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(a) Venous phase of contrast enhanced computed tomography scan and (b) multi planar reformation showing drainage of left renal vein directly into left common iliac vein. Inferior vena cava‑I, aorta‑ A, Left renal vein‑*, Left common iliac vein‑C b a
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Background: Evaluation of renal vascular variations is important in renal donors to avoid vascular complications during surgery. Venous variations, mainly resulting from the errors of the embryological development, are frequently observed.
Aim: This retrospective cross-sectional study aimed to investigate the renal vascular variants with multidetec...
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The gonadal veins, responsible for draining from the paired gonads (testes in males and ovaries in females), exhibit variations in anatomy. Traditionally, the right gonadal vein directs its drainage into the inferior vena cava, while the left gonadal vein typically connects to the left renal vein. However, in the case of a 45-year-old woman diagnos...
Citations
... The diagram showed that the prevalence of multiple RV was 7%, with a confidence interval of 6% to 9%. For the RV course variant, 64 studies were included (Figure 8) [3,7,15,18,[21][22][23][24][25][26][27]29,31,33,34,[37][38][39][41][42][43][44][45][46]49,50,53,[56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][72][73][74][75][76]78,79,81,82,[84][85][86][87][88][89][90][91][92]94,95,97,98]. For this second sample, the funnel plot graph showed an important asymmetry which presented a p value of 0.560, which is directly related to this asymmetry ( Figure 9, and the prevalence of the RV course variant was 5%, with a confidence interval of 4% to 5%. ...
... The most prominent compilation is hemorrhage [28,32,34,43,74,80,89]. On the other hand, ignorance of these variables can compromise or complicate surgery [30,31,101] and even cause injury to some of these vessels [26,33,83,88]. Various types of imaging, such as computed axial tomography (CAT) angiography [33,63,78], abdominal computed tomography (CT) with contrast [44][45][46]52,88], and multidetector computed tomography (MDCT) [24,31,50,57,63,64,93,102], have been recommended to study the different anatomical variations of RV. ...
Background: Variations in renal veins are quite common, and most people do not experience issues due to them. However, these variations are important for healthcare professionals, especially in surgical procedures and imaging studies, as precise knowledge of vascular anatomy is essential to avoid complications during medical interventions. The purpose of this study was to expose the frequency of anatomical variations in the renal vein (RV) and detail their relationship with the retroperitoneal and renal regions. Methods: A systematic search was conducted in the Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS databases from their inception until January 2024. Two authors independently carried out the search, study selection, and data extraction and assessed methodological quality using a quality assurance tool for anatomical studies (AQUA). Ultimately, consolidated prevalence was estimated using a random effects model. Results: In total, 91 studies meeting the eligibility criteria were identified. This study included 91 investigations with a total of 46,664 subjects; the meta-analysis encompassed 64 studies. The overall prevalence of multiple renal veins was 5%, with a confidence interval (CI) of 4% to 5%. The prevalence of the renal vein trajectory was 5%, with a CI of 4% to 5%. The prevalence of renal vein branching was 3%, with a CI of 0% to 6%. Lastly, the prevalence of unusual renal vein origin was 2%, with a CI of 1% to 4%. Conclusions: The analysis of these variants is crucial for both surgical clinical management and the treatment of patients with renal transplant and hemodialysis.
... The vast majority of studies describing anatomic variants of the abdominal para-aortic region have been performed on cadavers [20,[22][23][24][25]. There are very few studies of anatomic variants of this region performed with contrast-enhanced abdominal CT, which is a routine preoperative staging method [18,26,27], and even fewer studies of the frequency of surgically detected anatomic variants during para-aortic lymphadenectomy [17]. Our study compares a routine interpretation of abdominal CT by radiologists and correlation with intraoperatively detected vascular and urinary tract variants. ...
Background:
Para-aortic lymphadenectomy is an essential part of gynecologic oncologic surgical treatment. The surgeon should be aware of the complex usual anatomy and its common variants.
Methods:
Between January 2021 and May 2023, 58 women underwent para-aortic lymphadenectomy for gynecologic malignancies.
