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Right and Left Accessory Renal Arteries Arising from a Common Trunk Associated with Unrotated Kidneys
0022-5347 /84/1321-0007$02.00/0 Voi. 132.
THE JOURNAL OF UROLOGY
Printed in
Copyright© 1984 by The Williams & Wilkins Co.
Original Articles RIGHT AND LEFT ACCESSORY RENAL ARTERIES ARISING FROM A COMMON TRUNK ASSOCIATED WITH UNROTATED KIDNEYS HILEL NATHAN* AND ILYA GLEZER From the Department of Human Gross Anatomy and Development, Sophie Davis School of Biomedical Education, City College, New York, New York
ABSTRACT
We describe a rare anomaly of the kidneys and its vessels, which was found in a white adult male cadaver. The anomaly consisted of unrotated kidneys with partially extrarenal calices and pelves. In addition to the normal vessels, each kidney received a branch from a common trunk, originating from the inferior end of the aorta. We report an extremely rare anomaly of the kidneys and their vessels found during dissection in a white adult male cadaver. The anomaly consisted essentially of unrotated (or laterally rotated) kidneys that received accessory branches from a common arterial trunk of low aortic origin, with calices and pelves, which were extrarenal to some extent. We have not encountered a similar case in the hundreds of cadavers previously dissected. However, similar cases have been described in some anatomical books 1 • 2 and in a few articles from the extensive literature on malformation of the kidneys and its vessels. 3 • 4
merged into a short, single vein close to the renal pedicle. This vein split again into 2 veins that entered the left renal vein, thus, forming a triangular venous window. The left testicular artery originating from the aorta ran an arched course through this venous window. The right testicular vein drained into the superior right ren~l vein, crossing anterior to the inferior renal vem. Abnormal artery. Each kidney also received a branch from a single, aberrant renal artery, about 7 to 8 mm. in diameter, which left the inferior end of the aorta immediately above its bifurcation into the 2 common iliac arteries. From its origin the aberrant renal artery ran downward and to the left, then immediately turned upward and to the left in the direction of the left kidney. Thus, it formed an arch that opened upward and to the right side. About 2 cm. from its origin the aberrant renal artery divided into 2 branches, 1 for each kidney. The left branch continued in the direction of the original trunk toward the left kidney, passing first behind the inferior mesenteric vessels and then behind the spermatic vessels" It then passed anterior to the inferomedial part of the kidney to reach the inferior extremity of the hilus, just behind the beginning of the ureter. In this part of its course the artery ran in a deep groove on the front of the kidney. Before reaching the kidney the artery gave off 2 small branches that penetrated directly into the renal parenchyma. The artery ended by branching at the inferior portion of the hilus. The branch from the aberrant renal artery to the right kidney ran to the right side, crossing in front of the aorta, the inferior vena cava and the right spermatic vessels until it reached the kidney at the inferior part of its medial border. Like the left branch, the right branch crossed the inferomedial part of the anterior surface of the kidney, lying in a deep groove, and gave off a branch to the parenchyma. It ended by branching at the inferior part of the hilus behind the ureter. Aberrant left renal vein. A small additional aberrant vein from the left kidney, which is not shown in the figure, accompanied the left aberrant renal artery until the origin of the aberrant renal artery from the aorta, where it continued its course to drain into the lower end of the inferior vena cava. Ureters. The calices and pelves of the ureters of both kidneys bulged out from the center of the hili in front of the vessels. The right pelvis was somewhat more dilated than the left side but the general size of both appeared normal. The ureters were of normal diameter. They passed downwards crossing the an-
OBSERVATIONS AND DESCRIPTION
The abdominal cavity was opened and dissected (see figure). Both kidneys were in the normal location, although the left kidney was somewhat higher than the right one. The right kidney measured 13.5 x 7.5 x 3.5 cm. and the left kidney was 14 X 7 X 5.5 cm. The right kidney was irregularly polygonal in shape and the left one was oval, with a tendency to being rhomboid. The long axis ran downward and slightly lateraL Both kidneys appeared unrotated, with the hili directed anteriorly rather than medially, as in the case of normal kidneys. The hili were elongated, with vertical long axes, and measured 7.5 cm. on the right and 7 cm. on the left sides. The renal sinuses appeared to be much more shallow than those of normal medially rotated kidneys and, as a result, the vessels, calices and pelves of the ureters seemed to bulge forward from the sinuses. Renal vessels. In addition to the branches of the aberrant vessels, normal arteries of aortic origin, 1 for each kidney, were seen entering the hili at the medial borders. Two veins were seen exiting the hilus of each kidney. On the right side each of these veins entered the inferior vena cava independently" On the left side the 2 veins, 1 anterosuperior and 1 posteroinferior, merged about 5 cm. from the origin into a single vein that crossed the midline in front of the aorta and entered the inferior vena cava at a higher level than the right renal veins. The direction of all of the aforementioned vessels was downward and lateral. The left renal vein received from above the adrenal vein and from below 2 testicular veins. These 2 testicular veins ran independently, parallel to the testicular artery, until they Accepted for publication February 7, 1984.
