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Laparoscopic nephrectomy for autotransplantation
CASE REPORT
LAPAROSCOPIC NEPHRECTOMY FOR AUTOTRANSPLANTATION MICHAEL D. FABRIZIO, LOUIS R. KAVOUSSI, STEPHEN JACKMAN, DAVID Y. CHAN, ELAINE TSENG, AND LLOYD E. RATNER
ABSTRACT Proximal ureteral injuries often require extensive reconstruction to repair. Management options include nephrectomy, ileal ureter interposition, extensive spiral bladder flaps, or autotransplantation. We report a patient who sustained a proximal ureteral avulsion and underwent a less invasive repair by way of a laparoscopic nephrectomy and subsequent autotransplantation. UROLOGY 55: 145iii–145vi, 2000. © 2000, Elsevier Science Inc.
D
uring the past several years, an increasing number of iatrogenic ureteral injuries have been seen as a direct result of endoscopic urologic procedures.1– 4 Minor complications such as ureteral perforation are quite common.4 Fortunately, severe complications such as ureteral avulsion are a rare entity. Classically, an iatrogenic proximal ureteral avulsion is managed by either nephrectomy, ileal ureter interposition, autotransplantation, or rarely transureteroureterostomy.5–10 These procedures routinely require an extensive operation and a prolonged period of convalescence. Laparoscopy now gives the urologist a minimally invasive approach for a variety of urologic conditions once performed in an open fashion. In this report, we present a patient who sustained a proximal ureteral avulsion that occurred during ureteroscopy for a midureteral stone and who subsequently underwent laparoscopic nephrectomy with successful autotransplantation. CASE REPORT A 41-year-old man was transferred to our institution after sustaining a proximal ureteral avulsion during ureteroscopy. The patient had presented From the Johns Hopkins Medical Institute, James Buchanan Brady Urological Institute, Baltimore, Maryland and Division of Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, Maryland Address for correspondence: Michael D. Fabrizio, M.D., Devine Tidewater Urology, Eastern Virginia Medical School, 400 West Brambleton Avenue, Suite 100, Norfolk, VA 23510 Submitted: May 18, 1999, accepted (with revisions): July 21, 1999 © 2000, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
with a 1-cm left ureteral stone located just above the pelvic brim. The injury occurred while removing fragments with a 3F flat-wire basket and flexible ureteroscope. A segment of ureter was seen on the ureteroscope on removal, and cystoscopy revealed perivesical fat at the level of the left ureteral orifice. A double pigtail ureteral stent was placed over the safety wire and a Foley catheter was placed for drainage. The patient was transferred to our institution where he underwent computed tomographyguided percutaneous nephrostomy tube placement into the lower pole of the left kidney. An antegrade nephrostogram revealed a proximal ureteral injury consistent with an avulsion 5 cm below the ureteral pelvic junction (Fig. 1). A cystogram revealed an extraperitoneal injury (Fig. 2). Cystoscopy was performed with minimal irrigation, and the ureteral stent was found within the urinary bladder. The distal segment of nonviable ureter (10 cm) was intussuscepted into the urinary bladder. A 24F Foley catheter was left for gravity drainage, and broad-spectrum antibiotic prophylaxis was continued. The patient was 6 ft. 2 in. tall and weighed 147 kg, with normal renal function (creatinine 1.0 mg/ dL) and negative urine culture. A MAG-3 renal scan revealed a functioning left kidney, with a differential renal function of 70% in the right kidney and 30% in the left kidney. Preoperative obstruction was thought to have contributed to the impaired left renal function. The patient’s options were presented to him and included nephrectomy, autotransplantation, and ileal ureter interposition. The patient wished to 0090-4295/00/$20.00 PII S0090-4295(99)00367-2 145iii
FIGURE 2. Cystogram revealing extraperitoneal extravasation.
FIGURE 1. Antegrade nephrostogram consistent with ureteral avulsion.
