Renal autotransplantation after horseshoe kidney injury: a case report and literature review

Case report: Aortobiiliac bypass with autotransplantation of the horseshoe kidney and renal vascular reconstruction

INTRODUCTION AND IMPORTANCE

This case report describes the rare encounter of a large infrarenal abdominal aortic aneurysm (AAA) and a horseshoe kidney (HEN), which was managed through comprehensive preoperative planning and effective multidisciplinary collaboration, with the patient being fully informed and consenting to the publication of data and images.

CASE PRESENTATION

The patient was referred to the Department of Vascular Surgery with increasing abdominal pain. Computed tomography angiography showed that the aneurysm was significantly advanced. For surgical correction of the aortic aneurysm, the horseshoe kidney was autotransplanted intraoperatively to ensure renal vascular reconstruction for further renal perfusion after treatment of the aneurysm.

DISCUSSION

Abdominal aortic aneurysm carries a significant risk of rupture, with more than half of ruptures being fatal before reaching the hospital. When the AAA occurs concomitantly with a HEN, detailed imaging is critical for planning the procedure, as the unusual arterial supply to the HEN complicates the procedure and requires careful strategies to protect renal function while treating the aneurysm.

CONCLUSION

The treatment of complex cases with severe disease manifestations and difficult anatomy requires careful planning to ensure effective treatment and optimise patient survival and quality of life.

Horseshoe kidney: Morphologic features, embryologic and genetic etiologies, and surgical implications

The horseshoe kidney (HSK) is the most common congenital abnormality of the upper urinary tract with an incidence of approximately 1 in 500 in the general population. Although individuals with HSK are often asymptomatic, they are at increased risk for neoplasms, infections, ureteropelvic obstruction secondary to lithiasis or vascular compression. Direct injury from trauma is increased in these individuals as is the risk of intraoperative complications secondary to damage involving the typically complex renal or adrenal vascular supply. We briefly review etiological factors including renal and urinary system embryology, genetic mutations, abnormalities related to faulty cell signaling, aberrant cell migration, and other possible causes including environmental exposures and trauma. In addition, we call attention to factors that might influence the success of surgical procedures in patients with HSK. We argue that an understanding of possible etiologies of the HSK and its different subtypes may be useful when planning surgical procedures or considering risk-benefit ratios associated with different surgical options. We briefly present the organization of a HSK in a 100-year-old male demonstrating an unusual vascular supply discovered during a dissection laboratory session in a medical school anatomy course. We describe the structure of the HSK, the position and relationships of the HSK to other structures within the abdomen, and the associated vascular relationships.

Multimodality imaging spectrum of complications of horseshoe kidney

Horseshoe kidney is the most common congenital renal fusion anomaly with an incidence of 1 in 400–600 individuals. The most common type is fusion at the lower poles seen in greater than 90% of the cases, with the rest depicting fusion at the upper poles, resulting in an inverted horseshoe kidney. Embryologically, there are two theories hypothesizing the genesis of horseshoe kidney – mechanical fusion theory and teratogenic event theory. As an entity, horseshoe kidney is an association of two anatomic anomalies, namely, ectopia and malrotation. It is also associated with other anomalies including vascular, calyceal, and ureteral anomalies. Horseshoe kidney is prone to a number of complications due to its abnormal position as well as due to associated vascular and ureteral anomalies. Complications associated with horseshoe kidney include pelviureteric junction obstruction, renal stones, infection, tumors, and trauma. It can also be associated with abnormalities of cardiovascular, central nervous, musculoskeletal and genitourinary systems, as well as chromosomal abnormalities. Conventional imaging modalities (plain films, intravenous urogram) as well as advanced cross-sectional imaging modalities (ultrasound, computed tomography, and magnetic resonance imaging) play an important role in the evaluation of horseshoe kidney. This article briefly describes the embryology and anatomy of the horseshoe kidney, enumerates appropriate imaging modalities used for its evaluation, and reviews cross-sectional imaging features of associated complications.

Kidney Autotransplantation: Between the Past and the Future

PURPOSE OF REVIEW

The practice of kidney autotransplantation (KAT) has become an increasingly favorable approach in the treatment of certain renovascular, ureteral, and malignant pathologies. Current KAT literature describes conventional open procedures, which are associated with substantial risks. We sought to compare previously reported outcomes, evaluate common surgical indications, and assess associated risks and benefits of current KAT methods. A thorough evaluation and review of the literature was performed with the keywords "autologous transplantation" and "kidney."

RECENT FINDINGS

Early outcomes of robotic KAT are encouraging and have been associated with fewer complications and shorter hospital stay, but require robotic technique proficiency. KAT is an important method to manage selected complex urological pathologies. Robotic KAT is promising. Nevertheless, future studies should utilize larger patient cohorts to better assess the risks and benefits of KAT and to further validate this approach.

A Nationwide Analysis of Kidney Autotransplantation

There are limited data regarding outcomes of patients underwent kidney autotransplantation. This study aims to investigate outcomes of such patients. The nationwide inpatient sample database was used to identify patients underwent kidney autotransplantation during 2002 to 2012. Multivariate analyses using logistic regression were performed to investigate morbidity predictors. A total of 817 patients underwent kidney autotransplantation from 2002 to 2012. The most common indication of surgery was renal artery pathology (22.7%) followed by ureter pathology (17%). Overall, 97.7 per cent of operations were performed in urban teaching hospitals. The number of procedures from 2008 to 2012 were significantly higher compared with the number of them from 2002 to 2007 (473 vs 345, P < 0.01). The overall mortality and morbidity of patients were 1.3 and 46.2 per cent, respectively. The most common postoperative complications were transplanted kidney failure (10.7%) followed by hemorrhagic complications (9.7%). Obesity [adjusted odds ratio (AOR): 9.62, P < 0.01], fluid and electrolyte disorders (AOR: 3.67, P < 0.01), and preoperative chronic kidney disease (AOR: 1.80, P = 0.03) were predictors of morbidity in patients. In conclusion, Kidney autotransplantation is associated with low mortality but a high morbidity rate. The most common indications of kidney autotransplantation are renal artery and ureter pathologies, respectively. A kidney transplant failure rate of 10.7 per cent was observed in patients with kidney autotransplantation. The most common postoperative complication was hemorrhagic in nature.