* Current address: Department of Anatomy and Anthropology, Sack-
ler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.
7
8
NATHAN AND GLEZER
of its branches (common, external or internal iliac, middle sacral, testicular, inferior phrenic or superior mesenteric). The striking feature in our case is that both unrotated kidneys received accessory branches from 1 single trunk. In their analysis of nearly 11,000 cases from the literature and their own dissections Merklin and Michels did not comment on such variations. 12 However, Chiarugi1 and Piersol2 mention the possibility of renal arteries of both kidneys arising from 1 single trunk of aortic origin. In a radiological study of 62 patients a case was reported of a left ectopic kidney with a single trunk of aortic origin dividing into renal arteries for each side. 4 Jeffery also described a case of an unrotated right kidney receiving a · branch from the left renal artery. 3 In cases of horseshoe kidneys a single median artery is found frequently supplying the isthmus and proximal parts of the fused kidney mass. 5·7·8·12-15 In these cases the artery generally takes its origin, as in our case, from the most inferior parts of the aorta, from the median sacral artery or from other arteries in the vicinity. In a case of a dumbbell-shaped horseshoe kidney described by Herman and Fetterolf a left renal artery of high aortic origin gave off branches to both hili of the fused kidneys.16 It may well be that the vessel to both kidneys in our case was the result of the 2 kidneys approaching each other at the midline during embryological ascent, such as to induce the formation of a single common vessel from the aorta. The Adrenal Gl nD possibility of a transient fusion of the 2 kidneys, with subseCava Vein quent separation during the ascent, also may be considered. The common renal vessel may have persisted while the kidneys completed the ascent to the final location. It seems probable that the transaction from below the vessel was the cause for the rotational defects of the kidneys. It is well established that many of the rotational defects of kidneys are accompanied by aberrant vessels and often produced by them.a-10·12 A rare case of an arterial connection between the lower poles of the 2 kidneys was described by Guggemos and associates. 17 This connection may have had the same development as in our case, that is a common arterial trunk with branches to both kidneys at the beginning, with the common trunk originating from the aorta and undergoing a process of atrophy at a later stage, leaving only the connected branches between the 2 kidneys. Artery In regard to the presence of extrarenal calices and pelves of the ureters, our specimen did not seem to represent a real pathological condition of elongation of the calices as described Testicular and by Gray and Skandalakis,8 and Malament and associates. 18 It appears rather to be due to the anteroposterior flattening of Both kidneys appear unrotated with hili anteriorly directed. Sinuses the unrotated kidneys, with the sinuses becoming more shallow are shallow, and calices and pelves of ureters are bulging from bottom. and, as a result, the calices and pelves protruding from the hili. Arterial trunk, originating from lowest part of aorta, supplies branches In fact, the calices were not elongated, as in the pathological to both kidneys in addition to normal vessels. ARA, aberrant renal artery. Lbr, left branch. Rbr, right branch. RRA, right renal artery. · condition. In other words, we believe that cases of extrarenal LRA, left renal artery. RRVs, right renal veins. LRV, left renal vein. P, calices and pelves, due only to flattening of the renal pelvis as pelvis (ureter). a result