Arterial

The origin of the right renal artery is beneath the left renal vein and it typically passes posterior to the inferior vena cava (IVC) (Fig. 54–5; see also Fig. 1–33). During transabdominal left radical nephrectomy, knowledge of this anatomic relationship may prevent inadvertent ligation of the right renal artery (Fig. 54–6; see Fig. 54–7 on the Expert Consult website). The inferior adrenal artery and a branch that supplies the renal pelvis and ureter arise from the renal artery. In the majority of cases the renal artery branches in the distal third of the vessel or the renal sinus.

Figure 54–5 Arterial anatomy can be well defined using CT (A) and three-dimensional reconstruction (B).

Figure 54–6 Relationship of right kidney to great vessels. IVC, inferior vena cava; Ao, aorta.

(© The Lahey Clinic.)

Figure 54–7 Vessel loops isolate right renal artery (red) at take off from aorta. The left renal vein (blue) is mobilized cephalad to divide the right renal artery near the aorta.

The kidney is divided into four segments (superior, anterior, posterior, inferior) that are supplied by one or more segmental renal arteries, which are end arteries (Fig. 54–8 on the Expert Consult website). Ligation or occlusion of a segmental artery, or any of its branches, leads to devitalization of renal tissue. Intraoperatively, one can administer methylene blue dye and occlude the segmental arteries to define the borders of the vascular segments. Despite variation in the origin of the branches supplying the renal segments, the anatomic pattern of the segments is constant (Graves, 1954). Three planes between the vascular segments can be demonstrated (see Fig. 54–8 on the Expert Consult website) and are important for intrarenal surgery. In theory, incision in the plane between the anterior and posterior segments affords reduced blood loss (Brodel, 1900) and has been described for anatrophic nephrolithotomy (Smith and Boyce, 1968). This plane, located on the posterior surface of the kidney, is not to be confused with the “Brodel white line,” a whitish linear depression on the lateral aspect of the anterior surface of some kidneys formed by fusion of anterior and posterior columns of Bertin, which demarcates a highly vascular area (Brodel, 1900) (Fig. 54–9).

Figure 54–9 Brödel white line and posterior vascular segment.

(© The Lahey Clinic.)

Figure 54–8 Renal vascular segments.

(© The Lahey Clinic.)

Typically, the first division of the renal artery creates the anterior and posterior segmental branches (see Fig. 1–30A and B). The posterior segmental branch of the main renal artery arises proximal to the hilum, passes posterior to the renal pelvis, and supplies the posterior renal segment. Classically, a crossing vessel responsible for ureteropelvic junction (UPJ) obstruction is an aberrant posterior segmental artery passing anterior to the UPJ. The anterior segmental branch of the main renal artery divides into four divisions: the apical (superior) segmental artery, the anterior superior segmental artery, the anterior inferior segmental artery, and the basilar (inferior) segmental artery. These are also referred to as the apical, upper, middle, and lower anterior segmental arteries, respectively. These segmental arteries then divide further into lobar arteries (associated with each renal pyramid) and further into two or three interlobar arteries (Fig. 54–10). The interlobar arteries travel through the renal medulla alongside either side of the pyramids. They divide at the corticomedullary junction into arcuate arteries that give rise to the interlobular arteries that travel radially to the capsule. They give off numerous side branches en route, including the afferent arterioles.

Figure 54–10 Anatomic relationship of cascading intrarenal vessels.

(© The Lahey Clinic.)

Venous

In parallel to the renal arterial system, the renal venous system progresses from the interlobular veins to the arcuate, interlobar, lobar, and segmental veins (see Fig. 1–32). The segmental veins combine to form three to five venous tributaries, the confluence of which forms the main renal vein near the hilum. Each kidney is typically drained by a single renal vein that courses anterior to the renal artery and joins the lateral aspect of the vena cava. The left renal vein is longer than the right, making the left kidney attractive for donor nephrectomy. The left renal vein typically passes anterior to the aorta.

Unlike the arterial structure of the kidney, the renal venous system is characterized by a rich anastomotic network between the various renal segments. One may ligate and divide segmental veins without compromising drainage. The right renal vein does not receive significant branches. Tributaries draining into the main left renal vein include the gonadal vein, the left adrenal vein, and one or two large lumbar veins, all of which can be injured during mobilization of the left renal vein. Because of these collateral vessels, one is at liberty to ligate the left renal vein at the caval junction without eliminating venous return.

Anomalies of Renal Vasculature

Frequent anatomic variation in the renal vasculature contributes to the complexity of open renal surgery. Multiple renal arteries, which typically arise from the aorta or iliac arteries, are the most common variation, occurring in 25% to 30% of the population (Merklin and Michels, 1958; Boijsen, 1959; April, 1997). Supernumerary hilar renal arteries originate at the aorta adjacent to the renal artery and traverse the renal hilum, whereas polar renal arteries originate at a greater distance from the main renal artery and enter the renal parenchyma directly. Ectopic and horseshoe kidneys more frequently have supernumerary renal arteries (Fig. 54–11).

