| Background Laparoscopic technique in urology surgery has been widely used. The thought of pursuing "minimum injury and the best curative effect" develops throughout medicine history. In1980s, due to the emergence of laparoscopic urology surgery, the traditional open surgery is gradually replaced by laparoscopic surgery. Statistically speaking, of all the urological surgical cases which need surgical treatment, only less than10of them must rely on traditional open surgery while the rest cases can achieve the same effect of traditional open surgery but by way of minimally invasive surgery.At present, the application of laparoscopy in renal disease is particularly remarkable, of which includes radical nephrectomy, duplicated partial nephrectomy with ureterectomy, partial nephrectomy, renal pedicle lymphatic disconnection, Anderson-Hynespyeloplasty living related renal donorsnephrectomy, ectopical nephrectomy, renal cyst unroofing, nephroptosis nephropexy. But the renal vascular variations are quite common. For instance, most of the accessory branching which enters the renal up and down poles dominates up segment or down of kidney. Where, the inherent renal arteries up and down segments may be absent or distributed repeatedly, Thus, sufficient understanding of the anatomy variations could avoid false ligature, cutting, leakage ligature and intraoperative bleeding. Take laparoscopic donars nephrectomy for instance. It is good to know variant renal arteries dissect to the aorta initial ostium,which not only can ensure that the length of the vessels, but also protect the arterial suppliment of renal parenchyma. This is different of up and lower pole of renal ectopic arteries, In which case ectopic renal vein don’t need to keep when, However, if the abnormal. In addition, duplicated arteries or small ectopical vein before transplanting should be. therefore, preoperative fully realize renal vascular anatomy, which is significance for enhancing success rate of operation. Renal artery anatomy variation include renal arteries branch before renal hilum and renal arteries accessory branching from aorta abdominalis, superior mesenteric artery, arteria iliaca communis. In general, diameter of branch into the renal hilum and renal artery trunk is close to each other, while that of the branches to upper and lower polars were generally slim. It’s confimed that renal artery accessory branches are more common in the left, accessory arteries could accompany with renal vascural into the renal hilum or directly into the upper and lower pole renal parenchyma. Pollak et al studies four hundred cadavers, and800kidneys are available for study. Single renal arteries are found in72percent of the kidneys, with the rest multiple arteries. The renal veins showed a more uniform anatomical pattern and out of which92percent are single. Halpern EJ et al was compared computed tomographic (CT) angiography and magnetic resonance (MR) angiography for preoperative evaluation of living renal donors. By averaging data for both modalities, supernumerary arteries were present in49%of kidney donors and were bilateral in approximately17%. Domestic, Gong et al studied kidney vasular with computer tomographic angiography and get renal anatomical variants were noted in51.4%of patients and proximal arterial branches were found in56.7%, accessory renal arteries were found in36.1%. According to reported,incidence rate of duplicated renal veins was11-20%, that was lower than duplicated renal arteries, and couldn’t accompany with renal arteries.Renal vein duplication abnormality often happened in right of what. In the left, anormalous pattern of renal veins include retroaortic (1.7-3.4%) and circumaortic renal veins (2.4-8.7%). Circumaortic renal vein is also named as renal collar, left renal vein bifurcated. The two branches passed behind the aorta, one tributary continued behind the aorta, and the other traveled before the aorta and drainage kidney blood. A study of1008cases revealed that retro-aortic left renal veins were present in0.5%of cases and additional renal veins in0.4%of cases.In the past, the kidney and peripheral vascular anatomic research mainly is autopsy. Now, There exist a lot of renal vascular imageology detection method, noninvasive methods mainly include MRA, vascular ultrasound and CTA, and so on. MRA could clearly display renal artery, part branching and accessory renal artery, but MRA spatial resolution is not high enough, and has some limitation to show renal arteries branch and accessory renal arteries, which also takes a long time, and also confined to some comtraindication. Vascular ultrasound images is not intuitive enough, What is worse, too many variations exist in this method, and there are too many factors influencing the success of detection, which makes the results not reliable.Multi-spiral three dimentional computed tomography angiography is such vascular imaging technology that after intravenous injected the contrast agent, Using spiral CT on target blood vessels scanning continuous uninterrupted thin layer three-dimensional volume at the level of client level, then does image post-processing with computer, maked target vessel