| ORIGINAL REPORTS |
ABSTRACT
A case of a renal artery stenosis and ipsilateral renal cell carcinomawith long term results is reported. A 65-year-old man with renovascularhypertension, renal insufficiency, and nephrotic range proteinuria presentedwith an incidental renal cell carcinoma. Concomitant in situ left partialnephrectomy and splenorenal arterial bypass was achieved. The patient isdoing well without evidence of malignancy, stable renal function, markedlyimproved proteinuria and stable blood pressure more than three years later.The techniques of this procedure are detailed and underscore the possibilityof successful removal of a renal cell carcinoma with preservation of renalfunction despite renal artery stenosis.
INTRODUCTION
Renal parenchymal sparing is widely accepted for the treatment of renalcell cancer particularly in patients with renal insufficiency.1Likewise, the benefits of renal revascularization procedures are well documented.2,3These techniques individually have been well elucidated.4 However,we believe this is the first detailed report of a simultaneous ipsilateralpartial nephrectomy and renal artery bypass procedure.
CASE REPORT
A 65-year-old man presented with long-standing hypertension, renal insufficiency,nephrotic range proteinuria and transient ischemic attacks. In the courseof evaluation for a possible abdominal aortic aneurysm and hypertension,screening abdominal ultrasound revealed an incidental two centimeter solidleft renal mass. His antihypertensive medications were nifedipine (ProcardiaXLTM)* 90 mg. per day and clonidine patch 0.1 mg./day/week. Blood pressurewas 150/90 mm. Hg. and serum creatinine was 2.3 mg.%. Creatinine clearancewas 49 ml. per minute and 24 hour urinary protein was 2.8 grams. CT scanconfirmed a 2 cm. solid left renal mass (fig.1a).The CT also showed well perfused kidneys with equal dimensions. A differentialnuclear renal function study was not considered necessary. Metastatic workup including CT of the chest, isotopic bone scan, and MRI of the abdomenwere unremarkable. Renal angiography showed a hypervascular left lowerpole renal mass, high grade ostial stenosis of a single left renal artery,and a normal right renal artery (fig.1b). The abdominal aorta and iliac arteries demonstrated moderate calcificatherosclerosis, minimal ostial disease of the celiac takeoff and a patentsplenic artery. Further testing demonstrated no evidence of significantcarotid or coronary artery disease.
Because of the patients renal insufficiency and a well perfused, viableleft kidney a partial nephrectomy and splenorenal arterial bypass was selectedas the procedure of choice. On July 9, 1994, exploration was performedthrough a left subcostal intraperitoneal approach. After ensuring therewere no metastatic deposits, the left retroperitoneum was exposed by reflectingthe descending and transverse colon medially. With the exception of thekidneyís upper pole where the adrenal was dissected free, Gerotaísfascia was retained on the kidney and its mass. Next, the main renal arteryand vein were completely mobilized. Generally, when performing partialnephrectomy the renal artery is occluded with a vascular clamp and thekidney is cooled with sterile ice slush to limit blood loss and acute tubularnecrosis. However, owing to the high grade stenosis of the renal arterywith its consequent increased risk of thrombosis, we elected not to clampthe artery and perform partial nephrectomy without cooling. Systemic heparinizationwas not employed. The tumor and overlying perinephric fat were excisedwith sharp dissection. Intra operative pathology consultation demonstrated0.5 cm. tumor-free parenchymal margins. Bleeding points and open collectingsystem was controlled with absorbable sutures. The renal capsule and aportion of adjacent remaining vascularized perinephric fat were re-approximatedover the defect created by removal of the tumor. After ensuring good hemostasisand doppler pulsations to the remaining renal tissue, attention was focusedon the revascularization procedure.
The splenic artery was mobilized from near the celiac axis to the tailof the pancreas. Small branches were divided between fine silk ties. Avascular bulldog clamp was placed proximally and the splenic artery wastransected and secured distally with a heavy silk tie. Good blood flowwas demonstrated by temporarily releasing the clamp. At this juncture theleft renal artery was secured proximally with a heavy silk tie and dividedjust distal to the area of ostial stenosis. It was flushed with heparinizedsaline and a small vascular clamp was placed on the distal renal artery.Both the cut ends of the renal and splenic arteries were trimmed to lengthand spatulated. The vessels were then anastomosed end to end using fineinterrupted cardiovascular sutures. The bulldogs were released, first fromthe renal artery and then from the splenic artery. There was an excellentpulse in the renal artery and no anastomotic leakage. The vessels had asmooth course without kinking, tension, or coiling. Prior to closing, aclosed suction drain was employed in the perinephric space to identifythe development of any possible urinoma.
Postoperative course was marred by gangrenous cholecystitis and recurrentaspiration from a poor gag reflex. However, complete recovery ensued. Finalpathologic staging confirmed clear parenchymal margins but there were microscopicfoci of tumor in the perirenal fat. The tumor had clear cell pattern andwas moderately differentiated with a nuclear grade of II of IV. Also, thesurrounding noncancerous renal parenchyma showed 30% glomerulosclerosisand cholesterol emboli. The patient is now doing well more than three yearslater. Angiography shows excellent restoration of blood flow to the kidney(fig. 2). There is noevidence of any recurrent renal cell carcinoma on serial CT scans and chestX-rays. Blood pressure is better controlled (135/82 mm./Hg.) on nifedipine(Procardia XL) 30 mg. per day, clonidine 0.1 mg. per day, and atenolol25 mg. bid. Serum creatinine is stable and measures 1.9 mg.%, creatinineclearance is 34.1 ml. per minute, and 24 hour urinary protein is 0.48 grams.
