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Renal Aneurysmectomy in the Ex Vivo Setting
THE JOURNAL OF UROLOGY
Vol. 118, July, Part 1 Printed in U.S .iJ..
Copyright© 1977 by The Williams & Wilkins Co.
ANEURYSMECTOMY IN THE EX MARTIN G. MCLOUGHLIN*
AND
SETTING
G. MELVILLE WILLIAMS
From the Department of Urology, The Brady Urological Institute and Section of Surgical Sciences, Division of Transplantation, The Johns Hospital, Baltimore, Maryland
ABSTRACT
The use of ex vivo dissection and reconstruction as definitive surgical management in 3 cases of renal artery aneurysms is presented. The indications, rationale for therapy and review of techare discussed. He.rein we present 3 cases of renal artery aneurysms, suetreated ex vivo dissection and reconstruction. are now available so that a kidney can be served adequately in the extracorporeal setting.'· 2 In meticulous resection and reconstruction of aneurysmal ~,,cucuc.cm.>e, of the renal artery can be done without tension or undue haste.
the superior aspect of the 12th rib, cutting the diaphragm in the posterior aspect of the incision to produce an extrapleural, extraperitoneal incision. This approach ensured adequate exposure to the superior aspect of the kidney so that all vascular dissection could be done under direct vision. The removed in the standard transplant fashion, with ligation of the renal artery and vein. After removal of the kidney the ureter was traced down to the pelvic brim and cut. The kidneys were taken to a separate bench with a warm ischemic time of approximately 90 seconds and flushed with ice cold 6 per cent dextran in heparinized saline at OC and placed in a saline slush bath. After perfusion of 300 cc dissection of the intrahilar area was performed. In this ex vivo setting the aneurysmectomy and reconstruction could be per-formed without fear of hemorrhage so that meticulous suture placement was possible without any haste. After approximately 150 minutes of ice cold ischemic time the reconstructed kidneys were then placed extraperitoneally into the.,,., ...~"'" iliac fossa in the standard transplant fashion, vascular anastomoses to the iliac vessels and with ureteropyelostomy to provide urinary drainage. The postoperative IVP in case 3 is shown in figure 2, B. No major complications were noted in the early postoperative period and an uneventful convalescence resulted in discharge from the hospital 7 to 10 days postoperatively, with BUN ranging between 12 and 15 mg. per cent and serum creatinine ranging between 1 and 1.2 mg. per cent.
CASE REPORTS
Case . The had left flank pain and blood pressure of 160/100. The urea nitrogen (BUN) level was 10 mg. per cent and the serum creatinine level was 1 mg. per cent. An (IVP) showed an incomplete rim of calcium on the aspect of the left kidney. A flush aortogram revealed an aneur<;sm at the bifurcation of the segmental renal arteries (fig. 1). This 3 cm. renal artery aneurysm at the bifurcation of the anterior and posterior segmental vessels of the left kidney was surgically approached through a transabdominal incision. Exposure of the left kidney revealed extreme intrahilar adherence of the renal vein to the aneu.. rysm. The renal and vein were divided, and the was delivered to the wall with the ureter left intact. Warm ischemic time was approximately 1 minute before ice cold 6 per cent dextran in heparinized saline at OC perfused the and lowered the core renal temperature. After perfuf'HJAi.uw,c<:,Jl.Y 300 cc of this solution the was The aneurysmectomy and vascular reconstruction were performed in 2. hours 15 minutes of cold ischemic time. The reconstructed kidney was then placed in the iliac fossa with vascular anastomoses to the iliac vessels. The ureter was left in a fashion to the bladder. Postoperathe patient an uneventful course and the long ureter never resulted in obstruction to the urinary drainage 2, A). Ten days after the operation she was disfrom the hospital with renal function studies showing level of 12 mg. per cent and a serum creatinine level of per cent. 2 and 3. These 2. patients had left flank IVPs revealed incomplete rims of calcification medial to the left Arteriography revealed aneurysmal dilatations of a segmental renal artery. These 2 cases had toneal nephrectomy with dissection and reconstruction at a separate bench and then extraperitoneal implantation into the iliac fossa. Preoperative renal function studies in both patients revealed a BUN of 10 to 14 mg. per cent, with a range of serum creati.nine levels from 0.9 to 1.1 mg. per cent. These 2 kidneys both had 2 cm. aneurysms of the anterior segmental artery distal to the bifurcation of the renal artery into the anterior and segmental branches. The kidneys were removed flank incision, which was carried along ~-~~ui..uu••
DISCUSSION
The surgical approach to aneurysmal dilatation of the renal artery has been modified with the advent of improved
Accepted for publication November 12, 1976. * Current address: Urology Clinic, University of British Columbia, 855 W. 10th Ave., Suite 1, Vancouver, B. C., Canada.
