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Surgical Techniques

for Kidney Cancer

Rakesh V. Khanna
Gennady Bratslavsky
Robert J. Stein
Surgical Techniques for Kidney Cancer
Rakesh V. Khanna Gennady Bratslavsky

Robert J. Stein

Surgical Techniques
for Kidney Cancer

Rakesh V. Khanna Robert J. Stein
Department of Urology Glickman Urological and Kidney Institute
SUNY Upstate Medical University Cleveland Clinic
Syracuse, NY Cleveland, OH

Gennady Bratslavsky
Department of Urology
SUNY Upstate Medical University
Syracuse, NY

ISBN 978-1-4939-7688-1 ISBN 978-1-4939-7690-4 (eBook)

Library of Congress Control Number: 2017961493

© Springer Science+Business Media, LLC 2018

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Management options for kidney cancer have continued to progress over recent
years, with improvements in minimally invasive approaches and diagnostic imaging
and tests. Surgeons faced with these expanding options must make decisions as to
what is best for their patients. They must have a solid understanding of technique
and outcomes to be able to provide patients with information needed to make an
informed decision and to give them the best chance for a good result. Just because a
technique is feasible, doesn’t necessarily mean it is necessarily the best treatment
for that particular patient.
This book “Surgical Techniques for Kidney Cancer” is a concise reference
dealing with different management and surgical treatment options of kidney cancer
that can be a useful tool for surgeons making management decisions for patients
with kidney cancer. The authors give a nice summary of topics including renal
imaging, biopsy, robotic radical and partial nephrectomy, open radical and partial
nephrectomy, laparoscopic partial nephrectomy, cryoablation, and radiofrequency
ablation. The entire spectrum of disease complexity is covered, ranging from small
renal masses to advanced kidney cancer with cavoatrial tumor thrombus extension.
The book provides up-to-date information that incorporates current guidelines.
Dr. Stein, Dr. Bratslavsky, and their contributors have provided an elegant and
succinct overview of the salient issues of kidney cancer surgery that all surgeons
dealing with this disease should know.

Detroit, MI, USA Craig G. Rogers MD, FACS

Director of Renal Surgery, Urologic Oncology
Vattikuti Urology Institute, Henry Ford Health System


Kidney cancer is the eighth most common cancer in the USA. In 2017, it is
estimated that there will be 63,990 new cases of the disease and 14,400 patients will
die from the disease. It is a condition that all urologists will encounter and we owe it
to our patients to be familiar with its management in order to provide them the best
possible care.
While surgery remains the primary treatment in localized disease, additional
options also include surveillance of renal masses and ablative procedures. Treat-
ment options in the metastatic setting include cytokine therapy, targeted therapy,
and immune checkpoint inhibitors, but even in this setting, surgery also plays a role
in select patients.
The aim of this manual is to serve as a reference to the urologist managing
kidney cancer. This was created for urology residents and attendings. Starting from
diagnosis (imaging, biopsy) to treatment (ablation, open surgery, minimally inva-
sive surgery), surgical approaches for the management of kidney cancer are covered
and techniques to optimize outcomes are reported.
We are fortunate to have renowned faculty describe their techniques and to
contribute their knowledge to this manuscript. They have all devoted their time and
effort to see this project through. I hope that this will serve as a valuable tool when
seeing patients in the clinic and when preparing for surgery.
Lastly, the success of this endeavor resides with the reader. We encourage you to
give suggestions for topics for future editions. What would you like covered and
what can we do to make it better?
Continue striving for the best patient care.

Syracuse, USA Rakesh V. Khanna


I would like to thank the Almighty for giving me the ability to complete this
I would like to thank all the Authors who took time out of their schedules to
contribute to this manuscript. A special thanks goes to Brian Halm who put this
volume together and worked tirelessly to keep the manuscript on schedule.
This work is dedicated to my wife, family, and in remembrance of my parents.
This work would not have been possible without their support.

Rakesh V. Khanna


1 Imaging of Renal Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Sharad Maheshwari and Abhijit Raut
2 Renal Mass Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Ricardo Rios and Jed-Sian Cheng
3 Open Partial Nephrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Srinivas Vourganti and Adam R. Metwalli
4 Robotic-Assisted Laparoscopic Partial Nephrectomy . . . . . . . . . . . . . 41
Morgan Prince and Rakesh V. Khanna
5 Management of Renal Cell Carcinoma with Inferior Vena Caval
Tumor Thrombus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Eric Kirshenbaum, Belinda Li, Petar Bajic and Marcus L. Quek
6 Minimally Invasive Radical Nephrectomy Including Vena Cava
Thrombus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Stephanie Gleicher and Gennady Bratslavsky
7 Renal Cryotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Nishant Jain and Robert J. Stein
8 Radiofrequency Ablation of Renal Masses . . . . . . . . . . . . . . . . . . . . . 83
Kenan Ashouri, Joshua Heiman, Anne M. Lopez, Emily F. Kelly
and Raymond J. Leveillee
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Imaging of Renal Masses
Sharad Maheshwari and Abhijit Raut

Imaging Modalities

Various imaging modalities are available for evaluation of renal masses; from
routine ultrasonography (USG), computerized tomography (CT) scan, magnetic
resonance imaging (MRI), and positron emission tomography (PET-CT) scan. Each
modality has a specific role in the diagnosis.

Ultrasonography (USG)

USG is the initial modality for renal mass evaluation and has a superior capability
of visualization of an internal architecture of renal mass. Simple renal cysts can be
confidentially diagnosed on USG and differentiated from complex cysts and solid
masses. Color and power Doppler evaluation are useful for further characterization.
Contrast-enhanced Doppler USG is an alternative to CT and MRI among the
patients with contrast allergies or other contraindications to contrast [1].

Multi-detector CT (MDCT) Scan

MDCT has emerged as the modality of choice for evaluation and characterization of
renal masses. Current generation CT scanners are fast and produce isotropic
multiplanar high-resolution images. A comprehensive summary of different phases
of contrast-enhanced CT (CECT) evaluation of renal masses is given in Table 1.1.

S. Maheshwari (&)  A. Raut

Kokilaben Dhirubhai Ambani Hospital, Rao Saheb Achutrao Patwardhan Marg,
Four Bunglows, Andheri (West), Mumbai 400053, India

© Springer Science+Business Media, LLC 2018 1

R. V. Khanna et al. (eds.), Surgical Techniques for Kidney Cancer,
2 S. Maheshwari and A. Raut

Table 1.1 Comprehensive summary of different phases of post-contrast evaluation of renal

Phase Diagnostic Advantages Disadvantages
Plain Calcification, fat, No contrast used Masses between
quantification of 20 and 70 HU are
post-contrast indeterminate
homogenous lesion
HU and >70 HU are
Corticomedullary Contrast in cortical Tumor hypervascularity, Medullary
(CMP) phase capillaries, vascular anatomy, and lesions will be
35–40 s post injection peritubular detection of venous missed
15-20 s after bolus cells, proximal invasion
tracking delay convoluted tubules,
and columns of Bertin
Nephrogenic phase Contrast in the renal Detection of medullary Tumor
100–120 s post tubular system, lesion. Detection of vascularity
contrast injection or homogenous renal necrosis and scar cannot be assesed
80 s after bolus parenchymal
tracking enhancement
Excretory phase Contrast in collecting Tumor relation with Lesion
5–8 min post system collecting system useful in characterization
injection nephron-sparing surgery

Nonionic iodinated contrast is routinely used for CECT scans. It is safe when
glomerular filtration is more than 60 ml/min. High-risk patients and prior history of
contrast reaction should be reported. In cases with reduced glomerular filtration
rate, hydration is the mainstay.
Renal enhancement depends on various factors including the amount and rate of
contrast material injection, the timing of contrast-enhanced imaging, and the
intrinsic characteristics of the mass and the adjacent renal parenchyma [2].

Magnetic Resonance Imaging (MRI)

When CT and USG imaging are not diagnostic or when iodinated contrast is con-
traindicated due to prior severe contrast reaction or compromised renal function, MRI
of renal masses is the best alternative. MRI has superior soft tissue resolution and can
detect tumor composition and architecture without radiation hazard. MRI is used for
surveillance of patients with high risk for renal malignancy like Von Hippel–Lindau
(VHL) syndrome. Claustrophobia and long examination time are the major drawbacks
of MRI; however, protocols are tailored depending upon the indication of the study to
minimize time. The details of MRI sequences are given in Table 1.2.
1 Imaging of Renal Masses 3

Table 1.2 Details of MRI sequences

Sequences Diagnostic information
T1WI Differentiation of simple from complex cysts—hemorrhagic and
proteinaceous cysts
T2WI Solid and cystic components, solid nodule, and septae
Chemical shift imaging For detection of intracellular fat
Diffusion-weighted Differentiation of cellular and benign tumors; assess tumor
imaging (DWI) response
Post-contrast imaging To differentiate malignant from benign tumor, tumor recurrence

There are two important lesions characterizing MRI sequences:

1. Chemical shift imaging detects intratumoral fat. In presence of intracellular fat,

there is a drop of a signal on the opposed-phase imaging compared to the
in-phase imaging. Intracellular fat may be seen in clear cell RCC and lipid-poor
AML. The periphery of tumors with abundant fat (like AML) shows loss of
signal resulting in chemical shift artifact (“India ink” artifact).
2. Diffusion-weighted imaging is increasingly used to differentiate benign from
malignant lesions, assess tumor recurrence and treatment response. Highly
cellular lesions of neoplastic etiology are bright on DWI and dark on
analog-to-digital converter (ADC) map.

Pre- and post-contrast three-dimensional fat-saturated gradient T1 volumetric

images are obtained. Extracellularly distributed gadolinium chelate contrast agent
(0.1 mmol/kg) is used at the rate of 2 ml/sec followed by flush of 20 cc of normal
saline. MRI contrast is contraindicated among the patients with renal insufficiency
and strictly used when glomerular filtration rate is more than 30 mL/min/1.73 m2 in
order to avoid nephrogenic systemic fibrosis [3].


Fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET)

has a limited role in the detection of renal masses despite the technologic advances
in gamma cameras, collimation, and single-photon emission CT and PET imaging.
The role of PET-MRI may be promising; in the single examination diffusion–
perfusion imaging, MRI and metabolic functional PET information can be obtained.
However, till date, there is no sufficient data to support the role of PET-MRI in a
renal mass evaluation.
4 S. Maheshwari and A. Raut

Cystic Renal Lesions

Depending upon the imaging appearance, the renal cysts are benign, indeterminate,
or malignant. Most renal cysts are benign and need no medical attention. The
intermediate cysts need serial imaging or follow-up, while the malignant cysts may
be managed conservatively or surgically.
Homogeneous renal masses measuring less than 20 HU and more than 70 HU on
non-enhanced (NECT) CT are likely to be benign. Enhancement of renal mass more
than 20HU between NECT and CECT suggests the presence of solid element; while
less than 10 HU is indicative of benign etiology. Enhancement of the mass between
10 and 20 hydroureter is inexplicit and warrants further evaluation.
The Bosniak CT classification system for cystic renal masses was introduced in
1986 and modified in 1993 for surveillance and management of renal cysts and
cystic masses. Depending upon the internal architecture of the cystic renal masses
and degree of contrast enhancement, Bosniak CT classification differentiates simple
renal cyst to obvious cystic malignancy. The details are given in Table 1.3 [4]
(Figs. 1.1, 1.2, 1.3, 1.4, 1.5, and 1.6).

Table 1.3 Bosniak CT classification differentiate simple renal cyst to obvious cystic malignancy
Category CT features Management
I Simple water attenuation (0–20 HU) Benign cyst
with hairline-thin wall, no No follow-up or treatment
components/contrast enhancement
(Fig. 1.1)
II Sharply marginated, shows 1–3 thin Benign cyst
septa/fine calcification of the No follow-up or treatment
wall/septa; uniformly high attenuation
<3 cm; no contrast enhancement
(Fig. 1.2)
IIF Relatively complex Follow-up—at 6-month intervals for
Hairline-thin septae; minimal the first year, then annually for a
thickening of cyst wall/septa, minimal minimum of 5 years to assure stability
enhancement of septa/cyst wall;
thick/nodular calcification; totally
intracranial high attenuation,  3 cm
(Fig. 1.3 and 1.4)
III Grossly thickened walls/septa with Neither benign or malignant
measurable enhancement Partial or total nephrectomy
D/D multilocular cystic RCC,
multilocular cystic nephroma,
multilocular hemorrhagic cyst, chronic
renal abscess (Fig. 1.5)
IV Enhancing soft tissue component, Clearly malignant
mural nodule, septae (Fig. 1.6) Partial or total nephrectomy
1 Imaging of Renal Masses 5

Fig. 1.1 Bosniak type I cyst: a Ultrasound image through right kidney shows a well-defined
anechoic cyst (white arrow). b NECT shows well-defined hypodense lesion (white arrow) with
fluid attenuation. c CECT does not show any enhancing components

Fig. 1.2 Bosniak type II cyst: a NECT shows well-defined hyperdense lesion arising from left
kidney (white arrow). b Ultrasound image through left kidney shows a well-defined anechoic cyst
(white arrow) suggestive of Bosniak cyst type II
6 S. Maheshwari and A. Raut

Fig. 1.3 Bosniak type IIF cyst: a Power Doppler ultrasound image shows a well-defined cyst
(white arrow) with septations (star). There is no Doppler flow in the sepations. b CECT shows a
well-defined hypodense lesion in right kidney (white arrow) without any internal enhancement

Fig. 1.4 Bosniak type IIF cyst: a Power Doppler ultrasound image shows a well-defined cyst
with thick and nodular septation (white arrow). There is no Doppler flow in the sepations. b NECT
shows a thick calcified septation (white arrow)

Angiomyolipoma (AML)

AMLs are benign neoplasms composed of the variable amount of fat, smooth
muscle, and abnormal blood vessels. They are often seen in middle-aged or elderly
women and are common in tuberous sclerosis.
On USG, AMLs appear echogenic; however, only on the basis of echogenicity
confident diagnosis of AML is often difficult as many small RCCs are echogenic.
1 Imaging of Renal Masses 7

Fig. 1.5 Bosniak type III cyst: a NECT shows a well-defined hypodense lobulated lesion (white
arrow). b CECT shows a well-defined cyst with internal septation and measurable enhancement
(black star)

Fig. 1.6 Bosniak type IV cyst: a NECT shows a well-defined hypo- to isodense well-defined
exophytic lesion (white arrow). b CECT shows a well-defined cystic lesion with internal
contrast-enhancing solid elements, suggestive of Bosniak cyst type IV

Demonstration of macroscopic fat is pathognomonic of AMLs, which appears

typically hypodense on NECT scan (less than 10 HU) (Fig. 1.7). On MRI, AMLs
demonstrate signal loss on fat-suppressed images. “India ink” artifact is seen at the
interface of fat and soft tissue.
When AMLs are larger than 4 cm, they may bleed torrentially. A minority of
AMLs, a subset of the epithelioid AML may show aggressive behavior. These are
indistinguishable from a benign variety of AMLs on imaging.
8 S. Maheshwari and A. Raut

Fig. 1.7 AML: a Ultrasound shows a well-defined hyperechoic exophytic lesion (black markers)
arising from the upper of left kidney. b CECT shows a lobulated solid lesion with fat density
(black star) and enhancing vascular components, suggestive of angiomyolipoma. c DSA shows
angiogenic components with micro-aneurysms

Occasionally, AMLs show large exophytic component. These exophytic masses

are often difficult to distinguish from perinephric liposarcomas (Fig. 1.8).
Depending upon the size of the tumor, AML may require angioembolization and/or
partial nephrectomy while the later is subjected to radical surgical excision.


These benign renal tumors contribute to approximately 5% of adult renal tumors.

They are often incidentally seen over the age of 50. These tumors are cortical in
location. The imaging features of oncocytoma and RCC frequently overlap; thus,
preoperative definitive diagnosis is challenging.
1 Imaging of Renal Masses 9

Fig. 1.8 Exophytic AML versus perinephric liposarcoma. a CECT shows a lobulated enhancing,
fat-containing mass lesion arising from the right kidney with exophytic component wrapping
around the antero-lateral margin of the kidney (White arrows) suggestive of AML. b CECT of a
different patient shows a heterogeneously enhancing perinephric mass with fat component (white
arrow). On histopathology it was a liposarcoma

On imaging, they are circumscribed solid renal tumors with smooth margins and
show homogenous post-contrast enhancement. Pseudocapsule is formed by com-
pression of peripheral renal parenchyma. Larger tumors often show a central
stellate-shaped scar on CT and MRI (Fig. 1.9). Scar may also be seen in RCC.
Oncocytomas are hypervascular at catheter angiography and have characteristic
spoke-wheel pattern of feeding arteries.

Renal Cell Carcinoma (RCC)

RCC is the most common solid cortical renal mass. Depending upon variable
histology, tumor biology, and prognosis, different histologic subtypes of RCC are
identified as mentioned in the following table.

Histopathological variations of RCC

Clear cell RCC
Multilocular clear cell RCC
Papillary RCC
Chromophobe RCC
Collecting duct carcinoma
Renal medullary carcinoma
Sarcomatoid RCC
RCC associated with neuroblastoma
Mucinous tubular
Unclassified RCC
10 S. Maheshwari and A. Raut

Fig. 1.9 Oncocytoma: a T1 W MRI shows a well-defined lobulated isointense mass (white
arrow) with central hypointensity (white arrowhead), arising from the lower pole of left kidney.
A second smaller lesion is seen in the right kidney (black arrow). b Fat-suppressed T2 W image,
the left renal mass (white arrow), shows central T2 hyperintense scar (white arrowhead).
c Post-contrast T1 fat-suppressed coronal image shows well-defined left renal mass (white arrow)
with peripheral heterogeneous enhancement and central T1 hypointensity scar (black arrowhead).
Two more small lesions with similar appearance is seen in right kidney (small white arrow and
black star)

Clear cell RCC (CCRCC) or the conventional RCC, are the most common
histologic subtype of RCC and accounts for 75% of RCCs [5]. Multicentric and
bilateral clear cell RCCs are seen in VHL syndrome.
On USG, RCCs are expansile, solitary, solid renal masses with variable
echogenicity. Most RCCs are hyperechoic compared to the renal parenchyma.
Larger tumors are heterogeneous with internal cystic areas within.
1 Imaging of Renal Masses 11

Doppler examination can characterize solid masses; a Doppler frequency shift

>2.5 kHz is a reliable indicator of malignancy when infective etiology is ruled out
[6]. Contrast-enhanced Doppler US is promising with sensitivity, specificity, pos-
itive, negative predictive value, and accuracy of 97, 45, 91, 75, and 90%,
Clear cell RCCs are hypervascular and demonstrate areas of necrosis and
hemorrhage. Fat-containing RCCs with osseous metaplasia are rare and most
probably secondary to osseous metaplasia of nonepithelial stromal portion of the
tumor [7] (Fig. 1.10). Larger tumors may engulf the perirenal space or renal sinus
and show scattered, irregular areas of fat along the periphery [8]. Macroscopic fat
can be easily detected on CT imaging. Intracellular fat is observed in nearly 60% of
the tumors and detected by a drop of a signal on opposed-phase images compared
with in-phase images on MRI [9]. Calcification is seen in up to 15% of RCC and
confidently detected by CT imaging [10].

Fig. 1.10 RCC (clear cell type): a NECT shows a well-defined hypodense mass lesion arising
from the lower pole of left kidney (white arrow) with few subtle hyperdense areas. b CECT
obtained during corticomedullary phase shows a well-defined hypervascular mass lesion with areas
of central necrosis (white arrow). c Coronal thick MIP obtained from the arterial phase
demonstrates exophytic, well-defined vascular mass with hypertrophied tortuous arterial branches
within the lesion (white arrow). Arrowhead points the normal renal parenchyma
12 S. Maheshwari and A. Raut

Fig. 1.11 RCC with venous invasion: a CECT obtained during the corticomedullary shows a
large hypervascular mass (white arrow) in the right kidney with extension into the renal vein and
IVC (small arrow). b 3D MIP image of a CECT obtained during the nephrogram phase shows
vascular mass (long white arrow) and dilated collateral vessels (short white arrow). White
arrowhead shows varicocele secondary to venous invasion

Depending upon the presence of hemorrhagic and necrotic components, the MRI
appearance of RCC may vary. Necrotic component appears bright on T2WI and
hypointense on T1WI. On post-contrast scan, viable enhancement of the solid
component of the tumor is seen while necrosis shows no enhancement [11].
Pseudocapsule due to compressed surrounding renal parenchyma appears
hypodense on CT scan and hypointense on MRI. Pseudocapsular invasion implies
advance stage or higher nuclear grade [12].
Clear cell RCCs have a propensity to hematogenous metastasis to lymph node,
lungs, bones, and liver. Unusual sites of metastases are well known, e.g., through
lumbar vessels, in can metastasize to lumbar muscles [10].
Tumor size is a rough indicator of prognosis of RCC; smaller RCCs (<3 cm)
rarely metastases. Renal vein tumor thrombus is often associated with aggressive
and higher-stage tumors (Fig. 1.11).

Papillary RCC (pRCC)

pRCC accounts for 10–15% of sporadic RCCs and has a better prognosis compared
to the clear cell RCC. They are often multicentric and common in end-stage
On imaging, they are homogeneous soft tissue cortical masses showing a lesser
degree of post-contrast enhancement compared to clear cell RCCs. Larger pRCC
may demonstrate foci of calcification on CT (Fig. 1.12). Due to intratumoral hem-
orrhage, necrosis, and cystic degeneration, they display low signal on T2WI [13].
1 Imaging of Renal Masses 13

Fig. 1.12 RCC (papillary type): a NECT shows a well-defined heterogeneous mass lesion arising
from the lower pole of left kidney (white arrow) with focal calcification (white arrowhead). b CECT
obtained during corticomedullary phase shows well-defined hypoenhancing (white star) mass (white
arrow). c Coronal thick MIP obtained during the corticomedullary phase demonstrates exophytic,
well-defined hypovascular mass, as opposed to hypervascularity of clear cell RCC (Fig. 10)

Chromophobe RCCS (ChRCC)

These are 5% of renal cell cancers. These are often solitary and circumscribed
cortical tumors. They have variable CT features. More often these are homogenous
and show a central scar or necrosis. They show less vascular enhancment as
compard to cRCC, but higher than pRCC. Even large tumors show similar
enhancement pattern. A spoke-wheel pattern of enhancement, similar to oncocy-
toma, is often detected in these tumors.


