Renal mass in a solitary kidney is a challenging clinical scenario and partial nephrectomy (PN) is generally prioritized. For tumors with high complexity, an in vivo approach with hypothermia is most often preferred at our center. Ex vivo PN is another option although results with this approach have varied and its utility in this setting is not well defined. We present the case of a 44-year-old female with bilateral renal masses including a large right renal mass with inferior vena cava (IVC) tumor thrombus and centrally located left mass with renal vein thrombus. After undergoing right radical nephrectomy/IVC tumor thrombectomy, the creatinine level was 0.96 mg/dL and she was treated with neoadjuvant axitinib to downstage the left renal mass. She then underwent laparoscopic nephrectomy, ex vivo PN on ice with excision of the renal vein thrombus, and autotransplantation into the left iliac fossa. Final pathology revealed a 7 cm pT3a grade 3 clear cell renal cell carcinoma with negative margins. During the 90- day postoperative window, she experienced acute kidney injury, a pulmonary embolism requiring systemic anticoagulation, and retroperitoneal abscess requiring drain placement, all with good recovery. At 14-month follow-up, her creatinine was 1.47 mg/dL and she has never required dialysis. She had a local recurrence at 12 months postoperatively which was successfully managed with thermoablation. In conclusion, the management of bilateral locally advanced renal tumors is complex and challenging. In rare circumstances, ex vivo PN can be considered and performed with good results.


Renal mass in a solitary kidney is one of the greatest challenges that urologic oncologists can encounter. In such cases, nephron-sparing surgery (NSS) is prioritized to preclude the need for dialysis. Robotic and open partial nephrectomy (PN) are standard options for NSS today. However, a centrally located mass which may not be amenable to in situ NSS presents a unique clinical dilemma. Such a mass may require careful dissection of the hilar structures, segmental vessels and collecting system. Careful preservation and reconstruction of critical structures must be done while maintaining strong oncologic control. This is typically followed by the need for an effective renorrhaphy with focus on preserving as much vascularized parenchyma as possible. Conventional surgical options include attempting in situ 12

open or robotic PN or performing radical nephrectomy and placing the patient on dialysis with potential for later renal transplantation. However, one technique that may be utilized in such difficult situations is nephrectomy followed by ex vivo PN and autotransplantation. This technique was utilized at Cleveland Clinic in the early days of NSS but was abandoned after 1986 due to suboptimal results. We recently reviewed our experience with renal mass in a solitary kidney (n=1024 from 1975-2022) of which nine patients were managed with ex vivo PN. In this ex vivo cohort, four patients required dialysis and two required reoperation for renal vein thrombus, and this approach then fell out of favor1. Since then, however, the introduction of fine vessel-sealing devices, better thrombogenic materials for packing the renorrhaphy defect, improved methods for capsular closure and reconstruction, and more detailed imaging allowing for improved surgical planning have again made this a potentially useful option.

Advantages of ex vivo PN include a bloodless field which allows for meticulous dissection of the tumor away from hilar structures and precise excision of minimal healthy renal parenchyma to preserve nephrons while obtaining negative surgical margins. In addition, the ability to cool and flush the kidney with a preservative solution allows for complex reconstruction without strict time constraints. Small case series and reports have shown generally positive oncologic and functional results for this technique in carefully selected patients 3-7, 10.

Here we present a case of bilateral locally advanced renal tumors in a young morbidly obese woman which was successfully managed with radical nephrectomy/ IVC thrombectomy for one side and laparoscopic nephrectomy, ex vivo PN and renal autotransplantation for the contralateral side, with avoidance of dialysis.


A 44-year-old female was found to have bilateral solid, enhancing renal masses on imaging performed during work-up for hypertension. Her comorbidities included hypertension and morbid obesity (BMI 50). She reported right flank discomfort. There was no family history of genitourinary malignancy or other findings that would suggest familial RCC. Metastatic work-up was negative. Her baseline serum creatinine level was 0.89 mg/dL.

The right renal mass was 10 cm with level 2 inferior vena cava (IVC) tumor thrombus. The left mass was centrally located with renal vein thrombus and R.E.N.A.L. score of 12. Percutaneous biopsy of the right renal mass showed clear cell renal cell carcinoma (RCC), grade 2. The patient first underwent a right radical nephrectomy and IVC tumor thrombectomy with final pathology showing pT3b grade 3 clear cell RCC with negative margins. Recovery was uneventful. Biopsy of the left renal mass confirmed clear cell RCC, grade 2, and she was then treated with eight weeks of neoadjuvant axitinib as part of a phase 2 clinical trial to downstage the tumor in an effort to facilitate PN. CT imaging of the mass before and after tyrosine kinase inhibitor therapy are shown in FIGURE 1. The tumor was downsized from 5.2 cm to 4.0 cm and the venous thrombus also became smaller and more distinct. After considering all options, the decision was made to proceed with ex vivo PN, because it was thought that in vivo PN would be very challenging and likely impossible due to the tumor location, venous involvement, and proximity to vital structures within the hilum.

