Bilateral En-Block Horseshoe Kidney Laparoscopic Nephrectomy / Nefrectomía bilateral en bloque en riñón en herradura

Horseshoe kidney (HSK) has a prevalence of 1 in every 500 individuals. The management of patients with HSK is usually conservative, except in the presence of symptoms such as obstruction, stones, glomerulopathies, and tumors. In the following case report, we describe how a bilateral en-block transmesenteric laparoscopic nephrectomy in supine position was performed. A 5-year-old boy, with proximal hypospadias and early onset of chronic kidney disease due to focal segmental glomerulosclerosis on biopsy, underwent a genetic molecular evaluation that confirmed a pathogenic mutation at the WT-1 gene. Due to the increased risk of developing Wilms tumor, he underwent a bilateral transmesenteric nephrectomy. In a five-minute video, we describe how we performed an en-block transperitoneal and transmesenteric laparoscopic nephrectomy with special attention to patient positioning, including the feasibility of performing the dissection of the left renal hilum and isthmus with the patient in supine with no need for repositioning, and then moving to the dissection of the right renal hilum and completion of the procedure. The case herein reported enables us to describe the technical key-points to perform a bilateral en-block laparoscopic nephrectomy with shorter operative time and reduction of blood loss by preserving the entire specimen, without the need for an isthmus transection.

El riñón en herradura (RH) tiene una prevalencia de 1 en cada 500 individuos. El manejo del RH es usualmente conservador, excepto cuando genera síntomas como obstrucción, litiasis, glomerulopatías o tumores. Con este reporte de caso, describimos como se realizó una nefrectomia bilateral en bloque transmesentérica en un paciente con riñón en herradura. Un paciente de 5 años de edad, con hypospadias proximal y desarrollo temprano de enfermedad renal crónica por glomeruloesclerosis focal segmentaria, fue sometido a un estudio molecular que confirmó la presencia de una mutación en el gen WT-1. Dado el alto riesgo de desarrollar tumor de Wilms, se decidió realizar una nefrectomía transperitoneal laparoscópica bilateral. En un video de cinco minutos, describimos como se realizó una nefrectomía transperitoneal y transmesentérica en bloque, con especial atención al posicionamiento del paciente, incluso la viabilidad de realizar la disección del hilio renal izquierdo y el istmo con el paciente en supino, sin necesidad de reposicionarlo, y, después, la disección del hilio renal derecho y el fin del procedimiento. El caso reportado nos permite describir los puntos clave técnicos para realizar una nefrectomía laparoscópica bilateral en bloque con un tiempo operativo más corto y reducción del sangrado al preservar todo el espécimen, sin la necesidad de realizar la transección del istmo.

Management of Wilms’ tumor in a horseshoe kidney at the time of COVID-19 pandemic: A case report

@#Wilms’ tumor is one of the most frequent tumors in childhood. The incidence of Wilms’ tumor in a horseshoe kidney is estimated at 0.4 to 0.9%. It is highly treatable but a fast growing tumor. Management of cancer patients has become a dilemma for surgeons, due to the impact of the COVID-19 pandemic on the health care sector globally. Reported here is a rare case of a 2 year old boy, diagnosed with Wilms’ tumor in a horseshoe kidney. This report aimed to highlight the multimodality treatment of Wilms' tumor and the modifications to cancer diagnostic and treatment protocols to adapt to the current health care crisis brought about by the pandemic.

A case of Turner syndrome with horseshoe kidney and right side duplication kidney with UPJO and double kidney cyst / 中华泌尿外科杂志

This paper reports a rare clinical case of 46 X, i(X)(q10)TS in a female patient with horseshoe kidney and right duplication kidney with renal pelvic and ureteral junction stenosis and double kidney cysts, secondary to right renal calculi and hydronephrosis. After open surgical treatment, the curative effect was definite, which effectively relieved the stenosis at the junction of the renal pelvis and ureter and relieved the clinical symptoms of the patient. The patient was followed up for 3 months and recovered well. When TS is combined with horseshoe kidney with UPJO, open pyeloplasty with partial isthmus and renal fixation are still classic surgical procedures.

