- Email: [email protected]
Laparoscopic nephrectomy in crossed fused renal ectopia
ADULT UROLOGY
LAPAROSCOPIC NEPHRECTOMY IN CROSSED FUSED RENAL ECTOPIA KENNETH E. STANLEY, M.D. HOWARD N. WINFIELD, M.D. JAMES E DONOVAN, M.D. BERNARD FALLON, M.D. From the Department of Urology, University of Iowa College of Medicine, Iowa City, Iowa
ABSTRACT-Operative laparoscopy offers the patient a minimally invasive alternative to open surgery. We have recently performed a laparoscopic nephrectomy of the upper moiety of a crossed fused renal ectopia. The procedure lasted approximately six hours, and the patient was discharged on postoperative day 3. He was able to resume normal physical activity in one week. This case demonstrates the advantages of minimally invasive surgery.
Urologic laparoscopy recently has become a minimally invasive alternative to open surgery. This new technology has been applied to pelvic lymph node dissection for the staging of prostate cancer,’ varix ligation for the treatment of the clinically symptomatic varicocele,2 and bladder neck suspension for the treatment of stress urinary incontinence.3 In addition, laparoscopy has become an alternative to open renal surgery. Laparoscopic renal surgery was first investigated in the porcine animal model by Clayman et ~1.~ in 1989. It was subsequently applied to humans, and the first case report of a laparoscopic nephrectomy appeared in the literature in 1991.5 Since that time, a large clinical experience with laparoscopic renal surgery has been acquired throughout the country These cases usually involve the excision of a poorly functioning diseased kidney6 or the marsupialization of a benign renal cyst.’ We recently have had the opportunity to apply laparoscopic renal surgery, specifically laparoscopic nephrectomy, to the upper moiety of a crossed fused renal ectopia. MATERIAL AND METHODS CASEREPORT
An eighteen-year-old varsity football player was found to be hypertensive (210/100 mm Hg) at the FIGURE
Submitted: April 16, 1993, accepted (with revisions): May 21, 1993
UROLOGY
/ OCTOBER1993 / VOLUME42, NUMBER4
1.
renal ectopia kidney.
Illustration of right-to-left crossed fused with UPJ obstruction involving orthotopic
375
RIGHT KIOlJEY
LEFIKIOIM
FIGURE 2. DMSA renal scan reveals 96 percent function from pelvic kidney.
time of his preseason football physical examination. He was subsequently given enalapril 5 mg once a day which resulted in good blood pressure control. In addition, he had a history of childhood urinary tract infections as well as vague intermittent left flank pain. On further evaluation, his serum creatine was found to be 1.8 mg/dL (normal 0.8-1.3 mg/dL) and his creatinine clearance was 101 mL/min (normal 75-140 mUmin). A renal ultrasound revealed a hydronephrotic left kidney with severe cortical thinning (3.5 x 6 x 12.5 cm). The right kidney was absent from the renal fossa and was visualized in the pelvis (5 x 5 x 11.5 cm). The renal ultrasound did not show any evidence of left hydroureter and so a voiding cystourethrogram to rule out vesicoureteral reflux was not performed. With the working diagnosis of crossed fused renal ectopia with an associated ureteropelvic junction (UPJ) obstruction of the upper moiety (Fig. l), the patient underwent a dimercaptosuccinic acid (DMSA) renal scan. The scan revealed that 96 percent of the total renal function was from the pelvic kidney (Fig. 2). A retrograde pyelogram confirmed that a UPJ obstruction was the cause of the hydronephrosis. An indwelling ureteral stent was placed across the UPJ obstruction in hopes of improving the renal function. However, after four weeks, a second renal scan showed no improvement, and the patient was advised that a nephrectomy was indicated. After being informed of the various surgical options, he consented to a laparoscopic approach. PROCEDURE
In preparation for a laparoscopic nephrectomy, a computerized tomography (CT) scan was performed. This revealed that the hydronephrotic left kidney and the pelvic kidney were in close prox-
376
FIGURE 3. Arteriogram showing single renal artery to orthotopic kidney and dual blood supply to pelvic kidney (arrows).
imity at the level of L,. However, no renal parenchymal bridge could be clearly identified. An arteriogram showed a single artery leading to the hydronephrotic kidney at the level of L,. The pelvic kidney was perfused by a branch from the middle sacral artery as well as a branch from the left common iliac artery (Fig. 3). On the day prior to the procedure, the patient underwent a full mechanical bowel preparation. At the time of surgery, the left indwelling ureteral stent was changed over to an externalized 7-F end-hole stent through which an Amplatz superstiff guidewire was placed. In addition, an externalized 6-F end-hole stent and super-stiff guide
UROLOGY
/
OCTOBER 1993
/ VOLLM
42.NUMBER
4
:=I=--< 0
0
7
$.12mm O-lomm
FIGURE
4.