Figure 54–11 Horseshoe kidney with multiple arterial branches well defined with three-dimensional imaging.

Venous anomalies occur less frequently. Supernumerary renal veins occur less commonly on the left than right (Merklin and Michels, 1958). The most common variation is duplication of a renal vein (6%) (April, 1997). Retroaortic left renal veins occur in approximately 2% of patients. Circumaortic renal veins are present in 1.6% to 6.0% of the population (Kottra and Castellino, 1970). One must be vigilant to identify these infrequent anomalies during preoperative evaluation or intraoperative dissection.

Cardiovascular

Some patients will benefit from referral to a consulting cardiologist for consideration of resting 12-lead electrocardiogram, noninvasive evaluation of left ventricular function, noninvasive stress testing, medication adjustments, or preoperative coronary revascularization (coronary artery bypass graft or percutaneous coronary intervention). Patients with unstable coronary syndromes, decompensated heart failure, significant arrhythmias, or severe valvular disease should be evaluated and treated by a cardiologist before noncardiac surgery (Fleisher et al, 2007). It is incumbent on the urologist to identify these patients and others who are at risk of cardiovascular complications and to refer them for evaluation by a specialist.

In addition, patients with known coronary artery disease or signs or symptoms suggestive of new coronary artery disease should receive a preoperative cardiac assessment (Fleisher et al, 2007). In asymptomatic patients, referral should be made based on a history and physical examination (Lee et al, 1999; Fleisher et al, 2007). The history should elucidate symptoms of cardiovascular disease, risk factors for cardiac disease, and pertinent medications (Table 54–3). The Revised Cardiac Risk Index (RCRI), a simple validated index to predict cardiovascular complications, was developed at a tertiary care facility for prediction of cardiac risk of major noncardiac surgery in patients 50 years of age or older (Lee et al, 1999). The RCRI, which is composed of six independent predictors of cardiac complications, identifies patients at risk of cardiac complications (Table 54–4) and may be helpful for preoperative risk stratification.

Table 54–3 Pertinent Cardiovascular History

Table 54–4 Revised Cardiac Risk Index

Pulmonary

In noncardiothoracic surgery, risk factors for postoperative pulmonary complications include chronic obstructive pulmonary disease, age older than 60 years, inhaled tobacco use, American Society of Anesthesiologists (ASA) class II or higher, functional dependence (i.e., inability to perform activities of daily living or need for equipment and assistance for some activities of daily living), congestive heart failure, pulmonary hypertension, and hypoalbuminemia (Qaseem et al, 2006; Bapoje et al, 2007). The urologist should screen for these risk factors and refer the patient for preoperative pulmonary evaluation and risk reduction.

Even in the absence of baseline risk factors, open renal surgery itself may disturb a patient’s pulmonary equilibrium and render him or her at risk for postoperative pulmonary complications. For instance, transection of upper abdominal and flank muscles, removal of ribs, impairment of diaphragm function through nerve or muscular injury, pneumothorax, hemothorax, and pleuritic pain may all contribute to pulmonary difficulties. Prolonged surgery (>3 hours) is an independent predictor of pulmonary complications, as is either thoracic or upper abdominal surgery (Qaseem et al, 2006).

Pulmonology consultation, preoperative pulmonary function testing, chest radiography, or arterial blood gas analysis may benefit patients who are at risk of pulmonary complications. Preoperative interventions such as smoking cessation 6 to 8 weeks before surgery and inspiratory muscle training may reduce the risk of pulmonary complications (Bapoje et al, 2007). In patients with significant pulmonary risk factors or impairment an anterior surgical approach in the supine position might be preferable to the flank approach (Novick, 2007). Risk can be ameliorated after surgery by deep breathing exercises or incentive spirometry and by selective rather than routine use of nasogastric drainage (Qaseem et al, 2006; Bapoje et al, 2007).

Subcostal Flank Approach

This approach offers good exposure of the renal parenchyma and upper ureter. It is an advantageous approach for surgery on the lower renal pole, UPJ, and upper ureter (e.g., ureterocalicostomy, pyeloplasty, and stone surgery). Simple nephrectomy, insertion of a nephrostomy tube, and drainage of a perinephric abscess may all be accomplished through a subcostal flank incision. Because the approach is extraperitoneal, contamination of the peritoneal cavity is avoided. Access to the renal hilum and vascular pedicle is poor, which is the most salient disadvantage of this approach. The subcostal flank approach is not appropriate for radical or partial nephrectomy (Libertino, 1998). The incision may be caudal to the kidney, hampering access to the upper pole, renal pelvis, and hilum (Novick, 2007). Exposure may be further hindered by the iliac crest and subcostal nerve, the anterior division of the 12th thoracic nerve.

