Arterial

The origin of the right renal artery is beneath the left renal vein and it typically passes posterior to the inferior vena cava (IVC) (Fig. 54–5; see also Fig. 1–33). During transabdominal left radical nephrectomy, knowledge of this anatomic relationship may prevent inadvertent ligation of the right renal artery (Fig. 54–6; see Fig. 54–7 on the Expert Consult website). The inferior adrenal artery and a branch that supplies the renal pelvis and ureter arise from the renal artery. In the majority of cases the renal artery branches in the distal third of the vessel or the renal sinus.

Figure 54–5 Arterial anatomy can be well defined using CT (A) and three-dimensional reconstruction (B).

Figure 54–6 Relationship of right kidney to great vessels. IVC, inferior vena cava; Ao, aorta.

(© The Lahey Clinic.)

Figure 54–7 Vessel loops isolate right renal artery (red) at take off from aorta. The left renal vein (blue) is mobilized cephalad to divide the right renal artery near the aorta.

The kidney is divided into four segments (superior, anterior, posterior, inferior) that are supplied by one or more segmental renal arteries, which are end arteries (Fig. 54–8 on the Expert Consult website). Ligation or occlusion of a segmental artery, or any of its branches, leads to devitalization of renal tissue. Intraoperatively, one can administer methylene blue dye and occlude the segmental arteries to define the borders of the vascular segments. Despite variation in the origin of the branches supplying the renal segments, the anatomic pattern of the segments is constant (Graves, 1954). Three planes between the vascular segments can be demonstrated (see Fig. 54–8 on the Expert Consult website) and are important for intrarenal surgery. In theory, incision in the plane between the anterior and posterior segments affords reduced blood loss (Brodel, 1900) and has been described for anatrophic nephrolithotomy (Smith and Boyce, 1968). This plane, located on the posterior surface of the kidney, is not to be confused with the “Brodel white line,” a whitish linear depression on the lateral aspect of the anterior surface of some kidneys formed by fusion of anterior and posterior columns of Bertin, which demarcates a highly vascular area (Brodel, 1900) (Fig. 54–9).

Figure 54–9 Brödel white line and posterior vascular segment.

(© The Lahey Clinic.)

Figure 54–8 Renal vascular segments.

(© The Lahey Clinic.)

Typically, the first division of the renal artery creates the anterior and posterior segmental branches (see Fig. 1–30A and B). The posterior segmental branch of the main renal artery arises proximal to the hilum, passes posterior to the renal pelvis, and supplies the posterior renal segment. Classically, a crossing vessel responsible for ureteropelvic junction (UPJ) obstruction is an aberrant posterior segmental artery passing anterior to the UPJ. The anterior segmental branch of the main renal artery divides into four divisions: the apical (superior) segmental artery, the anterior superior segmental artery, the anterior inferior segmental artery, and the basilar (inferior) segmental artery. These are also referred to as the apical, upper, middle, and lower anterior segmental arteries, respectively. These segmental arteries then divide further into lobar arteries (associated with each renal pyramid) and further into two or three interlobar arteries (Fig. 54–10). The interlobar arteries travel through the renal medulla alongside either side of the pyramids. They divide at the corticomedullary junction into arcuate arteries that give rise to the interlobular arteries that travel radially to the capsule. They give off numerous side branches en route, including the afferent arterioles.

Figure 54–10 Anatomic relationship of cascading intrarenal vessels.

(© The Lahey Clinic.)

Venous

In parallel to the renal arterial system, the renal venous system progresses from the interlobular veins to the arcuate, interlobar, lobar, and segmental veins (see Fig. 1–32). The segmental veins combine to form three to five venous tributaries, the confluence of which forms the main renal vein near the hilum. Each kidney is typically drained by a single renal vein that courses anterior to the renal artery and joins the lateral aspect of the vena cava. The left renal vein is longer than the right, making the left kidney attractive for donor nephrectomy. The left renal vein typically passes anterior to the aorta.

Unlike the arterial structure of the kidney, the renal venous system is characterized by a rich anastomotic network between the various renal segments. One may ligate and divide segmental veins without compromising drainage. The right renal vein does not receive significant branches. Tributaries draining into the main left renal vein include the gonadal vein, the left adrenal vein, and one or two large lumbar veins, all of which can be injured during mobilization of the left renal vein. Because of these collateral vessels, one is at liberty to ligate the left renal vein at the caval junction without eliminating venous return.

Anomalies of Renal Vasculature

Frequent anatomic variation in the renal vasculature contributes to the complexity of open renal surgery. Multiple renal arteries, which typically arise from the aorta or iliac arteries, are the most common variation, occurring in 25% to 30% of the population (Merklin and Michels, 1958; Boijsen, 1959; April, 1997). Supernumerary hilar renal arteries originate at the aorta adjacent to the renal artery and traverse the renal hilum, whereas polar renal arteries originate at a greater distance from the main renal artery and enter the renal parenchyma directly. Ectopic and horseshoe kidneys more frequently have supernumerary renal arteries (Fig. 54–11).

Figure 54–11 Horseshoe kidney with multiple arterial branches well defined with three-dimensional imaging.

Venous anomalies occur less frequently. Supernumerary renal veins occur less commonly on the left than right (Merklin and Michels, 1958). The most common variation is duplication of a renal vein (6%) (April, 1997). Retroaortic left renal veins occur in approximately 2% of patients. Circumaortic renal veins are present in 1.6% to 6.0% of the population (Kottra and Castellino, 1970). One must be vigilant to identify these infrequent anomalies during preoperative evaluation or intraoperative dissection.

Cardiovascular

Some patients will benefit from referral to a consulting cardiologist for consideration of resting 12-lead electrocardiogram, noninvasive evaluation of left ventricular function, noninvasive stress testing, medication adjustments, or preoperative coronary revascularization (coronary artery bypass graft or percutaneous coronary intervention). Patients with unstable coronary syndromes, decompensated heart failure, significant arrhythmias, or severe valvular disease should be evaluated and treated by a cardiologist before noncardiac surgery (Fleisher et al, 2007). It is incumbent on the urologist to identify these patients and others who are at risk of cardiovascular complications and to refer them for evaluation by a specialist.

In addition, patients with known coronary artery disease or signs or symptoms suggestive of new coronary artery disease should receive a preoperative cardiac assessment (Fleisher et al, 2007). In asymptomatic patients, referral should be made based on a history and physical examination (Lee et al, 1999; Fleisher et al, 2007). The history should elucidate symptoms of cardiovascular disease, risk factors for cardiac disease, and pertinent medications (Table 54–3). The Revised Cardiac Risk Index (RCRI), a simple validated index to predict cardiovascular complications, was developed at a tertiary care facility for prediction of cardiac risk of major noncardiac surgery in patients 50 years of age or older (Lee et al, 1999). The RCRI, which is composed of six independent predictors of cardiac complications, identifies patients at risk of cardiac complications (Table 54–4) and may be helpful for preoperative risk stratification.