preserve his kidney and, after preoperative counseling, underwent laparoscopic transabdominal nephrectomy using the four-port technique11 and subsequent autotransplantation. The patient’s kidney was harvested through a 6-cm periumbilical incision that was closed in standard fashion. The renal artery had an early bifurcation, which could not be preserved after division with the Endovascular GIA (U.S. Surgical, Norwalk, Conn), thus creating two renal arteries. The renal vein was 5 cm in length. There was 6 cm of ureter remaining with the kidney. The two renal arteries were anastomosed in a side-to-side fashion, creating a single common orifice. Before implanting the kidney using a standard extraperitoneal (Gibson) approach, the bladder was opened using an anterior cystot145iv
omy employing the same incision. The intussuscepted ureteral segment was excised, and the posterior bladder defect was closed. The anterior cystotomy was closed in three layers. The renal artery and vein were anastomosed to the external iliac artery and vein, respectively. The ureter was implanted using a Lich-Gregoir extravesical technique and stented. On postoperative day 1, a MAG-3 scan confirmed good blood flow and function in the transplanted kidney. The patient was discharged on the morning of postoperative day 4. On postoperative day 7, the patient returned for a cystogram, which revealed vesicoureteral reflux and no evidence of leak (at 250 mL). There was no extravasation from his ureterovesical anastomosis, and postevacuation films revealed complete drainage of his transplanted kidney and urinary bladder (Fig. 3). He did not require any narcotic analgesics after discharge. He returned to full activity 2 weeks postoperatively. One month postoperatively, a MAG-3 scan revealed improved function compared with the preoperative study and no obstruction. COMMENT With the evolution of surgical techniques, ureteral injuries can occur during a variety of endoUROLOGY 55 (1), 2000
FIGURE 3. Postoperative cystogram with no extravasation and bilateral vesicoureteral reflux.
scopic procedures, including ureteroscopy and laparoscopy. Since 1990, an increasing number of ureteral injuries have occurred as a result of ureteroscopy. Fortunately, severe injuries such as ureteral avulsion are rare, occurring in less than 0.5% of all cases.1– 4 Although ureteral injuries can occur throughout the entire length of ureter, more severe injuries are associated with the proximal ureter, which has less muscular support and fewer mucosal cell layers than the distal or intramural ureter.1,12 Numerous studies have advocated prompt surgical repair for these ureteral injuries, as a delay in diagnosis and reconstruction leads to increased complications.2,3 Proximal ureteral avulsion can be managed using several techniques.5–10 Percutaneous nephrostomy tube placement allows the patient to be temporarily stabilized. Nephrectomy has been advocated in patients with poor renal function. Renal-sparing procedures in the setting of a severe injury are usually extensive, since most ureteral avulsions cannot be managed with ureteroureterostomy. An ileal ureter interposition is certainly an alternative for large segmental defects in the proximal ureter; however, there are several disadvantages, including recurrent urinary tract infection, stone formation, and electrolyte imbalances.7,13 Although extensive reconstructive techniques such as extended spiral bladder flaps can be used for proximal ureteral injuries,8 these are somewhat difficult in larger patients. Transureteroureterostomy is an option with proximal ureteral defects. However, it does require a sizable segment of viable ureter to cross the midline and is relatively contraindicated in patients with recurrent stone formation.1 Renal autotransplantation has been shown to be a very effective method in the treatment of multiple UROLOGY 55 (1), 2000
urologic conditions. Novick et al.5 reported on the use of renal autotransplantation for a variety of conditions in 22 patients. Historically, harvest of the kidney required an extensive operation through a flank or transabdominal route, exposing the patient to significant postoperative morbidity and recovery. More recently, laparoscopy has been shown to be an effective technique for harvesting donor kidneys. Ratner et al.14 reported the first human laparoscopic live donor nephrectomy in 1995. This operation has been shown to markedly decrease the length of hospital stay and perioperative analgesic requirement and to actually increase the incentive for donation.15 It has also resulted in an earlier return to work and daily activities. Our