Renal dysfunction associated with staged bilateral partial nephrectomy: The importance of operative positioning

Purpose: Remnant kidneys may be susceptible to injury during positioning fo r a contralateral flank incision. We document renal dysfunction in a remnan t kidney after staged partial nephrectomies. Materials and Methods: We review a case of renal dysfunction associated wit h staged bilateral partial nephrectomy. Pertinent data and radiographic fin dings are presented. Results: A man with multiple bilateral solid enhancing renal masses underwe nt left partial nephrectomy, resulting in sparing of 50% of the renal paren chyma. Postoperatively nuclear renography showed excellent flow and 33% fun ction on that side. Right partial nephrectomy was then performed via the st andard flank approach through the bed of the 11th rib, sparing 50% of the r enal parenchyma. Cold ischemia time was 40 minutes. Serum creatinine increa sed to 4.9 mg./dl. within 48 hours. Nuclear renography immediately postoper atively showed poor flow and 13% function in the left kidney. Conclusions: Limited published data imply detrimental hemodynamic and myocu taneous consequences due to use of the kidney rest. Table flexion with elev ation of the kidney rest may also cause ischemic damage in a previously ope rated contralateral kidney. Careful positioning is critical for preventing undue injury to the remnant kidney and in such cases elevation of the kidne y rest should be avoided. Alternatively stage 2 may be approached via an an terior incision.