An Incidental Finding

1. An Incidental Finding

2. 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 deficits • Unremarkable blood work up

3. 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.

5. 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.

10. 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 IVC • Other retroaortic. • Normal right Kidney • No other disease.

17. 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.

18. 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.

19. 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

20. 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.

21. Thank you