Table 54–3 Pertinent Cardiovascular History

Table 54–4 Revised Cardiac Risk Index

Pulmonary

In noncardiothoracic surgery, risk factors for postoperative pulmonary complications include chronic obstructive pulmonary disease, age older than 60 years, inhaled tobacco use, American Society of Anesthesiologists (ASA) class II or higher, functional dependence (i.e., inability to perform activities of daily living or need for equipment and assistance for some activities of daily living), congestive heart failure, pulmonary hypertension, and hypoalbuminemia (Qaseem et al, 2006; Bapoje et al, 2007). The urologist should screen for these risk factors and refer the patient for preoperative pulmonary evaluation and risk reduction.

Even in the absence of baseline risk factors, open renal surgery itself may disturb a patient’s pulmonary equilibrium and render him or her at risk for postoperative pulmonary complications. For instance, transection of upper abdominal and flank muscles, removal of ribs, impairment of diaphragm function through nerve or muscular injury, pneumothorax, hemothorax, and pleuritic pain may all contribute to pulmonary difficulties. Prolonged surgery (>3 hours) is an independent predictor of pulmonary complications, as is either thoracic or upper abdominal surgery (Qaseem et al, 2006).

Pulmonology consultation, preoperative pulmonary function testing, chest radiography, or arterial blood gas analysis may benefit patients who are at risk of pulmonary complications. Preoperative interventions such as smoking cessation 6 to 8 weeks before surgery and inspiratory muscle training may reduce the risk of pulmonary complications (Bapoje et al, 2007). In patients with significant pulmonary risk factors or impairment an anterior surgical approach in the supine position might be preferable to the flank approach (Novick, 2007). Risk can be ameliorated after surgery by deep breathing exercises or incentive spirometry and by selective rather than routine use of nasogastric drainage (Qaseem et al, 2006; Bapoje et al, 2007).

Subcostal Flank Approach

This approach offers good exposure of the renal parenchyma and upper ureter. It is an advantageous approach for surgery on the lower renal pole, UPJ, and upper ureter (e.g., ureterocalicostomy, pyeloplasty, and stone surgery). Simple nephrectomy, insertion of a nephrostomy tube, and drainage of a perinephric abscess may all be accomplished through a subcostal flank incision. Because the approach is extraperitoneal, contamination of the peritoneal cavity is avoided. Access to the renal hilum and vascular pedicle is poor, which is the most salient disadvantage of this approach. The subcostal flank approach is not appropriate for radical or partial nephrectomy (Libertino, 1998). The incision may be caudal to the kidney, hampering access to the upper pole, renal pelvis, and hilum (Novick, 2007). Exposure may be further hindered by the iliac crest and subcostal nerve, the anterior division of the 12th thoracic nerve.

After induction of anesthesia, insertion of an endotracheal tube, and introduction of a Foley catheter into the urinary bladder to monitor urine output, the patient is placed in the lateral position. The head is supported to maintain proper alignment of the cervical spine. The tip of the 12th rib should be positioned over the kidney bar (Fig. 54–18). The patient’s back should be nearly flush with the edge of the table to ensure unfettered access by the surgeon. To preserve stability and prevent forward roll, the dependent leg is flexed at the hip and knee and the top leg is kept straight. A pillow is placed between the knees. An axillary roll is deployed just caudal to the axilla to prevent compression or injury of the axillary neurovascular bundle. Other pressure points, including the upper foot, are padded with foam. The nondependent arm should be placed on a padded Mayo stand so that the arm is horizontal with slight forward rotation at the shoulder. The bed is flexed until the flank muscles are under stretch. A kidney bar can be employed if necessary. The bed is placed in Trendelenburg position so that the flank is rendered parallel to the floor. The patient is secured to the mobile part of operating table with 2-inch wide adhesive tape, which fixes the patient in place while allowing adjustment of flexion.

Figure 54–18 Position of the patient for the flank approach. Note the axillary pad. The kidney rest may be elevated if further lateral extension is needed.

After sterile preparation and draping, the skin incision begins at the costovertebral angle, approximately at the lateral border of the sacrospinalis muscle just inferior to the 12th rib. The incision is made a fingerbreadth below and parallel to the 12th rib and is carried onto the anterior abdominal wall. In an attempt to avoid the subcostal nerve, the incision can be curved gently downward at the midaxillary line. If needed, the incision can be extended caudally or medially to the lateral border of the rectus abdominis.

The incision is carried sharply through the subcutaneous tissue, exposing the fascia of the latissimus dorsi and external oblique muscles (Fig. 54–19). Electrocautery is used to incise the muscles in the line of the incision (Fig. 54–20), starting with the latissimus dorsi posteriorly. The serratus posterior inferior muscles, which insert into the lower four ribs, are also encountered in the posterior portion of the wound and transected. In the anterior aspect of the wound the external oblique muscle is divided. These maneuvers expose the fused lumbodorsal fascia, which gives rise to the internal oblique and transversus abdominis muscles. The lumbodorsal fascia and internal oblique muscle are divided (Fig. 54–21). By using two fingers inserted into an opening created in the lumbodorsal fascia at the tip of the 12th rib, the peritoneum is swept medially as the transversus abdominis is split digitally. The subcostal nerve should be identified between the internal oblique and transversus abdominis muscles and spared (Figs. 54-22 and 54-23).

Figure 54–19 Superficial incision through flank.

(From Libertino JA. Reconstructive urologic surgery. 3rd ed. Philadelphia: Mosby; 1997.)

Figure 54–20 Left subcostal incision. The latissimus dorsi muscle has been divided to expose the lumbodorsal fascia and the posterior aspects of the abdominal muscles.

Figure 54–21 Dissection through flank muscles.

(From Libertino JA. Reconstructive urologic surgery. 3rd ed. Philadelphia: Mosby; 1997.)

Figure 54–22 Opening lumbodorsal fascia to gain entrance to retroperitoneum.

(From Libertino JA. Reconstructive urologic surgery. 3rd ed. Philadelphia: Mosby; 1997.)

Figure 54–23 The lumbodorsal fascia and transverse muscles have been divided to expose the Gerota fascia. The subcostal nerve and vessels pierce the lumbodorsal fascia posteriorly and course forward on the transverse muscle.

To maximize exposure in the posterior aspect of the incision, one may incise the posterior angle of the lumbodorsal fascia, exposing the sacrospinalis and quadratus lumborum muscles. Dividing the costovertebral ligament permits superior retraction of the 12th rib if enhanced exposure is deemed necessary. A Bookwalter (Codman & Shurtleff, Raynham, MA) flank retractor is used for exposure.

To facilitate wound closure, the kidney bar is lowered and the table is partially taken out of flexion. The wound is closed in layers using No. 2 Nylon. The transversus abdominis and internal oblique muscles are closed in one layer. The lumbodorsal fascia is reapproximated, followed by the external oblique, serratus posterior inferior, and latissimus dorsi muscles. The skin edges are reapproximated with staples or subcuticular 2-0 polyglactin (Vicryl). A closed drainage system or Penrose drain should be externalized through a small counterincision below the wound. After applying a sterile dressing to the wound, the authors place the Penrose drain into a collection bag designed for urinary stomas, which is secured to the abdominal wall. This allows drainage to be easily recorded and protects the skin from the drain output.

