Question

A 30 year old man presents with pain in the right flank and hematuria. A CECT abdomen shows a large 8 x 8 cm solid mass in the right kidney and a 3 x 3 cm solid mass in the upper pole of the left kidney. What is the most appropriate surgical treatment for this patient?

• A. Bilateral radical nephrectomy
• B. Right radical nephrectomy and biopsy of the mass from the opposite kidney
• C. Right radical nephrectomy and left partial nephrectomy
• D. Right radical nephrectomy only

Hint:

Small pole tumor gets nephron sparing surgery; large tumor replacing the kidney gets radical nephrectomy.

Answer 1

The Correct Option is C

Step 1: Read the imaging picture.
The patient has flank pain and blood in the urine, and the scan shows a solid mass in each kidney: a large 8 x 8 cm mass on the right and a small 3 x 3 cm mass at the upper pole of the left kidney. Two separate solid enhancing renal masses in this setting point to bilateral renal cell carcinoma (RCC), the most common kidney cancer in adults.

Step 2: Set the treatment goal.
When both kidneys carry a tumour, the surgeon has to remove all the cancer while keeping as much working kidney tissue as possible. Taking out both kidneys completely would leave the patient with no native kidney function and force lifelong dialysis, so that option is used only when there is no other way to clear the tumour.

Step 3: Match each side to the right operation.
The right mass is large, at 8 x 8 cm, and likely takes up most of the kidney, so a nephron sparing operation is not safe there. A radical nephrectomy (removal of the whole kidney with the tumour) is done on the right.
The left mass is small, at 3 x 3 cm, and sits at the upper pole, which usually leaves enough normal kidney around it. A partial nephrectomy (removing just the tumour with a margin of normal tissue) can be done here, saving the rest of the left kidney.

Step 4: Rule out the other options.
Bilateral radical nephrectomy removes both kidneys entirely, which is not needed since the left mass is small enough for a kidney sparing operation, and it condemns the patient to dialysis. Biopsy of the left mass without removing it does not treat a solid mass that already looks malignant on CECT, it only confirms what imaging has already shown. Doing right radical nephrectomy alone and leaving the left mass untouched abandons a tumour that also needs surgical treatment.

Step 5: Final Answer.
The correct plan is to remove the whole right kidney and spare as much of the left kidney as possible.
\[ \boxed{\text{Right radical nephrectomy and left partial nephrectomy}} \]