Rare Renal Vascular Anomaly: A Challenge in Laparoscopic Nephrectomy

Abstract

Introduction:

Laparoscopic radical nephrectomy has become the standard treatment for localized T1 and T2 renal tumors. ¹ Technical difficulties may be faced during laparoscopic nephrectomy in patients with renal vascular anomalies. ² Renal vein anomalies are common and the most frequent anomaly is an additional renal vein that accounts for 9%–30% of individuals, mostly on the right side. Other variations include circumferential aortic left renal vein (7%) and retroaortic left renal vein (1.7%). ^3,4 An H-shaped left renal vein was described previously in a patient undergoing donor nephrectomy. ⁵ During nephrectomy, arterial division should be done before venous division to decrease renal edema and the risk of bleeding while manipulating the renal vein. With the renal artery controlled, the renal parenchyma should decrease in size and facilitate dissection of the renal hilum and the remaining attachments. This video depicts the surgical steps and technique used to overcome the challenge of aberrant renal vascular anatomy.

Methods:

A 32-year-old female patient presented with hematuria and right flank pain. A CT showed an 8 × 9 cm central right renal mass suspicious for a renal cell carcinoma. She was scheduled for a laparoscopic right radical nephrectomy. The procedure was performed in modified lateral decubitus position; a 10 mm optic trocar was placed midway between the umbilicus and subcostal margin at the level of the lateral border of rectus sheath muscle. Another 10 mm trocar (Hem-o-lok, scissors) and a 5 mm trocar (bipolar grasper) were inserted using the triangulation rule. An additional 5 mm trocar was placed for traction below the right costal margin arch at the lateral border of the rectus muscle. The patient was found to have two renal veins forming an H-shaped right renal vein. The surgery was particularly challenging since the renal veins were both overriding the renal artery, which required further dissection of the pedicle to allow arterial control before venous clamping.

Results:

Operative time was 94 minutes and no drain was placed. The patient was discharged on postoperative day 2 after an uneventful hospital stay. Final pathology analysis showed chromophobe renal cell carcinoma grade 2 stage pT1, measuring 7 × 6 × 6 cm, with tumor limited to the kidney without capsular involvement. The patient is considered at a low risk of recurrence. She is scheduled for a follow-up CT scan at 1 year and postoperation, then every 2 years for 5 years.

Conclusion:

The video shows the effective outcome of a laparoscopic right radical nephrectomy involving a right-sided H-shaped renal vein. Vascular anomalies can complicate regular procedures, hence preoperative planning may be warranted and intraoperative meticulous dissection should be done to avoid complications.

No competing financial interests exist.

Runtime of video: 6 mins 57 secs