Results:
Vascular and urinary tract anatomic variants were retrospectively reviewed from the prospective institutional database and results were compared with preoperative contrast-enhanced abdominal CT. Of these 58 women, 47 women had no vascular or urinary tract variants. One woman had a double inferior vena cava, two patients were found to have a retro-aortic left renal vein, four had accessory renal arteries, two had a double left ureter, one had a ptotic kidney in the iliac fossa, and one patient had bilateral kidney malrotation. Anatomic variants in the preoperative CT were described by a radiologist in only two patients, and additional vascular and urinary tract variants were found incidentally at the time of surgery.
Conclusions:
Acknowledgment of vascular and urinary tract variants is helpful for the surgeon to establish an appropriate surgical plan and to avoid iatrogenic surgical trauma.
... 3. Potential implications of the retro-aortic path of this vein include difficulties during renal transplant as well as compression between the vertebral column and the aorta leading to a posterior nutcracker phenomenon or, if the patient is displaying symptoms such as renal vein hypertension, hematuria and low back pain, posterior nutcracker syndrome [12,[23][24][25][26][27][28][29]. ...
Several urogenital and vascular anomalies were associated with an 81-year-old female cadaver. During routine dissection, three extrarenal calyces, an accessory renal artery originating directly from the abdominal aorta, and a circumaortic renal vein were observed at the left renal hilum. The typical renal anatomical structures were identified at the hilum of the left kidney, from anterior to posterior, as the renal vein, renal artery, and ureter. Three extrarenal calyces exited the hilum of the left kidney and united to form the pelvis, then narrowed and became the ureter which descended 21.5 cm to empty into the bladder. The accessory renal artery originated from the lateral aspect of the abdominal aorta and was 7.3 cm below the left renal artery. A corresponding accessary renal vein, identified as a circumaortic vein, left the hilum 4.5 cm below the left renal vein and traveled posterior to the abdominal aorta to drain into the inferior vena cava.
... Pandya et al.,evaluated renal venous variants and found that duplication was the most common variant observed and that circumaortic venous variation of the left renal vein was more common than retro-aortic. 30 Although venous variations are important, the present study also evaluated common arterial variations, giving surgeons and interventionists a complete picture of the renal vasculature. ...
Background: Kidneys are a pair of retroperitoneal organs supplied by a single renal artery and vein. However, the classic illustration of the renal vasculature, formed by one renal artery and one renal vein, occurs in ≤25% of cases. MDCT angiography is presently the most preferred investigation for assessing prospective renal donors.
Aims and Objectives: This study aims to familiarize urologists with the variations found in the renal vascular system, emphasizing prevalence, the adequate, appropriate terms, and the clinical and surgical implications involved.
Materials and Methods: A cross-sectional study in 50 patients clinically indicated to undergo CT Renal angiographic study over 2 years is included in the study. This study was carried out to look for any anatomical variants in renal vasculature. CT examination was performed on a multidetector 16 slice CT Siemens scanner in the department of radiodiagnosis. Once conventional CT is done, the data obtained can produce 3D post-processing images that simulate conventional angiograms.
Results: Out of 50 patients, single renal arteries are present in 27, and multiple renal arteries are present in 23 patients. Out of 27 patients with single renal arteries, 22.2 % has perihilar arterial branching. The most common variant was accessory renal arteries, which are found in 56% of individuals, followed by aberrant renal arteries found in 30% of individuals. Double renal arteries are found in 8.7% and triple renal arteries in 4.3% of cases. Out of 50 patients, 48 patients have a single renal vein, whereas two patients have supernumerary veins. The present study found right renal vein duplication in only 2% of patients.
Conclusion: Renal arteries and veins show numerous variations in their origin sites, numbers, course, and division patterns. These variants exist in the population with high prevalence and are thus crucial in preoperative and intra-operative analysis for better prognosis and reduced complications. Preoperative CT evaluation of renal vasculature using MDCT angiography helps depict the presence or absence of renal arterial and venous variants.
... The incidence of supernumerary renal veins varies but is frequently seen more on the right side. 31 Our study revealed 16.1% of donors on the right side and 3.8% on the left side. During nephrectomy, the vein is sacrificed when venous drainage of the smaller vein is <20%. ...
Background and Purpose
Vascular multiplicity is the most frequent anatomic variation in kidney donors. Despite concerns about risks, these allografts are increasingly used to overcome the shortage of kidney donors. The safety and clinical outcomes in living kidney donors were evaluated with vascular multiplicity after hand-assisted laparoscopic living donor nephrectomy (HALDN).
