Objective: Renal fusion anomalies are rare and usually present as horseshoe kidneys or crossed fusion ectopia. The complex renal anatomy seen in patients with these anomalies can present a challenge. Pre-operative planning is therefore paramount in the surgical management of these cases. Herein we report the use of interactive virtual three-dimensional (3D) reconstruction to aid renal surgery in patients with fusion anomalies of the kidney. / Materials and Methods: A total of seven cases were performed between May 2016 and October 2020. 3D reconstruction was rendered by Innersight Labs using pre-operative computed tomography (CT) scans. / Results: Five patients had malignant disease and two patients had benign pathology. Robotic and open operations were performed in four and three patients, respectively. / Conclusion: The use of 3D reconstruction in the cases reported in this series allowed for the identification of variations in renal vasculature, and this informed the choice of operative approach. / Oxford Centre for Evidence-Based Medicine Evidence Level: 4

Barod, R

Berger, L

Bex, A

Graafland, N

Hendricksen, K

Hyde, E

Morka, N

Mumtaz, F

Patki, P

Tran, M

English

UCL Discovery

https://doi.org/10.1177/20514158211068310Journal of Clinical Urology 1 –4© British Association ofUrological Surgeons 2022Article reuse guidelines: sagepub.com/journals-permissionsDOI: 10.1177/20514158211068journals.sagepub.com/home/uroIntroductionFusion anomalies of the kidney are rare but most often pre-sent as horseshoe kidneys, complex crossed fused renal ectopia or fused pelvic kidneys (cake kidneys) in about 1 in 400 or 1 in 1000 people, respectively.1,2 The surgical man-agement of benign and malignant diseases involving horse-shoe kidneys and crossed ectopic fusion anomalies can be challenging, owing largely to the complex anatomy and the difficulty of mobilisation. Advancements in surgery have enabled the use of minimally invasive approaches in this Interactive virtual 3D image  reconstruction to assist renal  surgery in patients with fusion  anomalies of the kidneyNaomi Morka1 , Lorenz Berger2 , Eoin Hyde2, Faiz Mumtaz3, Ravi Barod3, Prasad Patki3, Niels Graafland4, Kees Hendricksen4, Maxine Tran3,5 and Axel Bex3,4,5AbstractObjective: Renal fusion anomalies are rare and usually present as horseshoe kidneys or crossed fusion ectopia. The complex renal anatomy seen in patients with these anomalies can present a challenge. Pre-operative planning is therefore paramount in the surgical management of these cases. Herein we report the use of interactive virtual three-dimensional (3D) reconstruction to aid renal surgery in patients with fusion anomalies of the kidney.Materials and Methods: A total of seven cases were performed between May 2016 and October 2020. 3D reconstruction was rendered by Innersight Labs using pre-operative computed tomography (CT) scans.Results: Five patients had malignant disease and two patients had benign pathology. Robotic and open operations were performed in four and three patients, respectively.Conclusion: The use of 3D reconstruction in the cases reported in this series allowed for the identification of variations in renal vasculature, and this informed the choice of operative approach.Oxford Centre for Evidence-Based Medicine Evidence Level: 4KeywordsCrossed ectopic fusion, horseshoe kidneys, pre-operative planning, renal cancer, renal fusion abnormality, 3D reconstructionDate received: 14 December 2020; accepted: 3 December 20211 University College London Medical School, UK2 Innersight Labs Ltd, UK3 Specialist Centre for Kidney Cancer, Royal Free Hospital NHS Foundation Trust, UK4 The Netherlands Cancer Institute, The Netherlands5 Division of Surgery and Interventional Science, University College London, UKCorresponding author:Axel Bex, Division of Surgery and Interventional Science, University College London, Pond Street, London NW3 2QG, UK. Email: a.bex@ucl.ac.uk1068310 URO Journal of Clinical UrologyMorka et al.Cross-sectional Study2 Journal of Clinical Urology 00(0)population and optimal pre-operative planning using three-dimensional (3D) reconstructed images from computed tomography (CT) scans, can aid surgery. We report a case series of partial nephrectomies and hemi-nephrectomies carried out with the benefit of pre-operative 3D reconstruc-tion in patients with horseshoe kidney, crossed fused renal ectopia and fused pelvic kidneys.Materials and methodsWe retrospectively reviewed the records of seven patients with horseshoe kidneys, crossed fused renal ectopia and fused pelvic kidneys who underwent a partial nephrec-tomy or heminephrectomy between May 2016 and October 2020 and had signed