Management of Renal Carcinoma During Pregnancy

Renal carcinoma during pregnancy is rare. Only 1 of 500 women who will need some type of non-obstetrical abdominal surgery during pregnancy, with most cases involving acute appendicitis or cholecystitis, followed by ovarian masses, symptomatic hernias, and other rare illnesses.

Authors of a recent review article published in Clinical Genitourinary Cancer focused on the laparoscopic treatment of renal cell cancer during pregnancy.

Treatment
Laparoscopic treatment during pregnancy is becoming an option for more women. 

Either radical nephrectomy or nephron-sparing surgery is necessary in patients with renal cell cancer. Even with metastatic disease, radical nephrectomy is done in advance of systemic therapy. In those with T1 stage tumors, nephron-sparing surgery is recommended.

Patients who have renal masses that cannot be treated with nephron-sparing surgery should receive laparoscopic radical nephrectomy, per the European Association of Urology. The authors pointed out that considering there have been only a small number of cases involving radical nephrectomy in pregnancy, there are even fewer cases involving nephron-sparing surgery, thus leaving little data for study.

Historically, laparoscopy during pregnancy has been considered dangerous and to be avoided at all costs due to concerns over miscarriage, teratogenesis, preterm birth, and hypercapnia. With advances in surgical instrumentation and skills, however, this notion has been dispelled. Today, laparoscopic urologic surgery is more common-even in pregnancy.

Experts recommend that for non-emergent surgical treatments during pregnancy, surgery be done during the second trimester, so to minimize risks of spontaneous abortion during the first trimester and preterm labor during the third trimester.

“This has led some authors to suggest delaying surgery until the second trimester and that the gestational age limit for successful completion of laparoscopic surgery during pregnancy should be 26 to 28 weeks,” wrote the reviewers.

Approach
Two approaches examined by the reviewers include the transperitoneal approach and the retroperitoneoscopic approach.

“The choice of the laparoscopic approach depends on the surgeon and his laparoscopic experience. Selected tumors may be approached by either route or the other, according to the surgeons’ preference, the location, and technical complexity of the renal mass,” wrote authors, led by Lucio Dell’Atti, Department of Urology, University Hospital “Ospedali Riuniti” and Polythecnic University of Marche Region, Ancona, Italy.
The transperitoneal approach has usually been employed for anterior or lateral masses. Advantages of the transperitoneal route include a larger work space resulting in wider angulation and maneuverability with instrumentation, as well as increased orientation with respect to anatomic landmarks. One disadvantage of this approach is that it necessitates bowel mobilization to uncover the kidney.

The retroperitoneoscopic approach has usually been employed with posterior, posteromedial, or posterolateral renal tumors. Advantages of this approach include the avoidance of bowel mobilization and the provision of direct access to the kidney and renal vessels. Disadvantages of this approach include a smaller retroperitoneal working space, as well as a compromised view.

Robotic-assisted laparoscopic partial nephrectomy
“There is evidence observed in the literature that shows the successful implementation of robotic-assisted laparoscopic partial nephrectomy,” wrote the authors.

Lastly, the authors cited a 2007 case that resulted in no complications as support for the safety and feasibility of laparoscopic nephroid-sparing surgery.