Robotic Partial Nephrectomy For Tumors Research Articles

Evaluation of Renal Mass Biopsy Risk Stratification Algorithm for Robotic Partial Nephrectomy—Could a Biopsy Have Guided Management?

We evaluated a published biopsy directed small renal mass management algorithm using a large cohort of patients who underwent robotic partial nephrectomy for tumors 4 cm or smaller. A simplified algorithm of biopsy directed small renal mass management previously reported using risk stratified biopsies was applied to 1,175 robotic partial nephrectomy cases from 5 academic centers. A theoretical assumption was made of perfect biopsies that were feasible for all patients and had 100% concordance to final pathology. Pathology risk groups were benign, favorable, unfavorable and intermediate. The algorithm assigned favorable or intermediate tumors smaller than 2 cm to active surveillance and unfavorable or intermediate 2 to 4 cm tumors to treatment. Higher surgical risk patients were defined as ASA® 3 or greater and age 70 years or older. Patients were assigned to the pathology risk groups of benign (23%), favorable (13%), intermediate (51%) and unfavorable (12%). Patients were alsoassigned to the management groups of benign pathology (275, 23%), activesurveillance (336, 29%) and treatment (564, 48%). Most of the 611 (52%) patients in the benign or active surveillance groups were low surgical risk andhad safe treatment (2.6% high grade complications). A biopsy may not havebeen feasible or accurate in some tumors that were anterior (378, 32%), hilar (93,7.9%) or less than 2 cm (379, 32%). Of 129 (11%) high surgical risk patients the biopsy algorithm assigned 70 (54%) to benign or active surveillance groups. The theoretical application of a biopsy driven, risk stratified smallrenal mass management algorithm to a large robotic partial nephrectomy database suggests that about half of the patients might have avoided surgery. Despite the obvious limitations of a theoretical assumption of all patients receiving a perfect biopsy, the data support the emerging role of renal mass biopsies to guide management, particularly in high surgical risk patients.

Robotic Partial Nephrectomy: Complex Hilar Mass

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

Renal hypothermia achieved by in situ cold saline perfusion in robotic partial nephrectomy for tumor in a solitary kidney: initial experience

Renal hypothermia achieved by in situ cold saline perfusion in robotic partial nephrectomy for tumor in a solitary kidney: initial experience