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Journal of the Anatomical Society of India

Malformation of Renal and Testicular Veins - A Case Report

Author(s): Verma R, Kalra S & Rana K.

Vol. 54, No. 1 (2005-01 - 2005-03)

Maulana Azad Medical College, New Delhi.

Abstract:

The present case report is regarding the incidental finding of the malformation of renal and testicular vessels along with the lobulation of both kidneys during routine dissection of the abdominal region. On the right side, two renal veins were arising from the upper and lower ends of the hilum of the kidney, and subsequently draining separately into inferior vena cava. Also on the left side, the both veins were arising similarly as on the right side, but the lower vein was draining into inferior vena cava indirectly via upper renal vein.

There were two testicular veins on each side (medial and lateral) emerging from deep inguinal ring. The lateral testicular veins were draining into the upper renal vein and medial into the lower renal veins. But the renal artery was single on both the sides. This finding is of immense importance during surgical intervention in this region.

Both kidney were also lobulated.

Keywords: Renal, testicular, vein, malformation

Introduction:

Although there are published reports on double inferior vena cava and double renal vein but association of double renal and testicular vein seems to have not been reported. The present case report is on a rare association, of double renal and testicular veins alongwith its abnormal position and relation with respect to renal artery and lobulation of both the kidneys. This report is of immense importance during surgical intervention in this region. The possible embryological reason for the formation of double renal and testicular veins are also discussed.

Case Report:

A rare case of double renal, double testicular veins and single renal artery was observed during routine cadaveric dissection in the abdominal region. The kidneys were bilaterally lobular. This anomaly was observed in a fifty years old male and cause of his death could not be ascertained.

Two renal veins on both sides were running parallel to each other. The upper renal vein on both the sides were emerging from upper pole of kidney and draining into inferior vena cava at the level of upper border of L 2 vertebra. Lower renal vein of right side was emerging from lower pole of kidney and draining into inferior vena cava at the level of lower border of L 2 vertebra. Although on the left side, lower renal vein was emerging from lower pole of kidney but after receiving medial testicular vein it was draining into upper renal veins.

The two testicular veins on both sides were emerging from deep inguinal ring and were traversing supero-medially to drain into renal vein. Lateral testicular veins of both sides were draining into upper renal vein. Medial testicular veins of right side was bifurcating into two divisions-lateral one was connected with lower renal vein before draining into inferior vena cava whereas

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Fig 1: Double renal and double testicular vein along with right renal artery.

medial one was draining directly into inferior vena cava. On the left side, medial testicular vein was connected with lower renal vein, which ultimately drained into upper renal vein. Renal artery was single on the both sides. On the right side it was arising from the aorta at the level of upper border of L 3 vertebra, placed ventral to inferior vena cava, dorsal to right testicular veins and entering at the lower pole of kidney. On the left side, renal artery was arising from aorta at the level of upper border of L 2 vertebra and placed dorsal to upper left renal vein. In the middle of its course, it divided into three branches entering into upper pole, hilum and lower pole of kidney. Middle one was placed dorsal to the upper left renal vein. Both the kidneys have lobulation also.

Discussion:

In normal case, there in one renal vein and one testicular veins on each side. On right side, both renal veins and testicular vein open directly into inferior vena cava. But on the left side, testicular veins open first into left renal vein and than renal vein passes in front of aorta to drain into inferior vena cava.

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Fig 2: Left renal artery dorsal to left renal vein, dividing into three branches, along with lobulation of Kidney.

Renal artery arises from aorta at the level of L 2 vertebra. On the right side it passes dorsal to inferior vena cava and renal vein and on the left side dorsal to renal veins.

But in the present case, there were two renal vein on each side, placed parallel to each other. Upper renal vein was present at upper border of L 2, draining directly into inferior vena cava. Lower renal vein was observed at the level of lower border of L 2, right one draining into inferior vena cava and left one into upper renal vein.

Also, testicular veins were two in number, lateral one draining into upper renal vein and medial one into lower renal vein. On right side, a branch from medial testicular vein was draining directly into inferior vena cava.

