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Bolster material granuloma masquerading as recurrent renal cell carcinoma following partial nephrectomy

View Article: PubMed Central - PubMed

ABSTRACT

Nephron sparing surgery has seen a phenomenal rise in its application over the past few decades. The use of Surgicel and gel foam for closure of defect created after partial nephrectomy has become a routine practice at many centers. In this case report, we describe radiological artifact secondary to a surgical bolster mimicking a residual disease or an early recurrence in the kidney. This case highlights two facts; first, reapproximation of the renal tissue is best done without the use of Surgicel bolsters. Second, bolsteroma should always be kept in mind as a differential diagnosis in a case where computed tomography (CT) imaging is showing early recurrence. If the surgeon is sure about the surgical margins being negative and the CT image shows a bolsteroma, the patient should be observed and a repeat scan should be done at 3–6 months, which would show regression or disappearance of the lesion proving it to be an artifact rather than malignant lesion.

No MeSH data available.


Intraoperative pictures. (A) Sutured edges of renal parenchyma with Surgiflo™ instilled over it. (B) The suture line being covered by Surgicel™. (C) The completed suture line with Surgiflo™ being put over Surgicel™
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Figure 2: Intraoperative pictures. (A) Sutured edges of renal parenchyma with Surgiflo™ instilled over it. (B) The suture line being covered by Surgicel™. (C) The completed suture line with Surgiflo™ being put over Surgicel™

Mentions: Patient was planned for a left-sided partial nephrectomy because the left-sided disease was larger in size and potentially more aggressive. The right-sided tumor was planned for management subsequently. Patient underwent a left robotic partial nephrectomy using a Da Vinci Si™ (Intuitive surgical Sunnyvale, CA) platform. After port placement, robot was docked, colon was reflected, and the kidney was exposed. Renal artery and vein were dissected, and after doing an intraoperative ultrasound, tumor was marked with electrocautery. Renal artery was clamped using a bulldog clamp and tumor was excised with robotic scissors keeping a margin of healthy tissue. Intraoperative ultrasound and frozen section were used to ensure that the cut margins were free of tumor. Warm ischemia time was 21 min and defect in the renal parenchyma was sutured with Vicryl 1™ (Ethicon) on CT 1 needle over Surgicel bolsters using sliding renoraphy technique and synched with a Hem-o-lok™ (Teleflex) clip. After renoraphy, SurgifloTM haemostatic matrix (Ethicon), which is absorbable porcine gelatin paste, was put over the sutured surface of kidney for hemostasis [Figure 2A–C]. Perurethral catheter, ureteric catheter, and drain were placed. Perurethral catheter and ureteric catheters were removed on postoperative day 3 and drain was removed on postoperative day 4. Postoperative recovery was uneventful. Histopathology of the mass came out to be clear cell carcinoma, clinical stage was T1b Nx, and it was a Furman grade 2 tumor. Tumor had no lymphovascular invasion and all margins were free of tumor [Figure 3A and B].


Bolster material granuloma masquerading as recurrent renal cell carcinoma following partial nephrectomy
Intraoperative pictures. (A) Sutured edges of renal parenchyma with Surgiflo™ instilled over it. (B) The suture line being covered by Surgicel™. (C) The completed suture line with Surgiflo™ being put over Surgicel™
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5036333&req=5

Figure 2: Intraoperative pictures. (A) Sutured edges of renal parenchyma with Surgiflo™ instilled over it. (B) The suture line being covered by Surgicel™. (C) The completed suture line with Surgiflo™ being put over Surgicel™
Mentions: Patient was planned for a left-sided partial nephrectomy because the left-sided disease was larger in size and potentially more aggressive. The right-sided tumor was planned for management subsequently. Patient underwent a left robotic partial nephrectomy using a Da Vinci Si™ (Intuitive surgical Sunnyvale, CA) platform. After port placement, robot was docked, colon was reflected, and the kidney was exposed. Renal artery and vein were dissected, and after doing an intraoperative ultrasound, tumor was marked with electrocautery. Renal artery was clamped using a bulldog clamp and tumor was excised with robotic scissors keeping a margin of healthy tissue. Intraoperative ultrasound and frozen section were used to ensure that the cut margins were free of tumor. Warm ischemia time was 21 min and defect in the renal parenchyma was sutured with Vicryl 1™ (Ethicon) on CT 1 needle over Surgicel bolsters using sliding renoraphy technique and synched with a Hem-o-lok™ (Teleflex) clip. After renoraphy, SurgifloTM haemostatic matrix (Ethicon), which is absorbable porcine gelatin paste, was put over the sutured surface of kidney for hemostasis [Figure 2A–C]. Perurethral catheter, ureteric catheter, and drain were placed. Perurethral catheter and ureteric catheters were removed on postoperative day 3 and drain was removed on postoperative day 4. Postoperative recovery was uneventful. Histopathology of the mass came out to be clear cell carcinoma, clinical stage was T1b Nx, and it was a Furman grade 2 tumor. Tumor had no lymphovascular invasion and all margins were free of tumor [Figure 3A and B].

View Article: PubMed Central - PubMed

ABSTRACT

Nephron sparing surgery has seen a phenomenal rise in its application over the past few decades. The use of Surgicel and gel foam for closure of defect created after partial nephrectomy has become a routine practice at many centers. In this case report, we describe radiological artifact secondary to a surgical bolster mimicking a residual disease or an early recurrence in the kidney. This case highlights two facts; first, reapproximation of the renal tissue is best done without the use of Surgicel bolsters. Second, bolsteroma should always be kept in mind as a differential diagnosis in a case where computed tomography (CT) imaging is showing early recurrence. If the surgeon is sure about the surgical margins being negative and the CT image shows a bolsteroma, the patient should be observed and a repeat scan should be done at 3–6 months, which would show regression or disappearance of the lesion proving it to be an artifact rather than malignant lesion.

No MeSH data available.