After induction of anesthesia, insertion of an endotracheal tube, and introduction of a Foley catheter into the urinary bladder to monitor urine output, the patient is placed in the lateral position. The head is supported to maintain proper alignment of the cervical spine. The tip of the 12th rib should be positioned over the kidney bar (Fig. 54–18). The patient’s back should be nearly flush with the edge of the table to ensure unfettered access by the surgeon. To preserve stability and prevent forward roll, the dependent leg is flexed at the hip and knee and the top leg is kept straight. A pillow is placed between the knees. An axillary roll is deployed just caudal to the axilla to prevent compression or injury of the axillary neurovascular bundle. Other pressure points, including the upper foot, are padded with foam. The nondependent arm should be placed on a padded Mayo stand so that the arm is horizontal with slight forward rotation at the shoulder. The bed is flexed until the flank muscles are under stretch. A kidney bar can be employed if necessary. The bed is placed in Trendelenburg position so that the flank is rendered parallel to the floor. The patient is secured to the mobile part of operating table with 2-inch wide adhesive tape, which fixes the patient in place while allowing adjustment of flexion.

Figure 54–18 Position of the patient for the flank approach. Note the axillary pad. The kidney rest may be elevated if further lateral extension is needed.

After sterile preparation and draping, the skin incision begins at the costovertebral angle, approximately at the lateral border of the sacrospinalis muscle just inferior to the 12th rib. The incision is made a fingerbreadth below and parallel to the 12th rib and is carried onto the anterior abdominal wall. In an attempt to avoid the subcostal nerve, the incision can be curved gently downward at the midaxillary line. If needed, the incision can be extended caudally or medially to the lateral border of the rectus abdominis.

The incision is carried sharply through the subcutaneous tissue, exposing the fascia of the latissimus dorsi and external oblique muscles (Fig. 54–19). Electrocautery is used to incise the muscles in the line of the incision (Fig. 54–20), starting with the latissimus dorsi posteriorly. The serratus posterior inferior muscles, which insert into the lower four ribs, are also encountered in the posterior portion of the wound and transected. In the anterior aspect of the wound the external oblique muscle is divided. These maneuvers expose the fused lumbodorsal fascia, which gives rise to the internal oblique and transversus abdominis muscles. The lumbodorsal fascia and internal oblique muscle are divided (Fig. 54–21). By using two fingers inserted into an opening created in the lumbodorsal fascia at the tip of the 12th rib, the peritoneum is swept medially as the transversus abdominis is split digitally. The subcostal nerve should be identified between the internal oblique and transversus abdominis muscles and spared (Figs. 54-22 and 54-23).

Figure 54–19 Superficial incision through flank.

(From Libertino JA. Reconstructive urologic surgery. 3rd ed. Philadelphia: Mosby; 1997.)

Figure 54–20 Left subcostal incision. The latissimus dorsi muscle has been divided to expose the lumbodorsal fascia and the posterior aspects of the abdominal muscles.

Figure 54–21 Dissection through flank muscles.

(From Libertino JA. Reconstructive urologic surgery. 3rd ed. Philadelphia: Mosby; 1997.)

Figure 54–22 Opening lumbodorsal fascia to gain entrance to retroperitoneum.

(From Libertino JA. Reconstructive urologic surgery. 3rd ed. Philadelphia: Mosby; 1997.)

Figure 54–23 The lumbodorsal fascia and transverse muscles have been divided to expose the Gerota fascia. The subcostal nerve and vessels pierce the lumbodorsal fascia posteriorly and course forward on the transverse muscle.

To maximize exposure in the posterior aspect of the incision, one may incise the posterior angle of the lumbodorsal fascia, exposing the sacrospinalis and quadratus lumborum muscles. Dividing the costovertebral ligament permits superior retraction of the 12th rib if enhanced exposure is deemed necessary. A Bookwalter (Codman & Shurtleff, Raynham, MA) flank retractor is used for exposure.

To facilitate wound closure, the kidney bar is lowered and the table is partially taken out of flexion. The wound is closed in layers using No. 2 Nylon. The transversus abdominis and internal oblique muscles are closed in one layer. The lumbodorsal fascia is reapproximated, followed by the external oblique, serratus posterior inferior, and latissimus dorsi muscles. The skin edges are reapproximated with staples or subcuticular 2-0 polyglactin (Vicryl). A closed drainage system or Penrose drain should be externalized through a small counterincision below the wound. After applying a sterile dressing to the wound, the authors place the Penrose drain into a collection bag designed for urinary stomas, which is secured to the abdominal wall. This allows drainage to be easily recorded and protects the skin from the drain output.

Supracostal Flank Approach

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