PMC6521524_01
(a), (b) Pelvic CT images showing a left lower ureteral tumor near the ureteral orifice (red arrows). (c) Three-D CT imaging. The left renal artery (white arrow) and an aberrant renal artery (white dotted arrow) supplied the left part of the horseshoe kidney.
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Computed tomography (CT) revealed a left lower ureteral mass near the ureteral orifice, resulting in renal hydronephrosis (Figures 1(a) and 1(b)). Furthermore, three-dimensional (3-D) CT imaging showed a normal renal vascular system, while an aberrant renal artery located just below the root of the inferior mesenteric artery (IMA) was found to supply the bilateral sides of the lower part of the horseshoe kidney (Figure 1(c)).
(a) Laparoscopic ports used in this case. (b) Schema of procedure for ligation of the left renal vascular system. The main renal artery and an aberrant renal artery were ligated and divided in that order; then the renal vein was cut.
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In June 2017, laparoscopic left nephroureterectomy and bladder resection procedures were performed with 5 laparoscopic ports, with the port schema shown in Figure 2(a). After visualizing the left renal vascular system, the main renal artery supplying the left side of the upper part of the horseshoe kidney and left branch of the aberrant renal artery passing under the IMA were ligated by use of a Hem-o-lok  polymer clip and divided, after which the left renal vein was ligated and divided in the same manner (Figure 2(b)).
(a) Gross appearance of horseshoe kidney under white light after blockage of blood supply to the left kidney. (b) Resection of the renal isthmus under white light. Dotted circle indicates renal isthmus border. (c) Resected surface of right part of kidney under white light. Adequate hemostasis was obtained by bipolar coagulation and a fibrin patch. Dotted circle indicates renal isthmus border. (d) ICG-based NIRF images showing strong ICG fluorescence in the dominant region of the right part of the kidney after blockage of blood supply to the left kidney. (e) Proper resection of the renal isthmus could be performed with assistance from NIRF imaging. (f) Adequate hemostasis of the resected surface of the right part of the kidney was confirmed using ICG-based NIRF imaging.
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Strong ICG fluorescence was observed in the dominant region of the right part of the kidney, while no fluorescence was noted in the left kidney region (Figure 3(d)). These findings indicated that blood supply to the left side of the kidney was completely blocked, which was more apparent as compared to white light images (Figure 3(a)). During excision, visualization with white light and the NIRF was switched at the discretion of the operator in order to confirm the plane of excision between the right and left parts of the kidney (Figures 3(b) and 3(e)). Adequate hemostasis from the resected area could be obtained by electrocautery bipolar coagulation and use of a TacoSil  tissue sealing sheet, with no suturing required (Figures 3(c) and 3(f)).