Illustration of usual port placement laparoscopic nephrectomy.
for
wire were placed in the ureter leading to the pelvic kidney By manipulation of the externalized stent-guidewire system, the ureter could be more easily identified throughout the course of the procedure. A Foley catheter and a nasogastric tube were also placed. The patient was placed on the operating table such that he could be maneuvered into the fullflank position with the aid of a beanbag apparatus. He was well secured and all pressure points were padded. The pneumoperitoneum was established using the Hasson technique of open laparoscopy Two working ports, 10 mm and 12 mm, were placed along the midclavicular line. The patient was then rotated into the full left flank position and the left colon was mobilized by incising along the white line of Toldt. Once the colon was mobilized medially, two lo-mm working ports were placed along the anterior axillary line (Fig. 4). On gaining access to the retroperitoneum, the ureter was readily identified. It was mobilized along its length and followed to the level of the ureteropelvic junction. The testicular vessels were identified as they crossed anterior to the ureter. These vessels were gently mobilized away from the operative field and spared. On identification of the hydronephrotic left kidney, Gerota’s fascia was opened and the lower pole was identified. It was noted to be fused to the superior pole of the pelvic kidney. The dissection was then carried medially to expose the left renal hilum. The single renal artery and vein were identified and each was doubly clipped and transected. The kidney was then mobilized superiorly and laterally to remove it from the renal fossa. After having ligated the vessels of the renal hilum and fully mobilizing the kidney, the parenchymal bridge was addressed. The parenchymal bridge was transected sharply with endoscopic scissors. A significant amount of bleeding was noted from the raw surface of the still well-perfused pelvic kidney To control this bleeding, a laparoscopic transducer for the argon beam coagulator (Birtcher Medical Systems, Irvine UROLOGY
/ OCTOBER 1993 / VOLUME42, NUMBER 4
CA) was placed through a lateral lo-mm working port. The raw parenchymal surface was then fulgurated and hemostasis was obtained. The hydronephrotic kidney was then completely free except for the ureter. The ureter was followed as far into the pelvis as possible and transected. The stent-guidewire system was then removed. The patient was rotated back to the horizontal position, and the laparoscope was moved to one of the midclavicular lo-mm ports. The midline laparoscopic port, which was initially placed by the open Hasson technique, was removed and the fascial incision was extended such that its total length was approximately 2 inches. The decompressed and devascularized kidney was easily withdrawn through this small incision. The total operative time was six hours and fifteen minutes, and the estimated blood loss was 100 cc. Postoperatively, the patient was able to tolerate a liquid diet within twenty-four hours. He was ambulating and tolerating a regular diet within forty-eight hours, and was ready for discharge within seventy-two hours. His total postoperative analgesic consumption was 100 mg of intramuscular meperidine (2 doses of 50 mg). After leaving the hospital, the patient required no supplemental analgesics, and he was able to begin a light exercise routine in one week. After two weeks he had returned to the regular team workout which consisted of running and weightlifting. At six weeks of follow-up, the patient was feeling quite well. He was still required to take enalapril 5 mg once a day to control his hypertension. COMMENT While the horseshoe kidney is the most common renal fusion anomaly, crossed fused ectopia also may be encountered. This entity occurs twice as often in males as in females, and occurs three times more commonly in the left than right one. This anomaly is generally associated with a normal trigone. However, reflux may occur in the ectopic kidney. The orthotopic kidney is usually normal.8 This case represents a right-to-left crossed fused renal ectopia with a ureteropelvic junction obstruction of the orthotopic kidney The patient presented with hypertension which was probably unrelated to the hydronephrosis. He had a strong family history of essential hypertension. However, his past history of childhood urinary tract infections as well as intermittent left flank pain may well have been caused by the chronic hydronephrosis. 377
