Renal Mass with Renal Stones: A Challenging Scenario Managed with Robotic Assistance

Abstract

Introduction: A renal mass with a concurrent stone is a complex challenge. The challenge is to tackle both pathologies using a single anesthetic without compromising the oncologic or renal functional outcomes. This video demonstrates two cases using robot-assisted nephron-sparing surgery (RA-NSS) and provides tips for effective management to maintain the oncologic and functional safety. Methods: Simultaneous RA-NSS with stone retrieval was performed with DaVinci SiHD system using three robotic arms in two cases after obtaining due consent as per our previously described technique.1 Case 1 was a 66-year-old man, whereas the second case was a 56-year-old woman. In Case 1, during resection of the tumor the renal stone was identified through the opening in the pelvicaliceal system (PCS), which was further extended and three stones were retrieved intact. For Case 2, after dissecting the hilum, the renal pelvic dissection was performed followed by a pyelotomy to retrieve the stones. This mimics a previous published technique by Garisto et al.2 The PCS was closed with 3-0 polygalactin sutures over a Double-J stent (DJS), in both cases. Results: The warm ischemia time (WIT) was 27 minutes in Case 1 and the renal hilum was not clamped in Case 2. The estimated blood loss was 800 and 200 mL and the length of hospital stay was 7 and 5 days for Cases 1 and 2, respectively. The histopathology report in both the cases was clear cell with negative margins. The DJS were removed at 4 weeks. No adjuvant treatment was offered in both the cases. Both the patients were recurrence free with normal renal function at a follow-up of >5 years. Conclusions: During RA-NSS the focus is to limit WIT and maintain the oncologic margins. In a situation where a renal stone is large and the tumor is close to PCS (index Case 1), the NSS is performed initially followed by an incision further into pelvis for stone extraction. However, when the stone is in the pelvis and the tumor is in the periphery (index Case 2), pyelolithotomy should be performed first followed by NSS to decrease or avert the WIT. Patient consent statement: Both the patients of this video submission gave full consent for recording the surgical procedure and its use for publication. The authors have received and archived patient consent for video recording/publication None of the authors have any competing financial interests. Runtime of video: 8 mins 10 secs