Renal Cancer Flashcards
What percentage of surgically resected tumors < 4 cm are benign?
15-20%
What percentage of RCC cases are familial? What are syndromes?
4-6%
Von Hippel-Lindau (VHL)
Birt Hogg-Dube (BHD)
Hereditary leiomyomatosis RCC (HLRCC)
Succinate dehydrogenase deficiency
Tuberous sclerosis
BAP-1
PTEN hamartoma (Cowden Syndrome)
Major subtypes of RCC?
clear cell
papillary 1 or 2
chromophobe
collecting duct
unclassified
uncommon: acquired cystic, clear cell tubulo papillary, renal medullary (sickle cell)
Advanced PE findings?
Paraneoplastic syndromes (htn, polycythemia, hypercalcemia)
adenopathy
varicocele
Name benign renal tumors?
Papillary adenoma
Oncocytoma
AML
Metanephric adenoma
Adult cystic nephroma
Mixed epithelial stromal tumors
Juxtaglomerular cell tumor
What is T1 renal tumor? subtypes?
T1 → < 7 cm in greatest dimension, limited to kidney
T1a < 4 cm
T1b < 4 cm, but not > 7 cm
Describe renal tumor T2:
T2 → >7 cm in greatest dimension, limited to kidney
T2a → > 7 cm but < 10 cm
T2b → > 10 cm
Describe renal mass T3:
T3 → tumor extends into major veins or perinephric tissues, but not to adrenal or beyond Gerota’s
T3a → into renal vein or its segmental branches, or invades pelvicalyceal system, or invades perirenal and/or renal sinus fat but not beyond Gerota’s
T3b → Grossly extends into vena cava below diaphragm
T3c → extends into vena cava above diaphragm or invades wall of vena cava
Describe renal mass T4:
T4 → invades beyond Gerota’s (including contiguous adrenal extension)
Define renal cancer N and M stages:
Nx → LN not assessed
N0 → no region LN mets
N1 → mets to regional LN
M0 → no distant mets
M1 → distant mets
Describe renal mass stages:
Describe the treatment options for clinically localized renal cancer:
Active surveillance → cT1a < 4 cm → risk of mets <2%
Radical Nx → historically entire kidney, Gerota’s/ Zuckerkandel’s fascia, regional LN, and adrenal
Partial Nx → NSS
Thermal ablation → RFA and cryoablation
In a patient with renal mass, clinicians SHOULD obtain which imaging? How is mass characterized?
GUIDELINE STATEMENT 1
High-quality, multiphase, cross-sectional abdominal imaging (CT/MRI)
eGFR < 45 → hydration or MRI (especially characterizing small lesions < 2 cm)
NSF (CKD 4/5 → < 0.07%)
Characterize stage (size cranio-caudal, transverse, and A/P, morphology, involvement of vasculature, adenopathy)
Nephrometry score, PADUA score, C-index
Complexity (Bosniak 3 → irregular walls/septa + enhancement ~50% malignant; Bosniak 4 → complex cystic lesions, enhancing ~75-90% malginant)
Degree of contrast enhancement (> 15-20 HU on CT or 20% on MRI)
Presence or absence of fat
Nephrometry Score
RENAL
Radius, Exophytic/Endophyic, Nearness to CS, A/P, Location re: polar lines
In patients with suspected renal cancer, clinician SHOULD obtain which labs? Metastatic eval?
GUIDELINE STATEMENT 2
CMP, CBC, UA (proteinuria important prognostic factor)
UA 1+ protein → Protein: Cr or Alb:Cr
Elevated ALP → consider bone mets
Chest imaging → CXR or CT(evaluate for thoracic mets based on risk of dz)
What makes a renal mass higher risk?
presence of thrombi, presumed adenopathy, larger tumor size, infiltrative appearance, extensive tumor necrosis, severe relevant sxs or PE findings
In patient with solid or Bosniak 3 or 4 mass, in addition to labs and metastatic workup, what other classifications SHOULD be done?
