Case #1: This was a 66-year-old female with a solitary kidney after having undergone a prior left nephrectomy for a 5.5 cm clear cell RCC. In 2013, two right incidental renal masses (4.5 cm and 3 cm) were noted on follow-up imaging; her medical history included hypertension and her eGFR was 42. CT imaging of the 4.5 cm mass:
Management options posed to the panel included open partial nephrectomy, robotic partial nephrectomy, laparoscopic radical nephrectomy and percutaneous cryoablation. The consensus of the panel was to perform an on-clamp (ischemia time <30 min) partial nephrectomy, either open or robotic given the surgeon’s comfort level performing robotic procedures. Dr. Sundaram did a robotic partial nephrectomy of both masses and final pathology was pT1b (for the larger mass) and pT1a for the smaller mass, both with negative margins. On follow-up radiographic imaging, she developed a solitary pancreatic metastasis that was resected in 2015, followed by recurrence of an enhancing mass in the right kidney in 2016, which was observed until it was 3 cm. At this point she underwent an open partial nephrectomy secondary to a previously operated on right kidney, which the panel agreed would be quite complex robotically, particularly in the setting of a solitary kidney.
Case #2: This was a 54-year-old male with bilateral renal masses and prostate cancer. This gentleman’s PSA was 13.6 and a prostate biopsy demonstrated Gleason 4+3 prostate cancer in 5/6 cores on the right with 30% involvement. On staging CT, there was an 8-cm enhancing mass occupying the upper half of the left kidney, and a 2.8 cm enhancing mass on the lower pole of the right kidney. CT imaging of the left renal mass:
Additional medical history included CKD (eGFR 51), hypertension, hyperlipidemia, type 2 diabetes mellitus, and obstructive sleep apnea. The consensus of the panel was to treat the kidney before the prostate and they were given the following next treatment options: laparoscopic left radical nephrectomy, robotic right partial nephrectomy, robotic left partial nephrectomy, and percutaneous right renal cryoablation. The panel acknowledged that the classical teaching is to treat the easier side (right side in this case) first, however the agreement was to treat the larger side first in this case for several reasons: (i) the risk of conversion for the right-sided smaller mass these days is quite low, and (ii) the risk of pT3 disease and progression from the left sided lesion is quite high. Additionally, the panel agreed that these should be staged procedures, starting with a left robotic partial nephrectomy. Dr. Sundaram did perform a left robotic partial nephrectomy, with a warm ischemia time of 30 minutes and post-operative creatinine of 1.93 (from 1.72 preoperatively). Pathology demonstrated an 8cm x 7.5cm x 6.5cm papillary renal cell carcinoma, type 2, Fuhrman grade 3. In follow-up, the patient’s right renal mass in the solitary kidney was observed until it reached 5 cm in size at which time he had a robotic enucleation without vascular control – pathology was also papillary RCC.
Presented By: Ketan Badani, Mount Sinai Hospital, New York, NY; Mihir M. Desai, University of Southern California, Los Angeles, CA; Jihad Kaouk, Cleveland Clinic Foundation, Cleveland, OH
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, @zklaassen_md ,at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV