Incidental renal cell carcinoma identified during laparoscopic live-related donor nephrectomy

A 41-year-old man was admitted to hospital to undergo a left laparoscopic live donor nephrectomy. The recipient was his 49-year-old sister with autosomal dominant polycystic kidney disease, and a history of non-Hodgkin’s lymphoma, previously treated with chemotherapy and subsequent stem cell rescue. Preoperative donor work-up had revealed conventional vascular anatomy, with the left kidney contributing 45% to overall function. In addition, a small (7 mm) hypodense lesion was identified in the left kidney which was felt to be a benign cyst (Figure 1). The donor underwent an uncomplicated laparoscopic donor nephrectomy. The operative duration was 110 minutes; the kidney was delivered via a Pfannenstiel incision. During bench preparation of the kidney, it became apparent that the reported lesion was in fact a small solid mass. The decision was made to excise the lesion from the kidney and perform an immediate frozen section. This reported a fully excised papillary renal cell carcinoma (Figures 2a and 2b). The renal defect was closed using a perirenal fat interposition. The recipient underwent urgent counselling concerning the intraoperative findings regarding the donor kidney. Options discussed were discarding of the kidney or proceeding with transplantation. With the latter she was advised that there was a small risk of tumour recurrence and the potential implications of this. After extensive discussions with family she elected to be transplanted with the kidney. The cold-ischaemia time was approximately 180 minutes. Both the recipient and donor were discharged on day 5 without complication. The graft functioned immediately achieving a serum creatinine of 97 umol/L (estimated GFR 55 mL/min). The subsequent paraffin section report revealed a fully excised type 1 papillary renal cell carcinoma, Fuhrman’s Grade 1–2 (T1a). The case was discussed at local and regional multidisciplinary cancer meetings, and it was elected to perform surveillance of donor and recipient with serial ultrasound scanning.