of renal malrotation, should be considered as a different pathological entity from those in which they become extrarenal due to elongation. terior surface of the inferior poles of the kidneys and continued This study of anomalies of the kidneys and their vessels is normally to the bladder. not only of academic interest but may also be of practical Cyst. An irregular isolated 4½ X 3 cm. cyst occupied the importance either for correct interpretation of roentgenograms inferolateral border of and bulged into the hilus of the right and computerized tomography scanning of the organs, or for kidney. The cyst was opened and emptied during the dissection. surgical interventions in the area. DISCUSSIONS AND CONCLUSIONS
Morphological variations of the kidneys and their vessels, either in size, shape, location, position and so forth, are numerous and generally well known. 5- 7 The embryological bases for these variations also have been well established.8 Anomalies associated with the rotation of kidneys, as in our case, often are caused by or related to aberrant vessels. 9 - 11 However, generally, in these cases each kidney receives its corresponding normal or accessory vessel directly from the aorta or from one
Mr. Frank Pace provided the photographs. REFERENCES
1. Chiarugi, G.: Istituzioni di Anatomica. Milano: Societa Editrice Libraria, p. 481, 1948. 2. Piersol, G. A.: Human Anatomy, 3rd ed. Philadelphia: J.B. Lippincott Co., p. 805, 1911. 3. Jeffery, R. F.: Unusual origins of renal arteries. Radiology, 102: 309, 1972.
BRANCHES FROM SINGLE ARTERY TO BOTH UNROTATED KIDNEYS
4. Jeidell, H.: A note of the source and character of the early blood vessels of the kidney. Anat. Rec., 5: 47, 1911. 5. Anson, B. J., Pick, J. W. and Cauldwell, E.: The anatomy of the commoner renal anomalies: ectopic and horseshoe kidneys. J. Urol., 47: 112, 1942. 6. Awojobi, 0. A., Ogunbiyi, 0. A. and Nkposong, E. 0.: Unusual relationship of multiple renal arteries. Urology, 21: 205, 1983. 7. Hollinshead, W. H.: The kidneys, ureters, and suprarenal glands. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis, 2nd ed. New York: Harper & Row, Publishers, vol. 2, chapt. 10, pp. 518-573, 1971. 8. Gray, S. W. and Skandalakis, J. E.: Embryology for Surgeons. Philadelphia: W. B. Saunders Co., pp. 443-518, 1972. 9. Braash, W. F.: Anomalous renal rotation and associated anomalies. J. Urol., 25: 9, 1931. 10. Nathan, H.: Aberrant renal artery producing developmental anomaly of kidney associated with unusual course of gonadal (ovarian) vessels. J. Urol., 89: 570, 1963. 11. Olsson, 0. and Wholey, M.: Vascular abnormalities in gross anomalies of kidneys. Acta Rad., 2: 420, 1964.
9
12. Merklin, R. J. and Michels, N. A.: The variant renal and suprarenal blood supply with data on the inferior phrenic, ureteral and gonadal arteries. A statistical analysis based on 185 dissections and review of the literature. J. Int. Coll. Surg., 29: 41, 1958. 13. Gutierrez, R.: The clinical management of horseshoe kidney. Amer. J. Surg., 14: 657, 1931. 14. Kolin, C. P., Boatman, D. L., Schmidt, J. D. and Flocks, R. H.: Horseshoe kidney: a review of 105 patients. J. Urol., 107: 203, 1972. 15. Robinson, B.: The blood-vessels in fused (horseshoe) kidneys based on the study of sixty specimens and illustrations. Lancet-Clinic, 102: 141, 1909. 16. Herman, J. L. and Fetterolf, G.: "Dumb-bell" kidney. Ann. Surg., 57: 868, 1913. 17. Guggemos, E., Nystrom, J., Peppy, S. J., Sinatra, C. and Brody, H.: A rare case of an arterial connection between the left and right kidneys. Ann. Surg., 156: 940, 1962. 18. Malament, M., Schwartz, B. and Nagamatsu, G. R.: Extrarenal calyces: their relationship to renal disease. Amer. J. Roentgen., 86: 823, 1961.
