Use of horseshoe kidney as renal transplant from living donor: its surgical feasibility and pitfalls

[LAPAROSCOPIC LIVE DONOR NEPHRECTOMY WITH HORSESHOE KIDNEY: A CASE REPORT]

We performed laparoscopic live donor nephrectomy (LDN) on approximately 200 patients in Ehime Prefectural Center Hospital between 2003 and 2016. In 2016, a fifty-something woman who was a donor candidate for her husband was revealed to have a horseshoe kidney through contrast-enhanced computed tomography; other LDN procedures used a retroperitoneal approach, but this one used a transperitoneal approach since the latter approach allowed for a more favorable visual field. The left kidney was selected since renal scintigraphy showed equal bilateral renal function and renal arteries are simpler on the left side. The kidney was removed after the isthmus was successfully transected without ischemia. The opened calyx in the left kidney was sutured via bench surgery, and the kidney was transplanted to the recipient. Postoperative courses of both donor and recipient were good.

Laparoscopic Living-Donor Nephrectomy of a Horseshoe Kidney: A Case Report and Review of the Literature

We present the case of a living-donor nephrectomy of a horseshoe kidney. The recipient was a 33-year-old male with a history of end-stage renal disease secondary to IgA nephropathy. The donor was his 33-year-old partner who on preoperative cross-sectional imaging was found to have a horseshoe kidney with a single artery, vein and ureter. The donor operation was performed using a laparoscopic hand-assisted technique with transection of the interpolar fibrotic band using a stapler device. The backtable organ preparation was performed in a standard fashion with addition of a reinforcing hemostatic suture of the stapled fibrotic band. The donated kidney was transplanted extraperitoneally in the right iliac fossa of the recipient. The patient had an unremarkable postoperative course and was discharged home on post operative day 2 with normalizing renal function. To our knowledge, this is the first living donor nephrectomy of a horseshoe kidney performed using a laparoscopic hand-assisted technique.

Living-Donor Kidney Transplantation With Laparoscopic Nephrectomy From a Donor With Horseshoe Kidney: A Case Report

BACKGROUND

In living-donor kidney transplantation, laparoscopic nephrectomy from a donor has become widespread. However, more careful treatment is required for nephrectomy from a donor with horseshoe kidney. This report presents an interesting surgical case of laparoscopic nephrectomy from a donor with horseshoe kidney.

CASE PRESENTATION

A woman aged 53 years was a donor candidate for living-donor kidney transplantation for her husband. She had no medical history and had no problems on preoperative examination, but contrast-enhanced computed tomography revealed that she had horseshoe kidney. As the isthmus was thin and the contrast effect was poor, the isthmus was considered to have poor kidney parenchyma and consisted almost exclusively of fibrous tissue. Therefore, laparoscopic nephrectomy was performed for the donor. On the basis of the 99m Tc-dimercaptosuccinic acid renal scintigraphy results, the right kidney was collected. A laparoscopic nephrectomy with a retroperitoneal approach was performed using GelPort access platforms in a right abdominal incision with an accessory port. We firmly expanded the isthmus and then dissected it just above the aorta using a linear stapling device. Subsequently, we sutured a renal artery and vein with linear stapling devices. The recipient's surgery was also performed without any problems, and the postoperative course of both donor and recipient was good.

CONCLUSIONS

We suggest that even if the donor has horseshoe kidney, laparoscopic donor nephrectomy should be actively considered depending on the thickness of the isthmus of the horseshoe kidney.

Transplantation of a horseshoe kidney from a living donor using stapler for transsection

Although it rather became a routine procedure to evaluate and use a cadaveric horseshoe kidney, using one from a living donor is quite rare. In this paper, we present methods we used during such a case which may benefit the procedures in the future. A 29-year-old female patient was considered for transplant and only viable living donor was her 59-year-old mother. Dynamic computed tomography revealed horseshoe anomaly with one renal artery and one renal vein for each side, a long but thin isthmus connecting lower poles with no visible arterial supply. Descending urography showed no connecting caliceal system. Donor nephrectomy was performed and isthmus separation was carried out with vascular stapler. Recipient was discharged on the 6th day with no complications. Patient was followed up for 6 months with normal creatinine levels. When properly assessed before the surgery, using a horseshoe kidney is not so challenging as thought.

