Robotic Partial and Radical Nephrectomy in Renal Allograft: Demonstration of Technique

Abstract

Introduction: Renal tumors in allografts are rare but a serious condition. It presents a challenging clinical scenario where proper radiologic evaluation is commonly hindered by the suboptimal renal function. When surgical intervention is indicated, nephron sparing approaches are confronted with a risk of metastasis in an immunocompromised host, whereas graft nephrectomy results in significant postoperative morbidity and mortality as dialysis is reinitiated. Regardless of the surgical plan, graft surgery can be associated with significant vascular morbidities secondary to the dense desmoplastic reaction surrounding the anastomotic areas. Robotic surgery allows meticulous anastomotic dissection due to benefits of magnification, three-dimensional vision, and enhanced seven degrees of freedom of the robotic instruments. This may increase the chances of graft preservation. Moreover, it offers the benefits of minimally invasive surgery with less pain, shorter hospitalization, and less blood loss if total graft nephrectomy is desired. Methods: In this video, we are describing our technique of both robotic partial and total graft nephrectomy in a patient who was found to have a 1.4 cm allograft mass. The patient is a recipient of an extended criteria cadaveric kidney transplant 3 years before presentation. Evaluation was triggered by the fact that the recipient of the contralateral cadaveric kidney developed donor-derived squamous cell carcinoma originating from the allograft. Results: In this video, we demonstrated the key steps in the procedure, which included early control of the external iliac artery, release of the desmoplastic reaction around the transplanted vessels, vascular pedicle control, lysis of adhesions between the kidney and anterior abdominal wall, ultrasound-guided tumor excision, and renorrhaphy. Finally, the frozen section of the partial nephrectomy specimen revealed squamous cell cancer with negative margin. However, we felt that a radical nephrectomy was clinically indicated. Final pathology revealed T3 squamous cell carcinoma. Conclusion: Robotic approach may play a role in partial and the more commonly performed graft nephrectomy. It may provide an opportunity for better vascular dissection and offer the patient a minimally invasive approach to this challenging procedure. No competing financial interests exist. Runtime of video: 8 mins