eMedicine Specialties > Urology > Congenital Urologic Conditions

Horseshoe Kidney: Treatment

Author: Robert C Allen, Jr, MD, Consulting Staff, Alaska Urological Associates
Contributor Information and Disclosures

Updated: Dec 9, 2008

Treatment

Medical Therapy

The horseshoe kidney is susceptible to medical renal disease. These diseases, if present, are treated as indicated. A metabolic evaluation should be performed because metabolic causes for kidney stone disease are no less common in the patient with horseshoe kidney than in the general population with kidney stone disease. Any identified metabolic abnormality should be treated. Metabolic evaluation includes a 24-hour stone risk assessment and serum studies, including calcium, uric acid, and phosphorous.

Surgical Therapy

Surgical treatment is based on the disease process and standard surgical indications. The anomalous vascular supply to the kidney should be kept at the forefront of the surgeon's mind when planning the surgical approach. Generally, the midline abdominal incision provides access to both sides of the horseshoe kidney and vessels.

Ureteropelvic junction obstruction

UPJ obstruction is usually treated with open pyeloureteroplasty or ureterocalicostomy. With the advent of and surgeon familiarization with laparoscopic techniques, the preferred approach has become laparoscopic dismembered pyeloplasty. More recently, robotic dismembered pyeloplasty using the da Vinci surgical system has been successfully performed.1,2 Endopyelotomy is an option but yields success rates that are inferior to those of open or laparoscopic techniques.3

In bilateral UPJ obstruction, the midline transperitoneal incision provides access to both sides of the horseshoe kidney and the vessels. Symphysiotomy (division of the isthmus) is controversial and was recommended routinely after pyeloplasty to improve drainage. However, it is associated with an increased risk of hemorrhage, fistula, and renal infarction. In addition, after division of the isthmus, the kidneys, because of their abnormal vasculature, return to their original position. Therefore, symphysiotomy is rarely, if ever, indicated in conjunction with pyeloplasty.

Kidney stones

Kidney stones can be treated with ESWL, endoscopy, or open surgery. If pyeloplasty is to be performed, stones can be removed concomitantly with a flexible nephroscope and stone basket.4 Treatment decisions and indications are similar to those for a normal kidney. The presence of untreated obstruction or hydronephrosis precludes ESWL. Concomitant percutaneous nephrostolithotomy with endopyelotomy has been used successfully in the treatment of stones with obstruction. Alternatively, successful retrograde therapy of the UPJ with an "Accusize" cutting-balloon dilator followed by ESWL has also been performed.

Renal tumors

Guided by the angiographic findings, interruption of the blood supply of the tissue to be resected is the first step. This prevents significant hemorrhage during dissection and tissue removal. In cancer surgery, the isthmus usually needs to be divided to gain access to the tumor and surrounding lymph nodes.

Abdominal aneurysmectomy

Problems may arise when operating on the great vessels, eg, with abdominal aortic aneurysm repair. Horseshoe kidney complicates aortic aneurysm surgery in 1 out of 200 cases. The most important aspect of abdominal aneurysm repair in association with horseshoe kidney is appropriate surgical management of the common renal artery anomalies. Survival in these patients is predicated on preservation of renal function. Renal artery continuity can be established via branch grafts or reimplantation into the aortic graft. The approach can be midline-abdominal or retroperitoneal through a low-left thoracoabdominal incision. Successful endoluminal transfemoral repair via stent placement has also been described.

Renal transplantation

Horseshoe kidneys can be used for transplantation. They can be transplanted into a single recipient en bloc or can be divided and transplanted into two individuals. Dividing the isthmus can increase the risk of urinary fistula.

The donor’s medical history must be obtained to preclude complications such as hydronephrosis, renal calculi, and urinary tract infection. The decision to transplant a horseshoe kidney en bloc depends on renal isthmus morphology and vascular anatomy, as well as the medical and functional status of the kidney.

Preoperative Details

Because of the anomalous and variable vascular supply to the horseshoe kidney, authorities recommend preoperative arteriography to delineate the vascular anatomy in addition to the routine diagnostic procedures. Accessory and aberrant arteries to the parenchyma and the tumor are the rule.

Intraoperative Details

Because of the anomalous vasculature, the blood supply to the kidney must be identified and preserved.

Follow-up

For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Kidney Stones.

More on Horseshoe Kidney

Overview: Horseshoe Kidney
Workup: Horseshoe Kidney
Treatment: Horseshoe Kidney
Follow-up: Horseshoe Kidney
Multimedia: Horseshoe Kidney
References
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References

  1. Mufarrij PW, Woods M, Shah OD, Palese MA, Berger AD, Thomas R, et al. Robotic dismembered pyeloplasty: a 6-year, multi-institutional experience. J Urol. Oct 2008;180(4):1391-6. [Medline].

  2. Peters CA. Robotic pyeloplasty--the new standard of care?. J Urol. Oct 2008;180(4):1223-4. [Medline].

  3. Bellman GC, Yamaguchi R. Special considerations in endopyelotomy in a horseshoe kidney. Urology. Apr 1996;47(4):582-5; discussion 585-6. [Medline].

  4. Atug F, Castle EP, Burgess SV, et al. Concomitant management of renal calculi and pelvi-ureteric junction obstruction with robotic laparoscopic surgery. BJU Int. Dec 2005;96(9):1365-8. [Medline].

