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Ex vivo nephron-sparing surgery and kidney autotransplantation for renal tumors

Ex vivo nephron-sparing surgery and kidney autotransplantation for renal tumors The nephron-sparing techniques allow the excision of kidney tumors preserving renal function and ensuring adequate oncological results. We describe a case of a 77-year-old patient who underwent an ex vivo partial nephrectomy with orthotopic autotransplantation for kidney cancer. The postoperative course was marked by bleeding which required radiological embolization. Postoperative dialysis was required for about 1 month. The anatomopathological examination showed a clear cell carcinoma staged pT1b, pNX, R0. At 2 years follow-up, no recurrence was detected with a complete renal function restoration. Our experience shows that ex vivo nephron-sparing surgery with autotransplantation is a good alternative to total nephrectomy in the case of voluminous or perihilar tumors. Considering the high morbidity of this procedure, it should be only performed in specialized centers. CASE REPORT INTRODUCTION The nephron-sparing techniques allow the excision of the lesion, A 77-year-old woman was admitted for an asymptomatic mass of the left kidney. The patient was overweight (BMI: 27.3 kg/m ), preserving renal function and ensuring adequate oncological results [1]. This procedure is recommended in patients with a had arterial hypertension and non-insulin-dependent diabetes mellitus. The creatinine value and preoperative glomerular fil- solitary kidney, voluminous sized-masses, centro-renal location and when the in vivo partial nephrectomy (PN) is difficult to tration rate were within normal limits. CT-scan showed a mass of 50 × 30 × 40 mm diameter in achieve. Hardy et al. in 1963, described for the first time the treatment of a severe traumatic lesion of the ureter treated with the anterior and middle region of the left kidney involving the medium calyceal group (Fig. 1A). Due to the size of the tumor and explantation, repair and autotransplantation [2]. Since then, this procedure has been used extensively to repair ureter injuries, its central location, an ex-vivo PN and kidney autotransplantation was planned. renal artery aneurysms and much more rarely for kidney cancers [3]. Xifo-pubic incision was performed. The left colon and spleen were mobilized exposing the left kidney. The ureter was identi- In the present study, we report our experience with ex-vivo PN and kidney autotransplantation for renal tumors. fied at the level of the iliac vessels and the homolateral gonadal Received: December 7, 2020. Revised: December 29, 2020. Accepted: January 2, 2021 Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2021. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 1 Downloaded from https://academic.oup.com/jscr/article/2021/2/rjab004/6139136 by DeepDyve user on 23 February 2021 2 F. Crafa et al. Figure 1: (A) Preoperative computed tomography: the white arrow shows the renal mass; (B) removal of the tumor during bench surgery; (C) suture of the renal calices during bench surgery; (D) macroscopic examination of the surgical piece. vessels were sectioned. The renal hilum was exposed and then, The subsequent course was uneventful and the drains were renal artery and vein were clamped and dissected. The kidney removed on the 12th postoperative day. was immediately immersed in ice-cold serum and perfused with The patient was discharged on the 20th postoperative day 4 C hypertonic citrate adenine solution through the renal artery. with a progressive renal function improvement. Dialysis was The renal capsule was incised and the tumor was resected needed for about a month and was subsequently stopped. The with at least 1 cm margin of healthy parenchyma, with double J silicone catheter was removed 5 weeks later. microscopic frozen section examination negative for neoplastic The anatomopathological examination showed a clear cell residue (Fig 1B–D). The sectioned vessels were tied with carcinoma, with a stage II Fuhrman grading. The pathological polypropylene 6–0 (Ethicon ), while the renal calices and the tumor stage was pT1b, pNX, R0. pelvis were sutured with a polypropylene 7–0 running suture At 24 months follow-up, no evidence of local or distance (Ethicon ) (Fig. 2A and B). The kidney was repositioned in recurrence was detected and renal function was normal. its natural location (Fig. 2C). End-to-end artery anastomosis with polypropylene 7–0 separate stitches and end-to-end vein DISCUSSION anastomosis with two running sutures in polypropylene 6–0 were performed. Double J silicone catheter (Coloplast, Bologna) The main indications for ex vivo nephron-sparing surgery and was inserted and the ureteral stumps were anastomosed with kidney autotransplantation are centrally or perihilar located PDS 6–0 (Ethicon ). The hemostasis on the residual renal tumors, when PN in situ is risky due to the