EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Key words : Computed tomography angiography, Infrarenal duplicated inferior vena cava, Left kidney transplant, Vascular dissection

Laparoscopic donor nephrectomy (LDN) has become the standard surgery to procure kidneys for transplant.¹ The LDN procedure requires a major vascular dissection and is a technically challenging procedure.² Laparoendoscopic single-site donor nephrectomy (LESS-DN) has the added advantages of a smaller incision, better scar satisfaction, less need for analgesics, and shorter recovery time for return to work versus conventional LDN.³

Vascular anomalies increase the difficulty and complication of the donor LDN procedure for surgeons. Duplicated inferior vena cava (IVC) is a relatively rare vascular anomaly with a reported prevalence of 0.5% to 3%.^2,4-6

The inclusion of donors with anatomic variants permits the expansion of the donor pool. Herein, we report a case of successful left LESS-DN in a donor with an infrarenal duplicated IVC.¹

A 32-year-old male patient was evaluated as a potential kidney donor for his 50-year-old sister, who was on hemodialysis for 3 years due to hypertension. The donor had no significant medical history. After an extensive medical and psychological evaluation, the brother was approved for donation. Results of blood and urine tests were within reference ranges, and ultrasonography revealed kidneys of typical size and no anomalies. Preoperative computed tomography (CT) renal angiography showed healthy functional kidneys and simple collecting systems without duplication. However, there was a duplicated IVC below the level of the left renal vein (Figure 1). The left renal vein was longer than the right renal vein (68 mm vs 29 mm, respectively). The kidneys were measured by volume rendering on CT, and both kidneys were similar in size. There were bilateral single renal arteries.

Informed consent was obtained from both the donor and the recipient. The donor was prepared for surgery in a 45-degree flank position, and a 5-cm-long vertical transumbilical incision was made, including 1 cm above and 1 cm below the umbilicus. We performed LESS-DN using a laparoscopic system (GelPort, Applied Medical), followed by the insertion of one 12-mm trocar and two 10-mm trocars through the port. We used conventional laparoscopic instruments and a 30-degree angled camera system and followed the conventional steps of LDN to enter the abdomen. The left adrenal vein drained at the junction between the left renal vein and the IVC. Additionally, the lumber left gonadal vein and the left renal vein drained into the left IVC. We carefully dissected the left IVC and all tributaries. When we received notification that the recipient was ready, we proceeded with the extraction. The ureter was clipped and divided. Then, a 5-mm lumbar port was inserted, and the renal artery and the vein were cut with a powered vascular stapler (Echelon Flex, Ethicon). The graft was extracted via a retrieval bag after the 12-mm port was replaced with a 15-mm port. Finally, the GelPort apparatus was reinserted for hemostasis.³ The warm ischemia time was 2.5 minutes, and the operation time was 155 minutes (Figure 2).

Renal transplant was performed with good perfusion and immediate graft function. The donor had an uncomplicated postoperative course and was discharged in good condition 2 days after the operation. The recipient was discharged on posto-perative day 6 with normal renal function. Both donor and recipient remain alive with good renal function and without late surgical complications at 9 months.

The intrauterine development of the IVC occurs with the emergence and regression of the posterior cardinal, subcardinal, and supracardinal veins during the period from week 7 through week 10 of gestation.^7,8 The anomalous persistence of the right and left supracardinal veins results in IVC duplication.⁹ In a duplicated IVC, the common iliac veins fail to unite. There are 2 main types of duplicated IVC. In the most common variety, both IVC vessels ascend on either side of the abdominal aorta. The left-side vessel crosses anterior to the aorta at the level of the renal veins to join the right-side IVC.¹⁰

Anatomic variations can increase complications, operative time, and ischemia time and subsequently could affect the success rate of the surgical procedure.^9,11 Preoperative CT angiography is a reliable method for detection of arterial and venous anomalies.¹¹ Therefore, the venous phase of CT angiography is an essential step to determine the anatomy of the left renal vein tributaries.^7,12 Most bleeding during LDN occurs due to injury of tributaries of the left renal vein rather than injury to the vein itself. If there is a left-side IVC, then other anatomic variations should be suspected. Therefore, careful dissection and awareness of further venous variations are pertinent.⁷

Scrotal edema has been described in some cases of donor nephrectomy in patients with duplicated IVC.¹¹ Donors should be informed of this possible complication prior to surgery.

In donors with duplicated IVC, both open and laparoscopic approaches have been reported. Davari and colleagues described 2 cases of open nephrectomy in donors with left infrarenal duplicated IVC. In the first case, a left infrarenal IVC was removed due to complications by mild edema around the pelvis girdle and proximal left thigh that had persisted for 2 weeks. In the second case, the left renal vein was divided more proximally with a good short renal vein to preserve the continuity of the left IVC.⁵

Moreover, several laparoscopic approaches have been previously described. Christakis and colleagues have reported a conventional left-side LDN. Their patient presented with persistent painful left scrotal edema and associated bilateral hydroceles, which resulted in 2 emergency room visits.⁶ Additionally, successful retroperitoneoscopic and hand-assisted and laparoscopic approaches have been reported.^1,2,12

This report is the first to describe pure left LESS-DN in a donor with a duplicated IVC. The complete duplicated IVC was exposed, and the nephrectomy was performed safely. There were no complications due to the vascular anomaly.

Donors with anomalous venous anatomy can be safely offered LDN by surgeons with appropriate laparoscopic experience and access to adequate modern radiologic imaging, with a focus on venous phase CT angiography.

Volume: 21 Issue: 3 March 2023

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