THE EXPANDING SCOPE OF
NEPHRON-SPARING SURGERY

Preservation of Kidney in Renal Tumours
– a new standard of care

A 55-year-old gentleman was incidentally detected to have a large left renal mass on evaluation for hypertension and a left-sided stroke. CT-scan revealed a heterogeneously enhancing left upper pole renal mass (7.5x6cm) with no lymphadenopathy or renal vein involvement. He underwent Thrombolysis for his stroke and recovered well with mild residual memory and speech deficit. Given his recent history of stroke, the experts at Nanavati decided to wait for about 6-8 weeks for surgery.

Repeat MRI after 8 weeks showed no change in size. At this point, he was stable neurologically and fit for surgery but required 3 medications to control his blood pressure. Given the deleterious impact that hypertension could have on a single kidney, the doctors explained to him that they would attempt a Partial Nephrectomy to conserve normal renal tissue. However, given the complexity and size of the Tumour, the doctors consented for a Radical Nephrectomy as well.

A successful open Partial Nephrectomy preserving 50% of his left kidney was performed through the 11th rib supracostal approach. Two renal arteries were identified intraoperatively and temporarily clamped, with an ischemia time of 20 minutes. His post-operative recovery was uneventful and he was discharged with a serum creatinine of

0.8 mg (pre-operatively 0.7 mg). His Pathology revealed oncocytoma with negative margins of excision.

Partial Nephrectomy (PN) or NephronSparing surgery was traditionally performed only in cases of solitary kidneys, bilateral tumours or preexisting renal impairment; and Radical Nephrectomy was performed for all other Renal Tumours. Indications for Partial Nephrectomy evolved as studies showed that Chronic Kidney Failure (usually secondary to diseases like Hypertension and Diabetes Mellitus) was more likely to cause patient mortality than recurrences of Renal Cancer. Initially, Partial Nephrectomy (PN) was restricted to Tumours bigger than 4 cm in size, but with greater experience and further research, it is now advocated even in Tumours upto 10 cm if technically feasible.

Diabetes and Hypertension are rampant today with India being considered the Diabetes capital of the world. These lifestyle illnesses have a tremendous impact on the kidney, and uro-oncologists today aim to preserve renal function i.e. renal tissue whenever surgically possible. Robotic Surgery allows doctors the minimally invasive approach which has proven equivalent to open surgery. However, given the cost constraints, Robotic surgery was not performed in this case.

Dr. Vivek Venkat
Consultant
Uro-oncologist &
Robotic Urologist
Nanavati Super Speciality Hospital, Mumbai

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