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Renal Replantation (Orthotopic Autotransplantation) for Echinococcosis of the Kidney
0022-534 7/85/1333-0456$02.00/0 Vol. 133, March
THE JOURNAL OF UROLOGY
Copyright © 1985 by The Williams & Wilkins Co.
Printed in U.S.A.
RENAL REPLANTATION (ORTHOTOPIC AUTOTRANSPLANTATION) FOR ECHINOCOCCOSIS OF THE KIDNEY R. TSCHOLL
AND
R. AUSFELD
From the Departement Chirurgie, Urologische Klinik, Kantonsspital Aarau, Aarau, Switzerland
ABSTRACT
Ex vivo surgery with replantation of the kidney into the renal fossa was used to treat a centrally located renal hydatid cyst in a 44-year-old patient. The replanted kidney showed good urographic function 2 months postoperatively. Orthotopic replantation of the kidney into its original location is preferred to heterotopic autotransplantation into the groin. Echinococcal disease of the kidney is treated most often by total1•2 and sometimes partial nephrectomy. 3 • 4 Even partial excision of the cyst has been reported. 5 Opening of the lesion in situ is inadvisable, 1• 2 since no .scolecidal chemotherapy is available to date. To our knowledge ex vivo resection of the hydatid cyst followed by autotransplantation has never been performed to date. Renal autotransplantation is indicated rarely. 6 Many problems once considered fit for bench operations are handled better by adequate in situ techniques. Currently, renovascular disease not cured by intraluminal dilation and unfit for in situ procedures, 6 as well as some cases of extended injuries of the proximal ureter7 seem to be the best indications for an ex vivo operation. We believe that echinococcosis located centrally in the kidney and not involving the entire organ should be added to the list of valid indications. We report 1 such case. CASE REPORT
A 44-year-old Yugoslavian man was examined for lower back pain. Excretory urography (IVP) and computerized tomography (CT) revealed a partially calcified cyst in the middle and upper portions of the left kidney (figs. 1 and 2). The serological tests indicated Echinococcus granulosus. Immune electrophoresis showed the arc-5-band, which confirmed the diagnosis. Except for the left kidney no other manifestation was identified. Therefore, the hydatid cyst was removed. The kidney was exposed through a left flank incision. Partial nephrectomy proved impossible, since the cyst was located centrally and distended the main branches of the renal vessels. The renal artery and vein were secured proximally by vascular clamps and then were transected. The ureter was kept intact, and the kidney was removed and perfused with cold Collins' solution. The hydatid cyst was punctured, evacuated and refilled with hypertonic saline, and the puncture site was ligated. The cyst then was dissected out of the renal sinus with care taken not to injure the blood vessels. The kidney was reanastomosed to the transected renal vessels. Convalescence was uneventful. An IVP 2 months later showed normal function of the replanted kidney (fig. 3).
FIG. 1. Preoperative IVP shows hydatid cyst in middle and upper portions.
DISCUSSION
Kidneys with a hydatid cyst usually are removed, particularly if the cyst is large, located in the central region of the organ, leaks into the collecting system or induces hypertension. 8 Conservative treatment has been achieved in several instances. Direct puncture of the cyst has been advocated. 9 Although no negative consequences ensued apparently we agree that in situ opening of the cyst should be avoided because of the risk of anaphylaxis and seeding of the area with viable scoleces. 1 Echinococcal disease limited to one of the renal poles can be Accepted for publication September 7, 1984.