Primary renal lymphoma (PRL) is infrequent with an incident of less than 1% of

extranodal lymphomas [14]. PRL is limited to the kidney or adjacent perirenal
space. Kidney is the most common GU organ involved in disseminated lymphomas
14 S. Maheshwari and A. Raut

Fig. 1.13 RCC (chromophobe type): a NECT shows a well-defined isodense mass lesion arising
from the lower pole of left kidney (white arrow). b CECT obtained during corticomedullary phase
shows heterogeneously enhancing mass (white arrow) with hypoenhancing areas. c Coronal thick
MIP obtained during the arterial phase demonstrates exophytic, well-defined mass, with peripheral
subtle peripheral enhancement

and accounts for 30–60% of cases detected in autopsy [15]. However, on imaging
secondary renal lymphoma (SRL) is detected only in 3–8% of cases [16]. SRL
shows extensive extrarenal disease mainly in the form of retroperitoneal adenopathy
(Fig. 1.11). The imaging features of renal lymphoma correlate with pathologic
features. PRL and SRL have similar imaging features except for disseminated
extrarenal disease in the former.
A wide spectrum of imaging features is seen in renal lymphoma including
solitary lesion, multiple lesions, direct extension from retroperitoneal adenopathy,
preferential involvement of the perinephric space, and diffuse infiltration of one or
both kidneys. Retroperitoneal lymphadenopathy may cause obstructive uropathy.
Direct invasion of renal sinus and collecting system is rare. After chemotherapy,
most lymphomatous deposits disappear; rarely cystic degeneration, necrosis, and
calcifications may be seen [16].
1 Imaging of Renal Masses 15

On NECT, lymphomas are hyperdense compared to the surrounding renal par-

enchyma (HU 30–50) and are hypodense to the renal cortex on CECT scan. MRI
appearance of lymphoma is variable and may appear hypointense to renal cortex on
T1WI and hypo- to isointense on T2WI with mild heterogeneous post-contrast
enhancement. DWI shows restriction of diffusion and drop of a signal on ADC map
[17]. Most lymphomas have increased metabolic activity and have high-grade FDG
uptake on PET-CT.

Transitional Cell Carcinoma (TCC)

These uroepithelial neoplasms are commonly encountered in the urinary bladder,

and only 5% are seen in renal pelvis and ureter. In kidneys, renal pelvis is the most
common site of origin of TCC followed by the infundibulum and calyx [18]. Tumor
stage at diagnosis determines prognosis. Multicentric, synchronous, or metachro-
nous tumors warrant surveillance.
The majority of TCCs are low-grade, superficial, papillary tumors. These
low-grade tumors produce a focal intraluminal mass within the collecting system
[2]. Around 15% of TCCs are aggressive and show mucosal extension, mural
thickening, and luminal compromise. Early TCCs are separated from renal par-
enchyma by renal sinus fat or urine in the obstructed system with preserved peri-
pelvic fat. The advanced TCCs show centrifugal spread into the renal sinus and
parenchyma; however, the renal contour is reserved.
USG may be the first modality to detect TCC but has a limited role. MDCT
detects the mass, its extent, and assesses periureteric and perinephric infiltration,
lymph node, and distant metastasis. On NECT, TCCs are hyper-attenuating masses
to renal parenchyma and may show fine encrusted calcification, which may be
mistaken for calculi. NECT shows a lesser degree of enhancement compared to the
renal parenchyma. Large infiltrating renal pelvis masses are differentiated from
lymphoma, metastasis, and xantho-granulomatous pyelonephritis.
On CT urography, TCC appears as sessile filling defect causing widening of the
renal pelvis and may cause mass effect on the sinus fat or appear as a mass lesion or
uroepithelial thickening (Fig. 1.14).

Pseudotumors and Mimickers

Renal pseudotumors represent normal renal tissue that may mimic a renal neo-
plasm. The renal pseudotumors include congenital, acquired, inflammatory, and
vascular masses.
Congenital pseudotumors include prominent renal columns of Bertin, renal
dysmorphism, and dromedary humps. Hypertrophied column of Bertin is renal
cortical projection between two pyramids often involving renal sinus. It may be
16 S. Maheshwari and A. Raut

Fig. 1.14 TCC: a Coronal CECT image obtained during corticomedullary phase shows a focal,
poorly enhancing lesion in the infundibulum to the upper pole collecting system of left kidney
(white arrow). There is calyceal dilatation in the upper pole collecting system. b Axial CECT
image obtained during nephrogram phase shows delayed nephrogram (black star) in the upper
pole. The focal lesion shows enhancement (white arrow). c 3D VRT image obtained during the
nephrogram phase shows poor enhancement of the upper pole (white arrows) due to obstruction as
compared to the rest of kidney (white star)

mistaken for a mass on USG (Fig. 1.15). Similarly, pseudomasses due to adjacent
scarring may be misinterpreted on USG. These masses show attenuation or signal
identical to renal cortex and can be easily differentiated on CT and MRI. Dro-
medary hump is focal cortical bulge arising from lateral wall of the left kidney and
can be confidentially detected on USG.
Inflammatory masses, including focal pyelonephritis and renal abscess, may
resemble renal neoplasm. On CT scan, pyelonephritis shows typical peripheral
wedge-shaped areas of low attenuation with no appreciable wall while the renal
abscess is a well-defined mass showing variable central necrosis and peripheral
1 Imaging of Renal Masses 17

Fig. 1.15 Column of Bertin mimicking focal mass on ultrasound: a Ultrasound image shows a
focal hypoechoic mass-like lesion indenting the hilar fat (White arrows). b CECT obtained during
nephrogram phase shows prominent column of Bertin and not a mass at the same location

Vascular anomalies, including renal artery aneurysm or arteriovenous fistula, can

be easily diagnosed on USG Doppler and CECT.

Assessment of Renal Mass Prior to Surgery

Preoperative Assessment

Staging of the renal tumor is essential for appropriate management. CT and MR

imaging are accurate in diagnosis and staging of renal cancers and assist in planning
minimal invasive surgery to avoid major complications (Fig. 1.16).
Renal mass size can be accurately measured on imaging. Relationship of the
tumor with adjacent organs, vascular structures, pelvicalyceal system, and ureter
can be easily mapped on imaging. For small renal neoplasms (<4 cm in maximum
diameter), partial nephrectomy is preferred; if surgery is contraindicated then these
tumors may be subjected to thermal ablation [19].
Loco-regional nodes or metastases to the adrenal glands, liver, pancreas, bones,
lungs, and contralateral kidney can be identified on imaging. Extension of tumor
thrombus into the renal vein, IVC, and heart can be confidently diagnosed and
differentiated from bland thrombosis. Early tumor extension through the capsule
into the perinephric space is often challenging on CT and MRI [19].
Several scoring systems are proposed for preoperative anatomic assessment of
the renal tumors. Detailed discussion is beyond the scope of this chapter. Tumors
with lower nephrometry scores, nephron-sparing partial nephrectomy is preferred.
Thermal ablation is considered among the patients who are not a good candidate for
surgery. Elderly patients with small cancers (<4 cm) and low-grade tumors can be
managed with active surveillance.
18 S. Maheshwari and A. Raut

Fig. 1.16 Presurgical assessment of renal mass on CT scan 16. a CT angiogram demonstrates
relation of the renal artery (short white arrow) with renal vein (white arrowhead). Renal mass is
seen as bulge on the upper pole (long white arrow). b CECT obtained during nephrogram phase
shows well-encapsulated mass (white arrow) without any perinephric extension. Arrowhead shows
the relation of renal vein with the mass without any venous invasion. Renal artery (white star) is
postero-superior to the vein. c CT urogram shows blunting of the upper pole calyces (short white
arrow). White long arrow shows defect in the upper of kidney due to the mass (white arrow)

Post-treatment Assessment

Post-treatment patients are assessed for local recurrence, metachronous renal can-
cers, and regional or distant metastases [20]. 3–12 months baseline imaging eval-
uation with CT or MRI is recommended by the American Urological Association.
Following partial nephrectomy, initial soft tissue inflammation at the surgical
site may be seen with postsurgical status. The local recurrent tumor is identified as
an enhancing nodule at the surgical excision site. It may be difficult to differentiate
recurrence from postoperative granulation. Immediate postsurgical complications
such as collections, pseudoaneurysms, and a leak can be easily detected on CT scan
1 Imaging of Renal Masses 19

Response to the chemotherapy is assessed by the change in tumor size and

metastasis using RECIST criteria. It should be kept in mind that modern
chemotherapeutic agents produce tumor necrosis with or without a decrease in tumor
size. Thus on follow-up imaging, the metastatic lesions should also be evaluated for
degree of enhancement. FDG-PET may be useful.


The advent of cross-sectional, multiplanar, and metabolic imaging has an immense

role in the detection, definition, and diagnosis of renal masses. Imaging can dif-
ferentiate solid from cystic and malignant from benign masses and gives details
about relation of the mass with surrounding structures, including vascular and renal
collecting system anatomy. Imaging is helpful in preoperative staging, surgical
approach, determining prognosis and follow-up of renal masses.

1. Ignee A, et al. The value of contrast enhanced ultrasound (CEUS) in the characterization of
patients with renal masses. Clin Hemorheol Microcirc. 2010;46(4):275–90.
2. Silverman SG, et al. Management of the incidental renal mass. Radiology. 2008;249(1):
3. Sadowski EA, et al. Nephrogenic systemic fibrosis: risk factors and incidence estimation.
Radiology. 2007;243:148–57.
4. Israel GM, Bosniak MA. An update of the Bosniak renal cyst classification system. Urology.
5. Renshaw AA. Subclassification of renal cell neoplasms: an update for the practising
pathologist. Histopathology. 2002;41:283–300.
6. Jinzaki M, et al. Small solid renal lesions: usefulness of power Doppler US. Radiology.
7. Strotzer M, et al. Detection of fat in a renal cell carcinoma mimicking angiomyolipoma.
Radiology. 1993;188:427–8.
8. Prando A. Intratumoral fat in a renal cell carcinoma. AJR. 1991;156:871.
9. Outwater EK, et al. Lipid in renal clear cell carcinoma: detection on opposed-phase
gradient-echo MR images. Radiology. 1997;205:103–7.
10. Eble JN, et al. World Health Organization classification of tumors. Pathology and genetics of
tumors of the urinary system and male genital organs. Lyon (France): IARC Press; 2004.
11. Wagner BJ. The kidney: radiologic-pathologic correlation. Magn Reson Imaging Clin N Am.
12. Yamashita Y, et al. Cystic renal cell carcinoma: imaging findings with pathologic correlation.
Acta Radiol. 1994;35:19–24.
13. Prasad SR, et al. Cross sectional imaging evaluation of renal masses. Radiol Clin North Am.
14. Freeman C, et al. Occurrence and prognosis of extranodal lymphomas. Cancer. 1972;29
15. Ganeshan D, et al. Imaging of primary and secondary renal lymphoma. AJR Am J
Roentgenol. 2013;201(5):W712–9.
20 S. Maheshwari and A. Raut

16. Sheth S, et al. Imaging of renal lymphoma: patterns of disease with pathologic correlation.
Radiographics. 2006;26(4):1151–68.
17. Toledano-Massiah S, et al. Whole-body diffusion-weighted imaging in Hodgkin lymphoma
and diffuse large B-cell lymphoma. Radiographics. 2015;35:747–64.
18. Wong-You-Cheong JJ, et al. Transitional cell carcinoma of the urinary tract:
radiologic-pathologic correlation. RadioGraphics. 1998;18:123–42.
19. Cohan RH, et al. Renal masses: imaging evaluation. Radiol Clin North Am. 2015;53(5):
20. Ng CS, et al. Renal cell carcinoma: diagnosis, staging, and surveillance. AJR. 2008;191
21. Lall CG, et al. Making sense of postoperative CT imaging following laparoscopic partial
nephrectomy. Clin Radiol. 2012;67(7):675–86.
Renal Mass Biopsy
Ricardo Rios and Jed-Sian Cheng


The utilization of renal mass biopsies has become increasingly more common over
the past 15 years. While incidental detection of renal masses has increased the
treatment of renal masses, mortality from renal carcinoma has not changed [1]. This
is largely due to assertion that small renal masses are not aggressive and may not
impact patient survival. Multiple studies have demonstrated that only a low per-
centage of small renal masses are high grade or show potentially aggressive features
[2]. Previously, small renal masses were presumed malignant and were surgically
removed. However, recent treatment options for small renal masses have expanded
beyond surgical excision to include observation and ablation.
Historically, use of renal biopsies was reserved for nonrenal solid malignancies,
such as suspected lymphomas, and for suspected benign pathology, such as patients
with tuberous sclerosis suspected of having angiomyolipoma (AML). Currently,
routine use of renal mass biopsies is somewhat controversial. Several studies have
demonstrated that small renal masses have very indolent courses, and role of routine
biopsy is unclear. For patients that are choosing surveillance, delayed treatment on
these small renal masses does not seem to incur risk of disease progression. If the
mass was large and considered for treatment, a preoperative biopsy may not be
Role of renal mass biopsies has changed recently with recognition that
approximately 20% of clinical stage T1 renal masses represent benign disease.
Additionally, accuracy and safety of biopsies have improved with refinements in
CT- and MRI-guided techniques. False-negative rates have been now reported as
low as 2% in some series. This number is different from indeterminate renal

R. Rios  J.-S. Cheng (&)

Division of Urology, Cooper Medical School, Camden, NJ, USA

© Springer Science+Business Media, LLC 2018 21

R. V. Khanna et al. (eds.), Surgical Techniques for Kidney Cancer,
22 R. Rios and J.-S. Cheng

biopsies, which range from 10 to 15%. Previous concerns about needle-tract

seeding have rarely been reported and no longer preclude biopsy. A prior biopsy
also does not routinely affect a surgeon’s ability to resect the tumor or increase
intraoperative complications. Previous studies have demonstrated varying propor-
tions of benign lesions when biopsies have been taken in lesions 3–4 cm in size.
But, because of improvements in technique and improved accuracy, current EAU
guidelines on RCC recommend renal mass biopsy is performed in all patients
whose active surveillance is pursued and before ablative therapy or systemic
therapy without previous pathology.
The argument is that utilization of such data allows stratification of patients into
treatment versus active surveillance, which to date has been determined with
imaging that reveals enhancing masses. The decision for continued surveillance
versus treatment traditionally has been dependent upon several factors, including
patient age, co-morbidities, physiological status, and tumor location and size. An
argument for the use of renal mass biopsy is to determine type of cancer and
Fuhrman grade for management of renal masses. However, not all pathologists are
willing to comment on carcinoma subtype and grade of renal biopsies. Centers with
dedicated uro-pathologists are able to reliably give subtypes and grading of the
tumor. However, several series suggest that in frail, elderly patients, knowledge of
tumor pathology is irrelevant and does not change management [3].
Additionally, not only has renal mass biopsy been useful in setting of inter-
vention versus active surveillance, it may also be helpful in determining type of
intervention [5]. Patients with large indeterminate tumors may benefit from a
biopsy. This will help differentiate between transitional cell carcinoma, renal cell
carcinoma, metastatic lesion, versus other pathology. Knowing the origin of the
tumor can change treatment plans. For example, in the case of a large renal tumor
being transitional cell in origin, this may open discussion for neoadjuvant
chemotherapy and surgical resection will be a nephroureterectomy and not a radical
Other considerations for performing a biopsy include: 1) Intervention on a mass
in a solitary kidney or patient with borderline renal function in which surgery may
result in conversion to dialysis. 2) In cases of bilateral renal tumor, especially if a
previous renal tumor has been benign. 3) History of prior benign renal tumor with
the growth of new renal masses. 4) History of prior malignancy and suspected
metastasis to kidney.
Still, many institutions have suggested biopsies for all renal masses. Yet,
widespread use remains low. The trend in recent literature suggests that renal mass
biopsies have evolved from a limited diagnostic tool to one that may potentially be
extremely useful for management of patients. Kutikov et al. proposed a protocol
(Fig. 2.1) for clinical decision making regarding use of renal masses that takes into
account patient clinical presentation prior to renal biopsy [3]. It appears that the
diagnostic rate of renal biopsy is improving as the technique is evolving. Moreover,
the complication rate is low and previous fears of seeding of the biopsy tract have
been unfounded.
2 Renal Mass Biopsy 23

Fig. 2.1 Proposed decision algorithm for renal biopsy by Kutikov et al. [3]


Currently, most renal mass biopsies are performed by interventional radiologist. In

some centers, urologists are performing them as well. There is little evidence that
either subspecialties perform a more diagnostic or reliable biopsy. In many cases,
this is a same-day procedure or overnight stay if there were any concerns after
biopsy. Renal mass biopsies are predominately accomplished using two methods:
Fine-needle aspiration (FNA) and core biopsy. Both are generally performed under
CT or ultrasound (US) guidance. There are advantages and disadvantages to both
Ultrasound may be portable, multi-planar, more cost-effective and real-time
imaging. US-guided biopsies may be performed freehanded or with a guide.
A freehanded biopsy allows the radiologist to make adjustments if needle trajectory
is not ideal. This being the case, US guidance biopsy is highly operator dependent.
CT-guided biopsies have excellent spatial resolution, they have better needle
visualization than US-guided biopsies, gas and bone do not obstruct visibility, and
there is more rapid skill acquisition. Disadvantages to CT-guided biopsies include
higher cost than USA, higher exposure to radiation, and lack of dynamic real-time
monitoring during needle insertion.
Recommendations for core needle biopsies suggest using 18-gauge needles with
a tissue cutting tip. Fine-needle aspiration uses 21-gauge needles or smaller. The
needles are passed multiple times through the tumor and tissue aspirated is then
24 R. Rios and J.-S. Cheng

smeared on a slide and evaluated by pathology. Both FNA and core needle biopsy
should be performed through a cannula. Using a coaxial technique allows multiple
needle passes with each biopsy, which is beneficial by reducing procedure time and
minimizes needle-tract seeding.
Both FNA and core biopsies can be done in the same setting and under con-
scious sedation. Patients may be positioned prone, semiprone, or lateral decubitus.
A guiding cannula with stylet is inserted and directed to tumor surface. The stylet
should then be removed, and the needle is then passed through the cannula into the
renal mass.
For FNA, negative pressure should be applied though a syringe and the needle
should be pulled out then pushed back in approximately 15 times. This allows
collection of tissue while suction is kept constant. For best results, the aspirate
should be fixed and stained on site and read by cytotechnologist immediately after
sampling. Aspirate may be air-dried or alcohol fixed, and staining is commonly a
Giemsa stain or hematoxylin and eosin stain.
Core biopsies can be completed using 18-gauge automatic side-cutting needles
producing cores of 15–22 mm in length. Cores less than 10 mm or that are torn are
considered poor quality [4]. While FNA samples commonly utilize Giemsa stain-
ing, core biopsies are stained with hematoxylin and eosin along with stains specific
for RCC subtypes.


While outcomes from renal mass biopsies generally show similar trends of high
accuracy with low false-negative and false-positive rates, many studies are ham-
pered by lack of quality evidence regarding role of biopsy. Most studies are ret-
rospective and many lack surgical confirmation of histology. Additionally, many
publications have different definitions of biopsy success and different studies often
utilize different techniques for biopsy. Nonetheless, recent meta-analyses demon-
strate a high overall diagnostic rate (92%) for diagnosis of malignancy and fair
agreement between tumor grade at biopsy and final specimen. When specimens
prove to be nondiagnostic, several series demonstrate repeat biopsy to be diagnostic
in 83–100% of cases.
Another important distinction when comparing studies is that biopsy failures
have been often categorized into biopsy inaccuracy. These are samples that contain
normal renal parenchyma, blood, or fibrosis which should be categorized as biopsy
failure. Incorrectly allocating these specimens brings into question the reliability of
data regarding biopsies.
Some of the major concerns regarding biopsy included false-negative rates that
were historically high, and that many patients would require surgery regardless of
result. Lane et al. describe results from studies prior to 2001 as having
false-negative rates of 0–25% and false-positive rates of 0–5%. In these studies,
2 Renal Mass Biopsy 25

false-negative samples showed necrotic tissue, blood, or normal kidney that today
would be classified as insufficient or failed biopsy rather than misinterpretation.
Several studies have been conducted to assess accuracy of renal mass biopsies.
Study by Millet et al. [6] demonstrated that biopsy was highly accurate for diag-
nosing histologic subtype in RCC. Previous studies by Neuzillet et al. showed
agreement between histologic subtype and surgery in 41 of 45 clear cell carcino-
mas, 10 of 11 papillary carcinomas, and 5 of 5 chromophobe carcinomas.
The meta-analysis by Marconi et al. [7] demonstrated sensitivity of 99.1% and
specificity of 99.7% for assessment of tumor malignancy using core biopsy.
Fine-needle aspiration yielded sensitivity of 93.2% and specificity of 89.8%. While
core biopsy proves to generate better results, the author suggests there may be an
advantage to use combination of FNA and core biopsy for select cases to increase
diagnostic accuracy. Degree of concordance between RCC subtype on biopsy and
surgical specimens was 90.3% in overall population. Concordance between tumor
grade and biopsy was reported as 62.5% using Fuhrman I–IV system, but improved
to 87% when categorized into low grade (Fuhrman I–II) and high grade (Fuhrman
III–IV). One limitation to these results is heterogeneity of renal masses that is
evident in 5–25% of tumors resected.
Volpe et al. describe sensitivity of 70–100% and specificity of 100% with core
needle biopsy. They also show in a review of several series that accuracy is greater
than 90% with no significant difference between results obtained via CT or US
guidance. For FNA, they reported diagnostic rate of 76–97% with varying degrees
of false-positive results. They describe a majority of false-negative results due to
insufficient amount of tissue, sampling of necrotic areas or normal kidney which
should be categorized into biopsy failure rather than false negative.
Additionally, there have been several studies completed using 18-gauge needles
that demonstrate accuracy of renal mass biopsies. Accuracy rates for biopsy are
greater than 90% for malignant versus benign disease. These same studies have
demonstrated sensitivity ranges from 80 to 92% and specificity of 83–100%. This
compiled data is demonstrated below in Table 2.1.
Cystic neoplasms do have a lower diagnostic rate as there is less tissue in the
biopsy [4]. In these cases, it is important to biopsy the solid component of the cystic
lesion. The ability to biopsy these lesions are dependent upon the experience of the
person performing the procedure. In these cases, the role of biopsy becomes less
clear given the lower diagnostic rate.


