Prone Retroperitoneoscopy in Treating Complex Renal Vascular Malformations

Abstract

PURPOSE Two children presented with malignant hypertension. Investigations, including formal angiography, revealed complex renal vascular anomalies; obstruction in upper polar artery in one and arterio-venous malformation in the other. Open surgery and different laparoscopic approaches were considered, but prone retroperitoneoscopy was used in treating both. MATERIAL AND METHODS 1. A 6 year old girl presented with convulsions and malignant hypertension. Captopril DMSA was suggestive of right renal artery stenosis. On formal angiography, the kidney was perfused by what appears to be an arterio-venous malformation. Her blood pressure was very difficult to control on large doses of three antihypertensive agents. There were multiple small collaterals at the lower pole. The right ovarian artery was large and there was a prominent collateral supply originating from it where it crossed the ureter and there were pulsatile vessels along the ureter up to the renal hilum. The kidney was devascularised easily by controlling the main renal pedicle and the ureteric blood vessels prior to nephrectomy. 2. A 14 month old boy presented with six month history of poor appetite, weight loss and irritability. He was severely hypertensive and required 3 antihypertensives. Captopril DMSA showed disappearance of the upper pole of a simplex right kidney. Formal angiography showed acute obstruction of the main upper pole branch. The vessels to the upper pole could be clearly seen and controlled at surgery for partial right nephrectomy. He recovered with no urine leak or bleeding. RESULTS Prone retroperitoneoscopy was used very successfully in treating both. They recovered quickly but stayed longer for gradual withdrawal of antihypertensives. They are remaining well 6 months following surgery. CONCLUSIONS Prone approach provides excellent exposure of the renal blood vessels, aorta and vena cava. Gravity keeps the renal vessels under stretch allowing excellent two-hand dissection.