Question

A 30 year old man presents with pain in the right flank and hematuria. A CECT abdomen shows a large 8 x 8 cm solid mass in the right kidney and a 3 x 3 cm solid mass in the upper pole of the left kidney. What is the most appropriate surgical treatment for this patient?

• A. Bilateral radical nephrectomy
• B. Right radical nephrectomy and biopsy of the mass from the opposite kidney
• C. Right radical nephrectomy and left partial nephrectomy
• D. Right radical nephrectomy only

Hint:

Small pole tumor gets nephron sparing surgery; large tumor replacing the kidney gets radical nephrectomy.

Answer 1

The Correct Option is C

Step 1: Identify the disease.
Flank pain, blood in the urine, and two separate solid renal masses on CECT is the classic picture of bilateral renal cell carcinoma. Renal masses that are solid and enhance on contrast CT are treated as cancer until proven otherwise.

Step 2: Apply the rule for bilateral kidney tumors.
With tumors in both kidneys, the surgical plan always tries to leave the patient with functioning kidney tissue on at least one side, since losing both kidneys means dialysis for life. This is why nephron sparing surgery, meaning partial removal of the kidney rather than the whole organ, is preferred whenever the tumor size and position allow it.

Step 3: Judge each mass on its own size.
An 8 x 8 cm mass is large. A tumor of this size usually replaces most of the kidney and cannot be removed with a safe margin while sparing the organ, so the right kidney is removed completely (radical nephrectomy).
A 3 x 3 cm mass at the upper pole is small and sits at one end of the kidney, which is exactly the setting where a partial nephrectomy, cutting out the tumor with a rim of normal tissue and closing the defect, works well and keeps the rest of the kidney functioning.

Step 4: Check why the other choices fail.
Removing both kidneys entirely throws away a kidney that could have been partly saved. Biopsy alone leaves a probable cancer sitting in the left kidney with no definitive treatment. Treating only the right side and ignoring the left mass leaves known cancer behind.

Step 5: State the answer.
Right radical nephrectomy for the large tumor and left partial nephrectomy for the small tumor gives the best balance between clearing the cancer and keeping kidney function.
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