Extracorporeal Renal Surgery and Autotransplantation

Transcription

1 Extracorporeal Renal Surgery and Autotransplantation

2 Springer Berlin Heidelberg New York Barcelona Budapest Hong Kong London Milan Paris Santa Clara Singapore Tokyo

3 Inge B. Brekke Audun Flatmark (Eds.) Extracorporeal Renal Surgery and Autotransplantation With Contributions by D. Albrechtsen. 0. H. Bentdal. H. Bondevik. I. B. Brekke P. Fauchald. J. G. Fjeld A. Flatmark. A. Foss A. Hartmann H. Holdaas. R. Innes A. Jakobsen N. E. Kl0W. B. Lien o. 0yen. P. F. Pfeffer K. Rootwelt G. S0dal and K. Vatne With 51 Figures (in 99 Separate Illustrations) and 20 Tables, Springer

4 Inge B. Brekke, MD, PhD Head of Transplant Surgery Rikshospitalet (The National Hospital) University of Oslo, Pilestredet 32 N-0027 Oslo, Norway Audun Flatmark, MD, PhD Professor Emeritus Department of Surgery Rikshospitalet (The National Hospital) University of Oslo, Pilestredet 32 N Oslo, Norway ISBN -13: e-isbn-13: DOl: / Library of Congress Cataloging-in-Publication Data. Extracorporeal renal surgery and autotransplantation I Inge B. Brekke, Audun Flatmark (eds.) ; with contributions by D. Albrecbtsen... [et al.] p. cm. Includes bibliographical references and index. ISBN -13: (Hardcover: alk. paper) 1. Kidney - Surgery. 2. Kidneys - Transplantation. 3. Autotransplantation. I. Brekke, Inge B., II. Flatmark, Audrun, III. Albrechtsen, Dagfinn. [DNML: 1. Kidney - surgery. 2. Kidney Transplantation - methods. 3. Transplantation, Autologous - methods. WJ 368 E ] RD575.E '562-dc21 DNLM/DLC for Library of Congress CIP This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks, Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. Springer-Verlag Berlin Heidelberg 1997 Sof tcover reprint of the hardcover 1st edition 1997 The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: Erich Kirchner, Heidelberg Typesetting: Verlagsservice Teichmann, Mauer SPIN: /SPS Printed on acid-free paper

5 Preface Some transplant centers have adopted bench surgery and subsequent renal autotransplantation as a regular policy in the treatment of a variety of renal disorders. The center in Gothenburg was among the first to start using this technique. My close friend, the late Lars-Erik (Charlie) Gelin, who headed the Gothenburg clinic until 1980, was enthusiastic about the method. We had many discussions and exchanged results. The method has proven to be safe and has saved many patients from becoming uremic. We have both been strong advocates of the use of this technique. I performed my first renal autograft in April A 28-yearold man presented with hypertension ( mm Hg), foggy vision, and a serum creatinine concentration of 400 mmoljl. The main artery to the right kidney was occluded, but an accessory artery to the lower pole was open. The left kidney was nonfunctioning and, weighing only 20 g, it was later removed. The right kidney was taken to a side table. The thrombus in the right renal artery was removed and the kidney was flushed and retransplanted. The patient is now 53 years of age with a blood pressure of l25/90 and a serum creatinine concentration of 137 /-!moljl. Extracorporeal renal surgery with subsequent autotransplantation saved him from uremia and the need for a kidney allotransplant and has subsequently saved many another patient. By the end of November 1996, we had autografted more than 500 kidneys in 479 patients. In spite of shock wave techniques and endoscopy in the treatment of stone disease and PTRA for renovascular disease, we still regularly receive patients for bench surgery, particularly patients with renal or urothelial carcinoma. The present book summarizes our experience through the end of lnge B. Brekke, the present head of the transplant program, had the idea of writing this book 2 years ago. He has been the coordinator in the process, and I personally owe him many thanks.

6 VI Preface The editors acknowledge the cooperation of all contributors to this book. We are indebted to Ms Siv K. Nielsen for her excellent secretarial assistance and to Ms Kari Toverud for her fine and skillfully performed anatomical illustrations. We also thank The Norwegian Medical Association Funds for Quality Improvement and Medinnova, Rikshospitalet, for their financial support. The patience demonstrated by the Springer-Verlag staff during the processing of this book has been highly appreciated. AUDUN FLATMARK December 1996

7 Table of Contents 1 Effects of Renovascular Disease and Autotransplantation on Blood Pressure and Renal Function Anders Hartmann, Per Fauchald, and Hallvard Holdaas 1.1 Renovascular Disease Renovascular Hypertension Renal Dysfunction Associated with Renovascular Disease Effects of Renal Autotransplantation on Overall Renal Function General Considerations Denervation and Reinnervation Adaptive Changes in the Autotransplanted Kidney References 2 Radiological Investigation and Interventional Procedures in Patients with Renal Artery Disease Nils Einar Kl0W and KarleifVatne Introduction Screening Methods Preoperative Investigation Arteriography Intravenous Digital Subtraction Angiography Magnetic Resonance Angiography Computed Tomographic Angiography Duplex Doppler Imaging Postoperative Investigations Percutaneous Transluminal Renal Angioplasty Percutaneous Transluminal Renal Angioplasty of the In Situ Kidney Percutaneous Transluminal Renal Angioplasty of the Autotransplanted Kidney Conclusions References Renal Radionuclide Studies Jan G. Fjeld and Kjell Rootwelt Introduction Radiopharmaceuticals Equipment... 38

