Introduction

Renal cancer requires a combination of demolitive surgery and therapy. However, some renal tumors are considered unresectable or not nephron-sparing because of large size or for involvement of the inferior vena cava (IHV) or because kidney cannot safely tolerate total vascular occlusion over about 90 min. Ex vivo renal resection and autotransplantation (EVRRAT) means removal of the kidney from abdominal cavity, the subsequent resection of the tumor lesion on the table in cold ischemia (bench surgery) and the subsequent reimplantation of the same organ deprived of the tumor with nephro-sparing technique (NST). The first renal autotransplant was performed in 1963 by Hardy et al. (1) in Jackson, MS, for a high ureteral injury during an aortic operation. Indications for EVRRAT are as follows: multiple bilateral tumors, tumors in patients with impaired renal function, tumors of the solitary kidney, and large benign tumors. In these cases, it is mandatory to preserve as many nephrons as possible (2–8).

Methods

We retrospectively evaluated PUBMED databases, including the studies from 1980 to 2020. Only a very few studies have analyzed “ex vivo [and] ex situ renal resection, extracorporeal renal resection, [and] renal autotransplantation.” Two independent research conducted the review. The search terms were identified with medical subject heading (MeSH). Research inclusion criteria were the following terms: “ex vivo, ex situ renal resection, extracorporeal renal resection, [and] renal autotransplantation.” The outcomes were: indications, operative time, morbidity and mortality, and oncologic results. We excluded abstracts of all manuscripts as well as non-English manuscripts. After rejecting review articles and repetitive reports, the relevant literature included 14 manuscripts.

Results

In 1993, Hitchcock et al. (9) reported EVRRAT in a 12-year-old patient with spinal Ewing sarcoma underwent renal sparing autotransplantation to avoid radiation nephritis by positioning the kidney outside the field of radiation to prevent radiation damage. Abraham et al. (10), in their retrospective study of three patients, showed an operative time of 5–8 h and a cold ischemia of 90–150 min through laparoscopic approach. The authors confirmed that it was a good procedure if possible to apply. Gill et al. (11) and Meng and colleagues (12) reported on retroperitoneal laparoscopic nephrectomy and autotransplantation in four and two patients, respectively. Aslam et al. (22) had reported three case series of laparoscopic EVRRAT with one deep vein thrombosis and renal infarction of transplanted kidney. El Tayar et al. (13) and Maughan et al. (14) treated a large aneurysm by nephrectomy, ex vivo repair, and autotransplantation. Pretorian et al. (15) saved a patient from renal insufficiency due to renal reflux by performing a two-stage renal autotransplantation. Chandak et al. (16) applied EVRRAT for mycotic aneurysm. Bourgi et al. (17) treated nine patients for various pathologies, demonstrating a good post-operative creatinine clearance. While Pettersson et al. (18) showed the good oncologic result after 32 months of EVRRAT for urothelial carcinoma of the upper urinary tract, demonstrating only one radical nephrectomy for cancer recurrence in eight patients. Holmang and Johansson (19) conducted autotransplantation in 23 patients with urothelial neoplasm of the upper urinary tract, and concluded that renal autotransplantation could be harmful compared with standard nephroureterectomy. Komiakov et al. (20) in a 4-year follow-up of EVRRAT for renal tumors in nine patients established no dissemination of tumor and functional condition of the transplanted kidney. In 2015, Tran et al. (21), in their study of 52 patients, referred to more than 90% success rate over a 6-year follow-up period.

Discussion

EVRRAT achieves nephron-sparing in renal tumors. Kidney autotransplantation is performed to preserve renal parenchyma. If correct indications are followed, EVRRAT presents a viable and last option before nephrectomy whereas traditional surgery exposes the patient to chronic renal insufficiency (CRI) (17). Open surgery in EVRRAT is the best choice, but laparoscopic approach could be used to reduce morbidity of the procedure. Laparoscopic technique allows minimal skin incision. Renal extraction and subsequent transplantation could be performed through a standard extraperitoneal Gibson incision, with minimization of postoperative pain and length of hospital stay (11). Renal autotransplantation is an option for a highly selected group of patients having multiple bilateral tumors, tumors in patients with impaired renal function, and tumors of the solitary kidney; complex renal artery aneurysms; and high ureteric injuries, which are the most common indications of EVRRAT (17). It has short- and long-term complication rates comparable with those of other major surgical procedures.

Conclusions

EVRRAT is the last chance in patients with renal cancer. However, it has manifested numerous difficulties during and after surgery, with a local recurrence rate of 25% and a vascular thrombosis of 20%. However, as encountered in literature reviews, we noted that in some patients it provided good control over cancer, prevented long-term dialysis, and avoided renal transplantation, thereby giving the patients a good quality of life (2–8,22,23).

Human Rights Statement

All procedures and experiments met the ethical standards.