EMBRYOLOGY, ANATOMY, AND SURGICAL APPLICATIONS OF THE KIDNEY AND URETER

SURGICAL ANATOMY AND EMBRYOLOGY

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EMBRYOLOGY, ANATOMY, AND SURGICAL APPLICATIONS OF THE KIDNEY AND URETER Rizk E. S. El-Galley, MB BCh, FRCS(Edin), and Thomas E. Keane, MB BCh, FRCS(1)

EMBRYOLOGY OF THE KIDNEY AND URETER

Normal development of the collecting system is a complex relationship between the mesoderm and endoderm. Pronephros is the first renal tissue to develop during the first 4 weeks of gestation. It is a nonfunctional condensation of mesoderm adjacent to the midline in the cervical region. The duct of the pronephros is believed to persist as the mesonephric duct, whereas the tubules disappear. The mesonephric duct extends caudally to drain in the urogenital sinus by 28 days of gestation. During its descent, approximately 20 pairs of functioning mesonephric tubules are induced and open in the duct. After 10 weeks of gestation, the caudal mesonephros disappears, whereas the cranial nephrons persist to become part of the genital system. The ureteric bud originates from the posteromedial aspect of the mesonephric duct at the point where it enters the cloaca. The ureteric bud, covered by the metanephric mesenchyme, divides with four to six branchings to form the renal pelvis and calyces. The divisions forming the upper and lower poles develop faster than the center, which helps to maintain the reniform shape of the kidney. The next five to seven branchings contribute to the calyces, and the following five to seven branchings form the collecting ducts. The growing collecting ducts extend centrifugally to divide the kidney into the cortex and medulla. This growth induces the cortex to form glomeruli at the ampulla of the growing tubules. The collecting duct then elongates, the proximal tubules convolute, and the loops of Henle penetrate deeper into the medulla. A typical collecting duct drains 9 to 11 nephrons. The kidney originates at the level of the sacral spine in the embryo. It then

From the Emory Clinic, Atlanta, Georgia

SURGICAL CLINICS OF NORTH AMERICA

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ascends to its final position lateral to the upper lumbar vertebrae. During its ascent, it also rotates medially on its polar axis, causing the pelvis to face medial1y. ANATOMY OF THE UPPER URINARY TRACT Surgical Anatomy of the Kidney

Topographic The kidneys are paired, reddish brown, solid organs situated on each side of the midline in the retroperitoneal space. Their weight depends on body size, averaging 150 g and 135 g in men and women, respectively. Kidneys in adults vary in length from 11.0 cm to 14.0 cm, in width from 5.0 cm to 7.0 cm, and in thickness from 2.5 cm to 3.0 cm. Because of the effect of the hepatic mass, the right kidney is shorter, broader, and lies 1 cm to 2 cm lower than does the left kidney.’O, l4 Extraperitoneal Compartments and Perirenal Fasciae The extraperitoneal compartment can be divided into the anterior pararenal space, perirenal space, and posterior pararenal space (Fig. 1). The anterior pararenal space extends from the posterior parietal peritoneum to the anterior renal fascia and is confined laterally by the lateroconal fascia. It includes the ascending and descending colon, duodenal loop, and pancreas. Although the space is potentially continuous across the midline, fluid volumes, even under pressure, typically reach only the midline. In the perirenal space, each kidney is surrounded by a layer of fat that is covered by Gerota’s fascia. This fascia is completely fused superolaterally to the kidney, whereas medioinferiorly, fusion may be incomplete. This incomplete fusion is of clinical importance in determining the possible routes of spread of bleeding or infection around the kidneys. Both layers of Gerota’s fascia probably continue across the midline, with the posterior layer crossing behind the great vessels, whereas the anterior layer extends in front of the great vessels. The parietal peritoneum fuses with the anterior layer of Gerota’s fascia to form Toldt’s line. During surgical approaches to the kidneys, incision along this line enables surgeons to reflect the peritoneum with the mesocolon, through a relatively bloodless plane, and gives access to the renal hilum. The posterior pararenal space is limited medially by the fusion of the transversalis fascia with the psoas muscle fascia. It is open laterally and inferiorly. A potential communication exists between this space on each side of the body by the properitoneal fat of the anterior abdominal wall, deep to the transversalis fascia. Unlike the other two spaces, this space contains no organs. Anatomic Relationships The upper pole of the left kidney lies at the level of T12, and the lower pole, at the level of L3. The right kidney usually extends from the top of L1 to the bottom of L3. Because of the free mobility of the kidneys, these relationships change with body position and respiration. The right adrenal gland covers the uppermost part of the anteromedial surface of the right kidney. The anterior relationships of the right kidney include

IVC

Aorta

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B Figure 1. A and 6,The three extraperitoneal compartments. Anterior pararenal space (hatched). Perirenal space (stippled). Posterior pararenal space (cross-hatched). IVC = inferior vena cava. (Figure A from Meyers MA: Acute extraperitoneal infection. Sem Roentgenol 8:447, 1973; Figure B from Meyers MA: Dynamic Radiology of the Abdomen, ed 4. New York, Springer-Verlag, 1994, p 223; with permission.)

