Nephron Sparing Surgery in Renal Tumors : A Case Report

A 69 yrs old male pA 69 yrs old male presented to our OPD with h/o left sided varicocele. A known case of Diabetes, hypertension and bilateral medical renal disease, he underwent MRI abdomen which revealed a large lower pole lesion in left kidney with no renal vein or IVC thrombus. DTPA Scan revealed a 61% function in the affected kidney. Due to his bilateral medical renal disease and poorly functioning contra lateral kidney, he was planned for Nephron Sparing Surgery / partial nephrectomy (L) and DJ Stent-ing under cold ischaemia. Post op patient initially showed a rise in creatinine levels which gradually settled down to pre oper-ative levels.

Before we go into the discussion of partial nephrectomy or nephron sparing surgery (NSS) in RCC, I would like to emphasize on the presenting complaint. Varicocele in the left side is one of the presentation of Left sided kidney mass, which occurs due to the drainage of the gonadal vein into the renal vein on the left side and generally indicates tumor thrombus in the venous system renal/ IVC, however in this case it was because of compression of left gonadal vein by the renal mass.

RRenal tumors comprise approximately 3.8% of all new cancers with median age at diagnosis of 64 yrs. It is the third most common urological malignancy. The rate of RCC has increased by 1.6% per year for last 10 yrs, the reason of which is un-known. Majority of them are renal cell carcinomas and 80% of them are clear cell variety.

Smoking and obesity are high risk factors of RCC. Some genetic diseases are also associated with RCC, like Von Hippel Lindau (VHL) disease.

At presentation 25% are locally advanced. More often patient presents with metastatic disease (20%) . Only a few patients present with Virchows Triad – the ‘too late triad’ ( of hematuria, abdominal pain and ank mass). A CT Scan or MRI of the whole abdomen including pelvis clinches the diagnosis. A NEEDLE BIOPSY IS NOT NECESSARY BEFORE SURGERY IF THERE ARE CLEAR FINDINGS IN IMAGING. It is only required when non surgical intervention is planned or if the patient is planned to be kept under surveillance only.

SuSurgery is the only denitive curative treatment for renal cancer, either in the form of NSS/ Radical Nephrectomy. Any of the open, laparoscopic or robotic techniques may be employed for either of the two procedures; with each having its own advan-tages and disadvantages .Types of Partial Nephrectomy are Polar segmental resection, Wedge resection, Major transverse re-section and Bench resection & auto transplant.

Indications for Open partial nephrectomy BOX 1• Solitary kidney• Large tumour• Central tumour• Multiple tumours• Requirement for cooling• Ischaemia > 30 min

Indications for Minimally Invasive techniques BOX2• Small < 3cm• Non central lesion

OOriginally partial nephrectomy (NSS) was indicated only in the clinical settings in which radical nephrectomy would make pa-tient functionally anephric or patient will require dialysis, like RCC in solitary kidney, but now it is becoming more common. The absolute indications are Solitary kidney, bilateral renal masses and Renal Impairment. There are also relative indications like small unilateral tumors and hereditary RCC. Partial nephrectomy has same oncological outcome till the stage 1B tumors, i.e , till a size of 7 cm tumor. Node dissection has no survival advantage and is a staging procedure only. At least 20% RCC cases acases are suitable for NSS. Cold ischemia is preferred in those cases where we anticipate the operative time following clamp-