Three Dimensional (3D) Laparoscopic Nephron-sparing Treatment of a Huge Cystic Nephroma: A Case Report and Literature Review.

Background/Aim: Cystic nephroma (CN) is a very rare, benign, renal cystic lesion, which is characterized by a usually unilateral, multicystic kidney mass. In adults it is seen more frequently in females (1:8 male-to-female ratio). The peak incidence of CN is between 50 and 60 years of age. Median age at diagnosis is 55 years for females and 44 years for men and it is a rare entity in adults under 30 years of age. Case Report: We report the case of a 52-year-old female patient with chronic right-flank pain, who was treated at our hospital. A multiloculated 10×8.6 cm Bosniak IV renal cyst tumor was depicted on retroperitoneal computed tomography. After a three-dimensional laparoscopic partial nephrectomy, the histopathological specimen examination revealed: a multilocular cystic nephroma. Conclusion: CNs are rare benign tumors that should be included in the differential diagnosis when treating large multiloculated complex renal cysts.

Record and Appraisal of Endophytic Tumor Localization Techniques in Minimally Invasive Kidney-Sparing Procedures. A Systematic Review.

PURPOSE: Review and efficacy assessment of techniques used for intraprocedural endophytic renal mass localization. MATERIALS AND METHODS: Advanced search was carried out on PubMed, Cochrane Library, Web of Science and Google Scholar databases up to August 2020. Eligibility criteria were set, according to PRISMA statement. OR (95 % CI) for identification or technical success, positive margins and recurrence, were calculated for completely endophytic tumors. Risk of Bias was evaluated using ROBVIS tool. RESULTS: 77 studies used for result synthesis, including 1,317 endophytic tumors, with 758 of them completely endophytic. 356 endophytic tumors treated laparoscopically and 598 robotically, using ultrasound-based methods, transarterial embolization, dual-source CT, invasive signage, 3D printing, and augmented reality variations. Identification success was 97.8-100%, positive margins 0-12.5 %  (completely endophytic: 95 % CI; 0.255-1.971, OR 0.709 in laparoscopic, 95 % CI ; 0.379-3.109, OR 0.086 in robotic partial nephrectomy), recurrences 0-3.9 % (completely endophytic: 0 recurrences in laparoscopic, 95 % CI ; 0.0917-2.25, OR 0.454, in robotic partial nephrectomy), and complications 0-60 % . 363 were treated with ablation techniques using CT-based methods, thermal monitoring, transarterial embolization, ultrasound guidance and invasive signage. Technical success was 33.4-100 % (completely endophytic: 95 % CI ; 0.00157-2.060, OR 0.0569 for invasive and 95 % CI ; 0.598-13.152, OR 2.804 for non-invasive localization techniques) and recurrences were 0-20%. CONCLUSION: Ultrasound-based techniques showed acceptable identification success and oncologic outcomes in laparoscopic or robotic setting. Augmented reality, showed no superiority over conventional techniques. Near infrared fluoroscopy with intravenous indocyanine green, was incapable of endophytic tumor tracking, although when administered angiographic, results were promising, along with other embolization techniques. Percutaneous hook-wire or embolization coil signage, aided in safe and successful tracking of parenchymal isoechoic masses, but data are inadequate to assess efficacy.  CT-guidance, combined with ultrasound or thermal monitoring, showed increased technical success during thermal ablation, unlike ultrasound guidance that showed poor outcomes.

Hook-wire assisted localization of a completely endophytic renal mass during three-dimensional laparoscopic partial nephrectomy: Presentation of our technique.

INTRODUCTION: Totally endophytic renal masses may be invisible during laparoscopic partial nephrectomy, posing challenge to surgeons regarding tumor's identification and resection. CASE PRESENTATION: A 22-year-old male was incidentally diagnosed with a completely endophytic, cT1a renal mass. Percutaneous Computed Tomography-guided insertion of a hook-wire was performed prior to laparoscopic partial nephrectomy. The hook-wire anchored centrally into the tumor and its extra-renal part was easily identified intraoperatively, contributing to tumor's identification and surgical excision. Total operative time was 185 min, warm ischemia time was 21.5 min, tumor excision time was 10 min, and total renorraphy time was 31 min. No complications were encountered perioperatively. The patient was discharged on the fourth postoperative day. Histology revealed a pT1a, clear-cell renal cell carcinoma, with negative surgical margins. CONCLUSIONS: Our first experience indicates that hook-wire guided excision of a completely endophytic renal mass during laparoscopic partial nephrectomy is feasible, safe, and cost-effective.