THE JOURNAL OF UROLOGY
Printed in
Copyright© 1984 by The Williams & Wilkins Co.
Original Articles RIGHT AND LEFT ACCESSORY RENAL ARTERIES ARISING FROM A COMMON TRUNK ASSOCIATED WITH UNROTATED KIDNEYS HILEL NATHAN* AND ILYA GLEZER From the Department of Human Gross Anatomy and Development, Sophie Davis School of Biomedical Education, City College, New York, New York
ABSTRACT
We describe a rare anomaly of the kidneys and its vessels, which was found in a white adult male cadaver. The anomaly consisted of unrotated kidneys with partially extrarenal calices and pelves. In addition to the normal vessels, each kidney received a branch from a common trunk, originating from the inferior end of the aorta. We report an extremely rare anomaly of the kidneys and their vessels found during dissection in a white adult male cadaver. The anomaly consisted essentially of unrotated (or laterally rotated) kidneys that received accessory branches from a common arterial trunk of low aortic origin, with calices and pelves, which were extrarenal to some extent. We have not encountered a similar case in the hundreds of cadavers previously dissected. However, similar cases have been described in some anatomical books 1 • 2 and in a few articles from the extensive literature on malformation of the kidneys and its vessels. 3 • 4
merged into a short, single vein close to the renal pedicle. This vein split again into 2 veins that entered the left renal vein, thus, forming a triangular venous window. The left testicular artery originating from the aorta ran an arched course through this venous window. The right testicular vein drained into the superior right ren~l vein, crossing anterior to the inferior renal vem. Abnormal artery. Each kidney also received a branch from a single, aberrant renal artery, about 7 to 8 mm. in diameter, which left the inferior end of the aorta immediately above its bifurcation into the 2 common iliac arteries. From its origin the aberrant renal artery ran downward and to the left, then immediately turned upward and to the left in the direction of the left kidney. Thus, it formed an arch that opened upward and to the right side. About 2 cm. from its origin the aberrant renal artery divided into 2 branches, 1 for each kidney. The left branch continued in the direction of the original trunk toward the left kidney, passing first behind the inferior mesenteric vessels and then behind the spermatic vessels" It then passed anterior to the inferomedial part of the kidney to reach the inferior extremity of the hilus, just behind the beginning of the ureter. In this part of its course the artery ran in a deep groove on the front of the kidney. Before reaching the kidney the artery gave off 2 small branches that penetrated directly into the renal parenchyma. The artery ended by branching at the inferior portion of the hilus. The branch from the aberrant renal artery to the right kidney ran to the right side, crossing in front of the aorta, the inferior vena cava and the right spermatic vessels until it reached the kidney at the inferior part of its medial border. Like the left branch, the right branch crossed the inferomedial part of the anterior surface of the kidney, lying in a deep groove, and gave off a branch to the parenchyma. It ended by branching at the inferior part of the hilus behind the ureter. Aberrant left renal vein. A small additional aberrant vein from the left kidney, which is not shown in the figure, accompanied the left aberrant renal artery until the origin of the aberrant renal artery from the aorta, where it continued its course to drain into the lower end of the inferior vena cava. Ureters. The calices and pelves of the ureters of both kidneys bulged out from the center of the hili in front of the vessels. The right pelvis was somewhat more dilated than the left side but the general size of both appeared normal. The ureters were of normal diameter. They passed downwards crossing the an-
OBSERVATIONS AND DESCRIPTION
The abdominal cavity was opened and dissected (see figure). Both kidneys were in the normal location, although the left kidney was somewhat higher than the right one. The right kidney measured 13.5 x 7.5 x 3.5 cm. and the left kidney was 14 X 7 X 5.5 cm. The right kidney was irregularly polygonal in shape and the left one was oval, with a tendency to being rhomboid. The long axis ran downward and slightly lateraL Both kidneys appeared unrotated, with the hili directed anteriorly rather than medially, as in the case of normal kidneys. The hili were elongated, with vertical long axes, and measured 7.5 cm. on the right and 7 cm. on the left sides. The renal sinuses appeared to be much more shallow than those of normal medially rotated kidneys and, as a result, the vessels, calices and pelves of the ureters seemed to bulge forward from the sinuses. Renal vessels. In addition to the branches of the aberrant vessels, normal arteries of aortic origin, 1 for each kidney, were seen entering the hili at the medial borders. Two veins were seen exiting the hilus of each kidney. On the right side each of these veins entered the inferior vena cava independently" On the left side the 2 veins, 1 anterosuperior and 1 posteroinferior, merged about 5 cm. from the origin into a single vein that crossed the midline in front of the aorta and entered the inferior vena cava at a higher level than the right renal veins. The direction of all of the aforementioned vessels was downward and lateral. The left renal vein received from above the adrenal vein and from below 2 testicular veins. These 2 testicular veins ran independently, parallel to the testicular artery, until they Accepted for publication February 7, 1984.