8 VIII Table of Contents 3.2 Basic Principles for Quantitative Evaluation Blood Sampling Methods Extrarenal Surface Activity Measurement Kidney Uptake Transit Times Clinical Procedures: Methodology Glomerular Filtration Rate Renography Intervention Renographies Autotransplant Renography Selected Procedures in Preoperative Work-up Renovascular Disease Urinary Obstruction Renal Cancer Autotransplant Follow-up Total Renal Function Autotransplant Function References Nephrectomy and Extracorporeal Renal Preservation: Technical Details Bj0fn Lien and Inge B. Brekke Preoperative Evaluation and Preparation Anatomical Considerations Nephrectomy: Technical Details Choice of Incision Nephrectomy for Nonmalignant Disease Nephrectomy for Renal Carcinoma Extracorporeal Renal Preservation References 5 Renal Autotransplantation: Indications, Basic Surgical Techniques, and Complications Inge B. Brekke and Gunnar Sodal Introduction and Historical Background Indications Basic Surgical Techniques Extracorporeal Preparation of the Kidney Kidney Replantation Complications Vascular Complications Urological Complications References... 72

9 Table of Contents IX 6 Renal Artery Atherosclerosis Aksel Foss, Arnt Jakobsen, and Dagfinn Albrechtsen Introduction Atherosclerotic Renal Artery Disease: The Natural Story Management of Blood Pressure in Atherosclerotic RVH Percutaneous Transluminal Renal Angioplasty vs Surgery Surgical Management of Atherosclerotic Renal Artery Disease Renal Autotransplantation in Atherosclerotic Renal Disease Summary References 7 The Role of Bench Surgery in the Treatment of Renal Artery Stenoses and Aneurysms Caused by Fibromuscular Dysplasia Inge B. Brekke and Bj0rn Lien Introduction Diagnosis Indications for Surgery Hypertension Preservation and Restoration of Renal Function Loin Pain/Hematuria Syndrome Choice of Surgical Technique Extracorporeal Renal Artery Reconstruction Renal Reimplantation and Postoperative Control Results Effect on Hypertension Effect on Kidney Function Surgical Complications Patient Survival Conclusion References Complicated Renal Calculous Disease Treated by Extracorporeal Surgery and Autotransplantation Per F. Pfeffer, Helge Bondevik, and Gunnar S0dal Introduction Indications for Extracorporeal Surgery Preoperative Examination and Evaluation Surgical Procedures Postoperative Follow up Results Recurrence of Calculi Autotransplant Function Postoperative Complications Summary References

10 X Table of Contents 9 Ex Vivo Renal Resection and Autotransplantation for Renal and Urothelial Carcinoma Gunnar S0dal, 0ystein Bentdal, and Audun Flatmark Introduction Indications for Extracorporeal Surgery Surgical Technique }.l Preparation of the Kidney (Bench Surgery) Postoperative Follow-Up Own Experience Results Perioperative Complications Long-Term Results Discussion References 10 Simultaneous Aortic Reconstruction and Renal Autotransplantation Inge B. Brekke, Ole 0yen, Robert Innes, and Audun Flatmark Introduction Prevalence of Aortorenal Disease Juxta- and Para renal Aortic Aneurysms Coexistent Aortic and Renal Artery Disease Indications for a Combined Procedure Preoperative Assessment Surgery Peroperative Management Aortic Replacement and Renal Autotransplantation Postoperative Care and Evaluation Results Perioperative Morbidity and Mortality Effect on Blood Pressure and Renal Function Summary References Management of Ureteral Defects by Renal Autotransplantation 0ystein H. Bentdal and Gunnar S0dal Introduction Alternative Surgical Techniques Own Experience Results Summary... '" References Subject Index

11 Contributors All authors, except Helge Bondevik, are staff of Rikshospitalet (The National Hospital), University of Oslo, Pilestredet 32, 0027 Oslo, Norwayo Albrechtsen, Dagfinn, MD, PhD and Assistant Medical Director Bentdal, 0ystein Ho, MD, PhD Bondevik, Helge, MD, PhD Now Consultant Vascular Surgeon Brerum County Hospital, Brerum Brekke, lnge Bo, MD, PhD Head of Transplant Surgery Fauchald, Per, MD, PhD Professor of Nephrology Head of Nephrology Section Department of Medicine Fjeld, Jan Go, MD, MoSco, PhD Consultant Section for Nuclear Medicine Department of Clinical Chemistry Flatmark Audun, MD, PhD Professor Emeritus Department of Surgery Foss, Aksel, MD, PhD

12 XII Contributors Hartmann, Anders, MD, PhD Consultant Nephrology Section, Department of Medicine Holdaas, Hallvard, MD, PhD Consultant Nephrology Section, Department of Medicine Innes, Robert, MD Consultant Department of Anesthesiology Jakobsen, Arnt, M.D., PhD Consultant transplant surgeon, Department of Surgery Present position Medical Director KI0W, Nils Einar, MD, PhD Consultant Department of Radiology Present address: Department of Radiology University of Minnesota Box 292 UMHC, 420 Delaware Street S.E., MN 55455, USA Lien, Bj0rn, MD 0yen, Ole, MD, PhD Pfeffer, Per E, MD, PhD Rootwelt, Kjell, MD, PhD Professor of Nuclear Medicine Head of Section for Nuclear Medicine Department of Clinical Chemistry S0dal, Gunnar, MD Vatne, Karleif, MD Consultant Department of Radiology