105.

fm 11/30/06
Raman et al. Genitourinar y Imaging Original Research
MDCT of Normal and
Variant Renal Anatomy

Surgically Relevant Normal and

Variant Renal Parenchymal and
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A C E N T U
R Y O F Vascular Anatomy in Preoperative
16-MDCT Evaluation of Potential
MEDICAL IMAGING
Laparoscopic Renal Donors
Steven S. Raman1 OBJECTIVE. Using 16-MDCT, we describe and quantify the frequency and types of renal
Suwalee Pojchamarnwiputh1,2 anatomic variants and findings relevant for preoperative evaluation and surgical planning for
Kobkun Muangsomboon1,3 potential laparoscopic renal donors.
Peter G. Schulam4 MATERIALS AND METHODS. On 16-MDCT, 126 consecutive potential donors un-
H. Albin Gritsch4 derwent scanning before contrast administration and after IV power injection of nonionic con-
trast material during the arterial, nephrographic, and excretory phases. On a 3D workstation,
David S. K. Lu1
CT images were evaluated retrospectively in consensus by three abdominal imagers. The num-
Raman SS, Pojchamarnwiputh S, ber and branching pattern of bilateral renal arteries and veins, including anomalies of the infe-
Muangsomboon K, Schulam PG, Gritsch HA, rior vena cava and lumbargonadal axis, were categorized along with the frequency of inciden-
Lu DSK tal findings of the renal parenchyma and collecting system.
RESULTS. Major arterial variants including supernumerary and early branching arteries
were present in 16% and 21%, respectively, of left kidneys and 22% and 15%, respectively, of
right kidneys. Major and minor venous variants were detected in 11% and 58% of left kidneys
and 24% and 3% of right kidneys. Late confluence of the venous trunk was identified in 17%
of left kidneys and 10% of right kidneys. Incidental parenchymal and urothelial abnormalities,
most commonly cysts and calyceal calcifications, were identified in 30% of the kidneys. Other
relevant incidental findings included focal infarcts, cortical scars, atrophic scarred kidney, and
bilateral papillary necrosis. Urothelial variants included bilateral simple ureteroceles and right-
sided complete duplicated collecting system.
CONCLUSION. 16-MDCT angiography and urography allow confident detection and
classification of a variety of anatomic and incidental anomalies relevant to the preoperative se-
lection of potential laparoscopic renal donors and to surgical planning.
Keywords: anatomy, genitourinary tract imaging, kidney
disease, kidney transplantation, living liver donor, MDCT
ince 1995, laparoscopic nephrec- nor kidneys, however, is the high proportion
DOI:10.2214/AJR.05.1002

Received June 10, 2005; accepted after revision

December 7, 2005.
1Department of Radiology, David Geffen School of
Medicine at the University of California at Los Angeles,
BL-428 CHS/Box 951721, Los Angeles, CA 90095-1721.
Address correspondence to S. Raman
(sraman@mednet.ucla.edu).
2Present address: Department of Radiology, Chang Mai
University, Chang Mai, 50200 Thailand.
3Present address: Department
of Radiology, Siriraj
Hospital, Mahidol University, Bangkok, 10700 Thailand.
4Department of Urology, University of California at
Los Angeles, Los Angeles, CA.
AJR 2007; 188:105114
0361803X/07/1881105
American Roentgen Ray Society
S tomy has supplanted traditional
open donor nephrectomy as the
preferred method to harvest a kid-
ney for living donor transplantation [1]. Ad-
vantages of the laparoscopic technique include
decreased morbidity, decreased recovery time,
decreased pain, and improved cosmesis [2].
Laparoscopic donor nephrectomy entails a
steep learning curve and can be technically
challenging because of the limited surgical
field of view. Certain areas in the laparoscopic
operative field, such as the posterior aspect of
the renal veins, are difficult to visualize when
compared with the operative field in open do-
nor nephrectomy [35].
The left kidney is preferred for laparo-
scopic living donor nephrectomy because of
its relative technical ease of removal and flex-
ibility afforded by the longer left venous pedi-
cle [2]. A relative drawback of left-sided do-
of venous variants, including collateral
venous pathways related to the left renal vein
[6]. Knowledge of these variants is relevant
because these potentially large and confound-
ing vessels related to the lumbar and gonadal
veins usually anastomose to the posterior as-
pect of the renal veinswhere laparoscopic
visualization is limited.
Preoperative knowledge of venous variants
may help the surgeon anticipate these anom-
alies and avoid inadvertent ligation of
transection of these vessels, which may cause
unanticipated hemorrhage in the laparoscopic
field. Thus, laparoscopic surgeons demand
more information from preoperative cross-
sectional imaging with regard to arterial and
venous anomalies both for donor and kidney
selection and for surgical planning. For exam-
ple, a less desirable right donor nephrectomy
may be performed if complex vascular anat-

