Surgical margin follow-up after nephron-sparing surgery: the possible role of CEUS



To evaluate the possible role of CEUS in the management of patients who underwent nephron-sparing surgery (NSS) and presented questionable findings on the surgical margins at the CECT follow-up exam.


In our retro-prospective study, we included 952 patients with small renal masses (SRMs) treated with NSS between 2012 and 2015 and followed with CECT for at least 3 years at Careggi University Hospital. Twenty-two of them presented solid masses on the site of surgery with questionable enhancement at CECT and were further studied with CEUS. This examination was followed by a quantitative analysis of the enhancement pattern.


Out of the 22 masses, 18 were considered possible granulomas, presenting slow wash-in and low enhancement peaks compared to the surrounding parenchyma and persistent delayed wash-out at CEUS. Four lesions presented a suspicious malignant enhancement pattern, with rapid wash-in, high peak and rapid wash-out. In accordance with instructions from the urologist, the first group of 18 patients was strictly monitored, revealing that the mass dimensions and enhancement pattern were stable for at least 3 years of follow-up, while the other 4 patients underwent a second intervention and their masses were confirmed as tumor recurrence at the histopathological evaluation.


CEUS can play a key role in the surgical margin follow-up after NSS when a suspicious enhancing mass is detected by CECT, giving an accurate depiction of the enhancement pattern and thus helping the clinician in the management of the patient.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    Ljungberg B, Albiges L, Abu-Ghanem Y et al (2019) European association of urology guidelines on renal cell carcinoma: the 2019 update. Eur Urol 75(5):799–810

    Article  Google Scholar 

  2. 2.

    Bjornsson J, Short MP, Kwiatkowski DJ et al (1996) Tuberous sclerosis-associated renal cell carcinoma: clinical, pathological, and genetic features. Am J Pathol 149:1201–1208

    CAS  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Ng CS, Wood CG, Silverman PM et al (2008) Renal cell carcinoma: diagnosis, staging, and surveillance. AJR Am J Roentgenol 191(4):1220–1232

    Article  Google Scholar 

  4. 4.

    Kim JK, Kim TK, Ahn HJ et al (2002) Differentiation of subtypes of renal cell carcinoma on helical CT scans. AJR Am J Roentgenol 178(6):1499–1506

    Article  Google Scholar 

  5. 5.

    Oliva MR, Glickman JN, Zou KH et al (2009) Renal cell carcinoma: T1 and T2 signal intensity characteristics of papillary and clear cell types correlated with pathology. AJR Am J Roentgenol 192(6):1524–1530

    Article  Google Scholar 

  6. 6.

    Pantuck AJ, Zisman A, Belldegrun AS (2001) The changing natural history of renal cell carcinoma. J Urol 166:1611–1623

    CAS  Article  Google Scholar 

  7. 7.

    Kopka L, Fischer U, Zoeller G et al (1997) Dual-phase helical CT of the kidney: value of the corticomedullary and nephrographic phase for evaluation of renal lesions and preoperative staging of renal cell carcinoma. AJR Am J Roentgenol 169(6):1573–1578

    CAS  Article  Google Scholar 

  8. 8.

    Bechtold RE, Zagoria RJ (1997) Imaging approach to staging of renal cell carcinoma. Urol Clin North Am 24:507–522

    CAS  Article  Google Scholar 

  9. 9.

    Sheth S, Scatarige JC, Horton KM et al. (2001) Current concepts in the diagnosis and management of renal cell carcinoma: role of multidetector ct and three-dimensional CT. Radiographics. 21 Spec No: S237–54

  10. 10.

    Hertzberg BS, Middleton WD (2015) Ultrasound: the Requisites, 3rd edn. Elsevier, Netherlands

    Google Scholar 

  11. 11.

    Dinney CPN, Awad SA, Gajewski JB et al (1992) Analysis of imaging modalities, staging systems, and prognostic indicators for renal cell carcinoma. Urology 36:22–29

    Google Scholar 

  12. 12.

    O’Connor SD, Silverman SG, Ip IK et al (2013) Simple cyst-appearing renal masses at unenhanced CT: can they be presumed to be benign? Radiology 269(3):793–800

    Article  Google Scholar 

  13. 13.

    Gill IS, Aron M, Gervais DA et al (2010) Clinical practice. Small renal mass. N Engl J Med 362:624–634

    CAS  Article  Google Scholar 

  14. 14.

    Almassi N, Gill BC, Rini B et al (2017) Management of the small renal mass. Transl Androl Urol 6(5):923–930

    Article  Google Scholar 

  15. 15.

    Jonisch AI, Rubinowitz AN, Mutalik PG et al (2007) Can high-attenuation renal cysts be differentiated from renal cell carcinoma at unenhanced CT? Radiology 243(2):445–450

    Article  Google Scholar 

  16. 16.

    Zhao Y, Wu Y, Zuo Z et al (2017) CT angiography of the kidney using routine CT and the latest Gemstone Spectral Imaging combination of different noise indexes: image quality and radiation dose. Radiol Med 122(5):327–336

    Article  Google Scholar 

  17. 17.

    Jain Y, Liew S, Taylor MB et al (2011) Is dual-phase abdominal CT necessary for the optimal detection of metastases from renal cell carcinoma? Clin Radiol 66(11):1055–1059

    CAS  Article  Google Scholar 

  18. 18.

    Zhong Y, Shen Y, Pan J et al (2017) Renal epithelioid angiomyolipoma: MRI findings. Radiol Med 122(11):814–821

    Article  Google Scholar 

  19. 19.

    Tedeschi E, Caranci F, Giordano F et al (2017) Gadolinium retention in the body: what we know and what we can do. Radiol Med 122(8):589–600

    Article  Google Scholar 

  20. 20.