GUIDELINE STATEMENT 3
Assign CKD stage base on GFR and degree proteinuria
In regards to counseling for suspicious renal mass, who SHOULD be considered as players of the multidisciplinary team?
GUIDELINE STATEMENT 4
Urologist → lead counseling process
IR → RMB or ablation
Nephrologist → CKD, proteinuria, DMII, ongoing renal protection
Pathologist → GU dedicated, also evaluation of normal parenchyma
Medical Oncologist → poss neoadjuvant or adjuvant trials, recurrence
Genetic Counseling → 4-6% familial, multifocal or b/l
Clinicians SHOULD provide counseling that includes current perspectives about tumor biology and what patient-specific risk assessment:
GUIDELINE STATEMENT 5
Sex, tumor size/complexicty, histology, imaging characteristics
cT1a (low oncologic risk → indolent, <2% risk mets)
When counseling treatment options for renal mass, clinicians SHOULD review the most common urologic and non-urologic morbidities of each treatment pathway including:
GUIDELINE STATEMENT 6
the importance of age, comorbidities/frailty, and life expectancy
RN → greatest risk dec. GFR or de novo CKD, favorable peri-op outcomes and low risk of complication compared to PN
PN → excellent preservation of GFR, higher risk txf, urine leak or other complications needing additional tx (stent, drains, embolization of pseudo-aneurysm)
TA → inferior RFS, most favorable peri-operative outcome profile (best for small peripheral tumors)
AS → favorable oncologic and OS outcomes in well-selected patients; possible anxiety or poor outcomes
What SHOULD clinicians review in regards to renal function recovery related to renal mass management:
GUIDELINE STATEMENT 7
Progressive CKD
ST and LT need for RRT
LT OS considerations
Clinicians SHOULD refer to nephrology renal mass patients with:
GUIDELINE STATEMENT 8
High risk of CKD progression (eGFR < 45), confirmed proteinuria, DMII pre-existing CKD, or expected GFR < 30 after sx
In regards to renal cancer, when is genetic counseling RECOMMENDED:
GUIDELINE STATEMENT 9
< 46 yo
Multifocal or b/l masses
personal hx suggests familial renal neoplastic syndrome
1st or 2nd degree relative with hx of renal cancer or known clinical/genetic dx of familial neoplastic syndrome (even if kidney cancer not observed)
path demonstrates histologic features suggestive of syndrome
Syndrome: Von Hippel-Lindau (VHL)
Gene: VHL
Clear cell RCC, renal cysts, hemangioblastomas of CNS, retinal angiomas, pheochromocytoma
Syndrome: Hereditary Papillary Renal Carcinoma (HRPC)
Gene: MET
Type 1 papillary RCC
Syndrome: Birt Hogg-Dube (BHD)
Gene: FLCN
chromophobe RCC, oncocytoma, hybrid oncocytic/chromophobe tumors (HOCTs), cc RCC (less common), renal cysts, cutaneous fibrofolliculomas, lung cysts, spontaneous PTX
Syndrome: Hereditary Leiomyomatosis and RCC (FH)
Gene: FH
type 2 papillary or CD RCC, cutaneous leioyomyomas, uterine leiyomyomas
Syndrome: Succinate Dehydrogenase Kidney Cancer (SDH-RCC)
Gene: SDHB/C/D
ccRCC, choromophobe RCC, type 2 papillary RCC, oncocytoma, pheochromocytoma/paraganglioma
Syndrome: BAP-1 Tumor Predisposition Syndrome
Gene: BAP-1
ccRCC, uveal melanoma
Syndrome: Tuberous Sclerosis Complex
Gene: TSC 1 or 2
AML, ccRCC, oncocytoma, lymphangioleiyomyomastosis (LAM), seizures, developmental delay
Syndrome: Cowden/PTEN Syndrome associated RCC (CS-RCC)
Gene: PTEN
Thyroid, breast, and endometrial cancer, mucocutaneous lesions, RCC with papillary mc, other forms of RCC including cc
When considering RMB what SHOULD be counseled?