Post therapy Wilms tumour or ectopic immature renal tissue: A pathologist's diagnostic dilemma

Post chemotherapy Wilms Tumour (PCWT) is a diagnostic conundrum both for the clinician and the pathologist, in view of its morphological similarity with ectopic immature renal tissue (EIRT). However, due to their varying prognoses and different lines of management, it is important to distinguish between the two. Here, we discuss clinical presentation and pathology of a case of PCWT, arising in a horse shoe deformity of the kidney in a 5 year old girl. The discussion focuses on the pathogenesis of Extra Renal Wilms Tumour (ERWT) as well as its distinguishing morphological features and chemotherapy induced changes in Wilms tumour.

Hiperamonemia secundaria a infección urinaria en un paciente con malformación del tracto urinario en pediatría: a propósito de un caso / Hyperammonemia secondary to urinary tract infection in patients with pediatric urinary tract malformation: a case report

Ammonium is an important source of nitrogen for amino acid synthesis and is necessary for normal acid base balance. When ammonium concentrations are high it becomes a toxic compound. Hyperammonemia is a metabolic emergency. When underdiagnosed and not treated appropriately, it produces severe neurological sequelae and/or death. The clinical presentation of hyperammonemic encephalopathy varies, and includes from personality disorders, psychiatric disorders, confusion, irritability, lethargy, seizures to coma. Hyperammonemia occurs with an increase in ammonium production, as in intestinal hemorrhage, or with a decrease in the elimination of ammonium, such as in congenital metabolic errors, hepatic insufficiency or drug intoxication. As we can see, it may have multiple origins, but congenital errors of metabolism are always suspected as one of the causes. However, there are less frequent causes, such as urinary tract infection, especially in predisposing conditions. We describe the case of a 2-year-old boy with a history of horseshoe kidney and right ureterohydronephrosis, surgical correction of imperforate anus and rectal bladder fistula. This patient presented hyperammonemia with encephalopathy (Glasgow 7/15) while undergoing a urinary infection with Corynebacterium riegelii. Hyperammonemia is the result of the production in the dilated urinary tract of large amounts of ammonium due to bacterial urease and its subsequent reabsorption in the systemic circulation. The patient improved clinically (Glasgow 15/15) after parenteral antibiotic therapy and urinary tract clearance

El amonio es una fuente importante de nitrógeno para la síntesis de aminoácidos y necesario para el balance ácido base; si se encuentra elevado, se convierte en un compuesto tóxico. La hiperamoniemia es una urgencia metabólica; cuando no es diagnosticada y tratada de manera oportuna, produce graves secuelas de tipo neurológico o la muerte. La presentación clínica de la encefalopatía hiperamoniémica es variable, pudiéndose observar trastornos en la personalidad, trastornos psiquiátricos, confusión e irritabilidad, letargia, convulsión y coma. La hiperamoniemia se presenta por aumento en la producción de amonio, como en la hemorragia intestinal, o por disminución de la eliminación del mismo, como ocurre en los errores congénitos del metabolismo, en la insuficiencia hepática o en la intoxicación por fármacos. Puede tener múltiples orígenes, pero los errores congénitos del metabolismo son una de las causas que siempre se sospechan. Sin embargo, existen causas menos frecuentes, como la infección del tracto urinario (sobre todo en condiciones que predispongan a las mismas). Describimos aquí el caso de un niño de 2 años, con antecedentes de riñón en herradura y ureterohidronefrosis derecha, corrección quirúrgica de ano imperforado y fistula recto vesical. Este paciente presentó hiperamoniemia con encefalopatía (Glasgow 7/15) mientras cursaba una infección urinaria por Corynebacterium riegelii. La hiperamoniemia es el resultado de la producción en el tracto urinario dilatado de grandes cantidades de amonio, debido a la ureasa bacteriana y su posterior reabsorción en la circulación sistémica. El paciente mejoró clínicamente (Glasgow 15/15) después de la terapia antibiótica parenteral y desobstrucción de tracto urinario

Anatomical and clinical aspects of horseshoe kidney: a review of the current literature / Aspectos anatómicos y clínicos del riñón en herradura: una revisión de la literatura actual

SUMMARY: Horseshoe kidney (HSK) is the most common kidney malformation. This review analyses the literature surrounding the etiology, morphology and clinical anatomy of these kidney fusion anomalies. A systematic literature search was carried out using the Science Direct and Scopus applications. HSK is characterized by three anatomic abnormalities: ectopia, malrotation and vascular changes. The study put emphasis especially on blood supply and upper urinary tract changes in HSK's patients. Arterial blood supply was analysed not only basing on Graves pattern, but also a new model of supply created on horseshoe kidneys computed tomography was taken into account. In addition, study presents clinical aspects of especially significant pathology of HSK, like hydronephrosis, stones and urinary tract infection. This study focuses also on congenital anomalies associated with horseshoe kidney.

