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CASE REPORT
Year : 2006  |  Volume : 22  |  Issue : 2  |  Page : 150-151
 

Port site metastasis of renal cell carcinoma after laparoscopic transperitoneal radical nephrectomy


Departments of Urology and Renal Transplant, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Correspondence Address:
Anant Kumar
Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.26575

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   Abstract 

Laparoscopic radical nephrectomy is a safe and oncologically appropriate treatment modality for patients with renal cell carcinoma.[1] Till date, there are only 3 cases of port site metastasis reported after laparoscopic radical nephrectomy for renal cell carcinoma. We herein report another case of port site recurrence after transperitoneal radical nephrectomy for a 5 cm renal tumor.


Keywords: Laparoscopy; metastasis, renal cell carcinoma


How to cite this article:
Goyal R, Singh P, Mandhani A, Kumar A. Port site metastasis of renal cell carcinoma after laparoscopic transperitoneal radical nephrectomy. Indian J Urol 2006;22:150-1

How to cite this URL:
Goyal R, Singh P, Mandhani A, Kumar A. Port site metastasis of renal cell carcinoma after laparoscopic transperitoneal radical nephrectomy. Indian J Urol [serial online] 2006 [cited 2019 Aug 18];22:150-1. Available from: http://www.indianjurol.com/text.asp?2006/22/2/150/26575



   Case Report Top


A 16 year male child, a known case of juvenile rheumatoid arthritis (JRA), presented with hematuria and fever of one month duration. On evaluation, he was found to have a 5 x 5 cm central, solid mass in the right kidney with no lymph nodes and renal vein thrombosis. Transperitoneal laparoscopic radical nephrectomy was performed and at the time of clipping the hilar vessels, an accessory artery got avulsed, resulting in uncontrolled bleeding and decision to convert for open surgery. Flank incision was given by joining the subcostal and epigastric port and the procedure was completed uneventfully, except that the patient had few hilar lymph nodes, the largest one measuring 2 cm, which was missed on contrast enhanced computed tomography (CECT). Inspection of the specimen did not reveal any gross violation of surgical planes. Histopathology revealed clear cell renal cell carcinoma, extending into the perinephric fat with Fuhrman's grade III. Cut margins at the tumor site were free. One out of 8 lymph nodes was positive for malignancy.

The patient was on regular follow up with 3 monthly chest X-ray, liver function tests and hemogram. 7 months after the surgery, he presented with abdominal swelling of 15 days duration. CECT revealed recurrence at renal fossa, in the boney pelvis and at the umbilicus; through which a camera port was inserted [Figure - 1]. Fine needle aspiration cytology from the port site and the pelvic mass revealed malignant cells consistent with metastatic renal cell carcinoma. There was no recurrence at the site of surgical incision of conversion.


   Discussion Top


Metastasis to the port site is a relatively rare event after laparoscopic urological procedures. Only 11 cases have been reported so far.[1],[2] There are various factors hypothesized for the etiology of port site tumor recurrence like natural tumor behavior, immune factors, local wound factors and laparoscopy- related factors such as leakage of gas from port site (chimney effect), specimen morcellation and tumor handling.[3],[4] Of all the factors mentioned above, aggressive nature of the tumor appears to be most important factor affecting the outcome.[1] Our patient was a child and had a T 3 N 1 M 0 disease which relates to adverse tumor biology. Immunosuppression was another important factor, as this patient was already receiving steroids for rheumatoid arthritis In this case; laparoscopy could be attributed to the port site recurrence, as there was no recurrence at the site of incision [Figure - 2]. Intra abdominal pressure due to CO 2 use might have caused implantation of tumor cells under pressure along the port site and not at the site of incision of conversion, which was given in the last.

Port site metastasis seems to be a multifactorial phenomenon with an undetermined incidence. The suggested preventive steps are, avoiding laparoscopic surgery when ascites is present, proper trocar fixation to prevent dislodgment, avoiding gas leakage along and around the trocar, minimal handling and honoring surgical planes, using a bag for specimen removal, placing drainage when needed before desufflation and povidone-iodine irrigation of trocars and port site wounds.


   Editorial comments Top


This case report highlights the importance of careful followup in urological cancers as regards to laparoscopy. In our enthusiasm to remove everything laparoscopically one must pause and think about the long term consequences. Though the case reported here had a clear indication for laparoscopic radical nephrectomy but turned out to be pathologically T3N1 highlighting the limitations current imaging modalities for staging RCC. Patient developed port site recurrence within seven months and may be attributed to the aggressive behaviour of the tumour but the site of metastasis to the port should make us ponder over extending indications of laparoscopic radical nephrectomy to T2 tumours and beyond. One must always remember that what may be technically feasible may not be the best treatment option and one should exercise caution and not compromise on the basic objective of the treatment.

 
   References Top

1.Rassweiler J, Tsivian AA, Kumar R, Lymberakis C, Schulze M, Seeman O, et al . Oncological safety of laparoscopic surgery for urological malignancy: Experience with more than 1,000 operations. J Urol 2003;169:2072-5.  Back to cited text no. 1    
2.Tsivian A, Sidi AA. Port site metastases in urological laparoscopic surgery. J Urol 2003;169:1213-8.  Back to cited text no. 2  [PUBMED]  
3.Matusi Y, Hiroki O, Kentaro I, Terada N, Yoshimura K, Terai A. Abdominal wall metastasis after retroperitoneoscopic assisted total nephroureterectomy for renal pelvic cancer. J Urol 2004;171:793  Back to cited text no. 3    
4.Highshaw RA, Lopez FV, Jonasch E, Yasko AW, Matin SF. Port site metastasis: the influence of biology. Eur Urol 2005;47:357-60.  Back to cited text no. 4    


    Figures

  [Figure - 1], [Figure - 2]

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2 F-18 FDG PET Findings in a Port Site Recurrence After Laparoscopic Radical Nephrectomy in a Patient With Renal Cell Carcinoma
Gaurav Malhotra,Narendra Nair,Amit Abhyankar,Sushama Awasare,Surendra H. Moghe
Clinical Nuclear Medicine. 2008; 33(2): 146
[Pubmed] | [DOI]



 

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