Right renal SOL with left renal large cyst

52 years female patient with history of painless haematuria off and on since 3 weeks. 

Once right flank pain before 10 days. 
She is diabetic and hypertensive.  Both are under control with regular medicines. 
Renal function,  liver functions normal.  Hb:13.5. Urine sterile,  no rbc at present. 
She presented to me with USG,  CECT AND X RAY CHEST.
Please discuss :
Clinical staging 
Your treatment 
Surgical approach 
Will you operate during lock down... What precautions? 

Right renal SOL with left renal large cyst Right renal SOL with left renal large cyst Right renal SOL with left renal large cyst Right renal SOL with left renal large cyst Right renal SOL with left renal large cyst


  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    09 Apr 2020 09:45:58 AM

    Sir this is bosnik 4 renal cyst...solid components n enhancement....

    I wiil offer her radical nephrectomy as mass is big and by partial nephrectomy..it's seems from ct 1/3 renal parenchyma can't be saved..

  • Nitesh Jain
    Nitesh Jain
    09 Apr 2020 10:06:18 AM

    Looks like Bosnian IV cyst 

    Staging - T2, N1, Mx
    Will do CT chest as well - I presume it will be normal 
    Will offer Radical Nephrectomy , in current scenerio minimal invasive Lap / Robotic is not preferable because of risk of aerosol spread so a open may be better approach ... as it is semi emergent situation as there is fairly a large mass with Hematuria ... and the lockdown period is having no predictability I will go ahead with surgery with all informed consent including consent for the COVID 

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    09 Apr 2020 10:25:42 AM

    Sir this is bosnik 4 renal cyst...solid components n enhancement....

    I wiil offer her radical nephrectomy as mass is big and by partial nephrectomy..it's seems from ct 1/3 renal parenchyma can't be saved..

  • Dr. Roy Chally
    Dr. Roy Chally
    09 Apr 2020 12:54:31 PM

          The problem of covid virus infection is going to stay with us for quite some time. Screen the patient for covid infection at a time when the patient and relatives are comfortable to get the surgery done. 

  • Utsav Shah
    Utsav Shah
    09 Apr 2020 04:48:17 PM

    Respected Anil Sir,

    1) Diagnosis: Right renal complex cyst with solid components and enhancement: S/O Bosniak Type 4 cyst. Considering the presentation of hematuria, RCC is likely and shall be my working diagnosis. 

    2) Clinical Staging: T2b N1 M0
    -T2b:- as >10 cm
    -N1:- 17mm node seen in landing zone
    -M0:- Chest, liver clear. 

    3) Treatment: Right radical nephrectomy

    4) Laparoscopic SOS Open approach

    5) Yes. I will definitely operate under lockdown. It is indicated as it is Stage 3[attaching document by AUA after reviewing NHS recommendations and also propogated by our own USI]

    6) Precautions: Universal precautions as if we are operating a seropositive case. 

  • Utsav Shah
    Utsav Shah
    09 Apr 2020 04:52:16 PM

    Uploading the recommendations for surgery during COVID-19 time.

    It is recommended by AUA after reviewing NHS guidelines and also forwarded by USI. 

  • Prabir Basu
    Prabir Basu
    09 Apr 2020 09:04:55 PM

    Sir , for the sake of a devil's advocate, I shall be answering your 5th question upfront.

    If we go through the only available Chinese study which dealt with clinical outcomes in major surgeries during the Covid 19 incubation period, we see a almost 20% fatality rate which is much higher than the overall cancer specific mortality rate.

    Furthermore, it states that old age, comorbidities, longer operative time, difficult surgery were significant risk factors that these (50%cases) required postoperative ICU monitoring +_ ventilation support.

    The authors believed that major surgery not only caused immediate impairment of immune function but also induced early systemic inflammatory response.


    Now if we extrapolate these findings to our index case,

    1. Index case has all mentioned risk factors.

    2. Large tumor abutting on diaphragm may likely need thoracoabdominal approach for quick extirpation. Hence postoperative ICD and ventilation will be required with its attendant risk of aerosol spread.


    Plus we take into consideration;

    1. She is not actively bleeding, her Hb is f9.

    2.Blood components may not be so easily available.