RESUMEN: El riñón en herradura (RH) es la malformación renal más común reportada en la literatura. Esta revisión analiza la literatura que rodea la etiología, morfología y anatomía clínica de esta anomalía de fusión renal. Se realizó una búsqueda sistemática de la literatura utilizando las aplicaciones Science Direct y Scopus. El riñón en herradura se caracteriza por tres anomalías anatómicas: ectopía, malrotación y cambios vasculares. El estudio puso énfasis especialmente en el suministro de sangre y los cambios del tracto urinario superior en los pacientes con RH. El suministro de sangre arterial se analizó no solo basándose en el patrón de Graves, sino que también se tuvo en cuenta un nuevo modelo de suministro creado en los riñones en herradura. Además, el estudio presenta aspectos clínicos de patología especialmente significativa de RH, como hidronefrosis, cálculos e infección del tracto urinario. Este estudio se centró también en las anomalías congénitas asociadas con el riñón en herradura.

Horseshoe Kidney / Riñón en herradura

Abstract We present the clinical case of a 39 year old male that presented with a violent death in the city of Medellin. During the necropsy, a horseshoe Kidney was found, which was never diagnosed according to the patients' medical history. It is a case relevant in the medical field given the unusual vasculature that was found, because it's not a usual arrangement. The lack of symptoms and its spontaneous finding during the necropsy, shows us that it's not a rare find in our environment and that it has a big impact in the surgical fields, and in occasions, with urinary tract infections. Methodology: Descriptive. Informed consent was given by the deceased relatives for the use and analysis of the medical history.

Resumen Se expone el caso de un hombre de 39 años que presenta muerte violenta en la ciudad de Medellín. Durante la necropsia se encuentra un riñón en herradura, que no tuvo diagnóstico clínico en su momento, según los hallazgos en su historial médico. Es un caso que puede tener implicaciones en el campo médico, dada la vasculature accesoria que presenta, presentación que no es comúnmente observada. La falta de sintomatología y su hallazgo espontáneo durante la necropsia hacen ver que, a pesar de la poca incidencia, no es extraño encontrar el caso en pacientes de nuestro entorno. Este tiene mayor impacto en el campo quirúrgico y, en ocasiones, en las afecciones urinarias. Metodología: descriptivo. Se obtuvo consentimiento informado, de la familia del occiso, para el estudio de su historial médico.

En bloc transplantation of horseshoe kidney in Korea

Transplantation of the horseshoe kidney can be performed en bloc or split into 2 grafts according to the vascular anomaly and the existence of the urinary collecting system in isthmus. From 2011 to 2014, there were 3 horseshoe kidney transplantations in Korea and transplantations were performed at 2 different centers. The transplantations were carried out successfully for all recipients without complications. All recipients have shown good graft kidney function after transplantation. No severe complication was revealed during follow-up period. We described the surgical technique used in the en bloc method to overcome various vascular anomalies and difficulties in choosing cannulation site and postoperative complications. En bloc transplantation of a horseshoe kidney is a useful strategy for patients with end-stage renal disease, and can provide favorable outcomes compared to the transplantation of a normal kidney.

Clinical effect of extracorporeal shock wave lithotripsy in the treatment of horseshoe kidney stones / 中华泌尿外科杂志

Objective To explore the clinical effect of extracorporeal shock wave lithotripsy (ESWL) for the treatment of horseshoe kidney stones.Methods A total of 42 cases of horseshoe kidney stones from March 1987 to January 2015 were enrolled.Among them,33 cases were male and 9 cases were female.Their age range was 19 to 71 years,average age was 42 years old.25 cases got left renal pelvis stone,17 cases were on the right renal pelvis side.The diameter range of stone was 0.4-3.7 cm,the average was 1.8cm.ESWL was applied to treat whole group.The prone position was used to removing calculus.The frequency of treatment was 2000-2700 times,with an average of 2500 times;the treatment voltage was 4-7KV.The gravel time of the treatment was 30-45min,the average was 35min.Results One time for ESWL was 29 cases,two times for ESWL was 8 cases,three times for ESWL was 3 cases,four times for ESWL was 2 cases.The first discharge stones time was 3 to 10 days.There was no special discomfort after operation.40 cases got hematuria after operation,which occurred in 1 to 3 days after ESWL Renal colic was in 7 cases which happened on 1-3 days after ESWL.Condusions Calculi in horseshoe kidney may be treated by ESWL.It is a safe and simple operation.The prone position may bring satisfactory effect.