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the liver, which overlies the upper two thirds of the anterior surface, and the hepatic flexure of the colon, which overlies the lower one third. The right renal hilum is overlaid by the second part of the duodenum. The anterior surface of the kidney beneath the liver is the only area covered by peritoneum. The anteromedial surface of the left kidney is also covered by the left adrenal gland in its uppermost part. The spleen, body of the pancreas, stomach, and splenic flexure of the colon are all in an anterior relationship to the left kidney. The area of the kidney beneath the small intestine, spleen, and stomach is covered by peritoneum (Fig. 2). Although the adrenal glands arise in an intimate anatomic relationship to the kidneys, their separate embryologic origin means that their development is generally unaffected by common renal anomalies. The adrenal glands are fixed superiorly to Gerota's fascia, but they can be easily separated from the kidneys in surgery. Both kidneys share relatively symmetric relationships to the posterior abdominal wall. The upper third or upper pole of each kidney lies on the diaphragm, behind which is the pleural reflection. An operative approach to this area with a high incision above the 11th or 10th rib risks entering the pleural space. The upper border of the left kidney usually extends to the upper border of the 11th rib, whereas the upper pole of the right kidney, which is lower, is usually at the level of the 11th intercostal space. The lower two' thirds of the posterior surface of both kidneys lie on three muscles, which from medial to lateral are the psoas major, quadratus lumborum, and aponeurosis of the transversus abdominis muscles. The renal vessels and pelvis lie against the contour of the psoas muscle, which tilts the lower pole of each kidney away from the midline. Alterations in this alignment may be seen with space-occupying lesions and should prompt a careful assessment (Fig. 3).

Figure 2. Anatomic relationships. Because of the free mobility of the kidneys, these relationships change with body position and respiration. (From El-Galley RES, Keane TE: Kidney, ureters, and bladder. In Wood WC, Skandalakis JE (eds): Anatomic Basis of Tumor Surgery. Milwaukee, Quality Medical Publishing, 1999, p 827; with permission.)

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Figure 3. Anatomic relationships. The kidneys share relatively symmetric relations to the posterior abdominal wall. M = muscle. (From El-Galley RES, Keane TE: Kidney, ureters, and bladder. In Wood WC, Skandalakis JE (eds): Anatomic Basis of Tumor Surgery. Milwaukee, Quality Medical Publishing, 1999, p 828; with permission.)

Renal Parenchyma

The renal parenchyma is divided into an internal, dark medulla and an external, lighter-hued cortex. The medulla is composed of 8 to 18 conic structures, called the renal pyramids, which are made of ascending and descending loops of Henle and collecting ducts. The round tip of each pyramid is known as the renal papilla. These papillae cannot be seen during surgical dissection because each papillary projection is encompassed by a smooth muscular sleeve called a minor calyx. These minor calyces coalesce to form two or three major calyces, which in turn join to form the renal pelvis. The renal pelvis extends through the renal hilum behind the renal vessels and continues as the ureter. Anatomic variations in the renal pelvis are not uncommon. The renal pelvis, which is usually partially extrarenal, may lie completely extrarenal or intrarenal. In some cases, the renal pelvis may be duplicated, with duplication of the renal units, but when this variation exists, it tends to occur bilaterally, which should be considered when evaluating urographic studies to differentiate disease from normal variations. The renal cortex lies between the bases of the pyramids and the renal capsule. The tongues of cortical tissue, which extend between the renal pyramids, are called Bertin’s columns and, when enlarged, can closely resemble a renal mass. The outer border of the renal cortex is typically smooth. Indentations on the cortical surface might represent persistent fetal lobulations, previous scarring and infection, or space-occupying lesions.

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Renal Blood Supply

Arterial Supply. Each kidney is classically supplied by a renal artery and a larger renal vein arising from the aorta and the inferior vena cava, respectively, at the level of L2, below the takeoff of the superior mesenteric artery. They enter the renal hilum medially, with the vein anterior to the artery and both anterior to the renal pelvis. Although the right kidney is in a lower position than is the left kidney, the right renal artery arises from the aorta at a higher level and takes a longer course than does the left renal artery. It must travel downward, behind the inferior vena cava, to reach the right kidney, whereas the left renal artery passes slightly upward to reach the left kidney. Because of the posterior position of the kidneys, both renal arteries course in a slightly posterior direction. Two small but important branches arise from the main renal artery before its termination in the hilum: (1) the inferior adrenal artery and (2) the artery that supplies the renal pelvis and upper ureter (Fig. 4). Ligation of this branch may result in ischemia to the area of the upper ureter with stricture formation. The main renal artery divides into five segmental arteries at the renal hilum. Each segmental artery is an end artery, so occlusion leads to ischemia and infarction of the corresponding renal segment. The first branch is the posterior artery, which arises just before the renal hilum and passes posterior to the renal pelvis to supply a large posterior segment of the kidney. The main renal artery then terminates into four anterior segmental arteries at the renal hilum. They are the apical, upper, middle, and lower anterior segmental arteries. The apical and inferior arteries supply the anterior and posterior surfaces of the upper and lower poles of the kidneys, respectively. The upper and middle arteries supply the two corresponding segments on the anterior surface of the kidney. The segmental arteries course though the renal sinus and branch into the lobar arteries, which are usually distributed one for each pyramid.I3Each lobar artery divides into two or three interlobar arteries that pass between the renal pyramids to the corticomedullary junction, where they become the arcuate

Figure 4. There are two small but important branches arising from the main renal artery before its termination in the hilum: the inferior adrenal artery and the artery that supplies the renal pelvis and upper ureter. V = vein. (From El-Galley RES, Keane TE: Kidney, ureters, and bladder. In Wood WC, Skandalakis JE (eds): Anatomic Basis of Tumor Surgery. Milwaukee, Quality Medical Publishing, 1999, p 832; with permission.)

