PMC8850344_01
(A) Axial CT scan of the pelvic solitary kidney; (B) sagittal MRI scan of the pelvic solitary kidney and the rectum; (C,D) three-dimensional reconstruction of the pelvic organs.
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F1
Three-dimensional CT reconstruction and pelvic MRI demonstrated that the pelvic kidney was 7.7 x 8.4 x 10 cm in size, and that 2/3 of the kidney was located in the pelvic cavity with the hilum facing toward the right common iliac artery (Figures 1A,B). Three separate renal arteries originated from the right common iliac artery and two separate renal veins drained into the left common iliac vein (Figure 1C). The ureter was short and tortuous (Figure 1D).
(A-D) Intraoperative images of abdominal dissection under laparoscopy.
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F2
At first, complete laparoscopic exploration was performed: the kidney was located in the pelvic cavity with the rectum and rectosigmoid pushed to the right (Figure 2A); adhesions were observed between the mesosigmoid and the peritoneum above the kidney as well as the mesoileum (Figure 2B); no tumor implants or occult liver lesions were identified. The inferior mesenteric artery (IMA) was ligated at about 1 cm from its origin after clearance of No.253 lymph nodes (Figure 2C). For the left side, the kidney and mesorectum were dissected under counter-traction using the superior rectal artery (SRA) as a landmark (Figure 2D).
(A-C) Intraoperative images of pelvic dissection under laparoscopy.
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F3
However, in this patient, without seminal vesicle being used as a landmark, we chose the peritoneal reflection as the cutting point, although we were still not able to recognize the Denonvilliers'fascia and accidentally entered an incorrect plane between the posterior wall of the bladder and the anterior layer of the Denonvilliers'fascia (Figure 3A). We had not realized this mistake until the ureter and left trigone of the bladder were exposed and identified (Figure 3B). Then, we transected the Denonvilliers'fascia and entered the correct surgical plane between the posterior layer of the Denonvilliers' fascia and the mesorectum (Figure 3C).
Postoperative images of abdominal and perineal incision and specimen.
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F4
Only one colostomy and several minor trocar incisions were presented in the abdominal wall without extra incisions (Figure 4).