AJR:188, January 2007 105


TABLE 1: CT Parameters for Preoperative Evaluation of 126 Potential
Kidney Donors
Scanning Unenhanced Arterial
Parameters Scan Phase
Time None Bolus tracking 85 s after
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Region scanned T11 to iliac crest T11S2
kVp 120 120
Effective mAs 180220 200240
Table speed (mm) 24 12
Gantry rotation (s) 0.5 0.5
Collimation (mm) 1.5 0.75
Reconstruction
Thickness (mm) 5 0.75
Space (mm) 5 0.6
omy (e.g., multiple arteries or veins) is
present in the left kidney. Preoperative imag-
ing also helps identify the less normal kidney
(i.e., with incidental findings such as a small
stone or hemorrhagic cyst), which is usually
chosen in living donor transplantation.
To date, however, a comprehensive radio-
logic assessment of the types and frequency of
surgically relevant bilateral arterial, venous,
and parenchymal variants using contemporary
MDCT equipment and protocols is lacking in
the donor population. Knowledge of the types
and frequency of variant vascular anatomy, es-
pecially venous anatomy, has been derived
largely from autopsy and surgical series [7].
Prior studies assessing the role of CT have used
older scanners including single- [816], dual-,
or quad-detector scanners [7, 1724].
Most studies in the radiology literature have
been primarily designed to assess the perfor-
mance of imaging in comparison with surgery
rather than to describe the types and frequency
of renal arterial and venous variants. By de-
sign, most studies are limited mainly to the left
side and are inherently biased toward donors
with the simplest anatomy because those with
complex arterial anatomy are excluded. De-
scription of venous anatomy has been limited
to major variants, such as circumaortic left re-
nal vein or duplicate inferior vena cava (IVC).
The frequency of variant venous anatomy re-
lated to the lumbargonadal axis, directly rele-
vant for laparoscopic surgical planning, has not
been well described.
The advent of 16-MDCT has enabled im-
proved temporal and spatial resolution, de-
creased motion and partial volume artifacts,
and near isotropic data acquisition. With im-
proved postprocessing software, the data
106
Raman et al.
Nephrographic Excretory
Phase Phase
5 min after
arterial phase nephrographic phase
T11S2 T11 to pubic symphysis
120 120
200240 120
12 15
0.5 0.5
0.75 0.75
0.75 1 baseline attenuation measurements of renal masses
0.6 0.5
may be displayed to maximum advantage
using a variety of techniques. Although 16-
MDCT has been shown to be excellent for
detection of normal and variant anatomy in a
subset of patients undergoing left-sided do-
nation [25], this sample is biased toward a
donor cohort largely free of complex vascu-
lar anomalies. However, this sample is bi-
ased toward a healthy population and does
not account for the spectrum of right- and
left-sided variants. To our knowledge, no
study has described and quantified the fre-
quency of incidental renal anomalies and the
bilateral prevalence of arterial and venous
variants, especially the incidence of minor
venous variants, in a laparoscopic donor
population on 16-MDCT.
The purpose of this study was to describe
and quantify the frequency of bilateral laparo-
scopically relevant renal vascular, parenchy-
mal, and urothelial variants using preopera-
tive 16-MDCT angiography and urography in
a cohort of potential renal donors.
Materials and Methods
Patients
An institutional review board exemption was ob-
tained for this study. From June 2003 to April 2004,
126 consecutive living renal donors (57 men and 69
women; age range, 1869 years; mean age, 39.7
years) underwent preoperative IV contrastenhanced
16-MDCT examination before the planned laparo-
scopic nephrectomy. All patients were enrolled in a
renal transplantation program in our institution.
MDCT Protocol
Images of all 126 patients were obtained using a
16-MDCT scanner (Sensation 16, Siemens Medi-
cal Solutions) with the same protocol consisting of
105.fm 11/30/06
images acquired in the unenhanced, arterial, neph-
rographic, and excretory phases.
After fasting for at least 3 hours, each patient in-
gested 250 mL of water during a 15- to 20-min pe-
riod before scanning began to enable improved dis-
tention of the collecting system. An explanation of
the CT procedure and the breathing instructions
were then given to each patient by the CT technol-
ogist. All phases were performed during expiration.
Unenhanced CT scans were obtained from the 11th
thoracic vertebral body to iliac crest with the pa-
rameters shown in Table 1. These scans were used
to localize the kidneys and to provide diagnostic in-
formation (e.g., show renal calculi and provide
or other unexpected findings).
Using a power injector, 100150 mL of 350
mg/mL nonionic contrast material (iohexol [Om-
nipaque 350, GE Healthcare]) was IV injected a
rate of 4.0 mL/s via an 18-gauge peripheral line in
an antecubital vein. The estimated dose was deter-
mined on the basis of patient weight as follows:
weight of less than 100 lb (45 kg), 100 mL;
100200 lb (4590 kg), 125 mL; and greater than
200 lb (90 kg), 150 mL. The start time of arterial
phase scanning was determined using automatic
bolus tracking (Smart Prepare, Siemens Medical
Solutions). Scanning was initiated 5 seconds after a
threshold of 150 H was reached in the region of in-
terest within the abdominal aorta just above the kid-
neys. For the arterial phase, scanning was initiated
approximately 20 seconds after bolus injection, and
the area of coverage included T11 to the S2 level to
allow coverage of the common iliac artery bifurca-
tion. For the nephrographic phase, scanning began
85 seconds after the end of the arterial phase with
the same scanning parameters (Table 1).
For the excretory phase, scanning began 5 min-
utes after the nephrographic phase using the param-
eters in Table 1, and the area scanned ranged from
above the kidneys to the bladder base. We de-
creased the milliampere-seconds setting (mAs) by
50% to decrease the radiation dose to the donor. We
also administered 250 mL of saline IV after the
nephrographic scan and before the excretory phase
scan to help decrease excreted iodine concentration
of contrast medium and increase urine volume.
During the 5-minute delay before scanning donors
were asked to rotate three times on the CT table to
decrease layering and improve the homogeneity of
bladder opacification.
Image Processing and Analysis
The volumetric imaging data were reviewed on
a workstation with 2D and 3D capability (Vitrea 2,
Vital Images) by three abdominal imaging radiolo-
gists individually. Any discrepancies were resolved
in consensus to serve as a gold standard. For each
AJR:188, January 2007