Horseshoe kidney: a review article.

Horseshoe kidney is a rare non-fatal congenital malformation of renal development. It usually remains asymptomatic and in many cases it is discovered incidentally. This anomaly is found twice as often in men than in women. The present report, horseshoe kidney was discovered in 62-year-old male cadaver during routine dissection. The inferior poles of the kidneys were fused to form a parenchymatous isthmus, resulting in a horseshoe kidney. The horseshoe kidney was located anterior to the abdominal aorta and the inferior vena cava at a level lower than the normal kidney. Both renal hila were directed anteriorly and the ureters which drained from each renal pelvis descended anterior to the isthmus to enter the urinary bladder normally. There were 3 renal arteries, 1 on the right and 2 on the left. The inferior vena cava was behind the isthmus and the lower pole of the right kidney. Two renal veins opened independently into the inferior vena cava. It is important to be aware of this renal anomaly in clinical practice, especially during renal surgeries, renal transplants, or surgical and endovascular procedures on the aorta.

Horseshoe kidney – a case report.

Horseshoe kidney is a rare non-fatal congenital malformation of renal development. It usually remains asymptomatic and in many cases it is discovered incidentally. This anomaly is found twice as often in men than in women. The present report, horseshoe kidney was discovered in 62-year-old male cadaver during routine dissection. The inferior poles of the kidneys were fused to form a parenchymatous isthmus, resulting in a horseshoe kidney. The horseshoe kidney was located anterior to the abdominal aorta and the inferior vena cava at a level lower than the normal kidney. Both renal hila were directed anteriorly and the ureters which drained from each renal pelvis descended anterior to the isthmus to enter the urinary bladder normally. There were 3 renal arteries, 1 on the right and 2 on the left. The inferior vena cava was behind the isthmus and the lower pole of the right kidney. Two renal veins opened independently into the inferior vena cava. It is important to be aware of this renal anomaly in clinical practice, especially during renal surgeries, renal transplants, or surgical and endovascular procedures on the aorta.

Horseshoe Kidney: A Multidetector Computed Tomography Study.

Background and Objective:Horseshoe kidney is themost common renal fusion anomalywith a reported prevalence of 1 in 400 persons with a male to female ratio of 2:1. In many cases its presence may go unnoticed and undiagnosed because the patient may remain asymptomatic throughout life. The objective of our study is to report radiological and anatomical features of horseshoe kidney detected incidentally during retrospective evaluation of multidetector computed tomography scans. Materials and Methods: Contrast enhanced multidetector computed tomography scans of 682 patients, 355 males and 327 females, were reviewed retrospectively. Results: Seven cases of horseshoe kidney were detected incidentally, sixmales and one female,with an incidence of 1.02%. In all cases,malrotation of the kidneyswere observedwith the hilumfacing anteriorly or anterolaterally. The isthmus was made up of parenchymal tissue in all the cases and the fusion was midline in four cases and lateral in three cases. Horseshoe kidney in all cases was supplied by multiple renal arteries, varying from 3 to 6. In three cases symmetrical arterial supply and in the rest asymmetrical supplywas observed. Nephrolithiasis and hydronephrosis were noted in two patients. No other associated congenital anomaly was observed in all seven patients. Conclusion: Contrast enhanced multidetector computed tomography evaluation of patients with horseshoe kidney provide excellent information about its vascularity, collecting system and other associated conditions.

Transplantation of a Horseshoe Kidney Found During Harvest Operation of a Cadaveric Donor: A Case Report

A 34-yr-old female was diagnosed as being brain dead. Preoperative ultrasound revealed no abnormal focal lesions. However, the horseshoe kidney was identified during organ harvest. En bloc nephrectomy was performed. The kidney was divided at the midline of isthmus. The divided right kidney was discarded due to numerous arteries and veins. The divided left kidney was transplanted. After declamping, the kidney was well perfused and started clearing. Resistive index was 0.72. Glomerular filtration ratio was 84.69 mL/min on postoperative day 14. The horseshoe kidney can be successfully transplanted and could be a good solution for the shortage of organ donors.

