Anaesthesia for autotransplantation after extracorporeal nephron sparing surgery for bilateral giant renal angiomyolipoma
A 28-year-old unmarried female weighing 55 kg presented with lower abdominal discomfort and vague lump in the abdomen of 5 years duration. She was diagnosed to have giant tumour in both kidneys. She sought medical advice at different hospitals and the tumour was deemed inoperable. Examination showed huge flank masses. Blood investigations were normal and contrast enhanced abdominal CT with angiogram showed bilateral highly vascular huge renal masses suggestive of angiomyolipoma []. She was taken up for right radical nephrectomy, bench surgery and autotransplantation after adequate pre-operative preparation.\nWe instituted general anaesthesia supplemented with low thoracic epidural at T11-12 interspace and epidural analgesia was maintained with 0.2% ropivacaine and fentanyl 2 mcg/ml at the rate of 4-6 ml/h. Anaesthesia was induced with glycopyrrolate 0.2 mg, midazolam 1mg, ramosetron 0.3 mg, fentanyl 100 mcg and propofol 100 mg. Intubation was facilitated with 100 mg succinylcholine and anaesthesia was maintained with N2O, O2, isoflurane and atracurium.\nElectrocardiogram, pulse oximetry, invasive blood pressure, end-tidal carbon dioxide, central venous pressure (CVP), core temperature and hourly urine output were monitored. Abdomen was entered through a right thoracoabdominal incision [], excising the tenth rib and splitting the diaphragm. Right kidney with the mass (30 cm × 15 cm) was removed and cannulated for cooling with the histidine tryptophan ketoglutarate solution. The warm ischemia time was 1 min and 45 s. Bench dissection was carried out and kidney was autotransplanted. Cold ischemia time was 4 h. During this period, the anaesthetic goal was to maintain mild hypertension. Mannitol was given for renoprotection (0.5 g/kg). Patient had massive blood loss approximately 5 l, which was corrected with five units of packed cells, four units of fresh frozen plasma, 9 l of crystalloids and 1 l of colloid. Dopamine and subsequently dobutamine infusion were administered to maintain her haemodynamic parameters. Urine output was sluggish after the release of cross clamps. Patient was electively ventilated. She had continuous oozing from the wound site suggestive of coagulopathy due to massive blood loss and transfusion which was corrected with further transfusion of blood components (two units of packed cells, three units of fresh frozen plasma, four units of platelets and four units of cryoprecipitate). She was haemodynamically stable and coagulopathy was corrected by the second post-operative day and she was weaned off inotropic and ventilatory support.\nAfter 4 weeks, she was posted for the left nephrectomy with bench surgery and autotransplantation as she had a large tumour (26 cm × 18 cm) in the left kidney with high risk of bleeding. Renal Doppler showed suboptimal function of right transplanted kidney. Only a single arcuate artery in the lower pole cortex picked up Doppler flow with increased resistance index. Anaesthetic plan was to restrict fluids intraoperatively and to maintain haemodynamic status. The surgical technique and induction of anaesthesia were similar to what was used for the right nephrectomy. Patient was adequately hydrated before nephrectomy with 3 l of crystalloids to maintain adequate urine output. Warm ischemia time was 2 min 13 s. Cold ischaemia time was 2 h 48 min. After the nephrectomy, fluids were restricted with a goal to maintain CVP of 6-7 cm of water. Before the release of the cross clamp after transplantation, CVP was increased to 16-18 cm of H2O. The target blood pressures were systolic more than 140 mm Hg, mean arterial pressures more than 95 mm Hg and the diastolic pressure more than 85 mm Hg as was practiced in renal allotransplantation. Frusemide 200 mg and sodium bicarbonate 25 ml were administered and urine output was adequate after reperfusion. Blood loss was around 1.5-2 l. She was infused nine litres of crystalloids, 500 ml colloid and two units of packed cells. The surgery lasted for 6 h. She was ventilated overnight and extubated next day. The urine output was 3.6 l. At the time of discharge her creatinine was 1.4 mg/dl and it was 1.5 mg/dl on day 30. The follow-up angiogram after 1 month showed a well-perfused kidney on the left side.