The Clinical Anatomy Of Renal Artery Localization In Transperitoneal Laparoscopic Surgery For Renal Tumor

BackgroundRenal tumor is one of the most common tumors of the urinary organs,and 80%⁹0%of renal tumors are renal cell carcinoma?RCC?^[1-2].Laparoscopic radical nephrectomy?LRN?and laparoscopic partial nephrectomy?LPN?have become the main surgical methods for the treatment of renal tumor^[3-4].The most important step of LRN or LPN is to identify and effectively control the renal artery.Now,there are various studies which are related to the localization of renal artery during LRN or LPN^[5-9].However,the data with regard to anatomy of renal arteries and its adjacent structures in LRN or LPN is scarce.Objective1.To investigate the anatomical basis and operational techniques of rapid and exact localization of renal artery during transperitoneal LRN or LPN so as to shorten operative time and improve patient safety.2.To study the basic anatomy and variations of renal arteries,renal veins,gonadal veins and lumbar veins,and to summarize the adjacency relationship and regularity of the main structures of renal pedicles so as to guide clinical practice.MethodsThe clinical data of patients undergoing transperitoneal LRN or LPN were retrospectively collected in the department of Urology of Kaifeng Central Hospital and the First Affiliated Hospital of Zhengzhou University from Jan.2018 to Dec.2019.The“two-complex and one-sided technique”was used to locate and dissect the renal artery,and then the other steps were performed.All procedures were recorded in videos,and we recorded the anatomical data of renal arteries,renal veins,gonadal veins and lumbar veins,and the vascular variations were also described,these data were analyses using statistical software.ResultsOf the 237 cases undergoing transperitoneal LRN or LPN,146 cases received the“two-complex and one-sided technique”to locate the renal artery.For 21 cases with the renal artery above the renal vein,both“two-complex and one-sided technique”and“window-opening technique”were used to locate the renal artery.In the other 70 cases with variant renal artery,vein or multiple branches,the“two-complex and one-sided technique”or“window-opening technology”was used to locate the renal artery.1.Renal artery There were 185 cases with single renal artery and 52 cases with multiple renal arteries.The average diameter of the left and right renal artery was 5.9±1.0 mm and5.5±1.1 mm,respectively,with statistically significant difference?t=2.8,p=0.006?.The accessory renal artery was found in 36 cases of the right kidney and 16 cases in the left,with statistically significant in occurrence rate??²=7.6,p=0.006?.2.Renal vein There were 209 cases with single renal vein and 28 cases with multiple renal veins.The average diameter of the left and right renal vein was 11.5±1.9 mm and10.8±1.7 mm,respectively,with statistically significant difference?t=2.5,p=0.011?.The accessory renal vein was found in 26 cases of the right kidney and 2 cases in the left,with statistically significant in occurrence rate??²=20.9,P=0.001?.3.Relative position of single renal artery and renal vein Single branch?167 cases?of the renal artery that located superior and post-superior in the single renal vein were 10 and39 cases,respectively.The renal artery located directly behind,rear below and below the renal vein were 79,32,and 7 cases,respectively.4.Gonadal veins In the 113 cases of left renal surgery,the gonadal veins were detected in 108 cases and all of them entered into the inferior wall of the renal vein,with an average diameter of 2.5±0.8 mm and 105 cases were single and 3 cases had double branch.The gonadal veins were detected in 121 of 124 cases in right renal surgery with an average diameter of 2.4±0.8 mm,and 114 cases were single and 7 cases had double branch,and of which 109 entered into the anterior lateral wall of the inferior vena cava?11.8±8.3 mm distance from the lower edge of the renal vein?and 10 cases entered into the inferior wall of the renal vein?4.1±1.5 mm from the outer edge of the inferior vena cava?and 2 cases entered into the superior wall of the renal vein.5.Lumbar vein In the 113 cases of left renal surgery,lumbar veins were detected in 82cases with an average diameter of 2.5±1.5 mm,and of which 56 cases had single branch and 26 cases had 2 to 4 branches,and 45 of the 82 cases showed typical lumbar vein triangles.Conclusion1.Most patients had single renal artery or renal vein,but the relative positions are not constant.The“two-complex and one-side technique”can be used as the basic operational method for the renal artery positioning in transperitoneal LPN or LRN.For patients whose renal artery are higher than renal vein,the“window-opening technology”could be performed as a supplement technique.Accessory arteries and veins occurred more often in the right kidney than in the left kidney.2.The running and termination points of the left and right gonadal vein are relatively constant and the gonadal vein could be used as an important anatomical marks in LPN or LRN.The lumbar vein triangle window is a reliable auxiliary sign for the positioning of the left renal artery in LPN or LRN.