RENAL DYSFUNCTION ASSOCIATED WITH STAGED BILATERAL PARTIAL NEPHRECTOMY: THE IMPORTANCE OF OPERATIVE POSITIONING

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Abstract
Remnant kidneys may be susceptible to injury during positioning for a contralateral flank incision. We document renal dysfunction in a remnant kidney after staged partial nephrectomies. We review a case of renal dysfunction associated with staged bilateral partial nephrectomy. Pertinent data and radiographic findings are presented. A man with multiple bilateral solid enhancing renal masses underwent left partial nephrectomy, resulting in sparing of 50% of the renal parenchyma. Postoperatively nuclear renography showed excellent flow and 33% function on that side. Right partial nephrectomy was then performed via the standard flank approach through the bed of the 11th rib, sparing 50% of the renal parenchyma. Cold ischemia time was 40 minutes. Serum creatinine increased to 4.9 mg./dl. within 48 hours. Nuclear renography immediately postoperatively showed poor flow and 13% function in the left kidney. Limited published data imply detrimental hemodynamic and myocutaneous consequences due to use of the kidney rest. Table flexion with elevation of the kidney rest may also cause ischemic damage in a previously operated contralateral kidney. Careful positioning is critical for preventing undue injury to the remnant kidney and in such cases elevation of the kidney rest should be avoided. Alternatively stage 2 may be approached via an anterior incision.