Blackwell Science, LtdOxford, UKBJUBJU International1464-410XBJU InternationalFebruary 2004

933

Mini-review Article
RENAL AUTOTRANSPLANTATION
C. WOTKOWICZ and J.A. LIBERTINO

The Department of Urology in the

Lahey Clinic has a considerable
Renal autotransplantation
reputation in the treatment of C. WOTKOWICZ and J.A. LIBERTINO
renovascular conditions, and this Division of Urology, The Lahey Clinic, Burlington, MA, USA
month they have produced a review Accepted for publication 18 July 2003
of renal autotransplantation. This
interesting, if infrequently used,
surgical technique is potentially BACKGROUND
useful to urologists in several
different situations. In 1963, J.D. Hardy completed the first renal
autotransplant when he repaired a high
ureteric injury by reimplanting the repaired
Intermittent androgen suppression
organ into the ipsilateral iliac fossa. Hardy’s
was introduced based on solid accomplishment was made possible thanks to
laboratory evidence, and has been allotransplantation techniques developed by
accepted by many as a way of Dr Murray and colleagues in Boston a decade
treating advanced prostate cancer. earlier. Managing renal disease via a ‘bench-
The authors from Vancouver, from work’ approach soon became a novel idea
the department where it was pursued worldwide by surgeons. In 1967, Ota
introduced, present a review on et al. [1] used this ex vivo approach to
reconstruct canine renal arteries, and in the
its use. same year successfully treated a 39-year-old
man with renovascular hypertension
Laser prostatectomy has gone secondary to renal artery stenosis (RAS) using
through interesting developments an autogenic saphenous vein autotransplant.
since it was introduced some years
ago. Many techniques and types of In the following decade many groups used
laser have come and gone, after and improved these techniques. In 1970,
Belzer et al. [2] described pulsatile renal
initial excitement, but some have
perfusion techniques in canine models, and
lasted the course. The author from 4 years later the group successfully treated
New York, who has extensive bilateral RAS with splenic, iliac and
experience in this area, has written hypogastric arterial grafts. The following year
an interesting review on the Husberg et al. [3] used ex vivo techniques to
subject. excise a RCC and repair a paediatric ureteric
and vascular anomaly. By 1975, Putnam et al.
The work of the Department of [4] were using this technique to remove
staghorn calculi.
Urology in Bern relating to ileal
orthotopic bladder substitution is By 1990, Novick et al. [5] reported a
well known, and their technique 90% clinical improvement rate using
has been presented in last month’s extracorporeal renal artery reconstructions. In
Surgery Illustrated Section in this 1985, Jordan et al. [6] reported their success
Journal. Here they present a review in 16 children with renovascular disease.
of the postoperative management Renal artery occlusive disease is second only
of such patients. to aortic coarctation in terms of surgically
amenable hypertension in children.
From a technical perspective the ability to
create a common renal artery from several
anomalous arteries, as first described
during the 1970s, has increased ex vivo
reconstruction attempts and renal
transplants. These advances are particularly
important as multiple renal arteries occur
unilaterally in 23% and bilaterally in 10% of
the population. The clinical performance of
these allografts was compared with single
renal artery transplants by Novick et al. [7],
who found equivalent integrity between both
conduits. These advances, complemented
by three-dimensional (3D) radiographic
reconstructions of the renal parenchyma and
vasculature, have minimized unexpected
intraoperative findings during harvesting.
The guidelines for renal artery reconstruction
(RAR) according to Brayman et al. [8] suggest
performing ‘bench surgery’ if the ischaemic
time will be >45 min. In cases where distal
vascular dissection and fine microvascular
repair are necessary, ‘bench work’ is
recommended for better exposure.
Renovascular disease refractory to
percutaneous treatment may necessitate
ex situ repair, as may failing in situ grafts.
Additional indications include stenotic
disease of distal renal arteries, intrarenal
aneurysms, arteriovenous malformations
and significant multivessel disease. Other
circumstances that benefit from this
technique include ureteric injury and
extensive calculous disease refractory to
conservative and medical treatments. Renal
malignancies may be treated depending on
the anatomical location of the lesion and the
clinical history of the patient, most adult
candidates having a solitary kidney. Most