FIG. 1. Case 1. Flush aortogram shows aneurysmal dilatation of left renal artery at bifurcation of secondary renal vessels.
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MCLOUGHLIN AND WILLIAMS
Fm. 2. A, case 1-IVP shows prompt function without any obstruction from long looping ureter. B, case 3-IVP shows prompt function with good drainage after ureteropyelostomy.
reconstructive techniques. The definitive therapy in unilateral lesions in the past was nephrectomy but, with better understanding of preservation of the kidney and with modern vascular reconstructive techniques, the primary therapy is reconstructive surgery. 3 The diagnostic criteria for the indications for an operation on renal artery aneurysms have been well documented. 4 The need to review whether one uses the standard in vivo technique as opposed to the still controversial ex vivo reconstructive technique seems appropriate. Most renal artery lesions, although appearing intrahilar on arteriography, can be exposed easily with intrahilar dissection in the in vivo setting. The use of renal artery clamping, hypothermic saline slush and Gil-Vernet retractors results in an exposure that affords easy removal and reconstruction of aneurysms of the primary or early secondary vessels. The ex vivo setting provides adequate exposure for intrarenal dissection and reconstruction of peripheral aneurysmal dilatations. The decision on which approach to use for any given case is planned preoperatively but can be modified during the operation, depending on case of dissection, resection and reconstruction. The flank approach in cases 2 and 3 resulted from our belief that renal vascular reconstruction in the kidney per se seems best approached through this incision. If the reconstructive repair should involve the ostia or the aorta then the standard transperitoneal incision affords the best approach. The supracostal flank incision, cutting the diaphragm and entering the extrapleural thoracic cavity and the extraperitoneal retroperitoneal cavity, offers adequate exposure for any distal reconstructive operation or for removal of the kidney. We explore the renal artery aneurysms through this flank incision and perform intrahilar dissection. If the aneurysm is markedly adherent to the renal vein or is high in the secondary or at the bifurcation of the tertiary vessels, meticulous
dissection and reconstruction may be difficult in the in vivo setting. Thus, the kidney is removed, cutting the renal artery, renal vein and ureter. The kidney is then flushed with an ice cold solution, and dissection and reconstruction are performed at a separate bench. The flank incision is closed and the reconstructed kidney is placed extraperitoneally into the iliac fossa with the vascular anastomoses to the iliac vessels and the urinary drainage system is reconstructed with a ureteropyelostomy. The controversy of whether bench surgery is really a gimmick or whether this tool has a place in the armamentarium of renal vascular surgery is still much in debate. The rational approach that proximal renal artery aneurysms are best handled in the in vivo setting and that aneurysms deep in the hilus are best handled in the ex vivo setting seems justified. CONCLUSION
Reconstructive surgery for renal artery aneurysms requires adequate exposure and meticulous dissection. The in vivo setting offers adequate exposure for proximal renal artery aneurysms but if the intrahilar dissection is difficult or if tertiary vessels are involved the ex vivo setting seems best suited for the reconstructive phase of the operation. REFERENCES
1. Hodges, C. V., Lawson, R. K., Pearse, H. D. and Stranberg, C.
0.: Autotransplantation of the kidney. J. Urol., UO: 20, 1973. 2. Taylor, R. W., Banowsky, L. H. and Borden, T. A.: Ex vivo renal surgery and autotransplantation: a preliminary report. J. Urol., 111: 148, 1974. 3. Poutasse, E. F.: Renal artery aneurysms. J. Urol., 113: 443, 1975. 4. McCarron, J. P., Jr., Marshall, V. F. and Whitsell, J. C., II.: Indications for surgery on renal artery aneurysms. J. Urol., 114: 177, 1975.