While complications from renal biopsy were once a major concern, experience and
improvements in technique have greatly minimized risks from the procedure. The
only absolute contraindication to renal mass biopsy is uncorrected coagulopathy.
Minor complications have less than 5% occurrence, and major complications are

Table 2.1 Tumor characteristic, nondiagnostic rates, and concordance [8–12]

Study No of Study time Size, range Solid/cystic Guidance % Nondiagnostic Histology subtype Complications
biopsies period (cm) (CT/US) biopsies, % (n) concordance % (n/n)
Menogue et al. 250 1999–2009 2.5 (0.9–4) Solid 100% US or CT 20.8 (52) 98 (117/120) Lumbar pain, 0.4%;
hematoma, 0.4%
Abel et al. 166 1991–2007 9.2 (3–32) NR US or CT 5.4 (9) 94.4 (75/79) NR
Schmidbauer 121 2005–2007 4.0 (0.8–9) Solid 100% CT 2.6 (2) 91 (53/58) Hematoma, 3.4%;
et al. pneumothorax, 0.8%
Lebret et al. 119 1999–2005 3.3 (1–10) Solid 100% CT 21 (25) 86 None
Neuzillet et al. 88 1995–2003 2.8 (0.2–4) NR CT 9.1 (8) 92 (58/63) None
R. Rios and J.-S. Cheng
2 Renal Mass Biopsy 27

exceedingly rare. Some of these include infection or AV fistulas, with infection as

an easily treatable complication and fistulas should be suspected in patients with
persistent bleeding.
Previously, there was considerable concern regarding renal hemorrhage after
biopsy, due to the vascular nature of the kidney and renal carcinomas. While
imaging with CT or MRI following biopsy generally does show some degree of
bleeding, blood transfusion is necessary in only 1–2% of cases. Risk of bleeding
was believed to be greater using larger bore needle, but there have not been studies
that directly care degree of hemorrhaging or complications between large- and
small-gauge needles.
Risk of pneumothorax from pleural injury is another documented risk from renal
biopsy, but rates are exceedingly low. This complication generally occurs when
attempting to gain access to an upper pole tumor. Needle passage between 11th and
12th rib from posterior approach would traverse the pleura in 14–29% of patients.
While pleural injury may result, clinically significant pneumothorax is uncommon
and occurs in less than 1% of biopsies.
Tumor seeding along needle tract from biopsy was previously a great concern
for clinicians and had been a controversial potential complication. This is no longer
considered a complication, as the overall estimated risk of seeding is less than
0.01%, and only six cases have been reported all prior to 1994. With such low
incidence, potential metastasis via tumor seeding is no higher than that of other
Pathology report indicates oncocytic neoplasm. This is not a true complication
but does complicate the discussion with the patient. This diagnosis is given
whenever the pathologist is unable to distinguish between an oncocytoma versus a
chromophobe renal cell carcinoma. This result sometimes causes a treatment


• Renal mass biopsies have been controversial but have emerged as a useful
clinical tool.
• Biopsy should be performed if the results will change the clinical management
of the patient.
• Biopsy should be performed before ablative procedures to confirm the lesion
being treated.
• Biopsy should be considered for any patients placed on active surveillance for
renal mass.
• The diagnostic rates are high for solid tumors, and nondiagnostic biopsies can
usually be rebiopsied with similar diagnostic rates.
• Biopsy complications are low.
28 R. Rios and J.-S. Cheng

1. Halverson SJ, et al. Accuracy of determining small renal mass management with risk stratified
biopsies: confirmation by final pathology. J Urol. 2013;189 (Feb).
2. Lane BR, et al. Renal mass biopsy—a renaissance? J Urol. 2008;179 (Jan).
3. Kutikov A, et al. Renal mass biopsy: always, sometimes, or never? Eur Urol. 2016.
4. Volpe A, et al. Techniques, safety and accuracy of sampling of renal tumors by fine needle
aspiration and core biopsy. J Urol. 2007;178 (Aug).
5. Maurice M, et al. Increasing biopsy utilization for renal cell carcinoma is closely associated
with treatment. Urol. 2015;86.
6. Milet I, et al. Can renal biopsy accurately predict histological subtype and fuhrman grade of
renal cell carcinoma? J Urol. 2012;188 (Nov).
7. Marconi L, et al. Systematic review and meta-analysis of diagnostic accuracy of percutaneous
renal tumour biopsy. Eur Urol. 2015;69.
8. Menogue SR, et al. Percutaneous core biopsy of small renal mass lesions: a diagnostic tool to
better stratify patients for surgical intervention. BJU Int. 2013;111 (Apr).
9. Abel EJ, et al. Percutaneous biopsy of primary tumor in metastatic renal cell carcinoma to
predict high risk pathological features: comparison with nephrectomy assessment. J Urol.
2010;184 (Nov).
10. Schmidbauer J, et al. Diagnostic accuracy of computed tomography-guided percutaneous
biopsy of renal masses. Eur Urol. 2008;53.
11. Lebret T, et al. Percutaneous core biopsy for renal masses: indications, accuracy and results.
J Urol. 2007;178 (Oct).
12. Neuzillet Y, et al. Accuracy and clinical role of fine needle percutaneous biopsy with
computerized tomography guidance of small (less than 4.0 cm) renal masses. J Urol.
2004;171 (May).
Open Partial Nephrectomy
Srinivas Vourganti and Adam R. Metwalli

Historically, the utilization of partial nephrectomy (PN) was reserved for so-called
absolute indications (i.e., solitary kidney or bilateral disease). However, over the
past several decades, PN has become more utilized as retrospective and prospective
data has accumulated demonstrating similar cancer control when compared with
radical nephrectomy [1–4]. As a result, recent guidelines recommend PN when
feasible for small renal masses [5]. PN can be performed through open, laparo-
scopic, and robotic approaches. In this chapter, the surgical approach and outcomes
for open partial nephrectomy (OPN) will be reviewed.

Historical Development of OPN

The first recorded OPN was performed in the late nineteenth century, though it was
hardly a mature procedure. Subsequent animal studies were used to refine the
surgical technique for renorraphy. As early as the third decade of the twentieth
century, surgeons and pathologists had reported the low rate of metastasis for
kidney tumors smaller than 5 cm; though more than 80% were found to have
metastasized when tumors were twice that size [6, 7]. Significant advances in
the understanding of renovascular anatomy and cold ischemia techniques were
developed during the 1960s to 1980s due to lessons learned from the complex open

S. Vourganti (&)
Department of Urology, Rush University Medical Center,
1725 W. Harrison Street, Chicago, IL 60612, USA
A. R. Metwalli
Center for Cancer Research, Urologic Oncology Branch,
National Cancer Institute, National Institutes of Health,
Building 10, CRC, Room 2W-5940, Bethesda, MD 20892, USA

© Springer Science+Business Media, LLC 2018 29

R. V. Khanna et al. (eds.), Surgical Techniques for Kidney Cancer,
30 S. Vourganti and A. R. Metwalli

surgery prevalent for advanced urolithiasis as well as trauma surgery. These lessons
were subsequently applied to renal cancer surgeries [8–12]. Many of these tech-
niques are now a standard part of renorraphy after resection of renal tumors in PN.
The advent of cross-sectional imaging, first with computed tomography
(CT) and more recently with magnetic resonance imaging (MRI), has resulted in a
well-described downward stage migration versus the large and often metastatic
tumors detected earlier [13]. Such incidentally detected renal masses are smaller
and far less likely to be metastatic at presentation. This lower presenting stage has
allowed PN to arise as a more viable option, especially as unaffected parenchyma
has become visible on preoperative imaging. Furthermore, similar movements in
other surgical oncology disciplines toward organ-preserving therapies in other sites
such as breast cancers and peripheral sarcomas influenced the adoption of PN for
smaller incidentally discovered renal masses.
The initial report of conservative “parenchyma-sparing” operation for renal cell
carcinoma (RCC) was published in 1989 by Novick et al. [14] in 100 patients, 44%
of whom had unilateral tumors. The vast majority of this series represented obligate
indications, with only 4 with normal functioning contralateral kidney. However,
only a few years later, multiple reports arose documenting the outcome of elective
indication of PN for RCC [15–17]. A myriad of surgical improvements have been
subsequently reported as advances in hemostatic agents, and surgical techniques
and tools have made PN more accessible to urologists. In addition, increasing
understanding of differences in imaging characteristics and metastatic potential
among differing histologies has also influenced the application of PN [18].
The potential of long-term medical benefits of PN was initially anticipated due to
a large retrospective analysis suggesting that chronic kidney disease increased risk
of all-cause and cardiovascular mortality [19]. Subsequently, numerous retrospec-
tive reports indicated that PN offered the benefit of lower risk for cardiovascular and
all-cause mortality [20–23]. Consequently, enthusiasm for PN for small and
intermediate renal masses reached an all-time peak. However, the publication of the
prospective EORTC 30904 trial failed to demonstrate an overall survival advantage
and actually showed a decreased OS relative to radical nephrectomy [4]. This trial
did confirm that PN does substantially reduce the likelihood of developing sig-
nificant CKD [24]. That the preserved renal function did not translate into benefit in
all-cause mortality remains a point of debate within the urologic literature. Nev-
ertheless, PN has been shown to be an oncologically equivalent procedure and is
now deemed the standard of care for small renal masses when feasible. The full
measure of any potential long-term benefits to PN remains to be determined.

Preoperative Evaluation and Planning

As with any major operation, a detailed medical history must be obtained. A thor-
ough accounting of medical comorbities is critical as many have significant dele-
terious effects on renal function. Furthermore, special attention must be paid to a
3 Open Partial Nephrectomy 31

comprehensive family history as hereditary RCC conditions are well defined. Many
hereditary RCC syndromes have specific associated stigmata which can steer the
treating surgeon toward genetic testing or other non-standard preoperative evalu-
ations (i.e., CNS imaging if Von Hippel Lindau gene alteration is suspected).
A history of cardiac disease will prompt an echocardiogram and possibly a cardiac
stress test in addition to the standard electrocardiogram (EKG). Cross-sectional
imaging with CT or MRI should be performed within 6–8 weeks of surgery. In the
presence of detectable vascular invasion, imaging should be done within 1 week of
surgery to ensure precise surgical planning related to the extent and level of vas-
cular invasion which can change rapidly. Laboratory values are obtained within a
week of surgery to evaluate renal function, electrolytes, and hematologic parame-
ters. If any renal dysfunction is detected, renal scintigraphy may be useful to
determine the appropriateness of PN versus total nephrectomy.

Technical Aspects of OPN

OPN can be performed through numerous approaches, including midline, subcostal,

flank, or thoracoabdominal incision. Dorsal lumbotomy is an alternative approach
but has inferior exposure and is usually reserved for non-oncologic indications. The
use of warm or cold ischemia and enucleative resection techniques along the tumor
pseudocapsule (eschewing a margin) are other technical considerations.

Flank Incision

The patient is positioned in the lateral decubitus position over the table’s flexion
point. The kidney rest is not employed in our practice. The table is flexed to
maximize the distance between the costal margin and the anterior superior iliac
crest. A line is marked from the tip of the 11th rib toward the umbilicus. Preemptive
local anesthetic with 0.25% bupivacaine is instilled along this line and the skin is
then incised. Dissection to the external oblique fascia is carried out with electro-
cautery and then the fascia is incised parallel to the skin incision. The neurovascular
bundle coursing below the 11th rib is identified and preserved; care is taken to leave
enough distance between the fascial edge and the bundle to avoid nerve entrapment
during fascial closure. Resection of the tip of the 11th rib is unnecessary and is
avoided in our practice due to significant postoperative pain associated with this
practice. The external and internal oblique muscles are divided with electrocautery
and then the transversalis muscle is split. The medial extent of these muscle divi-
sions is the lateral edge of the ipsilateral rectus abdominis muscle. Occasionally
with very large tumors that are easily palpable through the abdominal wall, the
incision is extended medially into the rectus abdominis although this is rare.
The peritoneum typically extends over the surface of the kidney and Gerota’s
fascia so it is important to start the mobilization of the peritoneal edge more lateral
32 S. Vourganti and A. R. Metwalli

than it may appear. Blunt dissection of the peritoneum of the underside of the
abdominal wall is helpful to facilitate medial retraction of the peritoneum and its
contents to maximize exposure of the ipsilateral retroperitoneum. In fact, often
lateral dissection of the kidney and posterior Gerota’s fascia away from the lateral
body wall and psoas muscle posteriorly is performed initially which increases
mobility of the kidney and exposes the peritoneal reflection on the anterior surface
of Gerota’s fascia more clearly. This may allow easier separation of the peritoneum
from the anterior surface of the kidney. In the absence of identifiable adrenal
pathology, the adrenal compartment of Gerota’s fascia is separated from the renal
compartment of Gerota’s fascia and the adrenal gland is left in its orthotopic
position. A Thompson retractor is used to expose the retroperitoneum fully, then the
kidney if fully mobilized while still encapsulated in Gerota’s fascia so that renal
hilum exposed. The renal artery and vein are left en bloc and a Cosgrove clamp is
placed across the entire hilum should hilar occlusion be needed.
Gerota’s fascia is then opened widely in a clamshell fashion typically cephalad
to caudal so that the kidney is fully dissected within Gerota’s fascia. The entire
surface of the kidney is inspected and intraoperative renal ultrasound is performed.

Laparotomy Incision

This approach has the patient in the supine position and is preferred by some
surgeons due to the excellent exposure of the main renal and retroperitoneal vas-
culature. Particularly when venous invasion is noted on preoperative imaging,
central access to the renal hilum and inferior vena cava is helpful. In addition,
supine approach is preferred in the presence of loco-regional lymphadenopathy to
more easily resect regional lymph nodes. Furthermore, a midline incision is not
muscle splitting unlike a flank approach; therefore, it is easier to close and may offer
some benefit in terms of postoperative pain and expedited recovery. In addition, the
supine positioning may offer less risk for positioning injuries such as nerve com-
pression or rhabdomyolysis compared to lateral decubitus positioning. However,
access to the superolateral aspect of the renal fossa is more limited with this
approach which may increase the difficultly in resecting larger tumors as well as
limit visualization of parasitic collateral vessels in that area.

Anterior Subcostal Incision

In this approach, the patient is positioned supine and a curvilinear marking line is
drawn roughly two finger breadths below the costal margin from the midline to the
tip of the 11th rib at the anterior axillary line. A 10 blade is used to incise the skin
and electrocautery is used to divide the subcutaneous fat down to the anterior rectus
fascia. The fascia and the anterior rectus muscle is divided with electrocautery
taking care to slowly divide through the muscle to adequately cauterize the lon-
gitudinal vessels in the rectus muscle thus avoiding unnecessary blood loss or
3 Open Partial Nephrectomy 33

postoperative rectus hematoma. Extend the incision laterally to the tip of the rib
dividing the medial aspect of the external and internal oblique muscles. Carefully
incise the posterior rectus sheath to identify the peritoneum. Lift the peritoneum and
incise sharply with Metz scissors. Open the peritoneum widely the length of the
incision. This exposes the upper quadrant and then mobilization of the colon along
the white line of Toldt is performed. Once the colon is mobilized, the anterior
surface of Gerota’s fascia is visible. Kocherize the duodenum sharply on the right
side. Mobilize the tail of the pancreas and the spleen on the left.

Thoracoabdominal Incision

With the advent of more sophisticated retractors such as the Thompson retractor,
the advantage of the added exposure provided by the thoracoabdominal incision has
been almost completely mitigated. The thoracoabdominal approach requires
dividing both the costal cartilage and the diaphragm and necessitates a postoper-
ative chest tube as the pleural space heals. This results in significant postoperative
pain and a prolonged recovery from this incision. These factors, in addition to the
added inconvenience of the chest tube, have resulted in this approach largely falling
out of favor amongst urologists.

Tumor Resection

The kidney must be totally exposed to perform PN; therefore, Gerota’s fascia must
be divided. For sporadic tumors, some urologists will only expose the lesion in
question; however, the incidence of multifocality of RCC is between 7 and 25%
[25, 26] so complete exposure of the entire kidney is recommended. Gerota’s fascia
is divided most often in a cephalo-caudal direction utilizing the natural avascular
planes within the fat and between the fat and the renal capsule to completely
mobilize the kidney within Gerota’s fascia. Careful visual inspection of the kidney
is performed followed by meticulous intraoperative ultrasound. Once all tumors are
identified, resection of the tumors is planned taking into account the fact that renal
hilar occlusion times should be minimized as much as possible. If hilar occlusion is
likely, ice slush should be readily available for hypothermic ischemia during tumor
resection. Mannitol is often administered 5–10 min prior to renal hilar occlusion
although there is little to no data supporting its use as a renoprotectant [27–29].
Once ischemia is induced, the kidney should be cooled for at least 5 min before
tumor resection begins.
Two methods of tumor excision can be performed depending upon the clinical
situation. If the tumor histology is known from a preoperative renal biopsy, then the
surgeon can consider tumor enucleation in addition to standard wide-margin tumor
resection. If the histology is unknown, then enucleation may be less appropriate due
34 S. Vourganti and A. R. Metwalli

to the potential for invasive tumor phenotypes (high-grade conventional tumors,

papillary type 2 RCC, or Succinate Dehydrogenase (SDH) altered tumors).

Tumor Enucleation

The renal capsule is scored circumferentially around the tumor and then the capsule
is cut with a 15 blade. Penfield dissectors are used to split the renal parenchyma
toward the tumor until the tumor capsule is identified. The tumor is then separated
from the surrounding parenchyma bluntly with Penfield dissectors. At the base of
the tumor, a perforating feeding vessel is often encountered which can be cauter-
ized, over sewn, or clipped with micro-metal clips. The peri-tumoral parenchyma
tends to be compressed and therefore does not bleed as briskly as is seen in
wide-margin excisions. If this is performed without renal hilar occlusion, then
vascular tip suction catheters are placed in each corner of the capsular incision as
the dissection proceeds in between them.

Wide-Margin Tumor Excision

The ideal size of the margin of non-tumor renal parenchyma surrounding the tumor
continues to be subject of intense debate [30–32]. Some urologists continue to
recommend a 1-cm margin of normal parenchyma surrounding the tumor [33, 34].
Other surgeons now suggest a minimal margin is sufficient [35, 36]. The available
data would indicate that a positive surgical margin does not affect cancer pro-
gression or survival [37–39].
Whatever margin the surgeon chooses, this can be achieved either sharply or
bluntly with Metzenbaum scissors or a scalpel. Intraoperative ultrasound can be
used to mark the capsule at the desired distance away from the tumor. The capsule
is then scored with electrocautery and then incised. Historically, the back of the
scalpel blade was used to split the parenchyma around the tumor leaving a
1-cm-wide margin around the tumor. Closed tips of the Metzenbaum scissors can
be used in the same way as the back of a scalpel blade as can the Penfield dissectors
as described above. The key is to divide the parenchyma to a depth below the
deepest extension of the tumor in the kidney. This can be difficult to determine in
real time which is why careful ultrasound prior to excision is helpful. For a minimal
margin excision, the closed-tipped Metzenbaum can be used in a similar manner to
the enucleation technique but rather than peel all the parenchyma away from the
tumor capsule, a thin layer of normal parenchyma is left adherent to the tumor
capsule. This adherent parenchyma general tapers to a point at the deepest extent of
the tumor and this can be sharply divided. The advantage of this approach is that the
contour of the tumor is visible dramatically reducing the likelihood of inadvertently
sharply cutting into the tumor due to misjudging the depth of the tumor extension.
3 Open Partial Nephrectomy 35


The base of the defect can be managed with primary closure, suture ligation, or
packing; which specific technique is employed is largely based on surgeon pref-
erence. Multiple case studies of varied techniques have evaluated renorraphy
techniques without hemostatic agents, bolsters, and even suturing [40–44]. At this
time, there is little compelling evidence that use of hemostatic agents and bolsters
increases complications. Consequently, the most important aspect of renorraphy is
selecting an effective technique and using it each case so that the surgeon and
surgical team are comfortable and efficient with this approach.
For superficial lesions, no renorraphy is needed in many cases. Often hemostatic
agent with or without oxidized cellulose mesh and pressure is sufficient to achieve
excellent hemostasis. For deeper lesions and for those defects with notable arterial
bleeding at the base, a 3-0 braided PGA suture renorraphy secured with knots or
Lapra-Tys may be necessary. This is more easily detectable when renal hilar
occlusion is not used as arterial bleeding is immediately evident. Consequently, if
renal hilar occlusion is employed, removal of the hilar clamp after oversewing the
base but prior to capsular closure may be beneficial to reveal small arterioles not
occluded by the initial base stitch.
The anatomy of the defect may dictate the use of a bolster. At our institution, a
bolster of oxidized cellulose mesh is used to obliterate dead space created by
enucleation of spherical tumors. For defects that will reapproximate without sub-
capsular dead space, no bolster is used. A serrated PGA suture (V-lock) can be used
in lieu of a non-serrated braided PGA but a Lapra-Ty may still be needed as a
capsular anchor.
For tumors approaching the collecting system, a ureteral catheter is placed in the
ipsilateral ureter for retrograde injection of methylene blue dye if entry into the
collecting system is suspected at the time of tumor resection. Large collecting
system defects, lower pole defects, and peripheral collecting system entry should be
closed with a running 3-0 braided PGA suture. Small entries into the collecting
system, particularly for very endophytic lesions, do not require closure since an
adequate renorraphy will ensure the path of least resistance for urine is toward the
renal pelvis and ureter. For lower pole defects and large defects, a double-J ureteral
stent can be placed postoperatively over a wire through the ureteral catheter placed
at the outset of the case.