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C. WOTKOWICZ and J.A. LIBERTINO
renal masses may be excised in situ thanks
to refinements in surgical approach and
imaging. The role of extracorporeal partial
nephrectomy has since become very limited,
but must remain an option for reserved
circumstances.
Preserving renal function during periods of
ischaemia has been extended using various
hypothermic perfusates. For procedures of up
to 3 h, the choice is heparinized saline or
hyperosmolar solutions, as formulated by
Sacks et al. [9]. Hypothermic pulsatile
perfusion with EuroCollins or University of
Wisconsin solutions to flush the renal vein
clear is advantageous for cases of >4 h. These
solutions provide an external isotonic milieu
that minimizes membrane transport
metabolism. The concentrations of heparin
(5000 units) and mannitol (12.5 g) found in
preserving solutions help to prevent graft
thrombosis, the commonest complication
in renal transplantation. Hypothermic
perfusates also shrink renal parenchyma to
better expose the distal vasculature [7].
Advances in microsurgery have enhanced the
size and types of grafts used during RAR. By
incorporating the strength of the microscope
within loupes, the surgeon is now able to
use suture material (up to 10/0) and fine
instruments to manage micro-vesicular
lesions. The location of the diseased arterial
segment is crucial in determining the
feasibility of ex vivo RAR. The advantages
of extracorporeal repair include optimal
exposure, a bloodless surgical field and facile
dissection. Vascular patency can also be
interrogated before reimplanting the repaired
kidney.
RADIOLOGY AND
RENOVASCULAR DISEASE
Although a renovascular cause accounts for
1–5% of the estimated 40 million people with
hypertension in the USA, proper selection for
surgical management has provided relief in
most patients studied. Much of this success
can be attributed to developing techniques
which detect renovascular disease at
morphological and functional levels.
Angiography remains the reference standard
for the diagnosis of renal artery disease, while
3D CT reconstructions have been beneficial in
evaluating disease of the renal parenchyma.
Recent work by Endo et al. [10] showed the
versatility of 3D reconstructed rotational
digital subtraction angiography images, a
254
technique previously developed by
neuroradiologists to evaluate cerebral
aneurysms and carotid artery stenosis. The
technique provides an assessment of vessels
as distal as the interlobar and arcuate arteries.
Pharmacologically echo-enhanced duplex
Doppler ultrasonography provides accurate
detection of RAS with a sensitivity and
specificity of 83–87% and 81–91%,
respectively [11]. Selective renal digital
subtraction angiography is better than
conventional methods for evaluating patients
with renal impairment because less contrast
medium is required.
Functional investigations like colour-duplex
ultrasonography, divided renal-vein renin
sampling, radioisotope renography, 99mTc-
DPTA and -MAG3 scans can be used to
evaluate the potential for benefit in patients
with hypertension and/or ischaemia
associated with RAS. For those patients with
minimal renal function secondary to chronic
changes, a nephrectomy or interventional
arterial embolization may be most prudent.
The convenience of imaging techniques has
resulted in increased ‘incidental’ findings of
RAS. According to Sorcini et al. [12] significant
RAS (>50%) has been found in 20–29% of
patients undergoing abdominal aortography
to evaluate coronary disease. Additional
epidemiological studies indicate similar
correlations between RAS and abdominal
aortic aneurysms, aorto-iliac occlusive disease
and peripheral vascular disease. Therefore,
given the high prevalence of aorto-iliac
atherosclerosis in the vasculopathic
population, radiologists should assess
the iliac vessels for disease, given their
potential as anastomotic sites in renal
autotransplantation. The hypogastric artery
with its accompanying branches should also
be evaluated as a graft source for multivessel
repair.
CLINICAL EXPERIENCE WITH
RENAL AUTOTRANSPLANTATION
Since our centre began repairing renovascular
disease with ex vivo techniques, 25
patients have been selected for renal
autotransplantation because of renovascular
lesions (six male, seven female), RCC (four
male, one female) ureteric complexities (two
male, three female) and arteriovenous
malformations (AVMs, one each). Twenty-five
operations were completed, requiring three
nephrectomies for complications after
surgery, i.e. two for vascular compromise and
one secondary to infection. Two kidneys were
not reimplanted after explantation because of
the extent of the vascular and oncological
disease. One patient underwent bilateral renal
autotransplantations for RAS. Although not
included, numerous allotransplants have been
conducted by our transplant service after
surgically repairing damaged or multiple renal
arteries.
RENOVASCULAR DISEASE
The stimulus for evaluating the renal
vasculature within the hypertensive
population was provided in the early 1930s
when Goldblatt [13] induced systemic
hypertension with his ‘clip models’ of the
canine renal artery. His work produced three
models of hypertension: (i) a one-clip, one-
kidney model; (ii) a one-clip, two-kidney
model; and (iii) a two-clip, two-kidney model.
The two ‘two-kidney’ models show renal
hypertension caused by the renin-angiotensin
system control of sodium and volume status.
According to Goldblatt, the relief of RAS may
alleviate hypertension when done in a timely
fashion, but chronic stenosis induces
secondary nephrosclerotic changes and
ischaemic atrophy [13]. These end-organ
changes are not surgically correctable, and in
many cases may necessitate a nephrectomy.
Ram et al. [14] found that kidney size
correlates inversely with renal function after
intervention, where kidneys of <8 cm long
derive limited benefit from surgery.
The management of renovascular
hypertension must account for the degree of
hypertension attributable to the renal system.
Medications may alleviate hypertension in
certain circumstances, but their use is more
effective before and after surgery. The chronic
use of angiotensin-converting enzyme
inhibitors and angiotensin-II receptor
antagonists causes a deterioration in function
in ischaemic kidneys via a dose-dependent
reduction in GFR. The percutaneous
management of renal lesions has been
practised since 1978, when Gruntzig et al. [15]
first used the technique. Indeed, both
percutaneous transluminal renal angioplasty
and stenting have increased in prevalence as a
primary alternative to surgical correction,
giving great advances in interventional
radiology. These techniques have created a
highly selected group of patients requiring ex
© 2004 BJU INTERNATIONAL