First, a left radical nephrectomy was performed in similar fashion to laparoscopic donor nephrectomy using only 5 mm working ports (see video link: tinyurl.com/a4ps2hrv ).

An additional 10 mm port was placed in the left lower quadrant and this was utilized for the vascular stapler and specimen bag. This port site was extended in Gibson fashion for specimen extraction. The kidney was then chilled on ice and perfused with hypothermic Collins' solution before being defatted and undergoing ligation of small vascular branches. The central mass with extension into the vein was visualized on ultrasound and a n anterior wedge of parenchyma was excised to allow for hilar and tumor ex posure. The renal vein was opened and the tumor thrombus resected followed by sequentia l dissection of tumor out of the central aspec t of the kidney. A fine vessel sealer was used when necessary to ligate small vessels feeding the tumor. Af ter oversewing the parenchyma, suturing rema ining transected vessels, and packing the defect with FibrillarTM (Ethic on, Cincinnati, OH), the outer renorrhaphy was performe d with 2- 0 chromic sutures as shown in the surgical video above.

Autotransplantation was then performed with the kidney placed into the left iliac fossa with concerns of a possible abscess existing Gibson incision and the vascular anastomoses were performed to the external iliac vessels in the usual manner. The ureter was reimplanted into the bladder dome over a double-J ureteral stent. The total operative time was 6 hours including 3 hours of back-bench work on ice that involved resecting the mass and reconstructing the kidney and the renal vein. Warm ischemia time included five minutes during extraction of the kidney and 25 minutes while performing the vascular anastomoses. The estimated blood loss was 500 cc. Final pathology revealed a 7 cm pT3a grade 3 clear cell RCC with negative margins.

The patient experienced acute kidney injury with peak creatinine of 5.91 mg/dL on postoperative day three which improved to 1.54 mg/ dL by six weeks with estimated GFR of 43 mL/min/1.73 m2. She did not require dialysis at any point during her post- operative course. At two months following surgery, she was readmitted with leukocytosis and fever and was found to have a retroperitoneal fluid collection concerning for possible abscess. She underwent drain placement by interventional radiology. Drain culture was positive for actinomyces neuii and was treated with a course of antibiotics. During this stay, she was also diagnosed with a pulmonary embolism which was treated with systemic anticoagulation. Both complications were successfully managed with conservative measures.

At 12-month follow-up, the patient was found to have a local recurrence with a 3.0 cm enhancing left anterolateral renal lesion. The central aspect of the kidney and the renal vein remained diseasefree. She underwent selective embolization and cryoablation by interventional radiology, with the tumor treated in two different sittings to optimize the precision of the treatment and minimize loss of vascularized parenchymal volume. Recovery was strong with a recent serum creatinine level of 1.47 mg/dL, correlating with an estimated GFR of 45. She is currently 16 months post- PN and free of disease with stable renal function. She is maintained on close surveillance and is now also on adjuvant immunotherapy with pembrolizumab.


We present a very challenging case of a 44-year-old female with morbid obesity and hypertension found to have bilateral renal lesions with venous involvement who underwent right radical nephrectomy with IVC thrombectomy followed by left laparoscopic nephrectomy, ex vivo PN and autotransplantation. At 16-months follow-up, she has good renal function with creatinine of 1.5 mg/dL and has not required dialysis. She had local recurrence that was managed with selective embolization and thermoablation and is now disease-free on adjuvant immunotherapy.

