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fm 11/30/06
Raman et al. Genitourinar y Imaging Original Research
MDCT of Normal and
Variant Renal Anatomy

Surgically Relevant Normal and

Variant Renal Parenchymal and
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R Y O F Vascular Anatomy in Preoperative
16-MDCT Evaluation of Potential
Laparoscopic Renal Donors
Steven S. Raman1 OBJECTIVE. Using 16-MDCT, we describe and quantify the frequency and types of renal
Suwalee Pojchamarnwiputh1,2 anatomic variants and findings relevant for preoperative evaluation and surgical planning for
Kobkun Muangsomboon1,3 potential laparoscopic renal donors.
Peter G. Schulam4 MATERIALS AND METHODS. On 16-MDCT, 126 consecutive potential donors un-
H. Albin Gritsch4 derwent scanning before contrast administration and after IV power injection of nonionic con-
trast material during the arterial, nephrographic, and excretory phases. On a 3D workstation,
David S. K. Lu1
CT images were evaluated retrospectively in consensus by three abdominal imagers. The num-
Raman SS, Pojchamarnwiputh S, ber and branching pattern of bilateral renal arteries and veins, including anomalies of the infe-
Muangsomboon K, Schulam PG, Gritsch HA, rior vena cava and lumbargonadal axis, were categorized along with the frequency of inciden-
Lu DSK tal findings of the renal parenchyma and collecting system.
RESULTS. Major arterial variants including supernumerary and early branching arteries
were present in 16% and 21%, respectively, of left kidneys and 22% and 15%, respectively, of
right kidneys. Major and minor venous variants were detected in 11% and 58% of left kidneys
and 24% and 3% of right kidneys. Late confluence of the venous trunk was identified in 17%
of left kidneys and 10% of right kidneys. Incidental parenchymal and urothelial abnormalities,
most commonly cysts and calyceal calcifications, were identified in 30% of the kidneys. Other
relevant incidental findings included focal infarcts, cortical scars, atrophic scarred kidney, and
bilateral papillary necrosis. Urothelial variants included bilateral simple ureteroceles and right-
sided complete duplicated collecting system.
CONCLUSION. 16-MDCT angiography and urography allow confident detection and
classification of a variety of anatomic and incidental anomalies relevant to the preoperative se-
lection of potential laparoscopic renal donors and to surgical planning.
Keywords: anatomy, genitourinary tract imaging, kidney
disease, kidney transplantation, living liver donor, MDCT
ince 1995, laparoscopic nephrec- nor kidneys, however, is the high proportion

Received June 10, 2005; accepted after revision

December 7, 2005.
S tomy has supplanted traditional
open donor nephrectomy as the
preferred method to harvest a kid-
of venous variants, including collateral
venous pathways related to the left renal vein
[6]. Knowledge of these variants is relevant
ney for living donor transplantation [1]. Ad- because these potentially large and confound-
1Department of Radiology, David Geffen School of vantages of the laparoscopic technique include ing vessels related to the lumbar and gonadal
Medicine at the University of California at Los Angeles, decreased morbidity, decreased recovery time, veins usually anastomose to the posterior as-
BL-428 CHS/Box 951721, Los Angeles, CA 90095-1721. decreased pain, and improved cosmesis [2]. pect of the renal veinswhere laparoscopic
Address correspondence to S. Raman
Laparoscopic donor nephrectomy entails a visualization is limited.
steep learning curve and can be technically Preoperative knowledge of venous variants
2Present address: Department of Radiology, Chang Mai challenging because of the limited surgical may help the surgeon anticipate these anom-
University, Chang Mai, 50200 Thailand. field of view. Certain areas in the laparoscopic alies and avoid inadvertent ligation of
3Present address: Department
operative field, such as the posterior aspect of transection of these vessels, which may cause
of Radiology, Siriraj
Hospital, Mahidol University, Bangkok, 10700 Thailand.
the renal veins, are difficult to visualize when unanticipated hemorrhage in the laparoscopic
compared with the operative field in open do- field. Thus, laparoscopic surgeons demand
4Department of Urology, University of California at nor nephrectomy [35]. more information from preoperative cross-
Los Angeles, Los Angeles, CA. The left kidney is preferred for laparo- sectional imaging with regard to arterial and
AJR 2007; 188:105114
scopic living donor nephrectomy because of venous anomalies both for donor and kidney
its relative technical ease of removal and flex- selection and for surgical planning. For exam-
ibility afforded by the longer left venous pedi- ple, a less desirable right donor nephrectomy
American Roentgen Ray Society cle [2]. A relative drawback of left-sided do- may be performed if complex vascular anat-

AJR:188, January 2007 105 11/30/06

Raman et al.