GUIDELINE STATEMENT 10
generally safe & complications low risk: hematoma, pain, hematuria, PTX, hemorrhage (txf)
Sensitivity 9.67%, Specificity 94.4%, PPV 98.8% (core), NPV 60-80%
non-diagnostic rate 14%, concern for missed histologic heterogeneity
Discussion:
RMB is safe and low risk (no reported tumor seeding)
Dx of RCC is highly reliable
LImits:
Benign bx must be distinguished from non-dx
Benign is not always correct
Grade concordance from bx to sx is not perfect
Oncocytic neoplasm are diagnostic dilemma
Bx or aspiration of cystic mass not advised (spillage)
When concerned about hematologic, metastatic, inflammatory, or infectious mass, clinicians SHOULD consider? What type of cancers are common?
GUIDELINE STATMENT 11
RMB
Lymphoma, lung, melanoma, colon, thyroid
RMB SHOULD be obtained on utility-based approach when it may influence mgmt. It is NOT required when:
GUIDELINE STATMENT 12
Young or healthy patients who are unwilling to accept uncertainties
older or frail patients who will be managed conservatively no matter results
How SHOULD RMB be done?
GUIDELINE STATEMENT 13
Multiple core biopsies and preferred over FNA
Why is NSS (PNx) important? When is it appropriate to consider?
GUIDELINE STATEMENT 14
for mgmt of cT1a mass
**reduces risk of CKD or CKD progression and is associated with favorable outcomes
GUIDELINE STATEMENT 15
solid or Bosniak 3 or 4 complex cystic masses in anatomically or functional solitary kidney, bilateral tumors, known familial RCC, pre-existing CKD, or proteinuria
GUIDELINE STATEMENT 16
solid or Bosniak 3 or 4 complex cystic masses who are young, multifocal masses, or comorbidities likely to impact GFR in future (htn, DM, stones, obesity)
Intraoperatively, how SHOULD clinicians prioritize nephron sparing and balance with what other goals?
GUIDELINE STATEMENT 17
optimize nephron mass preservation
avoid prolonged warm ischemia (<25-30 mins)
GUIDELINE STATEMENT 18
Prioritize negative sx margins
Enucleation should be considered in pts with familial RCC, multifocal dz, severe CKD
*depends on tumor characteristics, growth pattern, interface with normal tissue
When SHOULD a clinician consider RNx?
GUIDELINE STATEMENT 19
Solid or Bosniak 3 or 4 complex cystic renal mass with:
increased oncologic potential (size, RMB, imaging features)
ALL of following:
high tumor complexity (PN challenging in experienced hands)
no pre-existing CKD or proteinuria
normal contralateral kidney (new baseline GFR would be >45)
Patients undergoing renal sx, SHOULD have LND when?
GUIDELINE STATEMENT 20
clnically concerning regional LAN, perform LND including all clinically positive nodes for staging (no real survival benefit)
(concerning features: > 10 cm mass, clinical stage T¾, high grade tumors (3 or 4), sarcomatoid features, histologic tumor necrosis)
For patients with renal mass, when SHOULD adrenalectomy be performed?
GUIDELINE STATEMENT 21
imaging and/or intraoperative findings suggest mets or direct invasion of adrenal gland
pT4 (contiguous)
M+ if hematogenous
How SHOULD renal mass surgery be performed?
GUIDELINE STATEMENT 22
Minimally invasive (when it would not compromise outcomes)
*benefits in ST complications, fewer longer term
After PNx of RNx, adjacent renal parenchyma SHOULD be evaluated:
GUIDELINE STATEMENT 23
evaluate for intrinsic renal dz and particularly for CKD or risk factors for CKD
When SHOULD clinicians refer to medical oncology for renal masses?