* Current address: Department of Anatomy and Anthropology, Sack-
ler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.
7
8
NATHAN AND GLEZER
of its branches (common, external or internal iliac, middle sacral, testicular, inferior phrenic or superior mesenteric). The striking feature in our case is that both unrotated kidneys received accessory branches from 1 single trunk. In their analysis of nearly 11,000 cases from the literature and their own dissections Merklin and Michels did not comment on such variations. 12 However, Chiarugi1 and Piersol2 mention the possibility of renal arteries of both kidneys arising from 1 single trunk of aortic origin. In a radiological study of 62 patients a case was reported of a left ectopic kidney with a single trunk of aortic origin dividing into renal arteries for each side. 4 Jeffery also described a case of an unrotated right kidney receiving a · branch from the left renal artery. 3 In cases of horseshoe kidneys a single median artery is found frequently supplying the isthmus and proximal parts of the fused kidney mass. 5·7·8·12-15 In these cases the artery generally takes its origin, as in our case, from the most inferior parts of the aorta, from the median sacral artery or from other arteries in the vicinity. In a case of a dumbbell-shaped horseshoe kidney described by Herman and Fetterolf a left renal artery of high aortic origin gave off branches to both hili of the fused kidneys.16 It may well be that the vessel to both kidneys in our case was the result of the 2 kidneys approaching each other at the midline during embryological ascent, such as to induce the formation of a single common vessel from the aorta. The Adrenal Gl nD possibility of a transient fusion of the 2 kidneys, with subseCava Vein quent separation during the ascent, also may be considered. The common renal vessel may have persisted while the kidneys completed the ascent to the final location. It seems probable that the transaction from below the vessel was the cause for the rotational defects of the kidneys. It is well established that many of the rotational defects of kidneys are accompanied by aberrant vessels and often produced by them.a-10·12 A rare case of an arterial connection between the lower poles of the 2 kidneys was described by Guggemos and associates. 17 This connection may have had the same development as in our case, that is a common arterial trunk with branches to both kidneys at the beginning, with the common trunk originating from the aorta and undergoing a process of atrophy at a later stage, leaving only the connected branches between the 2 kidneys. Artery In regard to the presence of extrarenal calices and pelves of the ureters, our specimen did not seem to represent a real pathological condition of elongation of the calices as described Testicular and by Gray and Skandalakis,8 and Malament and associates. 18 It appears rather to be due to the anteroposterior flattening of Both kidneys appear unrotated with hili anteriorly directed. Sinuses the unrotated kidneys, with the sinuses becoming more shallow are shallow, and calices and pelves of ureters are bulging from bottom. and, as a result, the calices and pelves protruding from the hili. Arterial trunk, originating from lowest part of aorta, supplies branches In fact, the calices were not elongated, as in the pathological to both kidneys in addition to normal vessels. ARA, aberrant renal artery. Lbr, left branch. Rbr, right branch. RRA, right renal artery. · condition. In other words, we believe that cases of extrarenal LRA, left renal artery. RRVs, right renal veins. LRV, left renal vein. P, calices and pelves, due only to flattening of the renal pelvis as pelvis (ureter). a result