Double Renal Vein Research Articles

Double renal vein Anastomosis for rare venous anomaly: A method to achieve good venous outflow in the transplanted kidney

Multi-organ procurement was performed on a 48-year-old donor after the patient was declared brain dead. A standard approach was performed for two dissections of abdominal organs. During the cold phase of dissection, an additional left sided retro-aortic vein was identified. The second vein had separate opening to the inferior vena cava in addition to the normal positioned pre-aortic left renal vein. Both veins were divided close to the origin from the inferior vena cava. During the back table preparation, it was noticed that same volume of preservative fluid was identified to be draining from both veins. Both veins were isolated and anastomosed separately on the 61-year-old recipient. Patient was initiated on anti-platelet therapy and made successful recovery.

Anatomical variants of renal veins: A meta-analysis of prevalence

The main aim of this article is to establish the actual prevalence of renal vein variations (circumaortic renal vein, retroaortic renal vein, double renal vein), and to increase awareness about them. To this purpose, we have performed a meta-analysis of prevalence, using the MetaXL package, We included 105 articles in the final analysis of prevalence, of which 88 contained data about retroaortic renal vein, 84 – about circumaortic renal vein, and 51 - about multiple renal veins. The overall prevalence for retroaortic renal vein was 3% (CI:2.4–3.6%), for circumaortic renal vein − 3.5% (CI:2.8–4.4%), and for multiple renal veins - 16.7% (14.3–19.2%), much higher on the right 16.6 (14.2–19.1%) than on the left side 2.1 (1.3–3.2%). The results were relatively homogenous between studies, with only a minor publication bias overall.

Presentation of double renal artery with double renal vein: A case report

Presentation of double renal artery with double renal vein: A case report

Multiphase whole-body CT angiography before multiorgan retrieval in clinically brain dead patients: Role and influence on clinical practice.

To evaluate the contribution of multiphase whole-body CT angiography (CTA) for identifying the contra-indications to multiorgan retrieval (MOR) and improving the preoperative organ harvesting strategy. One hundred and eleven consecutive patients who were clinically brain dead underwent multiphase whole-body CTA to confirm the diagnosis of brain death and for assessment of MOR. The CTA protocol included volumetric acquisitions of the brain and abdominopelvic cavity without IV administration of iodinated contrast material, then images of the thorax-abdomen-pelvis 25s after IV contrast administration, of the brain at 60s and finally an abdominopelvic CT acquisition at 90s. The diagnosis of brain death was based on well-established criteria. The assessment of thorax, abdomen and pelvis was based on a systematic checklist. Post-processing imaging techniques were used in all patients. No organs were retrieved from 21patients due to patient refusal (19%). Twenty-two potential MOR were denied because of general contra-indications including 12/22 (54%) based on CTA criteria alone. Finally, 68patients were eligible for MOR and 160organs were harvested. The exclusion of specific organs was based on CTA alone for 2/16 livers, 4/70 kidneys and 5/55 lungs. Fifty hearts and 58 pancreases were not harvested, none based on CTA results alone. Hepatic abnormalities and vascular anatomical variants were identified in 10% of patients. At least one renal artery variant was found in 28% of patients, 13% presented with a double renal vein and 8% with a hepato-mesenteric artery. Multiphase whole-body CTA for MOR is based on the simultaneous association of cerebral CTA to determine brain death with CTA of the thorax, abdomen and pelvis. This rapid, standardized and easily accessible procedure has no harmful effects on harvested kidneys. It makes it possible to select the donors and the organs to be harvested and allows the retrieving surgeon to identify and anticipate technical difficulties.

