Vol. 116, July Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright © 1976 by The Williams & Wilkins Co.

RENAL AUTOTRANSPLANTATION FOR UPPER URETERAL STENOSIS JAMES H. DEWEERD,* STEPHEN C. PAULK, FRED M. TOMERA

AND

LYNWOOD H. SMITH

From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota

ABSTRACT

In 2 cases of irreparable upper ureteral damage autotransplantation of the kidney with pelvioureteral anastomosis proved to be a satisfactory alternative to nephrostomy drainage or nephrectomy. Indications for renal autotransplantation fall into 3 categories: ureteral abnormality, renal artery disease and renal parenchymal or pelvic disease. Since Hardy's report in 1963 of a successful autotransplant and ureteroneocystostomy for ureter al injury, 1 single cases of ureter al disease have been managed successfully in a similar fashion by others. 2 - 6 Autotransplants for renal artery disease, some with ex vivo repair, have been documented by Hodges 7 (10 renal units in 8

advocated by Guerriero and associates, 10 have been applied to 3 cases of bilateral hypernephroma by Calne. 11 Our experience with 2 patients, each with irreparable loss of upper ureteral integrity and function, is reported herein. CASE REPORTS

Case 1. A 49-year-old man was first seen in 1966 for evaluation of recurrent bilateral renal calculi. Numerous

Fm. 1. Case 1. A, stone at right pelvic outlet and multiple small stones in left kidney. B, resultant right hydronephrosis; left kidney is normal except for stones. C, after transplant with excellent excretory function and significantly improved collecting system.

stones were passed or had been removed transurethrally. Three surgical procedures, 1 on the left and 2 on the right renal unit, had been performed elsewhere since the onset of disease in 1951. Diagnosis was idiopathic renal lithiasis with hypercalciuria, complicated by chronic urinary tract infection. Anatomic changes included right renal and upper ureteral calculi, right ureteral stricture and multiple small left renal calculi. Between 1966 and 1974, 4 more renal and upper ureteral operations were performed- I on the left and 3 on the right side-to remove

patients), Kaufman• and Clunie" and their associates, in addition to at least 7 cases cited in the recent foreign literature. 7 Extracorporeal operations for parenchymal and pelvic lesions, including trauma, tumor and stone disease, as Accepted for publication November 7, 1975. Read at annual meeting of North Central Section, American Urological Association, Phoenix, Arizona, October 5-12, 1975. * Requests for reprints: Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55901.

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DEWEERD AND ASSOCIATES

pelvic and upper ureteral stones. Two of the right flank operations included attempts to correct the severe upper ureteral stenosis by pelvioureterostomy and Davis intubated uretorotomy. The patient was seen again in 1975 after 2 episodes of acute right pyelonephritis precipitated by the impaction of a stone (1 by 1.5) at the stenosed upper ureter (fig. 1, A and B). Small stones in the lower pole of the left kidney remained unchanged in size and number. On February 21 the right flank was reopened for the sixth time. Dense, almost cartilaginous scar tissue encased the kidney, its pedicle and upper ureter. The kidney was finally mobilized along with adequate lengths of renal artery and vein. The ureter was never identified, except as a minute lumen when a 1 by 2 cm: mass of solid scar tissue was transected at the level of the lower pole of the kidney. The kidney was removed and immediately perfused with iced normal saline (pH adjusted with sodium bicarbonate of concentration 5 mEq. per 1.) and stored in saline slush. An extracorporeal operation included identification of the renal pelvis, incision along its medial margin and removal cf dense encasing scar tissue after removal of the ureteropelvic juncture and stenosed ureter. The calculus was located in the pelvis and removed. Roentgenograms were made to ensure that no calcific material remained. The kidney was placed in the right iliac fossa and revascularized by end-to-end arterial (renal to internal iliac) and end-to-side venous (renal to external iliac) anastomoses. Excellent perfusion followed 3 hours 15 minutes of ischemia time.

The lower 40 per cent of the right ureter was normal. It was mobilized and a longitudinal incision was made. Pelvioureterostomy was performed using a lOF silastic tubing stent. Increasing quantities of clear urine were being produced as the pelvioureteral anastomosis was completed. Convalescence was uneventful. The stent was removed 14 days postoperatively and transport of urine to the bladder was immediate. The patient was discharged from the hospital 16 days postoperatively. Re-examination after 4 months demonstrated a rewarding early result. There was no evidence of recurring stone in the transplanted kidney. Excretory function was prompt and the collecting system was amazingly normal (fig. 1, C). A midstream urine specimen contained no cellular elements and the Gram stain and cultures were negative. Serum creatinine was 1 mg. per dl. Case 2. A 47-year-old man had had a right orchiectomy for an embryonal cell carcinoma in January 1968. A radical retroperitoneal lymphadenectomy produced 2 lymph nodes containing nests of tumor cells and 2 courses of radiotherapy, 5,000 rads to the midline abdomen and 5,000 rads to the right lower quadrant, were given. Our initial evaluation 8 months later revealed generous renal collecting systems bilaterally with normal renal function (serum creatinine 0.9 mg. per dl.) and extrinsic obstruction of the third portion of the duodenum. Exploratory laparotomy in October revealed an extrinsic fibrotic sheath covering the aorta and vena cava and obstructing the duodenum. Specimens removed for biopsy were negative for tumor. An anterior gastroenterostomy was performed.

