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Renal Cell Carcinoma Invading the Renal Sinus - The Ball Valve Phenomenon: Implications For Nephron Sparing Surgery
Brett D Lebed, Leo R. Doumanian, Bryan Kansas, Robert G Uzzo
Fox Chase Cancer Center, Philadelphia, PA
Introduction: While there have been significant advancements in nephron sparing surgical (NSS) techniques, pre-operative radiographic imaging indicating renal hilar involvement may be a relative contraindication for NSS. We describe the “ball valve” phenomenon, as applied to renal masses invading the renal sinus, and define it as the uncomplicated reduction of a renal mass herniating into, or arises from parenchyma within the renal sinus.
Methods: We reviewed the radiographic and clinical data from 148 consecutive NSS performed by a single surgeon (RGU) and identified 23 with radiographic evidence of tumor “ball valving” the renal sinus. All tumors contacted the renal artery, vein, or pelvicaliceal system within the renal sinus on enhanced imaging. Data regarding outcomes and techniques were analyzed.
Results: NSS was successful in all cases. No cases required vascular reconstruction despite pre-operative imaging suggesting vessel involvement. Median tumor size was 3.5 cm (0.6-19cm). 96% (22/23) had absolute (12/23) or relative (10/23) indications for NSS, including 5 patients with solitary kidneys and 7 with bilateral lesions. Pelvicaliceal repair was required in 9 patients (39%). Median ischemia time was 40 minutes (22-80). Median EBL was 200cc (50-1200). Pathology confirmed RCC in 17/23 patients (74%). No patient required renal replacement. Major post-operative complications occurred in 3 patients.
Conclusions: Recognition of a renal hilar mass “ball valving” or herniating into the renal sinus is essential when planning NSS for complex central lesions. Reduction and dissection of hilar renal masses is associated with minimal intra-operative complications, favorable post-operative outcomes, and can obviate the need for renal replacement therapy.
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