Laparoscopic Approach for Reconstructive and Ablative Procedures in Ectopic Pelvic Kidneys: A Challenge in 8 Cases

Introduction and Objective: Laparoscopy is the most widely followed approach in ablative or reconstructive kidney surgeries. The aim of this study is to assess the utility and safety of laparoscopic approach in pelvic ectopic kidney surgeries. Methods: Between July 1, 2021 and June 30, 2022, 8 patients with pelvic kidneys; 4 with pelviureteric junction obstruction, 3 with pelvic stones, and 1 nonfunctioning kidney underwent laparoscopic pyeloplasty, pyelolithotomy, and nephrectomy, respectively. The records of all 8 patients were evaluated retrospectively for analyzing the operating time, blood loss, postoperative hospital stay, intra- and postoperative complications, surgical difficulty, and the success in completing the case laparoscopically. The patients were followed for at least 6 months to know the outcome. After pyeloplasty the improvement in function and drainage as well were recorded. Results: Of 8 cases, 6 (75%) were completed laparoscopically. One pyelolithotomy and 1 pyeloplasty patient were converted to open surgery. The median operative time was 180 (140-240) minutes, median blood loss was 100 (50-300) mL, and median hospital stay was 4 (3-6) days. One patient, who had open conversion, had Clavien grade I complication in the form of prolonged fever. Pyeloplasty patients at 6 months follow-up showed improvement in symptoms as well as function. Conclusion: The laparoscopic approach has obvious benefits in pelvic surgeries. Laparoscopy for ectopic pelvic kidneys are challenging due to abnormal anatomy of vessels and kidneys. Proper exposure of kidneys and exact identification of vessels can accomplish laparoscopic procedure in ectopic kidneys successfully with patients having nil complications and early convalescence.

The role of retrograde intrarenal surgery in kidney stones of upper urinary system anomalies

INTRODUCTION

Fusion, pelvic, and duplicated urinary tract anomalies of the kidney are rarely seen. There might be some difficulties in the stone treatment, in the administration of extracorporeal shockwave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), and laparoscopic pyelolithotomy procedures in these patients due to the anatomical variations in kidneys with anomalies.

AIM

To evaluate RIRS results on patients with upper urinary tract anomalies.

MATERIALS AND METHODS

Data of 35 patients with horseshoe kidney, pelvic ectopic kidney, and double urinary system in two referral centers were reviewed retrospectively. Demographic data, stone characteristics, and postoperative characteristics of the patients were evaluated.

RESULTS

The mean age of patients (n=35, 6 women and 29 men) was 50 years. Thirty-nine stones were detected. The total mean stone surface area in all anomaly groups was found to be 140 mm2, and the mean operative time was 54.7±24.7 minutes. The rate of using ureteral access sheath (UAS) was very low (5/35). Eight patients needed auxiliary treatment after the operation. The residual rate, which was 33.3% in the first 15 days, decreased to 22.6% in the third month follow-ups. Four patients had minor complications. In patients with horseshoe kidney and duplicated ureteral systems, it was observed that the risk factor increasing the presence of residual stones was the total stone volume.

CONCLUSIONS

RIRS for kidneys with low and medium stone volume anomalies is an effective treatment method with high stone-free and low complication rates.

Extrarenal calyces in a pelvic kidney with ureteropelvic junction obstruction in an adult male - A rare case report

Extrarenal calyces (ERC) is a rare renal anomaly. First described in 1925, and till now, >60 cases have been reported worldwide. The association of ERC in ectopic kidneys with ureteropelvic junction obstruction (UPJO) is a very rare presentation. We encountered a case of an adult male with ERC in a pelvic kidney with UPJO, in which the dilated ERC mimicked the ureter and created intraoperative confusion.

Off-the-Shelf Strategy for Endovascular Aneurysm Repair of Ectopic, Dominant, Renal Artery Originating From the Aortic Bifurcation: Case Report

INTRODUCTION

An ectopic renal artery originating from the aortic bifurcation can strongly interfere with surgical or endovascular intervention in the infrarenal aorta.

CASE

We present an infrarenal symptomatic aneurysm with a right ectopic/pelvic kidney associated with 1 renal artery originating from the aortic bifurcation.

RESULT

During an endovascular aortic repair (EVAR) procedure, the dominant ectopic right kidney was perfused by an iliac branch device (IBD) used as an iliac extension. However, out of instructions for use (IFU), this is an "off-the-shelf" resolution for this type of rare case.

CONCLUSION

The use of an "off-the-shelf" IBD to perform an EVAR with an ectopic renal artery, in patients unfit for open surgery, is a potentially valuable option.