A common presenting sign of a previously silent hydronephrosis is hematuria following minimal trauma.’ The fact that this kidney was essentially nonfunctional, as well as the risk of significant renal injury during his routine sports activities, favored nephrectomy as the treatment of choice for this patient. Of particular utility during laparoscopic renal surgery is the argon beam coagulator. We have found that it provides excellent hemostasis of the raw parenchymal surface that is often encountered during laparoscopic renal cyst marsupialization as well as partial nephrectomy.” Laparoscopic nephrectomy allowed this patient to be discharged from the hospital within three days of the procedure. In addition, he was able to avoid the long convalescence period that would have been required following open surgery. This case demonstrates the remarkable advantages of minimally invasive surgery. Kenneth E. Stanley, M.D. Department of Urology University of lowa College of Medicine 200 Hawkins Drive Iowa City, Iowa 52242
378
REFERENCES 1. Winfield HN, Donovan JF Jr, See WA, Loening SA, and Williams RD: Laparoscopic pelvic lymph node dissection for genitourinary malignancies: indications, techniques, and results. J Endouro16: 103-l 11, 1992. 2. Donovan JF Jr, and Winfield HN: Laparoscopic varix ligation with the Nd:YAG laser. J Endouro16: 165-171, 1992. 3. Albala DM, Schuessler Ww, and Vancaillie TG: Laparoscopic bladder neck suspension. J Endourol 6: 137-141, 1992. 4. Clayman RV, Long Sl, Kavoussi LR, Long SR, Dierks SM, Meretyk S, and Soper HS: Laparoscopic nephrectomy in the pig: technique and results. J Endouro14: 247-252, 1990. 5. Clayman RV, Kavoussi LR, Soper NJ, Dierks SM, Meretyk S, Darcy MD, Roemer FD, Pingleton ED, Thomson PG, and Long SR: Laparoscopic nephrectomy: initial case report. J Urol146: 278-282,1991. 6. Clayman RV, Kavoussi LR, Soper NJ, Albala DM, Figenshan RS, and Chandhoke PS: Laparoscopic nephrectomy: review of the initial 10 cases. J Endouro16: 127-132, 1992. 7. Morgan C Jr, and Rader D: Laparoscopic unroofing of a renal cyst. J Urol 148: 1835-1836, 1992. 8. Snow BW: Ectopic kidneys and renal fusion anomalies, Baltimore, AUA Update Series, ~016, 1987. 9. Kelalis PP: Ureteropelvic junction, in Kelalis PP, King LR, and Bellman AB (Eds): Clinical Pediatric Urology, Philadelphia, WB Saunders Co., chap 16, 1985, pp 450512. 10. Winfield HN, Donovan JF, Godet AS, and Clayman RV: Laparoscopic partial nephrectomy: initial case report for benign disease. J Endourol (in press) 1993.
UROLOGY
/ OCTOBER1993
/ VOLUME42, NUMBER4
LAPAROSCOPIC NEPHRECTOMY IN CROSSED FUSED RENAL ECTOPIA KENNETH E. STANLEY, M.D. HOWARD N. WINFIELD, M.D. JAMES E DONOVAN, M.D. BERNARD FALLON, M.D. From the Department of Urology, University of Iowa College of Medicine, Iowa City, Iowa
ABSTRACT-Operative laparoscopy offers the patient a minimally invasive alternative to open surgery. We have recently performed a laparoscopic nephrectomy of the upper moiety of a crossed fused renal ectopia. The procedure lasted approximately six hours, and the patient was discharged on postoperative day 3. He was able to resume normal physical activity in one week. This case demonstrates the advantages of minimally invasive surgery.
Urologic laparoscopy recently has become a minimally invasive alternative to open surgery. This new technology has been applied to pelvic lymph node dissection for the staging of prostate cancer,’ varix ligation for the treatment of the clinically symptomatic varicocele,2 and bladder neck suspension for the treatment of stress urinary incontinence.3 In addition, laparoscopy has become an alternative to open renal surgery. Laparoscopic renal surgery was first investigated in the porcine animal model by Clayman et ~1.~ in 1989. It was subsequently applied to humans, and the first case report of a laparoscopic nephrectomy appeared in the literature in 1991.5 Since that time, a large clinical experience with laparoscopic renal surgery has been acquired throughout the country These cases usually involve the excision of a poorly functioning diseased kidney6 or the marsupialization of a benign renal cyst.’ We recently have had the opportunity to apply laparoscopic renal surgery, specifically laparoscopic nephrectomy, to the upper moiety of a crossed fused renal ectopia. MATERIAL AND METHODS CASEREPORT
An eighteen-year-old varsity football player was found to be hypertensive (210/100 mm Hg) at the FIGURE
Submitted: April 16, 1993, accepted (with revisions): May 21, 1993
UROLOGY
/ OCTOBER1993 / VOLUME42, NUMBER4
1.
renal ectopia kidney.