TABLE 1: CT Parameters for Preoperative Evaluation of 126 Potential images acquired in the unenhanced, arterial, neph-
Kidney Donors rographic, and excretory phases.
Scanning Unenhanced Arterial Nephrographic Excretory After fasting for at least 3 hours, each patient in-
Parameters Scan Phase Phase Phase gested 250 mL of water during a 15- to 20-min pe-
Time None Bolus tracking 85 s after 5 min after riod before scanning began to enable improved dis-
arterial phase nephrographic phase tention of the collecting system. An explanation of
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Region scanned T11 to iliac crest T11S2 T11S2 T11 to pubic symphysis the CT procedure and the breathing instructions
kVp 120 120 120 120 were then given to each patient by the CT technol-
ogist. All phases were performed during expiration.
Effective mAs 180220 200240 200240 120
Unenhanced CT scans were obtained from the 11th
Table speed (mm) 24 12 12 15 thoracic vertebral body to iliac crest with the pa-
Gantry rotation (s) 0.5 0.5 0.5 0.5 rameters shown in Table 1. These scans were used
Collimation (mm) 1.5 0.75 0.75 0.75 to localize the kidneys and to provide diagnostic in-
Reconstruction formation (e.g., show renal calculi and provide
Thickness (mm) 5 0.75 0.75 1 baseline attenuation measurements of renal masses
or other unexpected findings).
Space (mm) 5 0.6 0.6 0.5
Using a power injector, 100150 mL of 350
mg/mL nonionic contrast material (iohexol [Om-
nipaque 350, GE Healthcare]) was IV injected a
omy (e.g., multiple arteries or veins) is may be displayed to maximum advantage rate of 4.0 mL/s via an 18-gauge peripheral line in
present in the left kidney. Preoperative imag- using a variety of techniques. Although 16- an antecubital vein. The estimated dose was deter-
ing also helps identify the less normal kidney MDCT has been shown to be excellent for mined on the basis of patient weight as follows:
(i.e., with incidental findings such as a small detection of normal and variant anatomy in a weight of less than 100 lb (45 kg), 100 mL;
stone or hemorrhagic cyst), which is usually subset of patients undergoing left-sided do- 100200 lb (4590 kg), 125 mL; and greater than
chosen in living donor transplantation. nation [25], this sample is biased toward a 200 lb (90 kg), 150 mL. The start time of arterial
To date, however, a comprehensive radio- donor cohort largely free of complex vascu- phase scanning was determined using automatic
logic assessment of the types and frequency of lar anomalies. However, this sample is bi- bolus tracking (Smart Prepare, Siemens Medical
surgically relevant bilateral arterial, venous, ased toward a healthy population and does Solutions). Scanning was initiated 5 seconds after a
and parenchymal variants using contemporary not account for the spectrum of right- and threshold of 150 H was reached in the region of in-
MDCT equipment and protocols is lacking in left-sided variants. To our knowledge, no terest within the abdominal aorta just above the kid-
the donor population. Knowledge of the types study has described and quantified the fre- neys. For the arterial phase, scanning was initiated
and frequency of variant vascular anatomy, es- quency of incidental renal anomalies and the approximately 20 seconds after bolus injection, and
pecially venous anatomy, has been derived bilateral prevalence of arterial and venous the area of coverage included T11 to the S2 level to
largely from autopsy and surgical series [7]. variants, especially the incidence of minor allow coverage of the common iliac artery bifurca-
Prior studies assessing the role of CT have used venous variants, in a laparoscopic donor tion. For the nephrographic phase, scanning began
older scanners including single- [816], dual-, population on 16-MDCT. 85 seconds after the end of the arterial phase with
or quad-detector scanners [7, 1724]. The purpose of this study was to describe the same scanning parameters (Table 1).
Most studies in the radiology literature have and quantify the frequency of bilateral laparo- For the excretory phase, scanning began 5 min-
been primarily designed to assess the perfor- scopically relevant renal vascular, parenchy- utes after the nephrographic phase using the param-
mance of imaging in comparison with surgery mal, and urothelial variants using preopera- eters in Table 1, and the area scanned ranged from
rather than to describe the types and frequency tive 16-MDCT angiography and urography in above the kidneys to the bladder base. We de-
of renal arterial and venous variants. By de- a cohort of potential renal donors. creased the milliampere-seconds setting (mAs) by
sign, most studies are limited mainly to the left 50% to decrease the radiation dose to the donor. We
side and are inherently biased toward donors Materials and Methods also administered 250 mL of saline IV after the
with the simplest anatomy because those with Patients nephrographic scan and before the excretory phase
complex arterial anatomy are excluded. De- An institutional review board exemption was ob- scan to help decrease excreted iodine concentration
scription of venous anatomy has been limited tained for this study. From June 2003 to April 2004, of contrast medium and increase urine volume.
to major variants, such as circumaortic left re- 126 consecutive living renal donors (57 men and 69 During the 5-minute delay before scanning donors
nal vein or duplicate inferior vena cava (IVC). women; age range, 1869 years; mean age, 39.7 were asked to rotate three times on the CT table to
The frequency of variant venous anatomy re- years) underwent preoperative IV contrastenhanced decrease layering and improve the homogeneity of
lated to the lumbargonadal axis, directly rele- 16-MDCT examination before the planned laparo- bladder opacification.
vant for laparoscopic surgical planning, has not scopic nephrectomy. All patients were enrolled in a
been well described. renal transplantation program in our institution. Image Processing and Analysis
The advent of 16-MDCT has enabled im- The volumetric imaging data were reviewed on
proved temporal and spatial resolution, de- MDCT Protocol a workstation with 2D and 3D capability (Vitrea 2,
creased motion and partial volume artifacts, Images of all 126 patients were obtained using a Vital Images) by three abdominal imaging radiolo-
and near isotropic data acquisition. With im- 16-MDCT scanner (Sensation 16, Siemens Medi- gists individually. Any discrepancies were resolved
proved postprocessing software, the data cal Solutions) with the same protocol consisting of in consensus to serve as a gold standard. For each

