Renal Cell Cancer in Presacral Ectopic Kidney: Preoperative Diagnostic Imaging Compared to Surgical Findings

Surgical management of a locally invasive renal cell carcinoma in an ectopic pelvic kidney

The coincidence of renal cell carcinoma in an ectopic kidney is a unique phenomenon. We report a case of 55 years old male patient who presented with backache and accidentally discovered ectopic kidney with an upper polar mass. Preoperative assessment was done with pelviabdominal sonography and triphasic renal CT. Our patient underwent radical nephrectomy through a midline incision with unexpected vasculature encountered intraoperatively. According to our knowledge, only eight cases of pelvic kidney tumors have been reported in the literature and this case is unique with its complex vascular structure.

Congenital Diaphragmatic Hernia with Intrathoracic Renal Ectopia: Thoracoscopic Approach for a Complete Anatomical Repair

Congenital diaphragmatic herniae (CDH) with associated intrathoracic ectopic kidneys are rare congenital anomalies, with a reported incidence of only 0.25%. The authors report a case of a 24-day-old baby girl who was diagnosed with a left-sided CDH on a chest X-ray taken for pneumonia. Computed tomography scan showed CDH hernia, containing small and large bowel and whole left kidney with adrenal gland. Thoracoscopic reduction in the bowel, kidney, and adrenal gland into the abdomen and primary closure of the defect was achieved with no complications. During investigation of the child, it was discovered that her maternal aunt had also had a left-sided congenital diaphragmatic hernia containing the kidney, which was treated via open surgery after birth; she subsequently developed renal cell carcinoma and required radical nephrectomy of that kidney during her third decade.

Wilms tumor in a left pelvic kidney: A case report

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Nephroblastoma is the most common pediatric renal tumor.

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Genitourinary anomalies and syndromes frequently co-exist.

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The existence of Wilms tumor in association with unilateral pelvic renal ectopia is very rare.

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Nephroblastoma in a left pelvic kidney presenting as lower abdominal mass in a 10 year old is presented.

Introduction

Wilms tumor(nephroblastoma) is the most common renal tumor in childhood.The most frequent anomalies and syndromes associated with this tumor involve the genitourinary tract. The occurrence of Wilms tumor with renal ectopia is rare.When present,Wilms tumor is usually found in association with other forms of renal ectopia like horseshoe kidneys or crossed fused renal ectopia. However, reports of the occurrence of Wilms tumor in unilateral pelvic renal ectopia is uncommon. We report a case of Wilms tumor in a pelvic left kidney.

Presentation of case

A 10 year old girl presented to the out-patient department with a one year history of lower abdominal mass, pain and hematuria. Examination revealed a mass in the suprapubic region. Radiological investigations showed a tumor in a left pelvic kidney. She was managed with preoperative chemotherapy, surgery and adjuvant chemotherapy. Histopathologic examination of the nephrectomy specimen confirmed the diagnosis of nephroblastoma.

Discussion

The occurrence of Wilms tumor in association with renal ectopia is rare. There are few reports of tumors arising in unilateral pelvic ectopic kidneys. A multi-modal treatment approach involving the use of chemotherapy, surgery and radiotherapy (for high-risk tumors) in the management of Wilms tumor gives good outcome.

Conclusion

Tumors arising from a pelvic kidney should be considered as part of the differential diagnosis of lower abdominal masses in children.

Robot-assisted Partial Nephrectomy and Bilateral Pyelolithotomy in Ectopic Pelvic Kidneys

OBJECTIVE

To show how to perform a robot-assisted partial nephrectomy and bilateral pyelolithotomy in ectopic pelvic kidneys. This is a congenital abnormality of position and rotation¹ frequently associated with urolithiasis.² Renal cell carcinoma is a very rare event in pelvic kidneys.^3,4 These 2 findings in the same patient could be a surgical challenge and whenever possible a "one stage" treatment is preferred.

MATERIALS AND METHODS

A 44-year-old male with bilateral pelvic kidneys admitted because of left back pain. Abdominal CT scan showed a 17 mm stone in the left renal pelvis, a 12 mm stones in the right pelvis and a 34 × 27 mm right lower pole renal mass. A robotic surgery was indicated. Patient was placed in Trendelenburg position with ports configuration as for transperitoneal radical prostatectomy. The right kidney was firstly approached: after isolation of the ureter and suspension of the renal artery, a clampless partial nephrectomy was performed; then through a longitudinal pyelotomy the stone was extracted. To minimize the opening of the posterior peritoneum covering the left kidney, the site of the stone was identified by intraoperative ultrasound; then, through a longitudinal pyelotomy the stone was extracted. Given the watertight sutures and the lack of ureteral obstructions no pigtails ureteral catheters were inserted. A Jackson-Pratt drainage was placed through the inferior port.