FIG. 1. A preoperative right renal angiogram (left) and optimum exposure of diseased vessels provided by the
ex vivo technique (right).
FIG. 2. The initial aortic angiogram showed pooling of contrast material (left). Selective angiographic studies
after surgery of the iliac vessels showed improved flow to the distal parenchyma of the right kidney (right).
vivo surgery to treat renovascular
hypertension in our clinical experience.
Renal artery aneurysms (RAAs) are amenable
to percutaneous approaches and in situ
repairs, depending on their location.
Interestingly, observation alone may also be
suitable. However, with increasing size, the
threat of rupture, haemorrhage and infarction
increases with no signs or symptoms.
Aneurysms may erode into nearby veins
forming fistulae, and these communications
may progress to giant AVMs, which are often
repaired via embolization or nephrectomy.
Their causes include: congenital
abnormalities, RAAs, iatrogenic injury after
biopsy, nephrostomy tube placement,
nephrectomy, renal-vein erosion by malignant
tumours, penetrating or blunt abdominal
trauma and fibromuscular dysplasia.
© 2004 BJU INTERNATIONAL
Two patients exemplifying the use of
renovascular surgery are discussed. The first
was a 39-year-old woman with bilateral RAS
and aneurysms. Given her age and gender,
this prototypical presentation of early-
onset hypertension is easily attributed to
fibromuscular dysplasia, as first described by
Leadbetter and Burkland [16]. The right kidney
was removed, two aneurysms repaired and
the reconstructed kidney reimplanted into the
left iliac fossa. (Fig. 1) Four months later the
left renal artery was repaired in situ using a
saphenous vein autograft. Four years later, a
RAA in the upper pole branch of the native
left kidney was treated with percutaneous
embolization. Her follow-up has been without
complications.
The second patient was an elderly man,
referred to our clinic for evaluation of a
RENAL AUTOTRANSPLANTATION
significant right renal AVM. An aortic
angiogram showed pooling of contrast
material within the boundaries of the right
kidney (Fig. 2). Subsequently, the diseased
kidney was explanted, the AVM explored,
and the arterial inlet redirected with no
autografting. An ipsilateral reimplantation
was then completed, and subsequent digital
subtraction studies showed a marked
improvement in the distal parenchymal
perfusion (Fig. 2). Although frequently
reported, AVMs are rarely repaired in this way,
given the complexity of the disorder; instead,
most surgeons resort to nephrectomy.
RENAL CELL CANCER AND
AUTOTRANSPLANTATION
The surgical management of tumours
in solitary kidneys and bilateral renal
tumours is a controversial topic in urological
oncology. Conservative surgical procedures,
such as in situ excision and extracorporeal
‘bench surgery’ with subsequent
autotransplantation, are viable alternatives to
radical nephrectomy, which necessitates
chronic dialysis and allotransplantation with
chronic immunosuppression. The approach is
reserved for patients with a solitary kidney or
those cases where preserving renal function
may be compromised if one of two kidneys
were removed. There are numerous successful
case reports citing autotransplantation to
treat renal malignancies. However, there are
relatively few such patients, as the location
and degree of lesion invasion must be
anatomically compatible with atraumatic
nephrectomy, extracorporeal instrumentation
and reimplantation. Van der Velden et al. [17]
discussed their clinical experience with
extracorporeal surgery in the management of
six patients with RCC in solitary kidneys. They
reported one postoperative death from a
gastrointestinal bleed and that the five
remaining patients were dialysis-free at a
mean of 54 months. Ex vivo surgery allows
maximum parenchymal preservation and
limits tumour seeding.
In treating Wilms’ tumours, the paediatric
oncologist now focuses on parenchymal
preservation, aiming to delay chronic
dialysis and allotransplant-associated
immunosuppression. A report by Desai et al.
[18] discussed the successful management
of three patients using extracorporeal
techniques.
255
C. WOTKOWICZ and J.A. LIBERTINO