Transplantation of a Horseshoe Kidney Found During Harvest Operation of a Cadaveric Donor: A Case Report

A 34-yr-old female was diagnosed as being brain dead. Preoperative ultrasound revealed no abnormal focal lesions. However, the horseshoe kidney was identified during organ harvest. En bloc nephrectomy was performed. The kidney was divided at the midline of isthmus. The divided right kidney was discarded due to numerous arteries and veins. The divided left kidney was transplanted. After declamping, the kidney was well perfused and started clearing. Resistive index was 0.72. Glomerular filtration ratio was 84.69 mL/min on postoperative day 14. The horseshoe kidney can be successfully transplanted and could be a good solution for the shortage of organ donors.

A Case of Acute Pyelonephritis Caused by Enterococcus Hirae in a Patient with a Horseshoe Kidney / 대한내과학회지

Enterococcus hirae mainly causes infections in animals. It has been rarely encountered in humans and, in most such cases, it is considered to be a contaminant or resident flora. Since the first case of septicemia by E. hirae was reported in 1998, only two cases of acute pyelonephritis (APN) have been reported in Korea. We describe herein a case of APN caused by E. hirae in an 83-year-old man with a horseshoe kidney. Although E. hirae was isolated only from urine and not from the blood, we were able to diagnose it as the causative organism based on the patient's clinical findings, imaging study results, and risk factors including old age, benign prostatic hypertrophy, and a horseshoe kidney.

Clinical Manifestations and Characteristics in Patients with Horseshoe Kidney

PURPOSE: We aimed to investigate the clinical characteristics and associated diseases in children with a horseshoe kidney and compared these data between children and adults. METHODS: We performed a retrospective analysis of the medical records and radiological findings of 43 patients diagnosed with a horseshoe kidney in the Busan Paik Hospital. The subjects were divided into the children's group (14 cases, age or =18 years). RESULTS: The study group consisted of 17 males and 26 females with a median age of 34 years. In the children's group (14 cases), 5 subjects were male and 9 were female, with a mean age of 6.7+/-6.2 years. Most of the subjects were asymptomatic and were incidentally diagnosed with horseshoe kidney during their evaluation for another disease. Among the associated diseases in the children's group, Turner syndrome was the most common (5 cases), whereas ureteropelvic junction (UPJ) stricture was observed in 2 cases (14.2%). None of the children exhibited abnormal renal function during the follow-up period. In the adult group (29 cases), 12 subjects were male and 17 were female, with a mean age of 48 years. Eighteen patients were incidentally diagnosed with horseshoe kidney during their evaluation for another disease, and 11 patients had hematuria or abdominal pain due to renal stones. Among the associated diseases in the adult group, Turner syndrome was the most common (5 cases), and UPJ stricture was observed in 5 cases; the other accompanying diseases included hydronephrosis and overactive bladder. Six patients exhibited decreased renal function (serum creatinine level >1.5) during the follow-up period. CONCLUSION: Horseshoe kidney is usually diagnosed incidentally in both children and adults. In the present study, we noted that Turner syndrome was the most common associated disease in children. In addition, most children were asymptomatic but had a high risk of urologic complications after the transition to adulthood. Therefore, children with horseshoe kidney require continuous follow-up.

Horseshoe kidney with surplus renal vessels: A case report in Thai cadaver.

A horseshoe kidney (HK) was discovered in an 84-year-old Thai male cadaver during routine dissection. Inferior poles of the kidneys fused to form a parenchymatous isthmus and constituted a HK. The HK located anterior to the abdominal aorta and the inferior vena cava at a level lower than the normal kidney. Both renal hila directed anteriorly and ureters which drained from each pelvis descended anterior to the isthmus to enter the urinary bladder. Eight renal arteries and five renal veins were observed. In this case the bulky isthmus, anatomical abnormalities, and a variable blood supply were found in association with the HK. It is important to be aware of this anomalous existence in clinical practice, especially during kidney surgeries, kidney transplants, or surgical and endovascular procedures on the aorta.

