Page 525 - Read Online

Page 2 of 6 Naspro et al. Mini-invasive Surg 2021;5:50 https://dx.doi.org/10.20517/2574-1225.2021.77

INTRODUCTION
Renal-cell carcinoma (RCC) accounts for about 2% of all cancers. Up to 30% of patients experience
[1]
metastasis at diagnosis or during follow-up . The most common localizations of RCC metastasis are lung,
liver, bone, adrenal, brain, and nodes. Late single metastatic RCC recurrence, more than 10 years after
nephrectomy, in ipsilateral or contralateral adrenal gland is a rare event reported in 3% and 0.7% of
[2]
remaining kidney units, respectively . In the case of single metastasis or recurrent disease, surgery can be
considered as a treatment option in those patients who have a favorable risk profile and in whom complete
resection is achievable . The surgical approach must be chosen according to the patient’s characteristics,
[3]
size of the lesion, and surgeons’ expertise . Nowadays, minimally invasive surgery is the gold standard for
[4]
the treatment of urological malignancies, and many techniques are being developed in order to reduce
surgical morbidity as much as possible. In particular, laparoscopic adrenalectomy series in the literature
[4]
show low morbidity and complication rates in addiction to short hospital stays . Moreover, the
retroperitoneoscopic approach and single-port approaches have shown equivalent or favorable
[3-4]
perioperative outcomes to be a justified alternative for advanced surgeons . We present a case report of a
70-year-old male who underwent retroperitoneoscopic single-site left adrenalectomy for adrenal RCC
metastasis 20 years after laparotomic adical nephrectomy for cell renal-cell carcinoma (CRCC).

The aim of our work is to show the practicability of 3D retroperitoneoscopic single-site retroperitoneal
adrenalectomy after previous homolateral renal surgery.

CASE REPORT
We present a 70-year-old Caucasian male with a history of hypertension, benign prostatic hyperplasia, and
previous B-cell lymphoma with negative follow-up. In May 1999, he underwent laparotomic left RN for a
10 cm CRCC of middle/lower pole of the left kidney with thrombosis of the left renal vein and peri-renal
fatty tissue invasion (pT3b N0); no ipsilateral adrenalectomy was performed at that time due to surgeon’s
preference. The patient was thereafter followed for 10 years according to the renal cancer European
[1]
Association of Urology (EAU) guidelines .In May 2019, due to a lateral cervical mass, the patient
underwent left lateral cervical lymph node dissection with diagnosis of stage IA G3 B-cell lymphoma and
was subsequently treated with local radiation therapy. In September 2019, a CT scan performed for routine
lymphoma follow-up revealed an inhomogeneous left adrenal solid expansive lesion of 30 mm × 20 mm
[Figure 1]. A multi-disciplinary meeting with hematologists, oncologists, and endocrinologists was
scheduled, and indication to surgery, with diagnostic and curative intent, was proposed. In consideration of
the previous surgery and of the localization of the mass, a retroperitoneal approach was chosen; moreover,
the retroperitoneoscopic single-site technique was considered to reduce morbidity.

Surgical procedure
In November 2019, the patient underwent left retroperitoneoscopic single-site adrenalectomy. Utilizing a
left lateral decubitus position, a 2.5 cm lateral incision was made [Figure 2] at the tip of the twelfth rib,
through which a single-site gel port (GelPOINT® Advanced Access Platform, Applied Medical, Rancho
Santa Margarita, CA, USA) was inserted [Figure 2]. The retroperitoneal operating space was created with an
air inflating balloon as previously described . A standard 10 mm, 0-degree 3D laparoscopic camera [Image
[5]
1 S TM 3D (Karl Storz, Tuttlingen, Germany)] was used throughout the procedure in addition to standard
and bent single-port laparoscopic 5 mm instruments. The caiman® 5 (Braun Vetcare, 78532 Tuttlingen,
Germany) was used for dissection and vessel sealing. The adrenal gland was identified and bluntly isolated
from the psoas, posteriorly and inferiorly from the colon. The left adrenal vein was identified, isolated, and
secured using 5 mm polymer clips. The specimen was removed within a retrieval bag, and a 20-Fr drainage
was placed in the lateral part of the incision [Figure 3].