Diagnostic accuracy of CT angiography in evaluation of vascular anatomy in comparison with intraoperative findings an assessment of 392 patients

Introduction: Transplantation of kidneys from living related donors is the treatment of choice for patients with end stage renal disease. With lessmorbidity and early recovery, laparoscopy has become the standard of care for donor nephrectomies. The precise knowledge of vascular anatomy is crucial to a successful outcome. Computed tomography (CT) findings are misleading and less informative in a small number of cases. The reported accuracy of CT angiography in assessing the vascular anatomy is around 85 to 100 %. We did a prospective study to assess the diagnostic accuracy of CT angiography in the evaluation of vascular anatomy in comparison with intra operative findings.Aim: To assess the accuracy of CT in predicting the anatomy in patients who underwent laparoscopic donor nephrectomy.Materials and methods: 392 patients who underwent laparoscopic donor nephrectomy in our institute between January 2010 and December 2012 were included in our study.Results: CT scan correlated well with the intra operative findings in most of our patients with good sensitivity and specificity. CT interpreted a case of double renal vein as single and a case of circumaortic vein reported on CT was not detected intra operatively. A case of right side early branching was not detected on CT. A case of a retroaortic branch of renal vein was missed on CT scan. The incidental findings detected on CT scan such as calculi, mass and hemangioma or fibroid can be of help in managing the patient after surgery.

Radical Nephrectomy in a Horseshoe Kidney with Endo-Caval Thrombosis: Infrahepatic Caval Vein Control with Piggy-Back Technique

Introduction: Renal cell carcinoma with vascular invasion of vena cava is still a great challenge for uro-oncologists. The surgical approach to this clinical scenario is even more challenging when coupled with anatomical anomalies, like horseshoe kidney and the presence of abnormal vessels. Materials and Methods: In this video, we will show a case of a large left renal tumor in a horseshoe kidney with double renal vein and endo-caval thrombus that reaches the suprahepatic veins (T2b—third level). The video describes, step by step, the piggy-back surgical technique, which allows to completely expose the inferior infrahepatic vena cava, splitting it from the liver that remains connected just to the three suprahepatic veins. This technique, borrowed from the liver transplant, allows, without increasing the risk of intraoperative complications and maintaining a high oncologic efficacy, to have an excellent vascular control that, in cases like the presented one, may avoid recourse to the use of extracorporeal circulation and allows urological equipe to complete the operation, without the aid of cardiac surgeons. Moreover, the video shows how it is possible, on a horseshoe kidney, the presence of abnormal vessels, whose arterial component has to be preserved to maintain a proper blood flow in the residual renal parenchyma. Results: The postoperative course was uneventful, underlining the reliability of the chosen surgical approach. The patient died after 10 months from cardiopulmonary failure. Conclusions: The video shows how it is possible to surgically approach an advanced left kidney cancer on a horseshoe kidney with abnormal vessels and an associated endo-caval thrombus that reaches the suprahepatic veins, without recurring to extracorporeal circulation. The piggy-back technique allows in this case a better exposure of the infrahepatic vena cava, allowing the procedure to be effectively performed. No competing financial interests exist. Runtime of video: 6 mins 54 secs Video technique employed: The video has been shot by one of the surgeons, using a full HD handy cam. The camera has been covered to be sterile and to be used over the field. Video editing has been made using Adobe Premiere and Adobe photoshop (for overlay graphics). Smithmicro POSER and Autodesk 3D studio MAX have been used for tridimensional patient images. A high-end computer has been used to finally render the video in full HD.

V73 Radical nephrectomy in a horseshoe kidney with endo caval trombosis: Infra hepatic caval vein control with Piggy back technique

Introduction: Renal cell carcinoma with vascular invasion of vena cava is still a great challenge for uro-oncologists. The surgical approach to this clinical scenario is even more challenging when coupled with anatomical anomalies, like horseshoe kidney and the presence of abnormal vessels. Materials and Methods: In this video, we will show a case of a large left renal tumor in a horseshoe kidney with double renal vein and endo-caval thrombus that reaches the suprahepatic veins (T2b— third level). The video describes, step by step, the piggy-back surgical technique, which allows to completely expose the inferior infrahepatic vena cava, splitting it from the liver that remains connected just to the three suprahepatic veins. This technique, borrowed from the liver transplant, allows, without increasing the risk of intraoperative complications and maintaining a high oncologic efficacy, to have an excellent vascular control that, in cases like the presented one, may avoid recourse to the use of extracorporeal circulation and allows urological equipe to complete the operation, without the aid of cardiac surgeons. Moreover, the video shows how it is possible, on a horseshoe kidney, the presence of abnormal vessels, whose arterial component has to be preserved to maintain a proper blood flow in the residual renal parenchyma. Results: The postoperative course was uneventful, underlining the reliability of the chosen surgical approach. The patient died after 10 months from cardiopulmonary failure. Conclusions: The video shows how it is possible to surgically approach an advanced left kidney cancer on a horseshoe kidney with abnormal vessels and an associated endo-caval thrombus that VID-2014-0035-ver9-Veneziano_1P.3d 07/26/14 8:32pm Page 1

