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Angiomyolipoma (AML) is a benign renal tumour that occasionally requires intervention. We evaluated the surgical management of symptomatic angiomyolipoma, with special attention to the feasibility of nephron-sparing surgery. A retrospective study was conducted enlisting 23 patients (including 3 patients with tuberous sclerosis) who had their AML treated surgically from 1991 to 1998. The study included 7 males and 16 females, with a mean age of 49 years (range 24-75). The mean tumour size was 12.3 cm (range 1.5-30.0) including 7 lesions < or = 4 cm and 16 lesions > 4 cm. The presenting features included abdominal/loin pain (9 patients), spontaneous rupture (5 patients), non-specific symptoms (7 patients) and incidental findings (2 patients). AML was diagnosed by computed tomography in 16 patients and malignancy was suspected in 7 patients. The latter group included 5 patients with lesions smaller than 4 cm, one of them having coexisting AML and renal cell carcinoma. All patients underwent elective surgery, with the exception of one, who required a semi-emergency operation. Nephron-sparing surgery using frozen section in 5 patients (all diagnostic) was carried out on 16 patients, including all 5 patients with previous haemorrhage and 2 patients with suspected lesions from preoperative studies. Total nephrectomy was performed in 7 patients, including the other 5 patients with lesions suspected to be malignant. There was no operative mortality. Two complications were encountered in the entire group. We conclude that elective nephron-sparing surgery is feasible, even for massive angiomyolipoma or after previous rupture, especially when the diagnosis is made by preoperative imaging and/or intraoperative frozen section.

It has been found that patients suffering from chronic renal failure (CRF) are prone to develop acquired cystic kidney disease, which may subsequently lead to the development of renal cell carcinoma (RCC). We reviewed 250 consecutive cases of RCC diagnosed between January 1990 and June 1998 in our department and found 19 had associated CRF (7.6%). Their clinical presentation, mode and duration of dialysis, diagnostic evaluations, pathological stage and surgical outcome were reviewed. Sixteen had CRF with chronic glomerulonephritis and 3 with adult polycystic kidney disease. Three patients were on continuous ambulatory peritoneal dialysis (CAPD), 5 were on haemodialysis (HD) and 3 had renal transplant (2 on HD, 1 on CAPD previously). The remaining 8 patients were not on renal replacement therapy at the time of diagnosis. Ten patients were asymptomatic with incidental radiological findings while 9 had specific urological symptoms, most commonly haematuria. Ultrasonography (USG) and computed tomography (CT) scan were the main modalities of imaging employed. Nine out of the 10 asymptomatic patients had suspicious lesions detected incidentally by USG. All had subsequent preoperative CT scans confirming the presence of these lesions. All patients had single focus RCC except for 1 with multi-focal disease involving both kidneys. Sixteen patients had early stage (T1 or T2) and low grade (G1 or G2) RCC. The remaining 3 patients had advanced stage (T3a or T3b) and high grade (G3) tumours. Since half of the patients were asymptomatic, USG may be a useful tool in the outpatient review of patients with CRF and allow early diagnosis and surgical treatment of early stage, low-grade tumours and therefore may have better survival.

Up to 10% of patients with renal cell carcinoma have intracaval neoplastic extension. The results of nephrectomy and caval cavotomy to remove the renal tumour and caval thrombus were reviewed. From September 1991 to October 1997, 16 consecutive patients (13 males, 3 females) with a mean age of 59 years (range 45 to 75 years) underwent radical nephrectomy together with cavotomy and thrombectomy (15) or caval resection (1). The tumour thrombi extended to the infrahepatic vena cava in 9 patients, intrahepatic cava in 5 and suprahepatic cava in 2. The surgical approaches included abdominal (8), right thoraco-abdominal (5) and abdominal with median sternotomy (3), respectively; cardiac bypass was not required. The mean cava clamp time was 15 minutes and the average operative time was 127 minutes (range 70 to 190 minutes). There was no operative mortality but the complication rate was 31%. The mean hospital stay was 12 days (range 7 to 23 days). Ten patients had Robson's stage IIIa disease, 4 had stage IIIc disease and 2 had stage IV disease. During a mean follow up of 20 months (range 1 to 54 months), 6 patients were alive with no recurrence and 10 patients had died of the disease. The survival of stage IIIa patients was significantly better than stage IIIc and IV patients. In summary, caval thrombectomy is associated with acceptable operative morbidity and mortality; however, advanced staged disease dictates a short survival.

From January 1991 to August 1998, 220 radical nephrectomies were performed for renal cell carcinoma (RCC). During the same period, 27 patients underwent partial nephrectomy for their renal tumours. These included 19 male and 8 female (mean age, 54; range, 35-75). Their clinical presentation, diagnostic modalities and surgical outcome were evaluated. The lesions included 18 RCCs, 7 angiomyolipomas (AMLs), 1 oncocytoma and 1 dysoncogenetic renal tumour. Only 8 patients had specific urological symptoms. Computerised tomography (CT) scan was diagnostic in 78% of cases. Tumour size ranged from 15-50 mm for RCC and 30-190 mm for AML, respectively. Operative time averaged 92 minutes (range: 35-145). The hospital stay ranged from 3 to 25 days (mean 11). Complications occurred in four cases (14.8%); there was one death (3.7%). No tumour recurrence was detected during a mean follow up of 20 months. None of the patients developed significant renal impairment. Partial nephrectomy is feasible in small RCC and some large AML, and can be offered in selected patients.

A 50-year-old Indian man presented with non-specific right-sided abdominal pain. Ultrasound of the abdomen demonstrated a small right renal tumour. Computed tomography showed features suggestive of a benign renal oncocytoma. This was confirmed by frozen section during surgical exploration. A partial nephrectomy was carried out. The role and limitations of imaging in the management of solid renal masses is discussed.

Renal cell carcinoma is a malignant tumour that involves the vena cava in 4% to 10% of patients undergoing radical nephrectomy. Of these only a third to half presented with symptoms of vena caval involvement. We present a case of renal cell carcinoma with vena caval involvement that presented with just a swollen right leg. The patient was staged and had a nephrectomy and resection of the inferior vena cava. Due to extensive collateral venous drainage renal function was not compromised and he was discharged well.

A retrospective analysis of all primary upper urinary tract tumours (300) filed in the pathology department of a regional hospital in Hong Kong during 1972-87 showed that renal cell carcinoma (143) was the commonest malignant tumour. Transitional cell carcinoma of the renal pelvis (62) was the next most frequent. Fibromas, which occurred as frequently as angiomyolipomas (28) and outnumbered tumours such as squamous cell carcinoma (13) and nephroblastoma (12), were of little clinical significance since they were invariably incidental findings. Nephrectomies were seldom performed for kidneys involved in secondary malignancies. Rare tumours encountered were adenocarcinoma of the renal pelvis, leiomyosarcoma, malignant fibrous histiocytoma, adenoma, oncocytoma, mesoblastic nephroma and multilocular cystic nephroma. Angiomyolipomas were responsible for most cases of surgical emergency.

From 1970 to 1985 we treated 144 cases of malignant tumors of the kidney. Of these patients only 11 (8 per cent) had squamous cell carcinoma of the renal pelvis compared to transitional cell carcinoma of the renal pelvis in 53 per cent, renal cell carcinoma in 37 per cent and other types in 2 per cent. In all patients the squamous cell carcinoma was associated with chronically infected staghorn renal calculi of long duration. The patients usually presented late with extensive local infiltration, making surgical resection difficult. In addition, poor response to surgery, radiotherapy and chemotherapy resulted in a poor prognosis and short survival. A summary of our cases and a review of the literature are presented.