106 AJR:188, January 2007 11/30/06

MDCT of Normal and Variant Renal Anatomy

CT examination, the reviewers studied the source early arterial branch, two separate veins may be re- lay, the renal artery and vein could be identi-
axial images, which were supplemented by multi- sected. This may result in a back table venovenous fied in those two donors and both were
planar reformations (MPRs), volume rendering, anastomosis or possibly two venous anastomoses in included in the study.
and maximum intensity projections (MIPs) as nec- the recipient. At our institution, a late venous conflu-
essary. The reviewers edited CT volume data sets to ence is diagnosed on the left side when venous Arterial Anatomy and Variants
create optimal 3D MDCT angiography and MDCT branches converge within 1.5 cm from the left lateral The number and percentage of left and
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urography images in real time. Coronal, sagittal, wall of abdominal aorta and on the right side when right kidneys with single and multiple renal
and curved MPR images were used to evaluate vas- venous branches converge within 1.5 cm of the con- arteries are described in Table 2. Early
cular anatomy. For 3D MDCT angiography, vol- fluence with the IVC (Fig. 2). branching of the left renal arteries (< 2 cm
ume-rendering techniques were usually used, but Renal venous anomalies were subclassified as from the aorta) was present in 26 (21%) of
MIP rendering was also used as an adjunct display. major or minor. Major renal venous anomalies on 126 kidneys. Early branching of the right re-
The reviewers described and categorized the the left side included variants that affected recipient nal arteries was identified in 19 (15%) of 126
number and branching patterns of arteries and veins; venous anastomosis, such as duplicated IVC or cir- kidneys. Overall, the percentage of variants
the presence of arterial abnormalities, including mu- cumaortic left renal vein, or that altered donor lap- varied only slightly with respect to side.
ral stenosis and plaque; and the presence of inciden- aroscopic dissection, as in cases of retroaortic left
tal congenital and acquired renal abnormalities. renal vein. Major right-sided venous anomalies in- Incidental Arterial Abnormalities
Renal artery evaluationIn general, knowledge cluded primarily supernumerary veins. Minor In three donors, we found incidental arte-
of vascular anomalies is needed for donor and kidney venous anomalies bilaterally were those that influ- rial wall abnormalities. The first of these do-
selection and for preoperative planning. For assess- enced donor laparoscopic dissection planning but nors was a 63-year-old man who had calcifi-
ment of the arteries, we retrospectively evaluated the did not alter recipient venous anastomoses and in- cations within the wall of the abdominal aorta
number, branching pattern, and morphology of the cluded anomalies associated with the lumbar, go- and at the ostia of both renal arteries without
renal arteries bilaterally. Supernumerary renal arter- nadal, adrenal, or retroperitoneal veins, including associated significant luminal stenosis. This
ies were those that had a separate origin from the large gonadal and lumbar veins (> 5 mm) and their donor had no history of hypertension or
aorta or iliac arteries that was independent of the associated confluence with the main or branch re- diabetes, and the findings were attributed to
main renal arteries. In laparoscopic living renal do- nal veins. Preoperative knowledge of minor vari- age-related and age-appropriate incidental
nor transplantation, identifying the distance between ants (a venous road map) enables our laparo- atherosclerosis. The second donor was a 49-
the aorta and the takeoff of the first right or left renal scopic surgeons to anticipate these often large and year-old asymptomatic woman who had a
arterial branch from the main renal artery is impor- confusing vessels during dissection posterior to the subtle beadlike appearance of the middle
tant because that length determines the number of ar- renal vein. third of the bilateral renal arteries, presump-
terial anastomoses to be performed in the recipient. Renal parenchymal and urothelial evaluation tively diagnosed as medial fibromuscular
