Extracorporeal Renal Surgery and Autotransplantation: Indications, Techniques and Results

0022-5347 /80/1236-0806$02.00/0 Vol. 123, June Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright© 1980 by The Williams & Wilkins Co.

Original Articles EXTRACORPOREAL RENAL SURGERY AND AUTOTRANSPLANTATION: INDICATIONS, TECHNIQUES AND RESULTS ANDREW C. NOVICK, BRUCE H. STEWART

AND

RALPH A. STRAFFON

From the Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio

ABSTRACT

Renal autotransplantation and/or an extracorporeal renal operation has been done 67 times in 65 patients. The indications for operation were severe ureteral injury in 8 patients, urinary undiversion in 2, renovascular hypertension in 10, carcinoma in a solitary kidney in 3, recurrent renal colic in 1 and donor arterial reconstruction before renal transplantation in 43. Methods of renal preservation and operative repair are described. Sixty-five operations were successful and 2 operations failed because of severe perirenal fibrosis in patients undergoing urinary undiversion. Renal autotransplantation and extracorporeal reconstruction can provide the best solution for selected urologic problems not correctable by conventional methods. Transferal of a kidney from one site to another in the same patient evolved as a logical extension of the field of renal allotransplantation. Early attempts at autotransplantation resulted in failure until 1962, when Hardy successfully transferred a kidney into the ipsilateral iliac fossa in a patient whose ureter had been damaged severely by a previous aortic operation. 1 Effective methods of renal preservation and micro vascular surgical techniques also have resulted in the advent of extracorporeal renal surgery as a form of treatment for several complex renal disorders. In 1967 Ota and associates reported the first successful extracorporeal renal arterial repair combined with autotransplantation in a patient with renovascular hypertension.~ Since that time many other cases have been reported using various methods of renal preservation and operative repair.' 1 Herein we present the indications, methods and results of extracorporeal renal surgery and autotransplantation. MATERIALS AND METHODS

From January 1971 to March 1979 renal autotransplantation with or without an extracorporeal renal operation was done 24 times in 22 patients. Ten patients underwent renal autotransplantation as operative treatment for renovascular hypertension. These patients included 1 child with aortic hypoplasia, 2 patients with severe aortic atherosclerosis and 7 patients with branch renal artery disease not amenable to in situ repair. In the latter group autotransplantation was done after extracorporeal microvascular branch arterial repair. Ten renal autotransplants were done in 8 patients with extensive ureteral disease: 6 patients presented with iatrogenic ureteral injury, while 2 patients underwent bilateral autotransplantation to correct complications from previous supravesical urinary diversion. There were 3 patients with renal carcinoma in a solitary kidney who underwent extracorporeal partial nephrectomy and autotransplantation. Of these 3 patients 1 suffered cardiac arrhythmias during the bench procedure, which required termination of the operation. The repaired kidney was maintained Accepted for publication ,July 6, 1979.

on pulsatile perfusion overnight and autotransplantation was done 24 hours later, when the condition of the patient stabilized. A single patient with multiple recurrent renal calculi from cystinuria was treated by extracorporeal pyelolithotomy and autotransplantation with direct pyelovesicostomy. We also have done extracorporeal arterial repair in 43 donor kidneys with vascular anomalies before renal allotransplantation. The most commonly used methods were the conjoined arterial anastomosis, end-to-side reimplantation of a small renal artery into a larger one and use of a branched autogenous vascular graft to fashion a single renal artery. The indications and specific techniques used in these repairs are outlined in table 1. OPERATIVE TECHNIQUES

When patients are evaluated for renal autotransplantation preoperative renal and pelvic arteriography should be done to define renal arterial anatomy, to ensure iliac vessels relatively free of disease and, in patients with branch renal artery lesions, to assess the hypogastric artery and its branches as a reconstructive graft. The same preoperative and intraoperative measures should be taken as in live donor nephrectomy for allotransplantation to ensure minimal renal ischemia and immediate function after revascularization. These measures include adequate preoperative hydration, prevention of hypotension during the period of anesthesia, intraoperative administration of mannitol, minimal surgical manipulation of the kidney and rapid flushing and cooling of the kidney after its removal. The operation usually has been done through an anterior subcostal transperitoneal incision combined with a separate lower quadrant transverse semilunar incision. Occasionally, in non-obese patients, a single midline incision extending from the xyphoid to the symphysis pubis has been used. Patients with a solitary kidney are informed about the possible requirement for hemodialysis postoperatively. Renal autotransplantation. In some patients renal autotransplantation without extracorporeal repair is indicated, such as for ureteral disease or renovascular lesions confined to the main renal artery. In these cases the removed kidney is flushed 806