MDCT of Normal and Variant Renal Anatomy
CT examination, the reviewers studied the source
axial images, which were supplemented by multi-
planar reformations (MPRs), volume rendering,
and maximum intensity projections (MIPs) as nec-
essary. The reviewers edited CT volume data sets to
create optimal 3D MDCT angiography and MDCT
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urography images in real time. Coronal, sagittal,
and curved MPR images were used to evaluate vas-
cular anatomy. For 3D MDCT angiography, vol-
ume-rendering techniques were usually used, but
MIP rendering was also used as an adjunct display.
The reviewers described and categorized the
number and branching patterns of arteries and veins;
the presence of arterial abnormalities, including mu-
ral stenosis and plaque; and the presence of inciden-
tal congenital and acquired renal abnormalities.
Renal artery evaluationIn general, knowledge
of vascular anomalies is needed for donor and kidney
selection and for preoperative planning. For assess-
ment of the arteries, we retrospectively evaluated the
number, branching pattern, and morphology of the
renal arteries bilaterally. Supernumerary renal arter-
ies were those that had a separate origin from the
aorta or iliac arteries that was independent of the
main renal arteries. In laparoscopic living renal do-
nor transplantation, identifying the distance between
the aorta and the takeoff of the first right or left renal
arterial branch from the main renal artery is impor-
tant because that length determines the number of ar-
terial anastomoses to be performed in the recipient.
A short neck, also known as an early branch-
ing renal artery, exists when the first renal arterial
branch takes off between 1 and 2 cm from the origin
of the renal artery and is determined by surgical pref-
erence [8, 9, 20, 23]. In this instance, either an arte-
rioarterial anastomosis may be performed after har-
vest of the donor kidney, before transplantation, or
two separate arterial anastomoses may be performed
in the recipient. At our institution, we define an early
branch of the left side to be present when the first
branch originates within 2.0 cm from the left lateral
wall of the aorta. On the right side, an early arterial
bifurcation exists when the first branch arises proxi-
mal to the right lateral margin of the IVC (on the un-
dersurface of the IVC) (Fig. 1). We also evaluate the
main and branch renal artery morphology with atten-
tion to mural calcification, stenosis, asymmetric mu-
ral thickness, and beading pattern related to pre-
sumed medical fibromuscular dysplasia.
Renal vein evaluationFor venous evaluation,
we retrospectively evaluated the number and anasto-
motic pattern of renal veins with attention to lumbar
and gonadal veins. As with the arteries, the number
and branching pattern of veins are important for lap-
aroscopic donor nephrectomy and anastomoses in the
recipient. If branches of the renal vein coalesce near
the lateral wall of the aorta (termed a late conflu-
ence), then a short neck exists and, analogous to an
AJR:188, January 2007
early arterial branch, two separate veins may be re-
sected. This may result in a back table venovenous
anastomosis or possibly two venous anastomoses in
the recipient. At our institution, a late venous conflu-
ence is diagnosed on the left side when venous
branches converge within 1.5 cm from the left lateral
wall of abdominal aorta and on the right side when
venous branches converge within 1.5 cm of the con-
fluence with the IVC (Fig. 2).
Renal venous anomalies were subclassified as
major or minor. Major renal venous anomalies on
the left side included variants that affected recipient
venous anastomosis, such as duplicated IVC or cir-
cumaortic left renal vein, or that altered donor lap-
aroscopic dissection, as in cases of retroaortic left
renal vein. Major right-sided venous anomalies in-
cluded primarily supernumerary veins. Minor
venous anomalies bilaterally were those that influ-
enced donor laparoscopic dissection planning but
did not alter recipient venous anastomoses and in-
cluded anomalies associated with the lumbar, go-
nadal, adrenal, or retroperitoneal veins, including
large gonadal and lumbar veins (> 5 mm) and their
associated confluence with the main or branch re-
