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Transplantation Using Inverted Renal Unit and Donor Vena Cava-Iliac Vein Conduit to Bypass Recipient Distal Vena Cava and Iliac Venous Systems
0022-5347 /88/1406-1480$2.00/0 Vol. 140, December Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1988 by The Williams & Wilkins Co.
TRANSPLANTATION USING INVERTED RENAL UNIT AND DONOR VENA CAVA-ILIAC VEIN CONDUIT TO BYPASS RECIPIENT DISTAL VENA CAVA AND ILIAC VENOUS SYSTEMS LAWRENCE J. GIBEL, MAIA CHAKERIAN, ANTONIA HARFORD AND WILLIAM STERLING From the Urology Section, Albuquerque Veterans Administration Medical Center, and Urology Division and Transplantation Section, University of New Mexico, Albuquerque, New Mexico
ABSTRACT
We describe a transplantation procedure using donor vena cava and iliac vein to bypass venous abnormalities in a recipient in whom conventional renal transplantation had failed. Considerations for choosing this procedure are reviewed. (J. Urol., 140: 1480-1481, 1988) Renal transplantation has become a relatively standard surgical procedure. Urological abnormalities in the recipient most commonly account for departures from standard technique. Significant abnormalities in recipient venous systems are rare. CASE HISTORY
A 37-year-old man on home hemodialysis for 12 years requested evaluation for renal transplantation. Renal biopsy 17 years previously for evaluation of the nephrotic syndrome had demonstrated membranous glomerulonephritis. A year later the patient experienced severe pulmonary emboli requiring vena caval clip plication. Renal transplantation to the right iliac fossa with venous anastomosis to the external iliac vein was performed 7 years previously. The recipient vein was described as fibrotic and "fenestrated within, that is, as though there was a valve coming out of the wall in all directions". The transplanted kidney developed immediate urine output. Due to the onset of oliguria a biopsy was performed 7 days postoperatively. Histological studies demonstrated marked interstitial hemorrhage with no evidence of rejection. Allograft nephrectomy was performed on postoperative day 13. Pathological studies of the graft were consistent with extensive ischemic infarction. There were minimal signs of rejection. No specific characterization of the renal vasculature was made. Before the second transplant we performed venography of the left iliac system (part A of figure) and vena cava (part B of figure). Venous pressure studies demonstrated a left external iliac vein pressure of 15 cm. water, which was only 5 cm. water higher than the right atrial pressure. Due to the severity of the venous anatomical abnormalities we planned to perform the renal transplant venous anastomosis proximal to the vena caval plication. A local cadaveric donor was identified to be a 4-antigen match before actual organ retrieval. Minor alterations in our standard en bloc cadaveric renal procurement technique were taken to facilitate construction of the venous conduit. Care was taken to preserve the right common iliac vein and its continuity with the entire infrahepatic vena cava. The venous conduit was constructed using running suture closures of the orifices of the left renal vein and left common iliac vein, and ligating all minor branches. Before completing the conduit the proximal end of the vena cava was intubated and retrograde perfusion of saline was performed. Observation of the fluid exiting freely from the distal common iliac vein eliminated the possibility of venous valves in this inverted conduit. The proximal vena caval orifice then was closed and the conduit was pressure tested for leaks. Accepted for publication March 18, 1988.