stereo display vascular imaging technology finally.The main advantage of CTA is that three dimensional display vascular anatomy and variation, allowed three dimensional reconstruction images and measurements and the results are objective, intuitive, clearly display the renal vascular branching, walk the line, and its positional relationship with the kidney. As reported in the literature, CTA renal artery variation sensitivity approaches100%. CTA is not only time high resolution, but also acquisition isotropic volume data, and the operation was simple, minimally invasive, technology took short and complication rate was low, easy to accept patients with advantages. CTA was not only high time-resolution, and acquired isotropic volume data together with its less invasive technique, quicker time, lower complication rate, patients easily accept other advantages.Rankin thought that CT angiography was a non-invasive method of visualising the vascular system and in some instances could replace conventional angiography.Picus, D.study the use of helical CT angiography for examination of living renal donors. Pozniak had confimed that CT angiography was performed in205potential renal donors. Correlation with surgical findings in136donor nephrectomies helped confirm a high level of accuracy for CT angiography in the assessment of the renal vasculature:Sensitivity and specificity for identifying specific vessels was99.6%and99.6%for main renal arteries,76.9%and89.9%for polar arteries, and98.7%and95.5%for main renal veins, respectively. CT angiography allows the radiologist to provide the transplant surgeon with precise preoperative anatomy of the renal vasculature, thus reducing the risks and complications associated with the harvesting procedure and improving the chances for a successful outcomeAt present, CTA has been used for preoperative examination in order to understand renal vascular anatomy,which can help the surgeon to forecast operation difficulty, guided laparoscopic surgery, in foreign hospitals. Especially in the transplantation of laparoscopic donor nephrectomy, preoperative, CTA could help clarify renal vascular anatomy for donor preoperative evaluation. Due to late initiation time, high cost of CTA, reports now in China are focused on imaging anatomy. However, large sample of cases and corresponding literatures are lack in comparing CTA examination with laparoscopic surgical procedures.Our hospital imported SOMATOM Definition dual-source CT scanner from Germany siemems company to equip syngo post-processing workstation. The tool of enhancement scan uses high pressure syringe from binocular high pressure injector which made in American MED RAD company. The main features are that they have perfective imaging function for coronary, chest vascular, renal vascular, lower limb vascular, and has a very high temporal resolution and space resolution, and It is an advanced imaging inspection equipment all over the country and the world, which could be used to complete CTA inspection.The purpose of this study is to make use of the advantage of CTA which could display three-dimensional vascular anatomy and variants, and the application of our hospital existing equipment and resources, further familiarize with renal vascular anatomy and variations through retrospective analysis of clinical practice, research, and explore its own regular pattern combined with previous research, and judge the practical value of the CTA examination in guiding laparoscopic surgery.Objective1. Use64-slice spiral CT angiography (using single source model of dual-source computer tomographic angiography and its post-processing softwore), to explore the type of renal vascular anatomic variations, and to find what is directive to the clinical application of regular pattern.2. Based on previous researches, to evaluated the clinical application of CT Angiography in laparoscopic partial nephrectomy and laparoscopic living donor nephrectomy. To recommend simultaneous display of MSCTU and MSCTA to explicit the relation of abnormal vessel of kidney and urinary tract obstruction.Methods1. A hundred cases of abdominal diseases with CTA cases data were analysed retrospectively, and to eliminate renal artery stenosis, side kidney congenital and acquired and lack of such as renal transplanting patients.2. Syngo CT workplace processing system for three-dimensional imaging technology (3D) was used to clarify renal arteriovenous anatomical variation, and to measure the length, diameter of normal and abnormal renal arteries and renal vein.3. Various type and measurement results were statistically analyzed.4. based onprivious study, combined image anatomy and clinic was discussed.Results1. Abnormal renal artery of cases and the number of kidneys accounted for42%and24.5%respectively. The proximal arterial branch(category I) divided into category la, I b, I c. The propotion of three morphological variation to proximal arterial branch was category I a,30.61%(15/49), I b,14.29%(7/49) and I c,2.04% (1/49). So the propotion of morphological variation to the total variations was11.5%(23/200). Category Ⅱa, Ⅱb and Ⅱc of the renal artery variation of total variance