nal veins. Preoperative knowledge of minor vari-
ants (a venous road map) enables our laparo-
scopic surgeons to anticipate these often large and
confusing vessels during dissection posterior to the
renal vein.
Renal parenchymal and urothelial evaluation
Knowledge of these incidental anomalies is used for
donor and kidney selection. In general, the presence
of congenital fusion anomalies or complex cystic
(Bosniak classification of IIfIV) or solid
(angiomyolipoma or renal cell carcinoma) renal le-
sions precludes an individual from donation. Inci-
dental findingssuch as tiny nonenhancing lesions,
cysts, nonobstructing 3-mm-or-less stones, most
urothelial congenital anomalies, and cortical scars
may be considered in kidney selection because the
less normal-appearing kidney is selected for harvest,
thus the donor retains the more normal kidney.
Unenhanced images provided a baseline attenua-
tion measurement for the evaluation of incidental re-
nal lesions and for the detection of urolithiasis.
Nephrographic phase images were primarily used to
detect and characterize renal lesions and to assess the
presence of cortical abnormalities such as scars. Ex-
cretory phase images were used to evaluate the anat-
omy and associated abnormalities of the calyces, in-
fundibula, renal pelvis, ureters, and bladder.
Results
On consensus review, the MDCT images
were evaluated as technically satisfactory in
all 126 donors. Arterial phase images were
delayed in two patients due to technical prob-
lems (scanner malfunction). Despite the de-
105.fm 11/30/06
lay, the renal artery and vein could be identi-
fied in those two donors and both were
included in the study.
Arterial Anatomy and Variants
The number and percentage of left and
right kidneys with single and multiple renal
arteries are described in Table 2. Early
branching of the left renal arteries (< 2 cm
from the aorta) was present in 26 (21%) of
126 kidneys. Early branching of the right re-
nal arteries was identified in 19 (15%) of 126
kidneys. Overall, the percentage of variants
varied only slightly with respect to side.
Incidental Arterial Abnormalities
In three donors, we found incidental arte-
rial wall abnormalities. The first of these do-
nors was a 63-year-old man who had calcifi-
cations within the wall of the abdominal aorta
and at the ostia of both renal arteries without
associated significant luminal stenosis. This
donor had no history of hypertension or
diabetes, and the findings were attributed to
age-related and age-appropriate incidental
atherosclerosis. The second donor was a 49-
year-old asymptomatic woman who had a
subtle beadlike appearance of the middle
third of the bilateral renal arteries, presump-
tively diagnosed as medial fibromuscular
dysplasia (Fig. 3). The diagnosis was difficult
on the axial images and required coronal ob-
lique MPR. The third asymptomatic donor
had a slightly dilated posterior arterial branch
that was of unclear significance. All three do-
nors had neither a history of urologic abnor-
malities nor known medical conditions.
Venous Anatomy and Variants
In general, the frequency of surgically rel-
evant venous variants was greater than the
frequency of arterial variants. The number
and percentage of left and right kidneys with
single and multiple renal veins are described
in Table 3.
Major left renal venous anomalies (i.e.,
those directly associated with the IVC) includ-
ing supernumerary veins, such as circumaortic
left renal vein (Fig. 4), retroaortic left renal
vein, and duplicated IVC (Fig. 5), were identi-
fied in 14 (11%) of 126 left kidneys (Tables 3
and 4). Three of 10 cases with a circumaortic
left renal vein had a 5-mm-or-larger lumbar
vein or gonadal vein draining into either the
preaortic or the retroaortic branch of the circu-
maortic left renal vein. In one donor, a 5-mm
lumbar vein and a 5-mm gonadal vein con-
nected with the retroaortic component.
107
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Raman et al.
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A B
Fig. 1Oblique axial volume-rendered images show early branching of renal arteries in kidney donor candidates. A = anterior, P = posterior.
A, 56-year-old woman. Image shows early branch of right main renal artery (arrow).
B, 46-year-old man. Image shows early branch of left renal artery (arrow).