Renal autotransplantation is an established surgical option in highly select patients including those with extensive ureteral stricture disease or ureteral loss or complex renovascular diseases extending into the hilum. In these settings, where the kidney itself is left undisturbed with no loss of parenchyma and without the need for renal capsular closure, strong results have been observed8,9. However, the unique situation of ex vivo PN with autotransplantation for renal cancer has generally demonstrated less favorable results, likely because of the added complexity of combining both procedures. Specifically, the loss of parenchymal volume and major renal reconstruction, combined with the extensive ischemia that is inherently associated with exvivo surgery, places such patients at high risk for acute kidney injury and severe CKD or end-stage renal failure on a long-term basis, and vascular complications are also a concern with any transplantation. Nevertheless, nephrectomy, ex vivo PN and autotransplantation is still considered a potential option for patients with renal masses with high tumor complexity, particularly for those with a solitary kidney. Given the rarity of this clinical situation and infrequent use of this technique, the pertinent literature only includes case reports and small series although some of these reports have documented encouraging oncologic and renal functional outcomes (TABLE 1)2,3,5,6. A series of three cases of laparoscopic nephrectomy, ex vivo PN and autotransplantation included two patients with functionally solitary kidneys and one patient with stage IIIb chronic kidney disease (CKD)3. All lesions were pT1, clear cell RCC with negative margins. At 19 to 39 months followup, all patients were disease-free with stable renal function and were off dialysis. Another report included a patient with high-grade urothelial carcinoma in a calyceal diverticulum and a patient with a 5 cm centrally located RCC3. Both underwent laparoscopic nephrectomy, ex vivo PN and autotransplantation.

At 20 and 12-months follow-up, respectively, these patients were recurrence-free and remained off dialysis. A series of two patients with 4-5 cm central renal masses— one in a patient with a solitary kidney from previous contralateral nephrectomy and one in a patient with CKD—who underwent laparoscopic nephrectomy, ex vivo PN and autotransplantation demonstrated no short-term postoperative complications or dialysis requirements, although long-term oncologic outcomes were not reported5. Finally, Abraham et al. reported two patients with complex bilateral RCC and one patient with bilateral large angiomyolipoma who underwent ex vivo PN6. There were no postoperative complications in this series but one patient required temporary dialysis. These studies support the potential safety and feasibility of this procedure in appropriately selected patients. Whether any of the above patients might have been managed in vivo is of course very difficult to assess. Other series demonstrate the possible complications associated with this complex surgery (TABLE 1)4,7,10. A case report of a 77-yearold female with a 5 cm hilar mass who underwent open nephrectomy through a midline incision followed by ex vivo PN and orthotopic autotransplantation highlights some difficulties that can be encountered. Following ex vivo PN in this case, the kidney was returned to its orthotopic position and end-to-end arterial and venous anastomoses were performed as well as a uretero-ureterostomy over a double-J ureteral stent. The patient required hemodialysis for one month postoperatively and developed bleeding from a lower pole pseudoaneurysm requiring embolization on postoperative day 10. The patient was disease-free with stable renal function at 24-month follow-up4. Furthermore, a series of 11 patients who underwent ex vivo PN for complex renal tumors from 1996- 2009 showed a complication rate of 73% which included two urinary fistulas, two vascular thromboses requiring nephrectomy and dialysis, two pulmonary complications and four patients required temporary dialysis7. Tumor stage ranged from pT1 to pT3a and there were three cases of positive surgical margins (27%). In this series there were two local recurrences (18%) and five cases of progression to metastatic disease (45%) leading to two deaths (18%).

The largest case series on ex vivo PN published to date included five patients treated for complex RCC, five for complex upper tract urothelial carcinoma, one for isolated metastasis to the kidney, and one for renal nephroblastoma11. Postoperatively, two patients required temporary dialysis. Median follow-up was 84 months, and six patients (50%) eventually died with functioning grafts. There were five cases of local or distant recurrence and two additional patients died from their disease. Only one person developed end stage renal disease requiring dialysis. These studies highlight that strict patient selection is key and that oncologic safety should not be compromised during ex vivo PN. At our institution, ex vivo PN has only been considered primarily for patients with RCC, in contrast to some studies highlighted above with broader selection criteria. Our patient described in this study had pT3a disease with negative margins, although a local recurrence was identified that required salvage therapy, specifically thermoablation. The initial suboptimal results at our center with ex vivo PN led to abandonment of this approach for 36 years, until the present case. We recently reviewed all 1024 cases of renal mass in a solitary kidney from 1975-2022 at Cleveland Clinic of which 10 cases were managed with ex vivo PN, including the case presented here and nine other cases prior to 19861. Unfortunately, in our previous nine cases, four required dialysis and two required reoperation for renal vein thrombosis and this approach fell out of favor due to these suboptimal results.