The common technique for excising renal FIG. 3.

lesions, as described by Novick et al. [19], A 3D CT image reconstruction
begins with a nephrectomy followed by showing a centrally necrotic,
removal of Gerota’s fascia. Next, the kidney is peripherally enhancing,
flushed with hypothermic perfusate, wrapped hypovascular tumour in the
in gauze and placed in a basin of hypothermic anterolateral aspect of a solitary
solution. After hilar dissection the vascular right kidney.
access to the neoplasm is ligated. The tumour
is then excised centripetally, preserving a 2-cm
disease-free margin. Confirmatory pathology
is completed via frozen-section analysis when
necessary. Transected vessels and collecting
duct components are securely ligated and the
renal parenchyma approximated. Pulsatile
perfusion is used to assess the vascular
integrity before reimplantation.

A 65-year-old man was found to have a mass

in a solitary kidney during ultrasonography
for scrotal pain. Reconstructed 3D CT images
showed a mass centrally located along the
FIG. 4. Intra-operative images after explanting the mass in Fig. 3. On the left the mass is being excised in a
periphery of the kidney (Fig. 3). On further
basin of hypothermic perfusate. The images on the right depict the clean margins obtainable with the use of
questioning the patient acknowledged a
extracorporeal surgery.
1-year history of right flank discomfort
but denied haematuria or constitutional
symptoms. The kidney was explanted and an
estimated half of the renal cortex excised
before reimplantation (Fig. 4). The mass was
clear cell in origin and Furman Grade 2
(moderate). His postoperative course was
without complication.