EXTRACORPOREAL RENAL SURGERY AND AUTOTRANSPLANTATION

flow with 500 ml. chilled Ringer's lactate to which added 5 ml. 2 per cent procaine, 10,000 units aqueous "~'"'~'"" and 1 ml. sodium bicarbonate. Although 150 to 200 cc solution usually are sufficient to obtain clear effluent from the renal vein more uniform renal cooling is obtained by a larger amount of chilled solution. Anastomosis of the artery and vein to the prepared iliac vessels then is done, and circulation to the kidney is restored within 30 to 60 minutes. When autotransplantation is done for renovascular disease the ureter is left intact and, although it may follow a redundant course to the normal ureteral peristalsis provides effective ~,Aw•=s..~ of urine from the kidney. In such cases care must be taken not to rotate the kidney when moving it so as to produce an obstructive torsion of the ureter. In ,J_.c,-,,"~ with ureteral disease various methods are available to restore urinary continuity after autotransplantation, wreteroneocystostomy, ureteroureterostomy, ureteror pyelovesicostomy with or without a Boari flap. onhrAQtm-nu tube drainage is not used routinely and a Penrose drain is positioned extraperitoneally well away from the vascular anastomoses. renal surgery and autotransplantation. 'When an extracorporeal renal operation is done in conjunction with autotransplantation the removed kidney is flushed with 500 cc chilled Collins' intracellular electrolyte solution and then is submerged in a basin of ice slush saline to maintain hypothermia. Under these conditions if there has been minimal warm renal ischemia the kidney can safely tolerate periods outside the body far in excess of the time needed to perform even the most complex renal repair.4 When extracorporeal nephrectomy for renal carcinoma is done the ureter is attached to preserve important collateral vascular supply to the renal pelvis and ureter. In this case the repair under should be done on the abdominal wall with the TABLE

l. Extracorporeal donor arterial repair before renal

allotransplantation Indications

Kidneys

Technique of Repair

renal arteries renal arteries, 5 pts. renal arteries, 3 pts. renal arteries

29 8

Conjoined arterial anastomosis End-to-side arterial anastomosis

3

renal arte:ry branches artery aneurysm

2

Repair with branched vascular graft End-to-end arterial anastomosis Resection of renal artery and reanastomosis

--------------

Total kidneys repaired

43

807

ureter occluded temporarily to prevent retrograde blood flow to the kidney. When extracorporeal vascula:r :reconstruction without resection of renal parenchyma is done the ureter may be transected and the kidney may be placed on a separate workbench to perform the repair. This method is somewhat less cumbersome and, since urologic complications after ureteroneocystostomy are rare,5 this represents an acceptable alternative approach. When extracorporeal renal revascularization is done for branch renal artery disease a branched hypogastric arterial autograft is the optimum material for vascular reconstruction. 6 If this is not available a pre-fashioned branched saphenous vein graft may be used,7 with separate end-to-end anastomosis of each graft branch to a distal renal arterial branch. Other techniques that may be applicable are end-to-end anastomosis of a graft branch to 2 conjoined renal artery branches or direct implantation of a renal artery branch end-to-side into a limb of the graft. Such vascular repairs are done under surface hypothermia using 7 or 9-zero suture material with microvascular instruments and optical magnification. The latter generally can be achieved with 3.5 x ophthalmologic loupes. However, the operating microscope may be helpful in unusual cases. When extracorporeal arterial repair has been completed before autotransplantation the kidney is placed on the Mox 100 hypothermic pulsatile perfusion unit (fig. 1). With the perfusion pressure set at the systolic pressure of the patient any arterial anastomotic leaks can be identified readily and controlled. Another useful adjunct is to instill 2 cc ofindigo carmine into the arterial cannula and, thus, patency of all branch anastomoses is verified if this is distributed evenly throughout the perfused Figure 2 illustrates extracorporeal repair and autotransplantation for a renal artery aneurysm involving 7 branches of the renal artery in a solitary kidney. Extracorporeal partial nephrectomy for renal carcinoma is done after radical nephrectomy, with the flushed kidney in ice slush saline. To appreciate the full extent of the neoplasm the kidney first is divested of all perinephric fat. Since such tumors generally are located centrally the dissection then is begun in the renal hilus and extended to the periphery of the kidney Arterial and venous channels directed towards the neoplasm are secured and divided, while those vessels supplying uninvolved renal parenchyma are preserved (fig. 3). The overlying capsule and parenchyma are incised progressively to preserve a 2 cm. margin of normal renal tissue around the tumor. Again, microvascular techniques and optical magnification are invaluable aids to securing transected blood vessels and closing the