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artery. The arcuate arteries, as their name implies, arch over the bases of the pyramids and give rise to a series of interlobular arteries, which in turn take a straight course to the renal cortex, with some terminal small branches anastomosing with the capsular arteries. This anastomosis can enlarge to supply a significant amount of blood to the superficial cortical glomeruli, especially in cases of gradual narrowing of the renal arteries. Of importance to urologists is the relatively avascular plane on the posterior surface of the kidney, located approximately one third of the distance between the posterior and anterior surfaces. Incision through this line towards the renal pelvis is unlikely to traverse any major vessels. Similarly, transverse incisions are usually possible between the posterior segmental circulation and polar segments supplied by the apical or lower segmental arteries of the anterior circulation to gain access to upper or lower pole calyces. Venous Drainage. The renal cortex is drained by the interlobular veins, which, unlike the renal arteries, anastomose freely with the arcuate veins at the base of the medullary pyramids and the capsular and perirenal veins on the ;surface of the kidney. The arcuate veins drain by the interlobar veins to the lobar veins, which join to form the renal vein. The right renal vein, 2 to 4 cm in length, joins the lateral aspect of the inferior vena cava, usually without receiving any tributaries. The left renal vein is 6 to 10 cm in length, crosses anterior to the aorta, and ends in the left aspect of the inferior vena cava. It receives three tributaries lateral to the aorta: (1) the left adrenal vein superiorly, (2) the left gonadal vein inferiorly, and ( 3 ) a lumber vein posteriorly. At the renal hilum, the renal vein usually lies in front of the renal artery, but passing more medially, the renal artery may be 1 cm or more higher or lower than the vein. Renal Lymphatics. Lymphatic vessels within the renal parenchyma consist of cortical and medullary plexuses, which follow the renal vessels to the renal sinus and form several large lymphatic trunks. The renal sinus is the site of numerous communications between lymphatics from the perirenal tissues, renal pelvis, and upper ureter. Initial lymphatic drainage runs to the nodes present at the renal hilum lying close to the renal vein. These nodes form the first station for lymphatic spread of renal cancer. On the left side, lymphatic trunks from the renal hilum drain to the para-aortic lymph nodes from the level of the inferior mesenteric artery to the diaphragm. Lymphatics from the right kidney drain into the lateral paracaval and interaortocaval nodes from the level of the common iliac vessels to the diaphragm. Lymphatics from both sides may extend above the diaphragm to the retrocrural nodes or directly into the thoracic duct. Nerve Supply. The kidneys have both sympathetic and parasympathetic innervation, but the function of these nerves is poorly understood. Sympathetic fibers are derived from the greater and lesser splanchnic nerves, which link the celiac and superior mesenteric ganglia. Sympathetic and parasympathetic fibers travel around the renal artery to the renal pelvis.

Surgical Anatomy of the Ureter

Topographic Anatomy

The ureter is a muscular tube that follows a gentle S-shaped course in the retroperitoneum. The muscle fibers are arranged in three separate layers: (1) inner and (2) outer longitudinal and ( 3 ) middle circular. The length of the ureter in adults ranges from 28 cm to 34 cm, varying in direct relationship with the

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height of the individual. The average diameter of the ureter is 10 mm in the abdomen and 5 mm in the pelvis, but three areas of physiologic narrowing in the ureter should not be considered abnormal unless the proximal ureter is significantly dilated. These areas are located at the (1)ureteropelvic junction, (2) point where the ureter crosses the iliac vessels, and (3) ureterovesical junction. Both ureters have the same posterior relationships lying on the medial aspect of the psoas major muscle and traveling downward, adjacent to the transverse processes of the lumbar vertebrae. They enter the pelvis medial to the sacroiliac joints, cross over the bifurcation of the common iliac vessels, and follow the hypogastric artery in a gentle lateral curve on the pelvic wall. At the level of the greater sciatic foramen, they turn medially again to enter the bladder obliquely and course submucosally for 2 cm to 3 cm, ending in the ureteral orifices. Just proximal to their midpoints, both ureters cross behind the gonadal vessels. The right ureter passes behind the second part of the duodenum, lateral to the inferior vena cava, and is crossed by the right colic and ileocolic vessels. The left ureter passes behind the left colic vessels, descends parallel to the aorta, and passes under the pelvic mesocolon. In male patients, the ureter crosses under the vas deferens in close proximity to the upper end of the seminal vesicle before entering the urinary bladder. In female patients, the pelvic relationships are somewhat different. The ureter travels in the posterior border of the ovarian fossa and passes forward under the lower part of the broad ligament, lateral to the cervix, and under the uterine artery. This area is a common site for ureteric injury during hysterectomy. Arterial Blood Supply

The upper ureter derives its blood supply from a ureteric branch of the renal artery. During their course in the abdomen, the ureters receive blood from the gonadal vessels, aorta, and retroperitoneal vessels. In the pelvis, they receive additional branches from the hypogastric artery, vasal artery, and vesical arteries. The abdominal portion of the ureter has a medial vascular supply, whereas the pelvic part receives its blood vessels from the lateral side. This should be taken into consideration during partial mobilization of the ureter to preserve as much of the blood supply as possible. Venous and Lymphatic Drainage

Venous and lymph drainage of the ureters follow the arterial blood supply. Nerve Supply

The ureteric muscle fibers contain a-adrenergic (excitatory)and p-adrenergic (inhibitory) receptors, but peristaltic contractions occur in denervated ureters and can be altered by sympathomimetic or sympatholytic medications, which indicates that the role of nerve supply to the ureter is to modulate peristaltic activity rather than to initiate it. SURGICAL APPLICATIONS Approaches to the Kidney and Ureter

The kidneys can be approached though various incisions, such as lumbar, anterior transperitoneal, thoracoabdominal, and posterior lumbar incisions.

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Many factors should be taken into consideration before selecting an incision, such as the type of operation to be performed, abnormality in the kidney, body habitus, and pulmonary or spinal deformities. The most important factor is the type of operation to be performed. Surgery for benign kidney disease, such as simple nephrectomy, partial nephrectomy, deroofing of a renal cyst, or stone extraction, can be performed through an extraperitoneal flank incision. This approach offers the advantages of being extraperitoneal with a shorter period of ileus, and in obese patients, most of the panniculus falls away from the kidney. Exposure of the renal pedicle with lateral lumbar approaches is not as good as an anterior approach, however, because extensive dissection and mobilization of the kidney is frequently required before these vessels are clearly identified. It also produces the risk of entering the pleural cavity, particularly if a supracostal incision is performed. This incision can be performed above the 12th or 11th ribs, in an extrapleural or intrapleural manner, to expose the suprarenal gland or the upper pole of the kidney, and can also be extended downward to expose the ureter. If good exposure of the renal vessels is desired, especially for vascular procedures or surgery for advanced tumors, an anterior transperitoneal approach is the incision of choice. It can be performed through an anterior subcostal, midline, or paramedian incision. The midline incision is the fastest to perform and close, but the incidence of incisional hernia is higher with this incision than with a paramedian incision. Posterior lumbar approaches are easy to perform and are easier on patients, but the exposure is limited, especially with respect to renal vessels, but good access is provided to the renal pelvis and upper third of the ureter for stone surgery. This approach is not recommended, however, when dealing with malignancy. Lumbar Approaches Subcostal Approach