impossibility of parenchyma was completed with polypropylene 6–0 separate guaranteeing free surgical margins. In addition, it is the only stitches and with a hemostatic sponge (TachoSil - Nycomed, valid option for patients who have an acquired or functional Konstanz, Germany). Two drains were placed anteriorly and solitary kidney, as Ono et al. [4] showed in their case report. posteriorly to the surgical site. This technique is also an option for multifocal or bilateral The total duration of the procedure was 4 h with a total tumors; Abraham et al. [5] described a case of a young patient ischemia time of 2 h. The mean estimated blood loss was 120 ml. with giant bilateral angiomyolipoma who was treated with a No intraoperative complications occurred. The immediate post- bilateral open nephrectomy, ex-vivo PN and kidney autotrans- operative course was marked by an increase of creatinine value plantation in two separate sessions. and diuresis contraction for which the patient underwent dial- Concerning surgical approach, laparoscopic and open PN ysis for 1 month. On the 10th postoperative day, the patient have the same indications with similar oncological outcomes showed signs of active bleeding, confirmed by a CT-scan with and intraoperative complication rates when performed in high the presence of a lower polar artery pseudoaneurysm resolved experience centers [6, 7]. According to our expertise, we decided by radiological embolization. to perform an open surgical approach. Downloaded from https://academic.oup.com/jscr/article/2021/2/rjab004/6139136 by DeepDyve user on 23 February 2021 Ex vivo nephron-sparing surgery and kidney autotransplantation 3 Figure 2: (A) Approximation of the margins of the section with interposition of a hemostatic sponge; (B) kidney at the end of the bench surgery; (C) intraoperative view after vascular anastomoses. Regarding the anatomical kidney implantation, it is usually 3. Hau HM, Bartels M, Tautenhahn HM, Morgul MH, Fellmer P, placed in the iliac fossa with anastomosis between the renal and Ho-Thi P, et al. Renal autotransplantation—a possibility in iliac vessels [6, 8]. Only Kulisa et al. [7] performed an orthotopic the treatment of complex renal vascular diseases and ureteric transplant, like in our patient. In the case of autotransplantation injuries. Ann Transplant 2012;17:21–7. for ureteral injuries or vascular aneurysms, implantation in a 4. Ono S, Kenmochi T, Ito T, Aida N, Otsuki K, Akutsu N, heterotopic site is required. In the case of cancerous lesions, et al. Renal autotransplantation and extracorporeal nephron- implantation at the anatomical site may be a viable alternative. sparing surgery for De novo renal cell carcinoma in a kidney Acute vascular bleeding and urinary fistulas are the most allograft. Transplant Direct 2017;3:e122. frequent complications [7, 9]. In our case, the patient developed 5. Abraham GP, Siddaiah AT, Ramaswami K, George D, Das K. an artery pseudoaneurysm and an active bleeding that required Ex-vivo nephron-sparing surgery and autotransplantation for an interventional radiology procedure. Kulisa et al. [7] reported renal tumours: revisited. Can Urol Assoc J 2014;8:E728–32. two cases of vascular thrombosis requiring surgery and removal 6. Tran G, Ramaswamy K, Chi T, Meng M, Freise C, Stoller of the transplanted kidney. ML. Laparoscopic nephrectomy with autotransplantation: Functionally, acute tubular necrosis was the main cause of safety, efficacy and long-term durability. J Urol 2015;194: dialysis and it may be related to the time of cold ischemia [7]. 738–43. In conclusion, ex vivo PN with autotransplantation is a good 7. Kulisa M, Bensouda A, Vaziri N, Fassi-Fehri H, Badet L, alternative to total nephrectomy in the case of bulky and perihi- Colombel M, et al. Complex renal tumors on solitary kidney: lar tumors. Considering the high morbidity of this procedure, it results of ex vivo nephron-sparing surgery with autotrans- should be performed in expert centers. plantation. Prog Urol 2010;20:194–203. 8. Ju X, Li P, Shao P, Lv Q, Wang Z, Qin C, et al. Retroperitoneal laparoscopic nephrectomy combined with bench surgery and REFERENCES autotransplantation for renal cell carcinoma in the soli- 1. Mac Lennan S, Imamura M, Lapitan MC, Omar MI, Lam TB, tary kidney or tumor involving bilateral kidneys: experience Hilvano-Cabungcal AM, et al. Systematic review of oncolog- at a single Center and technical considerations. Urol Int ical outcomes following surgical management of localised 2016;97:473–9. renal cancer. Eur Urol 2012;61:972–93. 9. Moghadamyeghaneh Z, Hanna MH, Fazlalizadeh R, Obi Y, 2. Hardy JD. High ureteral injuries. Management by autotrans- Foster CE, Stamos MJ, et al. A Nationwide analysis of kidney plantation of the kidney. JAMA 1963;184:97–101. autotransplantation. Am Surg 2017;83:162–9. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Ex vivo nephron-sparing surgery and kidney autotransplantation for renal tumors

