An 86-year-old retired construction worker with no previous medical or surgical history consulted for occasional episodes of dizziness.
Physical examination revealed an irregular pulse of 92 per minute, blood pressure of 110 / 80, normal cardio-pulmonary examination and a BMI (Body Mass Index) of 26.
Abdominal examination revealed a painless right flank mass displacing with respiratory movements.
Preoperative evaluation showed an electrocardiogram with complete arrhythmia due to atrial fibrillation, normal blood count with sedimentation rate of 36 mm/hr, creatinine of 1.03 mg/dl, albumin and normal total proteins, and liver function.
Abdominal computed tomography showed a multilocular cystic mass of 12 cm in diameter in the lower pole of the right kidney.
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With the diagnosis of right renal tumor, the risks of surgery are discussed with the patient and family, who accept the procedure.
Three weeks after diagnosis, a hand-assisted laparoscopic radical nephrectomy was performed, indicated by the tumor mass volume.
The surgical procedure is carried out with the placement of 4 precautions.
Two of 10 mm, one right subcostal and another right pararectal, at the level of the defect, the latter for the introduction of the camera.
Two 5-mm epigastrium stents are installed to separate the liver.
The surgeon's hand is introduced through an oblique incision in the right iliac fossa.
The adrenal gland was resected radically.
The kidney is placed in a polyethylene bag and removed through the incision of the iliac fossa.
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The surgical time was 100 minutes, with estimated bleeding less than 100 ml.
There were no intraoperative or postoperative hemodynamic changes.
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The immediate postoperative course was uneventful, requiring non-steroidal analgesics (Ketorolaco) for pain control.
The patient was discharged 36 hours after surgery.
At the outpatient follow-up 9 days after surgery, the patient was asymptomatic and her tests showed hemoglobin of 13.7 mg/dl, creatinine of 1.74 mg/dl and urea nitrogen of 23.0 mg/dl.
The biopsy was informed as kidney and perirenal adipose tissue that together weighed 1400 gr. The lower pole was made and in close contact with the kidney was found a 9.5 cm cystic tumor, with an extensive yellowish-haemoric capsule.
On the periphery of the tumor, well-defined, pale yellow adipose-like tumor areas were recognized, which together constituted a 15 cm-diameter tumor and which remained in close contact with the fibro-cm layer.
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Histological examination showed preserved renal parenchyma architecture.
The central tumor myxoid presented malignant hypercellular proliferation, stellate cells, epithelioid, some giant cells, with scarce poorly defined cytoplasm, with irregular nuclei of prominent nucleoli.
In the peripheral portions, the tumor showed a clearly better differentiated adipose appearance with features of mixposarcoma G1-2.
The adipose tumor is separated from the surgical section by a thin layer of fibrous tissue of 1 mm thick.
The pathology report concluded that it was a perirenal mixposarcoma with indifference to myxofibrosarcoma G3 (myxoid variant malignant fibrocytoma).
The patient is currently asymptomatic and with stable renal function after 9 months of surgery.
