Single-Stage Minimally Invasive Management of Dual Malignancy in a Solitary Kidney and Crossover Adrenal Metastasis: Role of Bench Dissection and Autotransplantation

Abstract

Introduction: Double malignancy in a solitary functioning renal unit with crossover adrenal metatstasis in a patient with good performance status poses a challenging problem to the clinician. In situ partial nephrectomy or probe ablative therapies have been popularly practiced for such scenarios.1 We report a similar presentation that was managed by laparoscopic radical nephrectomy, bench dissection, and removal of the lesions followed by autotransplantation. The video demonstration of the operative exercise spans over 7 minutes 30 seconds. Materials and Methods: A 65-year-old man experienced left flank pain since 1 month. He underwent right radical nephrectomy and left adrenalectomy for crossover metastasis through bilateral subcostal incisions 2 years ago. Left scapula was resected for metastatic deposits 1 year ago. American Society of Anesthesiologists (ASA) score was Grade I. Blood profile was normal. Imaging revealed solitary functioning left kidney with two heterogeneously enhancing lesions 3.5×2.5 and 2×1.5 cm involving the upper and lower pole, respectively, and an enhancing lesion in contralateral adrenal. Renal vein and other organs were free of tumor. Laparoscopic approach was planned. Results and Discussion: Right laparoscopic adrenalectomy was conducted in left lateral decubitus. Dense adhesions were encountered. Adrenalectomy specimen was trapped in a retrieval bag. Thereafter in right lateral decubitus, left radical nephrectomy was performed. Upper pole dissection was difficult due to previous adrenalectomy. Specimens were extracted through a right lower quadrant incision. Warm ischemia time was 2 minutes. The kidney was immersed in ice slush and perfused with cold perfusate. In bench, both the lesions were removed with 1-cm cuff of healthy parenchyma. Renorrhaphy was performed with No 2/0 polyglactin suture. Autotransplantation was conducted through the same incision. Patient experienced short period of acute tubular necrosis postprocedure after which renal function normalized. He resumed normal activities by 1 week. Histopathology of renal lesions conferred to clear cell renal carcinoma Grade II, margins free. Histopathology of adrenal revealed metatstatic deposits of clear cell carcinoma. He received targeted chemotherapy. Small volume metastasis in solitary kidney in a patient with good performance score demands selective ablation with adjuvant therapy. In situ partial nephrectomy for dual lesions may subject the renal unit to increased warm ischemia and consequences thereof. Laparoscopic radical nephrectomy and bench dissection limits the warm ischemia incurred, provides optimum renal cooling, and enables maximum nephron salvage. Also, no facilities for cryoablation were available. Hence, we adopted this approach. Bench dissection with autotransplantation has been practiced in limited scenarios so far, and in most situations incisional approach has been employed both for extirpation and retrieval.2 In this scenario, extirpation was undertaken through minimally invasive approach. The morbidity profile and cosmesis were appreciable. Autotransplantation avoided the need for permanent hemodialysis that adds to patient morbidity and increases the financial burden borne by the patient. No competing financial interests exist. Runtime of video: 7 mins 30 secs