MANAGING URETERIC COMPLICATIONS

Renal autotransplantation should be

considered in patients with extensive ureteric
disease and in selected patients for whom
urinary undiversion is not an option. The
causes of ureteric obstruction are numerous, Patient Age/sex Disease Bilateral TABLE 1
and in our patients tend to be refractory to 1 44/M RAS/RAA Yes/Yes Characteristics of renal
stent management. Left untreated, urinary 2 38/M RAS/RAA Yes/No autotransplantation
stasis and hydronephrosis increase the risk 3 42/F RAA No patients
of infection, stone formation and renal 4 42/F RAA Yes
failure. In our clinical experience, 40% of 5 25/F RAS No
autotransplanted kidneys required removal 6 40/F RAA No
secondary to postoperative infection at the 7 39/F RAA Yes
site of ureteric anastomosis. 8 47/M RAS/RAA Yes/Yes
9 38/M RAS/RAA* Yes/Yes
A 35-year-old women with Crohn’s disease 10 16/M RAS No
underwent a colectomy complicated by 11 54/M RAS/RAA Yes/No
inflammation and scarring of the ureter. After 12 60/F RAS Yes *bilateral renal
the colectomy she underwent numerous 13 53/F RAA No autotransplants.
exploratory laparotomies, one of which
revealed a 3-cm narrowing of the right ureter
in the sacral area. At that time, a stent and
percutaneous nephrostomy tubes were placed perinephric and peri-ureteric fluid collections. immediately after surgery were unremarkable,
followed by ureterolysis with omental The kidney was removed and the repaired but the patient subsequently developed an
wrapping. Follow-up CT suggested persistent kidney reimplanted into the left iliac fossa infection at the anastomosis site, requiring
stenosis, as shown by hydronephrosis with with a pyelovesicostomy. Imaging studies transplant nephrectomy. Complications were

256 © 2004 BJU INTERNATIONAL


secondary to nephrostomy tubes injuring the
vascular suture lines with subsequent
haemorrhage. Although our success in
managing ureteric obstruction by
autotransplantation is limited, these cases
show the potential utility of the technique.
CALCULOUS DISEASE
Although not part of our population,
patients with recurrent nephrolithiasis
refractory to surgical management may
benefit greatly from autotransplantation and
pyelovesicostomy. This approach combined
with a Boari flap is recommended to prevent
reflux and allow passage of stones into the
bladder [20]. Novick et al. [21] cite the
following indications for autotransplantation:
recurrent nephrolithiasis of the renal pelvis or
ureter; recurrent staghorn calculus; coexisting
staghorn calculus and renovascular disease;
complications secondary to stone surgery;
recurrent renal colic; and calculi associated
with congenital renal anomalies. Current
advances in endourology have even further
limited the practicality of autotransplantation.
ALTERNATIVE TECHNIQUES
All patients in this review underwent ex vivo
‘bench repair’ and iliac fossa reimplantation,
but renovascular complications can be
managed without complete nephrectomy. In
this way renal arteries may be isolated and
reconstructed while maintaining venous and
ureteric competency. This technique involves
end-to-end arterial anastomoses that have
a greater tendency to stenose than do
end-to-side anastomoses created when
anastomosing into iliac vessels. However,
these techniques eliminate the chance of
developing a ureteric stricture at the site of
the ureteroneocystostomy as the integrity of
the collecting system is maintained. Other
methods of restoring urinary continuity
include ureteropyelostomy and
pyelovesicostomy.
CONCLUSIONS
Through advances in microvascular
techniques and renal preservation
solutions, extracorporeal surgery with
autotransplantation has broadened treatable
renal disease, ranging from multiple artery
reconstructions to complex oncology cases.
Although these advances have improved
outcomes using this technique, the procedure
itself remains a last resort because of the
© 2004 BJU INTERNATIONAL
widespread use of interventional radiology
and in situ graft repair. In our centre, 21 of 24
extracorporeal renal autotransplantations
were successful. For selected patients for
whom extracorporeal renal surgery is an
option, we feel that this technique provides a
better alternative than chronic renal dialysis
and/or the associated risks of renal
allotransplantation.
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RENAL AUTOTRANSPLANTATION
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Correspondence: C. Wotkowicz, Lahey
Clinic, 41 Mall Road, Burlington, MA 01805,
USA.
e-mail: Chad.Wotkowicz@umassmed.edu
Abbreviations: RAA, renal artery aneurysm;
RAS, renal artery stenosis; RAR, renal artery
reconstruction; 3D, three-dimensional; AVM,
arteriovenous malformation.
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