GUIDELINE STATEMENT 24
whenever there is concern for potential clinical mets or incompletely resected dz (macroscopic positive margin or gross residual dz)
patients with high-risk or locally advanced, fully resected renal cancers should be counseled of risk, benefits of adjuvant tx and encourage to participate in trials
What types of TA can be considered for renal mass? Who SHOULD be considered?
GUIDELINE STATEMENT 26
radiofrequency ablation (RFA) and cryoablation
GUIDELINE STATEMENT 25
consider as alternative mgmt of cT1a solid masses < 3 cm (percutaneous preferred over sx approach)
Describe RFA and cyroablation:
RFA → high frequency alternative current (460-500 kHz) to induce frictional agitation and heating in adjacent tissues
Cryo → temp -20 to -40 C, resulting in coagulative necrosis
When treating with TA, what SHOULD be performed prior to or at time of tx? What should counseling include?
GUIDELINE STATEMENT 27
RMB to provide pathologic dx and guide surveillance
GUIDELINE STATEMENT 28
info regarding increased likelihood of persistence or local recurrence vs. sx which may be addressed with repeat ablation or further intervention
Patient related factors for AS vs. Expectant Mgmt vs. Intervention
When SHOULD AS be utilized?
GUIDELINE STATEMENT 29
For solid renal mass < 2 cm, or complex but cystic
*Repeat imaging in 3-6 mo to assess growth/change, then periodic imaging based on growth rate
GUIDELINE STATEMENT 30
For solid or Bosniak 3 or 4 cystic complex mass, WHEN anticipated risk of intervention or competing risk of death outweigh oncologic benefits (asx pts periodic imaging)
GUIDELINE STATEMENT 31
For patients with solid or Bosniak 3 or 4 WHEN risk/benefit is equivocal and who prefer AS, consider RMB
When is intervention RECOMMENDED over AS? When is AS possible in this case?
GUIDELINE STATEMENT 32
solid or Bosniak 3 or 4 mass with oncologic benefits of intervention > risks of tx and risk of death
**Median growth rates > 5 mm/year are indicative of oncologically active tumors
AS with potential for delayed intervention → only if patient understands and willing to accept associated oncologic risk
Encourage RMB for additional stratification
continues to prefer AS → close clinical and cross sectional imaging continued
Follow up after intervention of renal mass: benign vs. malignant?
GUIDELINE STATEMENT 33
Discuss implications of stage, grade, and histology including risk of recurrence and sequelae of tx
Benign → occasional clinical eval and labs (no imaging)
GUIDELINE STATEMENT 34
Periodic H&P, labs, imaging for mets and local recurrence based on stage
What follow up labs for malignant renal mass s/p tx?
GUIDELINE STATEMENT 35
Cr, eGFR, UA
CBC, LDH, LFT, ALP, Ca → discretion of MD or if advanced dz
When following patient s/p tx for renal mass, when do you refer to nephrology?
GUIDELINE STATEMENT 36
with progressive renal insufficiency or proteinuria
When do you perform bone scan for renal mass f/up post tx? When head or spine CT/MRI?
GUIDELINE STATEMENT 37
clinical sxs bone pain, elevated ALP, or imaging suggestive of bony mets
GUIDELINE STATEMENT 38
Acute neuro sxs
GUIDELINE STATEMENT 39
site specific imaging warranted by sxs
PET should not be routinely used (selectively)
Patients renal mass with suggestive sxs/signs of mets next steps?
GUIDELINE STATEMENT 40
evaluate to define extent of dz
refer to med onc
sx or ablation considered with isolated or oligo-mets
In pts with new renal primary or local recurrence, what is next steps?