were28.57%(14/49),12.24%(6/49) and2.04%(1/49); catagory Ⅱrenal artery to total variance42.86%(21/49), of the total number of kidney10.5%(21/200). Category III renal artery of the total variance was6.12%(3/49), of the total number of kidney1.5%(3/200). Category IVof abnormal renal artery to total variance was4.08%(2/49), of the total number of kidney was1%(2/200). With no significant difference of the rate of renal artery variation between bilateral kidneys and the genders(P>0.05). Renal vein variation of cases and the number of kidney accounted for5%and2.5%, respectively.2. The mean (±SD) renal arteries length for left renal artery and right renal artery was4.54±1.48cm and4.96±1.58cm, respectively (P=0.17). The mean (±SD) renal arteries diameter was0.78±0.14cm for left renal artery and0.74±0.16cm for right renal artery, respectively (P=0.23). The mean (±SD) renal vein diameter for left renal vein and right renal vein was1.18±0.42cm and1.16±0.29cm, respectively (P=0.15). Significant difference exists between left renal vein length7.92±1.95cm and3.37±1.64cm right renal length (P<0.05). For male, the mean (±SD) renal arteries length for left renal artery and right renalartery was4.90±1.39cm and5.53±1.61cm, respectively (P=0.11). The mean (±SD) renal arteries diameter was0.83±0.16cm for left renal artery and0.79±0.14cm for right renal artery, respectively (P=0.37). The mean (±SD)renal vein diameter for left renal vein and right renal vein was1.04±0.38cm and1.11±0.27cm,respectively (P=0.43). Significant difference exists between left renal vein length8.80±2.07cm and3.80±1.73cm right renal length (P<0.05). For female, the mean (±SD) renal arteries length for left renal artery and rightrenal artery was4.29±1.50cm and4.60±1.48cm, respectively (P=0.32). The mean (±SD) renal arteries diameter was0.76±0.12cm for left renal artery and0.73±0.16cm for right renal artery, respectively (P=0.051). The mean (±SD) renal vein diameter for left renal vein and right renal vein was1.28±0.44cm and1.21±0.30cm, respectively (P=0.36). Significant difference exists between left renal vein length7.31±1.63cm and3.10±1.54cm right renal length (P<0.05). Between genders, no significant differernces existed among left renal artery length (P=0.073), right renal vein length(P=0.074) and diameter(P=0.143). And significant differernces in left renal artery diameter, left renal vein length and diameter, right renal artery length and diameter(p<0.05). The morphometry of anomal renal arteries were lengths (cm) of prehilar branching and accessory renal arteries3.05±1.48and5.50±2.66, diameters0.39±0.13and0.36±0.14. There was no statistical difference was in Bilateral renal artery (P=0.32).3.(1) Renal artery ranged from T12to L3vertebrae.(2) Renal artery trunk which ranged from in L1-L2intervertebral disc level accounted for47.8%(108/226). of which the left:23.0%(52/226). the right:24.8%(56/226). Normal renal artery, In normal renal arteries, renal artery which sat between L1-L2intervertebral disc level accounted for49.7%(74/149), and in abnormal renal arteries, it accounted for47.2%(34/72). There was significant difference between them (P<0.05).(3) In the patients of normal arteries, renal artery which was in the range of L1-L2vertebral body accounted for91.95%(137/149). In abnormal arteries, it accounted for94.4%(68/72). There was significant differernce between them.(4) Most of Suprarenal artery which from the trunk generate upper the tunk of renal arteries was92.0%(23/25)(in L1/L2between and above).(5) Take L1-L2vertebral body as the line, there was significant differernce between the opening postion of abdominal aorta of accessory renal artery and that of the main one (P<0.05).Conclusion1.64-slice spiral CT Angiography could directly,accurately show the original, number of mutate renal arteriovenous anatomical, and the relation between normal and abnormal. Renal arteriovenous variation is not rare, and its performance in a variety of forms. Categoried rutine renal vessel, preoperative laparoscopic surgery,would be good for doctor’s thought.2.64-slice spiral CT Angiography could acculatly measure the length and diameter of renal arteries and veins, which would benefit future scientific research,for instance medical equipment, et al.3. for the patient with accessory renal artery, if the main renal artery and accessory one are both higher than L1/L2intervertebral disc, the opening position of accessory renal artery at the abdominal aorta is much higher than that of the main one, which is good for estimating intraoperatively the renal artery position for the uriologic surgery.4. From the part of renal artery opening diameter, wheather exist accessory renal arteries can’t influence renal blood perfusion. But for renal artery is the characteristic segment distribution, the surgery should reserve the accessory renal artery.5. As the invention and implication of new technologies of imaging,such as the detailed3-D video road map, and the innovation use of simultaneous display of MSCTU and MSCTA. They would promote the development of minimally invasive surgery of urology,especially laparoscopic operation. |
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