V5-13: A new approach for third level diagnosis for complex renal cysts
VideoIntroductions and Objectives
Complex renal cysts may cause diagnostic matters, since it is often difficult to exclude malignancies. The Bosniak classification of renal cysts is a well-established worldwide method based on CT findings to categorize cystic renal masses but, expecially for cysts classified as Bosniak II and III, some studies highlight a not trascurable frequency of false negative and positive malignancy diagnoses. To overcome this limitation, cysts puncture for evacuation and core biopsies can be used trying to make a diagnosis but a recent Literature review emphasized the higher risk of biopsy failure, false-negative results, and potential spreading of tumour cells resulting from cystic rupture: these aspects lead many urologists to limit the indications of core biopsies. Trying to give an answer in this field we present a new “third-line” diagnostic tool for complex cysts renal tumors.
We present the case of a male patient, 35 years old, BMI 22. After an incidental US detection of a large cyst a the lower pole of the left kidney with exophytic growth pattern, the diagnosis was confirmed by an imaging workup consisting of contrast-enhanced abdominal CT-scan and abdominal MRI. In addition, they highlighted an involvement of renal pelvis and lower calyceal system. The MRI dynamic study showed the presence of 2 small intraluminal prominence. To specify the diagnosis in this complex cysts renal tumor, we proceeded as follows: patient was placed in a Galdakao-modified supine Valdivia position. Under US guidance a puncture of the cyst was performed by 16 G needle, named MICROPERC®, endowed by a dedicated sheet (4.85 F). The needle was then removed, the 4.85 F sheath was left in place. 20 mL of citrine fluid were suctioned and sent for extemporary cytological examination with unconclusive result. An adapter with “Luer-lock” junction was connected to the needle. After its setup, the optical fiber was inserted through the sheath and moved forward to the cyst. Endoscopic exploration of the cyst was performed and finally, two intraluminal prominence were identified. We therefore decided to perform a laparoscopic radical nephrectomy.
Operative time was 165 minutes. No perioperative complications occurred. Patient was discharged at third postoperative day. At histopahological examination a papillary malignant renal tumor was found.
The percutaneous needlescopic exploration of renal cysts according the described technique offers a new perspective in the diagnostic assessment of complex renal cysts. This approach could be used as a third-line diagnostic tool when either imaging or biopsy were inconclusive.