Vol. 118, July, Part 1 Printed in U.S .iJ..
Copyright© 1977 by The Williams & Wilkins Co.
ANEURYSMECTOMY IN THE EX MARTIN G. MCLOUGHLIN*
AND
SETTING
G. MELVILLE WILLIAMS
From the Department of Urology, The Brady Urological Institute and Section of Surgical Sciences, Division of Transplantation, The Johns Hospital, Baltimore, Maryland
ABSTRACT
The use of ex vivo dissection and reconstruction as definitive surgical management in 3 cases of renal artery aneurysms is presented. The indications, rationale for therapy and review of techare discussed. He.rein we present 3 cases of renal artery aneurysms, suetreated ex vivo dissection and reconstruction. are now available so that a kidney can be served adequately in the extracorporeal setting.'· 2 In meticulous resection and reconstruction of aneurysmal ~,,cucuc.cm.>e, of the renal artery can be done without tension or undue haste.
the superior aspect of the 12th rib, cutting the diaphragm in the posterior aspect of the incision to produce an extrapleural, extraperitoneal incision. This approach ensured adequate exposure to the superior aspect of the kidney so that all vascular dissection could be done under direct vision. The removed in the standard transplant fashion, with ligation of the renal artery and vein. After removal of the kidney the ureter was traced down to the pelvic brim and cut. The kidneys were taken to a separate bench with a warm ischemic time of approximately 90 seconds and flushed with ice cold 6 per cent dextran in heparinized saline at OC and placed in a saline slush bath. After perfusion of 300 cc dissection of the intrahilar area was performed. In this ex vivo setting the aneurysmectomy and reconstruction could be per-formed without fear of hemorrhage so that meticulous suture placement was possible without any haste. After approximately 150 minutes of ice cold ischemic time the reconstructed kidneys were then placed extraperitoneally into the.,,., ...~"'" iliac fossa in the standard transplant fashion, vascular anastomoses to the iliac vessels and with ureteropyelostomy to provide urinary drainage. The postoperative IVP in case 3 is shown in figure 2, B. No major complications were noted in the early postoperative period and an uneventful convalescence resulted in discharge from the hospital 7 to 10 days postoperatively, with BUN ranging between 12 and 15 mg. per cent and serum creatinine ranging between 1 and 1.2 mg. per cent.
CASE REPORTS
Case . The had left flank pain and blood pressure of 160/100. The urea nitrogen (BUN) level was 10 mg. per cent and the serum creatinine level was 1 mg. per cent. An (IVP) showed an incomplete rim of calcium on the aspect of the left kidney. A flush aortogram revealed an aneur<;sm at the bifurcation of the segmental renal arteries (fig. 1). This 3 cm. renal artery aneurysm at the bifurcation of the anterior and posterior segmental vessels of the left kidney was surgically approached through a transabdominal incision. Exposure of the left kidney revealed extreme intrahilar adherence of the renal vein to the aneu.. rysm. The renal and vein were divided, and the was delivered to the wall with the ureter left intact. Warm ischemic time was approximately 1 minute before ice cold 6 per cent dextran in heparinized saline at OC perfused the and lowered the core renal temperature. After perfuf'HJAi.uw,c<:,Jl.Y 300 cc of this solution the was The aneurysmectomy and vascular reconstruction were performed in 2. hours 15 minutes of cold ischemic time. The reconstructed kidney was then placed in the iliac fossa with vascular anastomoses to the iliac vessels. The ureter was left in a fashion to the bladder. Postoperathe patient an uneventful course and the long ureter never resulted in obstruction to the urinary drainage 2, A). Ten days after the operation she was disfrom the hospital with renal function studies showing level of 12 mg. per cent and a serum creatinine level of per cent. 2 and 3. These 2. patients had left flank IVPs revealed incomplete rims of calcification medial to the left Arteriography revealed aneurysmal dilatations of a segmental renal artery. These 2 cases had toneal nephrectomy with dissection and reconstruction at a separate bench and then extraperitoneal implantation into the iliac fossa. Preoperative renal function studies in both patients revealed a BUN of 10 to 14 mg. per cent, with a range of serum creati.nine levels from 0.9 to 1.1 mg. per cent. These 2 kidneys both had 2 cm. aneurysms of the anterior segmental artery distal to the bifurcation of the renal artery into the anterior and segmental branches. The kidneys were removed flank incision, which was carried along ~-~~ui..uu••
DISCUSSION
The surgical approach to aneurysmal dilatation of the renal artery has been modified with the advent of improved
Accepted for publication November 12, 1976. * Current address: Urology Clinic, University of British Columbia, 855 W. 10th Ave., Suite 1, Vancouver, B. C., Canada.
