Laparoscopic nephrectomy for angiomyolipoma with radiologic appearance of suspected Grawitz tumor on the left kidney of a 42-year-old woman: a case report

Laparoscopic nephrectomy for angiomyolipoma with radiologic appearance of suspected Grawitz tumor on the left kidney of a 42-year-old woman: a case report

Kurnia Penta Seputra^1,&, Astarin Ardiani¹

¹Department of Urology, Faculty of Medicine, Brawijaya University-Saiful Anwar Hospital Malang, East Java, Indonesia

^&Corresponding author
Kurnia Penta Seputra, Department of Urology, Faculty of Medicine, Brawijaya University-Saiful Anwar Hospital Malang, East Java, Indonesia

Introduction    

Angiomyolipoma is a benign renal neoplasm composed of fat, vascular and smooth muscle elements. It has an incidence of about 0.3-3%. Most small angiomyolipoma lesions are asymptomatic and are found incidentally on imaging studies, while renal cell carcinomas (RCC) are primary malignant adenocarcinomas derived from the renal tubular epithelium, and are the most common type of malignant renal tumor [1, 2]. In images, they have a variety of radiographic appearances, from solid and relatively homogeneous to markedly heterogeneous with areas of necrosis, cystic change, and hemorrhage. These types of renal tumor can look similar to one another in an imaging study until proved to be different by pathological anatomical appearance [3]. Management of tumors can be operative or nonoperative. A tumor suspected of being malignant is treated as a malignant tumor, and a resectable tumor can be treated with open surgery or minimally invasive surgery such as laparoscopy. Minimally invasive surgery has many benefits compared to open surgery, including the length of hospital stay, the need for transfusion during or after surgery, postoperative wound scarring, and recovery time [4]. This case report aimed to report the feasibility and outcome of a laparoscopic approach in treating benign or malignant renal tumors.

Patient and observation     

A 42-year-old woman came to the urology clinic at Saiful Anwar General Hospital as a referral from the Nephrology Department of Internal Medicine in the same hospital, with a chief complaint of abdominal discomfort. The patient had experienced abdominal discomfort for 2 years, but the condition had worsened in the previous 6 months; the pain usually lasted the whole day and worsened when doing the activity. She also complained of left flank pain that radiated to the lower front of the abdomen. There was no history of hematuria, stone expulsion or flank mass. Her general state and vital signs were within normal limits. Physical examinations revealed left flank pain during percussion. Laboratory findings were within normal limits. Abdominal ultrasound revealed a homogenous mass in the left suprarenal region, suspected of being a neoplasm (Figure 1). An abdominal CT scan with contrast revealed a solid mass with fatty compounds on the upper pole and middle kidney suspected of being an angiomyolipoma with a differential diagnosis of Grawitz tumor or multiple lymphadenopathies, with a bilateral functional adnexal cyst and simple renal cyst of the left kidney (Figure 2). The patient was then diagnosed with a possible Grawitz tumor and underwent a laparoscopic nephrectomy. The dissected kidney was removed from a cut made in the lower abdomen (Figure 3, Figure 4, Figure 5). The patient was discharged from the hospital 3 days later; 3 weeks after the operation, the wound had healed fast, and the patient mobilized very well with minor discomfort from the operation site. We followed up the patient 3 months after the operation; she had no complaint at all and was already back to work and doing normal activities without feeling discomfort in the abdomen.

Discussion     

Angiomyolipoma and RCC are very similar kinds of renal tumor, both consisting of blood vessels and fatty compounds; the difference is that they are benign and malignant tumors, respectively. The gold standard to determine whether a tumor is benign or malignant is by pathological anatomical examination [1]. Although examination such as an imaging study might be able to determine tumor type, there is always some limitation to it, especially if the tumor consists of similar compounds 4.5. In this case, abdominal CT with contrast revealed a mass with fatty compounds on the upper pole and middle kidney, suspicious of angiomyolipoma with a differential diagnosis of Grawitz tumor or multiple lymphadenopathies, with bilateral functional adnexal cyst and simple renal cyst of the left kidney. The suspicion of Grawitz tumor, in this case, was due to the fat content of this tumor being less than is usual for angiomyolipoma; in addition, there were also solid compounds within the fat mass [2-5]. The patient then underwent laparoscopic nephrectomy; this approach was used because all tumors suspected of being malignant are treated as malignant tumors until proven to be benign. There was also a simple cyst within the same kidney, so with this condition, we decided to do nephrectomy as early prevention of spreading of the tumor. Laparoscopy was used because it is a minimally invasive technique for treating both benign and malignant tumors which has a better outcome than open surgery in terms of length of hospital stay, recovery time, the need for transfusion and cosmetic appearance [4]. In this case, both malignant and benign tumors were located in the same kidney; therefore, we used this approach to treat both malignant and benign tumors at the same time.

Conclusion     

A laparoscopic nephrectomy approach is a feasible treatment for removing any kind of operable renal tumor, as an alternative to open surgery, with good postoperative outcomes such as comfortable mobilization, shorter hospital stay, and minimum postoperative scarring.

Competing interests     

The authors declare no competing interests.

Authors´ contributions     

All the authors contributed equally in the data collection and the drafting of the manuscript. All the authors read and agreed to the final manuscript.

Acknowledgments     

All authors thank to 10^th Malang Continuing Urology Education and Saiful Anwar Hospital for facilitating this article.

Figures     

Figure 1: abdominal ultrasound showing kidney mass with a size of 4.66 x 5.13 cm

Figure 2: abdominal CT with contrast revealed a mass on the upper pole of the kidney showing malignancy, with a simple cyst on the lower pole (A); Simple cyst on the lower pole of the kidney (B)

Figure 3: dissected kidney with the renal tumor removed from the abdomen; the mass had a fatty appearance with a high degree of vascularization

Figure 4: postoperative scar showing small surgical incision on the exposed part of the abdomen

Figure 5: three months postoperative, showing only minor scarring of the abdomen which gave a more satisfying cosmetic appearance

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