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Extracorporeal Renal Surgery
Vol. 112, Octcioer Printed in
THE JOURNAL OF UROLOGY
Copyright© 1974 by The Williams & Wilkins Co.
EXTRACORPOREAL RENAL SURGERY RICHARD MILSTEN,* JAMES NEIFIELD
AND
WARREN W. KOONTZ, JR.
From the Division of Urolof{y, Department of Surf{ery, Medical Collete of Virtinia, Virginia Commomcealih University, Richmond, Virginia
A recent innovation in the urological armamentarium is extracorporeal renal surgery which has been termed workbench surgery. The procedure involves ex vivo repair of the kidney followed by autotransplantation. It is in its infancy and relatively few people have experience with it. It is our purpose to trace the of this new surgical development and to proper credit to the individuals responsible for its evolution. The indications for an extracorporeal renal operation and technical considerations involved in its clinical application will be discussed. HISTORICAL BACKGROUND
Extracorporeal renal surgery has its roots in and owes its success to the vast attained in renal homotransplantation autotransplantation. A decade passed between the time of the first successful long-term renal homotransplantation in 1954 1 to the first successful case of workbench surgery. The feasibility of successfully moving a kidney to the iliac fossa with the ability to preserve a kidney outside of the hypothermia or pulsatile perfusion paved the avenue for extracorporeal repair. Credit for the first successful ex vivo repair followed autotransplantation goes to Ota. 2 Although reported in 1967 the article has not received the attention it deserved. The operation was performed on February 28, 1964 and involved a 39-year-old man with hypertension secondary to right renal stenosis. In this case the renal vessels were but the ureter was left intact. After linear and thromboendarterectomy an vein patch graft was performed. The patient was heparinized but no mention was made of perfusion or hypothermia. The patient was still normotensive 31 months postoperatively. are known To 24 cases of bench • 2 · 12 With the to have been performed ( see
exception of 1 case done for trauma, 1 for lesteatoma and 3 for tumor, all bench surgery has been performed for various forms of artery disease: stenosis, fibromuscular and aneurysm. Results from all authors are favorable but long-term followup is not yet INDICATIONS
Urological indications for renal are still being defined. Some surgeons have able to achieve meticulous repair of tertiary branch renal artery lesions ever, the extracorporea! technique advantages: a bloodless application of the operating microscope if needed, a longer ischemic time for repair, larly if pulsatile perfusion is used, and accurate arteriographic studies to In trauma cases causing severe renovascular injury, nephrectomy, repair and tion may be the only means to This is particularly true for branch lesions either because of the the surgical technique required in vivo or because of unstable patient. Even an excellent repair in situ may be jeopardized leaving the kidney where infection has been introduced penetrating injury or from an associated or pancreatic injury. It is conceivable that in an unstable or one with a solitary kidney or a diseased contralat era! kidney, the severely traumatized would otherwise be sacrificed could be •"'""""'""r1
jJHCU.~C
Accepted for publication Read at annual meeting of Section, American Urological Association, Costa de] Sol, Malaga, Spain, September 15-22, 1973. Supported in part a grant from the A. D. Williams Committee, Th2 College of Virginia, Commonwealth Richmond, Virginia. * Current United States Naval Hospital, Philadelphia, Pennsylvania 1914,5. 1 Campbell, M. F. and Harrison, J. H.: Urology, 3rd ed. Philadelphia: B. Saunders Co., p. 2241, 1970. 'Ota, K., Mori, S., Awane, Y. and Ueno, A.: Ex situ repair of renal for renovascular hypertension. Arch. 94: Jr., A. B. and Blaisdell. F. W.:
Renal autotransplantation. Adjunct to repair of vascular lesions. Arch. Surg., 105: 847, 1972. 'Gelin, L-E., Claes, G., Gustafsson, A. and Total bloodlessness for extracorporeal organ repair. Surg., 28: 1971. 5 Caine, R. · Tumor in a single kidney: excision and autotransp!antation. Lancet. 2: 6 Lawson, R. K., Hodges, C. V. and Pitre, Nephrectomy, microvascular repair, and autotransplantation. Surg. Forum, 23: 539, 1972. 7 Belzer, F. 0.: Personal 8 Belzer, F. 0.: Discussion of paper Stanley, J. C., Marshall, F. F. and Fry, nous saphenous vein aortorenal grafts. A ten-year experi ence. Arch. Surg., 105: 855, 1972. 'Richie, R. E.: Personal 197:3. 1 ° Corman, J. L., Gallot. Stonington, 0., Stables, D. Taubman, and T. E.: Arteriography during ex vivo renal perfusion. complication. Urology, 2: 222, 1973. 11 Olsson, C. A.: Personal communication, 197:J. 12 Gittes, R. F. and D. L.: Bench for renal cell carcinoma kidney. communication, 1974. 425
