Patient position and technical steps for laparoscopic radical nephrectomy (LRN) are well known, as well as the importance of knowing each patients' renal hilum anatomy. However, anatomical variants often pose surgical challenges, and innovative technical modifications may be required.
Thus, we present a transperitoneal LRN we performed with patient positioned in a moderate Trendelenburg, in order to address an ectopic pelvic kidney with five main vessels.
A 76-year-old man presented with a computed tomography (CT) scan reporting an incidental finding of a right pelvic kidney with anterior hilum rotation and several vascular variants: two renal arteries (RA) arising from the aorta (Ao), below the inferior mesenteric artery emergence; and two renal veins (RV), the most cephalic draining to the inferior vena cava (IVC) at L2 level, and the second with an anteromedial path along the kidney, but then contouring it, becoming posterior, and crossing between the common iliac arteries (IA), draining to the IVC immediately before the iliac bifurcation, at L5 level.
Since there was a 6 cm lesion suspicious for renal cell carcinoma (RCC), a LRN was proposed.
Patient was positioned in a moderate Trendelenburg. After placing two 10 mm and two 5 mm trocars in lower abdominal quadrants (AQ), we added three 5 mm trocars in the superior AQ, to assist surgical exposition. We isolated and ligated with Hem-O-Lok five main vessels – three RA arising from: right common IA, Ao near iliac bifurcation, and another superior aortic branch; and two RV: an inferior one apparently draining to the right common iliac vein, and a cephalic vein, running in parallel with duodenum, draining superiorly to the IVC.
Operative time was 3 hours. There were no complications. The drain was removed after two days, and the patient was discharged home on the third day postoperatively. Hemoglobin slightly decreased from 14.6 g/dl to 11.9 g/dl. The histopathologic examination revealed an 808 g surgical specimen, 8.8*8.0*6.5 cm kidney, with 7.0*6.0*4.5 cm clear cell RCC, in the middle and inferior pole, G3 pT3aNxR0, with focal invasion of hilar and perirenal fat. There was also vascular invasion.
In conclusion, this was a challenging but successful surgery, using only standard laparoscopic material. Robot-assistance or CT-scan 3D reconstruction might have been helpful, if available, but we showed these are not essential.
We emphasize the relevance of always keeping fascial plane dissection, respecting tissues' anatomical differences that are present, even in extreme variants as in this case, in which we had to perform a LRN in an unconventional position. To know our patient's anatomy is crucial. We cannot completely rely on radiological imaging reports and we must always study the case, be careful, stay alert and expect the unexpected.
Trendelenburg position seems to be a suitable approach for laparoscopic surgery in pelvic kidneys, in which we may have to adapt the classical described techniques to best suit our patients' particular anatomy.