A short neck, also known as an early branch- Knowledge of these incidental anomalies is used for dysplasia (Fig. 3). The diagnosis was difficult
ing renal artery, exists when the first renal arterial donor and kidney selection. In general, the presence on the axial images and required coronal ob-
branch takes off between 1 and 2 cm from the origin of congenital fusion anomalies or complex cystic lique MPR. The third asymptomatic donor
of the renal artery and is determined by surgical pref- (Bosniak classification of IIfIV) or solid had a slightly dilated posterior arterial branch
erence [8, 9, 20, 23]. In this instance, either an arte- (angiomyolipoma or renal cell carcinoma) renal le- that was of unclear significance. All three do-
rioarterial anastomosis may be performed after har- sions precludes an individual from donation. Inci- nors had neither a history of urologic abnor-
vest of the donor kidney, before transplantation, or dental findingssuch as tiny nonenhancing lesions, malities nor known medical conditions.
two separate arterial anastomoses may be performed cysts, nonobstructing 3-mm-or-less stones, most
in the recipient. At our institution, we define an early urothelial congenital anomalies, and cortical scars Venous Anatomy and Variants
branch of the left side to be present when the first may be considered in kidney selection because the In general, the frequency of surgically rel-
branch originates within 2.0 cm from the left lateral less normal-appearing kidney is selected for harvest, evant venous variants was greater than the
wall of the aorta. On the right side, an early arterial thus the donor retains the more normal kidney. frequency of arterial variants. The number
bifurcation exists when the first branch arises proxi- Unenhanced images provided a baseline attenua- and percentage of left and right kidneys with
mal to the right lateral margin of the IVC (on the un- tion measurement for the evaluation of incidental re- single and multiple renal veins are described
dersurface of the IVC) (Fig. 1). We also evaluate the nal lesions and for the detection of urolithiasis. in Table 3.
main and branch renal artery morphology with atten- Nephrographic phase images were primarily used to Major left renal venous anomalies (i.e.,
tion to mural calcification, stenosis, asymmetric mu- detect and characterize renal lesions and to assess the those directly associated with the IVC) includ-
ral thickness, and beading pattern related to pre- presence of cortical abnormalities such as scars. Ex- ing supernumerary veins, such as circumaortic
sumed medical fibromuscular dysplasia. cretory phase images were used to evaluate the anat- left renal vein (Fig. 4), retroaortic left renal
Renal vein evaluationFor venous evaluation, omy and associated abnormalities of the calyces, in- vein, and duplicated IVC (Fig. 5), were identi-
we retrospectively evaluated the number and anasto- fundibula, renal pelvis, ureters, and bladder. fied in 14 (11%) of 126 left kidneys (Tables 3
motic pattern of renal veins with attention to lumbar and 4). Three of 10 cases with a circumaortic
and gonadal veins. As with the arteries, the number Results left renal vein had a 5-mm-or-larger lumbar
and branching pattern of veins are important for lap- On consensus review, the MDCT images vein or gonadal vein draining into either the
aroscopic donor nephrectomy and anastomoses in the were evaluated as technically satisfactory in preaortic or the retroaortic branch of the circu-
recipient. If branches of the renal vein coalesce near all 126 donors. Arterial phase images were maortic left renal vein. In one donor, a 5-mm
the lateral wall of the aorta (termed a late conflu- delayed in two patients due to technical prob- lumbar vein and a 5-mm gonadal vein con-
ence), then a short neck exists and, analogous to an lems (scanner malfunction). Despite the de- nected with the retroaortic component.

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Raman et al.
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Fig. 1Oblique axial volume-rendered images show early branching of renal arteries in kidney donor candidates. A = anterior, P = posterior.
A, 56-year-old woman. Image shows early branch of right main renal artery (arrow).
B, 46-year-old man. Image shows early branch of left renal artery (arrow).

