Minimally invasive surgery of renal cell carcinoma of a transplanted kidney Clinical case

Introduction The incidence of renal cell carcinoma (RCC) in kidney transplant (KT) recipients is about 0.6%. This rate is 10 times higher than in the general population [1]. The causes of the high risk of developing RCC in KT are not completely clear and a connection with ongoing immunosuppressive therapy (IST) is highly likely [1, 2]. The detection of VHL and MET mutations in the genomes of the donor and recipient are of great practical significance to clarify the molecular and genetic mechanisms of the progression of clear cell and papillary RCC in KT [3]. To date, about 200 cases of allograft RCC have been described worldwide [1, 2]. Usually, most KT neoplasms are detected incidentally during routine ultrasound examination (USE) [1, 2, 4, 5]. The priority treatment strategy is the nephron-sparing surgery of KT malignant neoplasms [1, 2, 4, 5]. Despite the increasing number of publications, this issue is not widely covered and is still a point of debate. Clinical case The 41-years old male has been hospitalized with severe course of Covid-19 and KT dysfunction. His medical history was remarkable with end-stage renal failure due to chronic glomerulonephritis, a long period of maintenance hemodialysis, and cadaveric kidney allotransplantation in 2014. Serum creatinine (Pcr) at admission was 240 µmol/l. A rounded hypoechogenic solid poorly demarcated formation sized 2.7×3.0 cm and of the heterogeneous structure was detected near the renal sinus during routine USE ( Fig. 1A). Color Doppler mapping demonstrated the preserved blood flow in KT, but in the detected formation the blood flow was almost absent. In process of recovery from COVID-19 Pcr diminished to the patient’s usual values (150 µmol/l). To clarify the origin of KT formation and to exclude the possible metastases multispiral computed tomography with contrast enhancement was performed. A hypovascular mass was revealed and papillary RCC was suspected according to special contrast features. An object of 3.0×2.8×2.3 cm with an uneven accumulation of the contrast media (45-68 HU) in the middle third of KT is shown in Fig. 1B. The patient underwent laparoscopic partial nephrectomy. Intraoperative USE was performed using an intracorporeal ultrasonic transducer to localize the tumor and to outline the resection area ( Fig. 1C). Temporary stoppage of blood flow in the KT was carried out by applying the Blalock vascular clamp to the right external iliac artery. The intraoperative picture of allograft formation along the posterior surface of the kidney is shown in Fig. 2A. The operating time was 165 minutes, the time of KT ischemia was 21 minutes, and the volume of blood loss was 240 ml. Fig. 2B shows a resected KT tumor, histological examination of the tumor revealed papillary RCC type 1, ISUP grade 2, pT1aNoMoR0 ( Fig. 2C). The postoperative period was uneventful, and Pcr 14 days after surgery was 142 µmol/l. Conclusion A laparoscopic partial nephrectomy is a nephron-sparing approach to surgical treatment of RCC of the KT. The presented clinical case demonstrates the possibility and advantages of minimally invasive radical elimination of a malignant tumor. Such an approach allows for saving the KT function, decreases the risks of septic and hemorrhagic complications, and significantly reduces the time of hospitalization.

почечный трансплантат, почечно-клеточный рак, лапароскопическая резекция опухоли, клинический случай, kidney transplant, renal cell carcinoma, laparoscopic partial nephrectomy, clinical case

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