A B
Fig. 2Oblique coronal volume-rendered images of renal vein and late venous confluence in kidney donor candidates.
A, 46-year-old woman. Image shows late venous confluence of right renal vein (arrow).
B, 50-year-old woman. Image shows late venous confluence of left renal vein (arrow).

Minor left renal venous anomalies were de-
tected in 73 (58%) of 126 cases, including 5-
mm-or-larger gonadal or lumbar veins drain-
ing into the main renal vein (Fig. 6) in 50
cases (40%) or into the branch renal veins in
18 cases (14%). Other rare variants were
found including two cases of multiple drain-
ing gonadal veins, two cases of large draining
veins from a renal vein to the hemiazygos
vein, and one case of a communicating renal
vein to splenic vein in a donor without known
cirrhosis (Table 4).
A late confluence of left renal venous
trunks (< 1.5 cm from the left lateral wall of
the aorta) was present in 21 cases (17%). In
16 of the 21 cases with late venous conflu-
ence, a 5-mm-or-larger gonadal vein or lum-
bar vein was also present. In 14 of those 16
cases, these veins drained into a branch of the
main renal vein rather than into the main renal
vein itself.
All major right-sided venous anomalies
were supernumerary veins, which occurred in
30 (24%) of 126 kidneys (Table 3). Supernu-

108 AJR:188, January 2007

 105.fm 11/30/06

MDCT of Normal and Variant Renal Anatomy

TABLE 2: Number of Renal Arteries in nephrographic and excretory phases, respec- lated, presumably because of chronic com-
the Left and Right Kidneys tively. Parenchymal and urothelial abnormal- pression by an enlarged leiomyomatous
of 126 Potential Kidney ities were identified in 34 left kidneys (27%) uterus. One donor had simple bilateral ure-
Donors and 41 right kidneys (33%). These were teroceles, and another had a complete uncom-
No. of Left Kidney Right Kidney mostly small incidental lesions, such as Bos- plicated duplication of the right renal collect-
Renal niak I or II cysts, or nonenhancing low-den- ing system.
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Arteries No. %a No. %a

sity lesions less than 5 mm in diameter. Focal
1 106 84 98 78 areas of cortical volume loss, variable cortical
2 18 14 22 17 enhancement, or both were detected in eight
3 2 2 5 4 kidneys. These were presumed to be focal in-
4 0 0 1 1 farcts in three kidneys, cortical scars in four
kidneys, and both scarring and atrophy in one
Total 148 100 161 100
a Percentage of kidneys with one or
kidney (Fig. 7A).
more arteries.
Incidental nonobstructing calyceal calcifi-
cations were found in eight kidneys in asymp-
tomatic donors without underlying metabolic
merary veins more commonly present on the abnormalities on further serum and urinary
right side (158) than on the left side (136). On metabolic evaluation (i.e., no subclinical hy-
the right side, both late confluence of venous percalcemia, hypercalciuria, or uric acid ab-
trunks and minor variants, which included 5- normality). One of these donors was subse-
mm-or-larger gonadal vein draining into right quently treated by extracorporeal shock wave
renal veins, were uncommon, presenting in lithotripsy (ESWL). One potential donor had
13 (10%) of 126 kidneys and four (3%) of 126 incidentally detected bilateral irregular med-
kidneys, respectively. ullary contrast collections on the excretory
phase images, findings that are consistent
Renal Parenchyma and Urothelial Variants with bilateral papillary necrosis (Fig. 7B).
Both renal parenchymal and urothelial en- She had no history of diabetes or other known
hancement were deemed to be adequate and underlying risk factors on further medical in-
diagnostic in all studies obtained during the vestigation. Her ureters were also mildly di-
Cohort Characteristics
In our cohort of 126 potential kidney do-
nors (252 kidneys), 70 successfully donated.
Of these, 67 donors underwent left-sided lap-
aroscopic nephrectomy, one underwent right-
sided laparoscopic nephrectomy, and two
underwent right open nephrectomy. Of the re-
maining 56 cases, 26 cases were excluded be-
cause of complex vascular anatomy, arterial
problems (atherosclerosis, medial fibromus-
cular dysplasia), papillary necrosis, other re-
nal scarring, stone, or medical and psychoso-
cial factors. The reminding 30 donors are
awaiting potential transplantation.
Radiation Dose
The weighted CT dose index ranged from
11.66 to 16.8 mGy for the unenhanced scans,
11.5421.03 mGy for the arterial phase scans,
12.421.03 mGy for the nephrographic phase
scans, and 6.4910.38 mGy for the excretory
phase scans.