patient underwent a laparoscopic nephrectomy using three 10-mm trocars and a 2-mm trocar to elevate and retract the spleen. The kidney was harvested through a separate transabdominal incision to maintain a completely retroperitoneal approach during renal transplantation. The patient had an uneventful autotransplantation and postoperative recovery. On the basis of the patient’s overall narcotic use during the postoperative period and lack of analgesic use at home, it is likely that this minimally invasive approach allowed him to recover in a prompt fashion. We believe this approach allowed the patient to return to the activities of daily living in a significantly shorter time. CONCLUSIONS As a result of the increase in ureteroscopic procedures, iatrogenic ureteral injuries are more common. Autotransplantation is an attractive option in the treatment of severe proximal ureteral injuries. This case report illustrates how a historically extensive operation can be approached in a less invasive fashion. Laparoscopic donor nephrectomy has improved the perioperative and postoperative recovery for potential kidney donors. This technique can be successfully applied to other urologic procedures such as autotransplantation. REFERENCES 1. Assimos DG, Patterson LC, and Taylor CL: Changing incidence and etiology of iatrogenic ureteral injuries. J Urol 152: 2240 –2246, 1994. 2. Dowling RA, Corriere JN Jr, and Sandler CM: Iatrogenic ureteral injury. J Urol 135: 912–915, 1986. 3. Lask D, Abarbanel J, Luttwak Z, et al: Changing trends in the management of iatrogenic ureteral injuries. J Urol 154: 1693–1695, 1995. 4. Huffman J: Ureteroscopic injuries in the upper tract. Urol Clin North Am 16: 249 –255, 1989. 5. Novick AC, Stewart BH, and Straffon RA: Extracorporeal renal surgery and autotransplantation: indications, techniques and results. J Urol 80: 806 – 811, 1980. 6. Al-Ali M, and Haddad LF: The late treatment of 63 145v
overlooked or complicated ureteral missile injuries: the promise of nephrostomy and role of autotransplantation. J Urol 156: 1918 –1921, 1996. 7. Lytton B, and Schiff M: Interposition of an ileal segment for repair of ureteral injuries. J Urol 125: 739 –741, 1981. 8. Chang SS, and Koch MO: The use of an extended spiral bladder flap for treatment of upper ureteral loss. J Urol 156: 1981–1983, 1996. 9. Goodwin WE, Winter CC, and Turner RD: Replacement of the ureter by small intestine: clinical application and results of the “ileal ureter.” J Urol 81: 406 – 413, 1959. 10. Hardy JD: High ureteral injuries: management by autotransplantation of the kidney. JAMA 184: 97–106, 1963.
145vi
11. Fabrizio MD, Ratner LE, Montgomery RA, et al: Laparoscopic live donor nephrectomy. Urol Clin North Am 26: 247–256, 1999. 12. St. Lezin M, and Stoller ML: Surgical ureteral injury. Urology 38: 497–506, 1991. 13. Tanagho E: A case against incorporation of bowel segments into the closed urinary system. J Urol 133: 796 – 802, 1975. 14. Ratner LE, Cisek LJ, Moore RG, et al: Laparoscopic live donor nephrectomy. Transplantation 60: 1047–1049, 1995. 15. Ratner LE, Hiller J, Sroka M, et al: Laparoscopic live donor nephrectomy removes disincentives to live donation. Transplant Proc 29: 3402–3403, 1997.
UROLOGY 55 (1), 2000
LAPAROSCOPIC NEPHRECTOMY FOR AUTOTRANSPLANTATION MICHAEL D. FABRIZIO, LOUIS R. KAVOUSSI, STEPHEN JACKMAN, DAVID Y. CHAN, ELAINE TSENG, AND LLOYD E. RATNER
ABSTRACT Proximal ureteral injuries often require extensive reconstruction to repair. Management options include nephrectomy, ileal ureter interposition, extensive spiral bladder flaps, or autotransplantation. We report a patient who sustained a proximal ureteral avulsion and underwent a less invasive repair by way of a laparoscopic nephrectomy and subsequent autotransplantation. UROLOGY 55: 145iii–145vi, 2000. © 2000, Elsevier Science Inc.
D
uring the past several years, an increasing number of iatrogenic ureteral injuries have been seen as a direct result of endoscopic urologic procedures.1– 4 Minor complications such as ureteral perforation are quite common.4 Fortunately, severe complications such as ureteral avulsion are a rare entity. Classically, an iatrogenic proximal ureteral avulsion is managed by either nephrectomy, ileal ureter interposition, autotransplantation, or rarely transureteroureterostomy.5–10 These procedures routinely require an extensive operation and a prolonged period of convalescence. Laparoscopy now gives the urologist a minimally invasive approach for a variety of urologic conditions once performed in an open fashion. In this report, we present a patient who sustained a proximal ureteral avulsion that