FIG. 1. Case 1. Flush aortogram shows aneurysmal dilatation of left renal artery at bifurcation of secondary renal vessels.
15
16
MCLOUGHLIN AND WILLIAMS
Fm. 2. A, case 1-IVP shows prompt function without any obstruction from long looping ureter. B, case 3-IVP shows prompt function with good drainage after ureteropyelostomy.
reconstructive techniques. The definitive therapy in unilateral lesions in the past was nephrectomy but, with better understanding of preservation of the kidney and with modern vascular reconstructive techniques, the primary therapy is reconstructive surgery. 3 The diagnostic criteria for the indications for an operation on renal artery aneurysms have been well documented. 4 The need to review whether one uses the standard in vivo technique as opposed to the still controversial ex vivo reconstructive technique seems appropriate. Most renal artery lesions, although appearing intrahilar on arteriography, can be exposed easily with intrahilar dissection in the in vivo setting. The use of renal artery clamping, hypothermic saline slush and Gil-Vernet retractors results in an exposure that affords easy removal and reconstruction of aneurysms of the primary or early secondary vessels. The ex vivo setting provides adequate exposure for intrarenal dissection and reconstruction of peripheral aneurysmal dilatations. The decision on which approach to use for any given case is planned preoperatively but can be modified during the operation, depending on case of dissection, resection and reconstruction. The flank approach in cases 2 and 3 resulted from our belief that renal vascular reconstruction in the kidney per se seems best approached through this incision. If the reconstructive repair should involve the ostia or the aorta then the standard transperitoneal incision affords the best approach. The supracostal flank incision, cutting the diaphragm and entering the extrapleural thoracic cavity and the extraperitoneal retroperitoneal cavity, offers adequate exposure for any distal reconstructive operation or for removal of the kidney. We explore the renal artery aneurysms through this flank incision and perform intrahilar dissection. If the aneurysm is markedly adherent to the renal vein or is high in the secondary or at the bifurcation of the tertiary vessels, meticulous
dissection and reconstruction may be difficult in the in vivo setting. Thus, the kidney is removed, cutting the renal artery, renal vein and ureter. The kidney is then flushed with an ice cold solution, and dissection and reconstruction are performed at a separate bench. The flank incision is closed and the reconstructed kidney is placed extraperitoneally into the iliac fossa with the vascular anastomoses to the iliac vessels and the urinary drainage system is reconstructed with a ureteropyelostomy. The controversy of whether bench surgery is really a gimmick or whether this tool has a place in the armamentarium of renal vascular surgery is still much in debate. The rational approach that proximal renal artery aneurysms are best handled in the in vivo setting and that aneurysms deep in the hilus are best handled in the ex vivo setting seems justified. CONCLUSION
Reconstructive surgery for renal artery aneurysms requires adequate exposure and meticulous dissection. The in vivo setting offers adequate exposure for proximal renal artery aneurysms but if the intrahilar dissection is difficult or if tertiary vessels are involved the ex vivo setting seems best suited for the reconstructive phase of the operation. REFERENCES
1. Hodges, C. V., Lawson, R. K., Pearse, H. D. and Stranberg, C.
0.: Autotransplantation of the kidney. J. Urol., UO: 20, 1973. 2. Taylor, R. W., Banowsky, L. H. and Borden, T. A.: Ex vivo renal surgery and autotransplantation: a preliminary report. J. Urol., 111: 148, 1974. 3. Poutasse, E. F.: Renal artery aneurysms. J. Urol., 113: 443, 1975. 4. McCarron, J. P., Jr., Marshall, V. F. and Whitsell, J. C., II.: Indications for surgery on renal artery aneurysms. J. Urol., 114: 177, 1975.