Fie. 1. Hypothermic pulsatile perfusion is used after extracorporeal repair to assess vascular patency and hemostasis. Kidney is placed on separate workbench with connecting tubing running to and from pulsatile perfusion unit.

808

NOVICK, STEW ART AND STRAFFON

Frn. 2. A, preoperative right renal arteriogram in 44-year-old woman with 4 cm. non-calcified expanding aneurysm of renal artery in solitary right kidney. B, operative photograph of removed, flushed kidney submerged in ice slush saline. Note large, centrally located aneurysm from which 7 renal artery branches arise. C, postoperative angiogram after extracorporeal aneurysm resection and renal autotransplantation shows normal renal arterial anatomy.

collecting system. After the resection is completed tumor-free margins may be verified by frozen sections and/or extracorporeal arteriography. If arteriography is done the kidney should be flushed immediately to avoid toxicity of contrast agents or their cold-induced precipitation. 8 The reconstructed kidney then is placed on the pulsatile perfusion unit to assess pressure flow relationships and to permit suture ligation of remaining potential bleeding points. At this stage the kidney is perfused alternately via the renal artery and renal vein to facilitate arterial and venous hemostasis. Since the perfusate lacks clotting ability there may continue to be some parenchymal oozing, which can be ignored. If possible, the defect created by the partial nephrectomy should be closed by suturing the kidney upon itself to ensure further a watertight repair. When removal of the neoplasm has necessitated dissection of the vascular supply to the renal pelvis or the upper ureter, as in extensive lower pole tumors, a nephrostomy tube should be left indwelling for postoperative drainage. In our single patient with recurrent renal calculi, although extracorporeal pyelolithotomy was done, these stones could have been removed readily with standard in situ methods. The rationale for removing the kidney here was to perform autotransplantation with a Boari flap pyelovesicostomy to enable subsequent calculi to pass directly to the bladder (fig. 4). Extracorporeal donor arterial repair before allotransplan-

tation. There are 3 basic methods for extracorporeal donor arterial repair which, singly or combined, are readily applicable to most anatomic variants presented by kidneys with diseased, damaged or multiple arteries. These repairs are done before transplantation with the kidney preserved by surface hypothermia in ice slush saline. When 2 adjacent renal arteries of comparable size are present a conjoined (side-to-side) anastomosis of the 2 vessels is done to create a common ostium. For kidneys supplied by 2 renal arteries of disparate caliber end-toside anastomosis of the smaller artery to the larger one is done. A third method for transplanting kidneys with >2 renal arteries involves extracorporeal repair with a branched graft of autogenous hypogastric artery or saphenous vein. These techniques have been described in detail, 9 and they allow transplantation to be done as with a single renal artery, with no increase in revascularization time. RESULTS

In this series 10 patients underwent autotransplantation as surgical treatment for renovascular hypertension. Of the 10 patients 9 were cured postoperatively and 1 patient with bilateral disease is improved but probably will undergo revascularization of the heretofore unoperated contralateral kidney. There were no cases of postoperative arterial stenosis or occlusion, and no complications resulted from the ureteroneocystostomy

