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    Kidney non tumour

    Background

    In the non-tumour setting, partial nephrectomy may be used to kidney tissue damaged by trauma. Total nephrectomy may be used to remove non-functioning and congenitally deformed kidneys.

    Explants of transplant kidneys after failure in the host may also be received in the laboratory.1 Transplant specimens will consist of a kidney without any of the usual surrounding fat and lengths of renal vessels.

    This protocol is relevant to nephrectomies for non-tumour lesions of the renal parenchyma and transplant specimens. A separate protocol is provided for parenchymal tumours and those of the renal pelvis and ureter.

    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. Include the reason for nephrectomy and whether surgery was open or laparoscopic if known.

    Correlation of the specimen with previous radiological and pathological reports may be useful.

    See overview page for more detail on identification principles.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.
    • Not performed
    • Performed, describe type and result

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify anatomical features of the specimen:

    Procedure

    ​Record as stated by the clinician.
    • Total nephrectomy
    • Partial nephrectomy
    • Other, describe

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Featured denoted

    If unable to orientate, call the on-call pathologist or surgeon.

    Although laterality is usually indicated in the clinical notes, principal landmarks such as the adrenal gland, ureter, renal vein and artery will confirm whether the specimen is the right or left kidney. The ureter extends inferiorly from the renal sinus along the medial border of the kidney posterior to the renal artery and vein.2

    Anatomical components present (more than one may apply) and dimensions (mm)

    Describe and measure anatomical components if present.

    • Entire specimen
      • Weight
      • Size in three dimensions
    • Kidney, in three dimensions
    • Renal vein (anterior), length
    • Renal artery (middle), length
    • Ureter (posterior), length
    • Other, specify

    Specimen integrity

    • Intact
    • Opened
    • Fragmented (morcellated)
      • Number of pieces of tissue received

    Laparoscopically removed kidneys are received in fragments and require particular consideration during cut-up.2

    Evidence of previous biopsy or surgery (if present)

    Record if applicable.
    • Needle track
    • Scar
    • Sutures

    Photograph the intact specimen if required.


    Dissection

    Non-functioning and explant kidneys3

    Open the kidney longitudinally through the lateral/convex surface dividing the specimen into equal anterior and posterior halves. The initial section of kidney should be along its long axis at midpoint. This could be an incision along the midline through the hilum from lateral to medial or along probes placed in the largest branches of the renal vein.

    Photograph the specimen if required.

    Carefully palpate the perirenal fat superiorly to locate the adrenal gland. If present, section at 3-4mm intervals.

    Strip uninvolved perirenal fat from the capsular/hilar surface noting adherence to perinephric fat, cyst formation or scarring.

    Open the renal vein and artery and record any macroscopic evidence of stenosis/occlusion or thrombosis.

    Consider sending calculi/crystalline deposits for biochemical assessment.

    Take further sections parallel or perpendicular to the first incision. Parallel sections should include one just anterior to the renal pelvis to evaluate any venous involvement.

    After opening the specimen may require longer fixation in larger quantity of formalin.


    Internal Inspection

    Hilar structures

    Renal vein

    • Normal
    • Abnormal, describe
      • Occlusion, percentage (%)
      • Thrombosis
      • Other, describe

    Renal artery

    • Normal
    • Abnormal
      • Stenosis, percentage (%)
      • Thrombosis
      • Atherosclerosis
      • Other, describe

    Ureter

    • Normal
    • Abnormal
      • Stricture
      • Length (mm)
      • Diameter (mm)

    Cortical surface

    • Normal
    • Abnormal, describe

    Parenchyma

    • Colour
    • Cortical thickness (mm)

    Lesion(s)

    • Absent
    • Present
      • Infarct
      • Cyst
      • Abscess

    For each lesion, describe

    • Maximum size (mm)
    • Location
    In addition for each cyst, describe the following:
    • Configuration
      • Simple
      • Complex
    • Wall thickness (mm)
    • Contents

    Renal pelivs

    • Normal
    • Abnormal
      • Blunted calyces and papillae
      • Thickened
      • Dilated renal pelvis

    Calculi

    If present, describe
    • Number
    • Size (mm)
    • Location

    Note photographs taken, diagrams recorded and markings used for identification.


    Processing

    Dissect the specimen further and submit sections for processing according to the diagram provided.

    Transplant specimens will consist of a kidney without any of the usual surrounding fat and lengths of renal vessels.

    Submit representative sections of:

    • Ureter, renal vein and artery; transverse sections
    • All abnormalities such as infarcts, haemorrhage, necrosis and cysts (particularly cyst walls and solid, irregular areas)
    • Cortex, medulla and renal pelvis
    • Any areas suspicious for tumour

    Special stains (silver stain, Alcian Blue-Periodic acid Schiffs (ABPAS), Masson’s trichrome, Congo red) may be pre-ordered on a suitable block at this time to expedite reporting.


    Record details of each cassette.

    An illustrated block key similar to the one provided may be useful.

    Block allocation key

    Cassette id
    Site
    No. of pieces
    A
    Artery, vein and ureter
     
    B
    Cortex upper pole
     
    C
    Cortex lower pole
     
    D-G
    Cyst wall, representative sections
     
    H
    Medulla/renal pelvis
     

     

    Acknowledgements

    A/Prof Hemamali Samaratunga for her contribution in reviewing and editing this protocol.


    References

    1. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
    2. Rabban JT, Meng MV, Yeh B, Koppie T, Ferrell L and Stoller ML. Kidney morcellation in laparoscopic nephrectomy for tumor: recommendations for specimen sampling and pathologic tumor staging. Am J Surg Pathol 2001;25(9):1158-1166.
    3. O’Rourke D, Turner G and Allen D. Tissue Pathways for Urological Pathology, The Royal College of Pathologists, London, 2010.

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    25-Mar-2019
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