Supracostal Flank Approach

The supracostal flank incision is favored at the Lahey Clinic for most modest-sized renal tumors and most partial nephrectomies (Fig. 54–24). When properly executed it affords an extraperitoneal, extrapleural approach to the kidney with excellent exposure of the renal and suprarenal areas. In addition, this approach permits the 11th or 12th rib to pivot posteriorly without removing a rib. Turner-Warwick (1965), who popularized the approach, believed that the supracostal approach provides maximal posterior exposure, simplifies wound closure, and is less morbid than a transcostal incision requiring rib resection. More recently, an 8-cm modified mini-flank supra-11th rib incision has been described as a safe, effective approach to radical or partial nephrectomy for renal cortical tumors (Diblasio et al, 2006).

Figure 54–24 Relationship of flank musculature to supracostal area.

(© The Lahey Clinic.)

The level of the incision is determined by the patient’s anatomy, location of the lesion, and the operation planned. For partial nephrectomy the level of incision is determined by the position of the kidney in relation to the ribs as seen on preoperative radiographic studies and by the location and size of the tumor.

The patient is positioned as described for the subcostal flank incision. A skin incision at the superior aspect of the 12th or 11th rib is made, beginning at the lateral border of the sacrospinalis muscle and continuing until the lateral border of the ipsilateral rectus abdominis muscle. The incision is carried sharply through the subcutaneous tissue. The latissimus dorsi and serratus posterior inferior muscles are transected in the posterior aspect of the wound, revealing the intercostal muscles.

The external and internal oblique muscles are divided. The lumbodorsal fascia is opened at the tip of the rib to avoid both peritoneum and pleura. Moving medially, the transversus abdominis muscle is divided carefully while sweeping the peritoneum medially and inferiorly. The diaphragm is exposed by transection of the transversalis muscle. The pleura is identified between the divided transverses abdominis muscle and the diaphragm and can be mobilized superiorly.

The lateral aspect of the sacrospinalis is identified and is either incised or retracted to permit access to the neck of the rib and its attachments. Division of the intercostal muscles should start at the most distal aspect of the rib and proceed toward the spine. The corresponding intercostal nerve is identified and spared. To avoid the neurovascular bundle the intercostal muscles are divided in close proximity to the superior aspect of the rib. The plane between the chest wall and pleura is developed by entering the investing fascia surrounding the intercostal nerve, which allows an extrapleural dissection (Fig. 54–25). The slips of the diaphragm attached to the inferior ribs are transected. Proceeding posteriorly, the intercostal or transverse costal ligament is divided, which permits free movement of the 12th rib (supra 12th) or the 11th and 12th rib (supra 11th).

Figure 54–25 Following the intercostal nerve to remain extrapleural back to the intercostal ligament.

(© The Lahey Clinic.)

Proper closure restores separation between the thoracic and abdominal cavities. At time of closure, local anesthetic can be used to perform an intercostal nerve block under direct vision. As described by Turner-Warwick (1965), the detached diaphragm is externalized through the intercostal space and sutured to the free edge of the intercostal muscles and to the inferior cut edge of the serratus posterior inferior muscle. The edges of the transected latissimus dorsi muscle are reapproximated while incorporating the upper margin of the serratus posterior inferior muscle. A drain is externalized through a separate stab incision.

Over time, the senior author has modified the closure of the supracostal incision. The diaphragm is closed primarily and not externalized. A rib punch is used to create a hole in the rib above and below the incision. A No. 2 Nylon suture, which is passed through the ribs and the diaphragm, is used to restore integrity of the chest wall. The latissimus dorsi, serratus posterior inferior, and intercostal muscles are closed in a single layer.

Transcostal Flank Approach

The classic flank approach involves resection of the 11th or 12th rib and entrance into the retroperitoneum through the bed of the resected rib (Hess, 1939; Hughes, 1949; Bodner and Briskin, 1950). It provides similar exposure to the supracostal incision but is a more complicated and more morbid incision. This transcostal approach fell out of favor at the Lahey Clinic decades ago with the advent of the supracostal approach.

The site of incision is determined by the position of the kidney and the location of disease. Typically, for a lower pole tumor a supra-12th rib incision is adequate. For mid and upper pole tumors, a supra-11th incision is often satisfactory. On a urogram a horizontal line that traverses the hilum of the kidney will intersect with the rib that should be resected. In cases requiring upper pole access the surgeon should approach the kidney through the rib above the one indicated by the horizontal line transversing the hilum.

The patient is placed in the flank position. A trans-12th rib approach will be described. The skin is incised directly over the 12th rib from the lateral border of the sacrospinalis muscle and continuing until the lateral border of the ipsilateral rectus abdominis muscle. The latissimus dorsi, serratus posterior inferior, and external oblique muscles are divided with electrocautery over the center of the 12th rib, exposing the periosteum. The periosteum is incised with a knife. A periosteal elevator is employed to separate the rib from its periosteum. One must be vigilant to preserve the neurovascular bundle.

The exposed rib is resected with a rib cutter as posterior as possible. Rongeurs help remove additional rib and sharp fragments. Bone wax is used to obtain hemostasis and a smooth surface. The anterior attachments of the rib are divided, permitting the rib to be excised.

One enters the retroperitoneum by incising the posterior layer of periosteum at the tip of the rib. As the incision is extended laterally along the length of the rib bed, a finger is used to sweep away the pleura and peritoneum. The internal oblique is divided with cautery. Proceeding anteriorly, the transversus abdominis is then split with fingers. As in other flank approaches, effort should be made to preserve the 12th nerve coursing between the internal oblique and transverse muscles. The pleura is sharply separated from the fascia under the 11th rib above. The diaphragmatic attachments to the thoracoabdominal wall are divided. With sharp dissection the peritoneum is released from the transverse fascia to improve exposure.

In cases of 11th rib resection, the pleural reflection will be in the posterior aspect of the wound atop the diaphragm. One can mobilize the pleura superiorly by dividing its attachments to the diaphragm, or the two can be mobilized together by dividing the diaphragm.

To close the wound, the kidney rest is lowered and flexion is partially reduced. The incision is closed in layers. If an inadvertent pleural tear was created, an 8-Fr “dart” chest drain (Arrow International, Reading, PA) is placed and the pleural defect is closed using 2-0 silk. Infiltration of local anesthetic into the fascia around the intercostal nerves is helpful for analgesia. Drains are brought out through a separate stab incision.

Anterior Midline

An anterior midline incision is the incision of choice for management of renal trauma because it permits exploration for associated intraperitoneal injuries. It can also be employed for renovascular surgery, reconstructive procedures including ileal ureteral replacement, and bilateral renal procedures.