Patients and Methods
Data from all living kidney donors who underwent HALDN from 2008 to 2021 was retrospectively reviewed. Patients were divided into two groups as single (SRV) and multiple renal vessels (MRV), and a comparative analysis was done. The primary outcomes include operating room time (ORT), days of hospital stay, estimated blood loss, complications, conversion, and re-operations.
Results
MRV were present in 166 out of 612 donors (27.1%). Among those, 10 (1.6%) donors had simultaneous multiple arteries and veins. Additionally, the prevalence of artery and vein multiplicity was 21.8% (n = 134) and 3.5% (n = 22), respectively. Warm ischemia time was significantly different among the two groups but not clinically important. The number of conversions to open technique, the mean ORT, the median blood loss, and days of hospital stay were similar between the SRV and MRV groups, without significant differences. According to the modified Clavien-classification system, no differences were found in the complication rates between the two groups (p = 0.29). Complication rates were 3.3% and 3.6% for the SRV and MRV groups, respectively.
Conclusion
HALDN is a procedure with safe intraoperative results, even with vascular multiplicity. The presence of multiple renal arteries or veins has no negative impact on the outcome of the donor after living donor nephrectomy.
... Right-sided renal vein abnormalities are reported more commonly than left-sided, perhaps because the inferior vena cava (IVC) is predominantly formed by right-sided embryological structures [24]. However, there is abundant variation attributed to the left renal vein, likely due to its complex embryological origin [34,41]. These left sided variations include a retroaortic vein, wherein a single renal vein travels posterior to the abdominal aorta, and an additional renal vein that travels anterior to the abdominal aorta to independently drains into the IVC [41]. ...
... Regardless of where the left gonadal vein drains, both scenarios include the circumaortic vein traveling posterior to the aorta to drain into the IVC. Potential implications of the retro-aortic path of this vein include difficulties during renal transplant as well as compression between the vertebral column and the aorta leading to a posterior nutcracker phenomenon or, if the patient is displaying symptoms such as renal vein hypertension, haematuria and low back pain, posterior nutcracker syndrome [6,12,15,28,32,34,38,43]. ...
The following urogenital and vascular anomalies were observed in the left kidney of an 81-year-old female cadaver during routine dissection: three extrarenal calyces; an accessory renal artery originating directly from the abdominal aorta; and a circumaortic renal vein. The typical renal anatomical structures were identified, from anterior to posterior, as the renal vein, renal artery, and ureter appearing near the hilum of the left kidney. After closer examination, three extrarenal calyces were observed exiting from the hilum of the left kidney to form the pelvis, then narrowed and became the ureter which descended 21.5 cm to empty into the bladder. The accessory renal artery originated from the lateral aspect of the abdominal aorta 7.3 cm below the aortic origin of the left renal artery. A corresponding accessary renal vein, identified as a circumaortic vein, left the hilum 4.5 cm below the left renal vein and traveled posterior to the abdominal aorta to drain into the inferior vena cava. Extrarenal calyces are rare among urogenital tract variations. They can be associated with embryological abnormalities such as renal ectopia, horseshoe kidney or malrotation as well as clinical manifestations such as pelviureteric junction obstruction and hydronephrosis. Compression of the accessory renal artery can cause decreased blood flow to the inferior pole of the left kidney, thereby causing fibrosis, atrophy, or renal failure. The retro-aortic path of the circumaortic renal vein has been associated with posterior nutcracker phenomenon, hematuria, left renal vein thrombus formation, and renal vein hypertension. This unique combination of a collecting system anomaly and extrarenal vessel variations could have significant implications in abdominal surgery.
... Data on renal veins previously published from India explained that variations in renal vein anatomy were common with retroaortic veins, circumaortic veins, and plexiform left renal veins being seen in 2.5%, 4%, and 0.5% of cases, respectively. [14] In this study, the most common renal vein anomaly noted was that of a preaortic vein (26.3%), followed by a circumaortic vein seen in 5.26% of cases. The renal vein length in studies from Chennai showed a mean length of 30.1 mm on the right side and a mean length of 70.1 on the left side. ...