Transperitoneal and retroperitoneal approach in laparoscopic partial nephrectomy for posterior cT1 renal tumors: A retrospective, two-centers, comparative study.

OBJECTIVES: To compare perioperative, oncological and functional outcomes of Laparoscopic Transperitoneal Partial Nephrectomy (LTPN) and Retroperitoneal Laparoscopic Partial Nephrectomy (LRPN) for posterior, cT1 renal masses (RMs). MATERIALS AND METHODS: Databases of two urologic institutions applying different laparoscopic surgical approaches on posterior cT1 RMs between June 2016 and November 2018 were retrospectively evaluated. Data on patient demographics, perioperative data and tumor histology were collected and further analyzed statistically. RESULTS: Each group consisted of 15 patients. Baseline characteristics were comparable in each group. When compared to LTPN, LRPN was associated with significantly shorter operative time (OT) (115 min versus 199 min, p < 0.05). No significant differences were detected in the other outcomes. CONCLUSIONS: LRPN is associated with a significantly shorter OT compared to LTPN for posterior cT1 RMs. Both surgical approaches are safe, feasible and credible, demonstrating optimal results.

Laparoscopic Resection of a Non-functional, Extra-adrenal Paraganglioma: A Case Report and Literature Review.

Non-functional, extra-adrenal, retroperitoneal paraganglioma is a rare, neuroendocrine, and potentially malignant tumor. Its diagnosis and treatment may be challenging. A 69-year-old female patient was admitted because of a left para-aortic, solid, 4.4-cm mass, incidentally discovered during abdominal ultrasonography for screening purposes. Her clinical examination was unremarkable. Preoperative differential diagnosis based on cross-sectional imaging included tumor of neuroendocrine or mesenchymal origin. Hormonal investigation with 24-hour urinary catecholamines and metanephrines and plasma-fractionated metanephrines was in the normal range. Following consultation with the endocrinologist and anesthesiologist, the tumor was removed by using the three-dimensional (3D) laparoscopic transperitoneal surgical approach. The perioperative course was uneventful and the patient was discharged on the third postoperative day. Histopathologic findings were consistent with the diagnosis of retroperitoneal extra-adrenal paraganglioma of 5 cm in maximum diameter.

Macroscopic Appearance of Giant Adrenal Myelolipoma During Laparoscopy: An Adjunct in Differential Diagnosis.

Giant adrenal myelolipoma is a rare, benign, sizable, mesenchymal tumor. Preoperative differential diagnosis from retroperitoneal liposarcoma may be challenging. A 66-year-old female patient was admitted because of a sizable tumor at the right retroperitoneal space, incidentally discovered during abdominal ultrasonography for screening purpose. Preoperative imaging studies were indicative for the diagnosis of a giant adrenal myelolipoma (11.7 × 12.9 cm in size); however, a retroperitoneal liposarcoma could not be excluded. We decided to proceed with tumor's surgical removal by using laparoscopic transperitoneal approach and three-dimensional high-definition camera. Intraoperatively, the tumor did not infiltrate surrounding tissues and was surrounded by a thin capsule under which there were sparse, orange-colored spots that resembled adrenal cortex. This finding reinforced the initial and most possible diagnosis of adrenal myelolipoma and we easily enucleated the mass. Postoperative course was uneventful, and the patient demonstrated no recurrence on imaging six months postoperatively. Histology confirmed the diagnosis of giant adrenal myelolipoma, measuring 16.5 x 15 x 6.5 cm.

Multiple and Bilateral Sporadic Renal Cell Carcinomas: A Surgical Challenge.

Sporadic, synchronous, bilateral, or unilateral Renal Cell Carcinomas constitute a rare clinical entity. We report the case of a 68-year-old male patient who presented in our department due to incidentally discovered multiple, bilateral renal tumors. Magnetic Resonance Imaging demonstrated cT1b renal tumors at the lower pole of each kidney and a cT1a renal tumor at the upper pole of the right kidney. The patient underwent transperitoneal, laparoscopic left partial nephrectomy with renal artery occlusion, histology revealed high-grade, pT1b, clear-cell renal cell carcinoma; however we observed decline of patient's estimated glomerular filtration rate postoperatively. Forty days postoperatively, he underwent open partial nephrectomy for the right sided tumors with manual compression of the renal parenchyma and no use of ischemia. Histology revealed high-grade, pT1a, clear-cell renal cell carcinoma at the upper pole of the right kidney and low-grade, pT1b, clear-cell renal cell carcinoma at the lower pole of the right kidney. There was no additional decline in the serum creatinine value postoperatively. The patient avoided permanent or temporary dialysis and 6 months postoperatively he demonstrated no recurrence on imaging and his renal function remained stable.