With the patient in the supine position, a midline skin incision is made from the xiphoid process to the symphysis pubis, curving around the umbilicus. After dividing the subcutaneous tissues with electrocautery, the linea alba is sharply incised to expose the underlying preperitoneal fat and peritoneum. The peritoneum is grasped with two smooth forceps and elevated to reduce risk of bowel injury. The peritoneum is sharply opened between the two forceps. A finger is inserted into the peritoneal cavity and is used to tent the peritoneum away from bowel as the incision is extended with scissors. The ligamentum teres should be divided and suture ligated.

Control of the renal pedicle can be obtained directly through the posterior parietal peritoneum or by medial reflection of the colon. On the left, the approach involves a vertical incision in the posterior peritoneum below the ligament of Treitz. This space contains the anterior surface of the aorta, the crossing left renal vein, and often the inferior mesenteric vein and gonadal vessels. The superior mesenteric artery should be on the anterior surface of the aorta and is usually 1 to 2 cm cephalad to the left renal vein. Gentle dissection along the hilum at this level provides good vascular control. A second approach to the left renal hilum is through the lesser sac. In this approach, the gastrocolic omentum is divided and entered. The transverse colon can then be retracted inferiorly. The peritoneum below the pancreas can be incised. The vessels are identified (Fig. 54–36). It is the authors’ preference to incise the colon along the white line of Toldt and reflect the colon anteromedially. This permits access to the renal pedicle both anteriorly and posteriorly. The artery can be isolated posteriorly and the venous system identified and controlled anteriorly.

Figure 54–36 A, Left gastrocolic, phrenocolic, and lateral peritoneal attachments are divided. B, Stomach, pancreas, and spleen are gently retracted upward without mobilizing kidney.

(© The Lahey Clinic.)

Similarly, the right kidney can be reached directly by incision of the hepatic flexure and a Kocher maneuver to free the duodenum and reflect it medially. Further incision along the white line of Toldt frees the colon, permitting exposure of the anterior Gerota fascia. After the duodenum is reflected, the anterior surface of the vena cava is exposed. Care is taken not to injure the pancreas, gonadal vein, adrenal vein, or accessory renal vessels. The main renal vein is mobilized. Posterior to the renal vein along its superior margin lies the renal artery (Fig. 54–37), which normally runs a retrocaval course. The renal artery can be isolated here or between the vena cava and aorta when greater length is required.

Figure 54–37 Exposure of right renal artery behind overlying left renal vein. IVC, inferior vena cava; Ao, aorta.

(© The Lahey Clinic.)

After the procedure is complete, the peritoneum is closed with 2-0 polyglactin. The fascia is closed with polypropylene (Prolene) or polydioxanone. After bringing the subcutaneous tissues together with 3-0 plain sutures, the skin edges are reapproximated with staples or subcuticular 2-0 polyglactin. A Penrose drain is externalized through a separate stab incision.

Anterior Paramedian

The paramedian approach, which is a straightforward incision with a strong closure, is occasionally employed but provides limited exposure to the kidney. A paramedian skin incision is made approximately 3 cm lateral to the midline. The subcutaneous tissues are divided with electrocautery. The anterior rectus sheath is divided. By sharply transecting the transverse tendinous intersections, one is able to reflect the belly of the muscle medially. The posterior rectus sheath and transversalis fascia are then divided in the line of the incision.

By developing the plane between the peritoneum and transversalis fascia from diaphragm to iliac crest, one can make an extraperitoneal approach to the kidney, although this offers marginal renal access (Tessler et al, 1975). Alternatively, the peritoneum is opened and the kidney is approached as described earlier.

The peritoneum is closed with 2-0 polyglactin. The fascia is closed with polypropylene or polydioxanone. After bringing the subcutaneous tissues together with 3-0 plain sutures, the skin edges are reapproximated with staples or subcuticular 2-0 polyglactin. A Penrose drain is externalized through a separate stab incision.

Anterior Subcostal

The transperitoneal anterior subcostal incision can be employed for both radical and partial nephrectomy, especially for upper pole tumors. With extension of the incision to the lateral border of the contralateral rectus abdominis muscle, the transperitoneal anterior subcostal approach can be used for renovascular surgery. The extraperitoneal subcostal incision has limited utility in adults owing to marginal access to the renal pedicle. It is rarely employed.

The patient is placed in the supine position. The skin is incised from the tip of the 11th rib to the contralateral rectus abdominis muscle, starting two fingerbreadths below the costal margin. The subcutaneous tissues are divided with electrocautery, exposing the external oblique muscle laterally and the rectus sheath medially. After dividing fibers of the latissimus dorsi muscle in the lateral aspect of the wound, the external oblique muscle is transected. The anterior rectus sheath is opened, and the rectus abdominis muscle is retracted medially or divided. The internal oblique muscle, transversus abdominis muscle, posterior layer of the rectus sheath, and the transversalis fascia are divided. This exposes the underlying peritoneum.

For the extraperitoneal approach the peritoneum is reflected from the transversalis fascia using blunt dissection. The retroperitoneal space is entered laterally while retracting the peritoneum and its contents medially. In the more commonly employed transperitoneal approach the peritoneum is opened. The ligamentum teres is encountered in the midline, divided, and suture ligated. The kidneys are approached as described earlier.

The peritoneum is closed with 2-0 polyglactin. The fascia is closed with 1-0 polydioxanone. After bringing the subcutaneous tissues together with 3-0 plain sutures, the skin edges are reapproximated with staples or subcuticular 2-0 polyglactin. A Penrose drain is externalized through a separate stab incision.

Chevron Incision (Bilateral Subcostal Approach)

The chevron incision, essentially a bilateral anterior subcostal approach, is advantageous for renovascular surgery and radical nephrectomy with IVC tumor thrombectomy. Exposure of the renal pedicles and great vessels is outstanding. The incision starts at the tip of the 11th rib, extends approximately two fingerbreadths below and parallel to the costal margin, curves superiorly in the midline, travels parallel to the contralateral costal margin, and terminates at the tip of the contralateral 11th rib.

After dividing the subcutaneous tissues with electrocautery, the latissimus dorsi muscle, external oblique muscle, anterior rectus sheath, rectus abdominis muscle, internal oblique muscle, transversus abdominis muscle, posterior rectus sheath, and transversalis fascia are divided. The peritoneum is opened, dividing the ligamentum teres as described previously.

The peritoneum is closed with 2-0 polyglactin. The fascia is closed with 1-0 polydioxanone or 2-0 nylon. After bringing the subcutaneous tissues together with 3-0 plain sutures, the skin edges are reapproximated with staples or subcuticular 2-0 polyglactin. A Penrose drain is externalized through a separate stab incision.

