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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 5  |  Page : 806-808
Asymptomatic Bilateral Ureteropelvic Junction Obstruction due to Supernumerary Renal Arteries


1 Tuberculosis and Lung Disease Research Center, Tabriz University (Medical Sciences), Tabriz, Iran
2 Department of Radiology, Tabriz University (Medical Sciences), Tabriz, Iran
3 Department of Cell Biology, University of Alabama, Birmingham, AL, USA
4 Faculty of Medicine, Tabriz University (Medical Sciences), Tabriz, Iran

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   Abstract 

A supernumerary renal artery is a common arterial variation, which warrants consi­derations in a variety of urologic and retroperitoneal operations. Supernumerary renal arteries can be associated with other uro-vascular variations and anomalies such as duplicated renal veins and ureters, aberrant origin of the gonadal arteries, persistence of fetal renal lobulation, and kidney malrotation. The role of crossing supernumerary renal arteries in ureteropelvic junction obstruc­tion (UPJO) is controversial. We report a healthy potential renal transplant donor with bilateral UPJO, which appeared to be secondary to supernumerary renal (inferior polar) arteries. We believe that the bilateral occurrence of asymptomatic UPJO associated with supernumerary renal arteries has not been previously reported.

Keywords: Supernumerary, Renal, Artery, Transplantation, Ureteropelvic, Junction, Obstruction

How to cite this article:
Shoja MM, Tubbs R S, Shakeri A, Ardalan MR, Rahimi-Ardabili B, Ghabili K. Asymptomatic Bilateral Ureteropelvic Junction Obstruction due to Supernumerary Renal Arteries. Saudi J Kidney Dis Transpl 2008;19:806-8

How to cite this URL:
Shoja MM, Tubbs R S, Shakeri A, Ardalan MR, Rahimi-Ardabili B, Ghabili K. Asymptomatic Bilateral Ureteropelvic Junction Obstruction due to Supernumerary Renal Arteries. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Jul 16];19:806-8. Available from: http://www.sjkdt.org/text.asp?2008/19/5/806/42466

   Introduction Top


The role of crossing supernumerary renal arteries in ureteropelvic junction obstruction (UPJO) is controversial. [1] Though UPJO is be­lieved to be secondary to abnormal muscular relaxation, a crossing renal artery has been ob­served in 11–39% of cases. [1],[2],[3] In addition, it has been shown that UPJO associated with an anterior crossing vessel is amenable to laparos­copic management, which supports a causative role for a supernumerary renal artery at least in some cases. [4],[5] Geyer and Poutasse [6] argued that though aggravating the condition, a supernu­merary renal artery is not a sole factor in the production of dilatation of the pelvi-calyceal system.

We report a case of bilateral UPJO, which seems to be secondary to supernumerary renal arteries. To the best of our knowledge, the bilateral occurrence of asymptomatic UPJO associated with supernumerary renal arteries has not been previously reported.


   Case Report Top


A 19–year-old healthy man, a potential renal transplant donor underwent a pre-operative conventional angiography to illustrate the arte­rial supply of the kidneys. There was no past history of renal disease. Physical examination was unremarkable. Hemoglobin, hematocrit, blood urea and serum creatinine were within normal limits. Angiography revealed a bilate­ral inferior polar artery crossing the uretero­pelvic junctions and dilation of the proximal pelvicalyceal system consistent with UPJO, [Figure 1]. No other intraabdominal vascular va­riation was found. Kidney shadows and sizes were normal. Due to the presence of super­numerary renal arteries, the kidney donation was cancelled.


   Discussion Top


Multiple renal arteries are common varia­tions, with a prevalence of approximately 30% in the general population. [7] Previous anatomic works have shown that vessels crossing within 1.5 cm of the ureteropelvic junction are most commonly anterior to the ureteropelvic junc­tion. [8] The role of crossing arteries at the ure­teropelvic junction and resultant UPJO is con­troversial, but these vessels may contribute to ureterovascular tangle formation and secon­dary obstruction. [3],[9] As the appropriate proce­dure for treating crossing arteries remains un­defined, the role of the supernumerary artery is clinically important.