A B
Fig. 349-year-old woman with presumed medial fibromuscular dysplasia.
A and B, Coronal volume-rendered image (A) shows subtle irregularity of left renal artery and more prominent mural irregularity at midportion of right renal artery, which is
also seen in vessel view image (B).

AJR:188, January 2007 109

 105.fm 11/30/06

Raman et al.

TABLE 3: Number of Renal Veins in and frequency of bilateral renal vascular, paren- To date, arterial anomalies and branching
the Left and Right Kidneys chymal, and urothelial anomalies using state- patterns have been relatively well described
of 126 Potential Kidney of-the-art imaging and contemporary 2D and on catheter angiography [18], single-detec-
Donors 3D postprocessing techniques. Unlike the find- tor CT or 4-MDCT angiography [824],
No. of Left Kidney Right Kidney ings of older studies, our findings have direct and 16-MDCT angiography [25]. However,
Veins No. % No. % clinical relevance for practicing radiologists characterization of venous anomalies rele-
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1 116a 92 96 76 and urologists because a cohort of mostly vant to laparoscopic donor nephrectomy
young, asymptomatic potential renal donors has been restricted to only major variants in
2 10b 8 28 22
was studied. The results of this study provide an a few series [19, 21, 23]. Characterization
3 0 0 2 2
overall perspective on the frequency of various of minor venous variants, which is impor-
Total 136 100 158 100 clinically relevant anomalies in a donor popula- tant for surgical planning, has been de-
a Three of 116 cases were single retroaortic left renal tion. Knowledge of these anomalies is neces- scribed previously [25], with a few reports
vein. sary for appropriate donor and kidney selection relying largely on autopsy and surgical se-
b All cases were circumaortic left renal vein.
and operative planning, as outlined earlier. ries [7, 26, 27].

Discussion
Donor laparoscopic nephrectomy, a mini- Fig. 432-year-old
female kidney donor
mally invasive alternative to open nephrec- candidate. Coronal
tomy, although preferable, is more techni- volume-rendered image
cally challenging than open nephrectomy in obtained with 16-MDCT
scanner shows
part because of the limited surgical field of circumaortic left renal
view. Technical success is influenced in part vein.
by careful donor selection, which is based on
many factors including high-quality imaging.
Preoperative knowledge of renal vascular, pa-
renchymal, and urothelial anatomy based on
imaging has always been important for donor
and kidney selection. However, the advent of
near-isotropic CT data, enabled by 16-MDCT
and the multiplanar display enabled by so-
phisticated postprocessing software, helps
laparoscopic surgeons to anticipate variant
anatomy intraoperatively and avoid potential
donor complications, such as hemorrhage,
and potential recipient problems, such as graft
ischemia and urine leak [12].
In the assessment of living renal donors,
conditions precluding donation include con-
genital fusion anomalies, bilateral multiple
(> 3) arteries or veins, bilateral arterial or
venous aberrant supply or drainage (e.g., iliac
vessels), asymptomatic diffuse renal disease,
or incidental discovery of a solid mass in the
kidneys or other organs. In general, the less
normal kidney is selected for harvesting. If a
donor is acceptable, the left kidney is usually
harvested because of its longer pedicle. How-
ever, the right kidney may be used if left-sided
vascular anatomy is complex or if the right
kidney contains more relative abnormalities
(scars, infarcts, Bosniak II cystic lesions). Fi- Fig. 537-year-old man
with duplicated inferior
nally, a description of the anastomosing pat- vena cava (IVC) joining
tern of the lumbargonadal venous pattern is left renal vein
important for laparoscopic surgeons to iden- (arrowhead). Coronal
volume-rendered image
tify them easily at surgery. shows right IVC (black
In this study, for the first time, we have pro- arrow) and left IVC (white
vided a comprehensive assessment of the types arrow). S = superior.