A rare combination of vascular variations of both kidneys

Bilateral variations of renal vessels were encountered during the dissection of a 54-year-old male cadaver. There were triple renal arteries bilaterally, double renal veins on the right, and an unusual formation of renal vein on the left side. A bilateral occurrence of triple renal arteries has not been encountered in the literature, so does an incidence. Additional renal vessels have the potential to cause clinical complications such as hydronephrosis. Their existence has utmost importance in surgical and radiological interventions and radiological examinations.

Retroperitoneal laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction by double renal veins: a case report and literature review

Objective To report a retroperitoneal laparoscopic surgery for ureteropelvic junction obstruction (UPJO) by double renal veins.Methods A 28-year-old male patient with left low back pain for 6 months was diagnosed as left hydronephrosis and UPJO.A ureteral stent had been placed 3 months before and failed to improve hydronephrosis,so the ureteral stent was pulled out.CT scan showed that left UPJ went through the two renal veins,suggesting UPJO.Nephrogram showed that left GFR and right GFR were 35 ml/min and 34 ml/min,respectively.These results indicated mechanical obstruction of left upper urinary tract.The patient underwent retroperitoneal laparoscopic Anderson-Hynes dismembered pyeloplasty.Results The surgical procedure was successful.Two left renal veins were found,and the ventral one was in front of ureter,compressing the ureter.An aberrant renal artery went into left kidney with the ureter.0.5 cm stenosis of ureteropelvic junction was excised,and pyeloplasty was performed.A ureteral stent was placed into the ureter,then the pelvis and the ureter were sew up in front of the ventral renal vein.The surgical time was 240 min,and blood loss was 50 ml.Postoperative hospital stay time was 4 d.During 4 months' follow up,hydronephrosis was attenuated significantly.Conclusion Retroperitoneal laparoscopic surgery for UPJO with aberrant two renal vein might be a minimally-invasive and effective procedure. Key words: Renal veins; Ureteropelvic junction obstruction; Laparoscopes; Dismembered pyeloplasty