EXTRACORPOREAL RENAL SURGERY AND AUTOTRANSPLANTATION

809

that was done in 7 patients undergoing extracorporeal branch renovascular repair. In these latter cases the period of cold renal ischemia varied from 1 to 3 hours. Of 10 autotransplants for ureteral disease 8 have been successful with excellent function of the involved kidney from 1 to 8 years postoperatively. The 2 failures in this group, described elsewhere, 10 occurred in patients undergoing urinary undiversion in whom there were severe inflammation and fibrosis around the kidney and its vascular pedicle. All 3 patients who underwent extracorporeal partial nephrectomy and autotransplantation for carcinoma in a solitary kidney are alive, with functioning autografts and free of tumor from 10 to 48 months postoperatively (table 2). One patient (C. D.), in whom a generous and technically complicated resection was done, required hemodialysis for 6 months postoperatively. Resolution of postoperative acute tubular necrosis and hypertrophy of the renal remnant subsequently allowed dialysis to be discontinued, and the serum creatinine in this patient is now 3.1 mg. per cent. One patient (0. W.) in whom the lower half of the kidney was excised suffered a postoperative urine leak from ischemic necrosis of the renal pelvis and upper ureter. This FIG. 4. Cystogram after renal autotransplantation with Boari flap pyelovesicostomy in patient with recurrent renal colic.

leakage resolved after secondary repair and insertion of a nephrostomy tube. However, a stricture of the ureteropelvic junction developed with healing. This patient remains on nephrostomy drainage with a serum creatinine of 2.6 mg. per cent and a reconstructive procedure to restore urine flow to the bladder is being considered. Our single patient undergoing autotransplantation for multiple recurrent renal calculi is 6 months postoperative with a serum creatinine of 1.1 mg. per cent. Excretory urography shows excellent unobstructed function of the autograft and there has been no further stone formation during this short followup interval. Of 43 renal allotransplants done after extracorporeal donor arterial repair there were no cases of arterial thrombosis or hemorrhage from vascular anastomoses. One patient suffered late arterial stenosis at a suture line with resulting hypertension that has been controlled medically. There were no other cases of severe post-transplant hypertension and no graft ruptures occurred. Two patients had urine leaks at the site of ureteroneocystostomy. However, these patients were considered technical failures and not the result of devascularization with ureteral necrosis. DISCUSSION

FIG. 3. Method of extracorporeal partial nephrectomy for renal carcinoma. Dissection begins in renal hilus, ligating and dividing all vascular channels supplying neoplasm.

Extracorporeal renal surgery and/or autotransplantation has become the treatment of choice for several difficult urologic problems. The advantages of performing extracorporeal repair of the kidney include optimum exposure and illumination, a bloodless surgical field, greater protection of the kidney from ischemia, more facile use of microvascular techniques and optical magnification, and diminished risk of tumor spillage in cases of carcinoma. Nevertheless, since these operations are technically complex they are best reserved for problems that are not amenable to repair in situ with conventional methods. At this institution the most common indication for an extracorporeal renal operation has been the preparation of donor kidneys for allotransplantation with diseased, damaged or multiple arteries. Multiple renal arteries occur unilaterally and bilaterally in 23 and 10 per cent of the population, respectively, and have comprised the most frequent indication for such vascular repairs when a Carrel aortic patch is unavailable. The 3 extracorporeal methods of donor arterial repair described herein are technically uncomplicated, are readily applicable to most anatomic situations, allow performance of a precise repair between arteries of similar thickness and the repair can be examined carefully upon completion. In addition, since the

810

NOVICK, STEWART AND STRAFFON TABLE

Pt.-Age-Sex (yrs.)

