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Kidney autotransplantation describes the procedure in which a kidney with anomalies is removed from its original place, repaired on the back table if necessary, and then transplanted in another location, usually the right or left iliac fossa. It is an alternative approach for the treatment of select renovascular, ureteral, and malignant pathologies.

The first reported case of kidney autotransplantation in humans was performed by Shackman and Dempster in 1961 to preserve the kidney function in a case of unilateral renal artery stenosis. Hardy reported the first case done for high ureteral injury in 1962. In 1971, R.Y. Calne was the first to report a case of autotransplantation after ex vivo partial nephrectomy for the treatment of carcinoma in a solitary kidney.

In the following decades, the procedure was popularized to manage renovascular malformations, since back table surgery provided superior exposure for complex reconstructions. This was especially so on the right side, where the renal artery runs behind the inferior vena cava (IVC) and renal vein.

At present, the use of the procedure remains limited due to the magnitude of the operation and recent advances in endourologic and endovascular procedures. However, it remains an appealing alternative option for treatment of select cases when these interventions are not feasible or have failed.


Vascular Pathology

Many vascular pathologies can be treated by endovascular interventions; however, autotransplantation with back table repair remains an option in cases not amenable to endovascular intervention or after failure of endovascular repair.

  • Renal artery disease: renal artery aneurysms, fibromuscular hypertrophy, renal artery stenosis, and dissection

  • Renal vein disease

The most common venous indication is the left renal vein entrapment syndrome (nutcracker syndrome). In 1950, El Sadr and Mina first described the nutcracker phenomenon; the left renal vein is compressed between the superior mesenteric artery (SMA) anteriorly and the aorta posteriorly due to a narrow acute angle resulting in venous compression, venous hypertension, varicosity, and kidney congestion.

Although uncommon, it is an important diagnosis due to the morbidity that may be associated with long-term compression, including chronic kidney disease, venous hypertension, and risk of renal vein thrombosis.

It is important to note that such anatomy does not always lead to clinical symptoms. Hence, the term should be limited to patients who present with the characteristic clinical signs and symptoms, specifically hematuria, proteinuria, flank pain, pelvic congestion in females, and varicoceles in males, alongside the diagnostic imaging. To diagnose nutcracker syndrome, the angle between the SMA and the abdominal aorta has to be less than 45 degrees when measured in the sagittal plane. The diagnosis is confirmed on imaging, including ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI).

Management is determined by symptom severity. Often, symptom resolution occurs following a conservative approach. ...

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