Angiotomografía renal en el donante vivo y su correlación con la ablación quirúrgica / Computed tomography renal angiography of living donors and its correlation with surgery

Objetivos: Determinar la precisión de la angiotomografía renal (ATR) en la evaluación del sistema arterial y las variantes anatómicas en el donante vivo, con la correlación con su ablación quirúrgica. Materiales y métodos: Se evaluaron retrospectivamente los pacientes sometidos a nefrectomía laparoscópica como donantes vivos renales y sus ATR, entre 2014 y 2016 en nuestra Institución. Se utilizó análisis estadístico descriptivo para presentar los resultados. En la ATR se evaluaron: número de arterias renales principales, presencia y número de arterias polares y alteraciones del calibre de la arteria renal. Resultados: Se incluyeron 21 pacientes sometidos a nefrectomía laparoscópica como donantes vivos, 10 mujeres y 11 hombres (entre 23 y 61 años). En todos los casos se realizó la ablación del riñón izquierdo. De los 21 pacientes analizados, 15 no presentaron variantes anatómicas ni alteraciones del calibre en la ATR (una arteria renal principal, sin polares). Estos mismos hallazgos se certificaron en la ablación. En un caso, la ATR observó doble arteria renal principal con el mismo hallazgo quirúrgico; y en tres casos la ATR reconoció una única arteria polar, las cuales se corroboraron en la ablación. En estos 19 casos se demostró correlación entre la ATR y la ablación, con una precisión del 90,4% En los 2 casos restantes, hubo discrepancias. Conclusión: El conocimiento detallado del sistema arterial es necesario para la planificación quirúrgica de la nefrectomía laparoscópica del donante vivo renal. La angiotomografía renal constituye el método de elección para su evaluación, demostrando muy buena correlación entre sus hallazgos y los de la ablación.

Objective: To determine the accuracy of computed tomography renal angiography (CTRA) in the assessment and diagnosis of arterial vascular anatomy of the kidney and its variations in living kidney donors, with its correlation in harvesting kidneys. Materials and methods: Patients who had undergone laparoscopic nephrectomy as living kidney donors and their CTRA were retrospectively evaluated between 2014 and 2016 in our institution. Results are presented using statistical descriptive analysis. The following were assessed in the CTRA report: number of main renal arteries, presence and number of accessory polar arteries, and anomalies related to renal artery calibre. Results: Of the 21 patients that had undergone laparoscopic nephrectomy as living donors, there were 10 female and 11 male donors (age range 23 - 61 years). Renal harvesting included left kidney in all cases. In 15 cases, no anatomical variations or arterial renal dilations were found in computed tomography renal angiography (CTRA): (one main renal artery, without accessories arteries). The same findings were certified during the surgery. In one case CTRA showed a double renal artery, and the same finding occurred in the surgical harvesting; and three cases in which one single polar accessory artery was certified at surgery. An overall accuracy of 90.4% for CTRA was obtained in 19 cases. In the remaining 2 cases, a discrepancy was found. Conclusion: Detailed knowledge of the renal arterial anatomy is important for the preoperative evaluation of the laparoscopic nephrectomy in living renal donors. Computed tomography renal angiography (CTRA) is the technique of choice for these patients, as it demonstrates a high correlation between tomography findings and surgery harvesting.

Early outcomes of laparoscopic donor nephrectomy with multiple renal arteries

PURPOSE: We evaluated our experience with laparoscopic donor nephrectomy in patients with multiple renal arteries, comparing operative outcomes and early graft function with patients with a single renal artery. MATERIALS AND METHODS: From January 2003 to February 2009, 130 patients underwent laparoscopic donor nephrectomy at our institution, 108 (83%) with a single renal artery and 22 (17%) with multiple arteries. Donor and recipient outcomes for single artery and multiple arteries allografts were compared. RESULTS: The LDN operative time was similar between the single artery and multiple arteries groups (162 vs 163 min, respectively, p = 0.87). Allografts with multiple arteries had significantly longer warm ischemia time (3.9 vs 4.9 min, p = 0.05) and cold ischemia time (72 vs 94 min, p < 0.001) than those with single artery. The conversion rate was similar between single and multiple arteries groups (6% vs 4.5%, respectively, p = 0.7). Multiple arteries grafts had a non statistically significant higher rate of poor graft function when compared to single artery grafts (23% vs 12%, respectively, p = 0.18). Five patients in the single artery group (4.6%) and one patient in the multiple arteries group (4.5%) needed dialysis during the first postoperative week. Overall, recipient complication rates were similar between single and multiple arteries groups (12.9% vs 18.1%, respectively, p = 0.51). CONCLUSION: Laparoscopic donor nephrectomy with multiple arteries was associated with a non statistically significant higher rate of poor early graft function. The procedure appears to be safe in patients with multiple arteries, with similar complications rates. Multiple arteries should not be a contraindication for laparoscopic donor nephrectomy.

