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Renal Autotransplantation for Retroperitoneal Fibrosis
0022-5347 /81/1253-0408$02.00/0 Vol. 125, March
THE JOURNAL OF UROLOGY
Copyright © 1981 by The Williams & Wilkins Co.
Printed in U.S.A.
RENAL AUTOTRANSPLANTATION FOR RETROPERITONEAL FIBROSIS JAMES PALLESCHI* AND JACK W. McANINCH From the Department of Urology, University of California School of Medicine, San Francisco, California
ABSTRACT
Idiopathic retroperitoneal fibrosis is a disease of unknown etiology characterized by a dense rubbery retroperitoneal plaque that encases 1 or both ureters, causing hydronephrosis and impairing renal function. Primary or recurrent disease may result in extensive ureteral damage, leaving the urologist with limited surgical options. We herein report the fourth case managed successfully by renal autotransplantation. Recently, the bias in disfavor of renal autotransplantation and ex vivo vascular reconstruction has declined since experience has proved these procedures to be safe. Therefore, patients with extensive ureteral damage caused by retroperitoneal fibrosis may be managed successfully by autotransplantation. We herein report the fourth such case managed by this approach.
right side and extravasation of contrast medium in the previously operated area (fig. 2, A). The extravasated urine was drained through the old incision and a ureterostomy tube was placed in situ. A postoperative angiogram showed 2 right renal arteries (fig. 2, B). The patient was re-explored 1 week later through a midline incision. The original disease process plus
FIG. 1. A, IVP. B, retrograde pyelogram shows high grade right ureteral obstruction from extrinsic compression CASE REPORT
A 47-year-old woman with a 4-week history of right flank pain was seen first in October 1978. The medical history was unremarkable. The patient had never taken any medications regularly. An excretory urogram (IVP) and a right retrograde pyelogram showed high grade, right ureteral obstruction (fig. 1). At exploration a firm, rubbery plaque encasing the right ureter was found. Biopsies were taken and the ureter was shelled easily from the fibrotic plaque, then placed in a lateral, extraperitoneal position. A small ureterotomy was made above the area of encasement and an indwelling stent was inserted. The area was drained. Permanent sections confirmed the diagnosis of retroperitoneal fibrosis and the patient recovered uneventfully. However, 1 week after being discharged from the hospital she was admitted to our emergency room with severe right flank pain. An IVP showed severe hydronephrosis on the Accepted for publication May 9, 1980. Read at annual meeting of Western Section, American Urological Association, Kona and Honolulu, Hawaii, March 1-8, 1980. * Requests for reprints: Urology, M-553, University of California, San Francisco, California 94143. 408
extravasated urine made any attempt at identifying the distal ureter futile. A right nephrectomy, including 5 cm. of healthy proximal ureter, was done. The smaller lower pole and the main renal arteries were anastomosed end-to-side by interrupted 7zero sutures (fig. 3, A). The kidney then was autotransplanted into the contralateral iliac fossa using an end-to-end anastomosis with the hypogastric artery (fig. 3, B). The bladder was mobilized and a standard antireflux ureteroneocystostomy was done. The patient was discharged from the hospital 12 days postoperatively. An IVP at 6 months shows normal renal function in the transplanted kidney (fig. 4). DISCUSSION
Retroperitoneal fibrosis is a disease of unknown etiology that can be associated with either unilateral or bilateral ureteral obstruction. 1 Since renal damage on either side ranges from mild to severe, and since one cannot know which patients with unilateral obstruction will suffer contralateral disease, it is essential to salvage as much functioning parenchyma as possible. Nephrectomy is to be condemned for all but the most hopeless of kidneys.
ftEI"J.AL AUTOTH,At;rSPLAN-TA·TIO~T FOP, RETROPEftI'°fONE1\,L lfIBI{OSIS
FIG. 2. A, IVP after ureterolysis shows extravasation and recurrent obstruction. B, midstream angiogram shows main renal artery and smaller lower pole artery.
A
B
Fm. 3. A, anastomosis of lower pole artery to main renal artery. B, autotransplantation of kidney into contralateral pelvis.
