Campbell-Walsh Urology, 11th Edition

PART X

Neoplasms of the Upper Urinary Tract

60

Open Surgery of the Kidney

Aria F. Olumi; Mark A. Preston; Michael L. Blute, Sr.

Questions

1. A healthy 45-year-old man with no family history of cancer is found to have a 6-cm enhancing mass in the upper pole of his right kidney. A 2-cm solitary nodule is noted on preoperative chest radiography. Computed tomography (CT) confirms a solitary nodule in the lower lobe of the right lung. What is the most appropriate treatment course?
2. Systemic chemotherapy alone
3. Radical right nephrectomy and postoperative chemotherapy
4. Biopsy of pulmonary nodule
5. Radical nephrectomy and simultaneous pulmonary metastectomy
6. Radical nephrectomy with staged resection of pulmonary nodule 6 weeks postoperatively
7. What is the preferred technique for radical nephrectomy and removal of tumor thrombus above the level of the diaphragm in the absence of significant metastatic disease?
8. Flank incision with extensive liver mobilization and removal of tumor through an incision in the diaphragm
9. Flank incision with cardiopulmonary bypass and deep hypothermic circulatory arrest (CPB-DHCA)
10. Chevron incision with CPB-DHCA
11. Chevron incision with Pringle maneuver
12. Midline incision with CPB-DHCA
13. Deep hypothermic circulatory arrest (DHCA) can have irreversible neurologic effects after what period of time?
14. 10 minutes
15. 20 minutes
16. 40 minutes
17. 60 minutes
18. 90 minutes
19. In a 45-year-old man with a normal contralateral kidney and no family history of kidney cancer, in which of the following clinical scenarios would partial nephrectomy be indicated?
20. Two tumors less than 3 cm each in the upper and lower pole
21. Single 8-cm tumor in the upper pole
22. Single 2-cm tumor in a hilar location with small renal vein tumor thrombus
23. Single 4-cm tumor in any location
24. All of the above
25. What is the strongest modifiable risk factor for renal insufficiency after partial nephrectomy?
26. Duration of renal ischemia
27. Surgical approach
28. Administration of nephrotoxins
29. Resection margin
30. Administration of heparin
31. During a posterior right lumbotomy approach, what is the order of appearance of the renal artery, renal vein, and renal pelvis?
32. Artery, renal pelvis, vein
33. Artery, vein, renal pelvis
34. Renal pelvis, artery, vein
35. Vein, renal pelvis, artery
36. Renal pelvis, vein, artery
37. Match the following T stage with the tumor characteristics:
38. T3c
39. T1a
40. T3a
41. T4
42. T2b
43. Greater than 10 cm confined to capsule
44. Less than 4 cm confined to capsule
45. 6 cm invading adrenal gland
46. 5 cm with renal sinus fat invasion
47. 13 cm with renal vein thrombus invading the wall of the inferior vena cava
48. Five days after left partial nephrectomy for a hilar tumor, there is persistent drainage from the Penrose drain site. Laboratory analysis of the drain fluid demonstrates elevated amylase levels. Imaging studies demonstrate small bowel dilation consistent with ileus and fluid around the tail of pancreas. What is the ideal management?
49. Antibiotics
50. Immediate surgical exploration
51. Percutaneous drain placement
52. Nasogastric tube placement, parenteral nutrition, and conservative management
53. Nasogastric tube placement, low-fat diet, and conservative management
54. Which segmental branch of the renal artery is most consistent and supplies 25% of the arterial supply to the renal unit?
55. Apical (superior) segmental artery
56. Anterior superior segmental artery
57. Posterior segmental artery
58. Anterior inferior segmental artery
59. The basilar (inferior) segmental artery
60. What maneuver refers to the reflection of the second and third portions of the duodenum in a medial direction to expose the right renal vessels and ventral inferior vena cava?
61. Cattell maneuver
62. Langenbeck maneuver
63. Sorcini maneuver
64. Kocher maneuver
65. Pringle maneuver
66. What partial nephrectomy technique should be used as a last resort in a solitary kidney?
67. Enucleation
68. Wedge resection
69. Cryotherapy
70. Polar resection
71. Extracorporeal repair and autotransplantation
72. The subcostal nerve may be inadvertently transected during an anterior subcostal incision for a radical nephrectomy. Between what two layers does this nerve run?
73. Posterior peritoneum and transversalis fascia
74. Scarpa fascia and external oblique muscle
75. External oblique and internal oblique
76. Internal oblique and transversalis
77. Skin and Scarpa fascia
78. What is the motor deficit resulting from transaction of the subcostal nerve?
79. Winged scapula
80. Hemidiaphragmatic paralysis
