How far is too far? Exploring the indications for robotic partial nephrectomy in a highly complex kidney tumor

Abstract

Purpose: The conservative management of localized renal masses has been recently widened to cT2 tumors showing encouraging functional and oncological outcomes (1). This video aims to report the conservative management of a highly complex renal tumor treated with robotic pure enucleation in our center, specifically focusing on preoperative work-up, video-reported surgical steps and perioperative outcomes. Materials and Methods: A 63 year-old lady underwent CT scan revealing a single 75 x 68mm, mainly endophytic, right renal mass dislocating the vascular pedicle (cT3a). Two renal arteries and two veins were identified. PADUA, RENAL and simplified SPARE scores were 14a, 12a and 12 respectively. Since the contralateral kidney was hypotrophic, the indication for nephron-sparing approach was considered absolute. Preoperative surgical planning included the employment of 3D-virtual models (2). Results: Operative time was 150 minutes and warm ischemia time was 25 minutes. No major complication occurred. Histopathological analysis revealed a cromophobe renal cell carcinoma with extension to perirenal fat tissue (pT3a). Resection technique was classified as pure enucleation since Surface-Intermediate-Base (SIB) score was 0-0-0 (3, 4). At seven-months follow-up no signs of local or systemic recurrence were recorded. Postoperative CT-scan revealed optimal parenchymal volume preservation with last creatinine blood level of 1.16mg/dL. Conclusion: This video highlights how, in experienced hands, robotic partial nephrectomy represents a feasible, effective treatment option for surgical management of highly complex renal tumors. The employment of intraoperative ultrasonography and 3D-virtual models allowed to accurately tailor surgical approach, improving the perception of tumor anatomy and its vascularization and maximizing perioperative outcomes.

Predicting positive surgical margins in patients treated with robot-assisted partial nephrectomy: results from a prospectively maintained dataset of a single tertiary referral center

“…Therefore, their potential influence on PSMs remains unexplored in this analysis. Novel technological advancements in robotic surgery and 3D modeling might further enhance surgical precision [29,30] . Thirdly, the unicentric nature of this study could present potential variation in practices and techniques.…”

Assessment of the complexity of renal tumors by nephrometry (R.E.N.A.L. score) with CT and MRI images versus 3D reconstruction model images

“…Minervini et al analyzed the use of intraoperative ultrasonography and 3D-virtual models and found that it improved the perception of tumor anatomy and vascularization, maximizing outcomes (14).…”

Outcomes and Techniques of Robotic-Assisted Partial Nephrectomy (RAPN) for Renal Hilar Masses: A Comprehensive Systematic Review

“…Consequently, this consensus extends to the preferred surgical approach for these masses, with a strong endorsement for enucleative techniques which is the most common reported approach for managing a hilar lesion, adhering closely to the lesion while respecting the limits of the pseudocapsule [21,49]. This strategic choice in surgical method demonstrates an evolved understanding of renal anatomy and pathology, prioritizing organ preservation and functionality alongside effective cancer management [20,90,91].…”