Ureterolysis with intraperitoneal or lateral extraperitoneal placement of the ureters usually can be accomplished without much difficulty. In a small number of cases the disease process will extend into the ureteral wall, making ureterolysis more difficult. 2 In this situation use of an omental wrap can be helpful. 3 Problems of insufficient ureteral length arise when re-exploration is necessitated by recurrent ureteral obstruction. The
usual causes of such obstruction include urinary extravasation from an accidental or intentional ureterotomy as occurred in our patient, failure of the initial ureterolysis to achieve adequate drainage as reported by Linke and May,4 or recurrent ureteral entrapment by advancing disease. Repeat ureterolysis can be difficult in this situation. Kerr and associates reported that of 4 cases undergoing secondary ureterolysis 3 resulted in nephrectomy and 1 in nephrostomy. 5 Other operative alternatives have
410
PALLESCHI AND MCANINCH
provided sound vascular principles are observed. Review of several large series of transplant recipients reveals over-all vascular complication rates of <6 per cent in a population highly at risk to suffer surgical complications. 10- 12 Likewise, cumulative data from several investigators show that among 23 autotransplantations done with or without a bench procedure for retroperitoneal fibrosis, renovascular hypertension, staghorn calculi, ureteral or renal cancer, or insufficient renal length only 2 patients sustained vascular complications. 4 • 13- 20 Both occurred in patients undergoing bilateral procedures in whom contralateral autotransplants functioned successfully. Vascular spasm during a difficult donor nephrectomy precluded autotransplantation in 1 and resulted in a poorly functioning kidney in the other. The use of steroids in the treatment of recurrent unilateral obstruction due to retroperitoneal fibrosis deserves mention. Several investigators have demonstrated its effectiveness as an adjunct to ureterolysis in previously unoperated patients with idiopathic retroperitoneal fibrosis. 21 - 23 Although a trial of steroids probably is most effective early in the course of the disease it seems justified in patients with recurrent ureteral obstruction after ureterolysis if the obstruction is not severe and renal function is not in jeopardy. 21 - 24 In 1 of our own patients with long-standing disease unusual steroid sensitivity was observed as judged by improvement of the ureteral obstruction at high doses of prednisone. However, as a rule surgical intervention is indicated and renal autotransplantation should be given strong consideration in these cases. REFERENCES
FIG. 4. IVP at 6 months shows excellent function in autotransplanted kidney. included flap ureteroplasty or intubated ureterostomy, ureteral replacement with small bowel and urinary diversion, all of which can be associated with a high rate of early and late complications. 4-s Until recently, traditional attitudes toward renal autotransplantation and ex vivo vascular reconstruction were that because these procedures are considered hazardous they should be used as a court of last resorts when all other more conservative measures have failed. Nevertheless, extensive experience with homotransplantation has shown it to be a safe procedure that, when applied to the patient with extensive ureteral damage due to retroperitoneal fibrosis, allows the urologist to perform a ureteral anastomosis with healthy, viable ureter. To date, 3 patients, including our own, who underwent successful renal autotransplantation for retroperitoneal fibrosis have been reported on in the English literature. 4 ' 7 Indications for an operation included an extensively destroyed ureter in 2 cases and recurrent pyelonephritis after urinary diversion in 1. In none of these cases did the fibrotic process involve the iliac vessels-an obvious contraindication to autotransplantation. 9 Since the autotransplanted kidney in our case was placed in the contralateral iliac fossa we elected to perform a standard antireflux ureteroneocystostomy. Linke and May,4 and Stewart and associates7 used the ipsilateral iliac fossa and chose to perform ureteroureterostomy, Concerns regarding vascular complications are unwarranted