The transplant procedure was performed through a right 10th interspace, extrapleural, extraperitoneal approach, with the incision extending to the ipsilateral pubic tubercle. The native vena cava distal to the clip plication was involved and distorted by scar. At least 1 large (1.5 cm. in diameter) collateral vein could be seen entering the anterior surface of the vena cava proximal to the plication clip. The vena cava was normal 3 cm. proximal to the clip. The renal allograft was placed upside down in the right iliac fossa (part C of figure). The venous conduit anastomosis was performed to the lateral surface of the recipient vena cava 5 cm. inferior to the recipient right renal vein. The renal artery anastomosis was performed with a Carrel patch anastomosed to the side of the external iliac artery. Because the kidney was upside down the ureter was curved first laterally and then inferiorly towards the bladder. An extravesical ureteroneocystostomy was performed. Due to the unusual course of the ureter we elected to use an indwelling silicone stent. The patient experienced acute tubular necrosis and early graft rejection. The stent was removed 6 weeks postoperatively. Creatinine was 1.1 mg. per cent 8 months after transplantation. The patient has had no postoperative complications and he has returned to full activities. DISCUSSION
Renal transplantation has become a standard surgical procedure. The basic principles adhere to use of a retroperitoneal approach, vascular anastomoses to relatively distal vessels and urinary reconstruction with ureteroneocystostomy. Unusual problems with the recipient occasionally require alteration of the standard procedure. When evaluating this patient for the second transplant we were suspicious that the infarction of the first transplant may have been related to the abnormal right iliac venous system. In view of the history we believed that it was necessary to study the left iliac veins and vena cava. Due to the severity of the anatomical abnormalities demonstrated by venography we planned to perform the renal transplant venous anastomosis proximal to the vena caval plication by using the right iliac fossa location for the kidney and a long venous conduit. Alternative procedures were considered for this recipient. A transperitoneal approach incurs increased liability should bleeding, urinary extravasation or infection occur. It requires vascular anastomoses to the vena cava and aorta. The translumbar approach as described by Van Poppel and associates 1 requires nephrectomy, splenectomy, vascular anastomoses to the native renal vein and splenic artery, and pyelopyelic anastomosis for urinary reconstruction. In selecting our technique we sought to deviate as little as possible from the basic princi-
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TRANSPLANTATION USING INVERTED RENAL UNIT AND VENA CAVA-ILIAC VEIN CONDUIT
1481
A, 3 veins (solid arrow) in area of left iliac system are identified coursing in parallel fashion towards vena cava. Large ascending lumbar collateral (open arrow) arises from lateral aspect of left external iliac vein area. B, at anticipated vena caval confluence (large solid arrow) drainage is cephalad with configuation being slightly narrowed and irregular (small solid arrow). At L2 level vein courses slightly laterally and assumes normal configuration of inferior vena cava (open arrow). C, donor kidney is seen upside down in right iliac fossa. Donor vena cava and common iliac vein conduit are darkly shaded. Renal artery with Carrel patch has been anastomosed to external iliac artery. Shaded ring represents vena caval plication clip.
ples and our standard operative procedure. An additional consideration in using the iliac fossa location was to maintain accessibility for percutaneous needle biopsy of the allograft. Our alternate procedure enabled us to accomplish our goals. To the best of our knowledge this is the first report to describe the use of a lengthy venous conduit for renal transplantation. We recommend this technique for other recipients who require
renal transplantation in the face of extensive iliac or vena caval venous disease. REFERENCES 1. Van Poppel, H., Gil-Vernet, J. M., Caralps, A. and Fernandez, C.,
Jr.: Translumbar splenectomy in human kidney transplant recipients. J. Urol., 134: 247, 1985.
THE JOURNAL OF UROLOGY
Copyright© 1988 by The Williams & Wilkins Co.
TRANSPLANTATION USING INVERTED RENAL UNIT AND DONOR VENA CAVA-ILIAC VEIN CONDUIT TO BYPASS RECIPIENT DISTAL VENA CAVA AND ILIAC VENOUS SYSTEMS LAWRENCE J. GIBEL, MAIA CHAKERIAN, ANTONIA HARFORD AND WILLIAM STERLING From the Urology Section, Albuquerque Veterans Administration Medical Center, and Urology Division and Transplantation Section, University of New Mexico, Albuquerque, New Mexico
ABSTRACT
We describe a transplantation procedure using donor vena cava and iliac vein to bypass venous abnormalities in a recipient in whom conventional renal transplantation had failed. Considerations for choosing this procedure are reviewed. (J. Urol., 140: 1480-1481, 1988) Renal transplantation has become a relatively standard surgical procedure. Urological abnormalities in the recipient most commonly account for departures from standard technique. Significant abnormalities in recipient venous systems are rare. CASE HISTORY
A 37-year-old man on home hemodialysis for 12 years requested evaluation for renal transplantation. Renal biopsy 17 years previously for evaluation of the nephrotic syndrome had demonstrated membranous glomerulonephritis. A year later the patient experienced severe pulmonary emboli requiring vena caval clip plication. Renal transplantation to the right iliac fossa with venous anastomosis to the external iliac vein was performed 7 years previously. The recipient vein was described as fibrotic and "fenestrated within, that is, as though there was a valve coming out of the wall in all directions". The transplanted kidney developed immediate urine output. Due to the onset of oliguria a biopsy was performed 7 days postoperatively. Histological studies demonstrated marked interstitial hemorrhage with no evidence of rejection. Allograft nephrectomy was performed on postoperative day 13. Pathological studies of the graft were consistent with extensive ischemic infarction. There were minimal signs of rejection. No specific characterization of the renal vasculature was made. Before the second transplant we performed venography of the left iliac system (part A of figure) and vena cava (part B of figure). Venous pressure studies demonstrated a left external iliac vein pressure of 15 cm. water, which was only 5 cm. water higher than the right atrial pressure. Due to the severity of the venous anatomical abnormalities we planned to perform the renal transplant venous anastomosis proximal to the vena caval plication. A local cadaveric donor was identified to be a 4-antigen match before actual organ retrieval. Minor alterations in our standard en bloc cadaveric renal procurement technique were taken to facilitate construction of the venous conduit. Care was taken to preserve the right common iliac vein and its continuity with the entire infrahepatic vena cava. The venous conduit was constructed using running suture closures of the orifices of the left renal vein and left common iliac vein, and ligating all minor branches. Before completing the conduit the proximal end of the vena cava was intubated and retrograde perfusion of saline was performed. Observation of the fluid exiting freely from the distal common iliac vein eliminated the possibility of venous valves in this inverted conduit. The proximal vena caval orifice then was closed and the conduit was pressure tested for leaks. Accepted for publication March 18, 1988.