appropriate consent for data collec-tion. 3D reconstruction was carried out by Innersight Labs based on routine pre-operative CT scans using an observer-independent automated algorithm as described previously.3 The automated segmentation was quality-edited by bio-medical engineers (Innersight Labs) and verified by a clin-ical expert in the clinical setting. The cases are summarised in Table 1, a detailed report for each case is provided online (Supplemental Material).For the open-surgical approach, patients were in the supine position and access was created through a subcostal or midline incision. In patients who underwent robotic sur-gery, Veress needle insufflation was carried out after which an 8 mm camera port was inserted near the border of the lateral rectus muscle, all other ports were placed under direct vision, and included three further 8-mm ports and a 12-mm periumbilical assistant port.ResultsThe case details and perioperative outcomes are summa-rised in Table 1.Figure 1 shows the 3D reconstruction for each case together with a corresponding representative CT section of the renal pathology. Links to online 3D reconstructions are provided in supplementary material. Figure 2 demon-strates the complex anatomy in a patient with a history of previous open infrarenal aortic vascular prosthesis inser-tion for which a partial nephrectomy in the left moiety was planned (Case 1).DiscussionPatients with horseshoe kidneys and other renal fusion anomalies are more susceptible to certain urological con-ditions. There is a higher risk of developing urinary tract infections, nephrolithiasis, nephroblastomas, and urothe-lial cancers, but the incidence rate of renal cell carcinoma is comparable to the general population.4 The surgical management of renal pathology in patients with renal fusion anomalies is challenging, largely due to the unusual Table 1. Summary of cases.CaseGenderAgeSide and fusion abnormalityProcedure (including relevant previous interventions)PathologyTNMRenal scoreOperative time  (minutes)Blood loss (mL)1M76Left (horseshoe kidney)Open partial nephrectomy (previous history of aortic vascular prosthesis)Clear cell RCCpT1bN0M01021024002M80Left (horseshoe kidney)Robotic radical heminephrectomy with ureterectomyUpper urinary tract urothelial cell carcinoma (UUTUC)pT4NxMxN/A3203003F43Right (horseshoe kidney)Robotic partial nephrectomyClear cell RCCpT1bN0M0 72335004F46Right (horseshoe kidney)Robotic radical heminephrectomyBenign (non-functioning hydronephrotic moiety)N/AN/A160105M78Right (crossed fused renal ectopia)Robotic heminephrectomyChromophobe RCCpT3bN0M010x27018006F21Right (fused pelvic kidney)Open heminephrectomy (previous bladder augmentation and Mitrofanoff procedure)Benign (non-functioning moiety with a staghorn calculus)N/AN/A2107007M52Right (horseshoe kidney)Open radical heminephrectomy with retroperitoneal lymphadenectomySquamous cell carcinomapT3pN1MxN/A120200M: male; F: female; RCC: renal cell carcinoma; TNM: tumour nodes metastases; N/A: not applicable.Morka et al. 3Figure 1. Abdominal CT scans (left) and the corresponding 3D reconstructions (right) for the patients in this series.anatomy which impacts on the mobilisation of the kidney and requires more comprehensive pre-operative planning.As can be seen from our experience, the vascular anat-omy of horseshoe kidneys and other renal fusion anoma-lies is quite variable. Although Graves5 described distinct vascular presentations of horseshoe kidneys, there have been shown to be exceptions to this, with up to 64% show-ing a deviation from his classification in one study.6 The complexity of the vasculature and the lack of a collateral blood supply means that there is an increased risk of com-plications from the procedure.6 Knowledge of the patient’s vasculature will aid the surgeon in the choice of operative approach.Despite the potential difficulties of operating on renal fusion anomalies,7 minimally invasive approaches have been shown to be feasible and safe. Laparoscopic surgery in this population is becoming increasingly common, and a recent case series with 19 patients who underwent lapa-roscopic surgery for tumours in their horseshoe kidney reported no complications greater than Clavien-Dindo grade II.8 In high-volume centres, robotic surgery is likely to offer many potential benefits, such as shorter post-oper-ative stay and less intraoperative blood loss.3D reconstruction is a useful tool for pre-operative plan-ning of complex renal cases. Glybochko et al.9 noted that 3D reconstruction is beneficial compared to 2D imaging because it allows for greater accuracy and precision in deter-mining the location and measurements of anatomical