1. Ormond, J. K.: Idiopathic retroperitoneal fibrosis: a discussion of the etiology. J. Urol., 94: 385, 1965. 2. Skeel, D. A., Shols, G. W., Sullivan, M. J. and Witherington, R.: Retroperitoneal fibrosis with intrinsic ureteral involvement. J. Urol., 113: 166, 1975. 3. Turner-Warwick, R.: The use of the omental pedicle graft in urinary tract reconstruction. J. Urol., 116: 341, 1976. 4. Linke, C. A. and May, A. G.: Autotransplantation in retroperitoneal fibrosis. J. Urol., 107: 196, 1972. 5. Kerr, W. S., Jr., Suby, H. I., Vickery, A. and Fraley, E.: Idiopathic retroperitoneal fibrosis: clinical experience with 15 cases. J. Urol., 99: 575, 1968. 6. McCullough, D. L., McLaughlin, A. P., Gittes, R. F. and Kerr, W. S., Jr.: Replacement of the damaged or neoplastic ureter by ileum. J. Urol., 118: 375, 1977. 7. Stewart, B. H., Hewitt, C. B. and Banowsky, L. H. W.: Management of extensively destroyed ureter: special reference to renal autotransplantation. J. Urol., 115: 257, 1976. 8. Tanagho, E. A.: A case against the incorporation of bowel segments into the closed urinary system. J. Urol., 113: 796, 1975. 9. Olsson, C. A.: Extracorporeal renal surgery. In: Campbell's Urology, 4th ed. Edited by J. H. Harrison, R. F. Gittes, A. D. Perlmutter, T. A. Stamey and P. C. Walsh. Philadelphia: W. B. Saunders Co., vol. 3, chapt. 68, p. 2161, 1979. 10. Palleschi, J. R., Novick, A. C., Braun, W. E. and Magnusson, M. 0.: Vascular complications of renal transplantation. Urology, 16: 61, 1980. 11. Goldman, M. H., Tilney, N. L., Vineyard, G. C., Laks, H., Kahan, M. G. and Wilson, R. E.: A twenty year survey of arterial complications of renal transplantation. Surg., Gynec. & Obst., 141: 758, 1975. 12. Nerstr,am, B., Ladefoged, J. and Lund, F. I.: Vascular complications in 155 consecutive transplantations. Scand. J. Urol. Nephrol., suppl. 15, 6: 65, 1972. 13. Stewart, B. H., Banowsky, L. H., Hewitt, C. B. and Straffon, R. A.: Renal transplantation: current perspectives. J. Urol., 118: 363, 1977. 14. Turini, D., Nicita, G., Fiorelli, C., Masini, G. C. and Gazzarrini, 0.: Staghorn renal stones: value of bench surgery and autotransplantation. J. Urol., 118: 905, 1977. 15. Anderson, 0. S., Clark, S. S., Marlett, M. M. and Jonasson, 0.: Treatment of extensive renal calculi with extracorporeal surgery and autotransplantation. Urology, 7: 465, 1976. 16. Gittes, R. F. and McCullough, D. L.: Bench surgery for tumor in a
411 solita.Ty tJrol., 113: 12) 1975. 17. Diethelm, A.G., W. J., Sterling, W. A., Jr. and Tauxe, 'N. N.: Renal autotransplantation using hypothermic storage and pulsatile perfusion. J. Urol., 113: 755, 1975. 18. Murphy, G. P., Staubitz, W. J. and Kenney, G. M.: Renal autotransplantation for rehabilitation of a patient with multiple urinary tumors. J. Urol., 107: 199, 1972. 19. Pfister, R R. and Husberg, B.: Renal salvage through autotransplantation. Urology, 4: 703, 1974. 20. DeWeerd, J. H., Paul, S. C., Tomera, F. M. and Smith, L. H.: Renal autotransplantation for upper ureteral stenosis. J. Urol., lHi: 23, 1976.
21. OschnFt\ IV.L Brannan, VI.) Pond, H. S. and Goodlet, J·. S. Jr°" Medical therapy in idiopathic retroperitoneal fibrosis. J. Urol., 114: 700, 1975. 1
22. Ross, J. C. and Goldsmith, H. J.: The combined surgical and medical treatment of retroperitoneal fibrosis. Brit. J. Surg., 58: 422, 1971. 23. Mitchinson, M. J., Withycombe, J. F. R. and Jones, R. A.: The response of idiopathic fibrosis to corticosteroids. Brit. J. Urol., 43: 444, 1971. 24. Morandi, L. P. and Grob, P. J.: Retroperitoneal fibrosis. Response to corticosteroid therapy. Arch. Intern. Med., 128: 295, 1971.