Position. After the induction of general anesthesia and endotracheal intubation, the patient is positioned on the side on the operating table so that the center of the kidney rest or the table brake is just below the tip of the 12th rib. The kidney rest is elevated and the table is flexed to place tension on the incision site. Both arms should be supported in a horizontal position on well-padded arm rests to avoid pressure injuries to the vessels and nerves. A soft pad or a wrapped towel should be placed under the lower axilla to support the weight of the body away from the axillary vessels and nerves. The lower knee and hip are flexed, whereas the upper limb is fully extended with a soft pillow between both knees. Prophylaxis against deep venous thrombosis, such as pressure stocking or pneumatic compression devices, should be considered if the surgery is expected to be lengthy. Adhesive tape (3 in) can be applied to the upper shoulder and thigh to secure position (Fig. 5). Incision. Skin incision starts one finger breadth below the distal half of the 12th rib and is carried over the flank toward the umbilicus, where it can be extended as far as the opposite rectus abdominis muscle. The incision is deepfened through the subcutaneous fat to the first fascia1 layer, which is incised to expose the external oblique muscle anteriorly and the latissimus dorsi muscle posteriorly. These muscles are sharply divided to expose the fibers of the internal oblique muscle anteriorly and serratus posterior, which is sometimes seen below the latissimus dorsi muscle. These muscles are incised sharply in the line of the wound to expose the transversus abdominis muscle (Fig. 6).

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Figure 5. After the induction of general anesthesia and endotracheal intubation, the patient is positioned on the side on the operating table. (From El-Galley RES, Keane TE: Kidney, ureters, and bladder. In Wood WC, SkandalakisJE (eds): Anatomic Basis of Tumor Surgery. Milwaukee, Quality Medical Publishing, 1999, p 835; with permission.)

The subcostal nerve runs between the internal oblique and the transversus abdominis muscles, and caution should be used during incision of the internal oblique to identdy the nerve, dissect it free, and retract it away. Injury to this nerve might lead to numbness in a small area of the skin in the suprapubic region and weakness of the lower segment of the ipsilateral rectus abdominis muscle. The transversalis (thoracolumbar) fascia in the depth of the w o u n d i s sharply incised to allow entrance i n t o the retroperitoneal space. A finger is passed in this space, and the peritoneum is dissected medially, away f r o m the

Figure 6. Incision: lumbar approach. M = muscle; n = nerve. (FromEl-Galley RES, Keane TE: Kidney, ureters, and bladder. In Wood WC, Skandalakis JE (eds): Anatomic Basis of Tumor Surgery. Milwaukee, Quality Medical Publishing, 1999, p 836; with permission.)

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undersurface of the transversus abdominis muscle. The fibers of the transversus abdominis muscle can then be separated or incised to expose Gerota’s fascia covering the perirenal fat. Transcostal Approach

The transcostal approach can be performed through the loth, Ilth, or 12th ribs, but the lugher the level, the more the risk for pleural injury. The patient position is the same as for a subcostal incision. The rib chosen for the incision is palpated and may be marked before incising the skin. The periosteum is incised for the whole length of the rib. Then a periosteal elevator is used to strip the periosteum of the rib on the outer surface, followed by the upper and lower borders. This removes the attachments of the abdominal and intercostal muscles from the rib. Caution should be used not to injure the intercostal vessels when dissecting the lower edge of the rib. A Doyen rib elevator is passed between the posterior surface of the rib and the periosteum and is moved backward and forward to free the rib from its attachments. A rib cutter is used to cut the rib posteriorly as far as the dissection allows. The muscular slips of the corresponding crus of the diaphragm will still be attached to the periosteum. This is to be sharply incised, and the tranversalis fascia is dissected to expose Gerota’s fascia. Supracostal Approach

Instead of removal of the rib as in the transcostal approach, the supracostal incision provides a good exposure to the suprarenal gland and the upper pole of the kidney without the need for rib excision. The intercostal muscles can be freed from the upper border of the rib with electrocautery. Caution should be used while dissecting the intercostal muscles to avoid pleural injury or damage to the more cephalad intercostal vessels and nerve. The sacrospinalis muscle will be covering the intercostal muscle in the posterior part of the wound. It should be mobilized or divided to enable complete dissection of the intercostals. The costovertebral ligament should be divided to allow a hingelike movement of the rib during retraction, without breaking it. The diaphragmatic fibers attached to the posterior part of the periosteum should be divided, and the pleura is mobilized superiorly. Downward Extension of Lumbar Incisions

Lateral lumbar incisions, subcostal and transcostal, can be extended downward to the suprapubic region. This is particularly useful for exposure of the ureter and kidney, such as for nephroureterectomy using the same incision, but t h s approach is difficult in obese patients, and two separate incisions may be needed. The skin is cut in a gentle curve toward the lateral border of the rectus abdominis muscle, and the incision is carried to the pubis. Caution should be used not to extend the incision parallel to the latter border of the rectus sheath to avoid denervation of the rectus muscle. The abdominal wall muscles are cut in the direction of the wound, and the extraperitoneal space is entered in the same way as mentioned previously. The transversalis fascia is incised, and blunt dissection is used to mobilize the retroperitoneal fat and display the ureter. Thoracoabdominal Approach

Thoracoabdominal incision offers a good exposure of the kidney and adrenal gland in cases of upper pole kidney tumors, suprarenal tumors, or large