struc-tures. This is of particular importance when performing a partial nephrectomy or heminephrectomy in renal fusion anomalies with their unpredictable vascular supply.10 In our series, 3D reconstruction assisted in the identification of complex anatomy such as in Case 1 with secure identifica-tion of the vasculature following previous open aortic pros-thesis surgery, or for example in Cases 5 and 6. In Case 5, 3D reconstruction enabled us to access the main renal artery early on and to recognise the independent blood supply to the lower moiety. This allowed a clampless heminephrec-tomy and a relatively safer access to the caval tumour thrombus. In Case 6, in which an augmented bladder with a Mitrofanoff was located anterior to the fused pelvic kidney the course of the right and left blood supply was clearly identified along with the site of fusion. A limitation of our case series is that the utility of 3D reconstruction to facilitate renal surgery and improve patient outcomes and costs has not been investigated in a randomised setting in comparison to standard 2D cross-sectional imaging.ConclusionIn our experience, partial nephrectomies and hemi-nephrectomies are feasible in patients with renal fusion anomalies, using both open and minimally invasive approaches. Pre-surgical planning with interactive virtual 4 Journal of Clinical Urology 00(0)3D reconstruction demonstrates the complex anatomy and informs the choice of procedure, surgical approach, and patients selected for surgery.Conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: L.B. and E.H. are employed by Innersight Labs. All other authors report no conflicts of interest.FundingThe authors received no financial support for the research, authorship, and/or publication of this article.Informed consentWritten informed consent was obtained from the patients for their anonymized information to be published in this article.ContributorshipN.M. and A.B. were involved in the conception, design, data acquisition, and drafting of the original manuscript. F.M., R.B., P.P., N.G., K.H. and M.T. provided resources. A.B., F.M., R.B., P.P., N.G., K.H., M.T., E.H. and L.B. critically revised the manu-script. E.H. and L.B. assisted in data interpretation and the use of software. A.B. supervised the work.ORCID iDsNaomi Morka  https://orcid.org/0000-0002-1925-7223Lorenz Berger  https://orcid.org/0000-0002-9367-4105Supplemental materialSupplemental material for this article is available online.References 1. Weizer AZ, Silverstein AD, Auge BK, et al. Determining the incidence of horseshoe kidney from radiographic data at a single institution. J Urol 2003; 170(5): 1722–1726. 2. Dunnick R, Sandler C and Newhouse J. Textbook of Uroradiology. Philadelphia, PA: Wolters Kluwer Health, 2012, https://books.google.co.uk/books?id=U4cEZrux7_cC 3. Hyde ER, Berger LU, Ramachandran N, et al. Interactive virtual 3D models of renal cancer patient anatomies alter partial nephrectomy surgical planning decisions and increase surgeon confidence compared to volume-rendered images. Int J Comput Assist Radiol Surg 2019; 14(4): 723–732. 4. Briones JR, Pareja RR, Martin FS, et al. Incidence of tumoural pathology in horseshoe kidneys. Eur Urol 1998; 33(2): 175–179. 5. Graves FT. The arterial anatomy of the congenitally abnor-mal kidney. Br J Surg 1969; 56(7): 533–541. 6. Boatman DL, Cornell SH and Kölln CP. The arterial supply of horseshoe kidneys. Am J Roentgenol Radium Ther Nucl Med 1971; 113: 447–451. 7. Roussel E, Tasso G, Campi R, et al. Surgical management and outcomes of renal tumors arising from horseshoe kid-neys: Results from an international multicenter collabora-tion. Eur Urol 2021; 79: 133–140. 8. Kochkin AD, Gallyamov EA, Medvedev VL, et al. [Horseshoe kidney tumor laparoscopic surgery. First 19 Cases]. Urologiia 2019; 2: 36–39. 9. Glybochko PV, Alyaev YG, Khokhlachev SB, et al. 3D reconstruction of CT scans aid in preoperative planning for sarcomatoid renal cancer: A case report and mini-review. J Xray Sci Technol 2019; 27(2): 389–395. 10. Wake N, Wysock JS, Bjurlin MA, et al. ‘Pin the tumor on the kidney’: An evaluation of how surgeons translate CT and MRI data to 3D models. Urology 2019; 131: 255–261.Figure 2. Intraoperative images from Case 1 with blood vessels (red, blue sloops) as well as ureters and renal pelvis (yellow sloops) identified.

Interactive virtual 3D image reconstruction to assist renal surgery in patients with fusion anomalies of the kidney

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Interactive virtual 3D image reconstruction to assist renal surgery in patients with fusion anomalies of the kidney

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