Fig. 2Oblique coronal volume-rendered images of renal vein and late venous confluence in kidney donor candidates.
A, 46-year-old woman. Image shows late venous confluence of right renal vein (arrow).
B, 50-year-old woman. Image shows late venous confluence of left renal vein (arrow).

Minor left renal venous anomalies were de- veins from a renal vein to the hemiazygos ence, a 5-mm-or-larger gonadal vein or lum-
tected in 73 (58%) of 126 cases, including 5- vein, and one case of a communicating renal bar vein was also present. In 14 of those 16
mm-or-larger gonadal or lumbar veins drain- vein to splenic vein in a donor without known cases, these veins drained into a branch of the
ing into the main renal vein (Fig. 6) in 50 cirrhosis (Table 4). main renal vein rather than into the main renal
cases (40%) or into the branch renal veins in A late confluence of left renal venous vein itself.
18 cases (14%). Other rare variants were trunks (< 1.5 cm from the left lateral wall of All major right-sided venous anomalies
found including two cases of multiple drain- the aorta) was present in 21 cases (17%). In were supernumerary veins, which occurred in
ing gonadal veins, two cases of large draining 16 of the 21 cases with late venous conflu- 30 (24%) of 126 kidneys (Table 3). Supernu-

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MDCT of Normal and Variant Renal Anatomy

TABLE 2: Number of Renal Arteries in nephrographic and excretory phases, respec- lated, presumably because of chronic com-
the Left and Right Kidneys tively. Parenchymal and urothelial abnormal- pression by an enlarged leiomyomatous
of 126 Potential Kidney ities were identified in 34 left kidneys (27%) uterus. One donor had simple bilateral ure-
Donors and 41 right kidneys (33%). These were teroceles, and another had a complete uncom-
No. of Left Kidney Right Kidney mostly small incidental lesions, such as Bos- plicated duplication of the right renal collect-
Renal niak I or II cysts, or nonenhancing low-den- ing system.
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Arteries No. %a No. %a

sity lesions less than 5 mm in diameter. Focal
1 106 84 98 78 areas of cortical volume loss, variable cortical Cohort Characteristics
2 18 14 22 17 enhancement, or both were detected in eight In our cohort of 126 potential kidney do-
3 2 2 5 4 kidneys. These were presumed to be focal in- nors (252 kidneys), 70 successfully donated.
4 0 0 1 1 farcts in three kidneys, cortical scars in four Of these, 67 donors underwent left-sided lap-
kidneys, and both scarring and atrophy in one aroscopic nephrectomy, one underwent right-
Total 148 100 161 100
a Percentage of kidneys with one or
kidney (Fig. 7A). sided laparoscopic nephrectomy, and two
more arteries.
Incidental nonobstructing calyceal calcifi- underwent right open nephrectomy. Of the re-
cations were found in eight kidneys in asymp- maining 56 cases, 26 cases were excluded be-
tomatic donors without underlying metabolic cause of complex vascular anatomy, arterial
merary veins more commonly present on the abnormalities on further serum and urinary problems (atherosclerosis, medial fibromus-
right side (158) than on the left side (136). On metabolic evaluation (i.e., no subclinical hy- cular dysplasia), papillary necrosis, other re-
the right side, both late confluence of venous percalcemia, hypercalciuria, or uric acid ab- nal scarring, stone, or medical and psychoso-
trunks and minor variants, which included 5- normality). One of these donors was subse- cial factors. The reminding 30 donors are
mm-or-larger gonadal vein draining into right quently treated by extracorporeal shock wave awaiting potential transplantation.
renal veins, were uncommon, presenting in lithotripsy (ESWL). One potential donor had
13 (10%) of 126 kidneys and four (3%) of 126 incidentally detected bilateral irregular med- Radiation Dose
kidneys, respectively. ullary contrast collections on the excretory The weighted CT dose index ranged from
phase images, findings that are consistent 11.66 to 16.8 mGy for the unenhanced scans,
Renal Parenchyma and Urothelial Variants with bilateral papillary necrosis (Fig. 7B). 11.5421.03 mGy for the arterial phase scans,
Both renal parenchymal and urothelial en- She had no history of diabetes or other known 12.421.03 mGy for the nephrographic phase
hancement were deemed to be adequate and underlying risk factors on further medical in- scans, and 6.4910.38 mGy for the excretory
diagnostic in all studies obtained during the vestigation. Her ureters were also mildly di- phase scans.

