Hugo RAS Robot-Assisted Partial Nephrectomy for High-Nephrometry Score Complex Renal Mass: Case Report and Surgical Technique

Abstract

Hugo™ robot-assisted surgery (RAS) system has been conceived with enhanced modularity cart features and an independent arm-cart docking, nonetheless its role for nephron-sparing surgery has not been defined yet. From October 2022, 15, consecutive patients underwent off-clamp robot-assisted partial nephrectomy (RAPN) for T1 tumors. We are a solely off-clamp partial nephrectomy (PN) center, consequently the T2 RAPN was carried out clampless. Furthermore, we acquired experience and familiarity with Hugo RAS, thanks to an initial series of 15 robotic radical prostatectomies. We report the first RAPN with the new Hugo RAS system for a large highly complex right posterior hilar renal mass (8 cm, cT2) in a 63-year-old man with a BMI of 35.3 kg/m2. The choice to perform RAPN for high-nephrometry score renal mass without hilar clamping was because of the technique we usually perform at our center as we have never done on-clamp procedures. The purpose was to assess the feasibility and the modularity of Hugo RAS independent arm-cart docking even in complex posterior hilar renal tumor, and to explore its role in the setting of off-clamp RAPN. Preoperative hemoglobin, serum creatinine, and estimated glomerular filtration rate were 15.5 g/dL, 0.92 mg/dL, and 115.1 mL/min per 1.73 m2, respectively. The patient was placed on an extended flank position. A modified three-arm configuration was used by a conventional transperitoneal route. Port placement and docking time required 5 minutes. Complete kidney mobilization, identification of arterial branches feeding the tumor, and straightforward approach to the renal mass represented standard key steps of our off-clamp RAPN technique. Tumor enucleation was achieved developing an anatomical cleavage plane. Intraoperative bleeding was controlled with double suction, a slight increase of the pneumoperitoneum to 20 mm Hg, monopolar energy, and renorraphy with a 2/0 Monocryl single-running suture using a sliding-clip technique. No intraoperative complications occurred. No additional port placement was necessary. Console time was 110 minutes, estimated blood loss were ~500 mL. Patient was discharged on postoperative day 3 after bladder catheter and abdominal drain removal, with hemoglobin, serum creatinine, and eGFR of 11.8 g/dL (∆Hb 3.7 g/dL), 0.94 mg/dL, and 112.6 mL/min per 1.73 m2, respectively. Histologic evaluation revealed a chromophobe renal cell carcinoma. Considering the intra- and perioperative outcomes, the lack of complications, and the fast docking, this robotic platform seems to be an user-friendly technology. Currently, the small series considered as the granularity of data regarding the application of Hugo RAS in the RAPN setting hinder to assess that this novel platform is comparable with conventional robotic systems. Further studies with a larger cohort are needed to establish the noninferiority of this platform, but preliminary results seem encouraging. The authors declare no conflict of interest and any commercial associations during the past 3 years. No funding was received for this article. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Institutional Review Board Statement: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Source of Work: This study was carried out at Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy. Runtime of video: 4 mins 45 secs