Port-Site Metastasis After Robot-Assisted Partial Nephrectomy

Abstract

Introduction: With the increasing use of minimally invasive techniques in the management of urologic malignancies, reports of port-site metastasis (PSM) have raised concerns regarding the oncologic safety of these approaches.1 The first urologic PSM was reported in 1994, after lymph node dissection for bladder transitional cell carcinoma.2 Using multi-institutional, international data, an estimate for the incidence of PSM in urologic surgery has been reported to be 0.09%,3 and a contemporary review found 51 cases of urologic PSM reported in literature.4 However, renal cell carcinomas (RCC) represent a minority of these reported cases (8/51), and none occurred after robot-assisted partial nephrectomy (RAPN). We present a video describing our case of RCC-PSM after RAPN and demonstrating our technique for laparoscopic resection of the recurrent mass. Patients and Methods: In October 2011, a 68-year-old man underwent RAPN for an incidentally discovered 4-cm right renal mass with a nephrometry score of 10a. At no point during the resection was the mass violated. The final pathology demonstrated a 3.9-cm solid, Fuhrman grade III, clear-cell RCC with negative margins. In March 2012, routine follow-up CT scan revealed a 1.7-cm mass located on the abdominal wall, associated with an RAPN port site, and no other evidence of disease recurrence. Of note, the involved port site was the camera port site, not the specimen extraction site. The patient was completely asymptomatic. Ultrasound-guided biopsy demonstrated metastatic RCC, and in the absence of other metastatic disease, the patient was scheduled for resection of the PSM. With the patient in the left lateral decubitus position, a retroperitoneal approach was used to facilitate visualization of the intraperitoneal PSM. Once the retroperitoneal space was developed, the peritoneum was entered. The mass was well visualized and was circumferentially excised with wide margins. The mass was placed in an entrapment sack. The posterior rectus fascia was reinforced with a 2-0 polygalactin suture, which was secured with Weck Hem-o-lok clips (Teleflex, Research Triangle Park, NC). Hemostasis was ensured as the insufflation pressure was decreased to five mmHg, and the specimen was extracted, and the port-sites were closed. Results and Conclusions: The total operative time was 76 minutes, with a minimal (<10 mL) blood loss. The patient tolerated the procedure well and was discharged home on postoperative day one. The final pathology of the PSM demonstrated a 3.4-cm clear-cell RCC, granular variant, with negative margins. At present, one-month follow-up CT scan has demonstrated no evidence of disease recurrence or metastasis. The patient will be followed closely, with planned repeat imaging in six months. Although technique-related factors pertaining to specimen extraction have been implicated as a cause of PSM, our patient experienced recurrence at the camera port site, underscoring the importance of tumor and local wound-related factors in PSM. Several studies have also suggested that insufflation/desufflation during laparoscopic surgery may have an impact on the movement of tumor cells within the peritoneal cavity, potentially causing implantation at the port sites.5,6 Laparoscopic resection is a feasible minimally invasive alternative to open excision of PSM. No competing financial interests exist. Runtime of video: 5 mins 30 secs