Illustration of right-to-left crossed fused with UPJ obstruction involving orthotopic
375
RIGHT KIOlJEY
LEFIKIOIM
FIGURE 2. DMSA renal scan reveals 96 percent function from pelvic kidney.
time of his preseason football physical examination. He was subsequently given enalapril 5 mg once a day which resulted in good blood pressure control. In addition, he had a history of childhood urinary tract infections as well as vague intermittent left flank pain. On further evaluation, his serum creatine was found to be 1.8 mg/dL (normal 0.8-1.3 mg/dL) and his creatinine clearance was 101 mL/min (normal 75-140 mUmin). A renal ultrasound revealed a hydronephrotic left kidney with severe cortical thinning (3.5 x 6 x 12.5 cm). The right kidney was absent from the renal fossa and was visualized in the pelvis (5 x 5 x 11.5 cm). The renal ultrasound did not show any evidence of left hydroureter and so a voiding cystourethrogram to rule out vesicoureteral reflux was not performed. With the working diagnosis of crossed fused renal ectopia with an associated ureteropelvic junction (UPJ) obstruction of the upper moiety (Fig. l), the patient underwent a dimercaptosuccinic acid (DMSA) renal scan. The scan revealed that 96 percent of the total renal function was from the pelvic kidney (Fig. 2). A retrograde pyelogram confirmed that a UPJ obstruction was the cause of the hydronephrosis. An indwelling ureteral stent was placed across the UPJ obstruction in hopes of improving the renal function. However, after four weeks, a second renal scan showed no improvement, and the patient was advised that a nephrectomy was indicated. After being informed of the various surgical options, he consented to a laparoscopic approach. PROCEDURE
In preparation for a laparoscopic nephrectomy, a computerized tomography (CT) scan was performed. This revealed that the hydronephrotic left kidney and the pelvic kidney were in close prox-
376
FIGURE 3. Arteriogram showing single renal artery to orthotopic kidney and dual blood supply to pelvic kidney (arrows).
imity at the level of L,. However, no renal parenchymal bridge could be clearly identified. An arteriogram showed a single artery leading to the hydronephrotic kidney at the level of L,. The pelvic kidney was perfused by a branch from the middle sacral artery as well as a branch from the left common iliac artery (Fig. 3). On the day prior to the procedure, the patient underwent a full mechanical bowel preparation. At the time of surgery, the left indwelling ureteral stent was changed over to an externalized 7-F end-hole stent through which an Amplatz superstiff guidewire was placed. In addition, an externalized 6-F end-hole stent and super-stiff guide
UROLOGY
/
OCTOBER 1993
/ VOLLM
42.NUMBER
4
:=I=--< 0
0
7
$.12mm O-lomm
FIGURE
4.
Illustration of usual port placement laparoscopic nephrectomy.
for
wire were placed in the ureter leading to the pelvic kidney By manipulation of the externalized stent-guidewire system, the ureter could be more easily identified throughout the course of the procedure. A Foley catheter and a nasogastric tube were also placed. The patient was placed on the operating table such that he could be maneuvered into the fullflank position with the aid of a beanbag apparatus. He was well secured and all pressure points were padded. The pneumoperitoneum was established using the Hasson technique of open laparoscopy Two working ports, 10 mm and 12 mm, were placed along the midclavicular line. The patient was then rotated into the full left flank position and the left colon was mobilized by incising along the white line of Toldt. Once the colon was mobilized medially, two lo-mm working ports were placed along the anterior axillary line (Fig. 4). On gaining access to the retroperitoneum, the ureter was readily identified. It was mobilized along its length and followed to the level of the ureteropelvic junction. The testicular vessels were identified as they crossed anterior to the ureter. These vessels were gently mobilized away from the operative field and spared. On identification of the hydronephrotic left kidney, Gerota’s fascia was opened and the lower pole was identified. It was noted to be fused to the superior pole of the pelvic kidney. The dissection was then carried medially to expose the left renal hilum. The single renal artery and vein were identified and each was doubly clipped and transected. The kidney was then mobilized superiorly and laterally to remove it from the renal fossa. After having ligated the vessels of the renal hilum and fully mobilizing the kidney, the parenchymal bridge was addressed. The parenchymal bridge was transected sharply with endoscopic scissors. A significant amount of bleeding was noted from the raw surface of the still well-perfused pelvic kidney To control this bleeding, a laparoscopic transducer for the argon beam coagulator (Birtcher Medical Systems, Irvine UROLOGY
/ OCTOBER 1993 / VOLUME42, NUMBER 4