Indications

Simple nephrectomy, removal of the kidney within the Gerota fascia, is employed to manage nonmalignant diseases of the kidney. Indications for simple nephrectomy include durable nonfunction or poor function of a kidney due to obstruction, infection, trauma, stones, nephrosclerosis, vesicoureteral reflux, polycystic kidney, or congenital dysplasia. Nephrectomy is undertaken when reconstructive procedures have failed or are contraindicated due to poor function of the renal unit, advanced age, or significant comorbidity. Simple nephrectomy of a functional kidney may be employed to relieve intractable symptoms or associated problems, such as bleeding, pain, hypertension, or persistent infection. Simple nephrectomy is an accepted treatment for renovascular hypertension that is refractory to other organ-sparing therapies.

Preoperative Evaluation and Preparation

In addition to a genitourinary history, one must ascertain the patient’s full medical history, with a special focus on cardiovascular, pulmonary, and surgical history. Factors influencing choice of incision should be elucidated on history and examination, including body habitus and sites of prior abdominal or flank operations. One must be cognizant of a patient’s renal status and the anticipated function that will remain after surgery. Estimation of global renal function as previously described is essential. Determination of differential renal function by radionuclide scan is advisable, particularly if renal dysfunction or abnormal split function is suspected.

Techniques

Simple nephrectomy can be performed through the flank and anterior abdominal approaches as described earlier. The approach can be either extraperitoneal or transperitoneal. Removal of atrophic kidneys with end-stage disease can also be accomplished through a dorsal lumbotomy incision (Andaloro and Lilien, 1975; Novick, 1980). For all approaches the key steps of a simple nephrectomy are the approach, mobilization of the kidney, division of the artery followed by the vein, division of the ureter, removal of the kidney, and closure.

Standard Flank Approach

A flank approach (Fig. 54–38) is preferable in patients with multiple prior anterior abdominal operations and in obese patients. An extraperitoneal approach is preferred in patients with an infected renal unit or numerous prior transperitoneal procedures. The kidney can be approached extraperitoneally through the subcostal route, although consideration should be given to a supracostal approach depending on the patient’s anatomy.

Figure 54–38 A to D, Technique of simple left nephrectomy through an extraperitoneal flank incision.

The perinephric space is entered. To avoid inadvertent entry into the peritoneum a vertical incision is made in Gerota fascia on the lateral aspect of the kidney, revealing the underlying perinephric fat. The kidney is mobilized sharply by developing a plane between the renal capsule and the perinephric fat. If there have been numerous episodes of pyelonephritis or prior renal operations, developing this plane can be challenging. Inadvertent entrance into the renal capsule should be avoided. When developing the plane at the lower pole the ureter is identified but not yet ligated. Downward traction on the kidney permits the upper pole to be mobilized. The adrenal gland is left in position.

With the use of lateral traction on the kidney to expose the hilum, the vascular pedicle is dissected free from surrounding fat and lymphatics. The renal hilum can be approached either anteriorly or posteriorly. In the anterior approach, gonadal, adrenal, and lumbar branches draining into the left renal vein are ligated and divided. The mobilized renal vein is retracted to reveal the renal artery located posteriorly (see Figs. 54-8 and 54-39). The left renal artery should be differentiated from the superior mesenteric artery by ensuring that the renal artery emanates from the lateral aspect of the aorta and by palpating the superior mesenteric artery before ligating the renal artery. The renal artery is ligated away from the hilum using two medium vascular Hem-o-Lok clips on the stump side and a 2-0 silk tie on the specimen side. The artery is divided proximal to the silk tie. The arterial stump is then suture ligated with 2-0 silk. After division of the renal artery, the renal vein is similarly ligated and divided. In the posterior approach the artery is encountered before the renal vein and is ligated and divided before mobilization of the vein. The ureter is doubly clamped and divided. The specimen is removed. The distal aspect of the transected ureter is suture ligated with 2-0 polyglactin.

Figure 54–39 Ligation of adrenal and gonadal vessels and retraction of renal vein exposing main renal artery. IVC, inferior vena cava; Ao, aorta.

(© The Lahey Clinic.)

Ideally, the renal artery and vein are ligated individually as described previously, because taking the vessels en bloc may increase risk of arteriovenous fistula (Lacombe, 1985; Okamoto et al, 2001). In cases complicated by severe fibrosis and scarring, one may not be able to safely control the vessels individually, in which case en-bloc ligation and division may be necessary. A drain is brought out through a separate stab incision.

Subcapsular

In patients with a history of significant renal infection or prior renal surgery, severe inflammation and scarring may obliterate the usual tissue planes within the Gerota fascia, rendering mobilization of the kidney unsafe and inefficient. In these cases a subcapsular nephrectomy is indicated (Kimbrough and Morse, 1953; Kittredge and Fridge, 1958) (Fig. 54–40).

Figure 54–40 A to D, Technique of subcapsular nephrectomy.

Subcapsular nephrectomy can be an arduous procedure. In patients who had prior renal surgery, care should be taken in entering the retroperitoneal space because the perirenal fat may be attenuated and the parenchyma can be unintentionally incised when opening the transversalis fascia. After entry into retroperitoneal space and determination that scarring precludes traditional simple nephrectomy, the renal capsule is incised longitudinally over the convex surface of the kidney.

Holding sutures of 2-0 polyglactin or Allis clamps are placed on the anterior aspect of the renal capsule for traction. While gently pulling on the anterior edge of the renal capsule and proceeding toward the hilum, sharp dissection is used to free the capsule from the underlying parenchyma. When the capsular flap has been raised adequately to expose the hilum, the parenchyma of the kidney is retracted laterally to expose the renal vessels. The artery and vein are ligated and divided in succession. The ureter is ligated and divided. The kidney is removed. Any devascularized perirenal tissue is excised. A drain is essential.

Background

Renal artery surgery was first described in 1949 by Dos Santos for atherosclerotic disease utilizing a dedicated renal endarterectomy to treat an occlusive plaque. By restoring flow to the affected renal unit it became apparent that patency could be accomplished by removal of the intima and media of the arterial system. The drawbacks to this approach stemmed from the weakness of the native adventitia and the incidence of intimal flaps leading to postoperative aneurysms and restenosis. To maximize the repair surgeons soon came to recognize the benefits of vein patch renal angioplasty, thereby limiting narrowing and dilation. Transaortic endarterectomy was explored as an alternative option, allowing simultaneous repair; however, the high rates of recurrent stenotic disease precluded it becoming a mainstay in therapy (Libertino, 1992).

Renal endarterectomy and repair with saphenous vein or synthetic graft can be a suitable option for short well-defined segments of mural dysplasia. Recurrent stenosis is often attributed to residual microscopic mural disease not appreciated at the time of surgery. The authors prefer to treat renal stenotic lesions using aortorenal bypass procedures. If the saphenous vein is unavailable, cephalic vein or PTFE is recommended. In some instances the aorta is too diseased for reimplantation and alternate arterial conduits are chosen, as described later.