Laparoscopic Donor Nephrectomy in Different Anatomical Scenarios: Our Experience

Introduction: Laparoscopic donor nephrectomy currently ranks as the gold standard surgical exercise for renal harvest for transplantation and has been widely practiced in both single and multiple renal arteries.1 We present a video demonstration of this exercise in interesting anatomical scenarios. Methods: Voluntary renal donors underwent a standard workup protocol involving various specialities. Three-dimensional helical computed tomography angiogram (64-slice computed tomography scanner) was employed for delineation of anatomy. The left renal unit was favored on most occasions. All procedures were conducted through transperitoneal access. Four ports were used for left donor nephrectomy and five ports for right side procedure. For right renal harvest, a terminal hand-assisted approach was followed.2 After hilar mobilization, the ureter was divided first followed by control of renal artery and lastly renal vein. In case of multiple arteries or veins, the most accessible artery or vein was clipped and divided first followed by the other member irrespective of vessel caliber. In all cases, control of renal vein was obtained by using 10-mL hem-o-loc clips. Additional titanium clips were used as necessary. In no case, a vascular stapler was utilized. Graft retrieval was undertaken through Pfannenstiel incision for left side and oblique muscle splitting incision on right side. Results and Discussion: Between 1999 and 2011, 715 laparoscopic donor nephrectomies were successfully performed by the same surgeon. Mean donor age was 37.6 years. Mean body mass index was 23.2 kg/m2. 612 left and 103 right side renal allografts were harvested. 315 were men and 400 women. One hundred sixty-five renal units harbored multiple renal arteries (154 cases revealed two renal arteries, 10 cases revealed three renal arteries, and 1 case revealed four renal arteries). Interesting anatomical scenarios included double renal vein (two occasions, both right side), double lumbar vein (five occasions, all left side), double ureter (two occasions, one on left side and one on right side). In all these cases, a laparoscopic approach could be completed uneventfully. Mean warm ischemia time was 3.56 minutes. Mean operation duration was 110.4 minutes. Mean blood loss was 75.5 mL. Laparoscopic donor nephrectomy may be successfully attempted in the presence of different anatomical variants. Although a retroperitoneal approach has been favored by few operators,3 we practice the transperitoneal route as it enables wider working space and the anatomy is familiar. Meticulous attention should be paid during dissection of the ureterogonadal pedicle or the renal hilum to identify anatomical variations and avoid inadvertent injuries. The operator needs to be sufficiently versed with laparoscopic exercises. No competing financial interests exist. Runtime of video: 7 mins 55 secs

Viviperception on renal vessel variation by retroperitoneal laparoscopy a report of 525 cases

To study the variation of renal vessels with retroperitoneal laparoscopy so as to increase the safety of retroperitoneal laparoscopic surgeries. A total of 525 patients underwent retroperitoneal laparoscopic nephrectomy or partial nephrectomy at our hospital between January 2004 and June 2008. There were 316 males and 209 females with a mean age of (58 ± 13) years old. The procedures were as follows: (1) patients lay on one side with their waist up and the retroperitoneal cavity was established with our institutional method; (2) gerota's fascia was separated widely along the ventral surface of major psoas muscle; (3) the tissues around renal arteries and veins were isolated by ultrasonic scalpel. Careful observation was performed to explore if there were duplicated or accessory renal vessels; (4) renal vessels were cut by Endo-GIA/Hem-o-lok or blocked by bulldog clamps; (5) whole or partial kidney was finally resected (remaining procedures omitted). Among all patients, 58 patients (11.0%, 58/525) had a variation of renal vessels. There were double renal arteries on one side (n = 18), double renal veins (n = 10), 3 renal veins (n = 1) and double arteries and veins on one side (n = 3). Twenty-five patients (4.8%, 25/525) had one accessory renal artery on one side while 19 (76.0%, 19/25) accessory renal arteries went toward the upper kidney pole. The diameter of one patient's left spermatic vein was similar with that of renal vein and they were joined by lumber vein. The variation of renal artery is more common than that of renal vein. The accessory renal arteries are common and usually go toward the upper kidney pole. The variation of renal vessels should be considered before and during a laparoscopic procedure.

Laparoscopic Donor Nephrectomy in the Presence of Vascular Anomalies: Evaluation of Outcome

In this study we show the outcome of laparoscopic kidney donation for donors and recipients in cases of donors with vascular anomalies. We consider donors to have vascular anomalies if they have multiple arteries or venous abnormalities. Fifty-six cases had double renal arteries (left side n = 52, right side n = 4). Three patients had triple renal arteries. Eighteen cases had venous anomalies (retro-aortic renal vein n = 11, double renal vein n = 4, circum-aortic renal vein n = 2, atrophic proximal renal vein, n = 1). Two donors had multiple abnormalities (double renal arteries, double renal veins, and a retro-aortic renal vein in one case, and double renal artery and double renal vein in one case). Donor surgery was done transperitoneally in all cases, using three trocars on the left side and four on the right side. Outcome in these cases is compared to the outcome in cases with no vascular abnormalities (n = 321) performed in our institution. The total number of patients with vascular anomalies in our series is 79 (19.7%). All cases were completed laparoscopically. The mean operative time was 161 +/- 35 minutes. The mean blood loss was 65 +/- 38 mL, and no donor required blood transfusion. Mean warm ischemia time was 2.6 +/- 0.4 minutes, mean renal artery length was 3.1 +/- 0.4 cm, and mean renal vein length was 3.5 +/- 1.2 cm. Donors were discharged on the second postoperative day, and no donor required readmission. Kidneys were transplanted successfully and mean creatinine of the recipients on discharge was 1.3 +/- 0.3 mg/dL. Five patients had acute tubular necrosis; however, only one of them required dialysis (delayed graft function). Kidney function recovered thereafter in all patients. There were no significant differences in blood loss, warm ischemia time, donor hospital stay, or patient creatinine on discharge, between patients with vascular abnormalities in donors and those without vascular abnormalities in donors. However, operative time was significantly longer in donors with vascular abnormalities. Laparoscopic donor nephrectomy is safe for donors with vascular anomalies. Donors benefit from a less morbid procedure with no effect on functional outcome.

