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Abstract Background The gold standard treatment for renal cell carcinoma (RCC) with tumor thrombus (TT) is complete surgical excision. The surgery is complex and challenging to the surgeon, especially with large tumor thrombus extending into the inferior vena cava (IVC) and right atrium. Traditionally, these difficult cases required the use of cardiopulmonary bypass (CPB) with or without deep hypothermic cardiac arrest, but in recent years, different surgical techniques derived from the field of liver transplantation have been used in efforts to avoid CPB. Case presentation We present a case of RCC with TT level IIIc (extending above major hepatic veins) that “uncoiled” intraoperatively into the right atrium after division of the IVC ligament, transforming into a level IV TT. Despite the new TT extension, the surgery was successfully completed exclusively through an abdominal approach without CPB and while using intraoperative transesophageal echocardiography (TEE) monitoring and a cardiothoracic team standby. Conclusions This case highlights the need for a multidisciplinary approach and the utility of intraoperative continous TEE monitoring which helped to visualize the change of the TT venous extension, allowing the surgical teamto modify their surgical approach as needed avoiding a catastrophic event.

BackgroundA limiting factor in expanding the kidney donor pool is donor kidneys with renal tumors or cysts. Partial nephrectomy (PN) to remove these lesions prior to transplantation may help optimize organ usage without recurrence of malignancy or increased risk of complications.MethodsWe retrospectively analyzed all recipients of a living or deceased donor graft between February 2009 and October 2022 in which a PN was performed prior to transplant due to the presence of one or more concerning growths. Donor and recipient demographics, perioperative data, donor allograft pathology, and recipient outcomes were obtained.ResultsThirty-six recipients received a graft in which a PN was performed to remove suspicious masses or cysts prior to transplant. Majority of pathologies turned out to be a simple renal cyst (65%), followed by renal cell carcinoma (15%), benign multilocular cystic renal neoplasm (7.5%), angiomyolipoma (5%), benign renal tissue (5%), and papillary adenoma (2.5%). No renal malignancy recurrences were observed during the study period (median follow-up: 67.2 months). Fourteen complications occurred among 11 patients (30.6% overall) during the first 6mo post-transplant. Mean eGFR (± standard error) at 36 months post-transplant was 51.9 ± 4.2 ml/min/1.73 m2 (N = 23). Three death-censored graft losses and four deaths with a functioning graft and were observed.ConclusionPN of renal grafts with suspicious looking masses or cysts is a safe option to optimize organ usage and decrease the kidney non-use rate, with no observed recurrence of malignancy or increased risk of complications.

En bloc pediatric kidney (EBPK) allografts are a potential solution to expand the organ donor pool; however, EBPK transplantation has been traditionally considered suboptimal due to concerns of perioperative vascular and urologic complications. Accidental organ or vasculature injury during harvest is not uncommon; however, this does not necessarily mean that the organ should be discarded. Careful vascular reconstruction can be performed using donor vascular grafts, salvaging the organ without stenosis or thrombosis of the vessels. We report an extensive vascular reconstruction of the right renal artery, aorta, and inferior vena cava of a damaged EBPK allograft using a donor pediatric aorta vascular patch with the goal of avoiding postoperative vascular complications.

Renal cell carcinoma (RCC) is a common malignancy among kidney transplant recipients that often occurs in the native kidney. The incidence of RCC in the renal allograft is rare and carries the double risk of returning to dialysis and the development of metastatic cancer. The majority of reported cases of RCC in transplanted kidneys are in adult recipients and its occurrence in the pediatric age group is an uncommon event. There are currently no established guidelines on the treatment of RCC in transplant recipients.We report our experience of a 15-year-old male who developed allograft RCC 12 years later after transplantation. MRI confirmed the presence of the mass near the hilum of the renal allograft and biopsy revealed a Papillary Renal Cell Carcinoma (PRCC) type I. A partial allograft nephrectomy was successfully performed with negative tumor margins. The patient's serum creatinine 12 months post-operation was 1.9 mg/dL and presently he has no evidence of residual disease, recurrence, or metastasis.Partial nephrectomy is an effective treatment option for renal allograft RCC as it spares the patient from returning to dialysis until retransplantation is possible and necessary.

Renal transplantation is the gold standard treatment for patients with end-stage renal disease (ESRD) as it demonstrates improved long-term survival compared to patients who remain on renal replacement therapy. The widening gap between the demand and supply of organs warrants the expansion of donor criteria for renal transplantation. Kidneys with multiple cysts are often rejected for transplantation. Here, we present our recent experience of a 72-year-old patient with ESRD due to a biopsy-proven diabetic nephropathy who received a deceased donor kidney with adult polycystic kidney disease (APKD). At 31-month posttransplant, he had a serum creatinine of 1.6 mg/dL. Deceased donors affected by APKD should be considered an acceptable option for successful renal transplantation in select recipients, as well as an alternative kidney source to increase the donor pool.