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A minimally invasive approach for single stage management of double metatstasis in a solitary kidney and crossover adrenal metastasis

INTRODUCTION AND OBJECTIVES

Double metatstatic lesions in a solitary functioning renal unit with crossover adrenal metastasis have been rarely reported. This video demonstrates the operative management of a similar presentation.

METHODS

65 year old male experienced left flank pain since 1 month. He underwent right radical nephrectomy and left adrenalectomy for crossover metastasis through bilateral subcostal incisions 2 years prior. Left scapula was resected for metastatic deposits 1 year ago. ASA score was Grade I. Blood profile was normal. Imaging revealed solitary functioning left kidney with 2 heterogeneously enhancing lesions 3.5 X 2.5 centimeter and 2 X 1.5 centimeter involving the upper and lower pole respectively and an enhancing lesion in contralateral adrenal. Renal vein and other organs were free of tumor. Laparoscopic right adrenalectomy, left radical nephrectomy, bench dissection and autotransplantation was planned.

RESULTS

Right laparoscopic adrenalectomy was conducted in left lateral decubitus. Dense adhesions were encountered. 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. Both the lesions were removed with 1 centimeter cuff of healthy parenchyma and renorrhaphy performed with No 2/0 polyglactin suture. Autotransplantation was conducted through the same incision. Patient experienced short period of acute tubular necrosis in the postoperative period following which renal function normalised. He resumed normal activities by 1 week. Histopathology of both renal and adrenal lesions conferred to metastatic deposists of clear cell renal carcinoma. He received targeted chemotherapy.

CONCLUSIONS

Small volume metastasis in solitary kidney in a patient with good performance score demands ablation with adjuvant therapy. Minimally invasive ablative options are in situ partial nephrectomy, cryoablation or radical nephrectomy, bench dissection and autotransplantation. Bench perfusion of renal parenchyma with cold perfusate provides optimum renal cooling and maximum nephron salvage is possible. Also no facilities for cryoablation were available. Hence we opted for this approach. Despite technical challenges the procedure was successfully completed. The morbidity profile was excellent.