of renal malrotation, should be considered as a different pathological entity from those in which they become extrarenal due to elongation. terior surface of the inferior poles of the kidneys and continued This study of anomalies of the kidneys and their vessels is normally to the bladder. not only of academic interest but may also be of practical Cyst. An irregular isolated 4½ X 3 cm. cyst occupied the importance either for correct interpretation of roentgenograms inferolateral border of and bulged into the hilus of the right and computerized tomography scanning of the organs, or for kidney. The cyst was opened and emptied during the dissection. surgical interventions in the area. DISCUSSIONS AND CONCLUSIONS
Morphological variations of the kidneys and their vessels, either in size, shape, location, position and so forth, are numerous and generally well known. 5- 7 The embryological bases for these variations also have been well established.8 Anomalies associated with the rotation of kidneys, as in our case, often are caused by or related to aberrant vessels. 9 - 11 However, generally, in these cases each kidney receives its corresponding normal or accessory vessel directly from the aorta or from one
Mr. Frank Pace provided the photographs. REFERENCES
1. Chiarugi, G.: Istituzioni di Anatomica. Milano: Societa Editrice Libraria, p. 481, 1948. 2. Piersol, G. A.: Human Anatomy, 3rd ed. Philadelphia: J.B. Lippincott Co., p. 805, 1911. 3. Jeffery, R. F.: Unusual origins of renal arteries. Radiology, 102: 309, 1972.
BRANCHES FROM SINGLE ARTERY TO BOTH UNROTATED KIDNEYS
4. Jeidell, H.: A note of the source and character of the early blood vessels of the kidney. Anat. Rec., 5: 47, 1911. 5. Anson, B. J., Pick, J. W. and Cauldwell, E.: The anatomy of the commoner renal anomalies: ectopic and horseshoe kidneys. J. Urol., 47: 112, 1942. 6. Awojobi, 0. A., Ogunbiyi, 0. A. and Nkposong, E. 0.: Unusual relationship of multiple renal arteries. Urology, 21: 205, 1983. 7. Hollinshead, W. H.: The kidneys, ureters, and suprarenal glands. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis, 2nd ed. New York: Harper & Row, Publishers, vol. 2, chapt. 10, pp. 518-573, 1971. 8. Gray, S. W. and Skandalakis, J. E.: Embryology for Surgeons. Philadelphia: W. B. Saunders Co., pp. 443-518, 1972. 9. Braash, W. F.: Anomalous renal rotation and associated anomalies. J. Urol., 25: 9, 1931. 10. Nathan, H.: Aberrant renal artery producing developmental anomaly of kidney associated with unusual course of gonadal (ovarian) vessels. J. Urol., 89: 570, 1963. 11. Olsson, 0. and Wholey, M.: Vascular abnormalities in gross anomalies of kidneys. Acta Rad., 2: 420, 1964.
9
12. Merklin, R. J. and Michels, N. A.: The variant renal and suprarenal blood supply with data on the inferior phrenic, ureteral and gonadal arteries. A statistical analysis based on 185 dissections and review of the literature. J. Int. Coll. Surg., 29: 41, 1958. 13. Gutierrez, R.: The clinical management of horseshoe kidney. Amer. J. Surg., 14: 657, 1931. 14. Kolin, C. P., Boatman, D. L., Schmidt, J. D. and Flocks, R. H.: Horseshoe kidney: a review of 105 patients. J. Urol., 107: 203, 1972. 15. Robinson, B.: The blood-vessels in fused (horseshoe) kidneys based on the study of sixty specimens and illustrations. Lancet-Clinic, 102: 141, 1909. 16. Herman, J. L. and Fetterolf, G.: "Dumb-bell" kidney. Ann. Surg., 57: 868, 1913. 17. Guggemos, E., Nystrom, J., Peppy, S. J., Sinatra, C. and Brody, H.: A rare case of an arterial connection between the left and right kidneys. Ann. Surg., 156: 940, 1962. 18. Malament, M., Schwartz, B. and Nagamatsu, G. R.: Extrarenal calyces: their relationship to renal disease. Amer. J. Roentgen., 86: 823, 1961.