Techniques of robotic assisted partial nephrectomy with renal vein tumor thrombectomy and reconstruction: UCSD experience

Abstract

Use of partial nephrectomy for T3 renal cell carcinoma is controversial. We performed a multi-institutional analysis of outcomes following robotic assisted partial nephrectomy for clinical T3a masses. Herein we describe our results and techniques. Robotic ports are placed in a linear configuration angled towards the kidney in a cranial to caudal direction. The case is started with bowel mobilization, and in cases of left sided tumors, complete spleen mobilization. In all instances, the renal artery and main renal vein are clamped. In cases of medially located tumors, the renal vein is dissected medially to identify segmental branches. The segmental branch with tumor thrombus is isolated and clipped. In cases of more posteriorly located tumors, the tumor is resected towards the tumor thrombus. The thrombus is then identified and the segmental vein either cut and oversewn, or stapled. The renorrhaphy is completed in a two-layer fashion, with early hilar unclamping. Total operative time in three cases ranged from 264–322 minutes with an estimated blood loss in the range of 200 cc to 500 cc. The warm ischemia time ranged from 28 min to 37 min. Two patients were discharged home on post-operative day two and the third patient discharged on post-operative day three. No patients sustained an immediate post-operative complication or 30-day readmission for complication. All three patients maintained renal function > 90% of baseline. Final pathology on all three specimens confirmed pT3a disease with negative margins in all cases. Robotic partial nephrectomy is feasible and safe for select clinical T3a renal masses, with acceptable quality outcomes. Further investigation is required to help clarify the role of minimally invasive partial nephrectomy in these advanced stage localized tumors.