    3. Extensive Diathermy use may pose an additional aerosol route of spread.

    4. Significant utilisation of manpower and PPE during surgery and post-op care.

    5. Keeping a ventilator standby through out the post-op course.

    6. Difficult to arrange for a tumor board right now.

    7. We right now don't have CV test in preop viral serology.


    I would like to counsel the relatives regarding Trans Arterial Coil Embolization right now

    1. As a neoadjuvant therapy to reduce tumor size, vascularity and to minimise intraoperative blood loss. Her renal artery anatomy presumably  looks amenable for this procedure upfront.

    2. It can palliate her future risk of gross hematuria and landing in emergency surgery.

    3. Post embolization syndrome can be controlled with oral medications.

    4. In the meantime, we can buy time for the pandemic to thaw out.

     Yes it’s a  fact that  I am delaying the inevitable  but in good faith .Ultimately , she undergoes the surgery but later hopefully in a more controlled setting.


  • Dr. Anil Takvani
    Dr. Anil Takvani
    10 Apr 2020 08:14:37 AM

    @ Nitesh:

    What will be your approach for open radical nephrectomy?
    !0th or 11th rib bed, retroperitoneal approach?
    Chevron incision, transperitoneal approach?
    @ Utsav-an excellent replay.
    If you plan open radical nephrectomy what will be your incision and approach. What is your institute preference for open radical nephrectomy for very large upper pole mass?
    @ Tkenjit- Please share your training institute's approach.
    @ Prabir-You have given very interesting turn to discussion. I think we will be having many more views on your treatment selection and arguments in favor.
    We have many experts, I request them to share their experience...

  • Utsav Shah
    Utsav Shah
    10 Apr 2020 08:26:35 AM

    Respected Anil Sir,

    It is a large upper right upper pole mass with no renal vein or IVC. thrombus. In my institute we approach such a case using a subcostal incision or an extended flank incision. We wouldn’t have opted for a thoraco-abdominal approach because it is ONLY localised to the kidney. 

    A very interesting management option of angioembolisation has been given by Dr Basu Sir to buy time during this lockdown. In our institute, we do have an interventional radiologist and we have performed many angioembolizations in cases of bleeding post PCNL. However, we don’t have much experience with angioembolisation of renal mass.  There are a few points however I would like to raise here: 
    -It is recommended that the patient shud be operated within 24-48 hours of angioembolisation; preferable method would be to post the patient for angioembolisation and from the interventional radiologist suite just roll him to the urology theatre. If we wait more, we will encounter more complications of angio and the expected benefit will be lost. 

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    10 Apr 2020 11:00:33 AM

    In my institute in such kind of large upper polar mass,we have done radical nephrectomy by subcostal 11rib cutting incision retroperitoneal approach.However Campbell advocate midline transperitonial approach in large mass.

    Problem most commonly we have noticed is that these patient r having flank bulge ,which they complain.few cases of lumbar hernia,one lumbar hernia repair in surgery department itself n pain...seems to be more than anterior abdominal wall incision. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    10 Apr 2020 01:23:56 PM

    Midline transperitoneal approach? 

    Campbell? Dr.  Tikenjit,  I really doubt.. Thanks 

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    10 Apr 2020 01:39:30 PM

    Sorry sir...my mistake..it should be thoracoabdominal...

  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    10 Apr 2020 02:29:00 PM

    Dear Anil,

    Sorry for the delayed reply. I was not at all busy but was held up with nothing. I was just thinking what to do. Is there something left to be done. Till I realized that nothing is to be done right now. So was busy finishing that nothing

    Coming to the case: Renal tumour T2b N1M0

    Symptoms: painless haematuria off and on since 3 weeks and Once right flank pain before 10 days

    What are the options?

    1.      Open Right Radical Nephrectomy

    2.      Laparoscopic or Robotic right radical nephrectomy

    3.      Neo adjuvant chemo ??

    4.      Angio-embolization

    5.      Wait for COVID-19 epidemic to settle and then operate

    Let us dissect out different questions in our minds one by one

    Is there any harm in waiting? Is surgical wait time (SWT) detrimental? [1]

    1.      SWT < 3month and SWT> 3 month: no correlation with recurrence within 2 year and 5 year follow up (But Forty-five patients with SWT >9 months and 11 patients who died of any cause within 9 months after diagnosis were excluded from the analyses for CSS and OS)

    2.      no evidence that SWT was associated with CSS

    3.      Despite adjusting for patient and tumor characteristics, increasing SWT was still significantly associated with poorer OS

    What are the risk factors of Upstaging if we wait? [1]

    1.      Male gender

    2.      older age

    3.      higher CCI scores

    4.      local or systemic presentation*

    5.      larger tumor size*

    6.      clear cell histology

    (* Risk factors present in our patient)

    What are the risk factors for recurrence? CSS and OS? [1]

    1.      Older age

    2.      larger tumor size

    3.      clear cell histology

    (multivariate analyses.)