426
MILS TEN, NEIFIELD AND KOONTZ
Extracorporeal renal surgery Surgeon, Year
Indication
No. Cases
Ureter
Preservation Technique
Ota, 1964' Lim, 1968' Gelin, 1968' 1970' Caine, 1971' Hodges, 1972' Lim, 1972'
Renal artery disease Trauma Renal artery disease Renal cell Ca Renal cell Ca Renal artery disease Renal artery disease
1 1 3 1 1 2 2
Renal artery disease
3
Intact Divided Divided Divided Divided Divided Divided Intact Divided
Richie, 1972'
Renal artery disease
5
Intact
Starzl, 1972'°
Renal artery disease
3
Olsson, 1973"
Cholesteatoma
Divided Intact Divided
Gittes, 1973"
Renal cell Ca
1
Intact
Heparinization Hypothermia Hypothermia Hypothermia Hypothermia Hypothermia Hypothermia Hypothermia Pulsatile perfusion Pulsatile perfusion hypothermia Pulsatile perfusion Pulsatile perfusion Pulsatile perfusion
Belzer, 1972 7 •
"
repaired and preserved ex vivo for 48 to 72 hours, at which time the patient would be returned to the operating room and undergo autotransplantation. While this may seem formidable it poses less problems than a patient who would later require a homotransplant. If one has to receive a kidney there is no better donor than the recipient. In cases of renal cell carcinoma in which there is a solitary kidney or bilateral involvement, the surest way to accomplish resection of neoplasm without tumor spill is by an ex vivo operation. It has been suggested that staghorn calculi could be thoroughly removed with the least loss of renal parenchyma during bench surgery. However, this has not been attempted. The final indication for ex vivo surgery that we would propose involves a kidney in a young patient or one with contralateral renal disease in whom the diagnosis of malignancy is uncertain and in whom conservative therapy would dictate nephrectomy. In this case the kidney would be removed, explored on the bench and, if no neoplasm found, autotransplanted. DISCUSSION
In preparation for extracorporeal renal surgery 2 decisions must be made. First, the surgeon must decide if after removing the kidney he is going to use a pulsatile perfusion system or simple hypothermia for preservation. Guerriero 13 and Belzer 14 believe that the former is the method of choice for various reasons. 1) The use of a pulsatile perfusion machine permits constant monitoring of the functional status of the kidney by following pulse pressure and flow. 2) Microdissection is 13 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. 14 Belzer, F. 0., Keaveny, T. V., Reed, T. W. and Pryor, J.P.: A new method ofrenal artery reconstruction. Surgery, 68: 619, 1970.
facilitated since the vessels are distended. 3) The integrity of the anastomosis can be checked by observing for leaks of perfusate so that troublesome bleeding does not occur on reimplantation. 4) Continuous perfusion minimizes the risk of postoperative tubular necrosis. Belzer points out that tubular necrosis can reduce renal blood flow to 10 to 15 per cent of normal and, hence, predispose to thrombosis. 5) Elapsed time for repair is of little importance since Belzer has successfully preserved kidneys for up to 3 days by pulsatile perfusion. Belzer has done extremely difficult branch renal artery repairs in humans with the kidney being continuously perfused. However, others with experience in the field believe pulsatile perfusion is not necessary. Hodges and associates, 6 • 15 Lim and associates, 3 and Richie and Foster have simply prepared the kidney by placing a cannula in the renal artery and flushing with iced lactated Ringer's solution with heparin and procaine added. The kidney is then kept cool in a basin of iced sterile Ringer's lactate or saline solution. According to Hodges this technique permits at least 2 to 3 hours of ischemic time. Gelin and associates used a cooled rheomacrodex solution successfully without continuous perfusion. 4 Our own laboratory experience demonstrated that pulsatile perfusion is feasible during ex vivo repair and that anastomotic leaks after arterial repair and pumpers after partial nephrectomy were readily detectable. However, the fact that hypothermia alone is sufficient for preservation for most repairs, coupled with the cost and time involved in preparing the perfusate and the necessity of having a technician available to monitor the machine, makes its use unwarranted in our opinion unless long-term preservation is contemplated. Sacks and associates recently developed a new 15 Hodges, C. V., Lawson, R. K., Pearse, H. D. and Stranburg, C. 0.: Autotransplantation of the kidney. J. Urol., llO: 20, 1973.
