Genitourinary—Renal Mass

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70

Concept

Unusual question, but more important in everyday surgical life. Variety of renal masses including abscess, cyst, benign tumors, and malignancy—primary or metastatic. Look for suggestive history. Don’t fall prey to percutaneous biopsy of suspected malignancy, and don’t confuse with adrenal lesion!

How to Answer?

History

Flank pain

Hematuria

Fever, chills

Family history of Renal Cell Carcinoma (RCC) Prior malignancy (lung or breast can metastasize to

kidney)

New varicocele (especially left renal mass) Hypercalcemia

Tuberous sclerosis Renal insufficiency

Physical Exam

Unlikely to feel the mass Varicocele

Evidence of metastatic disease

How to Answer?

Need complete labs, CXR, U/A Diagnostic tests can include:

IVP—usually the first test to evaluate a pt with hema- turia

U/S—can determine if cystic or solid, can evaluate for simple cysts with no septa or calcifications (these can be symptomatic but almost always benign)

CT—can evaluate solid lesion, inspect renal vein and IVC, look for metastatic lesions

MRI—if any doubt about IVC thrombus

CT guided needle bx—rarely done for solid lesions as risk of bleeding and tumor seeding

Angiogram—pre-op embolization of large lesions is a consideration

Surgical Treatment

Dependent on lesion

RCC gets radical nephrectomy

Transitional Cell Carcinoma (TCC) gets radical nephroureterectomy

Don’t go into describing these—say you would refer to a urologist!

Make sure to assess renal function and contribution from side you are planning to remove—pt may need post-op hemodialysis

Common Curveballs

Lesion will be cystic with internal echoes/septae Pt will need hemodialysis post-op

Lesion will be TCC if you don’t rule it out with ureteroscopy/bx

Pt will bleed from any percutaneous bx attempt Pt will be symptomatic from simple cystic lesion (just

need to unroof)

Will actually be an adrenal lesion (changing scenario)

Strikeouts

Offering laparoscopic kidney resection Percutaneous bx of solid lesion

Not referring to urologist (at least try before taking on a case outside of your specialty)

Genitourinary—Renal Mass

Concept

How to Answer?

History

Flank pain

Fever, chills

Family history of Renal Cell Carcinoma (RCC) Prior malignancy (lung or breast can metastasize to

kidney)

New varicocele (especially left renal mass) Hypercalcemia

Tuberous sclerosis Renal insufficiency

Physical Exam

Unlikely to feel the mass Varicocele

Evidence of metastatic disease

How to Answer?

Need complete labs, CXR, U/A Diagnostic tests can include:

IVP—usually the first test to evaluate a pt with hema- turia

U/S—can determine if cystic or solid, can evaluate for simple cysts with no septa or calcifications (these can be symptomatic but almost always benign)

CT—can evaluate solid lesion, inspect renal vein and IVC, look for metastatic lesions

MRI—if any doubt about IVC thrombus

CT guided needle bx—rarely done for solid lesions as risk of bleeding and tumor seeding

Angiogram—pre-op embolization of large lesions is a consideration

Surgical Treatment

Dependent on lesion

RCC gets radical nephrectomy

Transitional Cell Carcinoma (TCC) gets radical nephroureterectomy

Don’t go into describing these—say you would refer to a urologist!

Make sure to assess renal function and contribution from side you are planning to remove—pt may need post-op hemodialysis

Common Curveballs

Lesion will be cystic with internal echoes/septae Pt will need hemodialysis post-op

Lesion will be TCC if you don’t rule it out with ureteroscopy/bx

Pt will bleed from any percutaneous bx attempt Pt will be symptomatic from simple cystic lesion (just

need to unroof)

Will actually be an adrenal lesion (changing scenario)

Strikeouts

Offering laparoscopic kidney resection Percutaneous bx of solid lesion

Not referring to urologist (at least try before taking on a case outside of your specialty)

Not ruling out metastatic disease IVC thrombosis—can extend to right atrium

Not checking for possible lung/breast CA with met to kidney

Performing radical nephrectomy only for TCC

Genitourinary—Renal Mass