V1079: Bilateral Ex-Vivo Nephron Sparing Surgery And Autotransplantation For Giant Bilateral Renal Angiomyolipoma.

Video

Introduction and Objectives
Management of large bilateral renal tumors generally involves bilateral nephrectomy followed by renal transplantation at later date bridging the waiting period with hemodialysis. These treatment options are associated with problems like critical shortage of kidney donations suitable for transplantation, significant reduced quality of life, high morbidity and mortality and high cost involved in these procedures. In view of these drawbacks there is resurgent interest in bench dissection and autotransplantation in recent years. In exceptional situations, bench surgery followed by autotransplantation may be indicated. We present video demonstration of bilateral ex-vivo nephron sparing surgery and autotransplantation for giant bilateral renal angiomyolipoma.

Methods
Twenty eight old female patient presented with bilateral flank mass associated with intermittent pain of 5 years duration. Per abdomen examination revealed bilateral large lumbar mass extending up to iliac region. Renal parameters were normal. Computerised tomography scan revealed bilateral large angiomyolipoma. Treatment options were discussed with the patient. Angioembolisation was not feasible in view of large size, multiple vessels supplying tumor and poor demarcation between tumor and normal renal parenchyma in the imaging. After explaining risk and outcome, bilateral nephrectomy, bench dissection and autotransplantation was planned. First, left nephrectomy, bench dissection with nephron sparing surgery and autotransplantation was conducted. After 4 weeks interval procedure was repeated on the right side. Operative, postoperative and follow up details were recorded.

Results
Total operation duration was 6 and 8 hours, blood loss was 200 and 230 ml, tumor size was 30x15 cms and 26x18 cms, tumor weight was 3 and 2.8 kilograms for left and right tumors respectively. Orals started after 24 hours, hospital stay was 5 days following both surgeries. Serum Creatinine was 1.4 and 1.5 mg/dl on 5th postoperative day and at 1 month follow up respectively.Follow up magnetic resonance imaging with angiogram showed good perfusion of left autotransplanted remnant kidney.

Conclusions
Ex-vivo nephron sparing surgery and autotransplantation for large renal angiomyolipoma is feasible with satisfactory renal functional outcome. Morbidity, poor quality of life and high cost involved in renal replacement therapy can be avoided with this procedure in selected cases. However this surgically challenging procedure should be regarded as the last resort.

Funding: None