4:27
EXTRACORPOREAL RENAL SURGERY
perfusate of modified intracellular electrolyte composition made hyperosmolar with mannitol. Canine kidneys have been successfully preserved for up to 48 hours simply flushing the kidney with 200 cc of the solution for 5 minutes and then keeping it in the same solution cooled to 2C. 1 • After deciding whether to use a pulsatile perfusion machine or simple hypothermia, one must decide whether to do a nephroureterectomy and n~a~,,,-a on the kidney separated from the patient then do autotransplantation with ureteroneocystostomy or whether to perform a nephrectomy and extra.corporeal repair without division of the ureter. Either technique is feasible and both have been successfully used in humans. Performing a nephroureterectomy makes ex vivo repair easier if the repair is going to require a long time and if continuous perfusion is desired. Belzer, citing less than a 1 per cent complication rate from ureteroneocystostomy, prefers to do a nephroureterectomy and then reimplant the ureter but Richie and Foster have been able to achieve continuous perfusion and repair with the ureter intact by bringing the kidney into the operative field and placing it on a pulsatile perfusion system. Hodges prefers ureteral division for bench surgery and Lim has done extracorporeal repair with and without dividing the ureter. One need not be concerned when a kidney is removed from its normal location and placed into the iliac fossa without shortening the ureter. Whitsell and associates have shown that in the absence of mechanical obstruction a normal ureter is capable of moving urine from the kidney to the bladder at an adequate rate, irrespective of the course, 17 This has direction or gradient against 1 'Sacks, S. A., Petritsch, P.H. and Kaufman, J. J.: Canine kidney preservation using a new perfusate. Lancet, 1: 1024, 1973. 11 Whitsell, J.C., II, Goldsmith, E. I. and Nakamura, H.: Renal autotransplantation without ureteral division: an experimental study and case report. J. Urol., 103: 577, 1970.
been corroborated in human autotransplantatim~ by Hodges, Lim, Richie, Ota and Kaufman. It is advantageous to be able to perform arteriography while the kidney is ex vivo to assess results. However, if the kidney is being maintained on a pulsatile perfusion machine it is that the contrast material be allowed to drain from the system and not be allowed to circulate with the perfusate. It has been shown that kidneys con· stantly perfused with contrast agents do less well than those that are not. 18 The necessity for thor ough and immediate washout is emphasized a case of Starzl, in which 2 kidneys were lost because of arterial thrombosis thought to be secondary to contrast medium used during ex vivo arterio graphic studies prior to autotransplantation. 10 It must be emphasized that the technique of extracorporeal renal surgery should be reserved for carefully selected cases evolving about the indica" tions discussed. SUMMARY
The first historical survey of extracorporeal renal surgery is presented. To date, 24 cases have been performed for trauma, neoplasm, cholesteatoma and renal artery disease. Renal preservation was accomplished using either pulsatile hypothermia. In 5 cases the ureter was left intact during bench repair. The cooperation and personal communications of Drs. Hodges, Belzer, Richie, Kaufman, Starzl, Straffon, Sacks, Olsson and Gittes are recognized. ADDENDUM
Since 1968 Gelin has performed 20 extra.corporeal renal operations for: renal artery aneurysm·-·6 cases, distal renal artery stenosis-5 cases, coral lite stones-3 cases and malignancy-6 cases. 19 18 Alfidi, R. J. and Magnusson, M. 0.: during perfusion preservation of kidneys. Amer. J. gen., H4: 690, 1972. 19 Gelin, L-E.: Personal communication, 1974.