110 AJR:188, January 2007


MDCT of Normal and Variant Renal Anatomy
TABLE 4: Major and Minor Venous Anomalies in the Left Kidneys of
126 Potential Kidney Donors
Anomalies
Major venous anomalies
Circumaortic left renal vein
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Prominent GV or LV
Separate retro- and preaortic veins
Retroaortic left renal vein
Prominent LV
Duplicated inferior vena cava
Minor and other collateral venous anomalies
Prominent GV or LV
Prominent GV or LV connecting to main renal vein
Prominent GV or LV connecting to venous branch
Large hemiazygos vein connecting to renal vein
Splenorenal shunt
Multiple draining gonadal veins
NoteGV = gonadal vein, LV = lumbar vein.
a Treated as supernumary vein in Table 3.
b One was associated with late venous confluence and the other was associated with retroaortic renal vein.
One important observation in this donor
cohort was that although the overall fre-
quency of venous variants was higher on the
left side than on the right side kidneys, the fre-
quency of major venous anomalies, such as
supernumerary veins, was higher for right-
sided kidneys (24% vs 8%). This is important
for kidney selection because the longer left-
sided vascular pedicle is preferred. Addi-
tional graft-related procedures, such as veno-
venous anastomoses, that may increase graft
ischemia time (and resulting graft dysfunc-
tion) might be less commonly needed in left-
sided kidneys. Also, the common major left-
sided venous anomaliessuch as circumaortic
left renal vein, retroaortic left renal vein, and
duplicated IVC draining into the left renal
veinwere relatively easy to characterize,
especially if imaging was extended to the
common iliac bifurcation and standard and
curved MPR images were reviewed [25].
In contrast, the frequency of minor renal
venous anomalies related to the size and anas-
tomotic pattern of the gonadal and lumbar
veins was more common on the left side than
on the right side (58% vs 3%, respectively).
These variants and their patterns of anasto-
moses, although difficult to describe on axial
images, are relatively easily identified on
coronal and curved MPR and volume-ren-
dered images. Our laparoscopic surgeons now
believe that the intraoperative road map avail-
able to them in the form of axial, MPR, and
AJR:188, January 2007
No. (%)
14 (11)
10a (8)
3
2 In prior series, multiple renal arteries were
3 (2)
1 2329% of right kidneys [3, 2528]. In our
1
73 (58)
68 (54)
50 (40)
18 (14)
2b
1
2 branching was more common in left renal ar-
processed volume-rendered images is impor-
tant for identifying the gonadal vein intraop-
eratively, anticipating often complex variants,
and minimizing potential hemorrhage from
inadvertent transection.
The lumbargonadal venous branches are
important landmarks for the laparoscopic sur-
geons because those branches trace the go-
nadal insertion into the main renal vein,
branch renal vein, or lumbar vein. They gen-
erally transect the main left renal vein just lat-
eral to its insertion with the lumbargonadal
complex. However, lumbar and gonadal veins
are often difficult to see laparoscopically es-
pecially if they join the undersurface of the
main renal vein, where laparoscopic visual-
ization is limited [18]. In prior surgical series
[26, 27], lumbar venous branches joined the
undersurface of the left main renal vein in up
to 43% of the subjects. In our series, 5-mm-
or-larger gonadal or lumbar veins drained into
the main renal vein in 50 cases (40%) or into
branch renal veins in 18 cases (14%) for left
kidneys. In many cases, the gonadal vein
joined the lumbar branch before eventual in-
sertion into a left renal vein.
Preoperative knowledge of the late left
venous confluence helps laparoscopic sur-
geons anticipate two venous transections if
they cannot gain control around the short
main renal vein segment distal to the anasto-
mosis. In our series, this variant was present
in 17% (21 of 126 of left kidneys) but was
105.fm 11/30/06
complicated by the presence of a 5-mm-or-
larger lumbar or gonadal vein in 81% (17 of
21) of cases. Unusual variantsincluding un-
named retroperitoneal branches, branches to
the hemiazygous system, and splenic vein
brancheswere all present. These may be
safely transected when recognized.
present in up to 2632% of left kidneys and
cohort, supernumerary arteries were less
common overall and were only slightly more
prevalent on the right side (22% of right and
16% of left renal arteries). Although we have
previously seen examples of arteries arising
from the common iliac vessels, in this cohort
all supernumerary renal arteries arose from
the abdominal aorta without aberrant iliac
branches. Similar to prior reports, early
teries (21%) than in right renal arteries (15%).
At our institution, defining the branching
pattern of renal arteries is important for laparo-
scopic nephrectomy because our surgeons pre-
fer at least a 2-cm neck free of arterial
branches. If unrecognized, injury to these ves-
sels may result in ischemic or hemorrhagic
complications. Laparoscopic criteria extend
the definition of an early branch to 2 cm from
the previously defined criterion of 1.5 cm from
the aorta defined for open nephrectomy [11].
Only three asymptomatic potential donors
had arterial wall abnormalities detected on
MDCT that precluded them from donation.
One had bilateral ostial atherosclerosis with
mild renal luminal stenosis. Further workup
with renal arterial pressure measurement was
not performed. Another asymptomatic donor
presented with subtle mural beading of the mid
renal artery that was presumed to be medial fi-
bromuscular dysplasia. Although this morpho-
logic finding has been described on catheter
angiography, it was seldom described in series
evaluating older CT technology. Detection of
these anomalies is likely enabled by the near-
isotropic 16-detector data sets. The third donor
had a slightly dilated posterior arterial branch.
These three donors were excluded because of
concern over the potential long-term complica-
tions (e.g., earlier onset hypertension) in the
donor [29] and potential for unknown compli-
cations in the recipient due to medial fibromus-
cular dysplasia in the graft.
In general, donors are screened before un-
dergoing imaging to exclude those with
known renal abnormalities. To detect and
characterize incidental renal and urothelial
abnormalities, we also perform high-resolu-
111
 105.fm 11/30/06