Etiology

The primary disease entities necessitating revascularization include atherosclerosis (75%) and fibrous dysplasia (25%). Patients can present with hypertension and renal insufficiency when the lesion is chronic. Less than 3% of the hypertensive population has a renovascular etiology versus an estimated 18% to 20% in patients undergoing cardiac angiography and 35% to 50% of patients with aortic occlusive disease (Olin et al, 1990; Anderson et al, 1994; Rihal et al, 2002). Hypertension is a direct result of activation of the renin-angiotensin-aldosterone system, whereas renal impairment (ischemic nephropathy) is secondary to reduced perfusion pressure and loss of glomerular filtration capacity.

Atherosclerosis

In general, atherosclerosis affects patients in the sixth to seventh decades of life. The diagnosis of renovascular hypertension caused by atherosclerosis is being discovered in younger patients, which may be attributable to increased imaging studies. Atherosclerosis may be limited to the renal artery in 15% to 25% of patients but tends to be part of a generalized process affecting the major arterial branches of the aorta. Bilateral disease is present in up to 40% of patients (Fig. 54–41). Unilateral disease is more common in the left renal artery with contralateral disease present in 40% at the 4-year mark (Libertino et al, 1988). Although renal arteries are end arteries by anatomic definition, the slow onset of atherosclerosis permits development of collateral vessels, resulting in minimal clinical symptoms.

Figure 54–41 Left renal artery stenosis secondary to atherosclerotic disease of the aorta.

Mural Dysplasia

Fibrous dysplasia is progressive and more common in children and young adults. Segmental stenotic sections develop secondary to hyperplasia of smooth muscle and the associated layers of the arterial wall. Various categories exist under the broad definition of fibrous dysplasia.

Primary intimal fibroplasia accounts for 10% of lesions and occurs in children and young adults. The process can develop in contralateral kidneys or other vessels in a progressive nature. Angiographically the disease has smooth, focal stenosis involving the proximal or middle portion of renal vessels or branches (Fig. 54–42).

Figure 54–42 Intimal fibroplasia.

(From Libertino JA. Reconstructive urologic surgery. 3rd ed. Philadelphia: Mosby; 1997.)

Medial fibroplasia accounts for 75% to 80% of fibrous lesions primarily in women between 25 and 50 years of age. With angiography, arteries demonstrate a “string of beads” in the distal two thirds of the main renal artery and its branches (Fig. 54–43). Multiple microaneurysms can also be appreciated. An estimated 33% demonstrate progression, whereas complete occlusion is rare.

Figure 54–43 Selective right renal angiogram demonstrating medial fibroplasia “beads on a string” in a solitary right kidney.

Perimedial (subadventitial) fibroplasia accounts for 10% to 15% of fibrous lesions and is limited to the renal arteries. Angiographically the appearance is similar to that of medial fibroplasia but there are no microaneurysms and extensive collateral circulation is present (Fig. 54–44). Without intervention this entity leads to severe stenosis and progressive obstruction with ischemic nephropathy. The disease often afflicts young females.

Figure 54–44 Selective right renal angiogram demonstrating perimedial (subadventitial) fibroplasia with decent collateral vasculature.

Fibromuscular hyperplasia is an extremely rare lesion, accounting for less than 5% of mural dysplasia in children and young adults. These lesions progress over time. Although most of these lesions can mimic one another the final diagnosis should be made after histologic examination when possible.

Renal Aneurysms

Aneurysmal disease can lead to progressive renal damage and hypertension. By definition these lesions may be true (congenital or acquired) or false from trauma. Angiographically they can be divided into saccular, dissecting, fusiform, and intrarenal. Saccular forms occur in the main renal artery or at the anterior-posterior branch point and are the most common (Fig. 54–45). Dissecting aneurysms result from a disruption of the internal elastic membrane in certain populations (e.g., atherosclerosis, intimal fibrodysplasia, and perimedial fibrodysplasia). Fusiform aneurysms are noncalcified and common in younger hypertensive patients with fibromuscular dysplasia (Fig. 54–46).

Figure 54–45 Saccular aneurysm in left renal artery (atherosclerosis).

(From Libertino JA. Reconstructive urologic surgery. 3rd ed. Philadelphia: Mosby; 1997.)

Figure 54–46 Fusiform aneurysms in right renal artery.

(From Libertino JA. Reconstructive urologic surgery. 3rd ed. Philadelphia: Mosby; 1997.)

Intrarenal aneurysms are considered congenital and account for one fifth of aneurysmal disease affecting the kidney (Fig. 54–47). In some instances they may develop secondary to atherosclerosis, mural dysplasia, trauma, inflammation (arteritis), or needle biopsy. Intervention is warranted for lesions larger than 2 cm or those associated with hypertension. Lesions can rupture and dissect leading to ischemia or may contribute to thrombus formation and warrant intervention (revascularization or coil placement). Women in childbearing age with evidence of aneurysms are urged to undergo repair secondary to risk of rupture and associated high rates of maternal and fetal mortality (Figs. 54-48 and 54-49) (Yang and Hye, 1996; Centenera et al, 1998).

Figure 54–47 A, Large left congenital renal aneurysm and arteriovenous malformation. B, Note early filling of the renal vein and inferior vena cava.

Figure 54–48 CT showing a 16-mm left renal artery aneurysm in a 26-year-old woman that was discovered during workup for abdominal pain to rule out appendicitis.

Figure 54–49 A, Selective angiography and coiling of aneurysm. B, Repeat angiogram demonstrating no flow to aneurysm.

Takayasu Disease

Takayasu inflammatory disease is characterized by localized periarteritis with mononuclear infiltration, multinucleated giant cells, and disruption of elastic arterial wall fibers. Although the disease has been primarily associated with patients of Asian descent, it is now known to coexist in the Western world. Takayasu arteritis typically affects young women (80% of affected patients are younger than 35 years old). Takayasu disease was initially described for its ocular findings. Clinicians later discovered that its arterial lesions were more widespread than initially thought. For diagnostic and surgical reasons it has been classified angiographically into four categories based on the location of the lesions: (1) aortic arch and its great vessels, (2) descending thoracic and upper abdominal aorta, (3) simultaneous involvement of categories 1 and 2 (65% of all cases), and (4) pulmonary artery with or without categories 1 through 3. Of the cases reported in the literature, 50% are associated with hypertension. Renal artery disease is most common, followed by proximal hypertension caused by coarctation of the aorta and loss of arterial elasticity (Fig. 54–50) (Ishikawa, 1978).

Figure 54–50 Bilateral renal artery stenosis caused by Takayasu disease.

(From Libertino JA. Reconstructive urologic surgery. 3rd ed. Philadelphia: Mosby; 1997.)

Background

The first successful renal autotransplant was recorded by J. D. Hardy in 1963 for ureteral disease. Since that time the indications for “renal bench” surgery have broadened and have resulted in improved clinical outcomes (Ota et al, 1967; Husberg et al, 1975; Putnam et al, 1975; Wotkowicz and Libertino, 2004). Complex renovascular disease, renal tumors, and staghorn calculi have been the mainstay of the authors’ experience. Extracorporeal partial nephrectomy was described more than 30 years ago for renal cell tumors and provides an alternative to dialysis in select patients. Laparoscopy has also been added to the field to help limit morbidity and speed recovery (Fabrizio et al, 2000; Meng et al, 2003).