THE JOURNAL OF UROLOGY
Copyright© 1974 by The Williams & Wilkins Co.
EXTRACORPOREAL RENAL SURGERY RICHARD MILSTEN,* JAMES NEIFIELD
AND
WARREN W. KOONTZ, JR.
From the Division of Urolof{y, Department of Surf{ery, Medical Collete of Virtinia, Virginia Commomcealih University, Richmond, Virginia
A recent innovation in the urological armamentarium is extracorporeal renal surgery which has been termed workbench surgery. The procedure involves ex vivo repair of the kidney followed by autotransplantation. It is in its infancy and relatively few people have experience with it. It is our purpose to trace the of this new surgical development and to proper credit to the individuals responsible for its evolution. The indications for an extracorporeal renal operation and technical considerations involved in its clinical application will be discussed. HISTORICAL BACKGROUND
Extracorporeal renal surgery has its roots in and owes its success to the vast attained in renal homotransplantation autotransplantation. A decade passed between the time of the first successful long-term renal homotransplantation in 1954 1 to the first successful case of workbench surgery. The feasibility of successfully moving a kidney to the iliac fossa with the ability to preserve a kidney outside of the hypothermia or pulsatile perfusion paved the avenue for extracorporeal repair. Credit for the first successful ex vivo repair followed autotransplantation goes to Ota. 2 Although reported in 1967 the article has not received the attention it deserved. The operation was performed on February 28, 1964 and involved a 39-year-old man with hypertension secondary to right renal stenosis. In this case the renal vessels were but the ureter was left intact. After linear and thromboendarterectomy an vein patch graft was performed. The patient was heparinized but no mention was made of perfusion or hypothermia. The patient was still normotensive 31 months postoperatively. are known To 24 cases of bench • 2 · 12 With the to have been performed ( see
exception of 1 case done for trauma, 1 for lesteatoma and 3 for tumor, all bench surgery has been performed for various forms of artery disease: stenosis, fibromuscular and aneurysm. Results from all authors are favorable but long-term followup is not yet INDICATIONS
Urological indications for renal are still being defined. Some surgeons have able to achieve meticulous repair of tertiary branch renal artery lesions ever, the extracorporea! technique advantages: a bloodless application of the operating microscope if needed, a longer ischemic time for repair, larly if pulsatile perfusion is used, and accurate arteriographic studies to In trauma cases causing severe renovascular injury, nephrectomy, repair and tion may be the only means to This is particularly true for branch lesions either because of the the surgical technique required in vivo or because of unstable patient. Even an excellent repair in situ may be jeopardized leaving the kidney where infection has been introduced penetrating injury or from an associated or pancreatic injury. It is conceivable that in an unstable or one with a solitary kidney or a diseased contralat era! kidney, the severely traumatized would otherwise be sacrificed could be •"'""""'""r1
jJHCU.~C
Accepted for publication Read at annual meeting of Section, American Urological Association, Costa de] Sol, Malaga, Spain, September 15-22, 1973. Supported in part a grant from the A. D. Williams Committee, Th2 College of Virginia, Commonwealth Richmond, Virginia. * Current United States Naval Hospital, Philadelphia, Pennsylvania 1914,5. 1 Campbell, M. F. and Harrison, J. H.: Urology, 3rd ed. Philadelphia: B. Saunders Co., p. 2241, 1970. 'Ota, K., Mori, S., Awane, Y. and Ueno, A.: Ex situ repair of renal for renovascular hypertension. Arch. 94: Jr., A. B. and Blaisdell. F. W.:
Renal autotransplantation. Adjunct to repair of vascular lesions. Arch. Surg., 105: 847, 1972. 'Gelin, L-E., Claes, G., Gustafsson, A. and Total bloodlessness for extracorporeal organ repair. Surg., 28: 1971. 5 Caine, R. · Tumor in a single kidney: excision and autotransp!antation. Lancet. 2: 6 Lawson, R. K., Hodges, C. V. and Pitre, Nephrectomy, microvascular repair, and autotransplantation. Surg. Forum, 23: 539, 1972. 7 Belzer, F. 0.: Personal 8 Belzer, F. 0.: Discussion of paper Stanley, J. C., Marshall, F. F. and Fry, nous saphenous vein aortorenal grafts. A ten-year experi ence. Arch. Surg., 105: 855, 1972. 'Richie, R. E.: Personal 197:3. 1 ° Corman, J. L., Gallot. Stonington, 0., Stables, D. Taubman, and T. E.: Arteriography during ex vivo renal perfusion. complication. Urology, 2: 222, 1973. 11 Olsson, C. A.: Personal communication, 197:J. 12 Gittes, R. F. and D. L.: Bench for renal cell carcinoma kidney. communication, 1974. 425