Right renal artery re-implantation and supra-coeliac clamping in a supra-renal abdominal aortic aneurysm.

Aim: We report the repair of a supra-renal abdominal aortic aneurysm involving celiac axis with right renal artery reimplantation. Materials and Methods: A 35 year old woman presented with a supra-renal abdominal aortic aneurysm with maximum diameter of 6.7cm. The right renal artery originated from the aneurysm. The left kidney was smaller in size and left renal artery originated from the aneurysm. The aneurysm was repaired with a 18mm dacron tube graft. A patch containing the celiac axis was and re-anastomosed to the Dacron tube. The right renal artery was re-implanted into the tube graft separately. The total clamp time taken for all the anastomosis was 45 minutes including the total time of 35minutes for renal and mesenteric ischemia. Results: Patient had post-operative acidosis, hypothermia and transient rise in renal parameters and could be extubated on second post-operative day i.e. 48 hours after surgery. Postoperative renal Doppler showed good flow across right renal artery atnd left renal artery, without renal infarct. Patient was discharged with normal renal parametres on tenth post-operative day. patency. Conclusion: We conclude that renal artery reimplantation on supra-coeliac clamping of aorta is feasible during supra-renal abdominal aortic artery aneurysm repair with minimum morbidity and excellent

Results of separate anastomoses of multiple renal arteries with recipient external iliac artery in renal transplant surgery

To evaluate the results of separate anastomoses of multiple arteries of the donor kidney with the external iliac artery of the recipient in renal transplant surgery. A descriptive study conducted at department of Urology and Renal Transplantation, Foundation University Medical College, Fauji Foundation Hospital, Rawalpindi and Hearts International Hospital, Rawalpindi from January 2005 to December 2007. Living voluntary kidney donors having multiple renal arteries as seen on preoperative screening. During regular renal transplant surgery, donors having multiple renal arteries as diagnosed on preoperative computerized tomographic renal angiography were selected for further study. Such kidneys from volunteer donors were harvested and no ex vivo bench surgery was performed to unit these multiple renal arteries. An arterial punch was used to make separate arteriotomies on the external iliac artery of the recipient and anastomoses of the multiple renal donor arteries were carried out separately with the external iliac artery in an end to side manner using 7/0 prolene suture. Of the fifty grafts harvested, 38 had two renal arteries arising from the aorta and reaching the renal hilum [Group I]. These were anastomosed separately to the external iliac artery. Nine grafts had triple renal arteries, two running to the hilum and one entering into the lower pole [Group II]. All these three arteries were anastomosed in an end to side manner with the external iliac artery. Three grafts had one main renal artery and a tiny upper polar cortical vessel incapable of anastomoses [Group III]. The small upper polar cortical artery was sacrificed and the main renal artery was anastomosed with the external iliac artery. One release of vascular clamps perfusion of the graft was observed. Diuresis of the graft was notices. Color Doppler study of the graft was carried out on third postoperative day. Serum creatinine of the recipient was determined on alternate days for one week, after a month and then regularly at three months interval for two years. Early and late vascular and urological complications were observed over a period of two years. A total of 50 kidneys with multiple renal arteries were harvested. On release of vascular clamps, reperfusion of all the allograft occurred within 5 to 75 seconds [mean: 30 seconds]. Diuresis from the graft started in 1/2 to 8 minutes [mean 3.5 minutes]. One of the recipients in Group I developed sudden decline of urine output 2 hours postoperatively and a color Doppler scan showed lack of perusion. On re-exploration a positional kink of the arteries was found which was corrected. Color doppler study on third postoperative day revealed normal perfusion of all the grafts. Serum creatinine of all the recipients steadily came down and reached normal values within a week. Serum creatinine levels remained within normal range over two years of follow-up. None of the patients developed postoperative hypertension or other vascular complications during the follow-up period. Three patients in Group I developed lymphocele requiring percutaneous aspiration. Two patients in Group II had wound infection. Performing separate anastomoses for multiple renal arteries of the donor with the external iliac artery of the recipients in renal transplant surgery is a safe, easy to perform and practical with minimal complications. The renal arterial anatomy of the donor kidney should be evaluated by the spiral computed tomographic angiography, prior to harvesting it in the host and this angiography should be available in all renal transplant surgery units