Robotic Partial Nephrectomy: Complex Hilar Mass

Abstract

Introduction: Partial nephrectomy is currently the gold standard for definitive treatment of small renal masses. Robotic partial nephrectomy has allowed for the resection of increasingly more complex tumors. In the past, partial nephrectomy for completely endophytic tumors was routinely done through an open approach. However, advancement in laparoscopic ultrasound and robotics has allowed for resection of endophytic tumors more effectively. At our center, we have been performing robotic partial nephrectomy for tumors of increasing complexity, with higher nephrometry scores. We present our technique in the accompanying video. Materials and Methods: A 36-year-old male was found to have a 3.3 × 3.1 solid mass with solid enhancement in the midpole of the right kidney. The mass was completely endophytic, with a R.E.N.A.L. score of 10ah. His preoperative creatinine was 0.76 mg/dL and estimated glomerular filtration rate (eGFR) was >60 mL/minutes/1.73 m2. A decision was made to proceed with a robotic partial nephrectomy. Our positioning and port placement have been previously described for a partial nephrectomy. We docked the robot over the patient's right shoulder, using a three-armed approach. We used the laparoscopic ultrasound extensively to localize the tumor. A cap of normal parenchyma was first removed, and then the tumor was dissected off the hilum. We then performed our standard renorrhaphy technique. Results: Warm-ischemia time (WIT) was 35 minutes, and 70% of normal parenchyma was preserved. Estimated blood loss was 200 cc. There were no intraoperative complications. Final pathology revealed a 3.8 × 2.7-cm tumor, clear cell renal cell carcinoma, Fuhrman grade 3. The resection margins were negative. The patient's creatinine on discharge was 0.92 mg/dL, and eGFR was >60 mL/minutes/1.73 m2. A nuclear renogram is pending. Conclusions: Robotic partial nephrectomy for a completely endophytic hilar tumor is technically feasible. We incurred a longer WIT; however, we were able to preserve 70% of functional renal parenchyma with good short-term renal function. For this young patient, we feel this was a better alternative than performing a radical nephrectomy for his endophytic hilar tumor. Jihad H. Kaouk: Intuitive Surgical, Inc. (Consultant); Ethicon, Inc. (Speaker); Endocare, Inc. (Speaker). No competing financial interests exist for the other authors. Runtime of video: 9 mins 43 secs