FIG. 2. Preoperative CT scan reveals hydatid cyst in left kidney
456
REl"
457
2. Haines, J. G., Mayo, r,.,t E., Allan, T. N. K. and Ansell, J. S.: Echinococca! cyst of the kidney. J. Urol., 117: 788, 1977. 3. Henry, J. D., Utz, D. C., Hahn, R. G., Thompson, J. H., Jr. and Stilwell, G. G.: Echinococcal disease of the kidney: report of case. J. Urol., 96: 431, 1966. 4. Leemans, J. and Kotowicz, A.: Traitement chirurgical conservateur d'un kyste hydatique du rein. Acta Urol. Belg., 43: 257, 1975. 5. Ramus, N. I. and Mitchell, J. P.: Renal hydatid disease. Brit. J. Surg., 61: 402, 1974. 6. Kaufman, J. J.: Overview: renovascular lesions and ex vivo renal surgery with autotransplantation. In: Current Operative Urology, 2nd ed. Edited by E. D. Whitehead and E. Leiter. Philadelphia: J.B. Lippincott Co., part 6, p. 229, 1984. 7. DeWeerd, J. H., Paulk, S. C., Tomera, F. M. and Smith, L. H.: Renal autotransplantation for upper ureteral stenosis. J, Urol., 116: 23, 1976. 8. Martorana, G., Giberti, C. and Pescatore, D.: Giant echinococcal cyst of the kidney associated with hypertension evaluated by computerized tomography. J. Urol., 126: 99, 1981. 9, Roylance, J,, Davies, E. R. and Alexander, W. D.: Translumbar puncture of a renal hydatid cyst, Brit. J. Rad., 46: 960, 1973. 10. Novick, A. C. and Stewart, B. H.: Commentary: indications for renal autotransplantation. In: Current Operative Urology, 2nd ed. Edited by E. D. Whitehead and E. Leiter, Philadelphia: J.B. Lippincott Co., part 6, chapt. 16, p. 204, 1984.
EDITORIAL COMMENTS
FIG. 3. IVP 2 months after ex vivo surgery of left kidney, excision of hydatid cyst and replantation of kidney.
managed by partial nephrectomy, 3 •4 whereas we believe that a central hydatid cyst should not be manipulated in situ but is treated best by an ex vivo operation, which achieves salvage of the kidney with the lowest risk for the patient. If an ex vivo operation is performed for other reasons the kidney usually is transplanted heterotopically into the groin 7 • 10 rather than replanted orthotopically into the renal fossa. While transplantation into the groin obviously is indispensable for proximal ureteral lesions and possibly also is preferable for renovascular disease, it is unpractical and unnecessary for a hydatid cyst. Heterotopic transplantation is used more frequently than ori-hn,trn,..., replantation, probably because the site of the vascular suture is more easily accessible in the iliac than in the renal fossa. However, this fact does not a second and incision in the lower abdomen, V.1 e conclude that resection of the cyst followed c,p,cu.,c<>CC'VH is a logical and safe treatment echinococcal disease of the kidney. REFERENCES
E. S., Hui, N. T. and De Pauw, A. P.: Echinococcal disease of the kidney. J. Urol., 115: 742, 1976.
1. Diamond, I-L M., Lyon,
This case report is interesting and I have had no personal experience with management of echinococcal cysts of the kidney. Even in centrally located cysts, in situ removal still might be possible by clamping the renal artery, cooling the kidney and dissecting out the cyst. There is some risk that one might enter the cyst and spill the material, which may result in anaphylaxis and seeding the area with viable scoleces. Once a decision is made for bench surgery then my preference would have been to autotransplant the kidney into the usual site in the iliac fossa rather than perform orthotopic autotransplantation. This case represents a rare indication for either bench surgery or autotransplantation. Ralph A. Straffon Department of Urology Cleveland Clinic Foundation Cleveland, Ohio
Central renal hydatid cyst is rare. Most urologists suggest total or partial nephrectomy, or aspiration of the echinococcal cyst and refilling with hypertonic saline for cure. Occasionally, spillage of the cyst with viable scoleces may seed the fossa. The authors have suggested ex vivo repair of the kidney with careful aspiration and hypertonic saline injection to minimize the possibility of echinococcal spread. Division of the renal pedicle to allow repair of the cyst outside of the fossa is rare in surgical experience. Replantation of the kidney into an orthotopic location is indeed rare in contrast with heterotransplantation into the iliac fossa. Although the surgical occasion appears unique the technique may be successful, although performed rarely. Joseph J. Kaufman Department of Surgery University of California School of Medicine Los Angeles, California
THE JOURNAL OF UROLOGY
Copyright © 1985 by The Williams & Wilkins Co.