Robot-assisted laparoscopic surgery with a fluorescent near-infrared ray ureteral catheter for a rectal cancer patient with pelvic kidney: A case report

An 85-year-old woman presented with a stomachache after a meal and was admitted to the previous clinic. Multi-detector computed tomography (CT) of the abdomen showed wall thickening in the rectum and right ectopic pelvic kidney. Colonoscopy revealed a mass at the rectum, and a biopsy showed adenocarcinoma. CT showed no lymphadenopathy or distant metastasis. Hartmann's procedure with fluorescent near-infrared ray ureteral catheters was used to avoid causing urinary injury. Robotic surgery was performed while checking the route of the ureter in near-infrared mode. The patient was discharged on postoperative day 14 without specific complications. This case appears to be the first of robot-assisted laparoscopic surgery for a rectal cancer patient with pelvic kidney.

Monochorionic Twin Discordance for Horseshoe Lung and Tricuspid Atresia

Background: The horseshoe lung is a congenital malformation in which the bases of the right and the left lung are fused. Case report: We describe a monochorionic twin gestation with malformation discordance. The abnormal twin had a horseshoe lung with hypoplasia of the right lung, tricuspid atresia, cleft lip, and a pelvic right kidney. Conclusion: The discordance of anomalies in this monochorionic twin suggests that a postzygotic mutation, epigenetic change, or environmental factors may be responsible for these malformations.

Renal artery dissection as an overuse Injury

The diagnosis of renal infarction is often convoluted due to its non-specific presentation. It can mimic disease processes as disparate as pyelonephritis, diverticulitis, or nephrolithiasis. This case is further complicated by the presence of a pelvic kidney with triplicate arterial input. It is difficult to estimate the incidence of pelvic kidneys as the numerous sources vary wildly in their estimations; however, the paucity information, in and of itself, speaks to the rarity of the condition. In this case, a 58-year-old male presents to the emergency department after experiencing sharp, sudden, and severe groin pain while swinging a golf club. The patient was noted to have an abnormally high systolic blood pressure in the 170s and hematuria, but all other initial labs and assessments were unremarkable. An initial computed tomography scan with intravenous contrast of the abdomen and pelvis showed partial necrosis of a pelvic kidney. Follow-up computed tomography angiography revealed that a dissection in one of the arteries supplying the kidney created an infarction and resultant necrosis. Vessel size, location and time between injury and diagnosis made endovascular intervention impractical. The patient was started on aspirin and Plavix, observed for 3 days and sent home.

Functional Evaluation of an Ectopic Supernumerary Kidney in Pelvis

BACKGROUND

Supernumerary kidney is an accessory organ with its own encapsulated parenchyma, blood vessels and ureters, either separated from the normal kidney or connected to it via fibrous tissue and ectopic kidney is a migration abnormality of the kidney. Here, we have evaluated a rare case of the supernumerary and ectopic kidney with DMSA, MAG3 and also CT fusion of the images.

METHODS

The absolute divided renal function was calculated for each kidney by DMSA. The MAG3 scintigraphy showed no obstruction in the ureteropelvic junction. Furthermore, the renogram curve and Tmax and time to ½ values were assessed. Two months after the conventional scintigraphies, the patient was referred to a CT scan and the fusion of DMSA SPECT and CT data was generated on a workstation.

RESULTS

The ectopic supernumerary kidney was functioning very well except a small hypoactive area, visible on DMSA, which was possibly a minimal pelvicalyceal dilatation. However, consequent CT scan did not show any pathology.

CONCLUSION

It is important to evaluate particularly complicated or rare cases with multimodality systems with 3D or fusion techniques for the accurate diagnosis.

Proton Therapy in the Treatment of Anal Cancer in Pelvic Kidney Transplant Recipients: A Case Series

PURPOSE

The incidence of anal cancer in patients with kidney transplants has increased. The definitive treatment for anal cancer is chemotherapy and intensity-modulated radiation therapy. In kidney transplant recipients, sparing the pelvic kidney in the process of delivering radiation to the anus can be challenging. Intensity-modulated proton therapy (IMPT) has been proposed as an alternative to intensity-modulated radiation therapy for the treatment of anal cancer in this population, given its increased ability to spare organs-at-risk.

CASE SERIES

We present 4 cases of patients with transplanted pelvic kidneys who subsequently developed anal cancer and were treated with IMPT from 2017 to 2019.

CONCLUSION

Use of IMPT appears to be an acceptable option for the treatment of anal cancer in patients with a pelvic kidney.

Chromosomal microarray findings in pregnancies with an isolated pelvic kidney

Objective To examine the risk for abnormal chromosomal microarray analysis (CMA) results among fetuses with an apparently isolated pelvic kidney. Methods Data from all CMA analyses performed due to an isolated pelvic kidney reported to the Israeli Ministry of Health between January 2013 and September 2016 were retrospectively obtained. Risk estimation was performed comparing the rate of abnormal observed CMA findings to the general population risk, based on a systematic review encompassing 9272 cases and on local data of 5541 cases. Results Of 120 pregnancies with an isolated pelvic kidney, two gain-of-copy number variants suggesting microduplication syndromes were demonstrated (1.67%). In addition, three variants of unknown significance were detected (2.5%). Conclusion The risk for clinically significant CMA findings among pregnancies with an isolated single pelvic kidney was not significantly different compared to both control populations. The results of our study question the practice of routine CMA analysis in fetuses with an isolated pelvic kidney.

