The tumor grew along the renal vein and into the inferior vena cava toward the heart. Renal tumors can grow rapidly; in this case the tumor grew rapidly into the inferior vena cava, occluding it. This increased the pressure in the leg veins, resulting in swelling and pitting edema of the ankles.
The patient unfortunately died on the operating table.
In this patient’s case, a “tongue” of tumor grew into the inferior vena cava. At the time of surgery, the initial dissection mobilized the kidney on its vascular pedicle; however, a large portion of tumor became detached in the inferior vena cava. The tumor embolus passed through the right atrium and right ventricle and occluded the pulmonary artery. This could not be cleared at the time of surgery, and the patient succumbed.
A 65-year-old businessman came to the emergency department with severe lower abdominal pain that was predominantly central and left sided. He had pain radiating into the left loin, and he also noticed he was passing gas and fecal debris as he urinated.
A CT scan of his abdomen and pelvis was performed (eFig. 4.191).
The CT scan demonstrated a collection of fluid (likely a pelvic abscess) in the left iliac fossa. Associated with this collection of fluid was significant bowel wall thickening of the sigmoid colon and multiple small diverticula arising throughout the sigmoid colon. Gas was present in the bladder. An obstruction was noted in the left ureter and the left pelvicalyceal system.
The patient underwent an urgent operation.
As the surgeons entered into the abdominal cavity through a midline incision, the tissues in the left iliac fossa were significantly inflamed. The surgeon used his hand to mobilize the sigmoid colon and entered a cavity from which there was a “whoosh” of pus as indicated on the CT scan. The pus was washed out and drained. The sigmoid colon was remarkably thickened and inflamed and stuck to the dome of the bladder. Careful finger dissection revealed a small perforation in the dome of the bladder, allowing the passage of fecal material and gas into the bladder and producing the patient’s symptoms of pneumaturia and fecaluria. The sigmoid colon was resected. The rectal stump was oversewn and the descending colon was passed through the anterior abdominal wall to form a colostomy. The bladder was catheterized and the small hole in the dome of the bladder was oversewn.
The patient had a difficult postoperative period in the intensive care unit where he remained pyrexial and septic. The colostomy began to function well.
An ultrasound was performed and demonstrated the continued dilation in the left kidney, and the patient underwent a nephrostomy.
Under ultrasound guidance a drainage catheter was placed into the renal pelvis through the renal cortex on the left. A significant amount of pus was drained from the renal tract initially; however, after 24 hours urine passed freely.
The likely cause for the obstruction was the inflammation around the distal ureter on the left. It is also possible that a small ureteric perforation occurred, allowing bacteria to enter the urinary tract.
The patient made a further uneventful recovery with resumption of normal renal function and left the hospital.
On return to the surgeon in the outpatient clinic some weeks later, the patient did not wish to continue with his colostomy and bag. Further to discussion, surgery was planned to “rejoin” the patient.
At operation the colostomy was “taken down” and the rectal stump was identified. There was, however, a significant gap between the bowel ends. To enable the bowel to be sutured, the descending colon was mobilized from the posterior abdominal wall. An anastomosis was performed and the patient left the hospital 1 week later and currently remains well.