Fig. 349-year-old woman with presumed medial fibromuscular dysplasia.
A and B, Coronal volume-rendered image (A) shows subtle irregularity of left renal artery and more prominent mural irregularity at midportion of right renal artery, which is
also seen in vessel view image (B).

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Raman et al.

TABLE 3: Number of Renal Veins in and frequency of bilateral renal vascular, paren- To date, arterial anomalies and branching
the Left and Right Kidneys chymal, and urothelial anomalies using state- patterns have been relatively well described
of 126 Potential Kidney of-the-art imaging and contemporary 2D and on catheter angiography [18], single-detec-
Donors 3D postprocessing techniques. Unlike the find- tor CT or 4-MDCT angiography [824],
No. of Left Kidney Right Kidney ings of older studies, our findings have direct and 16-MDCT angiography [25]. However,
Veins No. % No. % clinical relevance for practicing radiologists characterization of venous anomalies rele-
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1 116a 92 96 76 and urologists because a cohort of mostly vant to laparoscopic donor nephrectomy
young, asymptomatic potential renal donors has been restricted to only major variants in
2 10b 8 28 22
was studied. The results of this study provide an a few series [19, 21, 23]. Characterization
3 0 0 2 2
overall perspective on the frequency of various of minor venous variants, which is impor-
Total 136 100 158 100 clinically relevant anomalies in a donor popula- tant for surgical planning, has been de-
a Three of 116 cases were single retroaortic left renal tion. Knowledge of these anomalies is neces- scribed previously [25], with a few reports
vein. sary for appropriate donor and kidney selection relying largely on autopsy and surgical se-
b All cases were circumaortic left renal vein.
and operative planning, as outlined earlier. ries [7, 26, 27].

Donor laparoscopic nephrectomy, a mini- Fig. 432-year-old
female kidney donor
mally invasive alternative to open nephrec- candidate. Coronal
tomy, although preferable, is more techni- volume-rendered image
cally challenging than open nephrectomy in obtained with 16-MDCT
scanner shows
part because of the limited surgical field of circumaortic left renal
view. Technical success is influenced in part vein.
by careful donor selection, which is based on
many factors including high-quality imaging.
Preoperative knowledge of renal vascular, pa-
renchymal, and urothelial anatomy based on
imaging has always been important for donor
and kidney selection. However, the advent of
near-isotropic CT data, enabled by 16-MDCT
and the multiplanar display enabled by so-
phisticated postprocessing software, helps
laparoscopic surgeons to anticipate variant
anatomy intraoperatively and avoid potential
donor complications, such as hemorrhage,
and potential recipient problems, such as graft
ischemia and urine leak [12].
In the assessment of living renal donors,
conditions precluding donation include con-
genital fusion anomalies, bilateral multiple
(> 3) arteries or veins, bilateral arterial or
venous aberrant supply or drainage (e.g., iliac
vessels), asymptomatic diffuse renal disease,
or incidental discovery of a solid mass in the
kidneys or other organs. In general, the less
normal kidney is selected for harvesting. If a
donor is acceptable, the left kidney is usually
harvested because of its longer pedicle. How-
ever, the right kidney may be used if left-sided
vascular anatomy is complex or if the right
kidney contains more relative abnormalities
(scars, infarcts, Bosniak II cystic lesions). Fi- Fig. 537-year-old man
with duplicated inferior
nally, a description of the anastomosing pat- vena cava (IVC) joining
tern of the lumbargonadal venous pattern is left renal vein
important for laparoscopic surgeons to iden- (arrowhead). Coronal
volume-rendered image
tify them easily at surgery. shows right IVC (black
In this study, for the first time, we have pro- arrow) and left IVC (white
vided a comprehensive assessment of the types arrow). S = superior.

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MDCT of Normal and Variant Renal Anatomy