GUIDELINE STATEMENT 41
met evaluation including chest and abdomen
if isolated to ipsilateral kidney and/or retroperitoneum, sx resection or ablation can be considered
Describe risk categories of patients s/p PNx or RNx:
GUIDELINE STATEMENT 42
See table, sx margins positive → increase risk category by one level
Recurrence rates by risk level for renal mass post sx:
pT1 → 9.2% (Grade 1: 6.4%, Grade 2: 15.4%)
pT2 → 32% (organ confined RCC, Grade 3 or 4: 20-30%)
pT4 (most present mets) → 64.7% (N1 → CSS 2.8 y, 64.3% mortality after recurrence)
Follow up after TA:
GUIDELINE STATEMENT 45
bx confirmed malignancy or non-dx
CTU/MRU w/in 6 mo (then follow same as intermediate risk category)
f/up schedule after surgery for renal cancer:
GUIDELINE STATEMENT 43 and 44
Low risk → pT1, G1 or 2 → CT/MRI and CXR/CT q 12 mo
*after 2 years abd US alternating with CT/MRI can be considered
*after 5 y joint decision making
Intermediate risk → pT1 grade 3 or 4, pT2 any grade → CT/MRI and CXR/CT at 6 mo, then q 12 mo for 5 years (can consider abd US after 2 years alternating)
High risk → pT3 any grade → CT/MRI and CXR/CT q 6 mo for 3 y, then q 12 mo for 5 years
Very high risk → pT4 or N1 or sarcomatoid, rhabdoid, macro pos margin → CT/MRI q 3 mo x 1year, then q 6 mo years 2-3, then annually
f/up algorithm table for renal mass
Describe an extraperitoneal flank approach for Nx:
- Anesthesia, Foley, SCDs, abx
- Position lateral decubitus (side down opposite tumor), flexion to increase space btw ribs, pressure points padded, secured to table, right arm supported in anatomic position to protect brachial plexus
- Incise btw 11-12 ribs, dissect through flank layers, care to avoid perforating nerves
- Enter retroperitoneum, divide lumbodorsal fascia, avoid entry to pleura posteriorly and peritoneum anteriorly
- Mobilize kidney w/in Gerota’s posteriorly, laterally, superiorly, and anteriorly
- ID ureter
- Place kidney on anterior and medial traction to isolate hilum
- Dissect artery posteriorly
- Defat kidney near renal mass, maintain fat pedicle to possibly use for reconstruction
- Use US if needed to define boundaries and depth
- Mannitol??? /IVF (out of favor…)
- Clamp RA, surround kidney in slush
- Incise capsule 1 cm from tumor edge, excise tumor with neg margin
- Sample areas from bed if concern of incomplete excision
- Assess and repair CS
- Achieve hemostasis with focal suture ligatures, electrocautery, and hemostatic agents
- Reconstruct and reinforce defect (bolsters)
- Remove clamp ASAP
- Assess for arterial pulse/perfusion kidney
- Assess for hemostasis
- Re-approximate perinephric fat pedicle
- Place drain in proximity of kidney
- Inspect retroperitoneum, peritoneal boundary and pleura
- Inspect vasculature
- Remove flexion, reapproximate ribs
- Close muscle and facial layers
- Close skin
How do you manage an acute post operative urine leak?
- vast majority close with conservative mgmt
- small leaks → adjust drain to make sure not contributing, suction on renorrhaphy vs. obs
- larger or persistent leaks → urinary diversion, stent, IR drain/PCN; with stent need Foley to prevent VUR
- Secondary closure, fistula repair, nx (challenging cases or nephrocutaneous fistula)
- Algorithm:
leak from drain → take off suction → adjust away from anastomosis
Insert stent → placed PCN → IR drain urinoma → antegrade stent
Most important prognostic determinant of RCC?
local tumor extent/size/stage
histologic subtype
surgical margins
regional nodal status
evidence of distant met status
performance status
What about margins?