occurred during ureteroscopy for a midureteral stone and who subsequently underwent laparoscopic nephrectomy with successful autotransplantation. CASE REPORT A 41-year-old man was transferred to our institution after sustaining a proximal ureteral avulsion during ureteroscopy. The patient had presented From the Johns Hopkins Medical Institute, James Buchanan Brady Urological Institute, Baltimore, Maryland and Division of Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, Maryland Address for correspondence: Michael D. Fabrizio, M.D., Devine Tidewater Urology, Eastern Virginia Medical School, 400 West Brambleton Avenue, Suite 100, Norfolk, VA 23510 Submitted: May 18, 1999, accepted (with revisions): July 21, 1999 © 2000, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
with a 1-cm left ureteral stone located just above the pelvic brim. The injury occurred while removing fragments with a 3F flat-wire basket and flexible ureteroscope. A segment of ureter was seen on the ureteroscope on removal, and cystoscopy revealed perivesical fat at the level of the left ureteral orifice. A double pigtail ureteral stent was placed over the safety wire and a Foley catheter was placed for drainage. The patient was transferred to our institution where he underwent computed tomographyguided percutaneous nephrostomy tube placement into the lower pole of the left kidney. An antegrade nephrostogram revealed a proximal ureteral injury consistent with an avulsion 5 cm below the ureteral pelvic junction (Fig. 1). A cystogram revealed an extraperitoneal injury (Fig. 2). Cystoscopy was performed with minimal irrigation, and the ureteral stent was found within the urinary bladder. The distal segment of nonviable ureter (10 cm) was intussuscepted into the urinary bladder. A 24F Foley catheter was left for gravity drainage, and broad-spectrum antibiotic prophylaxis was continued. The patient was 6 ft. 2 in. tall and weighed 147 kg, with normal renal function (creatinine 1.0 mg/ dL) and negative urine culture. A MAG-3 renal scan revealed a functioning left kidney, with a differential renal function of 70% in the right kidney and 30% in the left kidney. Preoperative obstruction was thought to have contributed to the impaired left renal function. The patient’s options were presented to him and included nephrectomy, autotransplantation, and ileal ureter interposition. The patient wished to 0090-4295/00/$20.00 PII S0090-4295(99)00367-2 145iii
FIGURE 2. Cystogram revealing extraperitoneal extravasation.
FIGURE 1. Antegrade nephrostogram consistent with ureteral avulsion.
preserve his kidney and, after preoperative counseling, underwent laparoscopic transabdominal nephrectomy using the four-port technique11 and subsequent autotransplantation. The patient’s kidney was harvested through a 6-cm periumbilical incision that was closed in standard fashion. The renal artery had an early bifurcation, which could not be preserved after division with the Endovascular GIA (U.S. Surgical, Norwalk, Conn), thus creating two renal arteries. The renal vein was 5 cm in length. There was 6 cm of ureter remaining with the kidney. The two renal arteries were anastomosed in a side-to-side fashion, creating a single common orifice. Before implanting the kidney using a standard extraperitoneal (Gibson) approach, the bladder was opened using an anterior cystot145iv
omy employing the same incision. The intussuscepted ureteral segment was excised, and the posterior bladder defect was closed. The anterior cystotomy was closed in three layers. The renal artery and vein were anastomosed to the external iliac artery and vein, respectively. The ureter was implanted using a Lich-Gregoir extravesical technique and stented. On postoperative day 1, a MAG-3 scan confirmed good blood flow and function in the transplanted kidney. The patient was discharged on the morning of postoperative day 4. On postoperative day 7, the patient returned for a cystogram, which revealed vesicoureteral reflux and no evidence of leak (at 250 mL). There was no extravasation from his ureterovesical anastomosis, and postevacuation films revealed complete drainage of his transplanted kidney and urinary bladder (Fig. 3). He did not require any narcotic analgesics after discharge. He returned to full activity 2 weeks postoperatively. One month postoperatively, a MAG-3 scan revealed improved function compared with the preoperative study and no obstruction. COMMENT With the evolution of surgical techniques, ureteral injuries can occur during a variety of endoUROLOGY 55 (1), 2000
FIGURE 3. Postoperative cystogram with no extravasation and bilateral vesicoureteral reflux.