Many of the initial feasibility studies were performed in canine models and gradually expanded to the human population (Belzer et al, 1970). Vascular repair of complex intrarenal disease is performed using native veins of saphenous, splenic, and iliac origin or hypogastric arterial grafts. The last is often best suited to pediatric or young adult populations with limited size discrepancy and a lack of atherosclerotic disease. Technical advances with respect to surgical magnification have expanded the indications. Overall renal insult associated with these complex procedures has been limited with advances in hypothermic perfusates commonly used in transplantation, which provide an isotonic external milieu (Belzer et al, 1992). In limiting membrane transport the metabolic requirements decrease while maintaining cellular integrity. In addition the cold solution shrinks parenchyma, leading to better vascular and collecting system exposure (Novick et al, 1979).

Indications

Most arterial disease requiring bench approaches have extension at and beyond the anterior and posterior division branch points (Fig. 54–75). Stenotic lesions and aneurysms may be resected and repaired with interposition saphenous vein grafts. Multiple branch lesions may be amenable to hypogastric artery interposition utilizing the branches of the internal iliac artery when atherosclerosis is absent. Renal tumors have also been removed utilizing an ex-vivo approach in select patient populations (solitary kidneys), with limited small volume series in the literature (Fig. 54–76) (van der Velden et al, 1992). The ureter can be affected by the numerous processes (trauma, iatrogenic, and inflammatory) that lead to urinary obstruction or extravasation. Left untreated, these patients develop chronic infections and eventual renal failure. Recurrent nephrolithiasis can lead to ureteral stenosis secondary to repeat trauma from ureteroscopy and scarring from percutaneous approaches. Indications for autotransplantation include tumors in solitary kidneys, recurrent staghorn calculus and concomitant renovascular disease, sterile urine and recurrent nephrolithiasis causing damage to a ureter, calculi associated with congenital abnormalities, or extensive ureteral stricture. Transitional cell carcinoma of the renal pelvis or ureter in solitary kidneys can be managed with this approach.

Figure 54–75 A, CT scan in a 33-year-old man with an atrophic left kidney and fibromuscular dysplasia and a 2.4-cm aneurysm in the right kidney and uncontrolled hypertension. B, Three-dimensional reconstruction demonstrates location of renal artery aneurysm.

Figure 54–76 A, CT scan demonstrating larger midpolar tumor in a solitary right kidney. B, Three-dimensional arterial reconstruction. C, Kidney on back table in hypothermic solution prior to tumor excision. D, Mass excised with preservation of collecting system and intrarenal arterial tree. E, Contrast enhanced CT scan 4 years later demonstrating no evidence of recurrence.

Although an ileal segment interposition graft can obviate the need for ureteroscopy, the long-term metabolic sequelae are not insignificant (Chung et al, 2006). Autotransplantation, pyelovesicostomy, and a Boari flap can minimize reflux and allow passage of stones (Olsson and Idelson, 1980).

Autotransplantation is an acceptable option for complicated tumors in solitary kidneys and bilateral malignancies. A pyelovesicostomy is recommended to facilitate easy surveillance. Patients with traumatic arterial injuries can also be treated with autotransplantation.

Preoperative Evaluation and Preparation

In addition to preoperative screening, renal and pelvic anatomy are evaluated with dedicated 3D CT angiography, paying specific attention to the iliac vessels. The hypogastric artery and associated branches are ideal conduits for complex multiple-vessel repairs given their size, which is similar to the native renal artery branches. Renal functional scans (e.g., MAG3) should document at least 15% to 25% of the global renal function before surgery. Kidneys with extensive small vessel disease and compromised parenchyma are limited by poor flow dynamics and decreased filtration capabilities and are not candidates for renal autotransplantation. Patients with chronic renal insufficiency or solitary kidneys must consent for placement of vascular dialysis catheters before surgery, and the authors’ nephrology colleagues are made aware of this procedure.

Surgical Procedure

The advantages of renal bench surgery include a bloodless field and optimal exposure of the vascular tree and collecting systems. The ideal length of cold ischemic time should be no greater than 5 to 6 hours. Ex-vivo repair also allows the integrity of the anastomosis to be tested before reimplantation. The technical aspects of bench surgery are demanding and should be performed in high-volume centers with surgeons experienced in vascular and transplantation surgery. The authors prefer a flank approach for an adrenal-sparing donor nephrectomy with preservation of the proximal one third of the ureter. The kidney is completely mobilized and vessel loops passed around the main renal artery and vein. Renal vessels and ureter are dissected to provide maximum length (Fig. 54–77). Mannitol may be given before ligation and division of the vasculature to promote diuresis. Hypothermic University of Wisconsin solution is the authors’ choice for perfusate on removal and initiation of extracorporeal surgery (Belzer et al, 1992). Once the feasibility of the extracorporeal repair has been determined a second team can reposition the patient supine and expose the ipsilateral fossa for reimplantation via a Gibson incision. A single midline incision is another approach that allows access to both operative sites and keeps the ureter in continuity. After the vessels are taken the abdominal wall serves as a bench for microvascular repair or removal of tumor.

Figure 54–77 Nephrectomy for autotransplant is shown. A, Patient is placed in the flank position. An 11th rib supracostal incision maximizes renal exposure. B, Dissection of the left kidney demonstrates exposure of the renal vein to its origin at the vena cava (IVC). C, After ligation of the adrenal and gonadal vessels, the renal vein is mobilized to expose the renal artery. D, Division of the renal vessels is at the origin of the aorta (Ao) and vena cava. The ureter is transected below the pelvic brim. Care is taken not to maintain adventitial tissue or ureter. E, Chilled preservation solution (heparinized lactated Ringer solution) is perfused through the renal artery.

(© The Lahey Clinic.)

Once the renal vessels have been ligated the kidney is flushed with hypothermic solution and placed in an ice-slush solution to minimize ischemia. For vascular anastomosis 5-0 and 6-0 polypropylene is preferred; however, finer suture can be used with surgical magnification. Both native and graft vessels are intermittently flushed with heparinized saline to minimize clot formation. Arterial spasm can be alleviated with papaverine flushes. The integrity of the anastomosis is evaluated with flushing of hypothermic solution (see Figs. 54–78 [on the Expert Consult website] and 54–79).

Figure 54–79 A, Follow-up CT scan 3 years after operation demonstrates good renal function and lack of aneurysm. The patient takes no antihypertensive medication. B, Three-dimensional reconstructions demonstrate no aneurysmal dilation.

Figure 54–78 A, After explantation the aneurysm and associated branching vessels are isolated. B, Tenotomy scissors are used to sharply dissect free the aneurysm, avoiding damage to branching vessels. C, Aneurysm sac is dissected off, leaving room for patch angioplasty. D, Harvested internal iliac patch from reimplantation site is sewn to the artery. E, Internal iliac artery was chosen owing to lower rates of aneurysmal dilation under high pressure, which can occur with vein patch angioplasty. F, Reconstructed renal artery and native vein are reimplanted into the external iliac artery and vein.