<1 cm margins not associated with higher rates of local recurrence
positive margin slightly higher risk of local recurrence (but with adequate surveillance, no statistically higher mortality)
What are risk factors and pathogenesis of ccRCC? what about VHL association?
family hx, smoking, hereditary, obesity, HD
arises from PCT, associated with defects in VHL (60% sporadic)
VHL → works as tumor suppressor to inhibit ubiquitination of HIF → when mutated HIF builds up overproducing VEGF, GLUT-1 TGF-a, PDGF → angiogenesis, proliferation
Describe trans peritoneal lap Nx:
- anesthesia, foley, NGT
- lateral decubitus (tumor side up), 45 degree angle, pad pressure points (peroneal nerve, brachial plexus stretch injury)
- trochar placement to triangulate kidney
- Veress → incision at umbilical camera site → Kelly clamp to spread fat, ID fascia → grasp fascia using Kocher, upward traction, pass veress (2 pops) → 10 cc syringe, inject 5 cc saline without force to confirm intraperitoneal → advance needle 1 cm, no resistance → confirm low starting pressure → remove Veress, place trochar, attach gas, pass camera to inspect
- Hasson → consider with prev. abd sx → ID fascia, incised, peritoneum incised → 2 heavy sutures placed on either size of incision (incorporate fascia/peritoneum) → Hasson trochar in place and insufflation started
- Place working trochars under direct vision
- take down colon (white line of Toldt), care not to enter Gerota’s (left splenic flexure mobilized → drop from field, care to avoid tail of pancreas
- ID ureter on psoas
- gonadal ID and traced to hilum
- RV skeletonized (care not to avulse adrenal vein or lumbar (entering posterior RV)
- ID RA posterior and superior (make sure 1)
- Secure RA with Weck Clips (2-3, 1 on kidney side) or Stapler, Take vein with stapler
- Take gonadal and ureter, dissect free posterior, lateral, and superior aspect of kidney, place in bag
- Extract in lap bag to facilitate removal and reduce incision site implants
- Port sites > 10 mm closed
Common locations of positioning injuries for renal sx:
Brachial plexus
Lateral popliteal nerve
Femoral nerve
Sciatic Nerve
*usually resolve 4-6 weeks, can last up to 2y
What are insufflation/access related complications and treatment:
gas embolus → Millwheel murmur, CV collapse, head/neck cyanosis, dysrhythmia, hypoxia, decreased end tidal CO2 → terminate insufflation, release pneumo, left lateral decubitus, cardiopulmonary resuscitation, aspiration of gas via central line, 100% O2
Veress needle/trochar placement → major vascular injury → leave needle in place, use second Veress and try to repair injury → if trochar injury, open conversion, explore and repair → do not remove until conversion made and ID location and severity
Extraperitonal insufflation → high intra-abd pressure after small volume insufflated, subq emphysema, pneumoscrotum, PTX, pneumomediastinum → reposition insufflation needle
Name vascular complications and tx of lap surgery:
mgmt. based on severity of injury: clip vessel, increase pressure, apply pressure (gauze or instrument), biosealants (slow ooze), oversew, convert to open/hand assist (leave instrument on bleed), lower pressure to 5 mHg at end to ensure no active bleeding (watch trochar removal)
post operative bleeding → prolonged pain, distention, tachy, fall in hct → CT AP, obs. vs. exploration
Hollow viscus → electrocautery, access (needle/trochar), blind passage of instruments
Recognize in OR → repair, abx irrigation, broad spectrum
Post op → trochar site pain, fever, leukopenia with left shift, low threshold for CT w/oral contrast and delayed views to visualize colon
Solid Viscus → veress, trochar, retraction (do gently)
Minor injury → biosealants, argon beam, cellulose gauze, open if fail
Kidney trochar injury → if Gerota’s intact, stable RP hematoma, patient stable _> conservative obs
Explore if expanding hematoma, vascular instability, or unknown extent of injury
Complications of PNx:
Intraoperative hemorrhage
Delayed bleeding
Persistent leak from CS
Perirenal abscess
Urinoma
Reno-cutaneous fistula
Acute tubular necrosis
Conversion to RN
what control is needed with IVC thrombectomy?