CA) was placed through a lateral lo-mm working port. The raw parenchymal surface was then fulgurated and hemostasis was obtained. The hydronephrotic kidney was then completely free except for the ureter. The ureter was followed as far into the pelvis as possible and transected. The stent-guidewire system was then removed. The patient was rotated back to the horizontal position, and the laparoscope was moved to one of the midclavicular lo-mm ports. The midline laparoscopic port, which was initially placed by the open Hasson technique, was removed and the fascial incision was extended such that its total length was approximately 2 inches. The decompressed and devascularized kidney was easily withdrawn through this small incision. The total operative time was six hours and fifteen minutes, and the estimated blood loss was 100 cc. Postoperatively, the patient was able to tolerate a liquid diet within twenty-four hours. He was ambulating and tolerating a regular diet within forty-eight hours, and was ready for discharge within seventy-two hours. His total postoperative analgesic consumption was 100 mg of intramuscular meperidine (2 doses of 50 mg). After leaving the hospital, the patient required no supplemental analgesics, and he was able to begin a light exercise routine in one week. After two weeks he had returned to the regular team workout which consisted of running and weightlifting. At six weeks of follow-up, the patient was feeling quite well. He was still required to take enalapril 5 mg once a day to control his hypertension. COMMENT While the horseshoe kidney is the most common renal fusion anomaly, crossed fused ectopia also may be encountered. This entity occurs twice as often in males as in females, and occurs three times more commonly in the left than right one. This anomaly is generally associated with a normal trigone. However, reflux may occur in the ectopic kidney. The orthotopic kidney is usually normal.8 This case represents a right-to-left crossed fused renal ectopia with a ureteropelvic junction obstruction of the orthotopic kidney The patient presented with hypertension which was probably unrelated to the hydronephrosis. He had a strong family history of essential hypertension. However, his past history of childhood urinary tract infections as well as intermittent left flank pain may well have been caused by the chronic hydronephrosis. 377
A common presenting sign of a previously silent hydronephrosis is hematuria following minimal trauma.’ The fact that this kidney was essentially nonfunctional, as well as the risk of significant renal injury during his routine sports activities, favored nephrectomy as the treatment of choice for this patient. Of particular utility during laparoscopic renal surgery is the argon beam coagulator. We have found that it provides excellent hemostasis of the raw parenchymal surface that is often encountered during laparoscopic renal cyst marsupialization as well as partial nephrectomy.” Laparoscopic nephrectomy allowed this patient to be discharged from the hospital within three days of the procedure. In addition, he was able to avoid the long convalescence period that would have been required following open surgery. This case demonstrates the remarkable advantages of minimally invasive surgery. Kenneth E. Stanley, M.D. Department of Urology University of lowa College of Medicine 200 Hawkins Drive Iowa City, Iowa 52242
378
REFERENCES 1. Winfield HN, Donovan JF Jr, See WA, Loening SA, and Williams RD: Laparoscopic pelvic lymph node dissection for genitourinary malignancies: indications, techniques, and results. J Endouro16: 103-l 11, 1992. 2. Donovan JF Jr, and Winfield HN: Laparoscopic varix ligation with the Nd:YAG laser. J Endouro16: 165-171, 1992. 3. Albala DM, Schuessler Ww, and Vancaillie TG: Laparoscopic bladder neck suspension. J Endourol 6: 137-141, 1992. 4. Clayman RV, Long Sl, Kavoussi LR, Long SR, Dierks SM, Meretyk S, and Soper HS: Laparoscopic nephrectomy in the pig: technique and results. J Endouro14: 247-252, 1990. 5. Clayman RV, Kavoussi LR, Soper NJ, Dierks SM, Meretyk S, Darcy MD, Roemer FD, Pingleton ED, Thomson PG, and Long SR: Laparoscopic nephrectomy: initial case report. J Urol146: 278-282,1991. 6. Clayman RV, Kavoussi LR, Soper NJ, Albala DM, Figenshan RS, and Chandhoke PS: Laparoscopic nephrectomy: review of the initial 10 cases. J Endouro16: 127-132, 1992. 7. Morgan C Jr, and Rader D: Laparoscopic unroofing of a renal cyst. J Urol 148: 1835-1836, 1992. 8. Snow BW: Ectopic kidneys and renal fusion anomalies, Baltimore, AUA Update Series, ~016, 1987. 9. Kelalis PP: Ureteropelvic junction, in Kelalis PP, King LR, and Bellman AB (Eds): Clinical Pediatric Urology, Philadelphia, WB Saunders Co., chap 16, 1985, pp 450512. 10. Winfield HN, Donovan JF, Godet AS, and Clayman RV: Laparoscopic partial nephrectomy: initial case report for benign disease. J Endourol (in press) 1993.
UROLOGY
/ OCTOBER1993
/ VOLUME42, NUMBER4