1362 | Renal Autotransplantation in Postchemo- therapy Retroperitoneal Lymph Node Dis- section: A Case Report Abbas Basiri, Nasser Shakhsesalim, Mahmood Reza Nasiri, Mohammad Hadi Radfar Keywords: kidney transplantation; humans; case reports; lymph node excision; testicular neo- plasms; retroperitoneal space. INTRODUCTION Retroperitoneal lymph node dissection (RPLND) is a critical modality in the manage-ment of testicular cancer performed in two main settings; primary and postchemother-apy.(1) Postchemotherapy RPLND is generally associated with an increased incidence of major complications compared to primary one.(2) Renal vessels and ureter injuries during RPLND could lead to nephrectomy in some patients. Renal autotransplantation is a kidney saving procedure enabling the surgeon to avoid imperative nephrectomy or high diversion of urinary system in complicated cases.(3) To our knowledge, there is only one case report describ- ing renal autotransplantation as an adjunctive surgery in a patient who underwent RPLND.(4) CASE REPORT A 38-year-old man with a history of mixed germ cell tumor in his left undescended testis was referred to our institute. He had undergone left radical orchiectomy two years previously. The tumor pathology was mixed germ cell tumor containing embryonal carcinoma and immature Corresponding Author: Mohammad Hadi Radfar, MD Department of Urology, Urology and Nephrology Research Center, Shahid Labbafinejad Hospital, Shahid Be- heshti University of Medical Sciences, Tehran, Iran. Tel: +98 21 2254 1185 E-mail: mhadirad@yahoo.com Received August 2012 Accepted March 2013 Urology and Nephrology Research Center, Department of Urology, Shahid Labbafine- jad Hospital, Shahid Beheshti University, Tehran, Iran. CASE REPORT Case Report 1363Vol. 11 | No. 01 | Jan-Feb 2014 |U R O LO G Y J O U R N A L Renal Autotransplantation in Postchemotherapy RPLND | Basiri et al teratoma. Postoperatively, tumor markers remained elevated, and computed tomography (CT) scan revealed a retroperito- neal mass measured 70 × 85 mm. After receiving four cours- es of chemotherapy, tumor markers normalized but retroperi- toneal mass did not change. The mass was located in the left paraaortic area, adjacent to the left renal hilum (Figure 1). The patient was scheduled for RPLND. After a thoracoabdominal incision, it was revealed that the tu- mor was severely adhesive to the psoas muscle. Furthermore, left renal artery, vein, and ureter were encroached by the tu- mor. After very difficult dissection of the tumor from psoas muscle and aorta, it was impossible to separate the mass from renal vessels and ureter (Figure 2). Since the kidney itself was not involved by the tumor, we decided to perform renal autotransplantation. After clamping renal vessels and cutting the ureter in an uninvolved portion, en bloc removal of the kidney, ureter, and the mass was performed. The removed specimen was totally placed in cold normal saline, and intra- vascular washing of the kidney with cold kidney-preserving solution (ringer lactate serum, heparin, sodium bicarbonate, and lidocaine) was started. Tumor was separated from the kidney and uninvolved proximal portions of the renal ves- sels and ureter (Figure 3). The kidney was placed in the con- tralateral iliac fossa because of tissue adhesion and extensive dissection of ipsilateral pelvic cavity. Due to shortness of the renal vein, the kidney was rotated upside-down. Renal artery and vein were anastomosed to right common iliac artery and vein, respectively. Cold ischemic time was 20 minutes. Since we had to remove a significant length of the middle ureter, ureter was shortened and its direction was upward. We de- cided to anatomize distal part of the left ureter to the proxi- mal right ureter. Frozen section and permanent pathology of the margins were negative. Complete bilateral RPLND was carried out. Pathology report revealed embryonal carcinoma and immature teratoma. The patient was followed three months postoperatively with CT scan, laboratory tests including serum tumor markers and creatinine, intravenous urography (IVU), and diethylene tri- amine pentaacetic acid (DTPA) scan. Serum tumor markers and creatinine were normal. IVU and DTPA illustrated nor- mal functioning transplanted kidney (Figure 4). DISCUSSION RPLND, as a crucial step in the testicular cancer manage- ment, and is associated with some complications. Baniel and colleagues reported complication rate of 10.6% for primary RPLND, and 20.7% in postchemotherapy RPLND.