Case Report Laparoscopic Heminephrectomy for Renal Cell Carcinoma in Cross-Fused Ectopic Kidney Frederico R. Romero, David Y. Chan, Michael Muntener, Herman S. Bagga, Fábio Augusto R. Brito, and Louis R. Kavoussi Crossed renal ectopia is a rare congenital malformation. We report a case of renal cell carcinoma in a 51-year-old man with right-to-left crossed fused renal ectopia. The patient was treated with ultrasound-guided laparoscopic hemine- phrectomy. Postoperative three-dimensional computed tomography showed normal perfusion of the remaining part of the kidney, with good excretion of contrast from both units of the cross-fused kidney. UROLOGY 69: 779.e11–779.e13, 2007. © 2007 Elsevier Inc. C rossed renal ectopia is a congenital displacement of one kidney to the opposite side of the body. 1 Similar to horseshoe kidneys, crossed ectopic kidneys have a greater incidence of congenital and ac- quired anomalies, 2 often requiring surgical intervention. To our knowledge, only 7 cases of tumor occurring in combination with crossed-fused ectopia have been re- ported to date. 3–9 Six were renal cell carcinoma 3–8 and one was transitional cell carcinoma. 9 We report on the first patient treated with a laparoscopic approach. CASE REPORT A 51-year-old man with a past medical history of inflammatory bowel disease and osteoporosis presented with diarrhea. During the workup, he was incidentally diagnosed with right-to-left cross-fused renal ectopia, associated with a mass in the upper pole of the left renal unit. The patient did not complain of hematuria or pain, and no abdominal mass was palpable. The patient’s family history was significant for kidney can- cer. Computed tomography (CT) showed a 4-cm, solid, enhancing mass that extended to the renal pelvis and displaced the renal vein and a branch of the renal artery anteriorly (Fig. 1). Because renal cross-fused ectopia pose a significant therapeutic challenge, a three-dimensional (3D) CT scan was obtained to help in planning the surgical approach. 3D mapping showed cross-fused renal ecto- pia with the appearance of three renal pelvises. The native left kidney had a single renal vein and an early-branching renal artery. The ectopic fused crossed component was located anterior to the aorta and slightly lateral in the left lower quadrant, fusing with the inferior pole of the left kidney, with multiple renal arteries and veins. The solid renal mass was located in the upper pole of the left kidney (Fig. 2). No evidence of tumor spread was observed. After discussing the benefits and risks of each ther- apeutic option, the patient elected to undergo laparo- scopic partial nephrectomy (Video clips 1 and 2). The patient was placed in a modified left flank-up position. Flexible cystoscopy was performed after the induction of general endotracheal anesthesia, and a stent was placed under fluoroscopic guidance in the left ureter. Pneumoperitoneum was achieved in a standard man- ner, and four trocars were placed: a 10-mm trocar in the umbilicus, a 10-mm trocar half way between the umbilicus and the symphysis pubis, a 5-mm trocar half way between the umbilicus and the xiphoid, and a From the James Buchanan Brady Urological Institute, Johns Hopkins Medical Institu- tions, Baltimore, Maryland; and Department of Urology, North Shore-Long Island Jewish Health System, Long Island, New York Address for correspondence: Frederico R. Romero, M.D., James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, 600 North Wolfe Street, Baltimore, MD 21287-8915. E-mail: frederico.romero@gmail.com Submitted: August 28, 2006; accepted (with revisions): February 9, 2007 Figure 1. CT scan revealing heterogeneously enhancing mass displacing renal vessels anteriorly (arrows). © 2007 Elsevier Inc. 0090-4295/07/$32.00 779.e11 All Rights Reserved doi:10.1016/j.urology.2007.02.021