THE JOURNAL OF UROLOGY
Copyright © 1981 by The Williams & Wilkins Co.
Printed in U.S.A.
RENAL AUTOTRANSPLANTATION FOR RETROPERITONEAL FIBROSIS JAMES PALLESCHI* AND JACK W. McANINCH From the Department of Urology, University of California School of Medicine, San Francisco, California
ABSTRACT
Idiopathic retroperitoneal fibrosis is a disease of unknown etiology characterized by a dense rubbery retroperitoneal plaque that encases 1 or both ureters, causing hydronephrosis and impairing renal function. Primary or recurrent disease may result in extensive ureteral damage, leaving the urologist with limited surgical options. We herein report the fourth case managed successfully by renal autotransplantation. Recently, the bias in disfavor of renal autotransplantation and ex vivo vascular reconstruction has declined since experience has proved these procedures to be safe. Therefore, patients with extensive ureteral damage caused by retroperitoneal fibrosis may be managed successfully by autotransplantation. We herein report the fourth such case managed by this approach.
right side and extravasation of contrast medium in the previously operated area (fig. 2, A). The extravasated urine was drained through the old incision and a ureterostomy tube was placed in situ. A postoperative angiogram showed 2 right renal arteries (fig. 2, B). The patient was re-explored 1 week later through a midline incision. The original disease process plus
FIG. 1. A, IVP. B, retrograde pyelogram shows high grade right ureteral obstruction from extrinsic compression CASE REPORT
A 47-year-old woman with a 4-week history of right flank pain was seen first in October 1978. The medical history was unremarkable. The patient had never taken any medications regularly. An excretory urogram (IVP) and a right retrograde pyelogram showed high grade, right ureteral obstruction (fig. 1). At exploration a firm, rubbery plaque encasing the right ureter was found. Biopsies were taken and the ureter was shelled easily from the fibrotic plaque, then placed in a lateral, extraperitoneal position. A small ureterotomy was made above the area of encasement and an indwelling stent was inserted. The area was drained. Permanent sections confirmed the diagnosis of retroperitoneal fibrosis and the patient recovered uneventfully. However, 1 week after being discharged from the hospital she was admitted to our emergency room with severe right flank pain. An IVP showed severe hydronephrosis on the Accepted for publication May 9, 1980. Read at annual meeting of Western Section, American Urological Association, Kona and Honolulu, Hawaii, March 1-8, 1980. * Requests for reprints: Urology, M-553, University of California, San Francisco, California 94143. 408
extravasated urine made any attempt at identifying the distal ureter futile. A right nephrectomy, including 5 cm. of healthy proximal ureter, was done. The smaller lower pole and the main renal arteries were anastomosed end-to-side by interrupted 7zero sutures (fig. 3, A). The kidney then was autotransplanted into the contralateral iliac fossa using an end-to-end anastomosis with the hypogastric artery (fig. 3, B). The bladder was mobilized and a standard antireflux ureteroneocystostomy was done. The patient was discharged from the hospital 12 days postoperatively. An IVP at 6 months shows normal renal function in the transplanted kidney (fig. 4). DISCUSSION
Retroperitoneal fibrosis is a disease of unknown etiology that can be associated with either unilateral or bilateral ureteral obstruction. 1 Since renal damage on either side ranges from mild to severe, and since one cannot know which patients with unilateral obstruction will suffer contralateral disease, it is essential to salvage as much functioning parenchyma as possible. Nephrectomy is to be condemned for all but the most hopeless of kidneys.
ftEI"J.AL AUTOTH,At;rSPLAN-TA·TIO~T FOP, RETROPEftI'°fONE1\,L lfIBI{OSIS
FIG. 2. A, IVP after ureterolysis shows extravasation and recurrent obstruction. B, midstream angiogram shows main renal artery and smaller lower pole artery.
A
B
Fm. 3. A, anastomosis of lower pole artery to main renal artery. B, autotransplantation of kidney into contralateral pelvis.