Renal artery was single on the both sides arising at different levels. Right renal artery arising at the upper border of L 3 from aorta, instead of passing dorsal to inferior vena cava, it crossed ventral to it and dorsal to testicular veins. On left side, renal artery was a branch from abdominal aorta at the upper border of L 2 vertebra and passed posterior to upper renal vein. It divides into three branches, middle one was placed posterior to upper renal vein. In addition to these findings, both the kidneys were lobulated.

During development, in the 5 th week, three pair of major veins can be distinguished - Vitelline system draining GIT and gut derivatives, Umbilical system - carry orygenated blood from placenta, Cardinal system - draining head, neck and body wall. All the threesystems are bilaterally symmetrical and converge on the right and left horn of sinus venosus. However, the shift of systemic venous return to the right atrium, intiates radical remodelling that reshapes these system to yield the adult pattern. The cardinal system consists of anterior, posterior and common cardinal veins which open into sinus venosus. The posterior cardinal system is augmented and then superseded by paired subcardinal and supracardinal veins which develop in the body wall medial to the post cardinal vein and communicating with it cranially as well as caudally. The subcardinal system drains the structure of the median dorsal body wall, principally kidney and gonads. The right renal vein is a mesonephric vein that originally drains into that portion of right subcardinal veins which from part of inferior vena cava. The left renal vein is a mesonepheric vein that drains into left subcardinal vein - inter-subcardinal anastomosis. Testicular veins are remnant of that part of subcardinal vein which lie below intersubcardinal anastomosis.

The reason for our finding could be attributed to early stages of development. In this case, instead of single subcardinal and mesonephric veins, there may be doubling of subcardinal and mesonephric veins which gave rise to two pairs of renal and testicular vein respectively along with bilaterally lobulated kidney even in adult life. But on the left side, lower mesonephric vein joins medial subcardinal vein and instead of opening into inferior vena cava by intersubcardinal anastomosis, it opens directly into upper mesonephric veins.

Minor variation in mode of formation of veins are extremely common. Anomalies of major veins are however rare. Although detailed description of variation in inferior vena cava and renal veins were described in literature, but no published report could be found on association of renal and testicular venous malformation. With consistent to our findings, in a case reported by Toda (2001), there was double left renal vein associated with abdominal aortic aneurysm. One vein passing posterior to the aorta and one anterior to it forming a ring.

An additional renal vein on right side has also been reported which is similar to our findings (Dhar, 2002). A study of left renal vein variation in 1008 cases showed retroaortic vein in 0.5% cases and an additional vein in 0.4% cases (Satyapal, 1999).

Surucu (2002), reported a case of complex anomalies of vein of the retroperitoneum in a 57 year old male cadaver. There was double inferior vena cava with left supra-renal vein draining into left inferior vena cava and right testicular vein draining into right renal vein. In another case, multiple venous anomalies have been observed in 65 years old male cadaver. Left testicular vein and left supra-renal veins united inferior to superior mesentric artery, coursed anterior to the abdominal aorta and drained into inferior vena cava. Further, left renal vein coursed retroaortically and divided into three branches. The superior branch coursed on the vertebral column and drained into azygos veins while middle and inferior branches drained into inferior vena cava. In conformity with our report, in this case the right renal vein was double and both drained into inferior vena cava separately (Malcic, 2002).

References:

  1. Dhar P (2002): An additional renal vein. Clinical Anatomy, 15(1):64-66.
  2. Malcic-Gurbuz-Jasna; Akalin-aytul; Gumuscu,-Burak; Cavdar-Safiye (2002): Clinical implications of concomitant variations of testicular, suprarenal and renal veins: a case report. Ann Anat 184(1):35-39.
  3. Satyapal KS, Kalideen JM, Haffejee AA, Singh B, Robbs JV (1999): Left renal vein variations. Surg and Radiol Anat 21(1):77-81.
  4. Surucu, HS; Erbil KM; Tastan C; Yener N (2001): Anomalous veins of the retroperitoneum: clinical considerations. Surgical and Radiological anatomy 23(6):443-445.
  5. Toda R, Iguro Y, Moriyama Y, Hisashi Y, Masuda H, Sakata R (2001): Double left renal vein associated with abdominal aortic aneurysm. Ann Thorac Cardiovasc Surg 7(2):113-115.

Malformation of Renal and Testicular Veins - A case Report: Verma R, Kalra S & Rana K.

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