DISCUSSION
Renal cell carcinoma and coexistent ipsilateral renal artery stenosisappear to be an uncommon combination. Kaufman et. al.5 describedtwo patients with partial nephrectomy and vascular repair. However, detailsare not complete. Dean et. al.6 presented two cases of partialnephrectomy and autotransplantation for renal cell carcinoma and renalartery stenosis. Campbell et. al.7 presented 4 patients withpartial nephrectomy and ipsilateral renal artery bypass; 3 with aortorenalbypass and one with hepatorenal bypass.
One goal of therapy should include preservation of renal parenchymawhen there is potential for risk for ensuing renal failure and need fordialysis. Our patient had a creatinine clearance of 49 ml./min. suggestingthe need for nephron sparing surgery. Another goal of therapy is the correctionof significant renal artery stenosis to preserve functioning renal tissue,improve or stabilize blood pressure control and correct ischemic relatedproteinuria. The association of ischemic nephropathy and proteinuria iswell documented and may be corrected by reversing the problem.8Our case further documents this connection.
One consideration when performing nephron sparing surgery includes thepossibility of local recurrence either from multifocality, tumor spillageor inadequate margins. Fortunately, the incidence is generally only 4%.9Certainly in our case the expected recurrence would be higher (8.2%)9as there was perinephric fat involvement with tumor. Close follow up hasnot shown any recurrence but periodic, lifelong imaging is mandatory.
Careful preoperative preparation is mandatory to avoid significant cardiovascularor cerebrovascular accidents. Furthermore, precise surgical planning isneeded to select the appropriate revascularization procedure most feasible.Our patient had an abdominal aortogram, in the anterior-posterior viewas well as the lateral view. The lateral view enables good visualizationof the celiac axis origin. The primary open surgical treatment option forleft sided renovascular disease would be aortorenal bypass with an autologousgraft with saphenous vein or internal iliac artery. If the aorta is significantlydiseased then the next option would be a left iliac artery to left renalartery bypass with saphenous vein. Unfortunately, our patient had bothaortic and iliac artery atherosclerosis. The celiac axis was normal indicatinga normal splenic artery without significant obstruction. Therefore, splenorenalarterial bypass was chosen.
In conclusion, we have shown excellent results in a patient requiringipsilateral simultaneous partial nephrectomy and splenorenal arterial bypass.There is no evidence of recurrent malignancy as well as stable blood pressurecontrol and renal function for more than three years.
*Pfizer Inc., New York, New York
1. Licht, M.R. and Novick, A.C.: Nephron sparing surgery for renal cellcarcinoma. J. Urol. 149: 1, 1993.
2. Libertino, J.A., Bosco, P.B., Ying, C.Y., Breslin D.J., Woods, BOíB.,Tsapatsaris, N.P. and Swinton, N.W. Jr.: Renal revascularization to preserveand restore renal function. J. Urol., 147: 1485, 1992.
3. Novick, A.C., Ziegelbaum, M., Vidt, D.G., Gifford, R.W. Jr., Pohl,M.A. and Goormastic, M.: Trends in surgical revascularization for renalartery disease. Ten yearsís experience. J.A.M.A., 257: 498,1987.
4. Libertino, J.A.: Renovascular surgery. In Campbellís Urology,6th ed. Edited by P.C. Walsh, A.B. Retik, T.A. Stamey and E.D. VaughanJr. Philadelphia: W. B. Saunders Co., vol. 3, chapt. 67, sect. XIV, pp2521-2551, 1992.
5. Kaufman, J.J., Marks, L.S. and Smith, R.B.: Stenosis of the renalartery and coexistent lesions. Surg. Gynec. and Obst., 139: 59,1974.
6. Dean, R.H., Meacham, P.W. and Weaver, F.A.: Ex vivo renal arteryreconstructions: indications and techniques. J. Vasc. Surg., 4:546, 1986.
7. Campbell, S.C., Novick, A.C., Streem, S.B. and Klein, E.A.: Managementof renal cell carcinoma with coexistent renal artery disease. J. Urol.,150: 808, 1993.
8. Pickering, T.G., Blumenfeld, J.D. and Laragh, J.H.: Renovascularhypertension and ischemic nephropathy. In Brenner and Rectorís theKidney, 5th ed. Edited by B.M. Brenner. Philadelphia: W. B. Saunders Co.,vol. 2, chapt. 47, sect. IV, pp. 2106-2125, 1996.
9. Hafez, K.S., Novick, A.C. and Campbell S.C.: Patterns of tumor recurrenceand guidelines for follow up after nephron sparing surgery for sporadicrenal cell carcinoma. J. Urol., 157: 2067, 1997
ILLUSTRATIONS
Figure 1a. Preoperative CT revealing 2 cm. solid lower pole left renalmass.
Figure 1b. Preoperative angiogram showing high grade left renal arteryostial stenosis (arrow).
Figure 2. Postoperative angiogram showing widely patent end to end splenicartery to left renal artery bypass.