Anaesthesia for autotransplantation after extracorporeal nephron sparing surgery for bilateral giant renal angiomyolipoma

Extracorporeal ‘work bench surgery’ with subsequent autotransplantation is a challenge from both anaesthetic and surgical point of view when performed bilaterally or in a solitary kidney. A 28-year-old female with bilateral giant angiomyolipoma of kidneys was taken up for renal autotransplantation. Patient had a huge tumour, which was the largest reported exophytic tumour to be excised by this technique. Both kidneys were operated at an interval of 1 month, under combined general and epidural anaesthesia. Anaesthetic challenges faced during the procedure were maintenance of adequate perfusion of the grafted kidneys, containment of massive blood loss and coagulopathy during the perioperative period. Patient recovered in due course with functioning autotransplanted kidney. A careful pre-operative preparation with intraoperative maintenance of adequate blood volume and blood pressure is the key for graft survival.

Imaging of horseshoe kidneys and their complications

Horseshoe kidney is the most common renal fusion anomaly and the patients are prone to a variety of complications, such as stone disease, pelviureteric junction (PUJ) obstruction, trauma, infections and tumours. As result of the abnormal anatomy of a horseshoe kidney, imaging and treatment pathways vary substantially from the normal kidney. In this review, we describe the role of modern imaging in depicting horseshoe kidneys and their complications, in tandem with the role the interventional radiologist plays in treating these patients.

[Traumatic rupture of a horseshoe kidney]

One-third to one-half of all patients with horseshoe kidney are asymptomatic and the condition is found incidentally. This congenital renal anomaly has shown as a predisponent condition for renal injury in blunt abdominal trauma, but often the degree of injury has a nonoperative therapy. Horseshoe kidney rupture is an exceptional pathology that require a complete diagnostic study to make an adequate management when surgical therapy is indicated. We present a fifteen-year-old male with previously unsuspected horseshoe kidney that suffered an atypical right upper-pole and mesorrenal kidney rupture after low-velocity-impact blunt abdominal trauma. A correct presurgical diagnose let a deferred surgical approach with right lower pole and horseshoe renal isthmus preservation. The trauma conditions, an excesive clinic manifestation, a clinical investigation about known congenital simultaneous anomallies and typical radiological signs, can suggest this infrequent patology. Computed tomography provides the best radiological information.

Traumatismo abdominal por arma blanca con afectación de riñón en herradura

Abdominal stab wounds represent approximately 7% of abdominal injuries in our environment. However, renal involvement in these cases is relatively uncommon (2% of visceral lesions). We present a case of a stab wound in the anterior abdominal wall. In addition to intestinal lesions, the injury produced a lesion in a horseshoe kidney, a relatively uncommon malformation of the urinary system (1/400 individuals). Despite the rarity of this occurrence, when dealing with an emergency affecting a malformed kidney, knowledge of the inherent peculiarities of these defects is essential for the appropriate management of these patients.

Laparoscopic-assisted renal autotransplantation

OBJECTIVES

To report our experience with laparoscopic nephrectomy and autotransplantation for the management of a variety of conditions with significant loss of healthy ureteral tissue or ureteral length. Renal autotransplantation has been described as an effective method for addressing this problem, avoiding the need for nephrectomy or complex ureteral replacement. In an effort to decrease the morbidity associated with traditional autotransplantation we elected to perform laparoscopic procurement of the kidney.

METHODS

Four patients underwent laparoscopic nephrectomy using a transperitoneal four-port technique and subsequent autotransplantation into the iliac fossa for the treatment of proximal ureteral avulsion (2 patients), ureteral malignancy, and ureteral stricture. All patients had less than 5 cm of viable ureter.

RESULTS

All procedures were performed without intraoperative complications. All renal scans on postoperative day 1 demonstrated good perfusion. None of the patients had a postoperative rise in serum creatinine. On postoperative day 1, the mean creatinine value was 0.95 mg/dL. Three patients had an uneventful postoperative course. One patient, however, had loss of the graft because of renal vein thrombosis on postoperative day 7. She was later found to have an undiagnosed thrombophilic disorder (decreased levels of antithrombin III) and to have a recent history of oral contraceptive use.

CONCLUSIONS

Laparoscopic nephrectomy with renal autotransplantation is a feasible minimally invasive alternative to treat patients who have significant ureteral loss. This approach avoids the need for an upper abdominal or flank incision, resulting in decreased morbidity. The initial follow-up studies indicated stable renal function. Additional long-term observation is currently under way.

Climbing harness fit in kidney transplant recipients

OBJECTIVE

The superficial location of renal transplants places them at risk for traumatic damage. Significant injuries have been reported from automobile seat belts, for example. This study was designed to assess the potential for direct transplant injury from the use of climbing harnesses.

METHODS

Ten patients with kidney transplants were fitted with a variety of climbing harnesses after the locations of their grafts were defined.

RESULTS

With the exception of two harnesses in a single patient, all devices came into contact with all transplants.

CONCLUSION

Sports requiring the use of climbing harnesses (eg, rock climbing, rappelling, and challenge course participation) may be unsafe for recipients of kidney transplants.