81. Paresis of the flank musculature and flank bulge
82. Inability to flex ipsilateral adductor muscle
83. Weakness of contralateral rectus abdominis muscle
84. What percentage of patients have multiple renal arteries?
85. 0% to 2%
86. 2% to 10%
87. 10% to 20%
88. 20% to 30%
89. More than 30%
90. Which of the following is NOT an indication for simple nephrectomy?
91. Nonfunctional chronically infected kidney
92. Nonfunctional persistently hydronephrotic kidney causing pain
93. Renovascular hypertension refractory to medical and nephron-sparing surgical intervention
94. Polycystic kidney with minimal function and recurrent infections
95. Kidney with 8-cm enhancing upper pole hilar mass
96. Two days after cardiopulmonary bypass and circulatory arrest (20 minutes) for an extensive right-sided renal mass with thrombus extending into the atrium, using traditional median sternotomy, a relatively healthy 36-year-old patient is unable to be extubated and has no purposeful right-sided movement. Imaging reveals a large left-sided cerebrovascular infarct. What clinical scenario can explain this event?
97. Pulmonary air embolism
98. Cerebral ischemia from bypass and circulatory arrest
99. Tension pneumothorax
100. Right main stem bronchial intubation
101. Unrecognized paradoxical embolism
102. Which form of therapy has been considered the "gold standard" for localized renal cell carcinoma?
103. Chemotherapy
104. Immunotherapy
105. Radiation
106. Hormonal therapy
107. Surgical resection
108. On postoperative day 2 after radical nephrectomy for a 14-cm complex left renal tumor using an anterior midline incision, there are overt signs of peritonitis. The patient is 72 years old with significant atherosclerotic disease. At exploration, the entire small bowel is necrotic and nonviable. What artery was inadvertently ligated?
109. Celiac
110. Left gastric
111. Inferior mesenteric
112. Superior mesenteric
113. Right gastroepiploic
114. During resection of a large right renal mass, the main renal artery is identified, ligated, and divided, but the renal vein fails to decompress. What is the most likely explanation for this?
115. Renal vein tumor thrombus
116. Subclinical renal arteriovenous malformation
117. Bleeding disorder
118. Arterial collateral branch vessels
119. Extensive venous collateral obstruction
120. What is most appropriate setting for a thoracoabdominal incision?
121. Large right upper pole renal mass with tumor thrombus in the renal vein
122. 5-cm right renal tumor in a hilar location
123. Large left lower pole tumor with extensive lymphadenopathy
124. Large right renal mass with tumor thrombus to the retrohepatic level
125. A 10-cm right lower pole tumor with arteriovenous malformation
126. What is the most common complication associated with performing CPB-DHCA for the removal of large renal cell tumor thrombus?
127. Pulmonary air emboli
128. Intestinal ischemia
129. Bleeding and coagulopathy
130. Lower extremity tumor emboli
131. Tumor emboli
132. Which of the following is NOT a proposed benefit of renal artery embolization (RAE)?
133. Shrinkage of an arterialized tumor thrombus to ease surgical removal
134. Reduced blood loss
135. Facilitation of dissection due to tissue plane edema
136. Ability to ligate the renal vein before the renal artery at time of nephrectomy
137. Modulation of the immune response
138. None of the above
139. What is the most common complication after RAE?
140. Groin hematoma from puncture site
141. Paraplegia from spinal artery occlusion
142. Coil migration
143. Postinfarction syndrome (pain, nausea, and fever)
144. Adrenal insufficiency
145. What is the most common complication after partial nephrectomy for nonexophytic renal masses?
146. Hemorrhage
147. Renal failure
148. Rhabdomyolysis
149. Hydronephrosis
150. Urinary leak
151. Ten days after a left partial nephrectomy for a 4.5-cm hilar tumor, there is persistent fluid output from the surgical drain. No ureteral stent was placed at the time of surgery, and a small opening in the collecting system was oversewn. The creatinine concentration of the drain fluid is 34.5 mg/dL, consistent with urine. Despite conservative management, the volume fails to decline. A retrograde pyelogram demonstrates a moderate amount of contrast extravasation, confirming the urinary fistula. What is the most appropriate management at this time?
152. Immediate reexploration and repair
153. Percutaneous nephrostomy tube placement
154. Removal of surgical drain
155. Internalized ureteral stent placement
156. Internalized ureteral stent placement, continued surgical drain monitoring, and placement of Foley catheter