Ureterolysis with intraperitoneal or lateral extraperitoneal placement of the ureters usually can be accomplished without much difficulty. In a small number of cases the disease process will extend into the ureteral wall, making ureterolysis more difficult. 2 In this situation use of an omental wrap can be helpful. 3 Problems of insufficient ureteral length arise when re-exploration is necessitated by recurrent ureteral obstruction. The
usual causes of such obstruction include urinary extravasation from an accidental or intentional ureterotomy as occurred in our patient, failure of the initial ureterolysis to achieve adequate drainage as reported by Linke and May,4 or recurrent ureteral entrapment by advancing disease. Repeat ureterolysis can be difficult in this situation. Kerr and associates reported that of 4 cases undergoing secondary ureterolysis 3 resulted in nephrectomy and 1 in nephrostomy. 5 Other operative alternatives have
410
PALLESCHI AND MCANINCH
provided sound vascular principles are observed. Review of several large series of transplant recipients reveals over-all vascular complication rates of <6 per cent in a population highly at risk to suffer surgical complications. 10- 12 Likewise, cumulative data from several investigators show that among 23 autotransplantations done with or without a bench procedure for retroperitoneal fibrosis, renovascular hypertension, staghorn calculi, ureteral or renal cancer, or insufficient renal length only 2 patients sustained vascular complications. 4 • 13- 20 Both occurred in patients undergoing bilateral procedures in whom contralateral autotransplants functioned successfully. Vascular spasm during a difficult donor nephrectomy precluded autotransplantation in 1 and resulted in a poorly functioning kidney in the other. The use of steroids in the treatment of recurrent unilateral obstruction due to retroperitoneal fibrosis deserves mention. Several investigators have demonstrated its effectiveness as an adjunct to ureterolysis in previously unoperated patients with idiopathic retroperitoneal fibrosis. 21 - 23 Although a trial of steroids probably is most effective early in the course of the disease it seems justified in patients with recurrent ureteral obstruction after ureterolysis if the obstruction is not severe and renal function is not in jeopardy. 21 - 24 In 1 of our own patients with long-standing disease unusual steroid sensitivity was observed as judged by improvement of the ureteral obstruction at high doses of prednisone. However, as a rule surgical intervention is indicated and renal autotransplantation should be given strong consideration in these cases. REFERENCES
FIG. 4. IVP at 6 months shows excellent function in autotransplanted kidney. included flap ureteroplasty or intubated ureterostomy, ureteral replacement with small bowel and urinary diversion, all of which can be associated with a high rate of early and late complications. 4-s Until recently, traditional attitudes toward renal autotransplantation and ex vivo vascular reconstruction were that because these procedures are considered hazardous they should be used as a court of last resorts when all other more conservative measures have failed. Nevertheless, extensive experience with homotransplantation has shown it to be a safe procedure that, when applied to the patient with extensive ureteral damage due to retroperitoneal fibrosis, allows the urologist to perform a ureteral anastomosis with healthy, viable ureter. To date, 3 patients, including our own, who underwent successful renal autotransplantation for retroperitoneal fibrosis have been reported on in the English literature. 4 ' 7 Indications for an operation included an extensively destroyed ureter in 2 cases and recurrent pyelonephritis after urinary diversion in 1. In none of these cases did the fibrotic process involve the iliac vessels-an obvious contraindication to autotransplantation. 9 Since the autotransplanted kidney in our case was placed in the contralateral iliac fossa we elected to perform a standard antireflux ureteroneocystostomy. Linke and May,4 and Stewart and associates7 used the ipsilateral iliac fossa and chose to perform ureteroureterostomy, Concerns regarding vascular complications are unwarranted