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Oxford University Press
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Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2021.
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2042-8812
DOI
10.1093/jscr/rjab004
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Abstract

The nephron-sparing techniques allow the excision of kidney tumors preserving renal function and ensuring adequate oncological results. We describe a case of a 77-year-old patient who underwent an ex vivo partial nephrectomy with orthotopic autotransplantation for kidney cancer. The postoperative course was marked by bleeding which required radiological embolization. Postoperative dialysis was required for about 1 month. The anatomopathological examination showed a clear cell carcinoma staged pT1b, pNX, R0. At 2 years follow-up, no recurrence was detected with a complete renal function restoration. Our experience shows that ex vivo nephron-sparing surgery with autotransplantation is a good alternative to total nephrectomy in the case of voluminous or perihilar tumors. Considering the high morbidity of this procedure, it should be only performed in specialized centers. CASE REPORT INTRODUCTION The nephron-sparing techniques allow the excision of the lesion, A 77-year-old woman was admitted for an asymptomatic mass of the left kidney. The patient was overweight (BMI: 27.3 kg/m ), preserving renal function and ensuring adequate oncological results [1]. This procedure is recommended in patients with a had arterial hypertension and non-insulin-dependent diabetes mellitus. The creatinine value and preoperative glomerular fil- solitary kidney, voluminous sized-masses, centro-renal location and when the in vivo partial nephrectomy (PN) is difficult to tration rate were within normal limits. CT-scan showed a mass of 50 × 30 × 40 mm diameter in achieve. Hardy et al. in 1963, described for the first time the treatment of a severe traumatic lesion of the ureter treated with the anterior and middle region of the left kidney involving the medium calyceal group (Fig. 1A). Due to the size of the tumor and explantation, repair and autotransplantation [2]. Since then, this procedure has been used extensively to repair ureter injuries, its central location, an ex-vivo PN and kidney autotransplantation was planned. renal artery aneurysms and much more rarely for kidney cancers [3]. Xifo-pubic incision was performed. The left colon and spleen were mobilized exposing the left kidney. The ureter was identi- In the present study, we report our experience with ex-vivo PN and kidney autotransplantation for renal tumors. fied at the level of the iliac vessels and the homolateral gonadal Received: December 7, 2020. Revised: December 29, 2020. Accepted: January 2, 2021 Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2021. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 1 Downloaded from https://academic.oup.com/jscr/article/2021/2/rjab004/6139136 by DeepDyve user on 23 February 2021 2 F. Crafa et al. Figure 1: (A) Preoperative computed tomography: the white arrow shows the renal mass; (B) removal of the tumor during bench surgery; (C) suture of the renal calices during bench surgery; (D) macroscopic examination of the surgical piece. vessels were sectioned. The renal hilum was exposed and then, The subsequent course was uneventful and the drains were renal artery and vein were clamped and dissected. The kidney removed on the 12th postoperative day. was immediately immersed in ice-cold serum and perfused with The patient was discharged on the 20th postoperative day 4 C hypertonic citrate adenine solution through the renal artery. with a progressive renal function improvement. Dialysis was The renal capsule was incised and the tumor was resected needed for about a month and was subsequently stopped. The with at least 1 cm margin of healthy parenchyma, with double J silicone catheter was removed 5 weeks later. microscopic frozen section examination negative for neoplastic The anatomopathological examination showed a clear cell residue (Fig 1B–D). The sectioned vessels were tied with carcinoma, with a stage II Fuhrman grading. The pathological polypropylene 6–0 (Ethicon ), while the renal calices and the tumor stage was pT1b, pNX, R0. pelvis were sutured with a polypropylene 7–0 running suture At 24 months follow-up, no evidence of local or distance (Ethicon ) (Fig. 2A and B). The kidney was repositioned in recurrence was detected and renal function was normal. its natural location (Fig. 2C). End-to-end artery anastomosis with polypropylene 7–0 separate stitches and end-to-end vein DISCUSSION anastomosis with two running sutures in polypropylene 6–0 were performed. Double J silicone catheter (Coloplast, Bologna) The main indications for ex vivo nephron-sparing surgery and was inserted and the ureteral stumps were anastomosed with kidney autotransplantation are centrally or perihilar located PDS 6–0 (Ethicon ). The hemostasis on the residual