An Incidental Finding

Patient:

Referred to Urology service following an incidental finding of a 3.7 x 3.8 cm enhancing lesion arising from the lower pole of the left kidney

HxPC: Presented to A&E c/o intermittent seizures.

Increasing frequency over the previous 3/52.A/W generalized Left sided weakness and partial parasthesia. No cranial nerve deficitsUnremarkable blood work up

Plan: Admitted to the general internal medicine team Urgent CTB: 6 x 4.5 x 4 cm space occupying lesion in the

right parietal area. Followed by MRI brain on the same day.

Patient:

MRI showed a heterogenous 6 x 4.5 x 4 cm enhancing lesion in the right parietal area.

Extensive vasogenic odema and midline shift. Mass effect on the contralateral side. DDx: Meningioma.

A CT TAP was performed to R/O other malignant disease.

Patient:

CT TAP: 3.7 x 3.8 cm enhancing mass in the lower pole of the left kidney.

Solitary renal arteries bilaterally 2 renal veins draining the left kidney.

One coarsing anterior to the aorta and draining into the IVCOther retroaortic.

Normal right Kidney No other disease.

Management:

Following resection of the Meningioma, pt was admitted from home for an elective Left partial nephrectomy

This was an open procedure using a left subcostal approach. The renal artery was isolated. The lower pole branch was selectively

isolated and this was then dissected close to the hilum. The ureter was identified and isolated, the lower pole artery was

temporarily occluded and the tumor excised. Occlusion time was 11 mins. The lower pole calyx was closed. Robinsons drain and UC were inserted.

Post-op:

Pathology : Clear cell RCC pT1a Grade 2.

Pt self removed drain day 1 post op. Spiked 38.9C temp the same evening and was commenced on

IV Tazocin Day2 CT urogram showed a no collections or leaks. Fever resolved and there was an uncomplicated course to

discharge on day 7.

Learning Points:

The incidence of RCC has been rising steadily

Highest worldwide incidences in northern Europe and NA

M:F 1.5-2:1

A/W Smoking, high BMI, and HTN

Clear cell renal cell carcinoma is the most common histologic variant (75-88%)

Particular rise in the proportion of small, asymptomatic tumors detected

incidentally via abdominal imaging.

RCC can remain occult for much of the disease course

25-32% present with metastases

2011 study looking retrospectively at 3001 Colonographic, CT abdo and CTTAP

found incidental renal masses in 443 patients (14.4%).

Smaller, pre-symptomatic lesions may be amenable to a Nephron Sparing

approach

Learning Points:

Initial management of the incidentally diagnosed or early presenting

lesion is by partial or total nephrectomy.

The aim is neprhron sparing when possible.

Particularly in peripheral tumors

Laprascopic techniques are common.

However not suited to all cases and is limited when the calyx is incised

or if inter-renal suturing is required.

Higher incidence of positive surgical margins

Longer warm ischaemic time

No significant increase in organ loss.

Thank you