-
Prior to IVC thrombectomy vascular occlusion should include:
- Renal artery supplying the affect kidney with tumor thrombus
- Infrarenal IVC below thrombus
- Lumbar veins feeding in to the IVC
- Contralateral renal vein
- Hepatic blood supply for thrombus that extends about the hepatic veins. A Pringle maneuver is performed to decreased hepatic blood flow by placing a clamp across the hepatic artery and portal vein within the hepatoduodenal ligament. This is mainly done for level 3 or higher tumor thrombus.
- Suprarenal IVC above the thrombus
IVC thrombus classification:
- In the eighth edition AJCC staging manual, venous invasion is classified by the T stage according to the extent of invasion as described below:
- T3a tumor grossly extends into the renal vein or its segmental (muscle containing) branches
- T3b tumor grossly extends into the vena cava below the diaphragm
- T3c tumor grossly extends into the vena cava above the diaphragm
- However, the Neves Zincke classification is more useful from a technical surgical approach:113
- Level 0: Tumor thrombus limited to renal vein
- Level 1: Extending ≤2 cm above the renal vein
- Level 2: Extending >2 cm above the renal vein but below the hepatic veins
- Level 3: At or above the hepatic veins but below the diaphragm
- Level 4: Extending above the diaphragm
Where does RCC metastasize?
Lung → 50%
Liver → 33%
Bone 32 → 32
Brain → 25%
5 year survival for RN by stage?
Stage 1 → 95%
Stage II → 85%
Stage III → 60%
Stage IV → 20%
What are s/s important to ask at renal mass f/up after Nx or PNx? PE components?
History:
abdominal/flank/bladder pain or tenderness
fatigue
gross hematuria
weight loss
lower extremity edema
neuro complaints
MSK pain
SOB
PE:
LN, lower extremities, neuro exam, VS (weight and BP), abdominal exam
Labs to consider for f/up of post sx renal mass??
CBC, LDH, LFTs, UA, BUN/Cr (eGFR), ALP (sxs)
What is ddx of post sx bone pain (ribs) and elevated ALP on f/up?
Hyperthyroidism
Pregnancy
Hepatitis
Biliary Obstruction
Non malignant bone conditions (Pagets)
Bone mets
What is ddx of solid enhancing renal mass?
RCC
vascular malformation
infarct
urothelial carcinoma
oncocytoma
AML
metanephric adenoma
Met dz
renal abscess
XGP
What are risk factors for AKI with IV contrast?
htn
pre-existing CKD
hemodynamic instability
volume depletion
Age > 75 yo
CHF
High volume contrast media
What tactics can be utilized to prevents kidneys with IV contrast load?
adequate oral hydration
IV NaCl or NaCO3 solution
discontinue nephrotoxic meds
stop metformin and restart in 48 h
use lowest dose
iso- or low osmolar IV contrast agent
NAC
What do you look at for post-ablation CT?
additional, new renal nodules
satellite or port site soft tissue nodules
size change of mass (increase or decrease)
enhancement
what are tx options for post ablation failure?
salvage RNx
salvage PNx
repeat bx
repeat ablation
MC IVC injuries during PNx or Nx
avulsion of right adrenal vein from IVC or right gonadal from IVC
Define Bosniak classification of renal cystic tumors:
Bosniak 1: simple cyst, 0% malignancy
Bosniak 2: minimally complex cyst, 0% malignancy
Bosniak 2F: more minimally complex cyst, 5% malignancy
Bosniak 3: indeterminate, 55% malignancy
Bosniak 4: clearly malignant, 100% malignancy
Early Post-Op complication of PNx?
- Delayed bleeding
- work up pseudo-aneurysm with CT w/IV contrast → call IR for embolization
- Urinoma
- Place ureteral stent anf oley
- If persists, IR drain
- Perinephric abscess
- evaluate for urinoma source
- IR rain
- if persists, consider open drainage
Late Post-op complications of PNx?
- UJPO: scarring around hilum and UPJ
- HTN, with renal trauma also 5% (page kidney)
- AVM