renal tumors, when PN in situ is risky due to the impossibility of parenchyma was completed with polypropylene 6–0 separate guaranteeing free surgical margins. In addition, it is the only stitches and with a hemostatic sponge (TachoSil - Nycomed, valid option for patients who have an acquired or functional Konstanz, Germany). Two drains were placed anteriorly and solitary kidney, as Ono et al. [4] showed in their case report. posteriorly to the surgical site. This technique is also an option for multifocal or bilateral The total duration of the procedure was 4 h with a total tumors; Abraham et al. [5] described a case of a young patient ischemia time of 2 h. The mean estimated blood loss was 120 ml. with giant bilateral angiomyolipoma who was treated with a No intraoperative complications occurred. The immediate post- bilateral open nephrectomy, ex-vivo PN and kidney autotrans- operative course was marked by an increase of creatinine value plantation in two separate sessions. and diuresis contraction for which the patient underwent dial- Concerning surgical approach, laparoscopic and open PN ysis for 1 month. On the 10th postoperative day, the patient have the same indications with similar oncological outcomes showed signs of active bleeding, confirmed by a CT-scan with and intraoperative complication rates when performed in high the presence of a lower polar artery pseudoaneurysm resolved experience centers [6, 7]. According to our expertise, we decided by radiological embolization. to perform an open surgical approach. Downloaded from https://academic.oup.com/jscr/article/2021/2/rjab004/6139136 by DeepDyve user on 23 February 2021 Ex vivo nephron-sparing surgery and kidney autotransplantation 3 Figure 2: (A) Approximation of the margins of the section with interposition of a hemostatic sponge; (B) kidney at the end of the bench surgery; (C) intraoperative view after vascular anastomoses. Regarding the anatomical kidney implantation, it is usually 3. Hau HM, Bartels M, Tautenhahn HM, Morgul MH, Fellmer P, placed in the iliac fossa with anastomosis between the renal and Ho-Thi P, et al. Renal autotransplantation—a possibility in iliac vessels [6, 8]. Only Kulisa et al. [7] performed an orthotopic the treatment of complex renal vascular diseases and ureteric transplant, like in our patient. In the case of autotransplantation injuries. Ann Transplant 2012;17:21–7. for ureteral injuries or vascular aneurysms, implantation in a 4. Ono S, Kenmochi T, Ito T, Aida N, Otsuki K, Akutsu N, heterotopic site is required. In the case of cancerous lesions, et al. Renal autotransplantation and extracorporeal nephron- implantation at the anatomical site may be a viable alternative. sparing surgery for De novo renal cell carcinoma in a kidney Acute vascular bleeding and urinary fistulas are the most allograft. Transplant Direct 2017;3:e122. frequent complications [7, 9]. In our case, the patient developed 5. Abraham GP, Siddaiah AT, Ramaswami K, George D, Das K. an artery pseudoaneurysm and an active bleeding that required Ex-vivo nephron-sparing surgery and autotransplantation for an interventional radiology procedure. Kulisa et al. [7] reported renal tumours: revisited. Can Urol Assoc J 2014;8:E728–32. two cases of vascular thrombosis requiring surgery and removal 6. Tran G, Ramaswamy K, Chi T, Meng M, Freise C, Stoller of the transplanted kidney. ML. Laparoscopic nephrectomy with autotransplantation: Functionally, acute tubular necrosis was the main cause of safety, efficacy and long-term durability. J Urol 2015;194: dialysis and it may be related to the time of cold ischemia [7]. 738–43. In conclusion, ex vivo PN with autotransplantation is a good 7. Kulisa M, Bensouda A, Vaziri N, Fassi-Fehri H, Badet L, alternative to total nephrectomy in the case of bulky and perihi- Colombel M, et al. Complex renal tumors on solitary kidney: lar tumors. Considering the high morbidity of this procedure, it results of ex vivo nephron-sparing surgery with autotrans- should be performed in expert centers. plantation. Prog Urol 2010;20:194–203. 8. Ju X, Li P, Shao P, Lv Q, Wang Z, Qin C, et al. Retroperitoneal laparoscopic nephrectomy combined with bench surgery and REFERENCES autotransplantation for renal cell carcinoma in the soli- 1. Mac Lennan S, Imamura M, Lapitan MC, Omar MI, Lam TB, tary kidney or tumor involving bilateral kidneys: experience Hilvano-Cabungcal AM, et al. Systematic review of oncolog- at a single Center and technical considerations. Urol Int ical outcomes following surgical management of localised 2016;97:473–9. renal cancer. Eur Urol 2012;61:972–93. 9. Moghadamyeghaneh Z, Hanna MH, Fazlalizadeh R, Obi Y, 2. Hardy JD. High ureteral injuries. Management by autotrans- Foster CE, Stamos MJ, et al. A Nationwide analysis of kidney plantation of the kidney. JAMA 1963;184:97–101. autotransplantation. Am Surg 2017;83:162–9.

Journal

Journal of Surgical Case ReportsOxford University Press

Published: Feb 16, 2021

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