The supernumerary arteries usually course into the renal hilum to perfuse the upper or lower renal poles. [7] These accessory arteries perfuse anatomically equivalent regions of the kidney. It has been postulated that an upper polar artery is a separate apical artery and an inferior polar artery is a separate lower seg­mental artery. [10] The accessory arteries to the polar regions are usually smaller than the acce­ssory hilar arteries. [11] The association of super­numerary renal artery with uro-vascular varia­tions and anomalies such as ipsilateral or con­tralateral duplicated renal veins, duplicated ureter, aberrant origin of the gonadal artery, persistence of fetal renal lobulation, and kid­ney malrotation have been reported. [2],[7],[12] Singh et al suggested that the retroureteral variant is likely to be associated with UPJO and hydro­-nephrosis. [13]

Benedetti et al did not observe a significant difference with regard to the acute rejection rate and graft/patient survival in recipients of kidney with multiple and single renal arte­ries. [14] However, it is clear that the presence of a supernumerary renal artery may be a cause of technical difficulties for transplant surgeons. [7],[12] Supernumerary renal arteries are usually longer and narrower than the main renal arte­ries and are associated with a lower perfusion pressure and higher resistance. [7] Three main types of renal accessory arteries have been reported in relation to the main renal artery, namely, hilar, upper and lower polar arteries. An inferior polar artery may pass either ante­rior or posterior to the ureter.

Finally, supernumerary renal arteries should be considered as potential causes of UPJO even when bilateral. The incidence of UPJO secondary to such arterial variations should be carefully investigated as asymptomatic obs­truction may underestimate this incidence.

 
   References Top

1.Rouviere O, Lyonnet D, Berger P, Pangaud C, Gelet A, Martin X. Ureteropelvic junction obstruction: use of helical CT for preoperative assessment-comparison with intra-arterial angiography. Radiology 1999;213(3):668-73.  Back to cited text no. 1    
2.Bordei P, Sapte E, Iliescu D. Double renal arteries originating from the aorta. Surg Radiol Anat 2004;26(6):474-9.  Back to cited text no. 2    
3.Stephens FD. Ureteropelvic hydronephrosis and the aberrant renal vessels. J Urol 1982; 128(5):984-7.  Back to cited text no. 3    
4.Frauscher F, Janetschek G, Klauser A, et al. Laparoscopic pyeloplasty for UPJ obstruction with crossing vessels: contrast-enhanced color Doppler findings and long-term outcome. Urology 2002;59(4):500-5.  Back to cited text no. 4    
5.Simforoosh N, Tabibi A, Nouralizadeh A, Nouri-Mahdavi K, Shayaninasab H. Laparos­copic management of ureteropelvic junction obstruction by division of anterior crossing vein and cephalad relocation of anterior crossing artery. J Endourol 2005;19(7):827-30.  Back to cited text no. 5    
6.Geyer JR, Poutasse EF. Incidence of multiple renal arteries on aortography. Report of a series of 400 patients, 381 of whom had arterial hypertension. JAMA 1962;182:120-5.  Back to cited text no. 6    
7.Shakeri AB, Tubbs RS, Shoja MM, et al. Bipolar supernumerary renal artery. Surg Radiol Anat 2007;29(1):89-92.  Back to cited text no. 7    
8.Sampaio FJ, Favorito LA. Ureteropelvic junction stenosis: vascular anatomical back­ground for endopyelotomy. J Urol 1993;150 (6):1787-91.  Back to cited text no. 8    
9.Hoffer FA, Lebowitz RL. Intermittent hydronephrosis: a unique feature of uretero­pelvic junction obstruction caused by a crossing renal vessel. Radiology 1985;156(3): 655-8.  Back to cited text no. 9    
10.Sykes D. The arterial supply of the human kidney with special reference to accessory renal arteries. Br J Surg 1963;50:368-74.  Back to cited text no. 10  [PUBMED]  
11.Urban BA, Ratner LE, Fishman EK. Three­dimensional volume-rendered CT angiography of the renal arteries and veins: normal anatomy, variants and clinical applications. Radiographics 2001;21(2):373-86.  Back to cited text no. 11    
12.Shoja MM, Tubbs RS, Shakeri AB, Oakes WJ. Origins of the gonadal artery: embryologic implications. Clin Anat 2007;20(4):428-32.  Back to cited text no. 12    
13.Singh G, Ng YK, Bay BH. Bilateral accessory renal arteries associated with some anomalies of the ovarian arteries: a case study. Clin Anat 1998;11(6):417-20.  Back to cited text no. 13    
14.Benedetti E, Troppmann C, Gillingham K, et al. Short- and long-term outcomes of kidney transplants with multiple renal arteries. Ann Surg 1995;221(4):406-14.  Back to cited text no. 14    

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Correspondence Address:
Mohammadali M Shoja
MD No. 9, Bonbast-e-Jhaleh, Qatran-e-Shomaly Ave., Tabriz, 51738
Iran
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PMID: 18711302

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