Laparoscopic Renal Autotransplantation

Renal autotransplantation has been performed for aortorenal vascular disease, upper ureteral tumors and strictures, ureteral loss, loin pain-hematuria syndrome, and idiopathic retroperitoneal fibrosis (8-13). Renal autotransplantation involving two separate procedures, live donor nephrectomy and autotransplantation, is known to be a morbid open surgical procedure requiring two large skin incisions. Laparoscopy was thought to have the potential to minimize the morbidity of this renovascular surgical procedure.

Meraney et al. from the Cleveland Clinic investigated the feasibility and outcome of laparoscopic renal autotransplantation in the laboratory setting (14). This study represents the initial and only report of a completely laparoscopically performed renal autotransplantation.

In their survival study, six farm pigs underwent the laparoscopic renal autotransplantation procedure (14). Laparoscopic left donor nephrectomy was first performed, following which intracorporeal renal hypothermia was achieved via intra-arterial infusion of ice-cold saline solution through a balloon catheter, the same method described earlier by the same Cleveland Clinic group (6). The renal vessels were then anastomosed to the ipsilateral common iliac vessels in the end-to-side manner using laparoscopic intracorporeal free-hand suturing and knot-tying techniques. All animals underwent the procedure successfully, with return of pink color to the autotransplanted kidney and Doppler-confirmed renal arterial pulsation following revascularization. The mean operative time was 6.2 hours. The mean venous anastomosis time was 33 minutes, and the arterial anastomosis time was 31 minutes. The mean iliac clamping time was 77 minutes. The total renal ischemia time was 68.7 minutes, including warm ischemia of 5.1 minutes, cold ischemia of 33 minutes, and rewarming of 31 minutes. Postoperatively, one animal was found to have atrophic, thrombosed autograft. The remaining five animals had stable serum creatinine levels (mean of 1.6mg/dL) following staged contralateral nephrectomy after autotransplantation. Just before euthanasia, which was done at various times postoperatively (from one to four months), intravenous pyelography and aortography demonstrated prompt contrast uptake and excretion by the autotransplanted kidneys and patent arterial anastomoses in all five animals, respectively. Following euthanasia, histopathologic examination of the autograft showed normal renal architecture without evidence of ischemia or acute tubular necrosis.

Gill et al. from the Cleveland Clinic reported their initial experience with repair of renal artery aneurysm performed laparoscopically to minimize the patient morbidity associated with renal revascualrization. This report represented the initial laparoscopic renovascular surgery in the clinical setting.

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