    Dabestani S, Beisland C, Stewart GD et al (2018) Long-term outcomes of follow-up for initially localised clear cell renal cell carcinoma: RECUR database analysis. Eur Urol Focus S2405–4569(18):30072–30075

    Google Scholar 

  21. 21.

    Antonelli A, Ficarra V, Bertini R et al (2012) Elective partial nephrectomy is equivalent to radical nephrectomy in patients with clinical T1 renal cell carcinoma: results of a retrospective, comparative, multi-institutional study. BJU Int 109(7):1013–1018

    Article  Google Scholar 

  22. 22.

    Weight CJ, Larson BT, Fergany AF et al (2010) Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses. J Urol 183(4):1317–1323

    Article  Google Scholar 

  23. 23.

    Barbiero G, Groff S, Battistel M et al (2018) Are iatrogenic renal artery pseudoaneurysms more challenging to embolize when associated with an arteriovenous fistula? Radiol Med 123(10):742–752

    Article  Google Scholar 

  24. 24.

    Antic T, Taxy JB (2015) Partial nephrectomy for renal tumors: lack of correlation between margin status and local recurrence. Am J Clin Pathol 143(5):645–651

    Article  Google Scholar 

  25. 25.

    Comai A, Trenti M, Mayr R et al (2015) Computed Tomography after nephron sparing surgery. Abdom Imaging 40(7):2424–2431

    Article  Google Scholar 

  26. 26.

    Pozza S, De Marchi A, Albertin C et al (2018) Technical and clinical feasibility of contrast-enhanced ultrasound evaluation of long bone non-infected nonunion healing. Radiol Med 123(9):703–709

    Article  Google Scholar 

  27. 27.

    Faccioli N, Foti G, Casagranda G et al (2018) CEUS versus CT Angiography in the follow-up of abdominal aortic endoprostheses: diagnostic accuracy and activity-based cost analysis. Radiol Med 123(12):904–909

    Article  Google Scholar 

  28. 28.

    Tagliati C, Argalia G, Polonara G et al (2019) Contrast-enhanced ultrasound in delayed splenic vascular injury and active extravasation diagnosis. Radiol Med 124(3):170–175

    Article  Google Scholar 

  29. 29.

    Putz FJ, Erlmeier A, Wiesinger I et al (2017) Contrast-enhanced ultrasound (CEUS) in renal imaging at an interdisciplinary ultrasound centre: possibilities of dynamic microvascularisation and perfusion. Clin Hemorheol Microcirc 66(4):293–302

    CAS  Article  Google Scholar 

  30. 30.

    Le O, Wood C, Vikram R et al (2017) Feasibility of contrast-enhanced intraoperative ultrasound for detection and characterization of renal mass undergoing open partial nephrectomy. J Ultrasound Med 36(8):1547–1553

    Article  Google Scholar 

  31. 31.

    Drudi FM, Cantisani V, Granata A et al (2019) Multiparametric ultrasound in the evaluation of kidney disease in elderly. J Ultrasound. [Epub ahead of print]

    Article  PubMed  Google Scholar 

  32. 32.

    Nestola M, De Matthaeis N, Ferraro PM et al (2018) Contrast-enhanced ultrasonography in chronic glomerulonephritides: correlation with histological parameters of disease activity. J Ultrasound 21(2):81–87

    Article  Google Scholar 

  33. 33.

    Sidhu PS, Cantisani V, Dietrich CF et al (2018) The EFSUMB guidelines and recommendations for the clinical practice of contrast-enhanced ultrasound (CEUS) in non-hepatic applications: update 2017 (Short Version). Ultraschall Med 39(2):154–180

    Article  Google Scholar 

  34. 34.

    Meloni MF, Smolock A, Cantisani V et al (2015) Contrast enhanced ultrasound in the evaluation and percutaneous treatment of hepatic and renal tumors. Eur J Radiol 84(9):1666–1674

    Article  Google Scholar 

  35. 35.

    Singh A, Jai S, Ganpule S et al (2016) Bolster material granuloma masquerading as recurrent renal cell carcinoma following partial nephrectomy. Indian J Radiol Imaging 26(3):352–355

    Article  Google Scholar 

  36. 36.

    Agarval MM, Mandal AK, Agarwal S et al (2010) Surgicel granuloma unusual case of “recurrent” mass lesion after laparoscopic nephron sparing surgery for renal cell carcinoma. Urology 76(2):334–335

    Article  Google Scholar 

  37. 37.

    Tonolini M, Ierardi AM, Varca V et al (2015) Multidetector CT imaging of complications after laparoscopic nephron sparing surgery. Insight Imaging 6(4):465–478

    Article  Google Scholar 

  38. 38.

    Álvarez Rodríguez S, Hevia Palacios V, Sanz Mayayo E et al (2017) The usefulness of contrast-enhanced ultrasound in the assessment of early kidney transplant function and complications. Diagnostics (Basel).

    Article  Google Scholar 

  39. 39.

    Mueller-Peltzer K, Rübenthaler J, Fischereder M et al (2017) The diagnostic value of contrast-enhanced ultrasound (CEUS) as a new technique for imaging of vascular complications in renal transplants compared to standard imaging modalities. Clin Hemorheol Microcirc 67(3–4):407–413

    CAS  Article  Google Scholar 

Download references


No funding was used for this study.

Author information



Corresponding author

Correspondence to Elena Bertelli.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Bertelli, E., Mercatelli, L., Savi, E. et al. Surgical margin follow-up after nephron-sparing surgery: the possible role of CEUS. J Ultrasound 23, 515–520 (2020).

Download citation


  • CEUS
  • Nephron-sparing surgery (NSS)
  • Small renal masses (SRM)
  • Kidney
  • Cancer
  • Granuloma