RESULTS

Consolle time was 190 minutes. Estimated Blood Loss (EBL) was 50 ml. No complications were reported. The drain was removed on the second postoperative day, assessed that creatinine dosage was equal to serum. The length of stay was 4 days. Histopathology showed a pT1a G2 clear cell renal cell carcinoma with negative surgical margins, while stones analysis was calcium oxalate.

CONCLUSION

With the availability of robotic technology, the indications for minimally invasive surgery may be safely expanded to include concomitant morbidities in uncommon presentations.

Renal cell carcinoma in a lumbar ectopic kidney

Introduction

Lumbar ectopic kidney is a rare developmental renal anomaly. We report a case of renal cell carcinoma in lumbar ectopic kidney with an abnormality of the main renal artery piercing the renal parenchyma.

Case presentation

A 70‐year‐old female was referred to our division with an incidentally diagnosed ectopic kidney. Computed tomography angiography detected the right kidney at the lumbar (L3‐L4) level with an early‐enhanced 44‐mm‐diameter mass. The kidney had a laterally facing renal hilum and renal arteries piercing the renal parenchyma from the medial side. An open radical nephrectomy was performed using a peritoneal approach, and no perioperative complications were observed. The pathological diagnosis was clear cell carcinoma (pT1).

Conclusion

This is the first case report of renal cell carcinoma in a lumbar ectopic kidney. It highlights the importance of preoperational imaging for aberrant artery and careful surgical management.

Renal cell carcinoma in ectopic-pelvic kidney: A rare case with review of literature

The incidence of renal cell carcinoma in a pelvic kidney is rare, and has only been reported in a small number of cases. We report a 50-year-old male patient presented with vague abdominal pain and without hematuria. CT scan showed large heterogeneous soft tissue mass arising from a left pelvic kidney with areas of necrosis measuring 8.4×8.4×7.5 cm. Histopathology after radical nephro-ureterectomy showed grade II clear-cell renal carcinoma. Renal cell carcinoma of ectopic kidney is a rare disease. Even though the presentation might be atypical and challenging, the treatment strategy is still the same as for tumors of orthotopic kidneys.

Article

Pelvic kidney is the most common type of renal ectopia. These abnormally positioned kidneys are often clinically asymptomatic. However, they are prone to urinary infection, stone formation and trauma. Admitted patients often complain of lower abdominal pain and urinary infection. Pelvic kidneys may also lead to misdiagnosis when it is associated with hydronephrosis or large cystic structures. Thus, it is rather difficult to pinpoint the origin of the problem. We reported here different clinical presentations of our two patients with pelvic kidneys.

Surgical Management of Ectopic Kidney with Bilateral Iliac Vein Invasion

Renal cell carcinoma (RCC) is a very rare phenomenon in an ectopic kidney. We come across a 61-year-old gentleman with a history of 2 months of gross, painless haematuria and palpable pelvic mass on examination. CT scan showed 6.5cm X 5.1cm X 5.8cm mass in pelvic kidney with bilateral iliac vein invasion. With the help of intra-operative ultra-sound, tumour thrombus was extracted from both iliac veins with en mass removal of tumour. Patient was well intraoperatively as well as in postoperatively. We also presented an elegant imaging for the case.

Preoperative evaluation of pelvic kidney renal cell carcinoma with 64-slice CT and 3D-CT angiography

We report a case of a 55-year-old woman, who presented with a vague pelvic pain and was found to have an ectopic pelvic kidney involved by a mass. Preoperative assessment was done by multi-slice CT and 3D-CT angiography. According to our knowledge only eight cases of pelvic kidney tumor have been reported in the literature and our case is the first report of using multi-slice CT and 3D-CT angiography in the preoperative evaluation of these cases.

Papillary renal carcinoma arising in an ectopic native kidney and status after renal transplant: a report of a unique case and review of the literature

Renal ectopia is an uncommon developmental defect of upper urinary tract. Except for hydronephrosis and urinary calculus formation, it is believed that ectopic kidneys are not more susceptible to diseases compared to the normally positioned kidneys. Primary renal carcinoma in ectopic kidneys is rarely observed. Our literature review identified eight cases in nontransplanted patients; seven were clear-cell carcinoma and one was papillary renal carcinoma. On the other hand, native kidneys of renal transplant patients are fifteen times more likely to develop renal carcinoma than those of nontransplanted patients. Renal malignancy has never been reported in native ectopic kidneys of transplant recipients. We report the first case of a papillary renal carcinoma in a native ectopic kidney of a 30 year-old female, six-year status after renal transplantation.

Gerota's fascia over a pelvic ectopic kidney: Myth or reality?

