Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Horseshoe Kidney Treatment & Management

  • Author: Robert C Allen, Jr, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Mar 03, 2014
 

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.

Next

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.[5, 6] Endopyelotomy is an option but yields success rates that are inferior to those of open or laparoscopic techniques.[7]

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.[8] 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.

Previous
Next

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.

Previous
Next

Intraoperative Details

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

Previous
Next

Follow-up

For excellent education resources, see the Kidneys and Urinary System Center, as well as Kidney Stones.

Previous
Next

Outcome and Prognosis

The horseshoe kidney does not complicate pregnancy or delivery. Importantly, note that the presence of the horseshoe kidney alone does not affect survival. As mentioned above, the horseshoe kidney does have a higher propensity to become diseased. Therefore, survival depends on the disease process that the affected horseshoe kidney may harbor or develop.

Previous
Next

Future and Controversies

Despite the increased incidence of Wilms tumor in children with horseshoe kidney and carcinoid tumor in adults with horseshoe kidney, no recommendations regarding periodic surveillance to detect occult malignancies have been made.

Performing periodic renal ultrasonography in children with horseshoe kidney seems prudent for early detection of Wilms tumor. Periodic renal ultrasonography in the adult may also be prudent, especially in patients with hydronephrosis. All patients with horseshoe kidneys and stones should undergo 24-hour urine tests for kidney stone prophylaxis. Otherwise, surveillance should be performed as indicated based on the clinical situation.

Previous
 
Contributor Information and Disclosures
Author

Robert C Allen, Jr, MD, FACS Consulting Staff, Alaska Urological Institute

Robert C Allen, Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Society of Government Service Urologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, SWOG

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Additional Contributors

Erik T Goluboff, MD Professor, Department of Urology, College of Physicians and Surgeons, Columbia University College of Physicians and Surgeons; 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, Society for Basic Urologic Research

Disclosure: Nothing to disclose.

References
  1. Litwinowicz R, Szpor J, Janus G, Worek M, Okon K. Primary carcinoid tumour in horseshoe kidney. Pol J Pathol. 2011 Mar. 62(1):72-4. [Medline].

  2. Palmer BW, Strom K, Wong C. Hand-assisted laparoscopic nephroureterectomy with cystoscopic en-bloc excision of the distal ureter and bladder cuff and isthmusectomy in a horseshoe kidney for invasive urothelial carcinoma of the renal pelvis. JSLS. 2011 Jul-Sep. 15(3):412-4. [Medline]. [Full Text].

  3. Husillos-Alonso A, Bueno-Chomón G, Lledó-García E, Subirá-Ríos D, Ramón-Botella E, Hernández-Fernández C. First percutaneous computed tomography-guided radiofrequency ablation of renal tumor in horseshoe kidney. Urology. 2011 Aug. 78(2):466-8. [Medline].

  4. Ray AA, Ghiculete D, D'A Honey RJ, Pace KT. Shockwave lithotripsy in patients with horseshoe kidney: determinants of success. J Endourol. 2011 Mar. 25(3):487-93. [Medline].

  5. 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. 2008 Oct. 180(4):1391-6. [Medline].

  6. Etafy M, Pick D, Said S, Hsueh T, Kerbl D, Mucksavage P. Robotic pyeloplasty: the University of California-Irvine experience. J Urol. 2011 Jun. 185(6):2196-200. [Medline].

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

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

  9. 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. 2006 Oct. 34(5):291-8. [Medline].

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

  11. 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. 1998 Jun. 68(2):113-9. [Medline].

  12. 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. 2006 Mar. 97(3):579-83. [Medline].

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

  14. 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. 1999 Aug. 84(3):366-8. [Medline].

  15. 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. 1988 Dec. 222(4):408-17. [Medline].

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

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

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

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

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

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

  22. 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. 1993 May. 17(5):940-7. [Medline].

  23. 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].

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

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

  26. 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].

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

 
Previous
Next
 
Excretory urogram shows a horseshoe kidney with left hydronephrosis.
This CT scan demonstrates the isthmus of a horseshoe kidney. Note the uptake of contrast in the isthmus.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.