scopic procedures, including ureteroscopy and laparoscopy. Since 1990, an increasing number of ureteral injuries have occurred as a result of ureteroscopy. Fortunately, severe injuries such as ureteral avulsion are rare, occurring in less than 0.5% of all cases.1– 4 Although ureteral injuries can occur throughout the entire length of ureter, more severe injuries are associated with the proximal ureter, which has less muscular support and fewer mucosal cell layers than the distal or intramural ureter.1,12 Numerous studies have advocated prompt surgical repair for these ureteral injuries, as a delay in diagnosis and reconstruction leads to increased complications.2,3 Proximal ureteral avulsion can be managed using several techniques.5–10 Percutaneous nephrostomy tube placement allows the patient to be temporarily stabilized. Nephrectomy has been advocated in patients with poor renal function. Renal-sparing procedures in the setting of a severe injury are usually extensive, since most ureteral avulsions cannot be managed with ureteroureterostomy. An ileal ureter interposition is certainly an alternative for large segmental defects in the proximal ureter; however, there are several disadvantages, including recurrent urinary tract infection, stone formation, and electrolyte imbalances.7,13 Although extensive reconstructive techniques such as extended spiral bladder flaps can be used for proximal ureteral injuries,8 these are somewhat difficult in larger patients. Transureteroureterostomy is an option with proximal ureteral defects. However, it does require a sizable segment of viable ureter to cross the midline and is relatively contraindicated in patients with recurrent stone formation.1 Renal autotransplantation has been shown to be a very effective method in the treatment of multiple UROLOGY 55 (1), 2000
urologic conditions. Novick et al.5 reported on the use of renal autotransplantation for a variety of conditions in 22 patients. Historically, harvest of the kidney required an extensive operation through a flank or transabdominal route, exposing the patient to significant postoperative morbidity and recovery. More recently, laparoscopy has been shown to be an effective technique for harvesting donor kidneys. Ratner et al.14 reported the first human laparoscopic live donor nephrectomy in 1995. This operation has been shown to markedly decrease the length of hospital stay and perioperative analgesic requirement and to actually increase the incentive for donation.15 It has also resulted in an earlier return to work and daily activities. Our patient underwent a laparoscopic nephrectomy using three 10-mm trocars and a 2-mm trocar to elevate and retract the spleen. The kidney was harvested through a separate transabdominal incision to maintain a completely retroperitoneal approach during renal transplantation. The patient had an uneventful autotransplantation and postoperative recovery. On the basis of the patient’s overall narcotic use during the postoperative period and lack of analgesic use at home, it is likely that this minimally invasive approach allowed him to recover in a prompt fashion. We believe this approach allowed the patient to return to the activities of daily living in a significantly shorter time. CONCLUSIONS As a result of the increase in ureteroscopic procedures, iatrogenic ureteral injuries are more common. Autotransplantation is an attractive option in the treatment of severe proximal ureteral injuries. This case report illustrates how a historically extensive operation can be approached in a less invasive fashion. Laparoscopic donor nephrectomy has improved the perioperative and postoperative recovery for potential kidney donors. This technique can be successfully applied to other urologic procedures such as autotransplantation. REFERENCES 1. Assimos DG, Patterson LC, and Taylor CL: Changing incidence and etiology of iatrogenic ureteral injuries. J Urol 152: 2240 –2246, 1994. 2. Dowling RA, Corriere JN Jr, and Sandler CM: Iatrogenic ureteral injury. J Urol 135: 912–915, 1986. 3. Lask D, Abarbanel J, Luttwak Z, et al: Changing trends in the management of iatrogenic ureteral injuries. J Urol 154: 1693–1695, 1995. 4. Huffman J: Ureteroscopic injuries in the upper tract. Urol Clin North Am 16: 249 –255, 1989. 5. Novick AC, Stewart BH, and Straffon RA: Extracorporeal renal surgery and autotransplantation: indications, techniques and results. J Urol 80: 806 – 811, 1980. 6. Al-Ali M, and Haddad LF: The late treatment of 63 145v
overlooked or complicated ureteral missile injuries: the promise of nephrostomy and role of autotransplantation. J Urol 156: 1918 –1921, 1996. 7. Lytton B, and Schiff M: Interposition of an ileal segment for repair of ureteral injuries. J Urol 125: 739 –741, 1981. 8. Chang SS, and Koch MO: The use of an extended spiral bladder flap for treatment of upper ureteral loss. J Urol 156: 1981–1983, 1996. 9. Goodwin WE, Winter CC, and Turner RD: Replacement of the ureter by small intestine: clinical application and results of the “ileal ureter.” J Urol 81: 406 – 413, 1959. 10. Hardy JD: High ureteral injuries: management by autotransplantation of the kidney. JAMA 184: 97–106, 1963.
145vi
11. Fabrizio MD, Ratner LE, Montgomery RA, et al: Laparoscopic live donor nephrectomy. Urol Clin North Am 26: 247–256, 1999. 12. St. Lezin M, and Stoller ML: Surgical ureteral injury. Urology 38: 497–506, 1991. 13. Tanagho E: A case against incorporation of bowel segments into the closed urinary system. J Urol 133: 796 – 802, 1975. 14. Ratner LE, Cisek LJ, Moore RG, et al: Laparoscopic live donor nephrectomy. Transplantation 60: 1047–1049, 1995. 15. Ratner LE, Hiller J, Sroka M, et al: Laparoscopic live donor nephrectomy removes disincentives to live donation. Transplant Proc 29: 3402–3403, 1997.
UROLOGY 55 (1), 2000