Nephroureterectomy grossing

This article deals with the nephroureterectomy grossing, also the cut-up of nephroureterectomy specimens. These specimens include both a kidney, a ureter and a urinary bladder cuff.

Total nephrectomy specimens (without the ureter) and partial nephrectomy specimens are dealt with separately.

Introduction

Nephroureterectomies are done for urothelial carcinoma of the ureter and/or renal pelvis.

The false positive/negative for tumour rate is reported as high as 2.9%.

Specimen opening

1. Paint surface of specimen (optional).
2. Take the vascular margins - renal artery and renal vein (both en face) and place in one tissue cassette.
3. Open the kidney in the frontal plane (from lateral to medial).
   • The cut should go through the renal pelvis.
4. Place specimen(s) in formalin.

Protocol

Dimensions, weight and inking:

• Type: nephroureterectomy.
• Laterality: [left / right].
• Weight: ___ grams.
• Size of specimen (superior-inferior, left-right, anterior-posterior): ___ x ___ x ___ cm.
• Ureter (length x diameter): ___ x ___ cm.
• Size of bladder cuff: ___ x ___ cm.
• Renal vein (length x diameter): ___ x ___ cm.
• Renal artery (length x diameter): ___ x ___ cm.
• Adrenal gland: [___ x ___ x ___ cm / not identified].
• Inking of kidney: [colour].
• Inking of proximal ureter: [colour].
• Inking of mid ureter: [colour].
• Inking of distal ureter: [colour].
• Inking of bladder cuff/resection margin: [colour].
• Size of kidney (superior-inferior, left-right, anterior-posterior): ___ x ___ x ___ cm.
• Perinephric fat (maximal dimension): ___ cm.

Tumour:

• Dimensions (superior-inferior, left-right, anterior-posterior): ___ x ___ x ___ cm.
• Location: [upper pole / lower pole / renal pelvis / ureter].
• Colour: [white / tan / yellow].
• Morphology: [solid / cystic / solid and cystic - with ___ % cystic].
• Friability: [friable / not friable].
• Circumscription: [well circumscribed / indeterminate / infiltrative border].
• Hemorrhage: [present / absent].
• Necrosis: [present / absent].
• Margin: [nearest margin ___, distance ___ cm / positive margin, location ___].
• Extension into perinephric fat: [absent / not identified-pushing border / suspicious / present].
• Extension into the renal parenchyma: [absent / suspicious / present].
• Extension into renal hilar fat: [absent / not identified-pushing border / suspicious / present].
• Extension into renal vein: [absent / suspicious / present].

Other:

• Non-tumour renal parenchyma: [cortex unremarkable / thinned].
• Non-tumour collecting system mucosa: [smooth and regular / granular / irregular / dilated].
• Lymph nodes: [number of lymph nodes with [unremarkable cut surface / tumour] / not identified].

Representative sections are submitted:

• Renal vein margin and renal artery margin (en face).
• Urinary bladder cuff margin (on edge). §
• Urinary bladder cuff.
• Ureter - representative sections. ¶
• Tumour with nearest margin.
• Tumour in relation to perinephric fat. †
• Tumour in relation to renal parenchyma. ††
• Tumour and sinus fat.
• Normal kidney.
• Adrenal gland.

Protocol notes

• § Bladder cuff margin may be done en face.
• ¶ The ureter should be cross sections - not longitudinal sections. It is advantageous to ink the ureter three different colours; this allows one to determine where the remaining ureter is from.
  • If proximal ureter is blue, mid ureter is red and distal ureter is green: blue-red is proximal, red-green is distal; the orientation and anatomical location is important if one submits more tissue.
• † This typically upstages to pT4. It is uncommon that the tumour goes through the kidney and into the perinephric fat.
• †† Invasion into the renal parenchyma typically upstages to pT3. This can be difficult to judge on cut-up. If renal parenchymal invasion is not seen grossly at least three sections should be taken. Small tumours are usually submitted in toto.

See also

Related protocols

• Partial nephrectomy.
• Total nephrectomy for tumour.