Renal autotransplantation. Further use of a new perfusate

In situ perfusion by retrograde cannulation of a tumor artery for nephron-sparing surgery

BACKGROUND

Although ice slush cooling or ex situ perfusion with bench surgery is most widely used for protecting ischemic renal damage which possibly accompanies complicated nephron-sparing surgery, each has its own disadvantages. The former does not allow excessively long ischemia and the latter requires complicated procedures as autotransplantation. In order to mitigate against these problems, we devised a novel method of in situ renal perfusion with intracellular hyperosmolar solution.

METHODS

One renal segmental artery mainly supplying a tumor was isolated and cannulated with a small feeding tube. The tube was introduced through a small arteriotomy incision directed towards the proximal side, advanced until its tip remained in the main or first branch of the renal artery, and then it was anchored to that artery. After the main renal artery and vein were clamped, the kidney was perfused with cold Euro-Collins' solution through the tube, while the venous blood and perfusate were drained from the left gonadal vein or small venotomy incision of the right renal vein.

RESULTS

In one case of renal cell carcinoma and three cases of angiomyolipoma, two of which ruptured, nephron-sparing surgery was carried out under in situ hyperosmolar perfusion. Ischemic time of these four cases was an average of 96 minutes, varying from 45 to 145 minutes. All the kidneys functioned well postoperatively.

CONCLUSIONS

The method presented here is very simple, requires no unusual dexterity and safely allows for a long period of renal ischemia. This method is best indicated in cases where simple clamping of the renal pedicle with ice-slush cooling appears insufficient, yet ex situ surgery with autotransplantation seems excessive.

Function of human autologous kidney grafts after extracorporeal preservation with Sacks' II solution

The function of 18 human kidney grafts was studied before and 3 months after autotransplantation without prior bench surgery on the parenchyma or the vessels. Kidney protection was accomplished by pre-treating the patient with mannitol and low molecular weight dextran solution and flushing the kidney with a Xylocaine-heparin mixture and cold Sacks' II solution. The mean cold ischaemia time was 239 min (range 140-345 min). The glomerular filtration rate (GFR) remained unchanged post-operatively in terms of both total and split kidney GFR. Proximal and distal tubular integrity, as studied by determination of beta2-microglobulin excretion and concentration ability respectively, was also preserved.

Treatment of urothelial tumors of the upper urinary tract by nephroureterectomy, renal autotransplantation, and pyelocystostomy

Nephroureterectomy, renal autotransplantation, and pyelocystostomy have been performed in eight patients with urothelial tumors of the upper urinary tract. One patient had tumors in a solitary kidney, two patients had bilateral tumors, and five patients had unilateral tumors. Three patients have had recurrent calyceal tumors which were successively managed by the transurethral route. In one patient the kidney had to be removed after 4.5 years because of infiltrating tumor recurrence. Two patients died; the renal pelvis of the graft was tumor free at autopsy in both cases. The other five patients are alive and free from tumor recurrence. The procedure implies increased radicality compared with conventional conservative treatment and simplified follow-up. It may be considered in patients with bilateral tumors or tumors of a solitary kidney, and in selected patients with unilateral low-grade, low-stage tumors.

Autologous renal transplantation and pyelocystostomy after unsuccessful pyeloplasty

A total of 4 patients with persistent outflow obstruction after pyeloplasty for hydronephrosis was reoperated with renal autotransplantation and pyelocystostomy. All 4 patients had undergone an unsuccessful Anderson-Hynes pyeloplasty and 2 also had had a second operation. All patients had relief of pain, normalization of urine outflow and improved renal function during an observation of 27 to 37 months. Occasional asymptomatic bacteriuria occurred in 2 patients. Thus, renal autotransplantation and pyelocystostomy may be considered a useful and safe method to eliminate persistent outflow obstruction after unsuccessful pyeloplasty.

Autologous renal transplantation with direct pyelocystostomy in the treatment of recurrent renal calculi

Six male patients with severe recurrent urinary calculus disease underwent renal autotransplantation with direct pyelocystostomy to allow spontaneous passage of stones. The only serious complication was an early renal vascular thrombosis with graft loss in one patient who had been operated on three times before with ipsilateral partial resections for nephrolithiasis. The other five patients did well (observation time 4-34 months). Their renal function has remained unchanged. Autotransplantation with direct pyelocystostomy should be considered in patients with multiple recurrent stones of the upper urinary tract, especially when some degree of obstruction has developed or when other predisposing anomalies prevail.

Simultaneous bilateral renal artery reconstruction and intraoperative renal protection. A case report

A 22-year-old Japanese man with bilateral renal artery stenosis associated with hypertension underwent successful surgery of simultaneous bilateral renal artery reconstruction under conditions of intraoperative renal perfusion with St. Thomas Hospital solution which is used for cardioplegia in open heart surgery. Circulation in the left kidney was interrupted for 58 minutes and that of the right kidney for 35 minutes. The patient fully recovered with no serious impairment of renal function. In addition to these stenotic lesions of the renal artery, there were medial necrosis of the aorta and fibromuscular dysplasia of the superior mesenteric artery. Administration of SQ14,225, an angiotensin I converting enzyme inhibitor, was effective in controlling hypertension during the preoperative period.

Surgical treatment of renovascular hypertension in children: the roile of renal autotransplantation

We describe 2 children with renovascular hypertension treated successfully by autotransplantation, as well as an additional child in whom ex vivo microsurgical repair was attempted. The literature is reviewed and all patients within the pediatric age group with renovascular hypertension who were treated surgically are reported. The different types of vascular reconstructive techniques and, particularly, the previous use of autotransplantation are discussed.

In situ and ex situ renal artery aneurysmectomy in the solitary kidneys

We report 2 cases of renal artery aneurysms in congenital solitary kidneys, which were treated respectively by in situ and ex situ aneurysmectomy. Hyperosmolar intracellular electrolyte solution was valid in preserving renal function during renal ischemia in both cases. The occurrence of an aneurysm in a solitary kidney, ex situ operation and renal preservation during ischemia are discussed.

Extracorporeal surgery and autotransplantation for carcinoma of the pelvis and ureter

Multiple transitional cell tumours of the renal pelvis and proximal ureter of a solitary kidney were successfully managed by total ureterectomy, extracorporeal subtotal resection of the renal pelvis, autotransplantation, and calicovesicostomy. The method permits resection of a maximum of the uroepithelium of the upper urinary tract at the same time as it preserves available renal parenchyma. It also implies a new and exciting approach to the renal pelvis for endoscopic postoperative control and local treatment of the malignancy.

Treatment of extensive renal calculi with extracorporeal surgery and autotransplantation

Two patients with large calculi in solitary kidneys, treated by ex vivo stone extraction and autotransplantation, are presented. The results show this to be a valuable therapeutic modality for difficult renal calculi where an in situ approach would be hazardous.