PN Complications

Complications from OPN can be separated into intraoperative, postoperative, and

delayed complications. Intraoperative complications occur during the operation and
are usually related to dissection of sensitive structures such as the bowel or vas-
culature. Postoperative complications such as urine leak, hemorrhage, and ileus
arise can be treated in the immediate hospitalization following the surgery. Delayed
36 S. Vourganti and A. R. Metwalli

complications such as arterio-venous fistula, delayed urine leak, urinary or bowel

obstruction, and renal failure typically are noted after discharge and may require
re-admission to the hospital.
More than two decades ago, the complication rate following OPN was reported to
be nearly 40% for symptomatic RCC and 22% for incidental lesions [45]. More recent
data demonstrates a decrease in overall complication rate nearing 10% [46, 47]. The
rate of urine leak after OPN is 4.4–13.3% depending on tumor location relative to the
collecting system [48, 49]. For central tumors adjacent to the collecting system,
extra-renal urinary extravasation should be viewed as an expected outcome rather
than a complication, and at our institution, a prophylactic stent is often placed at the
end of the case rather than bring the patient back for a second procedure once it
manifests prior to discharge.
Postoperative arterio-venous fistula (AVF) typically presents symptomatically in
a delayed fashion most commonly 10–14 days after surgery but can be as long as
30 days postoperatively. This is seen in 1–2% of patients after PN [50–52]. These
generally present with gross hematuria and/or sudden onset flank pain with pallor,
tachycardia, and anemia. Asymptomatic AVFs are sometimes detected incidentally,
are far more common than symptomatic AVFs, and generally are self-limited and
do not require intervention. An AVF should be suspected in the setting of inter-
mittent painless bright red gross hematuria. Symptomatic AVFs should be managed
with arteriography and embolization by interventional radiology with a very high
success rate. A skilled interventional radiologist is paramount in this situation since
these AVFs can usually be managed with occlusion of tertiary and quaternary
arterioles. Whole kidney or significant loss of renal parenchyma due to emboliza-
tion of segmental arteries should be avoided, and surgical exploration and repair are
preferable in that case.
Renal failure after PN rarely requires intervention in the setting of two normally
functioning kidneys preoperatively. However, for a solitary kidney or a patient with
preexisting chronic kidney disease (CKD), a nephrology consultation may be of
value for fluid management and possible bridge dialysis postoperatively. Generally,
in the latter clinical scenario, the urologic surgeon must navigate the fine line
between aggressive volume resuscitation and fluid overload. Under-resuscitation
can exacerbate and markedly prolong postoperative renal dysfunction, but over
aggressive fluid management can lead to pulmonary compromise and anasarca.
Thus, prospective consultation with nephrology and intensive care providers may
be useful and will ensure that all care providers understand the relevant clinical
factors in the postoperative setting.
Other complications associated with PN are very uncommon with an incidence
of less than 1%. It is very important to discuss with the patient in clinic and during
the consent process about the risk of converting from partial to radical nephrec-
tomy. While this is highly uncommon, it is imperative that the patient understands
that this is always a possibility. The possibility of injury to surrounding organs is
also extremely rare but worth discussing because the consequences of these injuries
can be significant. The colon and small bowel must be mobilized and unrecognized
injuries can have devastating morbidity. These injuries are very rare in the primary
3 Open Partial Nephrectomy 37

surgical setting but more common in re-operative procedures when peri-nephric

fibrosis and adhesions obliterates normal anatomic planes. As such, patients should
be clearly informed of these risks prior to surgery.

PN Follow-up

Recent guidelines recommend stage-based follow-up algorithms in an effort to

standardize postoperative care for PN patients [53]. Postoperative evaluations
should include a complete history and physical exam, basic metabolic testing, and a
urinalysis. For low-stage tumors, cross-sectional imaging (CT, MRI) should be
performed at least once in the year following surgery after which additional imaging
is optional. Annual imaging with plain chest radiography is also recommended for
3 years. For higher risk tumors, cross-sectional imaging should be performed
within 6 months of surgery and then at least annually for five years. Beyond
5 years, additional cross-sectional imaging should be personalized by the treating
physician based on a risk assessment that includes histology, grade, stage, and life
expectancy. Delayed recurrences can occur well after 5 years from the initial sur-
gery even for some low-grade tumors. Further data is needed to find the right
balance between minimizing unnecessary imaging and missing a small but sig-
nificant number of late recurrences [54–56].


Partial nephrectomy has become a fundamental part of the treatment algorithms for
the surgical management of RCC. Particularly with the explosion of incidentally
detected small renal masses, the epidemic of obesity and diabetes with associated
CKD, nephron-sparing surgical approaches for RCC are becoming increasingly
important factors in the decision-making process. PN has been shown to have
equivalent oncologic outcomes to total nephrectomy and superior renal functional
preservation. Complication rates following PN are low and associated morbidity is
generally easily managed. Even in the era of minimally invasive and robotic
approaches to nephron-sparing surgery, OPN continues to maintain an important
role in the management of RCC.

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Robotic-Assisted Laparoscopic Partial
Nephrectomy 4
Morgan Prince and Rakesh V. Khanna


The incidence of renal cell carcinoma (RCC) continues to increase in the USA in
part due to earlier detection with prevalent imaging [1, 2]. The greatest increase in
incidence involves renal masses <4 cm, which consists of >40% of new cases
[1, 2]. Historically, treatment has consisted largely of radical nephrectomy, with
partial nephrectomy reserved for bilateral tumors, solitary kidneys, and patient with
poor renal function given fear of local recurrence and feasibility of the surgery [3].
However, publication of long-term follow-up supported the role of nephron-sparing
techniques in treatment of RCC [3, 4].
Long-term data demonstrates both equivalent cancer control and superior renal
function with partial nephrectomy when compared to radical nephrectomy [1]. The
American Urological Association’s updated 2017 guidelines recommend partial
nephrectomy as preferred treatment for T1a renal tumors [2]. In this setting, partial
nephrectomy is associated with decreased risk of development and progression of
chronic kidney disease (CKD) [2].
It is well established in retrospective and prospective studies that minimally
invasive partial nephrectomy is equivalent to open partial nephrectomy in both
oncologic and functional outcomes and superior in blood loss, length of stay, and
recovery time [1]. With the advent of robotic-assisted surgical techniques,
decreased complication rates and a shorter learning curve compared to laparoscopic
partial nephrectomy have been reported [1].

M. Prince  R. V. Khanna (&)

Department of Urology, SUNY Upstate Medical University,
Syracuse, NY, USA

© Springer Science+Business Media, LLC 2018 41

R. V. Khanna et al. (eds.), Surgical Techniques for Kidney Cancer,
42 M. Prince and R. V. Khanna

With the wide support for minimally invasive partial nephrectomy as a standard
of care for small, locally confined renal tumors, research focuses on expanding the
indications and refining surgical techniques to minimize morbidity [1].

Patient Selection and Preoperative Considerations

When selecting patients for nephron-sparing surgery, several factors should be

taken into consideration including preoperative estimated glomerular filtration rate
(eGFR), solitary kidney, bilateral tumors, history of abdominal surgery, medical
comorbidities, and body mass index (BMI) [5]. Patients should have high-quality,
multiphase, cross-sectional abdominal imaging, CT or MRI, for staging and char-
acterization purposes [2].
The R.E.N.A.L. nephrometry score, developed by Kutikov and Uzzo in 2009, is
a widely studied system to quantify and stratify renal masses. This scoring system
includes the following components: (R)adius describing size of tumor in diameter,
(E)xophytic/endophytic, (N)earness to collecting system, (A)nterior/posterior, and
(L)ine describing polar lines [6]. While the R.E.N.A.L. nephrometry score is used
for preoperative assessment, some studies found no predictive value over using
tumor size alone. However, others have demonstrated a correlation with percent
functional volume preserved, warm ischemia time, violation of collecting system,
and postoperative eGFR [1].

R.E.N.A.L. nephrometry score

Component Score
1 point 2 points 3 points
Radius (diameter, cm) 4 >4 but <7 7
Exophytic/endophytic  50% exophytic <50% exophytic Completely
Nearness to collecting 7 >4 but <7 4
system (mm)
Anterior/posterior A or P
Lines (polar) Does not cross Crosses 50% of mass across
polar line polar line polar line

A score of 4–6 is considered low complexity for surgical resection, 7–9 mod-
erate complexity, and 10–12 high complexity [6].
While the American Urologic Association considers partial nephrectomy, the
standard of care for T1a (  4 cm) renal tumors, many institutions are expanding to
include larger (4–7 cm;  7 cm) masses [5]. When compared to robotic partial
nephrectomy for renal tumors  4 cm, and when robotic partial nephrectomy is
performed for tumors  7 cm, median operative time, warm ischemia time, esti-
mated blood loss, and overall postoperative complications were significantly higher
4 Robotic-Assisted Laparoscopic Partial Nephrectomy 43

with larger tumors. However, there was no difference in decreased renal function,
positive margins, or complications  Clavian III [5].

Surgical Approach

Both retrospective and prospective randomized trials demonstrate equivalent onco-

logic outcomes and superior renal function with partial nephrectomy versus radical
nephrectomy [1]. Over the past decade, utilization of partial nephrectomy has
increased, moving from open to laparoscopic to robotic-assisted partial nephrectomy
[1]. Compared to open partial nephrectomy, laparoscopic partial nephrectomy has
been shown to deliver equivalent functional and oncologic outcomes but laparoscopy
was underutilized due to the technical difficulty of the case [1].
Since the advent of the da Vinci surgical system, minimally invasive partial
nephrectomy has been one of the fastest growing robotic procedures across all
surgical specialties increasing by 15% with a concurrent decrease in open radical
nephrectomies by 33% [1]. The first case series of robotic-assisted partial
nephrectomy was published out of the Mayo Clinic in 2004 by Gettman et al. [1, 7].
Surgical approach can consist of retroperitoneal or transperitoneal with the latter
more commonly performed due to more working space and identifiable anatomic
landmarks [1]. On the other hand, a retroperitoneal approach provides direct
exposure of the renal hilum and avoids manipulation of bowel reducing occurrence
of postoperative ileus [1, 8]. Retroperitoneal robotic partial nephrectomy has been
reported to decrease operative times when utilized for posterior upper pole renal
tumors [8]. This approach may also be useful in patients with high BMI in the
setting of large pannus or significant intra-abdominal fat [9]. One study sites
decreased intraoperative times and decreased EBL when using retroperitoneal
approach compared to transperitoneal approach in patients with BMI > 40 [9].
Foley catheter and nasogastric tube are placed after induction of anesthesia.
Patient is positioned in lateral decubitus position with ipsilateral side up, taking care
to properly pad all pressure points using foam pads, gel rolls, blankets, and pillows
[8, 9]. Dependent arm is positioned on padded arm board, while the ipsilateral arm
is supported in airplane position on pillows or an elevated arm board. An upper
body warmer can be utilized. Patient is secured to the table at several points, and the
operative table is fully flexed, increasing the operative space between the iliac crest
and 12th rib [8].
When performing retroperitoneal robotic partial nephrectomy, the robot is
docked at the patient’s head in line with the spine [8]. When performing a
transperitoneal robotic partial nephrectomy, the robot is docked posterior to patient
with the bedside assistant positioned facing the patient’s abdomen. Regardless to
approach, robotic-assisted partial nephrectomy can be performed using a three- or
four-arm configuration, and single-site surgery has been described for small tumors
with low complexity [9, 10].
44 M. Prince and R. V. Khanna

In the standard transperitoneal approach, midline port is placed 3–4 cm cephalad to

the umbilicus and three or four additional ports are positioned linearly along the lateral
border of the rectus muscle [11]. The colon is mobilized, ureter and gonadal vein are
identified, the renal hilum is identified and dissected, and Gerota’s fascia is opened.
The tumor is identified, and margins are scored, utilizing intracorporeal ultrasound
probe [5, 12]. Control of the renal hilum can be performed in multiple fashions as
described below. The tumor is resected, and renorrhaphy is performed [5].
When using a retroperitoneal approach, the para-nephric fat is dissected off
Gerota’s fascia. Gerota’s fascia is then incised 1–2 cm above the psoas tendon, and
dissection continues along the psoas muscle [8, 9]. The renal hilum is exposed, and
the remainder of the procedure follows the steps described above for a transperi-
toneal approach [8].
During renorrhaphy, a barbed suture or absorbable monofilament can be used in
running fashion to repair defects in the collecting system and for vascular repair.
A second layer can be performed to re-approximate the deep layer of the tumor bed
[1]. Bolsters can be utilized to create a tight closure in the resection bed [1]. Weck
Hem-o-lok clips are used in the Washington University sliding-clip renorrhaphy,
with clips placed on vicryl suture on either side of the resection bed and then slid
toward the defect, exerting tension on the bed [1].

On Clamp Versus off Clamp

It is generally accepted that prolonged warm ischemia time should be avoided to

preserve renal function with a commonly sited goal of less than 30 min [1, 13]. If
clamping of the hilar vessels is employed, there are several techniques utilized to
minimize warm ischemia time.
Early-unclamping consists of unclamping the renal pedicle after the tumor has
been excised and one to two running sutures of the resection bed have been placed
but before repair of the parenchyma [1, 13]. A retrospective multicenter study
performed by Peyronnet et al. compared standard unclamping and early-
unclamping in a total of 430 patients. While estimated blood loss was higher in
the early-unclamping group, the mean warm ischemia time was lower without any
difference in transfusion rates or complications [13]. Early-unclamping has also
been reported to decrease the risk of renal artery pseudoaneurysm [14].
To achieve zero ischemia time, a CT angiogram is obtained preoperatively to map
out the renal vasculature. Intraoperatively, only the vessels feeding the tumor are
controlled, resulting in no ischemic time for the remaining renal parenchyma [1].
Partial nephrectomy can also be performed entirely off clamp to optimize renal
function preservation, eliminate ischemia-reperfusion injury, and shorten hospital
stay [12]. Off clamp technique is generally utilized for smaller exophytic tumors
[12]. In one study by Tanagho et al., 29 robotic-assisted partial nephrectomies were
performed on clamp and 29 were performed off clamp. The mean change in eGFR
was less (−4.9 vs. −11.7 mL/min) with the trade-off of higher blood loss in the off
clamp group (146 vs. 104 mL) [1, 15].
4 Robotic-Assisted Laparoscopic Partial Nephrectomy 45

Radio frequency ablation has been described in conjunction with robotic partial
nephrectomy to develop a coagulated plane surrounding the tumor in attempts for
tumor resection off clamp. However, this did not provide benefit in hemorrhage and
did show higher rates of postoperative urine leak and thermal injuries [16]. Rizkala
et al. described sequentially placing sutures through the renal parenchyma deep to
and adjacent to the planned resection site. As the tumor resection is performed,
sutures are placed through the tumor bed, effectively controlling bleeding as it
occurs. Using this technique, they were able to decrease and, in many cases,
eliminate warm ischemia time [17].
Intracorporal renal hypothermia has also been described as a method to decrease
warm ischemia time. The hypothermia is thought to decrease intracellular meta-
bolism, decreasing hypoxia and reperfusion injury [18]. Several techniques have
been described, including endoscopic retrograde ureteric cooling, arterial infusion,
and intracorporeal ice slush via direct placement of ice slush or indirect using an
endocatch bag [18].

Tips and Tricks

Dissection requires good exposure. The bowel should be fully mobilized medially.
On the right side, the liver should be elevated and retracted cranially using a liver
retractor. On the left side, the splenic attachments to the diaphragm should be
divided allowing the spleen to fall away medially.
The ureter should be identified in order to avoid inadvertent injury as well as to
serve as a landmark to the renal hilum. The ureter lies posterior to the gonadal vein.
After the ureter is identified, it is placed on anterior traction and traced toward the
renal hilum.
As stated above, there are many approaches to the renal hilum (clamping en bloc
artery and vein, artery only clamping, selective clamping, off clamp). Careful
review of preoperative imaging is essential in preparation for hilar dissection. In
cases where hilar dissection is difficult, use of intraoperative ultrasound can be
beneficial to identify the renal vessels. Regardless of the approach that is used, the
hilum should be dissected sufficiently that if significant bleeding is encountered
hemostatic control can be achieved either with application of a Satinsky clamp or
with bulldog clamp.
The tumor is then identified. This is done either by intraoperative ultrasound or
by near-infrared fluorescence with the firefly system. The TilePro feature of the
robotic system allows the surgeon to control the ultrasound probe resulting in
high-quality images and localization of the tumor. The Gerota’s fascia is then
opened, and the kidney is defatted and mobilized. This is a crucial part of the
procedure as it will bring the tumor into view and expose renal capsule for sub-
sequent closure. In cases of posterior tumors, complete mobilization may be
required. Care should be taken in defatting lower pole tumors as the ureter can lie in
close proximity.
46 M. Prince and R. V. Khanna

Once the tumor is exposed, the margins are established either under ultrasound
guidance or under fluorescence. Tumor excision can then proceed as described
above (either under clamp or under unclamped conditions, under warm or cold
ischemia). It is the authors’ practice to generally perform partial nephrectomy under
warm ischemia with arterial clamping. In order to ensure complete arterial
clamping, after clamp application, Doppler ultrasound is performed documenting
no arterial flow.
The tumor is then excised. In order to avoid tumor entry, the tips of the curved
scissors should be directed downward away from the tumor. In cases where tumor
is in close proximity to the collecting system, one should aim to enter the renal
collecting system in order to avoid tumor violation. If significant bleeding is
encountered during this part of the procedure, consideration must be given to either
incomplete clamp application or a missed artery. If arterial bleeding is suspected,
one can either attempt to replace a hilar clamp or if both the artery and vein were
clamped, to remove the renal vein clamp allowing renal outflow.
After tumor excision, the renorrhaphy is performed as described earlier. The
Gerota’s fascia overlying the kidney should be reapproximated to minimize any
intraperitoneal urine leak and bowel adhesions. This is especially important in cases
where repeat surgeries are anticipated. The pneumoperitoneum should be turned
down and hemostasis confirmed at low pressure.


Postoperative renal function after partial nephrectomy is determined primarily by

preoperative baseline renal function, duration of warm ischemia time, and amount
of renal parenchyma remaining after resection [12]. When compared to laparo-
scopic partial nephrectomy in a meta-analysis of 23 studies, robotic partial
nephrectomy was found to have a lower rate of conversion to open or radical
nephrectomy, shorter length of stay in the hospital, shorter warm ischemic time, and
smaller decrease in eGFR. There was no difference in postoperative complications
regardless of Clavien grade, operative time, estimated blood loss, or positive
margins [1]. The Trifecta was first described as a composite outcome measure by
Kalifeh et al. The Trifecta is defined as no perioperative complications, negative
surgical margins, and warm ischemia time less than 25 min [19]. In the retro-
spective multi-institutional study by Zargar et al. [19], operating time, warm
ischemia time, intraoperative and postoperative complications, and estimated blood
loss were statistically significantly less in robotic partial nephrectomy compared to
laparoscopic partial nephrectomy.
Positive surgical margin has been reported as 2.2–2.7% in robotic partial
nephrectomy [1]. Long-term oncologic outcomes appear to be equivalent to
laparoscopic and open partial nephrectomy [1].
4 Robotic-Assisted Laparoscopic Partial Nephrectomy 47


Overall complication rate with robotic partial nephrectomy is similar to open and
laparoscopic partial nephrectomy, cited as 8.6–20% [1]. Postoperative hemorrhage
has been reported up to 5.8% of cases of robotic-assisted partial nephrectomy and
intraoperative hemorrhage cited as 1% [1, 14]. Urine leak is much less common in
robotic partial nephrectomy compared to open partial nephrectomy [1].

1. Potretzke AM, Weaver J, Benway BM. Review of robot-assisted partial nephrectomy in
modern practice. J Kidney Cancer VHL. 2015;2(2):30. doi:
2. AUA guidelines.
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4. Benway BM, Bhayani SB, Rogers CG, Porter JR, Buffi NM, Figenshau RS, Mottrie A.
Robotic-assisted partial nephrectomy: an international experience. Eur Urol. 2010;57(5):815–20.
5. Brandao LF, Zargar H, Autorino R, Akca O, Laydner H, Samarasekera D, Krishnan J,
Haber GP, Stein RJ, Kaouk JH. Robot-assisted partial nephrectomy for  7 cm renal masses:
a comparative outcome analysis. Urology. 2014;84(3):602–8 (Web).
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for quantitating renal tumor size, location and depth. J Urol. 2009;182(3):844–53.
7. Gettman MT, Blute ML, Chow GK, Neururer R, Bartsch G, Peschel R. Robotic-assisted
laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci
robotic system. Urology. 2004;64(5):914–8.
8. Ghani KR, Porter J, Menon M, Rogers C. Robotic retroperitoneal partial nephrectomy: a
step-by-step guide. BJU Int. 2014;114(2):311–3 (Web).
9. Hu J, Treat E, Filson C, McLaren I, Xiong S, Stephanian S, Hafez K, Weizer A,
Porter J. Technique and outcomes of robot-assisted retroperitoneoscopic partial nephrectomy:
a multicenter study. Eur Urol. 2014;66(3):542–9.
10. Komninos C, Tuliao P, Rha KH. Current status of robotic laparoendoscopic single-site partial
nephrectomy. Int J Urol. 2014;21(10):954–9.
11. Kallingal GJ, Swain S, Darwiche F, Punnen S, Manoharan M, Gonzalgo ML,
Parekh DJ. Robotic partial nephrectomy with the Da Vinci Xi. Adv Urol. 2016;2016:1–5.
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Ann. 2015;7(2):226.
13. Peyronnet B, Baumert H, Mathieu R, Masson-Lecomte A, Grassano Y, Roumiguié M,
Massoud W, Abd El Fattah V, Bruyère F, Droupy S, De La Taille A, Doumerc N,
Bernhard JC, Vaessen C, Rouprêt M, Bensalah K. Early unclamping technique during
robot-assisted laparoscopic partial nephrectomy can minimise warm ischaemia without
increasing morbidity. BJU Int. 2014;114(5):741–7 (Web).
14. Kondo T, Takagi T, Morita S, Omae K, Hashimoto Y, Kobayashi H, Tanabe K. Early
unclamping might reduce the risk of renal artery pseudoaneurysm after robot-assisted
laparoscopic partial nephrectomy. Int J Urol. 2015;22(12):1096–102.
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functional and perioperative outcomes of off-clamp versus clamped robot-assisted partial
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48 M. Prince and R. V. Khanna

16. Rimar K, Khambati A, Mcguire BB, Rebuck DA, Perry KT, Nadler RB. Radiofrequency
ablation-assisted zero-ischemia robotic laparoscopic partial nephrectomy: oncologic and
functional outcomes in 49 Patients. Adv Urol. 2016;2016:1–6.
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comparison with warm ischaemia. BJU Int. 2015;117(3):531–6 (Web).
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Management of Renal Cell Carcinoma
with Inferior Vena Caval Tumor 5
Eric Kirshenbaum, Belinda Li, Petar Bajic and Marcus L. Quek


Renal cell carcinoma (RCC) accounts for 2–3% of all malignancies in adults.
Approximately 64,000 new cases will be diagnosed in 2017 with 14,400
disease-specific mortalities [1]. Direct intraluminal extension of tumor into the renal
vein and inferior vena cava (IVC) may be seen in 4–10% of patients with RCC,
with 1% involving the right atrium [2]. Of those patients presenting with an IVC
tumor thrombus (IVCTT), 10–25% have extension above the level of the hepatic
veins [3, 4]. Surgery remains the mainstay of treatment for all stages of RCC. From
the first reported IVC tumor thrombectomy in 1913 until the 1970s, the operative
mortality had been exceedingly high. However, with improvements in imaging
techniques, advancements in anesthetic and perioperative care, and utilization of a
multidisciplinary approach, the 30-day mortality has fallen to 1.5–10% in recent
series, with some variability dependent on the cephalad extent of the IVCTT and
patient comorbidities [5, 6]. In addition, surgery offers the only chance of long-term
survival for these patients, with a reported 5-year survival of 40–68% in the setting
of non-metastatic disease [7].
The tumor thrombus associated with RCC typically derives its blood supply
from the main renal artery as opposed to local neovascularity from the surrounding
vein wall. The mechanisms by which these tumors gain entry into the renal vein
remain unknown. Other malignancies, such as hepatocellular and adrenocortical
carcinoma, and even rarely some benign renal tumors, are known to display this
intravascular growth pattern. Tumor growth follows the path of least resistance and
can rapidly extend toward the right atrium. While extension into the IVC tends to

E. Kirshenbaum  B. Li  P. Bajic  M. L. Quek (&)

Department of Urology, Loyola University Medical Center, 2160 South First Avenue,
Fahey Center, Room 261, Maywood, IL 60153, USA

© Springer Science+Business Media, LLC 2018 49

R. V. Khanna et al. (eds.), Surgical Techniques for Kidney Cancer,
50 E. Kirshenbaum et al.

carry a worse prognosis compared with renal vein only involvement, there is no
difference in the histopathologic or clinical characteristics (distribution of histologic
subtypes, rates of metastasis at diagnosis, site of metastasis) of IVC and renal vein
tumor thrombi [8]. Although these tumors infrequently invade the vein wall, this
pathologic finding is associated with a particularly poor prognosis even with
resection of the caval wall [9].