Raman et al.
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A B

C D

Fig. 6Renal vein and draining gonadal vein or lumbar vein in kidney donor
candidates.
A, 46-year-old woman. Coronal volume-rendered image shows left gonadal vein
(white arrow) connected with left main renal vein (black arrow).
B, 35-year-old woman. Coronal volume-rendered image shows left gonadal vein
(arrow) connected with inferior renal venous branch (arrowhead).
C, 36-year-old woman. Oblique coronal maximum-intensity-projection image shows
two right renal veins (black arrows) and right gonadal vein (white arrow) draining
into inferior renal vein. S = superior.
D, 50-year-old woman. Oblique volume-rendered axial image shows large lumbar
vein (arrow) connected with left main renal vein. A = anterior.
E, 31-year-old woman. Oblique volume-rendered axial image shows large lumbar
vein (white arrow) anastomosing with posterior renal venous branch (black arrow).
Common trunk joined main renal vein within 1 cm of aorta (late confluence).
P = posterior.
E

112 AJR:188, January 2007

 105.fm 11/30/06

MDCT of Normal and Variant Renal Anatomy

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A B
Fig. 7Parenchymal and urothelial abnormalities in kidney donor candidates.
A, 54-year-old man with cortical scars. Coronal maximum-intensity-projection image obtained during excretory phase of left kidney shows cortical thinning (arrows), which
indicates presence of scars and hydrocalyces adjacent to scar.
B, 51-year-old woman with bilateral papillary necrosis. Coronal volume-rendered image on excretory phase CT shows small contrast collections in renal papillary pyramids (arrows).

tion MDCT urography, which includes unen-
hanced, nephrographic, and excretory phase
imaging. Unenhanced CT urography images
are used to locate the renal arteries, to detect
renal calculi, and to serve as the baseline to
evaluate incidental renal lesions. Focal non-
obstructing calyceal calcifications were de-
tected in eight donor kidneys on unenhanced
scans. No metabolic disorders involving uric
acid, calcium, or oxalate were detected in
these donors on further evaluation. Parenchy-
mal abnormalities were present in 34 (27%)
left kidneys and 41 (33%) right kidneys of
126 donors. All were either cysts or low-den-
sity lesions smaller than 5 mm without clear
enhancement. None of these donors was ex-
cluded. In all donors who underwent nephrec-
tomy, lesions were determined to be cysts at
surgery. One potential donor who had atro-
phic scarred kidneys was excluded.
Incidental urothelial variants and abnor-
malities were uncommon. In our cohort, one
donor with nonobstructed duplications and
one with bilateral simple ureteroceles suc-
cessfully underwent nephrectomy. One po-
tential donor with incidentally detected renal
papillary necrosis was subsequently excluded
from donation because the finding was unex-
plained even on further questioning and eval-
uation. The CT urogram enables a high-reso-
lution evaluation of urothelial anatomy.
Limitations of this study must be acknowl-
edged. A surgical gold standard could not be
used because of the study design and goals;
thus, three-reviewer individual and consensus
reviews were used to establish the true diagno-
sis. Although most donors underwent prima-
rily left nephrectomy in this series, a surgical
standard would be impractical in a descriptive
study because only relatively simple variants
would be included and only a small cohort of
right renal variants would be included. Also,
many anomalies, such as medial fibromuscular
dysplasia, could not be proven because donors
were asymptomatic. However, in prior studies
this diagnosis was also essentially morpho-
logic. Finally, we acknowledge that the addi-
tion of excretory phase helical CT is not uni-
versally performed because of radiation
concerns. We used a low-dose protocol to de-
crease the dose. However, evaluation of the en-
tire urothelium is important because urothelial
variants and pathologic conditions may affect
the decision about whether to use the potential
donor kidney. Introduction of high-resolution
(1,024 1,024) CT topograms may change
our practice in the future. This basic donor pro-
tocol may be widely applicable and would also
be useful in the preoperative assessment of pa-
tients undergoing partial nephrectomy.
In summary, using a state-of-the-art CT
protocol, we described and characterized the
bilateral frequency of a wide variety of renal
vascular, parenchymal, and urothelial anoma-
lies relevant for renal donor and kidney selec-
tion and for laparoscopic operative planning.
Angiography and urography using 16-MDCT
allow excellent assessment of vascular paren-
chymal and urothelial variants in potential re-
nal donors to enable donor and kidney triage
and to aid in surgical planning for laparo-
scopic nephrectomy.

AJR:188, January 2007 113


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