EAU 2020: How to Best Approach the Large Renal Mass: Tips and Tricks

(UroToday.com) As part of the 2020 European Association of Urology (EAU) Virtual Meeting, a session on controversies in renal cancer surgery featured a presentation by Dr. Tim O’Brien discussing the optimal approach to large renal masses. As follows are 10 tips and tricks from Dr. O’Brien for managing large renal masses:

  • Tip #1: Remember that some masses cannot be removed. When determining resectability it is important to assess whether there is an invasion into the inferior vena cava (IVC), colon, tail of the pancreas, spleen, psoas muscle, diaphragm, lymph nodes, superior mesenteric artery (SMA), celiac trunk, duodenum, or bones.
  • Tip #2: It’s not all about size. Dr. O’Brien notes that some 20 cm masses are asymptomatic in patients with good performance status and are essentially “routine” nephrectomies (300 cc blood loss, operative time two hours). Conversely, some patients may present with a 13 cm mass, have hematuria and a pulmonary embolism with poor kidney function (2 L blood loss, operative time four hours).
  • Tip #3: For right-sided tumors – assess if the IVC is compressed or invaded. In these instances, it is important to carefully study preoperative imaging and pre-operatively plan accordingly (ie. vascular surgery consult, etc)
  • Tip #4: Large doesn’t always exclude partial. Particularly for large renal angiomyolipomas (AML), it is important to look for the renal ‘divot’ of an AML and assess the options for partial nephrectomy.
  • Tip #5: Operate with friends, this is a team sport. Dr. O’Brien notes that it is important to consider asking for assistance from other urologic oncology colleagues, cardiothoracic surgeons, and hepato-biliary surgeons.
  • Tip #6: It is important to make the correct incision, select the correct retractors and have the correct kit. This includes making the correct incision based on the side of the tumor and local extent. Dr. O’Brien is also an advocate of the Thompson liver retractor and having certain instruments such as horizontal angled clip appliers, Floseal, a no cable headlight, sharp-pointed instruments, and a 4-O Prolene® suture available at all times.
  • Tip #7: Ligate the renal artery early, the first 20-30 minutes is a dissection of the aorta. The first part of the operation is to dissect the fourth part of the duodenum off of the aorta by hugging the front of the aorta and subsequently sliding under the left renal vein. Also, Dr. O’Brien advocates for preoperative embolization of the renal artery if early ligation does not look possible.
  • Tip #8: For left (and right) sided tumors, the aorta is your friend. Specifically, when right-sided tumors cross the midline, hug the aorta to maintain reference in the retroperitoneum. When left-sided tumors approach the midline, hug the aorta and the iliac to maintain a frame of reference. It is also important to remember that above the renal vessels is dangerous, including the splenic artery and the SMA.
  • Tip #9: Exposure of the sub-diaphragmatic space. Mobilizing the right lobe of the liver allows exposure of the sub-diaphragmatic space for right-sided tumors, as does reflecting the spleen and the pancreas to expose the left sub-diaphragmatic space for left-sided tumors.
  • Tip #10: Remember that these masses are heavy. When 3kg of tumors are hanging off of the renal vein, avulsion of the vessel is a risk.

Presented by: Tim S. O’Brien, MA, DM, FRCS (Urol), Consultant Urological Surgeon, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom

Written by: Zachary Klaassen, MD, MSc, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Augusta, Georgia, Twitter: @zklaassen_md at the Virtual 2020 EAU Annual Meeting #EAU20, July 17-19, 2020