TABLE 4: Major and Minor Venous Anomalies in the Left Kidneys of complicated by the presence of a 5-mm-or-
126 Potential Kidney Donors larger lumbar or gonadal vein in 81% (17 of
Anomalies No. (%) 21) of cases. Unusual variantsincluding un-
Major venous anomalies 14 (11) named retroperitoneal branches, branches to
the hemiazygous system, and splenic vein
Circumaortic left renal vein 10a (8)
brancheswere all present. These may be
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Prominent GV or LV 3
safely transected when recognized.
Separate retro- and preaortic veins 2 In prior series, multiple renal arteries were
Retroaortic left renal vein 3 (2) present in up to 2632% of left kidneys and
Prominent LV 1 2329% of right kidneys [3, 2528]. In our
Duplicated inferior vena cava 1
cohort, supernumerary arteries were less
common overall and were only slightly more
Minor and other collateral venous anomalies 73 (58)
prevalent on the right side (22% of right and
Prominent GV or LV 68 (54) 16% of left renal arteries). Although we have
Prominent GV or LV connecting to main renal vein 50 (40) previously seen examples of arteries arising
Prominent GV or LV connecting to venous branch 18 (14) from the common iliac vessels, in this cohort
Large hemiazygos vein connecting to renal vein 2b all supernumerary renal arteries arose from
the abdominal aorta without aberrant iliac
Splenorenal shunt 1
branches. Similar to prior reports, early
Multiple draining gonadal veins 2 branching was more common in left renal ar-
NoteGV = gonadal vein, LV = lumbar vein. teries (21%) than in right renal arteries (15%).
a Treated as supernumary vein in Table 3.
b One was associated with late venous confluence and the other was associated with retroaortic renal vein. At our institution, defining the branching
pattern of renal arteries is important for laparo-
scopic nephrectomy because our surgeons pre-
fer at least a 2-cm neck free of arterial
One important observation in this donor processed volume-rendered images is impor- branches. If unrecognized, injury to these ves-
cohort was that although the overall fre- tant for identifying the gonadal vein intraop- sels may result in ischemic or hemorrhagic
quency of venous variants was higher on the eratively, anticipating often complex variants, complications. Laparoscopic criteria extend
left side than on the right side kidneys, the fre- and minimizing potential hemorrhage from the definition of an early branch to 2 cm from
quency of major venous anomalies, such as inadvertent transection. the previously defined criterion of 1.5 cm from
supernumerary veins, was higher for right- The lumbargonadal venous branches are the aorta defined for open nephrectomy [11].
sided kidneys (24% vs 8%). This is important important landmarks for the laparoscopic sur- Only three asymptomatic potential donors
for kidney selection because the longer left- geons because those branches trace the go- had arterial wall abnormalities detected on
sided vascular pedicle is preferred. Addi- nadal insertion into the main renal vein, MDCT that precluded them from donation.
tional graft-related procedures, such as veno- branch renal vein, or lumbar vein. They gen- One had bilateral ostial atherosclerosis with
venous anastomoses, that may increase graft erally transect the main left renal vein just lat- mild renal luminal stenosis. Further workup
ischemia time (and resulting graft dysfunc- eral to its insertion with the lumbargonadal with renal arterial pressure measurement was
tion) might be less commonly needed in left- complex. However, lumbar and gonadal veins not performed. Another asymptomatic donor
sided kidneys. Also, the common major left- are often difficult to see laparoscopically es- presented with subtle mural beading of the mid
sided venous anomaliessuch as circumaortic pecially if they join the undersurface of the renal artery that was presumed to be medial fi-
left renal vein, retroaortic left renal vein, and main renal vein, where laparoscopic visual- bromuscular dysplasia. Although this morpho-
duplicated IVC draining into the left renal ization is limited [18]. In prior surgical series logic finding has been described on catheter
veinwere relatively easy to characterize, [26, 27], lumbar venous branches joined the angiography, it was seldom described in series
especially if imaging was extended to the undersurface of the left main renal vein in up evaluating older CT technology. Detection of
common iliac bifurcation and standard and to 43% of the subjects. In our series, 5-mm- these anomalies is likely enabled by the near-
curved MPR images were reviewed [25]. or-larger gonadal or lumbar veins drained into isotropic 16-detector data sets. The third donor
In contrast, the frequency of minor renal the main renal vein in 50 cases (40%) or into had a slightly dilated posterior arterial branch.
venous anomalies related to the size and anas- branch renal veins in 18 cases (14%) for left These three donors were excluded because of
tomotic pattern of the gonadal and lumbar kidneys. In many cases, the gonadal vein concern over the potential long-term complica-
veins was more common on the left side than joined the lumbar branch before eventual in- tions (e.g., earlier onset hypertension) in the
on the right side (58% vs 3%, respectively). sertion into a left renal vein. donor [29] and potential for unknown compli-
These variants and their patterns of anasto- Preoperative knowledge of the late left cations in the recipient due to medial fibromus-
moses, although difficult to describe on axial venous confluence helps laparoscopic sur- cular dysplasia in the graft.
images, are relatively easily identified on geons anticipate two venous transections if In general, donors are screened before un-
coronal and curved MPR and volume-ren- they cannot gain control around the short dergoing imaging to exclude those with
dered images. Our laparoscopic surgeons now main renal vein segment distal to the anasto- known renal abnormalities. To detect and
believe that the intraoperative road map avail- mosis. In our series, this variant was present characterize incidental renal and urothelial
able to them in the form of axial, MPR, and in 17% (21 of 126 of left kidneys) but was abnormalities, we also perform high-resolu-