FIG. 2. Case 2. A, bilateral hydronephrosis with significant left renal atrophy. B, improved collecting system architecture, medium flows toward left kidney and into bladder and medial projection is closed end of pelvis. C, IVP-note caliceal detail is incomplete in single exposure but improved urine transport is confirmed (3 months after transplant).

25 ureteral obstruction v;ith signifia serum creatinine elevated to 1.65 mg, per dl. was recorded when the patient returned 4 years later, A renal arteriogram performed in anticipation of autotransplantation demonstrated single arteries bilaterally, An operation on January 2, 1973 revealed severe periureteral fibrosis, Ureterolysis proved to be feasible and was accomplished, rfhe viable ureter was wrapped in retroperitoneal fat when bringing omentum into the field proved impossible, No malignant tissue was found. The initial improvement and apparent stabilization were short lived. Twenty-six months later the right hydronephrosis progressed and serum creatinine rose to 2.66 mg. per di. (fig, 2, A), By April 1975 the creatinine level reached 3.5 mg. per dl. Autotransplantation was recommended again, On May 25 the right kidney was mobilized and removed with an adequate segment of artery and vein. Immediate perfusion with chilled buffered normal saline was accomplished while the kidney was immersed in saline slush. The previous radiation to the right lower quadrant made it necessary to plan implantation on the left side of the pelvis. Unexpected perivascular fibrosis was encountered but satisfactory vessels were mobilized for end-to-end arterial and end-to-side venous anastomoses. The left ureter was surrounded by a thin layer of fibrous tissue but was otherwise normal. The dependent end of the renal pelvis was closed. A 1.5 cm. longitudinal incision was made in the ureter and a comparable incision was made in the medial aspect of the pelvis, Side-to-side ureteropelviostomy was performed over an 8F silastic tube, thus preserving the ureteral continuity to serve the atrophic left kidney. The technical difficulties involved with mobilization and exposure throughout the entire procedure resulted in a total ischemia time of 4 hours 41 minutes. The kidney perfused well but did not immediately become characteristically tense. Urine production was delayed for l hour 15 minutes. Postoperative diuresis and a rise in serum creatinine to 4.75 mg. per dl. were attributed to a degree of acute tubular necrosis associated with the prolonged ischemia time, An IVP 6 weeks postoperatively demonstrated marked reduction in pyelocaliectasis and an intact transport system (fig, 2, B). The creatinine was 2.7 mg. per di. No evidence of ureteral malfunction followed removal of the ureteral stent. Three months postoperatively the serum creatinine ,Nas further reduced to 2,2 mg. per dl. and an IVP demonstrated the collecting and transport systems to be unchanged from those taken 6 weeks previously (fig, 2,

COMMENT

In each case the technical difficulties encountered were extreme. Fortunately, significant trauma to adherent vital organs and structures was avoided, Intravenous mannitol and furosemide were used effectively prior to and during mobiiization of renal vessels and after revascularization, A satisfactory lower ureteral segment is a necessary prerequisite. In case 2 a difficult left nephrectomy was avoided by incontinuity ureteropelviostomy. CONCLUSION

Autotransplantation of the kidney with pelvioureteral anastomosis has, as judged by favorable results in the 2 cases presented, proved to be a most satisfactory alternative to nephrostomy drainage or nephrectomy when an irreparable upper ureteral lesion is present. REFERENCES

1. Hardy, J. D.: High ureteral injuries: management by autotrans-

plantation of the kidney. J.A.M.A., 184: 97, 1963. 2. Marshall, V. F., Whitsell, J., McGovern, J. H. and Miscall, B. G.: The practicality of renal autotransplantation in humans. J.A.M.A., 196: 1154, 1966. 3. Murphy, G. P., Staubitz, W. J. and Kenny, G. M.: Renal autotransplantation for rehabilitation of a patient with multiple urinary tumors. J. Urol., 107: 199, 1972. 4. Linke, C, A. and May, A. G,: Autotransplantation in retroperitoneal fibrosis. J. Urol., 107: 196, 1972. 5. Devor, D. and Bandel!, H.: Kidney autotransplantation for ureteral loss from granulomatous colitis. Calif. Med., H8: 67, May 1973. 6. Rhame, R. C.: Application of renal autotransplantation to the treatment of simultaneous bilateral ureteral tumours. Brit. J. Urol., 45: 388, 1973. 7. Hodges, C. V., Lawson, R. K., Pearse, H. D. and Stranburg, C. 0.: Autotransplantation of the kidney. J. Uro!., HO: 20, 1973. 8. Kaufman, J. J., Alferez, C. and Navarrete, R. V.: Autotransplantation of a solitary functioning kidney for renovascular hypertension. J. Urol., 102: 146, 1969. 9. Clunie, G. J. A,, Murphy, K. J., Lukin, L., Nicoll, P. and Marsden, R. T, H,: Autotransplantation of the kidney in the treatment of renovascular hypertension. Surgery, 69: 326, 1971. 10. Guerriero, W. G., Scott, R., Jr. and Joyce, L.: Development of extracorporeal renal perfusion as an adjunct for bench renal surgery, J. Urol., 107: 4, 1972. lL Calne, R. Y.: Treatment of bilateral hypernephromas by nephrectomy, excision of tumour, and autotransplantation. Report of three cases, Lancet, 2: 1164, 1973.

Renal autotransplantation for upper ureteral stenosis.

Vol. 116, July Printed in U.S.A. THE JOURNAL OF UROLOGY Copyright © 1976 by The Williams & Wilkins Co. RENAL AUTOTRANSPLANTATION FOR UPPER URETERAL...
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