The technique described here of laparoscopic nephrectomy, ex vivo PN and autotransplantation is advantageous due to its ability to preserve maximal vascularized parenchymal volume and preclude the need for dialysis which has its own well- established morbidity. Good oncologic control is critically important and with the kidney on ice, frozen sections can be obtained and additional resection can be performed if necessary in an effort to achieve an R0 result. Most reports— including our own—utilized laparoscopic nephrectomy rather than open which may further reduce the morbidity of the approach. Disadvantages include longer operative time as this technique is essentially the combination of three urologic procedures. In addition to known complications of partial nephrectomy including urine leak and postoperative bleeding from the reconstructed kidney, are also the risks of renal transplant such as bleeding from the vascular anastomoses, acute arterial or venous thrombosis, arterial stenosis or ureteral stricture. This procedure also requires a surgeon or team of surgeons experienced in both nephron-sparing surgery and renal transplant. It is important to keep in mind that if good oncologic control cannot be achieved, then the procedure should be converted to radical nephrectomy and the patient can potentially be listed for delayed renal transplantation. In conclusion, laparoscopic nephrectomy, ex vivo PN and reconstruction with hypothermia, and autotransplantation is a viable approach for managing the most complex of renal masses in a solitary kidney (FIGURE 2). With improved technology, including fine vessel-sealing devices, better thrombogenic materials for packing the renorrhaphy, improved methods for capsular closure, and more detailed imaging allowing for more intelligent surgical planning, this has become a more feasible option which we are now adding back to our armamentarium. However, careful patient selection is of paramount importance, as this procedure naturally comes with increased perioperative risks, and should only be used when essential. For the great majority of complex PN in a solitary kidney, our preference remains in favor if in vivo PN with hypothermia. The morbidity that can be associated with ex vivo PN and autotransplantation likely reflects the complexity of the cases, and good judgment is required to determine where the threshold should be for abandonment of PN with conversion to RN for such patients.

FUNDING: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Conflicts of Interest: None


  • 1. Yasuda Y, Zhang JH, Attawettayanon W, et al. Comprehensive Management of Renal Masses in Solitary Kidneys. Eur Urol Oncol. 2023;6(1):84-94. doi:10.1016/J.EUO.2022.11.004
  • 2. Nayak JG, Koulack J, McGregor TB. Laparoscopic nephrectomy, ex vivo partial nephrectomy, and autotransplantation for the treatment of complex renal masses. Case Rep Urol. 2014;2014:1-4. doi:10.1155/2014/354104
  • 3. Meng M V., Freise CE, Stoller ML. Laparoscopic nephrectomy, ex vivo excision and autotransplantation for complex renal tumors. J Urol. 2004;172(2):461-464. doi:10.1097/01. JU.0000130668.94919.59
  • 4. Crafa F, Rossetti ARR, Striano A, Baiamonte M, Esposito F. Ex vivo nephron- sparing surgery and kidney autotransplantation for renal tumors. J Surg Case Rep. 2021;2021(2). doi:10.1093/JSCR/RJAB004
  • 5. Sokoloff MH, Chien GW, Thistlewaite JR, Harland R, Shalhav AL. Ex vivo partial nephrectomy and autotransplantation for renal cell cancer after laparoscopic renal harvest. Urology. 2004;63(6). doi:10.1016/j. urology.2004.02.017
  • 6. Abraham GP, Siddaiah AT, Ramaswami K, George D, Das K. Ex-vivo nephron- sparing surgery and autotransplantation for renal tumours: Revisited. Can Urol Assoc J. 2014;8(9-10):e728-e732. doi:10.5489/ CUAJ.1775
  • 7. Kulisa M, Bensouda A, Vaziri N, et al. [Complex renal tumors on solitary kidney: results of ex vivo nephron-sparing surgery with autotransplantation]. Prog Urol. 2010;20(3):194-203. doi:10.1016/J. PUROL.2009.10.019
  • 8. Tran G, Ramaswamy K, Chi T, Meng M, Freise C, Stoller ML. Laparoscopic Nephrectomy with Autotransplantation: Safety, Efficacy and Long-Term Durability. J Urol. 2015;194(3):738-743. doi:10.1016/J. JURO.2015.03.089
  • 9. Vrakas G, Sullivan M. Current Review of Renal Autotransplantation in the UK. Curr Urol Rep. 2020;21(9). doi:10.1007/S11934-020-00986-Z
  • 10. Baitman T, Miroshkina I, Gritskevich A, et al. Extracorporeal Partial Nephrectomy with Orthotopic Autotransplantation under Pharmaco- Cold Ischaemia for Cancer of a Single Kidney: A Case Report. Case Rep Oncol. 2020;13(3):1202-1208. doi:10.1159/000510404
  • 11. Janssen MWW, Linxweiler J, Philipps I, et al. Kidney autotransplantation after nephrectomy and work bench surgery as an ultimate approach to nephron- sparing surgery. World J Surg Oncol. 2018;16(1). doi:10.1186/ S12957-018-1338- 1

    # Corresponding Author: Steven C. Campbell, MD, PhD. Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Cleveland, OH, 44195. Campbes3@ccf.org