Answers

1. d. Radical nephrectomy and simultaneous pulmonary metastectomy.This patient would be best managed with a radical nephrectomy and simultaneous removal of the pulmonary nodule. Systemic therapy is not a primary treatment unless there is extensive metastatic disease at presentation. Given his age and lack of medical problems, there is no reason to delay the removal of his kidney and the pulmonary nodule. The tumor location and pulmonary nodule both can be accessed through one incision (i.e., thoracoabdominal).
2. c. Chevron incision with CPB-DHCA.CPB-DHCA has been established as the most prudent course for the removal of these tumor thrombi. The chevron incision provides the best exposure. Alternatives to CPB, including extensive liver mobilization and intrapericardial resection, carry an increased risk of bleeding.
3. c. 40 minutes.The duration of DHCA can vary depending on the degree of tumor thrombus. Vena cava resection and substitution can add additional time if there is significant tumor invasion into the wall of the vena cava. Studies have suggested that irreversible neurologic effects may be observed after 40 minutes of DHCA.
4. d. Single 4-cm tumor in any location.In patients with a normal contralateral kidney, the current literature supports elective partial nephrectomy for single T1 tumors.
5. a. Duration of renal ischemia.Duration of renal ischemia is the strongest modifiable risk factor for renal insufficiency after partial nephrectomy.
6. c. Renal pelvis, artery, vein.The renal pelvis is the first structure one encounters with the posterior right lumbotomy incision, followed by the artery and vein. This approach can be used to repair ureteropelvic junction obstruction, especially in children or patients with multiple prior abdominal and/or flank surgeries.
7. a: T2b; b: T1a; c: T4; d: T3a; e: T3c.
8. d. Nasogastric tube placement, parenteral nutrition, and conservative management.Conservative management of a pancreatic fistula should be the first approach in this patient. Initial nasogastric tube placement can help resolve the ileus. Parenteral nutrition will limit any pancreatic secretions from oral intake.
9. c. Posterior segmental artery.The posterior division is the first and most consistent branch point of the renal artery and supplies roughly one fourth of the blood supply.
10. d. Kocher maneuver.Mobilization of the second and third portions of the duodenum is referred to as a Kocher maneuver. The Pringle maneuver is the temporary occlusion of the porta hepatis. The Langenbeck maneuver is the division of the coronary and right triangular ligaments, providing medial rotation of the right lobe of the liver and exposure of the suprarenal inferior vena cava.
11. e. Extracorporeal repair and autotransplantation.All patients with solitary kidneys are high-risk candidates for partial nephrectomy and may have transient renal impairment postoperatively. The degree and duration of renal impairment may be increased owing to risks associated with renal autotransplantation (hemorrhage, thrombosis, lymphocele, stenosis).
12. d. Internal oblique and transversalis.The subcostal nerve runs between these two layers. Caution must be taken not to sever this nerve during flank incisions.
13. c. Paresis of the flank musculature and flank bulge.Damage to the subcostal nerve results in denervation and paresis of the flank musculature, leading to chronic postoperative pain or flank bulge.
14. d. 20% to 30%. Multiple postmortem and radiographic studies estimate that 25% of the general population have supernumerary renal arteries.
15. e. Kidney with 8-cm enhancing upper pole hilar mass.There should be little reservation about performing a radical nephrectomy for an enhancing mass, especially in the upper pole. Almost all nonmalignant disease affecting the kidney can be treated via a simple approach.
16. e. Unrecognized paradoxical embolism.This rare but devastating clinical situation occurs in patients with a patent foramen ovale. An embolism may originate from tumor thrombus manipulation or from deep venous thromboembolism.
17. e. Surgical resection.There have been numerous studies to suggest that surgical resection is the mainstay of therapy for kidney cancer.
18. d. Superior mesenteric.Ligation of the superior mesenteric artery produces ischemia in the bowel distribution above. The superior mesenteric artery can be mistaken for the left renal artery from the anterior approach. Visualizing the artery from a posterior position as it enters the hilum will help to minimize this complication.
19. d. Arterial collateral branch vessels.Failure of the renal vein to decompress after ligation of the main renal artery indicates additional arterial inflow, which may be secondary to a missed lower or upper pole artery or extensive collateral arteries.
20. a. Large right upper pole renal mass with tumor thrombus in the renal vein.The thoracoabdominal incision is ideal for larger tumors involving the upper pole. The incision is also ideal for managing tumor thrombus extending into the renal vein. The inferior vena cava can be nicely exposed via this approach.
21. c. Bleeding and coagulopathy.Intraoperatively, the administration of heparin in addition to hypothermia leads to significant coagulopathy. The bleeding from heparin is typically limited to an "ooze" intraoperatively and should not consume time and energy during the operation. After tumor removal, the rewarming process helps to promote coagulation.
22. f. None of the above. Proposed benefits of preoperative RAE include shrinkage of an arterialized tumor thrombus to ease surgical removal, reduced blood loss, facilitation of dissection due to tissue plane edema, ability to ligate the renal vein before the renal artery at time of nephrectomy, and modulation of the immune response.
23. d. Postinfarction syndrome (pain, nausea, and fever). The triad of fever, flank pain, and nausea occurs in up to 75% of patients after angioembolization.Fevers can often exceed 39.4 ° C (103 ° F) and are best managed with antipyretics.
24. e. Urinary leak.Partial nephrectomy for nonexophytic masses has an increased risk of entering the collecting system. Even when the collecting system is closed under direct vision, there may still be extravasation of urine that collects in the perirenal space. The use of postoperative surgical drains is imperative in the management of these collections to reduce the risk of infections. In addition, the drain output volume can be observed to determine if collections are resolving. Renal failure is rare unless operating on a solitary kidney or on a patient with marginal renal function. Rhabdomyolysis can be encountered secondary to patient positioning and increased body mass index.
25. e. Internalized ureteral stent placement, continued surgical drain monitoring, and placement of Foley catheter. Placement of a ureteral stent can promote urine drainage into the bladder. Keeping a Foley catheter in place reduces urine reflux.