Transplantation of a Horseshoe Kidney

Because of the continuing organ shortage, kidneys with atypical anatomy are frequently considered for transplantation. The most common anatomic variation of the kidney is the horseshoe kidney, with an incidence of 1 in 800. These kidneys are frequently accompanied by vascular and urinary tract abnormalities and there has always been a concern for primary nonfunction based on technical failure (1, 2). Discard of potentially usable horseshoe kidneys can occur because of vascular anatomic limitations or injuries. According to a recent report of horseshoe kidneys that were donated within the Eurotransplant region, 27% were discarded immediately and 9.6% were discarded after division. The reason was the complex vascular anatomy in at least 53.8% and 60%, respectively (3). We present a case of whole horseshoe kidney transplantation after extensive vascular reconstruction. A horseshoe kidney from a 52-year-old male deceased donor was accepted at the University of Pittsburgh Medical Center. The cause of death was a cerebrovascular accident. The backtable wedge kidney biopsy showed 10% glomerulosclerosis and mild interstitial fibrosis, arteriosclerosis, and arteriolosclerosis. The horseshoe kidney had been recovered en bloc with the accompanying aorta and inferior vena cava (IVC). The arterial supply to the horseshoe kidney consisted of two right hilar renal arteries connected to the aorta, two left hilar renal arteries that were transected at their common orifice at the aorta, an isthmic artery (previously a branch of the right external iliac artery), and a left superior pole artery transected midway from its aortic origin. Venous drainage consisted of bilateral double renal veins to the IVC. Reconstruction was performed by anastomosis of the hilar arteries to the single orifice at the original site on the aorta, the left superior pole artery to its transected branch, and the isthmus artery to a newly created orifice at the inferior aorta. The superior poles of the aorta and IVC were oversewn (Fig. 1).FIGURE 1.: Arterial vascular reconstruction of horseshore kidney.The recipient was a 63-year-old female with end-stage renal disease secondary to tacrolimus toxicity after lung transplantation. The recipient operation was performed through a standard extraperitoneal approach in the right iliac fossa. Revascularization was accomplished by anastomosis of the inferior IVC and aorta to the external iliac artery and vein, respectively. The ureters were anastomosed to the bladder using separate extravesical ureteroneocystostomies. The cold ischemia and anastomosis times were 34 hr and 35 min, respectively. Both kidneys reperfused entirely. Immunosuppression consisted of induction with daclizumab and maintenance immunosuppression with tacrolimus, mycophenolate mofetil, and prednisone. There were no vascular or ureteral complications. The serum creatinine was 1.6 mg/dL two weeks posttransplantation. Our decision to transplant the whole horseshoe kidney as a single kidney rather than divided into two kidneys was due to the presence of an isthmic artery. Horseshoe kidneys have previously been transplanted successfully with reasonable results. Due to the organ shortage, efforts to overcome the anatomic challenges of horseshoe kidneys are worthwhile. Anthony T. Corcoran Ron Shapiro Liise K. Kayler Department of Surgery University of Pittsburgh Medical Center Pittsburgh, PA

Use of computed tomography renal angiography for screening feline renal transplant donors.