Transplantation of a horseshoe kidney from a living donor: Case report, long term outcome and donor safety

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Horseshoe kidney is the most common urinary congenital abnormality.

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We describe a successful transplantation of a horseshoe kidney from a living donor.

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We emphasized the absence of other abnormalities and establish a low surgical risk.

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Good long term donor and recipient́s outcomes have been described.

Introduction

The use of a horseshoe kidney in renal transplant remains controversial, when it is found in the evaluation of a living donor, anatomical, surgical and ethical issues are involved.

Presentation of Case

An uncomplicated horseshoe kidney was detected in a 51-year-old woman who was the only suitable donor for her 30-year-old son. Kidneys were fused in the inferior pole and no vascular or urinary abnormalities were detected during imaging evaluation. The surgical procedure was approved by the hospital transplant committee. A laparotomy was performed by means of a medial upper incision. The isthmus of the kidney was divided using a harmonic scalpel and the left segment was used; it had 2 arteries too distant to create a common one, thus anastomosed separately. The renal vein was side-to-side anastomosed to the right external iliac vein and a Lich-Gregoir ureteral implant was made. There were no intraoperative or postoperative complications in the donor who currently remains asymptomatic. Recipient developed a delayed graft function (DGF), and was discharged on the 12th day after surgery. After 24 months of surgery, renal function has remained stable with a serum creatinine of 128 μmol/L (1.45 mg/dL).

Discussion

There are 7 reports of a horseshoe kidney from living donors in 8 patients without morbidity and a good long term outcome of all recipients.

Conclusion

If we anticipate a low operative risk and there is a suitable anatomy, we may consider the use of horseshoe kidneys from living donors a viable alternative.

Transplantation of Horseshoe Kidney from Living, Genetically Unrelated Donor

We report a case of renal transplantation using a horseshoe kidney from a living, genetically unrelated donor. The recipient was a 60-year-old man with diabetic nephropathy, and the donor was the 63-year-old wife of the recipient with a horseshoe kidney free of complications. Computed tomography showed two renal arteries and one renal vein on the left side, and the isthmus was perfused by several accessory arteries and veins. To demarcate the boundary of the isthmus, the left renal artery was ligated and cannulated for in situ perfusion. Furthermore, the isthmus was clamped, and the boundary of the isthmus was confirmed. The kidney was divided at the left margin of the perfused boundary. The cut ends of the isthmus were closed by sutures. The left kidney was transplanted into the right iliac fossa of the recipient. Asymptomatic fluid collection occurred on the cut surface at the isthmus of the donor, and this fluid decreased in due course. On the other hand, the recipient experienced no surgical complication or rejection, while maintaining serum creatinine levels of 2.00–2.20 mg/dL over a 22-month follow-up period. Horseshoe kidneys may be used for transplantation in selected cases after a detailed preoperative evaluation.

Horseshoe kidney transplantation

Even though the number of patients awaiting renal transplant is rapidly increasing, the donor pool remains relatively stable. In an attempt to increase this pool, marginal kidneys and kidneys with congenital anatomical variations are being used. Horseshoe kidneys, being the most common renal fusion anomaly, can provide a useful solution to the ever-increasing gap between demand and supply. These kidneys have been successfully transplanted en bloc into a single recipient or, alternatively they have been divided and transplanted into 2 recipients. We report a case of the successful transplantation of an en bloc horseshoe kidney into a single recipient. To the best of our knowledge this is the first of its kind in the U.K. The relevant literature is also reviewed with the aim of raising awareness about the necessity and promising outcomes of such transplants.