Chapter review

1. The right renal artery is posterior to the inferior vena cava.
2. Renal arteries are end arteries; ligation results in infarction of the segment that they supply.
3. The renal venous network intercommunicates.
4. Lumbar veins often enter the left renal vein and, not infrequently, the right renal vein. They enter posteriorly. Care must be taken when encircling the renal vein not to tear one of these lumbar veins.
5. There is no conclusive evidence that renal artery embolization has any immunologic therapeutic benefit.
6. The renal artery is always ligated before the renal vein when performing a nephrectomy; each vessel is ligated individually.
7. Patients with a glomerular filtration rate of less than 60 mL/min or those with significant proteinuria are at risk for postoperative renal failure following renal surgery—particularly when a nephrectomy is performed.
8. Adrenalectomy is not recommended as part of a radical nephrectomy unless imaging shows adrenal involvement with tumor or an upper pole tumor is contiguous with the adrenal.
9. Transesophageal echocardiography is an excellent modality to determine the level of the vena cava tumor thrombus immediately before the surgical event.
10. In patients with vena cava tumor thrombi cephalad to the hepatic venous outflow who require CPB, either mild hypothermia and no circulatory arrest or significant hypothermia with circulatory arrest may be performed. Each technique has its advantages and disadvantages. The method used is at the discretion of the surgeon.
11. The addition of a lymphadenectomy to a radical nephrectomy for renal cell carcinoma has a questionable impact on progression-free and overall survival. It may be considered in patients who have enlarged lymph nodes on preoperative imaging, those in whom cytoreductive surgery is being performed, and those with ominous pathologic findings of the primary renal tumor.
12. Ligation of the right renal vein will result in failure of the right renal unit due to lack of venous collateral vessels.
13. Ligation of the left renal vein is possible because collateral venous drainage may occur through lumbar and gonadal vessels.
14. The renal vein ostium of the vena cava should be excised in patients with vena cava tumor thrombi, as invasion of the vena cava vein wall at this site is not uncommonly found.
15. 25% of the general population have supernumerary renal arteries.
16. The superior mesenteric artery can be mistaken for the left renal artery from the anterior approach. Rarely, the hepatic artery can be mistaken for the right renal artery. Visualizing the artery from a posterior position relative to the renal vein as it enters the hilum will help identify the renal artery.
17. Proposed benefits of preoperative renal artery embolization include shrinkage of an arterialized vena cava tumor thrombus to ease surgical removal, reduced blood loss, facilitation of dissection due to tissue plane edema, and the ability to ligate the renal vein before the renal artery at time of nephrectomy. These patients may develop the postinfarction syndrome (pain, nausea, and fever). The triad of fever, flank pain, and nausea occurs in up to 75% of patients after angioembolization.