Preoperative knowledge of the renal vascular anatomy is important for selection of the appropriate feline renal donor. Intravenous urograms (IVUs) have been performed routinely to screen potential donors at the Veterinary Hospital of the University of Pennsylvania (VHUP), but the vascular phase views lack sufficient detail of the renal vascular anatomy. Computed tomography angiography (CTA), which requires a helical computed tomography (CT) scanner, has been found to provide superior renal vascular anatomic information of prospective human renal donors. The specific aims of this study were as follows: 1) develop the CTA technique for the feline patient; and 2) obtain preliminary information on feline renal vessel anatomy in potential renal donors. Ten healthy, potential feline renal donors were anesthetized and imaged using a third-generation helical CT scanner. The time delay between i.v. contrast medium injection and image acquisition, and other parameters of slice collimation, slice interval, pitch, exposure settings, and reconstruction algorithms were varied to maximize contrast medium opacification of the renal vascular anatomy. Optimal CTA acquisition parameters were determined to be: 1) 10-sec delay post-i.v. bolus of iodinated contrast medium; 2) two serially acquired (corresponding to arterial and venous phases) helical scans through the renal vasculature; 3) pitch of 2 (4 mm/sec patient translation, 2 mm slice collimation); and 4) 120-kVp, 160-mA, and 1-sec exposure settings. Retrospective reconstructed CTA transverse images obtained at a 2-mm slice width and a 1-mm slice interval in combination with two-dimensional reformatted images and three-dimensional reconstructed images were qualitatively evaluated for vascular anatomy; vascular anatomy was confirmed at surgery. Four cats had single renal arteries and veins bilaterally; four cats had double renal veins. One cat had a small accessory artery supplying the caudal pole of the left kidney. One cat had a left renal artery originating from the aorta at a 90 degrees angle with the cranial mesenteric artery. CTA of the feline renal vascular anatomy is feasible, and reconstruction techniques provide excellent anatomic vascular detail. CTA is now used routinely at VHUP to screen all potential feline renal donors.

Renal vein reconstruction with interposition allografts in cadaveric renal transplantation

Abstract. The short or injured renal vein in cadaveric transplantation is a surgical challenge. Over a 2-year period, we have performed ex vivo renal vein lengthening with an interposition vascular allograft in 17 recipients of cadaveric kidneys. Indications for renal vein extension allografts were a short right renal vein (N= 12), procurement injury to the vein (N= 4), and double renal vein (N= 1). In six cases (35.3%), ex vivo renal artery reconstruction was performed in combination with the venous repair. Our preferred approach is to employ allograft material in ex vivo reconstruction under cold storage conditions. Bench surgery ranged from 10 to 30 min, and the mean in situ anastomosis time was 20 min. The mean length of renal vein prior to reconstruction was 12 mm, and the mean length of venous interposition allograft after revascularization was 27 mm. There were no episodes of vascular thrombosis or primary nonfunction. Three patients (17.6%) required postoperative hemodialysis for acute tubular necrosis, which was subsequently resolved. The mean serum creatinine at 1 month post-transplant was 1.7 mg/dl. These preliminary results suggest that ex vivo renal vein reconstruction with an interposition allograft is a safe and effective modality which should be added to the transplant surgeon's armamentarium in select cases.

Vascular surgical problems in renal transplantation.

Vascular manipulations that differed from the standard technique of renal transplantation were required in 40 of 107 human renal transplantations (38%). Double renal arteries were managed successfully by a side-to-side arterioplasty to form a single common lumen in nine instances. Polar infarcts occurred in seven of eight cases requiring ligation of polar arteries. Double renal veins were probably handled by ligating one of the veins because of the extensive intrarenal venous communication. Endarterectomy of the recipient's iliac system was required in ten transplants because of extensive atherosclerosis. It is concluded that the frequency of vascular abnormalities encountered in renal transplantation requires that the transplant surgeon be familiar with a variety of vascular surgical techniques.