426
MILS TEN, NEIFIELD AND KOONTZ
Extracorporeal renal surgery Surgeon, Year
Indication
No. Cases
Ureter
Preservation Technique
Ota, 1964' Lim, 1968' Gelin, 1968' 1970' Caine, 1971' Hodges, 1972' Lim, 1972'
Renal artery disease Trauma Renal artery disease Renal cell Ca Renal cell Ca Renal artery disease Renal artery disease
1 1 3 1 1 2 2
Renal artery disease
3
Intact Divided Divided Divided Divided Divided Divided Intact Divided
Richie, 1972'
Renal artery disease
5
Intact
Starzl, 1972'°
Renal artery disease
3
Olsson, 1973"
Cholesteatoma
Divided Intact Divided
Gittes, 1973"
Renal cell Ca
1
Intact
Heparinization Hypothermia Hypothermia Hypothermia Hypothermia Hypothermia Hypothermia Hypothermia Pulsatile perfusion Pulsatile perfusion hypothermia Pulsatile perfusion Pulsatile perfusion Pulsatile perfusion
Belzer, 1972 7 •
"
repaired and preserved ex vivo for 48 to 72 hours, at which time the patient would be returned to the operating room and undergo autotransplantation. While this may seem formidable it poses less problems than a patient who would later require a homotransplant. If one has to receive a kidney there is no better donor than the recipient. In cases of renal cell carcinoma in which there is a solitary kidney or bilateral involvement, the surest way to accomplish resection of neoplasm without tumor spill is by an ex vivo operation. It has been suggested that staghorn calculi could be thoroughly removed with the least loss of renal parenchyma during bench surgery. However, this has not been attempted. The final indication for ex vivo surgery that we would propose involves a kidney in a young patient or one with contralateral renal disease in whom the diagnosis of malignancy is uncertain and in whom conservative therapy would dictate nephrectomy. In this case the kidney would be removed, explored on the bench and, if no neoplasm found, autotransplanted. DISCUSSION
In preparation for extracorporeal renal surgery 2 decisions must be made. First, the surgeon must decide if after removing the kidney he is going to use a pulsatile perfusion system or simple hypothermia for preservation. Guerriero 13 and Belzer 14 believe that the former is the method of choice for various reasons. 1) The use of a pulsatile perfusion machine permits constant monitoring of the functional status of the kidney by following pulse pressure and flow. 2) Microdissection is 13 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. 14 Belzer, F. 0., Keaveny, T. V., Reed, T. W. and Pryor, J.P.: A new method ofrenal artery reconstruction. Surgery, 68: 619, 1970.
facilitated since the vessels are distended. 3) The integrity of the anastomosis can be checked by observing for leaks of perfusate so that troublesome bleeding does not occur on reimplantation. 4) Continuous perfusion minimizes the risk of postoperative tubular necrosis. Belzer points out that tubular necrosis can reduce renal blood flow to 10 to 15 per cent of normal and, hence, predispose to thrombosis. 5) Elapsed time for repair is of little importance since Belzer has successfully preserved kidneys for up to 3 days by pulsatile perfusion. Belzer has done extremely difficult branch renal artery repairs in humans with the kidney being continuously perfused. However, others with experience in the field believe pulsatile perfusion is not necessary. Hodges and associates, 6 • 15 Lim and associates, 3 and Richie and Foster have simply prepared the kidney by placing a cannula in the renal artery and flushing with iced lactated Ringer's solution with heparin and procaine added. The kidney is then kept cool in a basin of iced sterile Ringer's lactate or saline solution. According to Hodges this technique permits at least 2 to 3 hours of ischemic time. Gelin and associates used a cooled rheomacrodex solution successfully without continuous perfusion. 4 Our own laboratory experience demonstrated that pulsatile perfusion is feasible during ex vivo repair and that anastomotic leaks after arterial repair and pumpers after partial nephrectomy were readily detectable. However, the fact that hypothermia alone is sufficient for preservation for most repairs, coupled with the cost and time involved in preparing the perfusate and the necessity of having a technician available to monitor the machine, makes its use unwarranted in our opinion unless long-term preservation is contemplated. Sacks and associates recently developed a new 15 Hodges, C. V., Lawson, R. K., Pearse, H. D. and Stranburg, C. 0.: Autotransplantation of the kidney. J. Urol., llO: 20, 1973.