Several classification schemes have been proposed to describe the cephalad extent
of the IVCTT. In the 2010 AJCC TNM staging system, tumor extension into the
renal vein is classified as T3a, IVC below the diaphragm as T3b, and IVC above the
diaphragm as T3c. Various reports have described either a three-level or four-level
system to describe the cephalad extent of the thrombus to aid in surgical planning.
Regardless of the classification system utilized, the primary anatomic landmarks are
the hepatic veins, diaphragm, and right atrium. All tumor thrombi should be
described based on these structures (infrahepatic, intrahepatic, supradiaphragmatic,
intraatrial), as the surgical approach and technical maneuvers are dictated by the
relationship to these landmarks.
The prognostic value of tumor thrombus level has been disputed. Whereas some
reports have indicated a worse survival for patients with higher levels of thrombus
[10–12], other large series have shown no decreased survival and no increased
incidence of lymph node positivity or metastasis [13–17]. Alternative prognostic
indicators have been proposed, including IVC tumor volume based on caval
diameter [18], among others.

Clinical Presentation

While the majority of RCC cases are identified incidentally on cross-sectional

imaging, some notable clinical signs and symptoms specifically associated with
venous congestion from the IVCTT may include varicocele in men, caput medusa,
Budd–Chiari syndrome, renal insufficiency from contralateral renal vein obstruc-
tion, and lower extremity edema. Pulmonary embolism may be seen in 5% of
patients at initial presentation.
5 Management of Renal Cell Carcinoma … 51


The surgical management of RCC with IVCTT requires accurate assessment of the
cephalad extent of the tumor thrombus. Historically, cavography was utilized for
the purpose; however, its invasiveness, need for high contrast loads, and poor soft
tissue detail, limits its current utilization.
While transabdominal ultrasonography (US) may at times be the initial imaging
modality in the diagnosis of a renal mass, it may not reliably visualize a tumor
thrombus. Ultrasound is unable to completely visualize the renal vein and IVC in
12.5–43.5% of cases. The sensitivity of US in identifying IVCTT below the
insertion of the hepatic veins has been reported to be as low as 68%. If, however,
the thrombus is intrahepatic, the sensitivity approaches 100% [19].
Multidetector helical computed tomography (MDHCT) allows for staging of the
tumor and provides high resolution (up to 2-mm slices) triphasic CT images. The
sensitivity of MDHCT for detecting caval thrombus is 64–95%; however, accurate
assessment of the cranial extent of the thrombus is made in only a third of cases
[20, 21]. Poor visualization of the cranial extent of thrombus is due to obstruction of
contrast flow around the tumor within the IVC.
The utilization of gadolinium-enhanced MRI has replaced venacavography as
the gold standard for diagnosis of caval thrombus. While MRI may differentiate
between blood and tumor thrombus even without contrast, gadolinium adminis-
tration allows for differentiation between tumor thrombus and non-enhancing bland
thrombus [9]. MRI has been shown to have a sensitivity of 100% for detection of a
thrombus within the IVC [19]. In cases of intracardiac involvement, both CT and
MRI are limited by motion artifact from the beating heart and therefore trans-
esophageal echocardiography (TEE) is useful. This modality also provides a means
for real-time intraoperative monitoring of the IVCTT which is critical during
mobilization of the kidney to watch for any tumor embolization and to ensure
complete extraction [22, 23].


Complete surgical extirpation remains the mainstay of therapy for renal cell car-
cinoma. In the setting of an IVCTT, the 5-year survival following radical
nephrectomy with IVC tumor thrombectomy is 40–68% in the absence of metas-
tasis. In comparison, the 1-year disease-specific survival of an untreated RCC
patient with caval thrombus is 29% with a life expectancy of 5 months [6]. This
highlights the primary role of surgery in this disease for patients deemed to be
appropriate operative risk.
The role of cytoreductive radical nephrectomy (cRN) in the metastatic setting is
evolving, especially in the era of targeted therapies. Depending on the extent of the
tumor thrombus, significant utilization of costly resources (blood products, car-
diopulmonary bypass, etc.) must be balanced with the sometimes marginal (if any)
52 E. Kirshenbaum et al.

survival benefit gained by surgery. In patients presenting with metastatic disease,

50% will have concomitant tumor thrombus in the renal vein or IVC [24]. A 3.5–
5 month average survival has been reported in metastatic patients with IVCTT with
a 1-year death rate of >70% if left untreated. Comparatively, in patients who have
undergone cRN in the presence of an IVCTT, the 1-year disease-specific survival
has been reported to be up to 60% with an overall median survival of approximately
14 months [25–27]. This improved survival is largely attributed to the utilization of
postoperative systemic therapy. However, there does appear to be an improved
response rate to immunotherapy in patients who have undergone cRN with a sig-
nificant 2-year survival advantage of combined therapy versus immunotherapy
alone [8]. The complication rate of cRN has been found to be acceptable with
diligent patient selection [16, 27, 28]. Various predictive models have been utilized
to assess a patient’s suitability for cRN including Karnofsky performance status,
Heng criteria, and Memorial Sloan Kettering Cancer Center risk stratification.
Although no single predictive model has been universally adopted, it is important to
appropriately select patients in order to avoid a potentially highly morbid procedure
in patients with little chance for clinical benefit [29, 30]. A potential drawback of
cRN is that if complications do occur, it may preclude patients from receiving
adjuvant systemic therapy. However, recent reports suggest that the majority of
patients who undergo cRN go on to receive systemic therapy [8, 27].

Preoperative Evaluation

A thorough preoperative cardiopulmonary assessment and metastatic survey,

including contrast-enhanced cross-sectional imaging, nuclear bone scan, and lab-
oratory tests, are mandatory. As previously mentioned, accurate assessment of the
cephalad extent of the IVCTT (typically with MRI) is essential in planning the
appropriate surgical approach. MR imaging should be performed in close proximity
to the surgery date as interval progression of the IVCTT may impact the operative
Tumor thrombus above the level of the hepatic veins may require veno-venous
or cardiopulmonary bypass (CBP) and circulatory arrest. Therefore, any patient
who may require this should have a full cardiac evaluation including stress testing
and/or coronary angiography [23]. Any significant coronary artery disease may be
addressed before or during IVC thrombectomy [31]. Prophylactic subcutaneous
heparin should be administered preoperatively to minimize bland thrombus for-
mation or propagation below the tumor. Acute IVC obstruction while waiting for
surgery may lead to disseminated intravascular coagulation (DIC) and death.

Surgical Approaches

The first tumor thrombectomy of the vena cava for RCC was reported by Berg [32].
Later, in 1922, Rehn described his method for partial IVC resection with
5 Management of Renal Cell Carcinoma … 53

reimplantation of the left renal vein into the remaining vena cava [33]. Ardekani
was the first to describe removal of tumor thrombus from the right atrium in 1971
[34], and by the 1980s and 1990s, numerous authors published case series reporting
5-year survival rates for IVC tumor thrombectomy ranging between 15 and 64% [4,
13, 14, 35, 36]. Circulatory arrest was described by Cummings et al. [37] followed
by the use of caval-atrial shunting by Foster et al. [38].
Choice of surgical approach is determined by renal tumor morphology and
location, level of tumor thrombus, and surgeon preference. We prefer a high 7th or 8th
rib right thoracoabdominal incision for all intrahepatic and supradiaphragmatic
(below the cavoatrial junction) IVCTT as it provides excellent exposure of the entire
cava and right atrium and allows mobilization of the liver and exposure of the
retrohepatic IVC. Even for left-sided primary tumors, a right-sided thoracoabdominal
exposure with a “T”-extension to the left costochondral junction provides adequate
exposure of the entire retroperitoneum. Infrahepatic IVCTT can be managed purely
through an intraabdominal approach (midline, anterior subcostal). For intraatrial
extension and for those in whom there is a high likelihood for cardiopulmonary
bypass, a midline transabdominal incision with a median sternotomy is preferred.
Critical components of surgical resection regardless of approach include early
ligation of the renal artery, complete mobilization of the kidney, complete isolation
of the IVC and all venous inflow, and perhaps most importantly, distal control
above the thrombus. All efforts must be made to avoid intraoperative tumor
embolization which occurs in 1.5% of cases with an associated mortality of 75%
[39]. Techniques utilized to avoid embolization include intraoperative TEE moni-
toring, gentle vascular mobilization, early distal control of thrombus, maintenance
of tourniquets until thrombus is completely removed, and en bloc resection.
Use of preoperative renal arterial embolization is a subject of controversy.
Embolization may reduce kidney size, facilitating easier access to the IVC for
vascular control [14]. Additionally, downsizing of the cephalad extent of the tumor
thrombus may eliminate the need for vascular bypass. However, risks of the pro-
cedure include postinfarction syndrome [40] as well as increased intraoperative
blood loss, postoperative complications, and perioperative death [41].
In some cases of complete caval obstruction with adequate collateralization,
caval resection of the infrahepatic IVC may be performed with little consequence.
In case of vein wall invasion or when the intraluminal diameter of the cava is
reduced to <50%, caval resection with replacement with a ringed PTFE graft or
pericardial patch grafting may be necessary.

Infrahepatic IVC Thrombus

When the tumor thrombus is limited to the infrahepatic IVC, complete isolation of
the inflow into the IVC is performed by ligation of the lumbar veins and right
gonadal vein. The contralateral renal vein is isolated and proximal and distal control
of the IVC is performed. The renal artery is ligated early to help decrease bleeding
from collateral vessels, and the kidney is completely mobilized within Gerota’s
fascia until it is attached by only the renal vein.
54 E. Kirshenbaum et al.

Rummel tourniquets or vascular clamps are placed on the IVC above and below
the tumor thrombus as well as the contralateral renal vein. When complete vascular
control is obtained, a longitudinal cavotomy is made around the insertion of the
involved renal vein and extended cephalad as needed staying well below the level
of the inferior hepatic veins. The tumor thrombus is then dissected out and
extracted. This step should be performed with the patient in Trendelenburg position
to help prevent the occurrence of air embolism. Instrument dissection may assist in
cases of thrombus adherence to the caval wall. The nephrectomy is completed and
the kidney and thrombus is removed en bloc. The cavotomy is then closed with a
running 4-0 cardiovascular suture.

Intrahepatic IVC Thrombus

Management of intrahepatic tumor thrombi requires careful mobilization of the liver
off of the retrocaval IVC as well as control of all venous inflow into the vena cava.
Vascular bypass at this level is not typically required with a reported utilization rate
of 28.5% [10].
Mobilization of the liver medially and cranially is achieved using the Langen-
buch maneuver, or division of the right triangular and coronary ligaments of the
liver. This maneuver exposes the retrohepatic IVC and major hepatic veins. Small
hepatic veins are ligated to allow for complete mobilization of the right hepatic lobe
(Fig. 5.1).
Cephalad control of the IVC can be safely obtained above the diaphragm by
opening the pericardium longitudinally with care taken to avoid the phrenic nerve.
The cavoatrial junction is exposed and a tourniquet can be placed around the
intrapericardial IVC (Fig. 5.2).
The Pringle maneuver then controls hepatic inflow by clamping the hepato-
duodenal ligament containing the portal vein and hepatic artery. In general, con-
tinuous warm hepatic ischemia time should not exceed 20 min. Intermittent Pringle
maneuver (20-min warm ischemia with a 5-min clamp-free interval) has been
shown in hepatobiliary surgery to be tolerated for up to 120 min of total ischemia
before inducing substantial liver damage [42].
The lumbar and gonadal veins are ligated. The IVC below the thrombus and the
contralateral renal vein are controlled with Rummel tourniquets or vascular clamps.
As described for infrahepatic tumor thrombi, cavotomy is begun at the level of the
renal vein and extended cranially. The tumor thrombus is extracted and the cavo-
tomy is closed.
As stated, bypass may be required for some intrahepatic thrombi if cardiac
venous return is insufficient upon cross-clamping to maintain organ/peripheral
perfusion or if there is extensive hemorrhage from collateral venous supply. Trial
occlusion of the vena cava should always be done before cavotomy to ensure
intravascular volume is able to maintain systemic blood pressure. Judicious use of
pressors and adequate intravascular volume resuscitation is necessary.
5 Management of Renal Cell Carcinoma … 55

Fig. 5.1 Mobilization of the right hepatic lobe medially by ligation of small hepatic veins to
expose the entire retrohepatic inferior vena cava

Supradiaphragmatic IVC Thrombus

A combined thoracic and abdominal approach is necessary for resection of
supradiaphragmatic IVCTT. Vascular bypass is used in most cases. If feasible,
supradiaphragmatic thrombi which do not reach the atrium can be milked under-
neath the diaphragm and below the hepatic veins as described by Ciancio et al. [43].
A clamp is then applied below the hepatic veins thus avoiding liver ischemia, and
resection can proceed as described for intrahepatic thrombi [44]. Concurrent
transesophageal echocardiography should be used to view the thrombus level and to
monitor for potential embolization. If the tumor cannot be milked caudally, distal
control can be obtained above the thrombus at the intrapericardial IVC where a
tourniquet is placed for temporary trial occlusion. Tourniquet is preferred here
because placing a vascular clamp in this space is difficult. Vascular bypass is
indicated if blood pressure is not maintained after occluding the IVC. It is usually
not necessary in patients who have complete occlusion of the IVC due to adequate
collateral venous drainage. The Pringle maneuver is performed and the cavoatrial
Rummel tourniquet is tightened. Contralateral renal vein and infrarenal IVC are
also controlled and thrombectomy is performed.
56 E. Kirshenbaum et al.

Right atrium



Fig. 5.2 Longitudinal incision is made in the pericardium to expose the cavoatrial junction.
A tourniquet is placed around the intrapericardial inferior vena cava above the level of the tumor

Intraatrial Tumor Thrombus with Cardiopulmonary Bypass

Bypass is usually reserved for patients with tumor thrombus at or above the level of
the diaphragm, especially for cases with large or adherent atrial thrombus. It
minimizes blood loss, improves visualization of the operative field, and better
maintains hemodynamic stability in patients at high risk for intraoperative
hypotension. It also circumvents the need for retrohepatic IVC dissection and porta
hepatis occlusion.
CPB is the most reliable technique in terms of cardiac safety, but is associated
with increased risks of stroke, air embolus, multiorgan failure, and renal dysfunc-
tion [45, 46]. Once the kidney is isolated by the renal vein and IVC exposure is
obtained, the patient is heparinized. Careful hemostasis prior to heparinization is of
paramount importance. Then, the aortic arch and right atrium are cannulated and
CBP is initiated. Hypothermia (cooling to less than 30 °C) is utilized if prolonged
bypass is expected in order to reduce the ischemic damage associated with circu-
latory disruption. The core body temperature is lowered to approximately 20 °C.
The aorta is cross-clamped and the majority of the blood volume is exsanguinated
to the oxygen-rich pump. Circulatory arrest is achieved with cardioplegic solution.
At this point, cavotomy and atriotomy can be performed for thrombus extraction.
Prior to closure, venacavoscopy using a flexible cystoscope has been described to
visualize the IVC lumen for any residual tumor [47]. Rewarming and transition
from bypass occur as the nephrectomy portion is then completed. The patient is
decannulated and chest tubes are placed for drainage.
5 Management of Renal Cell Carcinoma … 57

Circulatory arrest can be maintained for 40 min with minimal risk of long-term
cerebral ischemic sequelae [48]. The perioperative mortality associated with
hypothermic CBP with circulatory arrest is reported to be between 3 and 16% [49].
Patients who undergo hypothermic CPB are at increased risk of hemorrhage due to
prolonged bypass time and heparinization, coagulopathy due to hypothermia, and
multiorgan dysfunction.
An alternative to CPB, veno-venous bypass (VVBP) may be utilized in select
patients with limited or no atrial involvement. VVBP involves gaining access to and
cannulating the IVC below the thrombus and shunting blood to the right atrium or
right brachial vein to allow for venous return. VVBP has been found to decrease
blood loss and operative time and does not require hypothermia, systemic antico-
agulation, or circulatory arrest [7].

Tumor Invasion into IVC Wall

Tumor invasion into the IVC wall is of particular importance as it is a poor

prognostic indicator and presents significant intraoperative challenges. 23% of RCC
with IVCTT have concomitant invasion into the vein wall which most commonly
occurs at the renal vein ostium [23]. It is well established that vein wall invasion is
associated with increased complication rate [50]. Although preoperative imaging
cannot definitively predict wall invasion, IVC diameter greater than 4 cm has been
shown to predict the presence of vein wall involvement [51]. If vein wall invasion is
present and greater than 50% of lumen reduction is required, a pericardial patch or
polytetrafluoroethylene tube graft is often required. Vascular surgical consultation
is recommended if graft placement is required. If, however, the IVC is chronically
occluded, collateral venous drainage may be sufficient without the need for
reconstruction [52, 53].

Outcomes and Complications

Aggressive surgical resection remains a mainstay of treatment of IVCTT. The

30-day mortality is between 1.5 and 10% with a 5-year disease-specific survival of
40–68% [7, 51]. Given the complexity of surgery, early complications are common
and have been estimated to occur in 15–78% of cases [48, 54, 55]. The perioper-
ative complication rate is directly correlated with the level of thrombus extension,
age and comorbidities of the patient, use of CPB, and indirectly related to surgeon
experience [55]. These complications include hemorrhage, blood transfusion,
reoperation, sepsis, renal failure, myocardial infarction, pulmonary embolism,
pancreatitis, pneumothorax, and perioperative death [45]. Intraoperative tumor
thrombus embolization has a particularly high rate of mortality at 75% [39].
58 E. Kirshenbaum et al.

Anesthetic and Perioperative Care

IVC tumor thrombectomy requires a specialized and experienced team of surgeons,

anesthesiologists, and operating room staff. In the event that CPB is required,
cardiac anesthesiology and cardiac surgery should be involved [56, 57]. High
volume centers have stressed the importance of using the same team for all cases,
bringing familiarity to these challenging cases and helping better manage both
intraoperative and postoperative complications [58].
Intraoperative transesophageal echocardiography is utilized to monitor for any
thrombus propagation, to detect any fragmentation during the procedure, and for
direct cardiac monitoring. The active participation of an anesthesia provider
experienced in the use of TEE is paramount.
Careful hemodynamic monitoring is carried out throughout the procedure by the
cardiac anesthesiologist. Constant communication between surgeon and anesthe-
siologist allows for anticipation of bleeding and clamping of the vena cava. In the
event that CPB is required, the patient should be fully heparinized immediately
prior to initiation of bypass. Prior to heparinization, meticulous hemostasis should
be achieved.

Minimally Invasive Techniques

In addition to an open surgical approach for the management of IVCTT, minimally

invasive techniques have been utilized with pure laparoscopic, hand-assisted, and
robotic techniques being applied. Many have reported the feasibility of a minimally
invasive approach and suggest a reduction in patient morbidity and recovery time
[59, 60]. The reported conversion to open rate with laparoscopy approach 3–10%
with a complication rate of 10–19% [59]. In addition, preliminary data suggests
good oncologic results, although long-term follow up has not been well reported.
For level-I thrombi, one technique described in the literature involves milking the
thrombus into the distal renal vein and using a vascular stapler to separate the vein.
Of note, there must be a distance of at least 1 cm between the thrombus and IVC for
this approach [59]. For level-II thrombi, the infrarenal IVC, suprarenal IVC, and left
renal vein can be controlled with bulldog clamps with subsequent IVC incision and
thrombus removal [59, 61]. While it is well established that level-I and level-II
thrombi are amenable to laparoscopic approaches, higher-level thrombectomies via
laparoscopy have been sparsely reported. The first reported utilization of a
robotic-assisted technique for high-leveled thrombi was in 2015 by Gill et al. [5].
Few institutions are currently utilizing the robotic approach as it requires a
well-integrated multidisciplinary team with extensive experience in robotics. While
initial data suggests the feasibility of these approaches, further investigation must
be undertaken prior to widespread adoption [62].
5 Management of Renal Cell Carcinoma … 59


Long-term survival is possible for locally advanced renal cell carcinoma with IVC
tumor thrombus extension, especially in the absence of metastatic disease. An
aggressive surgical approach provides the best means for accomplishing this goal.
Accurate preoperative assessment of the cephalad extent of the tumor thrombus
allows for a planned controlled operative intervention. Adjunctive techniques
drawn from vascular, hepatobiliary, and cardiac surgery may be necessary. While
robotic-assisted laparoscopic surgery and other minimally invasive techniques will
undoubtedly gain acceptance in the urologist’s armamentarium, it will be the
improvements in systemic therapies that will likely have the greatest impact on the
survival of patients with locally advanced and metastatic kidney cancer.

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Minimally Invasive Radical
Nephrectomy Including Vena 6
Cava Thrombus
Stephanie Gleicher and Gennady Bratslavsky

Key Points

The following key points should be considered for minimally invasive radical
nephrectomy with inferior vena cava (IVC) thrombectomy:

• Arrange for preoperative imaging (preferably MRI, CT) to assess tumor extent
and invasion into IVC less than two weeks prior to surgery
• Minimally invasive techniques are largely based on open surgery principles
• Minimize IVC thrombus disruption by early ligation of the ipsilateral renal
artery and minor dissection of the kidney prior to thrombectomy
• Ensure ligation of collaterals and IVC feeder vessels, especially unpaired pos-
terior lumbar veins, throughout longitudinal extent of thrombus
• Utilize intra-operative Doppler ultrasound to determine cephalad and caudal
margins of thrombus
• Left-sided IVC thrombectomy may be achieved by the transperitoneal approach

– Retroperitoneal approach for left-sided thrombectomy is complex and lim-

ited to renal vein extension

• Surgical expertise in robotic/laparoscopic surgery is warranted

• Anticipate potential conversion to open surgery.