Pelvic Kidney: A Review of the Literature

Kidney development is a complex process that begins during the sixth to eighth weeks of life. Failure of ascent of the kidney will cause the kidney to remain in the pelvis i.e., pelvic kidney. Here, we review this entity in detail and illustrate such embryological derailment. In most cases, a pelvic kidney is an incidental finding and is usually asymptomatic. Anatomic variations of the renal vasculature have been reported in cases of pelvic kidneys and these are highlighted in this review. Clinicians who treat patients for renal or pelvic disease or interpret images of the pelvis should be well informed of the anatomy and embryology of the pelvic kidney.

Conversion during laparoscopic anterior resection for rectal cancer with a congenital solitary pelvic kidney: A case report

A 54-year-old female patient was hospitalized with a chief complaint of anal discomfort. Based on biopsy results, she was diagnosed with highly differentiated adenocarcinoma, and colonoscopy findings indicated a type 3 rectal tumor. We observed a right pelvic kidney on enhanced abdominal CT. We began a laparoscopic operation but converted to an open operation after resecting the right pelvic renal artery by mistake. After low anterior resection, urologists performed angioplasty of the right renal pelvic artery. The patient was discharged on postoperative day 16, after the preservation of right renal function had been confirmed. This case strongly suggests that it is important to understand the positional relationship of the inferior mesenteric and renal arteries by preoperative assessment using either 3-D CT angiography or magnetic resonance angiography.

Locally advanced carcinoma of the cervix associated with pelvic kidney treated with intensity-modulated radiotherapy: Overcoming a therapeutic challenge

The simultaneous occurrence of carcinoma of the cervix and pelvic kidney is rare. As the pelvic kidney occupies the conventional radiation portal for carcinoma of the cervix, treatment of these patients with radiation presents a therapeutic challenge. A 48-year-old stage IIIB cervical carcinoma patient with an incidental diagnosis of pelvic kidney was treated with radical chemoradiotherapy using intensity-modulated radiotherapy with concurrent weekly cisplatin, followed by intracavitary radiotherapy. The bilateral kidney dose was restricted within a tolerance limit of 16.6 Gy. At the 18-month follow-up, the patient was disease free and had no deterioration in kidney function. Intensity-modulated radiotherapy provided the necessary means for delivering radical radiation doses in this case scenario with adequate sparing of the kidney.

Gerota's fascia over a pelvic ectopic kidney: Myth or reality?

OBJECTIVE

To prospectively evaluate for the presence or absence of Gerota's fascia in a pelvic ectopic kidney, as this is not well documented.

MATERIALS AND METHODS

Between January 2007 and July 2011, all patients with normal renal functions presenting to the Urology Clinic with pelvic ectopic kidney were evaluated for the presence of fascia similar to Gerota's fascia. Specific evaluation included a contrast-enhanced computed tomography (CT) scan and open surgery where indicated. A literature search using PubMed was also done for the period between 1990 and May 2011 using the terms 'Gerota's fascia', 'perirenal fascia,' and 'pelvic kidney'.

RESULTS

Eleven patients were evaluated. The mean age was 28.6 years (range 7 to 50). The presentation included stone disease in six, pelvi-ureteric obstruction in three, and as part of the evaluation for other causes of lower abdominal pain, it was found in two. A CT scan performed on eight patients did not show any evidence of fascia, while surgical exploration done on seven showed a well-defined fascial layer, at least on the ventral aspect of the kidney. A literature search also did not show any information about Gerota's fascia in the pelvic kidney.

CONCLUSION

Further anatomical / radiological studies are needed to definitively document the presence of Gerota's fascia around a pelvic kidney. Our data is more in favor of the presence of such a perirenal fascia similar to Gerota's fascia.

Laparoscopic nephrectomy for a nonfunctioning pelvic kidney in preparation for renal transplantation

Pelvic kidneys pose a problem for any planned surgical intervention given their anomalous blood supply. Although minimally invasive approaches have been described for the management of benign conditions, only a handful of reports have described the use of laparoscopy for removal of ectopic or fused kidneys. We describe the laparoscopic removal of a symptomatic pelvic kidney in a patient before renal transplantation.

Laparoscopic pyelolithotomy in a pelvic kidney: a case report and review of the literature

BACKGROUND AND OBJECTIVES

Laparoscopic pyelolithotomy was performed in a pelvic kidney with a large renal pelvis calculus.

METHODS AND RESULTS

Laparoscopic pyelolithotomy was successfully performed in a pelvic kidney with an operative time of 310 minutes. The use of intraoperative fluoroscopy and a semi-automatic suturing device greatly facilitated the procedure. The patient's operative pain was managed with 3 doses of ketorolac; she resumed a regular diet the day after surgery, and was discharged on the first postoperative day.

CONCLUSIONS

For patients with a large stone in the renal pelvis of an ectopic kidney, laparoscopic pyelolithotomy provides an effective approach.