4:27
EXTRACORPOREAL RENAL SURGERY
perfusate of modified intracellular electrolyte composition made hyperosmolar with mannitol. Canine kidneys have been successfully preserved for up to 48 hours simply flushing the kidney with 200 cc of the solution for 5 minutes and then keeping it in the same solution cooled to 2C. 1 • After deciding whether to use a pulsatile perfusion machine or simple hypothermia, one must decide whether to do a nephroureterectomy and n~a~,,,-a on the kidney separated from the patient then do autotransplantation with ureteroneocystostomy or whether to perform a nephrectomy and extra.corporeal repair without division of the ureter. Either technique is feasible and both have been successfully used in humans. Performing a nephroureterectomy makes ex vivo repair easier if the repair is going to require a long time and if continuous perfusion is desired. Belzer, citing less than a 1 per cent complication rate from ureteroneocystostomy, prefers to do a nephroureterectomy and then reimplant the ureter but Richie and Foster have been able to achieve continuous perfusion and repair with the ureter intact by bringing the kidney into the operative field and placing it on a pulsatile perfusion system. Hodges prefers ureteral division for bench surgery and Lim has done extracorporeal repair with and without dividing the ureter. One need not be concerned when a kidney is removed from its normal location and placed into the iliac fossa without shortening the ureter. Whitsell and associates have shown that in the absence of mechanical obstruction a normal ureter is capable of moving urine from the kidney to the bladder at an adequate rate, irrespective of the course, 17 This has direction or gradient against 1 'Sacks, S. A., Petritsch, P.H. and Kaufman, J. J.: Canine kidney preservation using a new perfusate. Lancet, 1: 1024, 1973. 11 Whitsell, J.C., II, Goldsmith, E. I. and Nakamura, H.: Renal autotransplantation without ureteral division: an experimental study and case report. J. Urol., 103: 577, 1970.
been corroborated in human autotransplantatim~ by Hodges, Lim, Richie, Ota and Kaufman. It is advantageous to be able to perform arteriography while the kidney is ex vivo to assess results. However, if the kidney is being maintained on a pulsatile perfusion machine it is that the contrast material be allowed to drain from the system and not be allowed to circulate with the perfusate. It has been shown that kidneys con· stantly perfused with contrast agents do less well than those that are not. 18 The necessity for thor ough and immediate washout is emphasized a case of Starzl, in which 2 kidneys were lost because of arterial thrombosis thought to be secondary to contrast medium used during ex vivo arterio graphic studies prior to autotransplantation. 10 It must be emphasized that the technique of extracorporeal renal surgery should be reserved for carefully selected cases evolving about the indica" tions discussed. SUMMARY
The first historical survey of extracorporeal renal surgery is presented. To date, 24 cases have been performed for trauma, neoplasm, cholesteatoma and renal artery disease. Renal preservation was accomplished using either pulsatile hypothermia. In 5 cases the ureter was left intact during bench repair. The cooperation and personal communications of Drs. Hodges, Belzer, Richie, Kaufman, Starzl, Straffon, Sacks, Olsson and Gittes are recognized. ADDENDUM
Since 1968 Gelin has performed 20 extra.corporeal renal operations for: renal artery aneurysm·-·6 cases, distal renal artery stenosis-5 cases, coral lite stones-3 cases and malignancy-6 cases. 19 18 Alfidi, R. J. and Magnusson, M. 0.: during perfusion preservation of kidneys. Amer. J. gen., H4: 690, 1972. 19 Gelin, L-E.: Personal communication, 1974.