AN ANATOMICAL EXPLORATION INTO THE VARIABLE PATTERNS OF THE VENOUS VASCULATURE OF THE HUMAN KIDNEY. by KAPIL SEWSARAN SATYAPAL Submitted in partial fulfilment of the requirements for the degree of DOCTOR OF MEDICINE in the Department of Surgery University of Natal Durban 1993 To my wife Pratima, daughter Vedika, son Pravir, and my family. m ABSTRACT In clinical anatomy, the renal venous system is relatively understudied compared to the arterial system. This investigation aims to clarify and update the variable patterns of the renal venous vasculature using cadaveric human (adult and foetal) and Chacma baboon (Papio ursinus) kidneys and to reflect on its clinical application, particularly in surgery and radiology. The study employed gross anatomical dissection and detailed morphometric and statistical analyses on resin cast and plastinated kidneys harvested from 211 adult, 20 foetal and 10 baboon cadavers. Radiological techniques were used to study intrarenal flow, renal veins and collateral pathways and renal vein valves. The gross anatomical description of the renal veins and its relations were confirmed and updated. Additional renal veins were observed much more frequently on the right side (31 %) than previously documented (15.4%). A practical classification system for the renal veins based on the number of primary tributaries, additional renal veins and anomalies is proposed. Detailed morphometric analyses of the various parameters of the renal veins corroborated and augmented previous anatomical studies. Contrary to standard anatomical textbooks, it was noted that the left renal vein is 2.5 times the length of its counterpart and that there are variable levels of entry of the renal veins into the IVe. Justification for the distal segment of the left renal vein to be termed the surgical trunk, and the proximal segment to be the homologue of the right renal vein is presented. Radiological investigations demonstrated a non-segmental and non-lobar intrarenal venous architecture, an absence of renal vein valves and extensive venous collaterals centering on the left renal vein. These collateral channels, present in the foetus, and persisting in the adult, may be operative and of clinical significance in pathological states. No sex differences and no race differences of note were recorded in this study. The Chacma baboon displayed similar intra-renal venous anatomy. The applied clinical anatomy of these findings with particular regard to renal surgery and uro-radiology is emphasised. SUPPORTING SERVICES In this research the statistical planning and analyses, and recommendations arising from these analyses have been done with the support of the Academic Computer Services Department, University of Durban-Westville in association with the Institute for Biostatistics of the Medical Research Council, Durban. PREFACE This study represents original work by the author and has not been submitted in any form to another University. Where use was made of the work of others, it has been duly acknowledged in the text. The research described in this dissertation was supervised by Professors A.A. Haffejee and J.Y. Robbs (Department of Surgery, University of Natal) and conducted in the Department of Anatomy, University of Durban-Westville. ACKNOWLEDGEMENTS The author wishes to express his sincere gratitude to the following individuals and departments for their assistance in the preparation of this dissertation: My wife Pratima, daughter Vedika, son Pravir, and my family for their love, support and encouragement. Mr. Viren Rambiritch, Mr. Colin Pillai and Dr. I.M. Kalideen for their friendship, unwaivering assistance, expert guidance and constructive criticism. Mr. Ganas Mathura for his unstinting help in all technical aspects of this study. Ms Indirani Naidoo for her meticulous assistance in providing the statistical analyses and Mr Simon Tyrrell for his assistance in the planning stage. Mr. Arvind Sardar for his professional, patient and scrupulous attention to detail in the layout, diagrams and figures of this dissertation. Ms. Sandra Naidoo and Mr. Vimal Sardar for their patient and diligent typing of the manuscript. The University of Durban-Westville for providing the academic milieu and also for financially supporting this project. Professor M. Henneberg for his expert assistance. Ms. Fiona Clyde for the preparation of the photographs. Drs. S. Naidoo, R. Perumal, and S. Akoojee for providing the renal material. Professorl.Botha for access to the State Mortuary at Gale Street. Dr. A Seedat, Superintendant, King Edward VIII Hospital, Durban for access to foetal material . The Biomedical Resource Centre, University of Durban-Westville for providing animal material and for the use of their facilities. Professor 1. Meiring, Department of Anatomy, University of Pretoria, for provision of Chacma baboon renal specimens. The staff of the Department of Anatomy, University of Durban-Westville for their support and encouragement and Ms I. Reddy and Mr P. Ndlela And especially Professors AA Haffejee and 1. V. Robbs for their kind assistance and supervision. CONTENTS Page No . Abstract ........................................................................................................ iii Supporting Services •.•.•.•.•.•.•.•...•.•.•...•.••.•.•.•.••.•.•.•.•...•.•.•...•.•••••.••••••.•••...•.•.••.•.••••.••.••.•••••1V Preface .......................................................................................................... v Acknowledgements ........................................................................................................Vl Contents ....................................................................................................... vii List of Tables ........................................................................................................ Xl List of Plates ....................................................................................................... xii List of Figures ...................................................................................................... XlV CHAPTER 1 INTRODUCTION ............................................................................ 1 CHAPTER 2 REVIEW OF LITERATURE .......................................................... .4 2.1 The Renal Veins ......... ...................................................................... 6 2.1.1 The Left Renal Vein ........................................................................ 9 2.1.1.1 The Proximal Segment ................................ ..................................... 9 2.1.1.2 The Distal Segment ........................................................................ l 0 2.1.1.3 Relations ......................................................................................... l 0 2.1.1.4 Additional Left Renal Vein ............................................................ 12 2.1.2 Right Renal Vein ............................................................................ 14 2.1.2.1 Relations ......................................................................................... 14 2.1.2.2 Additional Right Renal Veins ......................................................... 15 2.1.3 Suprarenal Veins ............................................................................. 16 2.1.3.1 Left Suprarenal Vein ....................................................................... 17 2.1.3.2. Right Suprarenal Vein .................................................................... 18 2.1.4 Inferior Phrenic Veins ..................................................................... 18 2.1.5 Gonadal Veins (Testicular or Ovarian) ........................ ................... 18 2.1.5.1 Testicular Vein ........... ............. ..... ....... .. .......................................... 18 2.1.5.2 Ovarian Vein ................................................................................... 19 2.1.6 Capsular Veins ........ .. .................... .................................................. 21 2.1.7 Azygolumbar Veins ........................................................................ 24 2.1.8 Pyelo-ureteral Venules .................................................................... 27 2.1.9 Retroperitoneal Veins ..................................................................... 28 2.1.10 Intrarenal Venous Circulation ......................................................... 29 2.2 Embryology of the Renal Veins .................................................... .34 2.3 Variations of Renal Veins .............................................................. .41 2.3.1 Major Anomalies of the IYC ... ................................................... .. ..41 2.3.2 Lesser Variations of the IVC and its Tributaries: The Renal Veins ............................................................................. 41 2.3.2.1 Anomalies of the Kidney ................................................................ 41 2.3.2.2 Anomalies of the Renal Veins ........................................................ 44 2.3.2.3 Persistent Renal Collar ................................................................... 45 2.3.2.4 Left Retroaortic Renal Vein ........................................................... .47 2.4 The Renal Vascular Pedicle ............................................................ 48 2.4.1 Relationship of Renal Veins To Renal Arteries .............................. 51 2.4.2 Relationship of Gonadal Artery To Renal Veins ............................ 52 2.5 Vertebral Relations,