  5. Al-Tawheed AR, Al-Awadi KA, Kehinde EO, et al. Treatment of calculi in kidneys with congenital anomalies: an assessment of the efficacy of lithotripsy. Urol Res. Oct 2006;34(5):291-8. [Medline].

  6. Bauer SB, Perlmutter AD, Retik AB. Anomalies of the Upper Urinary Tract. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell's Urology. Vol 2. 6th ed. Philadelphia, Pa: WB Saunders; 1992:1376-81.

  7. Bégin LR, Guy L, Jacobson SA, et al. Renal carcinoid and horseshoe kidney: a frequent association of two rare entities--a case report and review of the literature. J Surg Oncol. Jun 1998;68(2):113-9. [Medline].

  8. Chammas M Jr, Feuillu B, Coissard A, et al. Laparoscopic robotic-assisted management of pelvi-ureteric junction obstruction in patients with horseshoe kidneys: technique and 1-year follow-up. BJU Int. Mar 2006;97(3):579-83. [Medline].

  9. Davidovic LB, Kostic DM, Jakovljevic NS, et al. Abdominal aortic surgery and horseshoe kidney. Ann Vasc Surg. Nov 2004;18(6):725-8. [Medline].

  10. Dewan PA, Clark S, Condron S, et al. Point of technique: Ureterocalycostomy in the management of pelvi-ureteric junction obstruction in the horseshoe kidney. BJU Int. Aug 1999;84(3):366-8. [Medline].

  11. Doménech-Mateu JM, Gonzalez-Compta X. Horseshoe kidney: a new theory on its embryogenesis based on the study of a 16-mm human embryo. Anat Rec. Dec 1988;222(4):408-17. [Medline].

  12. Ferko A, Krajina A, Jon B, et al. Juxtarenal aortic aneurysm associated with a horseshoe kidney. Transfemoral endoluminal repair. Arch Surg. Mar 1997;132(3):316-7. [Medline].

  13. Gleason PE, Kramer SA. Ectopic Kidneys and Renal Fusion Anomalies. AUA Update Series. 1995; Lesson 33;XIV:268-71.

  14. Hohenfellner M, Schultz-Lampel D, Lampel A, et al. Tumor in the horseshoe kidney: clinical implications and review of embryogenesis. J Urol. Apr 1992;147(4):1098-102. [Medline].

  15. Krishnan B, Truong LD, Saleh G, et al. Horseshoe kidney is associated with an increased relative risk of primary renal carcinoid tumor. J Urol. Jun 1997;157(6):2059-66. [Medline].

  16. Lampel A, Hohenfellner M, Schultz-Lampel D, et al. Urolithiasis in horseshoe kidneys: therapeutic management. Urology. Feb 1996;47(2):182-6. [Medline].

  17. Murphy JT, Borman KR, Dawidson I. Renal autotransplantation after horseshoe kidney injury: a case report and literature review. J Trauma. May 1996;40(5):840-4. [Medline].

  18. O'Hara PJ, Hakaim AG, Hertzer NR, et al. Surgical management of aortic aneurysm and coexistent horseshoe kidney: review of a 31-year experience. J Vasc Surg. May 1993;17(5):940-7. [Medline].

  19. Schuster T, Dietz HG, Schütz S. Anderson-Hynes pyeloplasty in horseshoe kidney in children: is it effective without symphysiotomy?. Pediatr Surg Int. 1999;15(3-4):230-3. [Medline].

  20. Snow BW. Ectopic Kidneys and Renal Fusion Anomalies. AUA Update Series. 1987; Lesson 6;VI:2-5.

  21. Stroosma OB, Schurink GW, Smits JM, et al. Transplanting horseshoe kidneys: a worldwide survey. J Urol. Dec 2001;166(6):2039-42. [Medline].

  22. Viola D, Anagnostou T, Thompson TJ, et al. Sixteen years of experience with stone management in horseshoe kidneys. Urol Int. 2007;78(3):214-8. [Medline].

  23. Yohannes P, Smith AD. The endourological management of complications associated with horseshoe kidney. J Urol. Jul 2002;168(1):5-8. [Medline].

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Further Reading

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Keywords

horseshoe kidney, horseshoe-shaped kidney, deformed kidney, renal fusion anomaly, kidney fusion anomaly, ureteropelvic junction obstruction, UPJ obstruction, ureter-pelvic junction obstruction, renal stones, kidney stone, stone formers, Wilms tumor, vesicoureteral reflux,

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Contributor Information and Disclosures

Author

Robert C Allen, Jr, MD, Consulting Staff, Alaska Urological Associates
Robert C Allen, Jr, MD is a member of the following medical societies: American College of Surgeons and American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

Erik T Goluboff, MD, Professor, Department of Urology, College of Physicians and Surgeons, Columbia University; Director of Urology, Allen Pavilion, New York Presbyterian Hospital
Erik T Goluboff, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Urological Association, Medical Society of the State of New York, New York Academy of Medicine, Phi Beta Kappa, and Society for Basic Urologic Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation
Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Stephen W Leslie, MD, FACS, Founder and Medical Director, Lorain Kidney Stone Research Center; Clinical Assistant Professor, Department of Urology, University of Toledo
Stephen W Leslie, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, National Kidney Foundation, and Ohio State Medical Association
Disclosure: Nothing to disclose.

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