S. Gleicher  G. Bratslavsky (&)

Department of Urology, SUNY Upstate Medical University, Syracuse, NY, USA

© Springer Science+Business Media, LLC 2018 63

R. V. Khanna et al. (eds.), Surgical Techniques for Kidney Cancer,
64 S. Gleicher and G. Bratslavsky


In 2017, it is estimated that 63,990 new patients will be diagnosed with renal cell
carcinoma (RCC) in the USA and 14,400 patients will die from the disease [1].
Approximately 4–9% of RCC tumors present with extension into the inferior vena
cava (IVC) [2–4]. While making the surgical intervention more challenging,
prognosis is largely associated with the absence of metastatic disease and complete
removal of the thrombus [5]. Radical nephrectomy with IVC thrombectomy has
largely improved survival for these patients with 30–60% survival at 5 years
reported in several series [5–7].
Several IVC staging classifications have been described, but the Neves Mayo
clinic description is most commonly used [5]. Caution must be exercised, however,
when interpreting the literature as there are differences between classifications with
inconsistencies between IVC thrombus levels (see below) [5, 8]. Of note, the Neves
Mayo clinic classification system will be used to describe thrombus level for this

Anatomic landmark Neves (Mayo Novick et al. (Cleveland

clinic) clinic)
Renal vein 0 I
IVC < 2 cm above renal vein I II
IVC > 2 cm above renal vein and below II
hepatic veins
IVC above hepatic veins and below III III
IVC above diaphragm IV IV

Regardless of classification used, open surgery has traditionally been the primary
approach for IVC thrombectomy in RCC patients. However, with the introduction
of laparoscopy and further refinement of surgical skills, minimally invasive IVC
thrombectomy has been slowly integrated into practice in some institutions.
Laparoscopic/robotic techniques are known for the benefits of a shorter hospital
stay and less postoperative pain [9–11]. For example, in our report of the first
(Level III) robotic-assisted radical nephrectomy with 11-cm retrohepatic vena caval
tumor thrombectomy combined with extended retroperitoneal lymph node dissec-
tion, the patient was discharged to home in 36 h without any complications [9].
Since the first report of laparoscopic IVC thrombectomy in 2000, numerous
studies have highlighted the feasibility of minimally invasive techniques [9–20].
Most published reports have focused on level I thrombectomy using a laparoscopic
approach [13, 17, 21]. Yet, the minimally invasive domain has rapidly expanded to
include level II and III laparoscopic thrombectomy and, over the past few years,
robotic-assisted thrombectomy [9–12, 14–16, 18, 20, 22–25]. This chapter will
focus on the surgical approach for a successful minimally invasive radical
nephrectomy with IVC thrombectomy. Given that long-term oncologic outcomes of
6 Minimally Invasive Radical Nephrectomy Including … 65

minimally invasive techniques for IVC thrombectomy are still not well studied nor
have they been compared with open surgery, the present chapter will focus mostly
on preoperative considerations and technical aspects needed for the successful
execution of this complex surgery.

Patient Selection and Preoperative Considerations

Patient selection and adequate and timely preoperative imaging are crucial for
successful radical nephrectomy with IVC thrombectomy regardless of the approach.
MRI continues to be the gold standard for visualization especially for higher level
thrombi [26, 27]. Multi-detector CT, with improved resolution and anatomical
detail, may also be used especially in poor MRI candidates [26–28]. Given the
tendency for rapid progression of renal tumors and the potential impact on surgical
planning, imaging should be performed within 14 days of surgery [26]. Patients
with extensive IVC invasion by tumor may require greater IVC excision with
grafting and, hence, may be better candidates for open surgery [10]. This highlights
the importance of preoperative imaging to assess for thrombus extent, thrombus
volume, and IVC wall invasion [28]. Cardiovascular clearance may be beneficial in
most patients as IVC clamping may not be tolerated in patients with preload
dependent cardiovascular disease [24]. Regardless of preoperative planning, how-
ever, surgeons should be ready for possible open conversion.

Surgical Approach

Preoperative Embolization

Most minimally invasive IVC thrombectomies have been performed on right-sided

renal tumors [19, 22, 23]. Some advocate for individuals with left renal tumors to
undergo preoperative arterial embolization. This may be beneficial due to the
limited access to the left renal artery while the patient is in flank position with the
right side up [10]. For similar reasons and to minimize the risk of open conversion,
bulky tumors may also benefit from preoperative embolization [10]. Preoperative
embolization remains a controversial topic, however, as worse outcomes (including
higher perioperative mortality) have been reported among those who underwent
preoperative embolization when compared to those who did not [29]. Regardless of
tumor laterality and the decision on embolization, the “thrombus first” approach is
necessary: IVC thrombectomy should be completed prior to nephrectomy.
66 S. Gleicher and G. Bratslavsky

Retroperitoneal Approach

For laparoscopy, the retroperitoneal approach may be applied to IVC thrombi

associated with right-sided renal tumors or left-sided renal masses with extension
into the renal vein. Due to limited access to the cava via the retroperitoneal
approach from the left side, left-sided RCC with extension into the IVC would
require a transperitoneal approach [15].
As for any retroperitoneal approach, the patient should be placed in a lateral
decubitus position with the affected kidney up. The port placement for the
retroperitoneal approach has been previously well described [15, 22]. Most
important technical considerations include development of the retroperitoneal
space, swiping of the peritoneum medially for creation of the larger working space,
maintaining the orientation of the dissection along the psoas muscle, early access to
the renal hilum, and early division of the renal artery [15, 22]. Careful dissection
toward the renal hilum allows for identification of the ipsilateral renal artery [15,
22]. For right-sided tumors, there should be adequate access to lower level caval
thrombi allowing for complete encircling of the cava in the event cross-clamping is
needed. The major limitation to the retroperitoneal approach is a small working
space, so it is not typically the preferred approach for IVC thrombi. Additionally, as
stated above, because of the limited access to the vena cava from the left
retroperitoneal space, it is not recommended for left-sided tumors with caval


Applied in both pure laparoscopic and the robot-assisted techniques, a transperi-

toneal approach may be used for thrombi associated with both right-sided and
left-sided renal tumors [10, 20]. Regardless of laterality, the patient is placed in a
left lateral decubitus position with extension of the right flank. After insufflation of
the intraperitoneal cavity, a 12 mm camera port is inserted near the umbilicus and
three to four additional ports are placed (usually in vertical line). The surgeon
should ensure that one small port is placed at the sub-xiphoid region for liver
retraction [10, 12, 20, 30]. In IVC thrombectomy, patient position does not change
for tumor laterality [20]. Positioning and port placement are highly dependent on
body habitus [9].
The dissection begins with an incision to the posterior peritoneum. The colon is
reflected medially. Duodenal kocherization exposes the IVC and the renal vessels
[9, 11, 12, 20, 24, 30].
6 Minimally Invasive Radical Nephrectomy Including … 67

Level I Thrombectomy

Identification of the hilum or interaortocaval space and gentle dissection to the

ipsilateral renal artery allows for early arterial ligation and may help to slightly
reduce the size of the thrombus. Care is taken not to disrupt the thrombus within the
renal vein. Ligation of the renal artery (with either an endo-GIA stapler or
Hem-o-lok clips) at the hilum or in the interaortocaval space (especially if the
patient had prior arterial embolization) is performed first. This allows for early
arterial control of the kidney and minimizes thrombus manipulation [9, 11, 12].
For thrombi limited to the renal vein, dissection of the IVC can be avoided. For
left-sided tumors, ligation of the left gonadal vein is often performed first. With a
flattened renal vein (secondary to diminished arterial flow), deployment an
endo-GIA vascular stapler proximal to the bulging tumor within the renal vein and
adjacent to the IVC is done after ultrasound confirmation of an uninvolved proximal
left renal vein at the IVC junction [12, 17, 21]. Using the endo-GIA vascular
stapler’s teeth, milking the thrombus from the renal vein may be performed [21].
Completion of the radical nephrectomy and placement of the en-bloc specimen in
an EndoCatch bag allows for a controlled extraction of the specimen.

Level II Thrombectomy

For IVC thrombi projecting less than 2 cm into the IVC, dissection of the con-
tralateral renal vein and pre-placement of a vessel loop with a secured Hem-o-lock
clip (Rummel tourniquet) for later identification and cinching are the first steps [24].
At the renal vein ostium, careful dissection of the IVC circumferentially and
identification of the extent of the thrombus with intra-operative ultrasound are
performed. Ligation of the right gonadal and posterior caval lumbar veins allows for
a relatively bloodless surgery during the cavotomy. Leaving 1–2 cm gonadal vein
stump for later assessment of hemostasis may be helpful. Careful mobilization of
the medial and superior aspects of the kidney may be performed, but is usually not
recommended for fear of tumor thrombus dislodgement and vascular embolization
[10]. Gentle lateral retraction of the kidney away from the IVC may return the
thrombus to the renal vein, but should be utilized with great caution. Attention to
caval tumor burden is always the priority to minimize the risk of inadvertent
dislodgement of tumor thrombus [14]. Ureteral division allows for additional taut
traction if needed [9]. Using ultrasound guidance, confirm the level and extent of
For smaller, less bulky level II thrombi, tangential IVC clamping, with thrombus
exclusion, may be employed via the laparoscopic Satinsky clamp [12, 23]. There
are flexible ports that allow for the introduction of the curved Satinsky.
For larger level II thrombi, the IVC must be completely clamped. Ultrasound
should be used to delineate caudal and cephalad tumor margins. Vessel loops may
be preplaced to demarcate the extent of the tumor. Alternatively, vascular bulldogs
68 S. Gleicher and G. Bratslavsky

may allow for excellent cross-clamping of the cava and the contralateral renal vein.
The right adrenal vein may require ligation. For right-sided thrombi, Rummel
tourniquets or the vascular bulldogs should be cinched in the following order:
infrarenal IVC, left renal vein, suprarenal IVC. For left-sided thrombi, a bulldog
clamp should be used for the right renal artery (to prevent renal engorgement due to
fewer venous collaterals on right side) and Rummel tourniquets or vascular bull-
dogs can be placed on the IVC. The vessels should be clamped or cinched in the
following order: infrarenal IVC, right renal vein, suprarenal IVC [20]. There is no
consensus if the right renal artery should be clamped for the left-sided IVC thrombi.
Clear communication with anesthesia prior to cinching is of paramount importance.
Extra fluids and blood should be available throughout the case. Performance of a
clamp trial for hemodynamic stability is a first step prior to cavotomy. If patient
tolerates clamping, assessment of hemostasis by a small venotomy at the gonadal
vein stump may be a helpful maneuver [10, 12, 23].
Incision of the renal vein at the level of the ostium of the right renal vein and the
IVC, leaving a sufficient cuff for closure to minimize luminal narrowing, is per-
formed. Caval excision in areas of thrombus attachment to the IVC is important.
Often, blunt dissection of the thrombus allows for its separation from the wall of the
IVC. If the invasion in the wall is suspected, the affected area should be excised to
avoid compromising oncologic outcomes. Upon thrombus removal, irrigation of the
IVC lumen with heparinized saline is performed [11, 12, 15, 23]. Closure of the
IVC with 4-0 prolene sutures in a single layer allows for excellent hemostasis.
Occasionally, an additional stitch may be needed. In cases of caval excision sec-
ondary to thrombus invasion with subsequent caval luminal narrowing (typically
>50%), robotic patching may be performed as first described by Lee et al. [31–33].
While several materials are available, bovine pericardium and expanded polyte-
trafluoroethylene (ePTFE) have been preferred for their low thrombogenic poten-
tial, long-term patency, low rates of reported infections, and ease of robotic
handling [31–33]. For right-sided thrombi, Rummel tourniquets or vascular bull-
dogs may be loosened and released in the following order: suprarenal IVC, left
renal vein, then infrarenal IVC. For left-sided thrombi, bulldog clamp and Rummel
tourniquets should be released in the following order: suprarenal IVC, right renal
vein, and infrarenal IVC. In cases of the right renal artery clamping, the renal warm
ischemia time should be recorded [20].

Level III Thrombectomy

Initially performed by Bratslavsky and Cheng [9] in March of 2013, this surgery
remains technically demanding and dangerous. Minimizing IVC manipulation is of
the utmost importance in level III thrombectomy. Initial dissections should focus on
finding the ipsilateral renal artery in the interaortocaval space, rather than the more
lateral renal hilum, to minimize renal manipulation and potential thrombus
6 Minimally Invasive Radical Nephrectomy Including … 69

disruption [10]. Simultaneous transesophageal echocardiography should be per-

formed throughout the thrombectomy to monitor for supra-diaphragmatic entry of
thrombus [9, 10].
Liver mobilization via incision of the right triangular ligament and cephalad
retraction will expose the retrohepatic IVC. Transection of the right triangular
ligament and mobilization of the right hepatic lobe will provide excellent access to
caudate lobe and its drainage to the IVC via short hepatic veins [9, 16]. Ligation of
the short hepatic veins from the caudate lobe is performed on both the liver and
caval side. Under ultrasound guidance, demarcation of the tumor extent is per-
formed and a Rummel tourniquet is preplaced (usually via a vessel loop). For
right-sided thrombi, Rummel tourniquets are cinched in the same order as in the
cases of the level II thrombi as follows: infrarenal IVC, left renal vein, hepatic IVC.
However, it should be noted that alternative sequences have been successfully
employed [9, 10, 16].
For left-sided thrombi only reaching the level of hepatic veins, bulldog clamp
and tourniquets may be cinched as follows: infrarenal IVC, right renal artery (not
always employed) right renal vein, intrahepatic IVC [10]. Upon cinched Rummel
tourniquets, transection of the ipsilateral renal vein with an endo-GIA vascular
stapler is often employed as the rest of the left renal vein will be removed with the
specimen. This also allows for greater IVC mobility to ensure all posterior feeder
vessels are sufficiently ligated [10]. Additionally, it allows for immediate disposal
of en-bloc thrombus with renal vein stump to minimize potential local spillage [10].
Assessment for hemodynamic stability is crucial upon clamping. Assessment for
hemostasis and adequate vascular control is performed via venotomy. Incision of
the renal vein stump at the level of the IVC ostium is performed and extended
proximally for full thrombus extraction. Upon en-bloc thrombus removal with the
renal vein stump, irrigation of the IVC lumen with heparinized saline is performed,
and closure of the defect with prolene is performed. Closure with a silk has also
been described as it has no suture memory and allows for a faster closure [9, 10].
Release of the tourniquets is performed as described above. Upon hemostasis, right
radical nephrectomy may be completed. For left radical nephrectomy, patient may
be repositioned.
The sequences above represent management of the low level III IVC thrombus
reaching the levels of the hepatic veins. It is important to recognize that in cases
where the tumor thrombus is above the level of the hepatic veins, the utilization of
the Pringle maneuver and cross-clamping of the supra-hepatic IVC is needed. These
cases are usually done via traditional open approach. Beyond experimental studies,
there have been no reported minimally invasive level III thrombectomies requiring
supra-hepatic control of the IVC [10, 12].
70 S. Gleicher and G. Bratslavsky


In general, IVC thrombectomy complication rates have been declining over the past
few decades [4]. Complications for minimally invasive radical nephrectomy with
IVC thrombectomy mirror those encountered with open surgery, including: hem-
orrhage, pulmonary embolus, deep vein thrombosis, myocardial infarction, wound
infection, acute renal failure, and ileus [4]. The risk for pulmonary embolus and
hemorrhage may be reduced with minimally invasive techniques as there is less
hilar and caval manipulation pre-thrombectomy [10]. However, there have been no
randomized studies to confirm this observation. The risk of intra-operative hem-
orrhage may be reduced as well. The use of the robotic lens with enhanced technical
agility may allow for improved precision during interaortocaval and hilar dissec-
tion. Vasculature ligation, especially of posterior caval feeder veins, may be
enhanced as well [10]. Again, no studies have confirmed significantly less
intra-operative blood loss or improved outcomes, but the utilization of the robotic
technology remains promising for management of these challenging patients.

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treatment of renal cell carcinoma. Eur Urol. 2015;68(1):115–22.
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Renal Cryotherapy
Nishant Jain and Robert J. Stein


Advances in imaging technology have led to a higher incidence of small inciden-

tally discovered renal masses. Currently, it is estimated that there will be over
60,000 new cases of renal cancer, of which 70% will be characterized as small renal
masses (SRMs). As a result of an epidemiological shift toward detection of smaller
renal masses, minimally invasive, nephron-sparing approaches, such as cryoabla-
tion, are increasingly utilized [1].
Nephron-sparing techniques have been associated with a decreased risk of
developing end-stage renal disease when compared to radical approaches [2].
Currently, partial nephrectomy (PN) remains the standard of care for treatment of
SRMs; however, certain ablative procedures offer fewer perioperative complica-
tions and shorter hospital stays, while providing similar oncological outcomes [3].
For these reasons, ablative technique is indicated for a T1a (<4 cm diameter,
localized) renal mass in a poor surgical candidate (e.g., elderly patient or patient
with multiple comorbidities), or in a patient in need of nephron-sparing treatment
(e.g., patients with chronic renal insufficiency, solitary kidney, or genetic predis-
position for renal tumors) [4].
Among minimally invasive ablative techniques, cryoablation is one of the most
applied and studied modalities, offering laparoscopic and image-guided percuta-
neous options. Both are limited by an inability to histologically assess margin status
of treatment. Also, in cT1b tumors (>4 but <7 cm), Caputo et al. [5] found
cryoablation to have a higher recurrence rate than that of robotic-assisted partial

N. Jain (&)  R. J. Stein

Q10, 9500 Euclid Ave, Cleveland, OH 44195, USA
R. J. Stein

© Springer Science+Business Media, LLC 2018 73

R. V. Khanna et al. (eds.), Surgical Techniques for Kidney Cancer,
74 N. Jain and R. J. Stein

nephrectomy. Nevertheless, long-term cancer-specific survival data suggests

cryoablation to be a safe and effective treatment option with acceptable
complication rates and optimal oncological and surgical outcomes in patients with
T1a renal tumors [6]. Furthermore, renal function is not compromised in cryoab-
lative techniques, even in patients with a solitary kidney [7].

Mechanism of Cryotherapy

Cryotherapy initiates tissue destruction by freezing and thawing, using a

vacuum-sealed liquid argon gas system for freezing and helium gas for thawing. As
a result, two synergistic mechanisms occur: (1) acute cytotoxic injury followed by
(2) subacute ischemia [8].
Initially, during the freeze phase, extracellular fluid freezes, increasing the
extracellular osmolarity and shifting fluid out of the cell. Intracellular pH and solute
composition balances are disrupted resulting in protein denaturation and cell
damage. Additionally, intracellular ice crystals form at −20 °C resulting in direct
cytotoxic injury. The thawing process is just as detrimental to the cell. As the tissue
thaws, a transient hypotonic state forms outside of the cell, resulting in cell lysis.
Subacutely, days to weeks after the initial treatment, cell death is largely due to
occlusion of local tissue microvasculature. Freezing causes small blood vessels to
expand, damaging the endothelial cells. Damaged endothelial cells lead to platelet
aggregation, which may result in vascular thrombosis and tissue necrosis. Woolley
et al. [9], determined in a canine model that two freeze-thaw cycles create a larger
area of liquefaction necrosis compared to a single freeze-thaw cycle; they also
concluded that a passive thaw offers no advantage over an active thaw; however,
this point has been contested in previous studies [10].
The critical temperature needed to achieve complete cell death is below −19.4 °C.
Campbell et al. [11] showed that in order for −19.4 °C to be reached in the
targeted lesion, the edge of the iceball must extend at least 3.1 mm beyond the margin
of the lesion. Furthermore, clamping the renal artery does not significantly affect the
temperature of the cryolesion during therapy [11]. By incorporating these animal
studies, clinically it has been our strategy to extend the edge of the iceball at least
0.5 cm beyond the edge of the tumor and to use two freeze-thaw cycles with a passive
thaw in order to assure complete cancer cell death.

Percutaneous Cryoablation

Percutaneous cryoablation is developing rapidly and an increasing number of

patients are being treated this way [12]. This technique is optimal for tumors located
posteriorly and inferiorly, although Schmit et al. [13] also argue that anterior tumors
can also be treated with high technical success and low complication rates. Anterior
7 Renal Cryotherapy 75

tumors located within 1–2 cm from the bowel require hydrodisplacement of the
bowel using sterile saline in order to achieve safe cryotherapy. This procedure can
be done under general anesthesia for patient comfort, though local anesthesia is also
acceptable; usually CT guidance is preferred, although it can also be carried out
using MRI or ultrasound guidance [7].
CT guidance allows for high resolution, cross-sectional imaging and is more
accessible than MRI. Only local anesthesia is required under CT guidance. The
main drawback with CT guidance is radiation exposure. This can be avoided with
MRI and ultrasound. MRI provides excellent resolution, but it is costly and requires
MRI-compatible cryoprobes [14]. Ultrasound guidance includes real-time moni-
toring, low cost, and portability. However, imaging may be difficult due to the lack
of resolution and possible acoustic shadowing, especially in obese patients.
Table 7.1 illustrates a low recurrence rate (<1%) and a high rate (over 96%) of
overall technical success with percutaneous cryoablation. Atwell et al. [15, 16]
identified large (>4 cm), central tumors as factors associated with suboptimal
treatment in a percutaneous approach. Vernez et al. [17] identified skin to tumor
length as an independent predictor of suboptimal treatment in percutaneous
cryoablation. Furthermore, the study identified that a skin to tumor length greater
than 10 cm had a 4 greater chance of failure, while tumor size and location were
not associated with suboptimal treatment. Atwell et al. [15, 16] and Vernez et al.
[17] acknowledge more long-term research on cryotherapy should be done at
varying tumor sizes and locations, but both studies argue that given advancements
in imaging technology, cryoprobes, and surgical expertise; percutaneous
cryotherapy is still an effective option (93% success rate, [15]) in tumors between 4
and 7 cm if partial nephrectomy is contraindicated.

