Surgical management of bilateral challenging renal tumors: The knowledge of anatomy drives the decision making

Objective: In 3% of cases renal cell carcinoma (RCC) is diagnosed with synchronous bilateral renal masses. However, until today, the optimal treatment strategies for these patients remain unknown.In clinical practice bilateral partial nephrectomies (PNs) are the treatment of choice because of the functional advantage relative to radical nephrectomy. Aim of the study is to show how the availability of such three-dimensional virtual model (3DVM) can be helpful in planning the surgical strategy in a challenging clinical case of bilateral highly complex renal masses.Patients and surgical procedure: one patient with high complexity bilateral renal masses (PADUA 13) was selected from our Institutional database. The patient underwent contrast-enhanced CT from which a 3DVM was obtained. Using such technological tool, it was possible to set the surgical strategy considering the anatomical details of the organ, leading the surgeon to plan synchronous right robot-assisted radical nephrectomy (RARN) and the sacrifice of the upper portion of the left kidney in light of its irrelevant contribution to the postoperative global renal function even if spared. Results: Operative time were 80 min and 148 min, for robot assisted partial nephrectomy and RARN, respectively. Total estimated blood loss was 350 ml with an ischemia time of 23.4 min. No intraoperative or postoperative complications have been recorded. At final pathological examination both kidneys presented a pT3a clear cell RCC. No positive surgical margins were recorded. DJ stent was removed 45 days after surgery. The patient was treated with dialysis for 6 months after surgery. One year later, serum creatinine level was 2.2 mg/dl, with an eGFR of 33%. No further dialytic sessions were needed. Conclusions: The use of 3DVMs, even if in case of extreme surgeries such as a synchronous radical and partial nephrectomy, allows to plan the most effective surgical strategy, well balancing the risk of complications with the postoperative recovery of the renal remnant.