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renal tumors in a highly positioned kidney. The morbidity rate of this incision is higher than that of other approaches because of opening the pleural cavity and needing a chest tube in the postoperative period. Position

The patient is placed in a semioblique position with the involved flank elevated with rolled towels or sand bags to 30" to 45". The operating table is extended to put the abdominal wall muscles under stretch. A soft pillow or an intravenous pyelogram bag is placed under the contralateral axilla, and the arms are supported on arm rests. Incision

The incision is started at the angle of the 9th, loth, or 11th rib and continued downward and anteriorly toward the midpoint of the ipsilateral rectus muscle. It can be extended to the contralateral rectus muscle, if needed. The muscles are divided as mentioned earlier, and the costovertebral ligament is freed. The pleura is usually opened during dissection of the intercostal muscles, which is completed to expose the thoracic surface of the diaphragm. Caution should be used to avoid injuring the lung. With two fingers inserted under the diaphragm anteriorly, blunt dissection is carried out to separate the abdominal surface of the diaphragm from the upper surface of the liver on the right and the spleen on the left. The diaphragm is divided from its thoracic surface, with caution used to avoid injuring the phrenic nerve. The internal oblique and transversus abdominis muscles, which pass medial to the ribs, are also divided. If the procedure is to be performed extraperitoneally, the peritoneum is mobilized medially and is freed from the undersurface of the diaphragm, transversalis fascia, and anterior rectus fascia. This allows the liver on the right side and the spleen and pancreas on the left side to be moved medially, away from the dissection (Fig. 7).

Figure 7. Incision: thoracoabdominal approach. (From El-Galley RES, Keane TE: Kidney, ureters, and bladder. In Wood WC, Skandalakis J E (eds):Anatomic Basis of Tumor Surgery. Milwaukee, Quality Medical Publishing, 1999, p 840; with permission.)

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Anterior Subcostal Incision

This incision provides a good exposure of the adrenal gland and the upper pole of the kidney, in addition to an adequate access to other upper abdominal organs, such as the liver on the right and the spleen and pancreas on the left. The bilateral subcostal incision (i.e., the chevron incision) is an excellent approach in cases in which simultaneous exposure of both kidneys or adrenal glands is required. Position

The patient is placed in supine position with a rolled sheet or sand bags under the ipsilateral flank, shoulder, and pelvis. The table is flexed to approximately 20" to put the abdominal wall muscles in stretch. If bilateral incision is planned, the patient is placed in the supine position, with a rolled sheet beneath the upper lumbar spine, and the table is flexed. Incision

Skin incision starts at the midaxillary line at the tip of the 12th rib and is carried medially in a gentle curve approximately 2.5 cm below the costal margin. It is usually ended at the lateral border of the rectus muscle but can be extended to the midline or the contralateral side, as required. The incision is deepened through the subcutaneous fat and fascia, then the external oblique muscle and anterior rectus sheath are incised. Electrocautery is used to cut the rectus abdominis, internal oblique, and transversus abdominis muscles. Caution should be used to identify and ligate the branches of the superficial epigastric artery, which lies on the posterior rectus sheath. The posterior rectus sheath, transversalis fascia, and peritoneum are picked in layers between two hemostats and are incised with the knife carefully to avoid injuring the abdominal structures. The opening is widened, and the surgeon's finger is admitted to palpate for adhesive structures to the abdominal wall, and the peritoneal cavity is opened to the full length of the incision. OPERATIONS FOR KIDNEY TUMORS Radical Nephrectomy

Renal cell carcinoma is a relatively rare tumor, accounting for approximately 3% of adult malignancies, but it is the most common tumor of the kidney and is the third most common tumor seen by urologists. The classic symptom triad of pain, hematuria, and flank pain is certainly a reliable clinical symptom complex, but most of these tumors are diagnosed at earlier stages and are commonly found on incidental radiologic investigations performed for other reasons. Indications

Renal cell carcinoma is refractory to most traditional oncologic treatment strategies, including chemotherapy, radiation, and hormonal therapy, so radical nephrectomy, that is, removing all of the contents of Gerota's fascia, is considered the standard treatment for localized tumors.z, Data indicate, however, that in

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carefully selected patients, partial nephrectomy may be an option. The role of radical nephrectomy in patients with metastatic disease is controversial, and it is not indicated unless a patient has intractable bleeding or pain, or requires debulking for immunotherapy or other systemic therapie~.~ Local extension into the renal vein or inferior vena cava is not considered a contraindication to radical nephrectomy, but tumor extension beyond Gerota’s fascia to involve other organs is associated with poor prognosis, and nephrectomy should be considered only for palliative reasons or as a part of an adjuvant therapy protoc~l.~, 12, l5 Preoperative Evaluation

The diagnosis of renal cell carcinoma is generally made by CT scanning showing a solid mass in the parenchyma of the kidney. Less than 5% of all renal cell carcinomas are cystic in appearance, with septations, irregular borders, dystrophic calcification, or other features that distinguish it from a simple renal cyst. The differential diagnosis of solid kidney masses includes oncocytoma (i.e., granular oncocytes on histology with a central scar in the tumor), angiomyolipoma (i.e., contains fat on CT), xanthogranulomatous pyelonephritis (usually in diabetics with a concurrent stone in a poorly functioning kidney), fibromas, or metastasis. Despite the diagnostic clues given by radiologic investigation, the histologic nature of these masses cannot be confirmed without tissue biopsy, which is generally contraindicated in these cases because of the risk for seeding malignant cells through the needle track or of obtaining benign tissue that approximates a malignant area. Accordingly, most of these patients require radical nephrectomy before the kidney abnormality is finally diagnosed. MR imaging is superior to CT scanning in determining the superior extent of a vena caval thrombus, but the new generation of CT scanners with rapid image acquisition are as accurate as MR imaging in vena caval imaging. These new imaging techniques have replaced, to a large extent, venocavography and arteriography, which are more invasive. Chest radiography, chest CT, or both are routinely done to rule out pulmonary metastasis, whereas bone scans are performed only if clinical evaluation suggests bone metastasis. Procedure