1. Ormond, J. K.: Idiopathic retroperitoneal fibrosis: a discussion of the etiology. J. Urol., 94: 385, 1965. 2. Skeel, D. A., Shols, G. W., Sullivan, M. J. and Witherington, R.: Retroperitoneal fibrosis with intrinsic ureteral involvement. J. Urol., 113: 166, 1975. 3. Turner-Warwick, R.: The use of the omental pedicle graft in urinary tract reconstruction. J. Urol., 116: 341, 1976. 4. Linke, C. A. and May, A. G.: Autotransplantation in retroperitoneal fibrosis. J. Urol., 107: 196, 1972. 5. Kerr, W. S., Jr., Suby, H. I., Vickery, A. and Fraley, E.: Idiopathic retroperitoneal fibrosis: clinical experience with 15 cases. J. Urol., 99: 575, 1968. 6. McCullough, D. L., McLaughlin, A. P., Gittes, R. F. and Kerr, W. S., Jr.: Replacement of the damaged or neoplastic ureter by ileum. J. Urol., 118: 375, 1977. 7. Stewart, B. H., Hewitt, C. B. and Banowsky, L. H. W.: Management of extensively destroyed ureter: special reference to renal autotransplantation. J. Urol., 115: 257, 1976. 8. Tanagho, E. A.: A case against the incorporation of bowel segments into the closed urinary system. J. Urol., 113: 796, 1975. 9. Olsson, C. A.: Extracorporeal renal surgery. In: Campbell's Urology, 4th ed. Edited by J. H. Harrison, R. F. Gittes, A. D. Perlmutter, T. A. Stamey and P. C. Walsh. Philadelphia: W. B. Saunders Co., vol. 3, chapt. 68, p. 2161, 1979. 10. Palleschi, J. R., Novick, A. C., Braun, W. E. and Magnusson, M. 0.: Vascular complications of renal transplantation. Urology, 16: 61, 1980. 11. Goldman, M. H., Tilney, N. L., Vineyard, G. C., Laks, H., Kahan, M. G. and Wilson, R. E.: A twenty year survey of arterial complications of renal transplantation. Surg., Gynec. & Obst., 141: 758, 1975. 12. Nerstr,am, B., Ladefoged, J. and Lund, F. I.: Vascular complications in 155 consecutive transplantations. Scand. J. Urol. Nephrol., suppl. 15, 6: 65, 1972. 13. Stewart, B. H., Banowsky, L. H., Hewitt, C. B. and Straffon, R. A.: Renal transplantation: current perspectives. J. Urol., 118: 363, 1977. 14. Turini, D., Nicita, G., Fiorelli, C., Masini, G. C. and Gazzarrini, 0.: Staghorn renal stones: value of bench surgery and autotransplantation. J. Urol., 118: 905, 1977. 15. Anderson, 0. S., Clark, S. S., Marlett, M. M. and Jonasson, 0.: Treatment of extensive renal calculi with extracorporeal surgery and autotransplantation. Urology, 7: 465, 1976. 16. Gittes, R. F. and McCullough, D. L.: Bench surgery for tumor in a
411 solita.Ty tJrol., 113: 12) 1975. 17. Diethelm, A.G., W. J., Sterling, W. A., Jr. and Tauxe, 'N. N.: Renal autotransplantation using hypothermic storage and pulsatile perfusion. J. Urol., 113: 755, 1975. 18. Murphy, G. P., Staubitz, W. J. and Kenney, G. M.: Renal autotransplantation for rehabilitation of a patient with multiple urinary tumors. J. Urol., 107: 199, 1972. 19. Pfister, R R. and Husberg, B.: Renal salvage through autotransplantation. Urology, 4: 703, 1974. 20. DeWeerd, J. H., Paul, S. C., Tomera, F. M. and Smith, L. H.: Renal autotransplantation for upper ureteral stenosis. J. Urol., lHi: 23, 1976.
21. OschnFt\ IV.L Brannan, VI.) Pond, H. S. and Goodlet, J·. S. Jr°" Medical therapy in idiopathic retroperitoneal fibrosis. J. Urol., 114: 700, 1975. 1
22. Ross, J. C. and Goldsmith, H. J.: The combined surgical and medical treatment of retroperitoneal fibrosis. Brit. J. Surg., 58: 422, 1971. 23. Mitchinson, M. J., Withycombe, J. F. R. and Jones, R. A.: The response of idiopathic fibrosis to corticosteroids. Brit. J. Urol., 43: 444, 1971. 24. Morandi, L. P. and Grob, P. J.: Retroperitoneal fibrosis. Response to corticosteroid therapy. Arch. Intern. Med., 128: 295, 1971.