(5) Intra- operative complications and need for additional procedures have been reported to occur in 11%-51.9% of postchemo- therapy RPLND (PC-RPLND) patients in different studies. (2,6) Intraoperative complications/additional procedures in PC-RPLND include nephrectomy, vascular injury, inferior vena cava (IVC) resection, IVC prosthesis, aortic replace- ment, arterial graft, orchiectomy, bowel resection, hepatic resection/biopsy, caval thrombectomy, adrenalectomy, chol- ecystectomy, ureteral resection with end-to-end anastomosis, Figure 1. Preoperative computed tomography scan showed the tumor adjacent to the renal pedicle. 1364 | Case Report and ureteral reimplantation.(2,6) The most common additional procedure in PC-RPLND is en bloc nephrectomy followed by vascular procedures.(6) In a report on en bloc nephrectomy in PC-RPLND patients published by Nash and colleagues, indications of nephrectomy included contiguous involvement of perirenal structures in 73%, renal vein thrombosis in 6%, and a combination of these conditions in 16% of patients.(7) Kapoor and colleagues described a case of renal arterial in- jury to a solitary kidney during PC-RPLND. They performed aortorenal revascularization and saved the patient’s kidney. (8) Renal autotransplantation is applied in complex urological reconstructions to avoid nephrectomy, but is reported in only one RPLND patient. Outcomes of renal autotransplantation have showed that it is an effective treatment to save the kidney when in situ techniques are not feasible.(9) In urological oncology, renal autotransplantation has been applied mainly in renal cell car- cinoma or urothelial tumors of the upper tract being present bilaterally or in a solitary kidney. There is only one report of performing renal autotransplantation in a RPLND patient. Kobayashi and colleagues reported a PC-RPLND patient in whom left renal artery was involved by a lymph node; renal function was impaired postoperatively but returned to nor- mal in a short time.(4) We presented our experience in a PC- Figure 2. Intraoperative view shows the mass adhered to renal hilum and ureter. Figure 4. Postoperative intravenous urography showed func- tional transplanted kidney. Figure 3. In-vitro dissection of the renal hilum and separating it from the mass. 1365Vol. 11 | No. 01 | Jan-Feb 2014 |U R O LO G Y J O U R N A L RPLND patient with involvement of renal vessels and ureter that made in situ vascular surgery impossible. Preserving the kidney was very important here due to the probable need for future nephrotoxic chemotherapy. CONCLUSION Regarding the incidence of need for nephrectomy in PC- RPLND, considering renal autotransplantation might be a solution to avoid ablative surgery in some instances. CONFLICT OF INTEREST None declared. REFERENCES 1. Subramanian VS, Nguyen CT, Stephenson AJ, Klein EA. Com- plications of open primary and post-chemotherapy retroperi- toneal lymph node dissection for testicular cancer. Urol Oncol. 2010;28:504-9. 2. Mosharafa AA, Foster RS, Koch MO, Bihrle R, Donohue JP. Complica- tions of post-chemotherapy retroperitoneal lymph node dissection for testis cancer. J Urol. 2004;171:1839-41. 3. Wotkowicz C, Libertino JA. Renal autotransplantation. BJU Int. 2004;93:253-7. 4. Kobayashi Y, Sekihara T, Nakamura M, et al. Retroperitoneal lymph node dissection for testicular tumor with renal autotransplantation: a case report. Hinyokika Kiyo. 1990;36:359-62. 5. Baniel J, Sella A. Complications of retroperitoneal lymph node dis- section in testicular cancer: Primary and post-chemotherapy. Sem- in Surg Oncol. 1999;17:263-7. 6. Heidenreich A, Thuer D, Polyakov S. Postchemotherapy retroperito- neal lymph node dissection in advanced germ cell tumours of the testis. Eur Urol. 2008;53:260-72. 7. Nash PA, Leibovitch I, Foster RS, Bihrle R, Rowland RG, Donohue JP. En bloc nephrectomy in patients undergoing post-chemotherapy retroperitoneal lymph node dissection for non-seminomatous testis cancer: indications, implications and outcomes. J Urol. 1998;159:707-10. 8. Kapoor A, Zippe C, Gill IS. Emergency aortorenal revasculariza- tion during salvage retroperitoneal lymph node dissection. J Urol. 1999:162:1377-8. 9. Novick AC, Jackson CL, Straffon RA. The role of renal autotransplan- tation in complex urological reconstruction. J Urol. 1990;143:452-7. Renal Autotransplantation in Postchemotherapy RPLND | Basiri et al