For flank approaches a standard curvilinear Gibson incision provides access to the iliac fossa and vessels. Cautious dissection and ligation of surrounding lymphatics is imperative to prevent postoperative lymphocele formation and to minimize the risk of suture line infections. The external vein is mobilized cephalad to the junction where the internal iliac artery crosses over. The venous anastomosis between the renal vein and external iliac vein is completed with continuous or running 5-0 polypropylene in an end-to-side fashion. A disease-free internal iliac artery is anastomosed with continuous or interrupted 6-0 polypropylene to the renal artery end to end. If there is evidence of disease not detected with preoperative imaging then an end-to-side approach is advisable to limit stenosis, recognizing that perfusion pressures may be lower secondary to flow turbulence. Intraoperative ultrasonography can be performed to assess inflow. Surgicel may be wrapped around the anastomosis to ensure hemostasis at needle sites, which tend to ooze once systemic anticoagulation is initiated after surgery. The ureter is reimplanted using an extravesical Grégoire-Lich anastomosis or a Leadbetter-Politano tunneled reimplant using absorbable suture (Figs. 54-80 and 54-81). A psoas hitch and/or Boari flap may be required for extremely short ureters. A 6-Fr transplant double-J stent is next placed across the anastomosis. A Penrose drain or 7-Fr Jackson-Pratt drain is left for 24 to 48 hours.

Figure 54–80 Modification of the Politano-Leadbetter technique is shown. A and B, The submucosal tunnel is created. Injection of 3 mL of saline raises the mucosal layer and permits earlier dissection. C, Right-angle clamp is placed along the mucosal tunnel.

(© The Lahey Clinic.)

Figure 54–81 The Grégoire-Lich technique of extravesical ureteroneocystostomy is shown.

(© The Lahey Clinic.)

Postoperative Care and Complications

Elevated lactate dehydrogenase levels can also indicate the presence of a renal infarct. A MAG3 scan can be obtained to evaluate uptake and excretion, but the majority of kidneys repaired ex vivo show immediate and somewhat prolonged periods of acute tubular necrosis. Patients will need to be on systemic heparin therapy during the immediate postoperative period, which increases the risk of hemorrhage and anastomosis rupture. Vascular leaks or thrombosis occur in 1% to 2% of transplants and need urgent surgical revision. Peritransplant fluid collections are of concern and need to be evaluated and treated. Collections discovered between weeks 1 and 3 are usually urinomas and occur in 4% to 5% of transplanted kidneys. Depending on severity they can be managed with revision of the ureteroneocystotomy or stent placement. Fluid collections presenting at 3 to 6 months represent lymphocele formations and occur in 5% to 10% of patients. Presenting symptoms include ureteral obstruction with rising creatinine concentration and iliac vein compression with lower extremity edema. Small lymphoceles can be managed conservatively whereas larger ones require more invasive procedures, such as percutaneous drainage or sclerosing agents. When percutaneous approaches fail, a peritoneal window can be created laparoscopically to facilitate permanent drainage. Patients with infected urine and extravasation can progress to abscess formation, suture line infection, and graft loss.

Outcomes

Numerous investigators have reported acceptable outcomes with extracorporeal surgery and renal autotransplantation. The authors’ success rate is 90% in more than 25 autotransplants, primarily for renovascular disease. Other contemporary series demonstrated similar results with resolution of hypertension in over 90% of patients with preserved or improved renal function, respectively (Jordan et al, 1985; Novick et al, 1990a; Wotkowicz and Libertino, 2004).

These outcomes support the role of autotransplantation for renovascular disease. Numerous case reports and small series demonstrate the feasibility of the procedure for additional indications as listed previously.

Pyelolithotomy

Pyelolithotomy can be effective in removing a small stone burden. This is rarely performed as a solitary procedure because efficacious minimally invasive techniques are more commonly employed. The kidney is approached through a flank or extraperitoneal anterior subcostal incision. The Gerota fascia is opened. The kidney is mobilized within the Gerota fascia and reflected medially to expose the posterior surface. The ureter is located inferiorly and tracked superiorly past the UPJ to the hilum. A U-shaped incision is made on the pelvis, avoiding the UPJ. A forceps is passed through the pyelotomy and is used to remove the stones. A nephroscope also can be employed to inspect the collecting system. A ureteral catheter is passed in an antegrade fashion to ensure that the ureter is free of stone debris. The pelvis is closed with a 4-0 absorbable suture, a Penrose drain is externalized, and the wound is closed in layers.

Extended Pyelolithotomy and Radial Nephrolithotomy

For larger stones and staghorn calculi, a pyelolithotomy can be extended into the sinus after dissecting intrasinus fat away from the pelvis and infundibula. The U-shaped incision will start at the base of an inferior calyx and end at the base of a superior calyx. The stone is separated from the urothelium and removed with forceps. One can dilate an infundibulum to remove a large calyceal component of the stone. In cases in which a calyceal stone is too large to remove through the infundibulum, a radial nephrotomy can be done to extract the stone. The stone is localized by palpation through the capsule, and a radial capsulotomy is sharply made over the stone. The parenchyma is bluntly opened, and the stone is extracted with forceps. The nephrotomy is closed with 2-0 polyglactin suture and Surgicel bolster.

Anatrophic Nephrolithotomy

Knowledge of the segmental renal arterial circulation is fundamental to anatrophic nephrolithotomy. The parenchyma is divided at the border between anterior and posterior vascular segments, permitting removal of complex staghorn calculi.

A supracostal approach is advantageous. The Gerota fascia is opened and the kidney is mobilized. The hilum is sharply dissected, exposing the main renal artery and posterior segmental artery. The renal pelvis and ureter do not need to be mobilized. The arterial branch to the posterior segment is clamped. As the posterior segment whitens, administration of methylene blue permits identification of the border between the anterior and posterior segments, which marks a relatively avascular plane. The line is scored with cautery.

The main renal artery is occluded. The kidney is placed in an ice slush bath and allowed to cool. The capsule is sharply incised along the border between the anterior and posterior segments, being careful to avoid the poles, which have a separate blood supply. The parenchyma is separated bluntly between the anterior and posterior segments. The renal pelvis and calyces are sharply incised, and the stone is removed. Intraoperative ultrasonography, fluoroscopy, and nephroscopy can be employed to ensure stone clearance.

A ureteral stent is placed in an antegrade fashion. The renal pelvis is reapproximated with a running 3-0 monocryl suture. Blood flow is restored to the kidney. Any bleeding vessels are sutured with 2-0 or 3-0 polyglactin. The renal capsule is closed with a running, locking 2-0 polyglactin suture. A Surgicel bolster can be employed. A Penrose drain is externalized through a separate stab excision.