Complications with Percutaneous Cryoablation

Jiang et al. [18] performed a meta-analysis using 11 studies with 1942 patients and
found that percutaneous cryoablation is associated with higher incidences of
perirenal hematomas, though overall complication rates remain similar when
compared to laparoscopic cryoablation; it is speculated that this may be attributed to
the lack of direct visualization with a percutaneous approach. The study also found
no statistical difference in recurrence rate, 3- and 5-year disease-free and overall
survival rates when comparing percutaneous cryoablation to laparoscopic

Laparoscopic Cryoablation

Laparoscopic cryoablation is more frequently performed on anterior and endophytic

small renal masses [19]. This technique can be done with either a transperitoneal or
retroperitoneal approach depending on the location of the tumor. The procedure is

Table 7.1 Overall success rate with percutaneous cryoablation

Study Tumor Avg tumor Overall Retreatment Length of Avg follow Recurrence Major complications
sample size (cm) success (% success) stay (days) up (months) rate (%)
size (%)
[15] 115 3.3 97 0% 1.2 13.3 0 6%: urosepsis, hematomas [3], PE, hematuria
[16] 93 3.4 96 1% (100%) 1.3 26 1 7%: retroperitoneal hemorrhage [3], obstructive
hematuria, pulmonary embolism, pulmonary edema
[26] 171 3.2 97.6 7.6% 1.5 20.1 1 4.6%: hemorrage, perirenal hematoma, pelvicalyceal
(69.2%) injury [3], pneumothoraces [2]
[13] 38 2.9 100 0% 1.1 18 0 3%: pulmonary embolism
N. Jain and R. J. Stein
7 Renal Cryotherapy 77

performed under general anesthesia after the patient is placed in the lateral position.
The kidney is mobilized away from the large bowel in order to expose Gerota’s
fascia, which is carefully dissected. Fat overlying the mass is sent for pathological
diagnosis and the extent of the mass is evaluated using laparoscopic ultrasound
probes. The cryoprobe is inserted through the skin and into the renal mass, just past
the deep edge of the tumor. Larger tumors may require multiple cryoprobes in order
to achieve technical success. A flexible ultrasound probe is placed on the opposite
end of the kidney to monitor the progress of the iceball. Once the iceball extends at
least 0.5 cm beyond the tumor margin, the first thaw process is initiated. The
second freeze cycle should not extend past the hemorrhagic blue halo, demarking
the edge of the first freeze cycle [14]. After the procedure, bleeding is controlled by
compression, hemostatic agents, and, if necessary, argon-beam coagulation.
In certain cases, open cryotherapy is also an option, although complications and
blood loss are higher compared to laparoscopic approach. Initially, renal cryoab-
lation was conducted using an open approach. Rukstalis et al. [20] performed open
cryoablation on 29 tumors (2.2-cm median diameter) and achieved a technical
success rate (% of nonenhacement on follow-up imaging) of 91%. However, the
mean blood loss was 200 ml and two patients required transfusions. Serious
adverse events were seen in five patients (17.2%), including: persistent renal cell
carcinoma, congestive heart failure, and chronic renal failure requiring dialysis in
three patients.
Laparoscopic cryoablation is an effective oncological treatment confirmed by
3- and 5-year disease-specific survival outcomes (see Table 7.2). O’Malley et al. [3]
conducted a matched-cohort study comparing laparoscopic cryoablation to
laparoscopic partial nephrectomy in 30 patients and found that laparoscopic
cryoablation has less blood loss, shorter operation time, and a lower risk of open
conversion; no difference was observed in clinical outcomes including: complica-
tion rates, length of stay, creatinine levels, hematocrit levels, morbidity, and
short-term efficacy. This study was limited by a small sample size and short
follow-up duration so more research needs to be conducted; however, early data
suggests promising outcomes for laparoscopic cryoablation.

Complications of Laparoscopic Cryoablation

A multinational retrospective study on laparoscopic cryoablation [6] pooled data

from 650 patients and found that after a 3-year follow up, the technical success rate
was 97.1% and the 3-year disease-specific survival rate was 100%. The overall
complication rate was 14.4% and the major complication rate, defined as
Clavien-Dindo score of 3 or more, was 3.1%. Other studies, shown in Table 7.2,
indicate overall complication rates ranging from 4 to 20%. A majority of compli-
cations deal with blood loss and a need for blood transfusions.

Table 7.2 Success rates of laparoscopic cryoablation

Study Tumor Avg Survival outcomes Retreatment Length Avg Recurrence Avg Complications
sample tumor (% success) of stay follow up blood
size size (days) (months) loss
(cm) (in cc)
[27] 80 2.3 5-yr disease-specific: 2.5% (100%) 2 93 20% (11% 111 20%: renal hemmorrage [1], splenic
92%, 10-yr: 83% (median) death) hematoma [8], pneumonia [2],
pneumothorax [1], Heart failure [1],
bilateral atelectasis [1], retroperitoneal
bleed [1], intercostal artery rupture [1]
[28] 131 2.14 5-yr disease-specific: 0% 4.71 46.04 0% 210 20.3%: converted to open surgery [2],
100% | 5-yr Overall: fracture of cryoablated tissue [3],
93.2% transfusion [6], uteropelvic junction
obstruction [1]
[29] 60 2.3 3-yr disease-specific: 3.3% (100%) 1.7 36 5.6% 87 4%: splenic hematoma, heart failure,
98%| 3-yr overall: 89% (minimum) pleural effusion, and herpetic
[30] 36 2.1 3-yr disease-specific: 0% 1 45.7 2.80% 97 8.3%: converted to open surgery,
100% hemmorage, and urinary leak
[6] 650 2.69 3-yr disease-specific: N/A N/A 36 2.9% N/A 14.4%: Clavien-Dindo 1–2 (11.3%), 3–
100%, 5-yr: 99.4%, 8-yr: residual 5 (3.1%)
99.4%| 3-yr overall: (unablated)
94.3%, 5-yr: 86.8%, 8-yr:
N. Jain and R. J. Stein
7 Renal Cryotherapy 79

Comparisons of Laparoscopic to Percutaneous Cryotherapy

Many studies have compared the effectiveness of laparoscopic and percutaneous

cryotherapy. Advantages of percutaneous cryoablation over a laparoscopic
approach include: less blood loss, shorter hospital stay, less requirement for pain
medication [21], and cost-effectiveness [22]. Laparoscopic cryotherapy offers direct
visualization of the tumor to allow for a higher rate of primary effectiveness [23]
and a lower rate of perirenal hematomas [18]. Also, more long-term research on
oncological outcomes, including 3- and 5-year survival rates, has been published
for laparoscopic cryoablation. Laparoscopic cryoablation has been used to treat
anterior tumors at a higher rate, although studies have shown that anterior tumors
can be treated with high success rates using a percutaneous approach [13].
Hui et al. [23] conducted a meta-analysis in 2008 comparing the two techniques
over the course of a year (13 months for percutaneous and 16 months for laparo-
scopic). The study looked at 1180 tumors and concluded that percutaneous
cryoablation had a significantly lower primary effectiveness rate than that of
laparoscopic cryoablation (87 vs. 94%); however, the secondary effectiveness,
following retreatment of residual or recurrent tumors, was not significantly differ-
ent. Furthermore, the study found that the major complication rate in the percuta-
neous treatment group was significantly lower than that in the laparoscopic
treatment group (3 vs. 7%). The primary contributors to the increase in laparoscopic
complications were blood transfusions and conversion to open surgery.
In 2017, Jiang et al. [18] performed a meta-analysis looking at 13 studies
(n = 2307) comparing laparoscopic cryoablation to percutaneous cryoablation and
found no statistical difference between the overall complication rate, recurrence
rate, 3- and 5-year overall and disease-free survival rate. Percutaneous cryoablation
was found to have shorter hospital stays, though no difference was found between
operative time and number of probes used. Younger patients and those with anterior
tumors were preferentially undergoing laparoscopic cryoablation.

Comparisons of Cryotherapy to Other Techniques

Another ablation technique available is radiofrequency ablation (RFA). This

technique is mostly delivered percutaneously and was first used in kidneys in 1997
[24]. RFA uses high-frequency electrical currents to generate heat (between 50 and
100 °C) thus destroying cancer cells. Similar to cryoablation, direct cellular damage
is followed by microvascular injury.
Kunkle et al. [12] conducted a comparative analysis (n = 1375) between
cryoablation and RFA and concluded that RFA has a significantly higher local
(12.9 vs. 5.2%) and metastatic (2.5 vs. 1%) tumor progression rate; RFA also has a
higher retreatment rate when compared to cryotherapy. Kunkle et al. [25] also
conducted a meta-analysis (n = 6471) comparing partial nephrectomy to cryoab-
lation and RFA. The study found partial nephrectomy to have the lowest rate of
80 N. Jain and R. J. Stein

retreatment, followed by cryoablation and then RFA (2.6% vs. 4.6% vs. 11.7%,
respectively). The study did not find any significant difference in the percent of
progression to metastatic disease in the three studies.


Renal cryotherapy is an advancing field of surgery. Currently, PN remains the gold

standard, but as more long-term data becomes available and as technology and
surgical expertise improve, more surgeons may offer renal cryotherapy, especially if
the patient is not fit for a partial nephrectomy.
Inspired by the early success of cryoablation and RFA, other technologies, such
as irreversible electroporation (IRE) are currently emerging. IRE is a new alter-
native that delivers focal electrical pulses that can induce cell death. Since IRE does
not rely on extreme temperatures, like cryoablation and RFA, it has the ability to
preserve nearby vasculature and nerves. Canvasser et al. recently published a study
(n = 42) on the short-term oncologic outcomes of IRE and achieved a 93% initial
success rate with no major complications (Clavien-Dindo score of 2 or more).
Though the study concluded IRE has suboptimal short-term local disease control, it
is possible in the future; procedural modifications and technology advancement
may alter the way small renal masses are treated.

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Radiofrequency Ablation of Renal
Masses 8
Kenan Ashouri, Joshua Heiman, Anne M. Lopez, Emily F. Kelly
and Raymond J. Leveillee


With the improvement of imaging techniques over the past several decades, the
detection rates of incidental renal masses and the incidence of renal tumors have
increased [1, 2]. These masses tend to be lower stage and prior to the advent of
nephron sparing surgery (NSS), the management of renal cell carcinoma
(RCC) primarily involved radical nephrectomy (RN) [2]. NSS, classically consid-
ered partial nephrectomy (PN), thermal ablation (TA), and non-thermal ablation
have added a multitude of alternatives to RN. The major advantage of NSS is the
conservation of renal parenchyma and renal function [3]. Thermal ablation can
involve either heating tissue using radiofrequency ablation, microwave ablation,
high-intensity focused ultrasound, or laser interstitial therapy, or cooling tissue by
means of cryoablation (CA) [4]. The most popular thermal ablative methods are
RFA and CA [5]. Advances and improvement of these NSS techniques have rev-
olutionized the management options for renal masses, particularly small renal
masses (SRM), classically defined as clinical stage T1a, <4 cm [3]. As per AUA
guidelines, PN remains the gold standard for SRM, but RFA is now recommended
as an option for renal tumors of clinical stage T1a or <3 cm in patients that will be
unable to tolerate more invasive surgery or as an option for healthy patients who
prefer less invasive intervention [6–9]. Recent outcomes data for RFA of renal
masses is shown in Table 8.1. When compared to PN and RN, RFA is associated
with improved preservation of renal function, lower complication rates, decreased

K. Ashouri (&)  J. Heiman  A. M. Lopez  E. F. Kelly  R. J. Leveillee

Division of Urology, Department of Surgery, Charles E. Schmidt College of Medicine,
Florida Atlantic University, Bethesda Hospital East, 2815 Seacrest Blvd,
Boynton Beach, FL 33435, USA

© Springer Science+Business Media, LLC 2018 83

R. V. Khanna et al. (eds.), Surgical Techniques for Kidney Cancer,
84 K. Ashouri et al.

financial cost, with a trade-off of possibly slightly inferior oncologic outcome [7, 9,
10]. These reported inferior oncologic outcomes must be viewed in light of lack of
uniformity of technique, device used, radiologic versus surgical application, and
reporting biases. In our opinion, when patients and tumor location are properly
selected, then TA rivals PN quite comparably. This chapter will review important
considerations and technical instructions for performing RFA of renal masses.

Available Devices

As noted above, RFA works by placing an electrode into tissue and passing current
from the electrode through tissue, using the impedance of the tissue to generate
heat. The unbridled current at high impedance, similar to a bare needle electrode or
conventional electrocautery, generates excessive heat and results in tissue char
which precipitously increases impedance thus insulating further spread of current
and limiting the ablative radius. Therefore, in order to maximize the effectiveness of
the tissue circuit, RFA systems generally operate on one of two possible regulatory
systems: electrical impedance or temperature. Several systems have been developed
for RFA of renal masses. The impedance-regulated systems include the Cool-tip®
(Covidien, Boulder, CO, USA) as shown in Fig. 8.1a, b and LeVeen® RF 3000
(Boston Scientific, Natick, MA, USA) as shown in Fig. 8.1c. The
temperature-regulated system is the Starburst Radiofrequency Interstitial Tissue
Ablation (RITA®) (Angiodynamics, Queensbury, NY, USA) as shown in Fig. 8.1d.

Fig. 8.1 Cool-tip® (Covidien, Boulder, CO, USA) probe features either a single-tip a or
cluster-tipped design. b This system employs chilled fluid to limit heat rise and maximize ablative
radius. c The LeVeen® RF 3000 (Boston Scientific, Natick, MA, USA), with its 12-tine “dry
umbrella” design, allowing a maximum deployed radius of 4 cm. d The Starburst RITA®
(Angiodynamics, Queensbury, NY, NY, USA) system is the temperature-dependent system. It
utilizes a 9-tined design can monitor temperature through five of the tines. Illustration by Rachael
Hilton, MD
8 Radiofrequency Ablation of Renal Masses 85

The Cool-tip® (Covidien, Boulder, CO, USA) is the system typically used at our
center. It is an impedance-regulated device which utilizes temperature as a treat-
ment end point. It generates a 480-kHz frequency and is available in a single-probe
or cluster-probe system in which the energy produced by each probe tip can be
individually modulated via simple controls on the generator box. The fundamental
principle of the system involves an internal perfusion of the ablation needle with
chilled water utilizing a peristaltic pump that cools the probe tip (or tips) during the
ablation cycle. This engineering design allows a maximum tissue–probe interface
temperature of 25 °C preventing char and allowing optimal thermal delivery, as the
RF monopolar current dissipates into the tissues in a wider circumference than a dry
electrode would allow (Fig. 8.2) [11, 12]. When the pump is turned off, the ther-
mistor at the tip of the electrode registers tissue temperature. It is customary at the
end of a treatment cycle (preset at 12 min by the manufacturer), a brief, non-chilled
cycle is begun in order to heat tissues adjacent to the probe to >80 °C.
The LeVeen® RF 3000 system (Boston Scientific, Natick, MA, USA) is based
on a “dry umbrella” design that uses 12 tines that expand to a diameter of 2–4 cm
(needle size is individualized based upon physician preference). Impedance is
monitored while current runs from the tines [4, 13]. As impedance increases, the

Fig. 8.2 Laparoscopic approach and visualization of RFA using the Cool-tip® (Covidien,
Boulder, CO, USA) probe. Note the real-time visualization of the ablative zone, encircled in white
in this figure
86 K. Ashouri et al.

system slowly decreases power output. This impedance-dependent principle is

known as “roll-off.” The implication is that it is local temperature with resultant cell
death and desiccation is what leads to efficacy. The LeVeen system provides no
tissue temperature feedback.
The Starburst RITA® (Angiodynamics, Queensbury, NY, USA) system is a
temperature-dependent system and employs a similar expandable tine design with
nine tines deployed from a 16-gauge shaft. The shaft mechanism allows the tines to
be deployed to a depth of 5 cm. The major advantage of this system is that five of
the nine tines have a thermocouple tip that monitors tissue–probe interface tem-
perature intraoperatively [13]. It should be noted that specific caution should be
taken using this device as differential expansion can lead to an irregular zone of
ablation or result in missed aspects of the lesion known as “skip lesions.” The
Starburst RITA can be used with dry or wet electrodes. When using dry electrodes,
the current density is limited by localization of current conduction. Wet electrodes
utilize the perfusion of saline to allow for improved tissue current conductance
resulting in an increased ablative radius. Dry electrodes typically require more
operative ablation time and often necessitate more tissue–electrode interface area
and multiple ablations.
Choosing a device is dependent on operator preference. Studies involving
ex vivo models have noted variations in the ablative lesion patterns. For example,
despite having the largest ablative volume, the Starburst RITA can result in a
“Christmas-tree” pattern due to its expandable tines, whereas the Cool-tip
demonstrated a barrel-shaped or ovoid pattern [14, 15].
Special consideration must be made when using MR guidance for RFA as
standard stainless steel probe tips will interfere with MR signaling. One way to
obviate this issue is to use non-ferromagnetic materials. One example of such a
device is the nitinol StarBurst Semi-Flex [16].

Patient Selection and Indications for RFA

Selection of patients for RFA is based on tumor size, location, and patient
comorbidities. Although the standard of care for NSS remains PN, it is important to
discuss alternative “options” in patients that are not ideal surgical candidates for RN
or PN. The most recent outcomes data is shown in Table 8.1. According to the 2017
AUA guidelines, RFA should be considered as a management “option” for solitary
renal tumors <3 cm [6]. Prior guidelines stated RFA was an option for masses up to
clinical stage T1b or <7 cm [7]. The new guidelines also state that a percutaneous
approach is preferred over laparoscopic approach and that masses should be
biopsied prior to ablation [6]. Tumor location is an important factor in selecting
patients, considering that the tumor must be accessible directly or with minimal
organ manipulation. Tumors next to bowel, the liver, and ureter or without any
direct needle path may be difficult to access and require more planning prior to
probe placement [17]. Tumors adjacent to the renal collecting system or major
8 Radiofrequency Ablation of Renal Masses 87

vasculature can limit the success of ablation as they conduct current through
moving fluid and dissipate the electrical field creating a “heat sink” effect, making it
difficult to reach adequate temperatures for ablation [18]. Cystic masses raise
unique concerns. Those that are predominantly fluid-filled can rupture as the heat
can “boil” the fluid and cause rapid expansion. They can also act as heat sinks and
should be aspirated prior to ablation [17]. Generally, we avoid utilizing RFA for
cystic lesions. Factors that contribute to candidacy for RFA include advanced age,
bilateral tumors, solitary kidneys, renal insufficiency, local recurrence after previous
PN (Fig. 8.3), von Hippel–Lindau disease, and inability to tolerate surgery [3].
Uncontrolled coagulopathy is an absolute contraindication to RFA [17]. Proper
patient selection ensures the safety and success of RFA.

Scientific and Engineering Principles of RFA

RFA irreversibly destroys tissue by thermally induced cell death and protein
denaturation. The end-result is shown in Fig. 8.4. Thermal ablative therapies work
through the principals of thermodynamics: conduction, convection, and radiation.
Tissue impedance prevents uniform passage of current and thus heat is generated.

Fig. 8.3 This figure shows an axial CT image of an anterior right renal lesion after salvage RFA
for tumor recurrence after initial partial nephrectomy
88 K. Ashouri et al.

Fig. 8.4 a The end-result of a successful ablation. This image is a SOMATOM (Siemens Medical
Solutions USA, Inc, Malvern, PA) 3D CT of a right mid-pole lesion s/p RFA at 1 month, depicted
by the blue coloration. b This figure shows a pathology specimen after radical nephrectomy for
ureteral stricture and provides unique insight to the gross tissue changes caused by RFA. The
ablated tumor can be seen here identified by the clamp within a well-circumscribed ablative zone
8 Radiofrequency Ablation of Renal Masses 89

Tissue electrical properties can vary from organ to organ, e.g., muscle versus neural
tissue versus fat, and within organs as well, e.g., renal cortex versus medulla. Thus,
a rudimentary understanding of this concept is important for the clinician to
understand when applying RF current for the purpose of thermal ablation. This heat
is transferred via conduction to the surrounding tissue, ultimately causing ischemic
damage, protein denaturation, nucleic acid disruption, vascular insult, or coagula-
tive necrosis [3]. When radiofrequency is applied to tissues, it generates heat by
resistive energy loss due to oscillation of alternating currents. A 380–500 kHz RF
needle electrode is inserted directly into the tissue [4]. The electrode can be con-
nected to either a monopolar power source, in which the current flows between the
probe and a ground pad positioned on the patient, or a bipolar power source in
which the current flows between two parallel electrodes which minimizes the spread
of current through nearby tissue [4]. According to the Pennes bio-heat equation,
thermal damage is linearly dependent upon treatment time and exponentially
dependent upon the increase in temperature [18]. At higher temperatures, irre-
versible tissue damage occurs more quickly, meaning shorter treatment duration
will achieve adequate cell death. Tissue necrosis occurs at 40–60 °C from direct
heating and conduction [19]. It is important to consider the concept of impedance
rise in charred tissue. When tissue temperature exceeds 100 °C, desiccation,
vaporization, and subsequent carbonization occur, creating char and leading to a
precipitous rise in impedance, effectively insulating the probe [19]. This limits the
ablative volume and inhibits operative success. It is recommended to use a probe
design that will reach a tissue temperature of at least 60–100 °C to adequately
achieve cell death. In order to achieve adequate tumor ablation, a margin of 5 mm
beyond the tumor is recommended [16].

RFA Delivery Modalities, Image Guidance, and Technical


Laparoscopic RFA

The laparoscopic US-guided approach, Fig. 8.2, is best utilized for anterior or
lateral renal tumors [3]. The bowel is mobilized, exposing the tumor surface, and
the probe is inserted under direct visualization via skin puncture, which minimizes
the risk of thermal injury to adjacent organs such as the bowel, the liver, the spleen,
or the ureters, as shown in Fig. 8.5 [20]. Positioning the patient in lateral decubitus
on the side of the tumor often provides the best access. At this point, the laparo-
scopic ports are inserted and the abdomen is insufflated. Prior to ablation, multiple
biopsies are taken via ultrasound guidance, as shown in Fig. 8.6a. Since heat is not
detectable via ultrasound, temperature monitoring is useful at the margins of the
tumor, as shown in Fig. 8.6b, but the decision to use temperature probes is ulti-
mately up to the provider [21]. Three to four fiber-optic temperature sensors can be
placed (superior, inferior, lateral, and medial) 5 mm from the tumor margin in
90 K. Ashouri et al.