When the peritoneum has been entered, the intra-abdominal contents, mainly the liver, are inspected for unrecognized metastasis, and the tumor is carefully examined for resectability. Then the diaphragm is retracted superiorly with a self-retaining retractor, and counter traction is applied to the superior border of the rib below after releasing the costochondral ligament. The renal pedicle can be approached ventrally by retracting the ascending colon and dividing the lateral paracolic peritoneum. The hepatic flexure and duodenum (on the right side) or descending colon (on the left side) are mobilized medially to expose the renal pedicle with the renal veins lying in front of the artery. An alternative is the dorsal approach to the renal pedicle, where the renal artery is readily accessible for ligation and division. Early ligation of the renal artery significantly reduces potential blood loss. It can be performed by dissecting the kidney and surrounding tissues free from the posterior abdominal wall and rotating it medially, and then the renal artery can be identified, ligated, and divided. The ureter, gonadal vessels, and periureteral fat are dissected free of the

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posterior peritoneum and divided into two or three separate bundles. The dissection is then carried superiorly. Superior to the renal vessels, the peritoneum fans out laterally, and the dissection is carried out to the lateral border of the peritoneum. In most larger tumors and some smaller tumors, the peritoneum cannot be dissected free of Gerota’s fascia, such that the surgeon is forced to remove a window of peritoneum with the specimen. Caution should be used to avoid injury to the bowel, especially the duodenum (Fig. 8). The superior portion of the specimen, including the adrenal gland, should be dissected free of the retroperitoneum. Because branches of the phrenic and other vessels may be present at this point, the authors generally use a series of large hemoclips, dividing the tissue below the clips to enhance hemostasis. The specimen should be free at this point, except for the venous structures. The adrenal vein is a short and easily avulsed vein. It should be identified and ligated carefully. The renal vein should be collapsed because the renal artery is divided. If the renal vein is still full, beware of branch arteries that may still be perfusing the specimen. The vein should be palpated for possible unsuspected thrombi, divided, and ligated. The specimen is then removed, and the wound is closed without drain in most cases. Recent evidence suggests that when dealing with lower pole tumors, adrenalectomy is commonly unnecessary.11

Management of Tumor Extension in the Vena Cava The presence of a solid mass in the vena cava might represent tumor extension into the lumen; blood thrombus; or, less commonly, tumor invasion of the vena caval wall. Tumor extension into the vena cava occurs in 4% to 10% of cases, and tumor-free survival equivalent to survival for stage 2 disease is achieved by complete removal of this extension in patients without lymph node

Figure 8. Procedure: radical nephrectomy. Injury to the bowel, especially the duodenum, should be avoided. (From El-Galley RES, Keane TE: Kidney, ureters, and bladder. In Wood WC, Skandalakis JE (eds):Anatomic Basis of Tumor Surgery. Milwaukee, Quality Medical Publishing, 1999, p 845; with permission.)

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involvement. Exploration of the vena cava is a major procedure, and a complete set of vascular instruments should be available. The extent of the tumor extension into the vena cava should be delineated preoperatively because this will help in planning the surgical approach. Patients with right-sided renal tumors and limited vena caval extension can be approached with a right flank incision. A thoracoabdominal incision is used for high, right-sided tumor extension, whereas a midline incision with a median sternotomy extension is commonly required for patients with left renal tumors and vena caval extension to a level of the hepatic veins or above (Fig. 9). Exposure of the retrohepatic vena cava is started with division of the right triangular and coronary ligaments of the liver and ligation of the small hepatic (i.e., caudate) veins. The liver is then mobilized medially to expose the vena cava, and a cardiac tourniquet is applied around the vessel for temporary occlusion. The contralateral renal vein and the infrarenal vena cava are also occluded with a Rumel tourniquet. Because approximately one fourth of the venous return in the vena cava comes from the liver, clamping the porta hepatis through the foramen of Winslow with a noncrushing vascular clamp reduces the blood loss remarkably. A cavotomy is made adjacent to the hepatic veins and extended inferiorly to the origin of the affected renal vein. A 20 F Foley catheter with a 30-mL balloon is introduced into the vena cava, and the balloon is inflated above the level of the thrombus and is withdrawn gently to extract the thrombus out of the vena cava. Commonly, the tumor prolapses through the cavotomy and can be extracted with a suitable forceps. The use of transesophageal sonography can facilitate removal of the thrombus by confirming its entire removal. Rarely, when the tumor invades to the wall of the vein, partial or complete resection of the vein is considered.

Figure 9. Management of tumor extension in the vena cava. A thoracoabdominal incision is used for high, right-sided tumor extension, whereas a midline incision with a median sternotomy extension frequently is required for patients with left renal tumors and vena caval extension to a level of the hepatic veins or above. (From El-Galley RES, Keane TE: Kidney, ureters, and bladder. ln Wood WC, Skandalakis JE (eds):Anatomic Basis of Tumor Surgely. Milwaukee, Quality Medical Publishing, 1999, p 848; with permission.)