Printed in U.S.A.
RENAL REPLANTATION (ORTHOTOPIC AUTOTRANSPLANTATION) FOR ECHINOCOCCOSIS OF THE KIDNEY R. TSCHOLL
AND
R. AUSFELD
From the Departement Chirurgie, Urologische Klinik, Kantonsspital Aarau, Aarau, Switzerland
ABSTRACT
Ex vivo surgery with replantation of the kidney into the renal fossa was used to treat a centrally located renal hydatid cyst in a 44-year-old patient. The replanted kidney showed good urographic function 2 months postoperatively. Orthotopic replantation of the kidney into its original location is preferred to heterotopic autotransplantation into the groin. Echinococcal disease of the kidney is treated most often by total1•2 and sometimes partial nephrectomy. 3 • 4 Even partial excision of the cyst has been reported. 5 Opening of the lesion in situ is inadvisable, 1• 2 since no .scolecidal chemotherapy is available to date. To our knowledge ex vivo resection of the hydatid cyst followed by autotransplantation has never been performed to date. Renal autotransplantation is indicated rarely. 6 Many problems once considered fit for bench operations are handled better by adequate in situ techniques. Currently, renovascular disease not cured by intraluminal dilation and unfit for in situ procedures, 6 as well as some cases of extended injuries of the proximal ureter7 seem to be the best indications for an ex vivo operation. We believe that echinococcosis located centrally in the kidney and not involving the entire organ should be added to the list of valid indications. We report 1 such case. CASE REPORT
A 44-year-old Yugoslavian man was examined for lower back pain. Excretory urography (IVP) and computerized tomography (CT) revealed a partially calcified cyst in the middle and upper portions of the left kidney (figs. 1 and 2). The serological tests indicated Echinococcus granulosus. Immune electrophoresis showed the arc-5-band, which confirmed the diagnosis. Except for the left kidney no other manifestation was identified. Therefore, the hydatid cyst was removed. The kidney was exposed through a left flank incision. Partial nephrectomy proved impossible, since the cyst was located centrally and distended the main branches of the renal vessels. The renal artery and vein were secured proximally by vascular clamps and then were transected. The ureter was kept intact, and the kidney was removed and perfused with cold Collins' solution. The hydatid cyst was punctured, evacuated and refilled with hypertonic saline, and the puncture site was ligated. The cyst then was dissected out of the renal sinus with care taken not to injure the blood vessels. The kidney was reanastomosed to the transected renal vessels. Convalescence was uneventful. An IVP 2 months later showed normal function of the replanted kidney (fig. 3).
FIG. 1. Preoperative IVP shows hydatid cyst in middle and upper portions.
DISCUSSION
Kidneys with a hydatid cyst usually are removed, particularly if the cyst is large, located in the central region of the organ, leaks into the collecting system or induces hypertension. 8 Conservative treatment has been achieved in several instances. Direct puncture of the cyst has been advocated. 9 Although no negative consequences ensued apparently we agree that in situ opening of the cyst should be avoided because of the risk of anaphylaxis and seeding of the area with viable scoleces. 1 Echinococcal disease limited to one of the renal poles can be Accepted for publication September 7, 1984.