Introduction: In countries without a well-developed deceased donor program, living donors form the backbone of the renal replacement strategy. Computed tomography (CT) angiography forms an integral part of the predonation evaluation. The course, number, and morphometric evaluation of the renal vasculature provided by CT angiography help to identify which kidney to harvest and which kidney to exclude from the donation. The characteristics of the Indian renal donor are a rarely studied topic with only a few studies on the same to date. Methodology: This is an observational study done over a period of 3 years noting the clinical and morphometric characteristics of the renal donors from a database. Results: In this study, 57 prospective living renal donors were included. Most donors were women. The length of the renal artery and renal vein was shorter in this cohort than in previously known statistics. The diameter of the renal vessels was also smaller than previous data. The left side kidney was more commonly harvested compared to the right. Conclusion: Renal angiographic morphometric data among the Indian population were different from previously known statistics. Angiographic data correlated well with intraoperative findings in the majority of patients.
... Renal vein variations are generally asymptomatic and frequently discovered incidentally (1,2). However, in some cases, increased venous pressure due to compression between the vertebrae and the aorta may cause symptoms, such as left side pain, hematuria, and proteinuria (3,4). It has also been reported that renal vein variations may be associated with left-sided varicoceles, pelvic congestion syndrome, dyspareunia, and dysmenorrhea (5,6). ...
Aim: The aim of this study was to investigate whether renal vein
variations had an effect on apparent diffusion coefficient (ADC)
values in diffusion magnetic resonance imaging (MRI).
Methods: Images of 958 patients who underwent MRI between
January 2017 and October 2018 were retrospectively evaluated
for renal vein variations based on the records obtained from the
image archive. Forty-six patients with renal vein variations and
thirty patients of similar age and gender as the control group
enrolled in the study. The ADC values of both kidneys were
measured at low-high b values.
Results: The ADC values in the left kidney were lower than in
the right kidney in both groups (2.04x10-3± 0.22x10-3 mm2/sec,
1.96x10-3±0.17x10-3 mm2/sec, for the renal vein variation group;
p=0.008 and 2.08x10-3±0.13x10-3 mm2/sec, 1.94x10-3±0.11x10-3
mm2/sec, for the control group; p=0.0001). However, no significant
difference was found between the renal vein variation and control
groups in terms of the ADC values in both kidneys.
Conclusion: Renal vein variations had no effect on renal ADC
values in asymptomatic patients. Further studies can provide
additional information for symptomatic patient groups.
Keywords: Renal vein variations, diffusion magnetic resonance
imaging, ADC
... The prevalence of multiple renal veins has been investigated in anatomical studies and by CT angiography [1][2][3][4][5]. In a metaanalysis of 105 studies, the mean incidence of multiple renal veins was 16.7% [1]. ...
As there is usually considerable overlap in the renal venous drainage, it is often possible to ligate supernumerary transplant renal veins in order to simplify the implantation procedure. Nonetheless, decisions about whether to implant multiple veins can be difficult and are usually made subjectively. Here, we describe the use of intraoperative Doppler ultrasound as an adjunct to decision-making when there are two renal veins and a novel technique for the sequential anastomosis of dual veins. The kidney was reperfused after anastomosis of the main renal vein with the second vein clamped. On-table Doppler ultrasound demonstrated reversed flow in diastole indicating that the second renal vein also needed to be anastomosed. By clamping the external iliac vein inferior to the first venous anastomosis it was possible to complete the lower polar renal vein anastomosis to the external iliac vein without interrupting the perfusion of the kidney.
... Renal vascular anomalies are rare, but if unexpected may represent an important concern in candidates for living kidney donation given its potential for donor and organ damage (vascular injury) in unexperienced hands. Hence, preoperative assessment of pertinent vascular anatomy by means of high resolution cross-sectional imaging is crucial to avoid potential complications, resulting advisable in every potential candidate to better select the most appropriate operation strategy [13]. ...
Introduction:
The extension of donor eligibility criteria represents one of the possible ways to increase the organ shortage, thus decreasing the waiting time for kidney transplantation. Expectedly, this strategy is associated with a growing number of more technically demanding living donor nephrectomy procedures requiring careful assessment, and sound surgical experience in order to avoid intraoperative complications.
Case presentation:
After a thorough evaluation through preoperative imaging, we performed a hand-assisted left laparoscopic living donor nephrectomy in a 56 year-old overweight patient with history of prior abdominal surgery, harboring a left-sided inferior vena cava (IVC).
Discussion/conclusion:
This case describes our comprehensive approach in this complex surgical scenario to preserve donor safety and provide an optimal kidney graft.