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Air should be evacuated from the vena cava before closure. A Satinsky clamp is applied to the cavotomy, and the edges of the vena cava are approximated gently with Allis clamps. The tourniquet on the contralateral renal vein and infrarenal vena cava and the clamp on the porta hepatis are released; the tourniquet on the suprahepatic vena cava is left in place. The Satinsky clamp is briefly vented to allow the air in the vena cava to be evacuated, and the clamp is closed again and the last tourniquet on the vein is released. The affected renal vein is transected flush with the vena cava. The entire cavotomy is then closed with a continuous 5-0 polypropylene suture. Lymph Nodes

The prognosis of renal cell carcinoma is mostly determined by presence or absence of nodal metastasis. Because of the position of the kidney just inferior to the cisterna chyli, tumor spread from the renal lymphatics to the cisterna chyli and widespread dissemination of the disease is common, so curative lymphadenectomy is impossible in most cases, and the value of lymphadenectomy is limited to the diagnosis of lymph node involvement.' A limited dissection of the tissue around the junction of the renal vessel to the nearest great vessel and resection of the visible or palpable nodes are usually sufficient. Nephroureterectomy

Most patients with transitional cell carcinoma of the calyces, pelvis, or ureter are treated with nephroureterectomy, provided that the contralateral collecting system is normal and no evidence of distant metastasis exists. Preoperative evaluation should include cystoscopy and bilateral retrograde pyelography for better evaluation of the collecting system. The operation can be performed through a flank incision with downward extension or, alternatively, two separate incisions or a midline incision can be used. The technique of nephrectomy is the same. The ureter is mobilized with blunt and sharp dissection down to its insertion in the bladder. A cuff of the bladder must be removed with the lower ureter because this is the most common site for tumor recurrence after nephroureterectomy. The bladder is then closed in two layers with 2-0 chromic catgut sutures. A Foley catheter is left in the bladder for drainage, and a drain is left in the pelvis next to the suture line. Partial Nephrectomy

Patients who develop renal cell carcinoma in a solitary functioning kidney or who have bilateral tumors are best treated with partial nephre~tomy.~, 6 , 8 Full preoperative evaluation should be carried out to confirm the localized nature of the disease. The arterial anatomy of the affected kidney should be carefully studied with preoperative conventional or MR angiography. Flank incisions through the bed of the 11th or 12th ribs, attempting to stay extrapleural and extraperitoneal, provide an excellent exposure of the peripheral renal vessels. Temporary occlusion of the renal artery and surface cooling of the kidney with iced slush during the procedure allow 30 minutes of operating time without significant ischemic injury to the kidney. In longer procedures, the kidney should be perfused with cold Collins solution through an arterial catheter, which allows for 3-hour operations, but small polar or peripheral renal

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tumors may not require renal artery occlusion, and the segmental artery can be identified and divided instead. Simple enucleation for malignant lesions should be avoided, even if the tumor looks well defined, because of the probable presence of microscopic extensions of these tumors beyond the pseudocapsule. Tumors of the upper or lower pole of the kidney are best resected by polar nephrectomy (i.e., guillotine resection), whereas midrenal tumors are resected with wedge resection. After mobilization of the kidney, the renal artery and vein are dissected free from the surrounding structures. Dissection of the branches of the renal artery delineates the segmental artery of the affected pole of the kidney, which is ligated and divided. In many cases, a corresponding venous branch is present and is similarly ligated and divided. The kidney is inspected for the ischemic line of demarcation, which outlines the segment of the kidney to be excised. If this area is not obvious, injection of a few milliliters of methylene blue in the distal part of the apical artery provides a better outline of the area to be resected. This segment of the kidney and the covering Gerota’s fascia are then excised by sharp and blunt dissection. Surgeons should ensure that the incision is at least 1 cm or 2 cm away from the visible edge of the tumor. The collecting system, if opened, is then closed with interrupted or continuous 4-0 chromic catgut to ensure a water-tight closure. Small vessels are identified and controlled with figure of eight P O chromic or other absorbable sutures. The edges of the kidney are then approximated with 2-0 sutures passing through the capsule and superficial parenchyma, with some perirenal fat applied to the edge of the kidney, and the sutures are tied on top of it. A drain is commonly placed in the perirenal space, especially if the collecting system is opened. A double-J stent is also commonly placed (Fig. 10). OPERATIONS FOR URETERIC TUMORS

Total ureterectomy is most commonly performed in combination with nephrectomy for the treatment of renal pelvic or ureteric neoplasms, but localized

Figure 10. Partial nephrectomy. (From El-Galley RES, Keane TE: Kidney, ureters, and bladder. In Wood WC, Skandalakis JE (eds): Anatomic Basis of Tumor Surgery. Milwaukee, Quality Medical Publishing, 1999, p 851; with permission.)

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solitary tumors of the ureter can be treated with partial ureterectomy. Transitional cell carcinoma accounts for more than 95% of ureteric tumors. Surgeons should be aware that this tumor is commonly multicentric, and careful search for other tumors in the urinary tract should be considered in every case before the diagnosis of solitary ureteric tumor is made. Squamous cell carcinoma, adenocarcinoma, and sarcoma account for less than 5% of ureteric tumors. Preoperative Evaluation

Gross hematuria is the most common presenting symptom of ureteric tumors. Most patients present with hematuria throughout urination and passage of vermiform clots. Gradual ureteric obstruction by tumor may lead to dull flank pain in approximately one third of patients, but the passage of blood clots might cause severe ureteric colic, and caution should be used not to summarily diagnose these patients with stone disease, especially if they have a history of bladder urothelial tumors. Most ureteric tumors present as a filling defect on excretory urography. Other causes of filling defects are blood clot; air bubble; radiolucent stone; sloughed renal papilla; and, less commonly, fibroepithelial polyp, fungus ball, granuloma, leukoplakia, and hemangioma. Cystoscopy should be performed on all patients with ureteric tumors to rule out the presence of bladder tumors. In approximately 40% of patients, bladder tumors develop. Retrograde urography provides better visualization of the upper urinary tracts and can be performed in patients with deteriorated renal function. Urine should be collected for cytology after radiography is performed. Physicians should use a nonionic contrast material to avoid the cytology artifact, which results from cell dehydration when hyperosmolar contrast materials are used. In some cases, ureteroscopy and brush biopsies are necessary to establish the diagnosis. Computed tomography is a useful imaging study for diagnosis and staging, but small tumors can be missed because of volume averaging. Ureteric stones are opaque on CT scanning and can be easily differentiated from tumors. Abdominal CT, chest radiography, bone scan, and liver function tests should be considered to rule out metastasis. Endoscopic Treatment of Ureteric Tumors