FIG. 2. Preoperative CT scan reveals hydatid cyst in left kidney
456
REl"
457
2. Haines, J. G., Mayo, r,.,t E., Allan, T. N. K. and Ansell, J. S.: Echinococca! cyst of the kidney. J. Urol., 117: 788, 1977. 3. Henry, J. D., Utz, D. C., Hahn, R. G., Thompson, J. H., Jr. and Stilwell, G. G.: Echinococcal disease of the kidney: report of case. J. Urol., 96: 431, 1966. 4. Leemans, J. and Kotowicz, A.: Traitement chirurgical conservateur d'un kyste hydatique du rein. Acta Urol. Belg., 43: 257, 1975. 5. Ramus, N. I. and Mitchell, J. P.: Renal hydatid disease. Brit. J. Surg., 61: 402, 1974. 6. Kaufman, J. J.: Overview: renovascular lesions and ex vivo renal surgery with autotransplantation. In: Current Operative Urology, 2nd ed. Edited by E. D. Whitehead and E. Leiter. Philadelphia: J.B. Lippincott Co., part 6, p. 229, 1984. 7. DeWeerd, J. H., Paulk, S. C., Tomera, F. M. and Smith, L. H.: Renal autotransplantation for upper ureteral stenosis. J, Urol., 116: 23, 1976. 8. Martorana, G., Giberti, C. and Pescatore, D.: Giant echinococcal cyst of the kidney associated with hypertension evaluated by computerized tomography. J. Urol., 126: 99, 1981. 9, Roylance, J,, Davies, E. R. and Alexander, W. D.: Translumbar puncture of a renal hydatid cyst, Brit. J. Rad., 46: 960, 1973. 10. Novick, A. C. and Stewart, B. H.: Commentary: indications for renal autotransplantation. In: Current Operative Urology, 2nd ed. Edited by E. D. Whitehead and E. Leiter, Philadelphia: J.B. Lippincott Co., part 6, chapt. 16, p. 204, 1984.
EDITORIAL COMMENTS
FIG. 3. IVP 2 months after ex vivo surgery of left kidney, excision of hydatid cyst and replantation of kidney.
managed by partial nephrectomy, 3 •4 whereas we believe that a central hydatid cyst should not be manipulated in situ but is treated best by an ex vivo operation, which achieves salvage of the kidney with the lowest risk for the patient. If an ex vivo operation is performed for other reasons the kidney usually is transplanted heterotopically into the groin 7 • 10 rather than replanted orthotopically into the renal fossa. While transplantation into the groin obviously is indispensable for proximal ureteral lesions and possibly also is preferable for renovascular disease, it is unpractical and unnecessary for a hydatid cyst. Heterotopic transplantation is used more frequently than ori-hn,trn,..., replantation, probably because the site of the vascular suture is more easily accessible in the iliac than in the renal fossa. However, this fact does not a second and incision in the lower abdomen, V.1 e conclude that resection of the cyst followed c,p,cu.,c<>CC'VH is a logical and safe treatment echinococcal disease of the kidney. REFERENCES
E. S., Hui, N. T. and De Pauw, A. P.: Echinococcal disease of the kidney. J. Urol., 115: 742, 1976.
1. Diamond, I-L M., Lyon,
This case report is interesting and I have had no personal experience with management of echinococcal cysts of the kidney. Even in centrally located cysts, in situ removal still might be possible by clamping the renal artery, cooling the kidney and dissecting out the cyst. There is some risk that one might enter the cyst and spill the material, which may result in anaphylaxis and seeding the area with viable scoleces. Once a decision is made for bench surgery then my preference would have been to autotransplant the kidney into the usual site in the iliac fossa rather than perform orthotopic autotransplantation. This case represents a rare indication for either bench surgery or autotransplantation. Ralph A. Straffon Department of Urology Cleveland Clinic Foundation Cleveland, Ohio
Central renal hydatid cyst is rare. Most urologists suggest total or partial nephrectomy, or aspiration of the echinococcal cyst and refilling with hypertonic saline for cure. Occasionally, spillage of the cyst with viable scoleces may seed the fossa. The authors have suggested ex vivo repair of the kidney with careful aspiration and hypertonic saline injection to minimize the possibility of echinococcal spread. Division of the renal pedicle to allow repair of the cyst outside of the fossa is rare in surgical experience. Replantation of the kidney into an orthotopic location is indeed rare in contrast with heterotransplantation into the iliac fossa. Although the surgical occasion appears unique the technique may be successful, although performed rarely. Joseph J. Kaufman Department of Surgery University of California School of Medicine Los Angeles, California