Fig. 8.5 This is a stylized figure of an axial CT showing the proximity of renal mass, highlighted
in red, to large bowel, highlighted in yellow. In this case, a laparoscopic approach or
hydrodissection would be appropriate

normal renal parenchyma. The temperature probes are placed under ultrasound
guidance using a 5-Fr coaxial guide needle in a radiopaque sheath (Huey, Cook
Vascular, Inc, Vandergrift, PA, USA). Under direct visualization via ultrasound, the
RFA probe is guided into the center of the tumor.
Previous AUA guidelines for small renal masses reported that the percutaneous
approach produced more “incomplete ablation” rates when compared to the
laparoscopic approach [7]. Hui et al. reported a single session effectiveness of 87%
for the percutaneous approach versus a 95% for the laparoscopic approach, which is
believed to be attributed to the “intention to treat” principle [17, 22]. Laparo-
scopic RFA is solely performed by surgeons, while percutaneous RFA is performed
by both surgeons and interventional radiologists. According to Castle et al. [17], the
advantage of the laparoscopic approach is that surgeons are more likely to treat
renal masses more aggressively than interventionalist and often practice under the
assumption that a lesion is malignant. Although the current AUA guidelines state
that the percutaneous approach should be preferred, consideration should be taken
regarding the ability to access the tumor and the safety of the procedure.
8 Radiofrequency Ablation of Renal Masses 91

Computed-Tomography Guidance

CT-guided RFA is best utilized for posteriorly located tumors. This approach can
be performed under general anesthesia or conscious sedation. General anesthesia is
preferred because it allows for complete control of respiratory movements to ensure
accurate probe placement [23]. The patient is placed in the lateral decubitus or
prone position. The lateral decubitus position, tumor-ipsilateral side down, is
advantageous because kidney movement is less affected by respiration. This posi-
tion is effective for upper pole tumors because there is a decreased likelihood of
pneumothorax as the ipsilateral lung is less inflated relative to the contralateral side
[24]. The prone position is commonly used because it is comfortable for the patient,
stable, and offers easy access to lower pole renal masses, such as shown in Fig. 8.7
[24]. Three to four fiber-optic peripheral temperature probes can be placed under
CT guidance 5 mm from the tumor margin in normal renal parenchyma. If using
temperature probes, it is recommended to place these sensors prior to biopsy
because bleeding can alter the radiographic planes [3]. Under CT guidance, the
RFA probe is positioned in the center within the deep margins of the tumor. Once
the probe is successfully placed, the RFA treatment is initiated. When the target
temperature or impedance goal is reached, ablation is complete. Patients who
undergo CT-guided RFA are typically discharged home the same day and return to
normal activities within one week [3]. This approach can be performed at an
outpatient center and has decreased costs compared to other approaches [9, 24]. In
contrast to the laparoscopic approach, CT guidance typically has lower complica-
tion rates because laparoscopic tissue manipulation is avoided [21].

Magnetic Resonance Guidance

MR-RFA for abdominal masses was initially described by Lewin et al. in 1998 and
has since become an effective modality for image-guided RFA of renal masses [25,
26]. The major advantages of MR-guided RFA over CT are the elimination of
operative radiation exposure and improved imaging of soft-tissue structures [27].
Soft-tissue mapping provides a key advantage in ablating masses that are in close
proximity to the diaphragm [28]. Considering that air does not transduce US and
that CT is limited by triangulation, MR-guided RFA aids in preventing intraoper-
ative diaphragmatic injury or pneumothorax in superior lesions. Despite CT guid-
ance having limitations regarding the confirmation of ablative success, MR
guidance will show isointense or hyperintense signaling in remaining tumor after
initial ablation [28]. The success of a single MR-RFA ablation session, however, is
within 92–100% [18]. MR fluoroscopy via rapid-gradient echo sequencing is par-
ticularly useful for intraoperative monitoring of the ablative zone and end point;
however, MRI is not capable of providing a continuous image. Other limitations of
MRI include cost, spatial limitations of the operating room, availability, the need
for additional operating time, and the need for MR-compatible RFA devices as
noted in previous sections [28].
92 K. Ashouri et al.

Fig. 8.6 a In the laparoscopic approach, US guidance is a key element of properly identifying the
tumor and allows for precise biopsy and probe placement. The picture-in-picture shows the
corresponding US image on the monitor. b Cool-tip® (Covidien, Boulder, CO, USA) probe placed
within a renal tumor with peripheral temperature probes
8 Radiofrequency Ablation of Renal Masses 93

Fig. 8.7 Coronal and axial images showing the same lower pole tumor making it amenable to a
CT-guided approach with the patient in the prone position

Cone-Beam CT Guidance

In contrast to MR guidance, the use of intraoperative CT provides little information

on soft-tissue structures. However, using digital fluoroscopy via rotating C-arm and
large detection beam on a flat panel, a 3D image can be rendered from a series of
200 X-ray images taken over the course of C-arm rotation to provide an excellent
assessment of the tumor in tissue space for RFA probe trajectory planning, as
shown in Fig. 8.8 [28]. This technique is known as cone-beam CT or rotational
angiography. Currently available systems include DynaCT (Siemens Medical
Solutions, Erlagen, Germany) as shown in Fig. 8.8b, Innovact (GE Healthcare,
Schenectady, NY), and XperCT (Philips Healthcare, Amsterdam, Netherlands). The
Artis Zeego iGuide system in Fig. 8.8c can be used to produce a trajectory for the
biopsy needle or probe on the image. A laser cross-hair projection of the ideal
trajectory on the patient and repeat imaging provides precise RFA probe placement
at a lower radiation dose than conventional CT and allows for improved target point
accuracy [28, 29]. The major limitation of cone-beam CT is respiratory movement
creating a potential discrepancy in the mapped trajectory. However, this can be
overcome with voluntary patient breath-holding during probe placement or oper-
ating under general anesthesia [28].

Other Complications and Special Considerations

RFA carries a much lower risk of both major and minor complications; however,
they do still occur [3, 6, 10, 17]. Most commonly, placement of the probe can lead
to a neuromuscular pain and discomfort at the insertion site that typically responds
well to non-narcotic analgesics [30, 31]. In about 10–20% of operations, hematuria
94 K. Ashouri et al.

Fig. 8.8 a Cone-Beam CT with C-arm and flat panel detector shown in motion to confirm the
placement of RFA probe. Note Cool-tip® (Covidien, Boulder, CO, USA) probe in place.
b DynaCT platform view of cone-beam CT, used to map probe trajectory. c Artis Zeego iGuide
system utilizing cone-beam CT imaging to produce an ideal trajectory for RFA probe placement
8 Radiofrequency Ablation of Renal Masses 95

Fig. 8.8 (continued)

occurs, most commonly in central ablations. Hematuria is usually self-limiting after

24 hours [30]. Pneumothorax has been reported to occur in 2–4% of procedures
[31]. The most common major complication is retroperitoneal hematoma which is
reported to only occur in approximately 1–8% of ablations [16]. Other rare, but
major complications that can arise from thermal damage to nearby structures are
ureteral injury, bowel perforation, or genitofemoral nerve damage [30]. Inadvertent
thermal damage to nearby tissues can be avoided with balloon displacement, ade-
quate retraction, or hydrodissection, in which 5% dextrose, which has minimal
conductivity, is used to develop a hydroperitoneum. Hydrodissection carries its own
risk of seizure, coma, and cardiac arrhythmia due to possible alteration in elec-
trolyte balance [18, 24, 30].
It is also important to note that the most recent AUA guidelines recommend
biopsy of renal masses prior to ablation, as no other tumor specimen is available for
examination after the procedure [6].

Step-by-Step Instructions and Special Considerations

for Our Laparoscopic Approach

The following section provides step-by-step instructions for laparoscopic RFA for
renal masses as done at our center. For details regarding percutaneous RFA, please
see the above section on modalities.
96 K. Ashouri et al.

The patient is placed in the supine position on the operating table, stabilized, and
fastened. The table is then rotated to approximately 30°, effectively putting the
patient in the lateral decubitus position with the tumor-dependent side up. The
abdomen is insufflated to 15 mmHg using the Veress needle or Hasson technique
and a 10-mm trocar is placed. This trocar will be used for both a 5-mm camera and
10-mm laparoscopic ultrasound probe at different points of the procedure. After
placement of the initial 10-mm trocar, two 5-mm trocars for grasping and
monopolar instruments are placed under camera visualization. Ideal placement of
the latter two trocars involves triangulating the lesion and optimizing necessary
retraction. Most cases will necessitate three trocars. After adequate placement of
trocars, the bowel is mobilized by incising the line of Toldt at the yellow–white fat
interface, as shown in Fig. 8.9. The bowel and liver can be retracted as necessary
using graspers. At this point, the camera can be removed from the 10-mm trocar and
placed in one of the 5-mm trocars to allow use of the ultrasound probe via the
10-mm trocar. The ultrasound probe is then advanced to the renal capsule to ade-
quately identify the lesion as shown in Fig. 8.6a. Gerotas Fascia is often opened.
Deeper masses can be difficult to identify without ultrasound guidance and an
adequate assessment of tumor depth is necessary. Considering that ablation does
not provide a surgical specimen, biopsy of the mass is a crucial aspect of the
procedure. Biopsy is performed by initially placing a needle guide with a stylet.
Once adequate positioning is achieved, the stylet can be removed. An 18-gauge
Tru-Cut® (Carefusion, Medline, Mundelein, IL) spring-loaded needle is then placed
through the sheath to obtain a minimum of three core biopsies of the mass. Bleeding

Fig. 8.9 This figure shows standard laparoscopic mobilization of colon by incision of line of
Toldt at the yellow–white fat interface using a grasper and unipolar scissors. Entry into Gerota’s
fascia is often not necessary
8 Radiofrequency Ablation of Renal Masses 97

from the biopsy site is often minimal; however, hemostasis can be achieved readily
as this is intrinsic to RFA. This is not the case for cryoablation as hemorrhage can
be exacerbated with thawing and probe removal. Special care should be taken to
remove the needle guide used for biopsies as utilization of the metal sheath for
probe placement could result in burning or damage to the skin at the entry site due
to the fact that the sheath is not insulated. It is up to the clinician as to which
RFA device will be appropriate, as discussed in the above sections. The probe
should then be inserted percutaneously and deployed per manufacturer recom-
mendations. After the ablation sequence is complete, the probe can be removed
from the lesion under cautery to achieve hemostasis. Insufflation pressure is
decreased to 7 mmHg to ensure that adequate hemostasis is achieved. Topical
hemostatic agents are not required as hemostasis is primarily done by ablation.
Laparoscopic incisions 1 cm or greater will need fascial closure. Probe entry site
can be closed with skin-glue. Our patients typically stay overnight and follow-up in
one week. Repeat imaging (CT or MRI) is done at 6 weeks, again at 6 months, and
then annually for 6 years to monitor ablative success.


RFA of renal masses should be offered to patients with clinical stage T1a disease
(current AUA guidelines state <3cm) with comorbidities precluding them from
candidacy for PN or who decline more invasive surgery [6, 7]. A multitude of
techniques and imaging modalities are available, including a laparoscopic
US-guided approach or percutaneous approach with CT guidance, MR guidance, or
cone-beam CT guidance. The device selection is a matter of user preference.
Considering the individual advantages and disadvantages of each device and the
scientific principles noted above, the user can select the appropriate RFA probe for
the case.


See Table 8.1.

98 K. Ashouri et al.

Table 8.1 Recent long-term outcomes of RFA

Median Primary modality N Mean 5-year CFS Complication Median
age masses tumor (10-year rate follow-up
size CFS)
Ma et al. 57 34 Percutaneous 58 2.2 cm 94.2(94.2) n/a 60.1
[32] 24 Laparoscopic
Lorber 67.8 CT 29 53 2.3 cm 100 (100) 14% 65.6
et al. [33] Laparoscopic 24
Leveillee 67 CT 180 292 2.5 cm 98.6 37% 26
et al. [34] Laparoscopic 112
Tracy 64 Percutaneous 172, 243 2.4 cm 93 n/a 27
et al. [35] Laparoscopic 68,
Open 3
Tan et al. 67 Percutaneous 32 47 2.0 cm 99 5% 45
[36] Laparoscopic 15
Ramirez 64 111 Laparoscopic 111 2.2 cm 93.3 8.8% 59
et al. [37]
Miller 84.5 41 Percutaneous 41 2.3 n/a n/a n/a
et al. [38]

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Note: Page numbers followed by “f” indicate figures; those followed by “t” indicate tables.

A cRN. See Cytoreductive radical nephrectomy

AML. See Angiomyolipoma (AML) (cRN)
Angiomyolipoma (AML), 6–8, 8f, 9f, 21 Cryoablation (CA), 83
Anterior subcostal incision approach, 32–33 Cryotherapy, 73–74
Arterio-venous fistula (AVF), 36 mechanism of, 74
Artis Zeego iGuide system, 93, 94f Cystic renal masses
AVF. See Arterio-venous fistula (AVF) Bosniak CT classification system for, 4, 4t
Bosniak cysts types, 5–6f, 7f
B Cytoreductive radical nephrectomy (cRN),
Bertin mimicking focal mass, column of, 17f 51–52

CA. See Cryoablation (CA) Diffusion-weighted imaging, 3, 3t
Cardiopulmonary bypass (CPB) Dorsal lumbotomy, 31
intraatrial tumor thrombus with, 56–57 DynaCT system, 93, 94f
CCRCC. See Clear cell renal cell carcinoma
Chemical shift imaging, 3, 3t EORTC 30904 trial, 30
ChRCC. See Chromophobe renal cell Excretory phase, of post-contrast evaluation of
carcinoma (ChRCC) renal masses, 2t
Chromophobe renal cell carcinoma (ChRCC),
13, 14f F
Clear cell renal cell carcinoma (CCRCC), Fine-needle aspiration (FNA), 23–24, 25
10–12, 11f Flank incision approach, 31–32
Computed-tomography guided radiofrequency Fluorine-18-2-fluoro-2-deoxy-D-glucose
ablation, 91, 93f positron emission tomography
Cone-beam CT/rotational angiography, 93, 94f (FDG-PET)
Congenital pseudotumors, 15 for renal mass evaluation, 3
Conventional renal cell carcinoma, 10 FNA. See Fine-needle aspiration (FNA)
Cool-tip® system, for RFA of renal masses,
84–85, 84f, 92f H
laparoscopic approach and visualization of Hypothermia, 45, 56
RFA using, 85f
Core needle biopsies, 23–24, 25 I
Corticomedullary (CMP) phase, of Inferior vena caval tumor thrombus (IVCTT)
post-contrast evaluation of renal renal cell carcinoma (RCC) management
masses, 2t with, 49–59
CPB. See Cardiopulmonary bypass (CPB) anesthetic and perioperative care, 58
classification, 50

© Springer Science+Business Media, LLC 2018 101

R. V. Khanna et al. (eds.), Surgical Techniques for Kidney Cancer,
102 Index

clinical presentation, 50 Mimickers, pseudotumors and, 15–17

imaging, 51 Minimally invasive partial nephrectomy, 42, 43
infrahepatic IVC thrombus, 53–54 Minimally invasive radical nephrectomy, with
intraatrial tumor thrombus with IVC thrombectomy, 63–70
cardiopulmonary bypass, 56–57 level I thrombectomy, 67
intrahepatic IVC thrombus, 54, 55f, 56f level II thrombectomy, 67–68
minimally invasive techniques, 58 level III thrombectomy, 68–69
outcomes and complications, 57 patient selection and preoperative
preoperative evaluation, 52 considerations, 65
supradiaphragmatic IVC thrombus, 55 preoperative embolization, 65
surgical approaches, 52–53 retroperitoneal approach, 66
treatment, 51–52 surgical approach, 65
tumor invasion into IVC wall, 57 transperitoneal approach, 66
Inferior vena cava (IVC) thrombectomy Minimally invasive techniques
minimally invasive radical nephrectomy IVCTT management, 58
with, 63–70 MRI. See Magnetic resonance imaging (MRI)
Innovact system, 93 Multi-detector CT (MDCT) scan, for renal
Intraatrial tumor thrombus, with mass evaluation, 1–2
cardiopulmonary bypass, 56–57 Multidetector helical computed tomography
Intracorporal renal hypothermia, 45 (MDHCT), for detecting caval
Intrahepatic IVC thrombus, 54, 55f, 56f thrombus, 51
IRE. See Irreversible electroporation (IRE)
Irreversible electroporation (IRE), 80 N
IVC thrombectomy. See Inferior vena cava Nephrogenic phase, of post-contrast evaluation
(IVC) thrombectomy of renal masses, 2t
IVCTT. See Inferior vena caval tumor Nephron sparing surgery (NSS), 37, 42, 73, 83
thrombus (IVCTT) NSS. See Nephron sparing surgery (NSS)

Laparoscopic cryoablation, 75, 77 Oncocytoma, 8–9, 10f
complications of, 77 Open partial nephrectomy (OPN)
percutaneous cryoablation and, 79 complications, 35–37
success rates of, 78t follow-up, 37
Laparoscopic radiofrequency ablation, for renal historical development, 29–30
masses, 89–90, 90f, 92f preoperative evaluation and planning,
step-by-step instructions for, 95–97 30–31
Laparotomy incision approach, 32 renorrhaphy, 35
LeVeen® RF 3000 system, for RFA of renal technical aspects
masses, 84, 84f, 85–86 anterior subcostal incision, 32–33
Level I thrombectomy, 67 flank incision, 31–32
Level II thrombectomy, 67–68 laparotomy incision, 32
Level III thrombectomy, 68–69 thoracoabdominal incision, 33
Lymphomas, 13–15 tumor resection, 33–34
tumor enucleation, 34
M wide-margin tumor excision, 34
Magnetic resonance imaging (MRI) OPN. See Open partial nephrectomy (OPN)
MR-guided RFA, 91
for renal mass evaluation, 2–3 P
sequences, 3, 3t Papillary renal cell carcinoma (pRCC), 12–13,
Mannitol, 33 13f
MDCT scan. See Multi-detector CT (MDCT) Partial nephrectomy. See Open partial
scan nephrectomy (OPN)
MDHCT. See Multidetector helical computed Percutaneous cryoablation, 74–75
tomography (MDHCT) complications with, 75
Index 103

laparoscopic cryoablation and, 79 surgical approaches, 52–53

success rate with, 76t treatment, 51–52
Perinephric liposarcoma, versus tumor invasion into IVC wall, 57
angiomyolipoma (AML), 8, 9f “parenchyma-sparing” operation for, 30
Plain phase, of post-contrast evaluation of renal and partial nephrectomy (PN), 30–31
masses, 2t Renal cryotherapy
pRCC. See Papillary renal cell carcinoma comparisons to other techniques, 79
(pRCC) laparoscopic cryoablation, 75, 77
Preoperative embolization complications, 77
for management of renal tumors with IVC percutaneous cryoablation and, 79
thrombi, 65 success rates, 78t
Presurgical assessment of renal mass, 17, 18f mechanism of, 74
Primary renal lymphoma (PRL), 13–14 percutaneous cryoablation, 74–75
PRL. See Primary renal lymphoma (PRL) complications, 75
Pseudotumors and mimickers, 15–17 laparoscopic cryoablation and, 79
Pyelonephritis, 16 success rates, 76t
radiofrequency ablation (RFA), 79–80
R Renal mass biopsies
Radiofrequency ablation (RFA), 79–80 complications, 25, 27
available devices, 84–86 outcomes, 24–25, 26t
computed-tomography guidance, 91, 93f proposed decision algorithm for, 23f
cone-beam CT guidance, 93, 94f techniques, 23–24
laparoscopic US-guided approach, 89–90, Renal masses
90f, 92f angiomyolipoma (AML), 6–8, 8f, 9f
step-by-step instructions, 95–97 assessments prior to surgery
long-term outcomes, 98t post-treatment assessment, 18–19
magnetic resonance guidance, 91 preoperative assessment, 17, 18f
other complications and special chromophobe renal cell carcinoma
considerations, 93, 95 (ChRCC), 13, 14f
patient selection and indications for, 86–87, cystic renal masses
87f Bosniak CT classification system for, 4,
of renal masses, 83–98 4t
with robotic partial nephrectomy, 45 Bosniak cysts types, 5–6f, 7f
scientific and engineering principles of, imaging modalities
87–89, 88f FDG-PET, 3
RCC. See Renal cell carcinoma (RCC) magnetic resonance imaging (MRI),
Renal cell carcinoma (RCC), 9–12, 11–12f 2–3, 3t
management with inferior vena caval tumor multi-detector CT (MDCT) scan, 1–2,
thrombus (IVCTT), 49–59 2t
anesthetic and perioperative care, 58 ultrasonography (USG), 1
classification, 50 lymphomas, 13–15
clinical presentation, 50 oncocytoma, 8–9, 10f
imaging, 51 papillary renal cell carcinoma (pRCC),
infrahepatic IVC thrombus, 53–54 12–13, 13f
intraatrial tumor thrombus with phases of post-contrast evaluation, 2t
cardiopulmonary bypass, 56–57 pseudotumors and mimickers, 15–17
intrahepatic IVC thrombus, 54, 55f, 56f radiofrequency ablation (RFA) of, 83–98
minimally invasive techniques, 58 available devices, 84–86
outcomes and complications, 57 cone-beam CT guidance, 93, 94f
preoperative evaluation, 52 CT-guided RFA, 91, 93f
supradiaphragmatic IVC thrombus, 55 laparoscopic RFA, 89–90, 90f, 92f
104 Index

MR-guided RFA, 91 Starburst RITA® system, for RFA of renal

other complications and special masses, 84, 84f, 86
considerations, 93, 95 Supradiaphragmatic IVC thrombus, 55
patient selection and indications for
RFA, 86–87, 87f T
scientific and engineering principles of TCC. See Transitional cell carcinoma (TCC)
RFA, 87–89, 88f Thompson retractor, 33
step-by-step instructions for Thoracoabdominal incision approach, 33
laparoscopic RFA, 95–97 Thrombectomies (level I–III), IVC, 67–69
renal cell carcinoma (RCC), 9–12, 11–12f “Thrombus first” approach, 65
transitional cell carcinoma (TCC), 15, 16f Transitional cell carcinoma (TCC), 15, 16f
R.E.N.A.L. nephrometry score, 42 Transperitoneal approach, for IVC
Renal pseudotumors, 15 thrombectomy, 66
Renorrhaphy, 35, 44 Transperitoneal robotic partial nephrectomy,
Retroperitoneal approach, for IVC 43–44
thrombectomy, 66 Tru-Cut® spring-loaded needle, 96
Retroperitoneal lymphadenopathy, 14 Tumor invasion into IVC wall, 57
Retroperitoneal robotic partial nephrectomy, Tumor resection, 33–34
43, 44 tumor enucleation, 34
RFA. See Radiofrequency ablation (RFA) wide-margin tumor excision, 34
Robotic-assisted laparoscopic partial
nephrectomy U
complications, 47 Ultrasonography (USG), for renal mass
outcomes, 46 evaluation, 1
patient selection and preoperative
considerations, 42–43 V
surgical approach, 43–45 Vein wall invasion, 57
on clamp versus off clamp techniques, Veno-venous bypass (VVBP), 57
44–45 VHL syndrome. See Von Hippel–Lindau
tips and tricks, 45–46 (VHL) syndrome
Von Hippel–Lindau (VHL) syndrome, 2, 10
S VVBP. See Veno-venous bypass (VVBP)
Secondary renal lymphoma (SRL), 14
Skip lesions, 86 W
Small renal masses (SRMs), 73 Wide-margin tumor excision, 34
partial nephrectomy (PN) for treatment of,
73 X
SRL. See Secondary renal lymphoma (SRL) XperCT system, 93
SRMs. See Small renal masses (SRMs)