OBJECTIVE

To prospectively evaluate for the presence or absence of Gerota's fascia in a pelvic ectopic kidney, as this is not well documented.

MATERIALS AND METHODS

Between January 2007 and July 2011, all patients with normal renal functions presenting to the Urology Clinic with pelvic ectopic kidney were evaluated for the presence of fascia similar to Gerota's fascia. Specific evaluation included a contrast-enhanced computed tomography (CT) scan and open surgery where indicated. A literature search using PubMed was also done for the period between 1990 and May 2011 using the terms 'Gerota's fascia', 'perirenal fascia,' and 'pelvic kidney'.

RESULTS

Eleven patients were evaluated. The mean age was 28.6 years (range 7 to 50). The presentation included stone disease in six, pelvi-ureteric obstruction in three, and as part of the evaluation for other causes of lower abdominal pain, it was found in two. A CT scan performed on eight patients did not show any evidence of fascia, while surgical exploration done on seven showed a well-defined fascial layer, at least on the ventral aspect of the kidney. A literature search also did not show any information about Gerota's fascia in the pelvic kidney.

CONCLUSION

Further anatomical / radiological studies are needed to definitively document the presence of Gerota's fascia around a pelvic kidney. Our data is more in favor of the presence of such a perirenal fascia similar to Gerota's fascia.

Laparoscopic radical nephrectomy in a pelvic ectopic kidney: keys to success

BACKGROUND AND OBJECTIVES

Laparoscopic radical nephrectomy of a pelvic kidney for renal cell carcinoma is a procedure with little precedent, but one that offers the advantages of the minimally invasive approach. We present our experience with this unique procedure.

METHODS

A 64-year-old male with a history of end-stage renal disease was diagnosed with a 2.6-cm enhancing mass in a pelvic left kidney with 2 separate sources of blood supply. He was offered either an open radical nephrectomy or a laparoscopic radical nephrectomy and opted for the minimally invasive approach.

RESULTS

The procedure was performed successfully without complications and with minimal blood loss. The case was marked both by difficulty in mobilizing the sigmoid colon and the limited working space of the pelvis, which made localization of the numerous hilar vessels challenging.

CONCLUSIONS

Laparoscopic radical nephrectomy for a pelvic ectopic kidney appears to be safe and efficacious. Success is dependent on familiarity with pelvic anatomy, optimal port placement, and preprocedure knowledge of the often-complicated vascular anatomy of the ectopic kidney. Preoperative imaging to delineate anomalous vascular anatomy is mandatory, and ureteral catheter placement is helpful for intraoperative identification purposes.

Pelvic kidney: associated diseases and treatment

The incidence of pelvic kidney has been approximated at between 1 in 2200 and 1 in 3000. The ectopic kidney is thought to be no more susceptible to disease than the normally positioned kidney, except for the development of calculi and hydronephrosis. Because of the greater risk of injuring aberrant vessels or overlying abdominal viscera and nerves, the pelvic kidney presents special treatment challenges. Alternative approaches to treating nephrolithiasis may yield better outcomes. The tortuous ureter often associated with a pelvic kidney hinders deflection of the flexible ureteroscope, potentially limiting access. Laparoscopy-guided intervention permits visual exposure of the kidney, enhancing safe puncture and tract placement integral to percutaneous nephrolithotomy. Laparoscopy-assisted anterior retrograde percutaneous nephroscopy involves percutaneous access using a Hunter-Hawkins retrograde nephrostomy needle with adjunctive laparoscopy to permit viewing and manipulation of overlying bowel. Ureteropelvic junction (UPJ) obstruction has been reported to occur in 22% to 37% of ectopic kidneys. Endoscopic incision presents difficulties beyond those of anatomically normal kidneys. The laparoscopic approach provides good surgical exposure, and operative times are comparable to those of laparoscopic pyeloplasty in anatomically normal kidneys. To date, only a handful of cases of malignancy in a pelvic kidney have been described. Like a nonfunctioning anatomically normal kidney, a nonfunctional pelvic kidney may require primary removal. There are a few reports of laparoscopic pelvic nephrectomy. Additional studies are needed to compare the various treatments for disease of the pelvic kidney in order to decide which options have the most beneficial outcomes.

Hydronephrotic Ectopic Pelvic Kidney Simulates Sacral Metastasis From Breast Cancer

A 57-year-old woman with a history of a right modified radical mastectomy after neoadjuvant chemotherapy for stage IIIB infiltrating ductal breast carcinoma presented for follow-up bone scan. Initial inspection was suspicious for sacral metastasis, but on closer review the absence of renal activity in the left flank was noted. Correlation with CT scan confirmed a hydronephrotic ectopic kidney overlying the sacrum.