Initial experience of horseshoe kidney treated with transperitoneal laparoscopic plastic surgery / 中华泌尿外科杂志

ObjectiveTo investigate the feasibility,technique and clinical effect of applying laparoscopic plastic surgery in the treatment of horseshoe kidney.Methods Eleven patients with horseshoe kidney were admitted from Mar.2006 to Mar.2011.There were 5 males and 6 females with mean age of 27years (14 to 46 years).Clinical manifestations included lower-back pain in 8 cases,lower-back pain and hematuria in 2 cases,lower-back pain and fever in 1 case.There were 6 cases accompanied with kidney calculi.All the cases with calculus were in left kidney and there was 1 case with multiple calculi.There were 11 cases accompanied with left hydronephrosis.Of which,there were moderate hydronephrosis in 6 cases,severe hydronephrosis in 5 cases.There were 3 cases accompanied with mild right hydronephrosis.There were 2 patients with renal insufficiency,1 patient with urinary tract infection.The surgery procedures included laparoscopic isthmectomy and plastic surgery in 3 cases,isthmectomy and plastic surgery and pelviolithotomy in 6 cases,isthmectomy and vascular compression release in 2 cases.ResultsAll patients had successful surgeries with the mean operative time of 145 min (95 - 190 min).The average blood loss was 250 ml ( 100 -400 ml).Average postoperative hospital stay was 10 d (7 - 15 d).One patient suffered from urinary leakage after surgery and recovered after anti-inflammatory therapy and local drainage.One patient suffered from secondary hemorrhage controlled with DSA.All the patients were followed up with a mean of 17 months (6 -28 months).In 6 cases with moderate hydronephrosis,5 patients recovered to mild hydronephrosis and 1 case improved from preoperative renal hydronephrosis 3.5 cm to postoperative 3.0 cm.In 5 cases with severe hydronephrosis,3 patients improved to moderate hydronephrosis,2 patients to mild hydronephrosis.One patient with kidney stone had 0.4 cm residual stone.Three patients complained of occasional mild backache.One patient suffered from hematuria and urinary tract infection,recovered after antiinflammatory therapy for 2 weeks.The remaining 6 patients were in good conditions during the follow-up.ConclusionTransperitoneal laparoscopic plastic surgery is able to deal with horseshoe kidney isthmus malformation and comorbidities,and is another alternative for the treatment of horseshoe kidney.

A Case of Ruptured Abdominal Aortic Aneurysm with Horseshoe Kidney / 日本心臓血管外科学会雑誌

Ruptured abdominal aortic aneurysm (AAA) associated with horseshoe kidney is an extremely rare condition. A 76-year-old man with lung cancer treated by radiotherapy was transfered to our hospital for emergency surgery of a ruptured AAA. Preoperative abdominal CT revealed an AAA 70 mm in diameter, massive hematoma in the retroperitoneal space and horseshoe kidney with a huge renal cyst. Because the patient was in serious condition, we performed emergency operation immediately after arrival at our hospital. The AAA was replaced by a straight prosthtic graft without division of the renal isthmus, however one aberrant renal artery was sacrificed. The postoperative course was uneventful with no evidence of renal dysfunction. In cases of ruptured AAA in a state of shock, emergency operation is first priority. Even though we could do only minimal preoperative examinations, the surgery of the ruptured AAA with horseshoe kidney can be performed safely, if an accurate perioperative judgement for the treatment of abberant artery and renal isthmus is made.

A Case of Abdominal Aortic Aneurysm Associated with Horseshoe Kidney / 日本心臓血管外科学会雑誌

Horseshoe kidney is a common renal anomalies, but coexistence with abdominal aortic aneurysm (AAA) is rare. Horseshoe kidney may cause various technical difficulties of aneurysm repair. A 76-year-old man was referred to our hospital for treatment of AAA with a horseshoe kidney. Preoperative 3-dimensional computed tomography (3D-CT) scans showed a pair of normal renal arteries and 3 accessory renal arteries from the anterior wall to abdominal aorta just proximal to an aneurysm. At operation, the aneurysm was exposed through a transperitoneal approach, and artificial graft replacement was performed with a woven Dacron bifurcated graft preserving the renal isthmus. The accessory renal arteries were not reconstructed. The postoperative course was uneventful. Postoperative 3-D CT showed minor infarction of renal isthmus, but renal function was not impaired.