br Discussion The RAA was first discovered

Discussion The RAA was first discovered during the autopsy of a large ruptured aneurysm in 1770; since then, numerous case reports and series have revealed its epidemiology and pathophysiology. Indicators for intervention in a patient with RAA include the following: rupture or acute dissection, symptomatic RAA (renal artery stenosis-related medically refractory hypertension, recurrent flank pain, or hematuria), renal thromboembolism, occurrence in a pregnant woman or a woman contemplating pregnancy, and a lesion >2 cm or with excessive interval growth. Notably, there is no consensus about the repair of large RAAs in asymptomatic patients; in one study, RAAs with diameters ranging from 1.5 cm to 3 cm were recommended for repair, although most surgeons suggested 2 cm. In another study, asymptomatic patients with RAAs smaller than 1.5 cm were recommended regular follow-ups without operative treatment because of the infrequency of RAA-related complications. In our patient, the RAA measured 1.6 cm in diameter and was treated conservatively at first; however, interval growth to 2.0 cm was noted at the 6-month follow-up, and surgical intervention was subsequently advised to prevent further complications. The first reported case of RAA repair using an extracorporeal technique for renovascular Phos-tag was described by Ota et al in 1967; several techniques have been described since then. Endovascular interventions such as coil embolization or stent graft placement are minimally invasive procedures for RAA management and can be used to treat extraparenchymal or intrarenal aneurysms. Excellent short-term results have been observed for simple saccular RAAs with narrow necks, and occasionally in broad-neck cases; notably, long-term outcomes have not been well defined. In our patient, the fusiform RAA was located in the left renal artery at bifurcation, and because of the complex RAA pattern, coil embolization or a stent graft was not a feasible option. Although in situ repair can be performed with relatively no restriction caused by the RAA morphology through an open approach with or without a free kidney and ureter, the surgical wound would need to be extended for proper display, which entails significant incisional morbidity. Concerning minimally invasive techniques, in situ repair under a laparoscopic or robotic procedure and control of warm ischemic time to <30 minutes would be a challenge for a surgeon in this case. Ex vivo repairs provide surgeons with a clear and bloodless surgical field, enabling them to perform the procedure with less effort and in sufficient cold ischemic time, under infusion with a renal preservation solution. One study examined seven cases of saccular RAAs (size, >2 cm) treated using laparoscopic nephrectomy followed by ex vivo repair of the renal artery and autotransplantation; the outcomes were satisfactory. No study of fusiform RAA management with a similar surgical technique has been reported. Laparoscopic donor nephrectomy is widely used in renal transplantation, and the benefits of reduced invasion, reduced blood loss, less pain, and improved recovery are well documented. Through hand-assisted laparoscopic donor nephrectomy, we harvested the affected kidney and extracted MPF through a 7-cm sized incision wound created for a hand-assisted port. During ex vivo RAA reconstruction by the vascular surgeon, a urologist simultaneously performed standard prepping and draping of the left pelvic area for autotransplantation, then dissected and exposed the external iliac vessels. Multidisciplinary teamwork facilitated acquiring the short cold ischemic time of approximately 180 minutes, which, because of the fusiform morphology of the RAA, rendered the aneurysmectomy more difficult than a saccular aneurysm would be. The location of the aneurysm at the bifurcation of the left renal artery, and marked atherosclerosis change also required greater effort for vessel reconstruction. Moreover, atherosclerosis with renal artery stenosis is the most common cause of renovascular hypertension. In our patient, control of blood pressure improved during further follow-up visits.