Selective resection of malignant tumors using bench surgical techniques

CASE REPORT

Selective Resection of Malignant Tumors Using Bench Surgical Techniques By Kathryn

D. Anderson

and

R. Peter

Altman

enlargement. There was no A 3-yr-old black female presented with a 3-wk history of abdominal pain, anorexia, fever, or hematuria. Pertinent physical findings were a large left flank mass and a small mass on the right. Blood pressure was 90/70 mm Hg. The clinical impression of bilateral Wilms’ tumor was confirmed by intravenous urogram, isotopic scan, and aortography. The left kidney was replaced by tumor. A selective renal angiogram demonstrated that the tumor on the right occupied the lateral aspect of the kidney, extending deep into the cortex, but apparently sparing the collecting system. A complete work-up showed no evidence of extrarenal disease. Through a transverse abdominal incision, a left radical nephrectomy was performed. Inspection and palpation of the right kidney confirmed the angiographic findings of a large tumor occupying the lateral aspect of the kidney. In addition, a small but distinct tumor nodule was palpated deep in the cortex; a larger nodule at the upper pole was also felt. The right hypogastric artery and right common iliac vein were mobilized. The vascular pedicle of the kidney was mobilized. The ureter was dissected for sufficient length to permit removal of the kidney from the abdomen; the lower third of the ureter was left undisturbed. Vascular clamps were placed across the renal vessels at the aorta and vena cava. A sterile tray was placed on the patient’s lower abdomen to serve as a work bench. The vessels were divided, leaving the ureter in continuity. The renal artery was cannulated and perfused with iced, balanced electrolyte solution to which 2000 units of heparin and procaine (1%) had been added. ‘Cooling was prompt. and the kidney rapidly assumed a homogeneous pale color. Warm ischemia time was less than 1 min. With the kidney cooled and continuously perfused, meticulous dissection of the three distinct tumor masses was carried out. Suture

ligation

of all vessels leaking

was reconstructed

by a continuous

perfusate locking

ensured chromic

excellent suture.

hemostasis Revascularization

(Fig.

I). The kidney utilized

the pre-

viously mobilized vessels: an end-to-end hypogastric artery to renal artery anastomosis and an end-to-side renal vein to common iliac vein anastomosis were carried out. The kidney perfused well immediately following removal of the vascular clamps, and within 30 min a brisk diuresis ensued. The patient experienced a transient phase of hypertension, with blood pressures ranging blood pressure was restored initially with Apresofrom I IO/80 to 160/l 10 mm Hg. Normotensive line. The patient was discharged on the 39th postoperative day on Aldomet. This medication was discontinued 4 mo after surgery. and the blood pressure has remained normal.

kidney on Fig . 1. Reconstructed work bench and three tu~mor nodules.

o 1976

by Grune

lournal of f’ediatrk

& Stratton,

Surgery,

Inc.

Vol. 11, No. 5 (October), 1976

881

a82

CASE REPORTS

Serial isotopic renal scans confirm excellent renal perfusion; serial intravenous urograms show prompt function without obstruction and without evidence of recurrent tumor. There is compensatory renal hypertrophy. Pulse therapy with Actinomycin D and vincristine according to the Children’s Cancer Study Group protocol for stage V nephroblastoma was started on the fifth postoperative day. Adjunctive radiation therapy to each renal bed, accomplished with shielding of the reimplanted kidney in the pelvis, was begun 7 wk postoperatively.

REFERENCES I. Hardy JD: High ureteral agement by autotransplantation JAMA 184:97, 1963 2. Calne nephrectomy, tion. Lancet

RY:

Tumor

excision, X:761,

1971

in and

injuries. Manof the kidney. a single

kidney;

autotransplanta-

3. Lilly JR, Pfister RR, Putnam CW, et al: Bench surgery and renal autotransplantation in the pediatric patient. J Pediatr Surg 101623, 1975