    Who gets operated first? [1]

    1.      non-favorable tumor characteristics: Larger tumour size, stage, grade*

    2.      fewer comorbidities*

    3.      Symptomatic presentation*

    (* conditions present in our patient)

    Why am I thinking of delaying the surgery?

    1.      Increased risk of COVID-19 infection (Pt to HCW and HCW to Patient)

    2.      Non-availability of essential services during lockdown (things like blood bank, laboratory)

    3.      Apart from this there is no compelling reason to delay the procedure

    What’s the chance of her progressing to a metastatic disease? (Let’s say that the COVID-19 related scenario prolongs indefitely) [2]

    No conclusive data ia available. The most commonly quoted study [2] is about SRM. It may not be applicable to our patient. SRM grow very slowly (<0.2cm/year) but larger lesions grow bit faster (0.4 or more per year (I am not sure of these figures. Do not remember the references. Please correct me if wrong)

    When do we expect the COVID-19 Graph in India to come down? [3]

    1.      This is as per the projections made by The Center For Disease Dynamics, Economics & Policy. They have projected three scenerios,

    a.      High – trajectory assumes no effect of current lockdowns and a rapid spread that is even higher than some other countries, consistent with data from New York.

    b.      Medium – More likely scenario with no effect of lockdown or temperature/humidity sensitivity, consistent with data from Italy.

    c.      Low – Optimistic scenario with decreased transmission, potentially due to temperature/humidity sensitivity.

    2.      Most likely scenario is Medium or Low. As per this the COVID cases would peak in May end (medium) or June End (low)

    3.      Hopefully we should be expecting resumption of normal work in July 2020

    4.      Waiting for that long seems difficult

    What are the risks if I operate her today?

    The main thing we are worried are the risks of COVID. The most commonly quoted article is from China [4]. Let us not forget that this article is from Wuhan, where the case density was much more. The cases were admitted/ operated between 1 January 2020 to 5 February 2020. If we compare the China’s graph [5] with our graph [6] we have already surpassed the incubation period mentioned in this study (if we compare the slope of graphs per se)



    Will I do a COVID-19 test?

    No, not useful unless the patient is symptomatic. It will invariably be negative (the PCR test I mean). Antibody test is not yet available. And I think it will become positive after PCR test (please correct me I am wrong, I am not confident while making this statement)

    Will I do a Laparoscopic / Robotic Surgery?

    Yes, if I am highly skilled in that surgery. (If clarification is needed on this point, please let me know, I will make another detailed statement like this)




    1.      Mano R, Vertosick EA, Hakimi AA, Sternberg IA, Sjoberg DD, Bernstein M, Dalbagni G, Coleman JA, Russo P. The effect of delaying nephrectomy on oncologic outcomes in patients with renal tumors greater than 4 cm. InUrologic Oncology: Seminars and Original Investigations 2016 May 1 (Vol. 34, No. 5, pp. 239-e1). Elsevier.

    2.      Jewett MA, Mattar K, Basiuk J, Morash CG, Pautler SE, Siemens DR, Tanguay S, Rendon RA, Gleave ME, Drachenberg DE, Chow R. Active surveillance of small renal masses: progression patterns of early stage kidney cancer. European urology. 2011 Jul 1;60(1):39-44.

    3.      https://cddep.org/wp-content/uploads/2020/03/covid19.indiasim.March23-2-eK.pdf

    4.      https://www.thelancet.com/action/showPdf?pii=S2589-5370%2820%2930075-4

    5.      Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. Jama. 2020 Feb 24.

    6.      https://www.covid19india.org/


  • Dr. Anil Takvani
    Dr. Anil Takvani
    11 Apr 2020 08:19:16 AM


    Excellent comments...Thanks
    Seeking many more experts to share their comments...

You want to add your comment? Please login