The transplant procedure was performed through a right 10th interspace, extrapleural, extraperitoneal approach, with the incision extending to the ipsilateral pubic tubercle. The native vena cava distal to the clip plication was involved and distorted by scar. At least 1 large (1.5 cm. in diameter) collateral vein could be seen entering the anterior surface of the vena cava proximal to the plication clip. The vena cava was normal 3 cm. proximal to the clip. The renal allograft was placed upside down in the right iliac fossa (part C of figure). The venous conduit anastomosis was performed to the lateral surface of the recipient vena cava 5 cm. inferior to the recipient right renal vein. The renal artery anastomosis was performed with a Carrel patch anastomosed to the side of the external iliac artery. Because the kidney was upside down the ureter was curved first laterally and then inferiorly towards the bladder. An extravesical ureteroneocystostomy was performed. Due to the unusual course of the ureter we elected to use an indwelling silicone stent. The patient experienced acute tubular necrosis and early graft rejection. The stent was removed 6 weeks postoperatively. Creatinine was 1.1 mg. per cent 8 months after transplantation. The patient has had no postoperative complications and he has returned to full activities. DISCUSSION
Renal transplantation has become a standard surgical procedure. The basic principles adhere to use of a retroperitoneal approach, vascular anastomoses to relatively distal vessels and urinary reconstruction with ureteroneocystostomy. Unusual problems with the recipient occasionally require alteration of the standard procedure. When evaluating this patient for the second transplant we were suspicious that the infarction of the first transplant may have been related to the abnormal right iliac venous system. In view of the history we believed that it was necessary to study the left iliac veins and vena cava. Due to the severity of the anatomical abnormalities demonstrated by venography we planned to perform the renal transplant venous anastomosis proximal to the vena caval plication by using the right iliac fossa location for the kidney and a long venous conduit. Alternative procedures were considered for this recipient. A transperitoneal approach incurs increased liability should bleeding, urinary extravasation or infection occur. It requires vascular anastomoses to the vena cava and aorta. The translumbar approach as described by Van Poppel and associates 1 requires nephrectomy, splenectomy, vascular anastomoses to the native renal vein and splenic artery, and pyelopyelic anastomosis for urinary reconstruction. In selecting our technique we sought to deviate as little as possible from the basic princi-
1480
TRANSPLANTATION USING INVERTED RENAL UNIT AND VENA CAVA-ILIAC VEIN CONDUIT
1481
A, 3 veins (solid arrow) in area of left iliac system are identified coursing in parallel fashion towards vena cava. Large ascending lumbar collateral (open arrow) arises from lateral aspect of left external iliac vein area. B, at anticipated vena caval confluence (large solid arrow) drainage is cephalad with configuation being slightly narrowed and irregular (small solid arrow). At L2 level vein courses slightly laterally and assumes normal configuration of inferior vena cava (open arrow). C, donor kidney is seen upside down in right iliac fossa. Donor vena cava and common iliac vein conduit are darkly shaded. Renal artery with Carrel patch has been anastomosed to external iliac artery. Shaded ring represents vena caval plication clip.
ples and our standard operative procedure. An additional consideration in using the iliac fossa location was to maintain accessibility for percutaneous needle biopsy of the allograft. Our alternate procedure enabled us to accomplish our goals. To the best of our knowledge this is the first report to describe the use of a lengthy venous conduit for renal transplantation. We recommend this technique for other recipients who require
renal transplantation in the face of extensive iliac or vena caval venous disease. REFERENCES 1. Van Poppel, H., Gil-Vernet, J. M., Caralps, A. and Fernandez, C.,
Jr.: Translumbar splenectomy in human kidney transplant recipients. J. Urol., 134: 247, 1985.