RY-56-F CD-48-F

OW-55-M

TABLE

2. Extracorporeal partial nephrectomy and autotransplantation for renal carcinoma in a solitary kidney %Kidney Resected

Tumor Location Upper third of kidney Central Lower half of kidney

40 65 60

3. In situ versus extracorporeal partial nephrectomy for

renal carcinoma in 22 patients No. Pts. Tumor location: Polar or lateral Central

18 4

In Situ Excision

Extracorporeal Excision

18

0 3

1*

* Earlier patient with incomplete excision of tumor in situ. 16

kidney is kept cold throughout the bench procedure transplantation then is done as with a single renal artery with no increase in revascularization time. For these reasons extracorporeal arterial repair is preferable to methods of transplantation that require performance of multiple arterial anastomoses in situ. Renal autotransplantation infrequently is indicated in the surgical treatment of renovascular disease. Significantly, of >350 patients who have undergone renal revascularization at this institution since 1969 only 10 (3.5 per cent) have required management by autotransplantation. It has been our experience that branch renal artery lesions can often be repaired in situ when disease-free branches occur outside the renal hilus. 11 The size of the involved branches has not been a determining factor and, using microvascular instruments with optical magnification, vessels as small as 1.5 mm. in diameter can be repaired in situ. Extracorporeal branch arterial repair and autotransplantation are, thus, indicated only when preoperative angiography demonstrates intrarenal extension of renovascular disease. Although some have recommended using pulsatile perfusion exclusively to achieve renal preservation during such repairs, 12 this involves an obligatory period of ischemia to each renal segment during repair of its corresponding branch. In difficult cases this may lead to prolonged acute tubular necrosis or nonfunction of the autograft13 and, therefore, we recommend that the flushed kidney be protected with external cooling throughout these repairs. Renal autotransplantation also is indicated when renovascular disease is associated with the middle aortic syndrome, 14 or in some patients with a surgically difficult aorta and iliac arteries relatively free of disease. 15 A recent review has shown that satisfactory results may be obtained after partial nephrectomy for bilateral synchronous renal neoplasms or carcinoma occurring in a solitary kidney. 16 In our experience the majority of these tumors (82 per cent) has been situated at either renal pole or on the lateral mid aspect of the kidney, enabling in situ partial nephrectomy with free margins of resection (table 3). Only 3 patients with large centrally located tumors have required extracorporeal partial nephrectomy and autotransplantation. Although the followup on these patients is relatively short they all currently are free of tumor with adequate renal function. These operations may be particularly complicated, and to preserve collateral ureteral vascular supply it is best to leave the ureter attached. As our third case (0. W.) illustrates, if complete removal of the neoplasm requires extensive hilar dissection of vessels supplying the renal pelvis or ureter a nephrostomy tube also should be left indwelling postoperatively. Renal autotransplantation continues to provide an effective form of management for patients with extensive ureteral disease or selected patients undergoing urinary undiversion. 10 We continue to advise caution in performing autotransplantation of kidneys that are severely inflamed, excessively manipulated or involved with significant parenchymal disease. Ureteral re-

Hrs. Renal Preservation

Current Serum Creatinine (mg.%)

2.5

1.6

3.1 2.6

3 24

Outcome Alive, 48 mos. postop. free of tumor Alive, 13 mos. postop. free of tumor Alive, 10 mos. postop. free of tumor, with nephrostomy tube

placement by intestinal segments or supravesical diversion is preferable in most of these complex cases. In patients with recurrent obstructing ureteral calculi and intractable colic autotransplantation with pyelovesicostomy can provide an excellent alternative to ileal ureteral replacement in permitting direct passage of subsequent stones into the bladder. 17 Olsson and Idelson also have emphasized the advantages of a specially constructed Boari bladder flap in functioning as a non-refluxing, large caliber urinary conduit in these patients.18 Gutman and associates recently reported successful extracorporeal repair and autotransplantation after an avulsion injury to the renal pedicle. 19 Although such injuries are uncommon and require early operative intervention for attempted renal salvage this is an ideal area for the application of extracorporeal microvascular renal reconstruction and autotransplantation. In 1 of our patients with carcinoma in a solitary kidney (0. W.) the repaired kidney was maintained on pulsatile perfusion for 24 hours before autotransplantation until the condition of the patient stabilized. This approach also might be used in the critically ill patient with multiple injuries and severe renal trauma, in whom renal salvage is believed to be important. Finally, we remain skeptical about the role of extracorporeal pyelonephrolithotomy and autotransplantation in patients with extensive renal calculous disease. It would appear thus far that the vast majority of these cases can be managed satisfactorily by either anatrophic nephrolithotomy20 or extended pyelolithotomy. 21 Despite increasing familiarity with methods of renal preservation and vascular reconstruction autotransplantation should continue to be used only in selected cases and when in situ operative management is not possible technically. REFERENCES

1. Hardy, J. D.: High ureteral injuries. Management by autotransplantation of the kidney. J .A.M.A., 184: 97, 1963. 2. Ota, K., Mori, S., Awane, Y. and Ueno, A.: Ex situ repair of renal artery for renovascular hypertension. Arch. Surg., 94: 370, 1967. 3. Stewart, B. H., Banowsky, L. H., Hewitt, C. B. and Straffon, R. A.: Renal autotransplantation: current perspectives. J. Urol., 118: 363, 1977.

