Robotic partial nephrectomy for complex renal tumors: surgical technique

Abstract

Objectives: Laparoscopic partial nephrectomy requires advanced training to accomplish tumor resection and renal reconstruction while minimizing warm ischemia times. Complex renal tumors add an additional challenge to a minimally invasive approach to nephron-sparing surgery. We describe our technique, illustrated with video, of robotic partial nephrectomy for complex renal tumors, including hilar, endophytic, and multiple tumors.

Methods: Robotic assistance was used to resect 14 tumors in eight patients (mean age: 50.3 yr; range: 30-68 yr). Three patients had hereditary kidney cancer. All patients had complex tumor features, including hilar tumors (n=5), endophytic tumors (n=4), and/or multiple tumors (n=3).

Results: Robotic partial nephrectomy procedures were performed successfully without complications. Hilar clamping was used with a mean warm ischemia time of 31 min (range: 24-45 min). Mean blood loss was 230 ml (range: 100-450 ml). Histopathology confirmed clear-cell renal cell carcinoma (n=3), hybrid oncocytic tumor (n=2), chromophobe renal cell carcinoma (n=2), and oncocytoma (n=1). All patients had negative surgical margins. Mean index tumor size was 3.6 cm (range: 2.6-6.4 cm). Mean hospital stay was 2.6 d. At 3-mo follow-up, no patients experienced a statistically significant change in serum creatinine or estimated glomerular filtration rate and there was no evidence of tumor recurrence.

Conclusions: Robotic partial nephrectomy is safe and feasible for select patients with complex renal tumors, including hilar, endophytic, and multiple tumors. Robotic assistance may facilitate a minimally invasive, nephron-sparing approach for select patients with complex renal tumors who might otherwise require open surgery or total nephrectomy.

Fig 1

Hilar tumor. CT demonstrates a 2.6 cm solid tumor located near the left renal vessels and abutting the renal pelvis.

Fig 2

Endophytic tumor. CT demonstrates a left 2.6 cm solid upper pole renal mass.

Fig 3

a. Multiple renal tumors. CT demonstrates two tumors in the mid/upper pole of the right kidney. b. Multiple renal tumors in the same patient. CT scan also demonstrates a right lower pole renal mass.

Fig 3

a. Multiple renal tumors. CT demonstrates two tumors in the mid/upper pole of the right kidney. b. Multiple renal tumors in the same patient. CT scan also demonstrates a right lower pole renal mass.

Fig 4

a. Port site placement for robotic partial nephrectomy. Periumbilical camera port for hilar tumor. Ports may be shifted laterally and superiorly for upper pole tumors. b. Schematic of port site placement demonstrating a periumbilical camera port (blue), robotic instrument ports (red), and assistant ports (yellow).

Fig 4

a. Port site placement for robotic partial nephrectomy. Periumbilical camera port for hilar tumor. Ports may be shifted laterally and superiorly for upper pole tumors. b. Schematic of port site placement demonstrating a periumbilical camera port (blue), robotic instrument ports (red), and assistant ports (yellow).