Declining cognition, ? nephrectomy

83yo male with a very large renal cancer for hand-assisted laparoscopic nephrectomy. Urologists had arranged a CPET to help the decision-making process.


  • HTN
  • Subcortical stroke 2017
  • RCC – large mass, visible externally and with a contralateral adrenal mass (likely metastasis).


  • CPET result
    • AT 8ml/kg/min and peak VO2 11ml/kg/min = elevated perioperative risk
    • Not always used in this context as with cancer requiring urgent surgical curative treatment it may not offer additional risk stratification. Minimal opportunity for cardiorespiratory optimisation.
  • Cognitive function
    • Surgeon noted that Patient coped well with wife present, but cognitive deficits were obvious when she was absent.
    • CPET MDT discussion prompted shared-decision making appointment at clinic
    • MMSE in clinic 12-13/30.


  • Cognitive screening in clinic
    • Very concerning when a patient scores 12-13/30 on MMSE, but what about 19-20/30 (a common score). Trajectory of their cognitive decline is important, speak with GP and look for geriatrician reviews or other MMSE sources.
    • This patient’s MMSE was performed in front of his family which was useful in demonstrating to them clearly how frail he is.
    • Accelerating his cognitive decline postop was seen as the biggest risk for him with this surgery.
  • Goals of care/prognosis
    • What is the role of the contralateral met in his decision making?
    • Surgery thought to be at best curative, at worst palliative (bleeding and pain from renal capsular and peritoneal stretch (regardless of malignant v. benign status).
    • PET scans not always helpful in diagnosing malignant vs. benign renal lesions, due to physiologic uptake of FDG in the kidneys. Can be useful for diagnosing metastases.
    • Adrenal lesions, benign and malignant, also have variable PET avidity due to background high metabolic activity.


  • Family discussion ongoing but likely patient will decline surgery