of the RAA and autotransplantation into the right iliac fossa. The same incision was used to remove the kidney from the retroperitoneum as was used to transplant into the right lower quadrant. She tolerated the procedure well. Her postoperative course was uncomplicated. Hand-assisted laparoscopic nephrectomy with ex vivo repair of a complicated RAA and autotransplantation is feasible and safe.
Renal artery aneurysm (RAA) is a rare vascular lesion with an incidence of 0.15e1% in the general population.1 Indications for treatment include pain, a lesion diameter of >2.5 cm, renovascular hypertension, hematuria, intrarenal thromboemboli, interval enlargement, and lesions in women of childbearing age. Endovascular repair of RAAs is a minimally invasive technique for repair, but this cannot be performed in all cases because of the size and location of the aneurysm and the presence or absence of a neck.2,3 In the 1960s, ex situ repair of a RAA was described, and more recently, laparoscopic nephrectomy with autotransplantation has been described.4,5 In this study, we performed hand-assisted laparoscopic nephrectomy with autotransplantation into the iliac fossa using the same
Department of Urology, University of Vermont, Burlington, VT. Correspondence to: Benjamin J. King, MD, Department of Urology, University of Vermont, Fletcher House 301, 111 Colchester Avenue, Burlington, VT 05401, USA; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1036.e9–1036.e13 http://dx.doi.org/10.1016/j.avsg.2013.08.015 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: June 10, 2013; manuscript accepted: August 11, 2013; published online: December 9, 2013.
incision used to remove the kidney from the retroperitoneum.
CASE REPORT A 58-year-old woman presented to the emergency department because of pain in the left lower quadrant of her abdomen. A computed tomography (CT) scan was performed to rule out diverticulitis, and an incidental right renal artery aneurysm (RAA) was found and measured to be 2.5 cm in diameter. Her medical history was significant for hypertension. The patient was referred to an interventional radiologist, and a CT angiography scan was performed that revealed a complex 2.5-cm right RAA at the bifurcation of the right renal artery (Fig. 1A). The CT angiography scan was also used to assess the right common iliac vessels to verify their patency and the lack of extensive calcifications that, if present, would make the anastomosis difficult. Three-dimensional reconstruction revealed a complex, broad-based, saccular aneurysm (Fig. 1B). Endovascular repair was discussed but was felt to not be feasible given the location of the aneurysm; in situ repair also was not possible because of the location of the aneurysm and presumed limited surgical access for reconstruction. Nephrectomy was also discussed with the patient, but the surgery team and the patient decided to make every attempt to spare both kidneys because of her history of hypertension and a renogram revealing 1036.e9
1036.e10 Case reports
Annals of Vascular Surgery
Fig. 1. The aneurysm shown on CT angiogram (A) preoperatively. Three dimensional reconstruction, superior view of right RAA (B). A, aorta; RA, renal artery.
that 44% of her renal function was derived from her right kidney. The patient agreed to ex vivo repair and autotransplantation after discussion with the multidisciplinary team. Surgery was performed under general anesthesia. One 5-mm and two 12-mm ports were placed (Fig. 2) after pneumoperitoneum was created with a Veress needle. The right renal artery and vein were identified and the kidney was mobilized from its attachments. At this point, a Gibson incision was made in the right iliac fossa (Fig. 2) and a GelPort (Applied Medical, Rancho Santa Margarita, CA) was introduced at this incision site. Using a handassisted technique, the renal artery, vein, and then ureter were stapled after being exposed. The ureter was transected distally with two-thirds of its length remaining attached to the kidney. We then delivered the kidney through the GelPort. The kidney was immediately perfused with cold Wisconsin solution for 15 min and placed in an ice slush. The vascular surgeon then began repair of the aneurysm while the patient was placed in the supine position in preparation for autotransplantation. The aneurysm was resected at the trifurcation of the 3 main branches leading into the kidney (Fig. 3A, B). After dissecting out the aneurysm, the vessels were reconstructed to create 1 continuous renal artery that divided into the appropriate vessels (Fig. 3C). Next, the kidney was autotransplanted into the right iliac fossa using the common iliac vein and artery in an end to side anastomosis (Fig. 4). After completing the anastomoses the side clamps were removed from the iliac vessels and the kidney immediately became pink. Ureterovesical anastomosis was performed with submucosal tunneling of the ureter to prevent reflux of urine. A double J ureteral stent was left in place. The cold ischemia time was approximately 140 min, with an overall case time of 6 hours. The patient was admitted to the surgical intensive care unit (SICU) immediately postsurgery to monitor her urine output and vital signs. She had an uncomplicated course in the SICU and was transferred to the regular surgical
floor on postoperative day (POD) 1. Her preoperative creatinine was 0.74 with a blood urea nitrogen (BUN) level of 16 mg/dL, and on POD 1 creatinine was normal at 0.63 with a BUN level of 16 mg/dL. Also on POD 1, duplex ultrasonography of the renal artery revealed normal right renal arterial flow. On POD 2, she had some nausea and an episode of vomiting that resolved with the return of bowel function. Her creatinine and BUN measurements remained normal; on discharge on POD 4, her creatinine level was 0.63 and her BUN measurement was 10 mg/dL. Immediately postoperatively, she was hypertensive (i.e., blood pressure of 160/66 mm Hg), which resolved within 4 hours, and she was normotensive on the date of discharge. Her vital signs otherwise remained normal throughout the duration of her hospital stay. Two weeks postoperatively, she underwent an additional right renal duplex ultrasonography scan that revealed a widely patent renal artery and vein with a normal kidney size in the right iliac fossa. Her ureteral stent was removed through the urethra without complication 5 weeks postsurgery. Six weeks postoperatively, she had healing abdominal surgical wounds, minimal pain, had returned to a regular diet with a creatinine level of 0.78 and a BUN measurement of 17 mg/dL, and she was normotensive.
DISCUSSION There are many options for the repair of renal artery aneurysms, and the treatment choice depends on the location of the renal artery and the size and complexity of the aneurysm. The first reported case of renal autotransplantation was in 1963 for ureteral disease, and the first reported case for repair of an RAA via an ex situ technique for renovascular hypertension was in 1967.4,6 Since that time, there
Vol. 28, No. 4, May 2014
Fig. 2. One 5mm port and two 12mm ports are shown. The Gibson incision is illustrated, and is typically made 2cm lateral to the anterior superior iliac spine and extending inferiomedial in a curvilinear fashion just above the inguinal ligament to the lateral border of the rectus sheath.
have been different techniques describing repair of RAAs, including stent graft placement, renal artery bypass, coil embolization, and nephrectomy.7,8 Coil embolization is a new, promising, and minimally invasive technique that has been reported in
Case reports 1036.e11
the literature, but its use is limited to saccular aneurysms with a narrow neck; in addition, long-term data on outcomes are not yet available.9 The indications for repair are variable in the literature, but the general consensus includes the following: a diameter of >2.0e2.5 cm, renovascular hypertension, hematuria, intrarenal thromboemboli, interval enlargement, and lesions in women of childbearing age.10e12 In our particular case, the aneurysm was 2.5 cm and the patient had a documented history of hypertension. The association of hypertension and RAA is described and documented, but the exact pathophysiology is unclear.11 Nephrectomy was considered in this case, but given her hypertension and normally functioning right kidney, this was considered a last resort. In situ repair can be performed unless the location and complexity of the aneurysm is not amenable to a narrow surgical field with a limited view. A warm ischemia time of
