Posted by CLDing on February 15, 1998 at 10:08:26:
In Reply to: Re: Renal & adrenal mass posted by hinwai on February 15, 1998 at 01:29:56:
Gittes showed me how to do parenchymal saving surgery for renal tumour in 1984 at the
Brighams. He was fastidious, he rolled the entire specimen in Indian ink upon removal and
had it sent to the pathologist for sectioning and random as well as what naked eye
dictates, of the surgical margins while he waits in the OT with the patient under, for the
FS report. I just carve out the tumour with about 5mm margin. It is quite amazing that the
renal parenchyma is actually like radiating strands bound tightly together and once the
cortex is incised together with a starting break in the cortex, you can digitally open a
plane centripetally, and quickly bump into any tumour if it crosses that plane - that is
the trick I have developed and used at the time when I was doing a lot of
nephrolithotomies. It has come in handy for the tumour situation. Handling the perinephric
fat in the tumour situation requires some commonsense as well.
I agree with you that doing the easier side first is the way to go for bilateral tumours.
Tomorrow I am going in for the more difficult side. I had done a 2/3 nephrectomy 2 months
ago when she presented with severe hematuria and clot retention and found she had
bilateral tumour one of which had been there for 5 years. She is lymphnode negative on CT
Scan, normal LFT and normal CXR!
Radical nephrectomy as preached by Robson and practised religiously by the late professor
Guliani does not have many other avid followers. Most urologists in real life have their
own variations of radical nephrectomy. It would appear that Guliani's results are a shade
better than the rest of the world (his protege presented his work at the SIU in Sydney in
?1993 - very forgetful, I attended that one). I am not suggesting that we do not do our
radical nephrectomies in a standard manner. I think the minimum is (i.e. if we are going
for radical) Everything within Gerota's fascia and the entire pedicle tissue at the base
of the left renal artery or right renal vein. Personally, I do a very clean dissection on
the right side because it is easier! I actually clean the cava except for the aortocaval
groove! The point which has really stimulated me is why all this bother if parenchymal
saving surgery is showing the same results? Perhaps the number of parenchymal saving
surgeries are inadequate to gauge long term results considering the great biological
variation of renal tumours, and also the early parenchymal saving surgery were all done
for small tumours. Still!!
I think you attitude towards this discussion board is both healthy and desirable. We are
all here to learn and that is necessary for our entire practising life! I have enjoyed
these discussions very much and just wish more would join in. Sometimes I just refrain
from responding for obvious reasons - some out there may be thinking that Chit Sin, you
and I are trying to dominate this board!!