AJR:188, January 2007 111 11/30/06

Raman et al.
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Fig. 6Renal vein and draining gonadal vein or lumbar vein in kidney donor
A, 46-year-old woman. Coronal volume-rendered image shows left gonadal vein
(white arrow) connected with left main renal vein (black arrow).
B, 35-year-old woman. Coronal volume-rendered image shows left gonadal vein
(arrow) connected with inferior renal venous branch (arrowhead).
C, 36-year-old woman. Oblique coronal maximum-intensity-projection image shows
two right renal veins (black arrows) and right gonadal vein (white arrow) draining
into inferior renal vein. S = superior.
D, 50-year-old woman. Oblique volume-rendered axial image shows large lumbar
vein (arrow) connected with left main renal vein. A = anterior.
E, 31-year-old woman. Oblique volume-rendered axial image shows large lumbar
vein (white arrow) anastomosing with posterior renal venous branch (black arrow).
Common trunk joined main renal vein within 1 cm of aorta (late confluence).
P = posterior.

112 AJR:188, January 2007 11/30/06

MDCT of Normal and Variant Renal Anatomy

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Fig. 7Parenchymal and urothelial abnormalities in kidney donor candidates.
A, 54-year-old man with cortical scars. Coronal maximum-intensity-projection image obtained during excretory phase of left kidney shows cortical thinning (arrows), which
indicates presence of scars and hydrocalyces adjacent to scar.
B, 51-year-old woman with bilateral papillary necrosis. Coronal volume-rendered image on excretory phase CT shows small contrast collections in renal papillary pyramids (arrows).

tion MDCT urography, which includes unen- cessfully underwent nephrectomy. One po- versally performed because of radiation
hanced, nephrographic, and excretory phase tential donor with incidentally detected renal concerns. We used a low-dose protocol to de-
imaging. Unenhanced CT urography images papillary necrosis was subsequently excluded crease the dose. However, evaluation of the en-
are used to locate the renal arteries, to detect from donation because the finding was unex- tire urothelium is important because urothelial
renal calculi, and to serve as the baseline to plained even on further questioning and eval- variants and pathologic conditions may affect
evaluate incidental renal lesions. Focal non- uation. The CT urogram enables a high-reso- the decision about whether to use the potential
obstructing calyceal calcifications were de- lution evaluation of urothelial anatomy. donor kidney. Introduction of high-resolution
tected in eight donor kidneys on unenhanced Limitations of this study must be acknowl- (1,024 1,024) CT topograms may change
scans. No metabolic disorders involving uric edged. A surgical gold standard could not be our practice in the future. This basic donor pro-
acid, calcium, or oxalate were detected in used because of the study design and goals; tocol may be widely applicable and would also
these donors on further evaluation. Parenchy- thus, three-reviewer individual and consensus be useful in the preoperative assessment of pa-
mal abnormalities were present in 34 (27%) reviews were used to establish the true diagno- tients undergoing partial nephrectomy.
left kidneys and 41 (33%) right kidneys of sis. Although most donors underwent prima- In summary, using a state-of-the-art CT
126 donors. All were either cysts or low-den- rily left nephrectomy in this series, a surgical protocol, we described and characterized the
sity lesions smaller than 5 mm without clear standard would be impractical in a descriptive bilateral frequency of a wide variety of renal
enhancement. None of these donors was ex- study because only relatively simple variants vascular, parenchymal, and urothelial anoma-
cluded. In all donors who underwent nephrec- would be included and only a small cohort of lies relevant for renal donor and kidney selec-
tomy, lesions were determined to be cysts at right renal variants would be included. Also, tion and for laparoscopic operative planning.
surgery. One potential donor who had atro- many anomalies, such as medial fibromuscular Angiography and urography using 16-MDCT
phic scarred kidneys was excluded. dysplasia, could not be proven because donors allow excellent assessment of vascular paren-
Incidental urothelial variants and abnor- were asymptomatic. However, in prior studies chymal and urothelial variants in potential re-
malities were uncommon. In our cohort, one this diagnosis was also essentially morpho- nal donors to enable donor and kidney triage
donor with nonobstructed duplications and logic. Finally, we acknowledge that the addi- and to aid in surgical planning for laparo-
one with bilateral simple ureteroceles suc- tion of excretory phase helical CT is not uni- scopic nephrectomy.

AJR:188, January 2007 113 11/30/06

Raman et al.

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