Over the past decade, because of advances in ureteroscopic instrumentation, ureteroscopy and laser ablation of ureteric tumors has been described as an alternative to open surgery. Tumors should be solitary, superficial, and accessible with the ureteroscope. Few reports on the long-term results of this treatment have been published, with recurrence rates of approximately 25%. Complications include ureteric perforation, extravasation, and stricture formation. Partial Ureterectomy Indications

Conservative treatment for localized ureteric tumors is especially indicated in patients with solitary kidney, a functionally dominant kidney, or bilateral tumors. Upper and middle ureteric tumors should be treated with segmental

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resection if they are solitary and low grade and with nephroureterectomy if they are multifocal or high grade. Distal ureteric tumors should be treated by distal ureterectomy and removal of a cuff of tissue from the bladder around the ureteric orifice. Approaches Surgical approaches to the ureter depend on the part of the ureter to be operated on. Upper tumors can be accessed with a subcostal flank incision. Middle tumors can be removed through a muscle-splitting incision in the appropriate position. Lower tumors can be approached through a lower midline, paramedian, or "hockey-stick" incision. The decision to go transperitoneal versus extraperitoneal depends on whether exploration of the abdominal viscera is necessary and on the type of urinary reconstruction planned. Technique Extraperitoneal exposure of the ureter is achieved by incising the abdominal muscles and the transversalis fascia. Physicians should enter the plane between the transversalis fascia and the parietal peritoneum. The peritoneum is mobilized medially with blunt dissection, and the ureter should be looked for in the retroperitoneal space. In some cases, the ureter is mobilized with the parietal peritoneum and can be palpated as a cordlike structure on the peritoneum surface. The femoral nerve and the tendon of the psoas minor muscle, if present, can be palpated as a cordlike structure in the pelvis and can be confused with the lower third of the ureter. Careful observation for peristaltic activity is helpful in these situations. The ureter enters the pelvis medial to the sacroiliac joint and in front of the bifurcation of the common iliac artery. This anatomic landmark may prove helpful in identifying the ureter more readily. A chronically obstructed ureter can be dilated and sufficiently hypertrophed to be confused with the colon, but it lacks the tinea coli and appendices epiploica that characterize the colon. When the ureter has been identified and the tumor is palpated, a decision about how long a segment should be removed is made. The ureter is then closed with noncrushing vascular clamps proximal and distal to this segment to avoid spillage of tumor cells. This segment is then excised. Primary anastomosis of the ureter should be considered only if the segment removed is sufficiently short to allow ureteric anastomosis without tension on the suture line. Both ends of the ureter should be spatulated to prevent anastomotic strictures. An absorbable interrupted suture ( e g , 4-0 Vicryl) should be used. If the resection was limited to the lower third of the ureter, ureteric reimplantation into the bladder with or without a psoas hitch and Boari flap should be attempted. In some situations, the segment removed precludes reimplantation. In these circumstances, the ureter can be mobilized proximally and anastomosed to a suitable length of mobilized ileum, which is then reimplanted into the bladder. Whenever the ureter is incised, a stent should be left in situ to allow the anastomosis to heal. Investigators recommend leaving a drain near the anastomotic site. Whenever mobilization of the ureter is performed, consideration must be given to its blood supply and the alternating directions from which it is derived, depending on which area of the ureter is involved.

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References 1. Ditonno P, Traficante A, Battaglia M, et al: Role of lymphadenectomy in renal cell carcinoma. Prog Clin Biol Res 378:169-174, 1992 2. Giuliani L, Giberti C, Martorana G, et al: Radical extensive surgery for renal cell carcinoma: Long-term results and prognostic factors. J Urol 143:468473, 1990 3. Giuliani L, Martorana G, Giberti C, et al: Results of radical nephrectomy with extensive lvmuhadenectomv for renal cell carcinoma. T Urol 130:664468. 1983 4. Graham SD Jr, Glenn JF: Enucleative surgery for renal malignancy. J Urol 122:546551 1979 5. Herr HW Partial nephrectomy for incidental renal cell carcinoma. Br J Urol 74:431433, 1994 6. Keane TE, Graham SD Jr: Conservative renal surgery: Has it a role in renal cell carcinoma? Surg Oncol Clin North Am 4:295-306, 1995 7. Neves RJ, Zincke H, Taylor WF: Metastatic renal cell cancer and radical nephrectomy: Identification of prognostic factors and patient survival. J Urol 139:1173-1176, 1988 8. Novick AC, Streem S, Montie JE: Conservative surgery for renal cell carcinoma: A single center experience with 100 patients. J Urol 141335, 1989 9. Ramon J, Goldwasser B, Raviv G, et al: Long-term results of simple and radical nephrectomy for renal cell carcinoma. Cancer 672506-2511, 1991 10. Resnick MI, Pounds DM, Boyce WH: Surgical anatomy of the human kidney and its applications. Urology 17:367, 1981 11. Robey EL, Schellhammer PF: The adrenal gland and renal cell carcinoma: Is ipsilateral adrenalectomy a necessary component of radical nephrectomy. J Urol 135:453-455,1986 12. Robson CJ: Radical nephrectomy for renal cell carcinoma. J Urol 89:37, 1963 13. Sampaio FJ, Aragao AH: Anatomical relationship between the intrarenal arteries and the kidney collecting system. J Urol 143:679, 1990 14. Tanagho EA: Anatomy of the lower urinary tract. In Walsh PC, Retik AB, Stomey TA, et a1 (eds): Campbell's Urology. Philadelphia, WB Saunders, 1992, pp 40-69 15. Wishnow KI, Lorigan J, Charnsangavej CJ: Results of radical nephrectomy for peripheral well-circumscribed renal cell carcinoma. Urology 34:171-174, 1989 J

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Address reprint requests to Thomas E. Keane, MB BCh, FRCS(1) Emory Clinic 1365 Clifton Road Atlanta, GA 30322