Retroperitoneal laparoscopic partial nephrectomy for multiple T1b renal carcinomas in a solitary kidney: A case report

Abstract

This case highlights the effective use of retroperitoneal laparoscopic partial nephrectomy (RLPN) in a 73-year-old female with two large renal carcinomas in her solitary kidney, including a 7 cm deeply infiltrating mass. The RLPN procedure successfully resected both tumors with a thermal ischemia time of 28 minutes, 110 minutes of surgery, and only 30 mL of blood loss. The patient’s postoperative recovery was excellent, with no hemorrhage or urine leakage and only a mild increase in serum creatinine levels. Discharged after 10 days without dialysis, this case supports RLPN as a safe, effective method for similar renal tumors.

1 Introduction

This case is particularly noteworthy due to the successful execution of retroperitoneal laparoscopic partial nephrectomy (RLPN) on a patient with a solitary kidney containing multiple large renal carcinomas. Such cases are rare and present significant surgical challenges, particularly in achieving complete oncological control while preserving renal function.Partial nephrectomy (PN), in the context of an isolated kidney with renal cell carcinoma, may provide favorable oncological and renal functional results at a manageable risk of complications. Most patients with a solitary kidney have stable long-term renal function after more than 50 % reduction in renal mass. PN for treating tumors in a solitary kidney is often performed using open surgery. This approach is typically favored due to the challenges associated with laparoscopic procedures, such as ensuring optimal tumor exposure, minimizing thermal ischemia time, and reducing the risk of postoperative complications like bleeding and urine leakage. Complete PN performed entirely through a retroperitoneal laparoscopic approach is clinically rare due to these complexities. In this case, we successfully employed advanced retroperitoneal laparoscopic partial nephrectomy techniques to achieve complete resection of two large tumors while maximizing the preservation of renal function.

2 Patient and observation

2.1 Patient information

The patient is a 73-year-old female with a medical history of a radical left nephrectomy performed several years ago due to malignant renal tumors (The specific pathological results of the tumor are unknown) . During a recent health examination, color Doppler ultrasound revealed two renal tumors in the right kidney, with the largest tumor exceeding 7 cm in diameter. The patient exhibited no gross hematuria or lumbar pain, and physical examination did not reveal any palpable lumbar masses. She had not undergone any treatment for these tumors at the time of discovery. The patient also has a history of hypertension and type 2 diabetes, both of which are well-controlled with medication, maintaining appropriate blood pressurand glucose levels. Enhanced CT confirmed the presence of two tumors in the solitary right kidney, with a high suspicion of malignancy ( Fig. 1 ). There was no evidence of local invasion or distant metastasis. Her serum creatinine level was recorded at 94 μmol/L. The final diagnosis was a solitary kidney with renal tumors, clinically staged as T1bN0M0.

2.2 Therapeutic interventions

The surgical plan was discussed with the patient, and potential surgical complications such as kidney failure were explained. The patient acknowledged understanding and signed the surgical consent form.Following effective anesthesia, the surgical bed is modified to the “folding knife position” and the patient is placed in the left lateral position with a soft pillow under their waist. A 2 cm skin incision was made in the posterior axillary line, beneath the lumbar rib margin. The muscle layer and lumbar dorsal fascia were then dilated into the retroperitoneal space, taking care not to dissect the muscle fibers as much as possible. Next, the retroperitoneal space was dilated using a dilator, and an incision was made in the iliac crest mid-axillary line, in the anterior axillary line beneath the rib margins, and slightly above the midpoint of the line connecting them. Finally, a pneumoperitoneum was regularly set up in the C02 (pneumoperitoneum at a gas pressure of 12 mm Hg, and a gas flow rate of 20L/min). The kidney’s lower pole is released and positioned to protect the ureter after the retroperitoneal fat is removed, opening the renal fascia and perinephric fat capsule. In order to locate the appropriate renal artery and properly release it for preparation, the renal hilum was divided along the lumbaris major muscle. The kidney was released intact after the perinephric fat had been sliced along the kidney’s long axis. A 3∗3 cm tumor (tumor 1) was observed dorsally in the kidney’s top pole, while a 6∗6 cm tumor (tumor 2) was observed ventrally in the kidney’s middle section. The three renal arteries were clipped and timed using renal vascular blocking clips.Tumor 2 was resected using scissors at a distance of 0.5 cm from the tumor. The blood vessels supplying the tumor and the collecting system encountered during the clipping process were sealed with Hem-o-lock clips until the tumor was entirely removed ( Fig. 2 A). Using an electrocoagulation hook to carefully cease the bleeding, hemostatic gel was sprayed. Barbed sutures (3-0 and 2-0) were utilized to seal the surgical wound ( Fig. 2 B). Tumor 1 was removed immediately after using the same procedure, and the injury was sutured ( Fig. 2 C and D). After suture completion, the renal artery was opened and pneumoperitoneum pressure was reduced to check for any active bleeding or seepage from the incision. The kidney’s ischemia period lasted for28 minutes.During the procedure, two tumors were removed. Fig. 3 illustrates a schematic representation of the surgical procedure. With an operating duration of 110 minutes and a thermal ischemia time of 28 minutes, the patient’s surgical treatment went smoothly. There were no complications following the procedure. On the first postoperative day, she was permitted to begin eating, and on the third postoperative day, she was allowed to leave his bed.After surgery, the patient’s postoperative serum creatinine rose to 358 Umol/L before gradually declining to 205 Umol/L 12 days later. The patient also had a 24-h urine output of more than 2000 ml and entirely normal electrolytes. The patient experienced hematuria and lumbar discomfort on the 14th day following surgery. Serum creatinine climbed to 454 Umol/L and then progressively fell to 162 Umol/L following the emergency ureteroscopy that was used to place the ureteral stent tube( Fig. 4 ). Following complete bed rest and cautious measures, the hematuria subsided and the lower back pain disappeared. The final pathological diagnoses of both Tumor 1 and Tumor 2 were clear cell renal cell carcinoma. No tumor cells were identified at the surgical margins of either tumor. According to the International Society of Urological Pathology (ISUP) grading system, both tumors were classified as Grade 2. Two weeks post-surgery, the patient successfully underwent ureteral stent removal. In solitary kidney patients, we believe it is necessary to perform a follow-up CT scan after stent removal to evaluate the morphology of the kidney and ureter. The follow-up CT scan revealed well-preserved morphology of the solitary kidney and ureter, with no evidence of perirenal hemorrhage. ( Fig. 5 ).