4. Magnusson, M. 0. and Stowe, N. T.: Controversy in organ preservation. Urol. Clin. N. Amer., 3: 491, 1976. 5. Novick, A. C., Braun, W. E., Magnusson, M. 0. and Stowe, N.: Current status of renal transplantation at the Cleveland Clinic. J. Urol., 122: 433, 1979. 6. Novick, A. C., Stewart, B. H. and Straffon, R. A.: Autogenous arterial grafts in the treatment of renal artery stenosis. J. Urol., 118: 919, 1977. 7. Novick, A. C. and Pohl, M.A.: Atherosclerotic renal artery occlusion extending into branches: successful revascularization in situ with a branched saphenous vein graft. J. Urol., 122: 240, 1979. 8. Alfidi, R. J. and Magnusson, M. 0.: Arteriography during perfusion preservation of kidneys. Amer. J. Roentgen., 114: 690, 1972. 9. Novick, A. C., Magnusson, M. and Braun, W. E.: Multiple-artery renal transplantation: emphasis on extracorporeal methods of donor arterial reconstruction. J. Urol., 122: 731, 1979. 10. Stewart, B. H., Hewitt, C. B. and Banowsky, L. H.: Management of extensively destroyed ureter: special reference to renal autotransplantation. J. Urol., 115: 257, 1976. 11. Novick, A. C., Straffon, R. A. and Stewart, B. H.: Surgical management of branch renal artery disease: in situ versus extracorporeal methods of repair. J. Urol., 123: 311, 1980. 12. Salvatierra, 0., Jr., Olcott, C., IV and Stoney, R. J.: Ex vivo renal

EXTRACORPOREAL RENAL SURGERY AND AUTOTRANSPLANTATION

13.

14. 15.

16.

I

artery reconstruction using perfusion preservation. J. Urol., 119: 16, 1978. Berkoff, H.: Unpublished discussion of paper by Salvatierra, 0., Jr., Olcott, C., IV and Stoney, R. J.: Ex vivo renal artery reconstruction using perfusion preservation. J. Urol., 119: 16, 1978. Kaufman, J. J.: The middle aortic syndrome: report of a case treated by renal autotransplantation. J. Urol., 109: 711, 1973. Novick, A. C., Banowsky, L. H. W., Stewart, B. H. and Straffon, R. A.: Renal revascularization in patients with severe atherosclerosis of the abdominal aorta or a previous operation on the abdominal aorta. Surg., Gynec. & Obst., 144: 211, 1977. Novick, A. C., Stewart, B. H., Straffon, R. A. and Banowsky, L. H.: Partial nephrectomy in the treatment of renal adenocarcinoma.

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J. Urol., 118: 932, 1977. 17. Goodwin, W. E. and Cockett, A. T. K.: Surgical treatment of multiple, recurrent, branched, renal (staghorn) calculi by pyelonephro-ileo-vesical anastomosis. J. Urol., 85: 214, 1961. 18. Olsson, C. A. and Idelson, B.: Renal autotransplantation for recurrent renal colic. J. Urol., 123: 467, 1980. 19. Gutman, F. M., Homsy, Y. and Schmidt, E.: Avulsion injury to the renal pedicle: successful autotransplantation after "bench surgery". J. Trauma, 18: 469, 1978. 20. Smith, M. J. V. and Boyce, W. H.: Anatrophic nephrotomy and plastic calyrhaphy. J. Urol., 99: 521, 1968. 21. Gil-Vernet, J.: New surgical concepts in removing renal calculi. Urol. Int., 20: 255, 1965.