Three-dimensional reconstruction and intraoperative ultrasonography: Crucial tools to safely approach highly complex renal masses

Abstract

_______________________________________________________________________________________Purpose: Robot-assisted partial nephrectomy (RAPN) is rapidly increasing its role in the nephron-sparing surgery setting (1). The recent introduction of technological advancements is leading more experienced surgeons to approach complex renal mass with a conservative intent (2, 3). In particular, three-dimensional reconstruction and the use of intraoperative ultrasonography are gaining attention as crucial tools to safely and effectively approach complex cases (4, 5). We aimed to video-report the management of highly complex renal mass treated with RAPN, focusing on preoperative surgical planning and intraoperative technical nuances. Materials and methods: A 73-year-old male patient was referred to our institution for an incidental detection of a 70 mm diameter, completely endophytic, hilar renal mass (PADUA score 13, RENAL score 11a). Contrast-enhanced CT scan images were processed by M3DICS (Turin, Italy) and used to obtain a 3D virtual model. RAPN was performed by a highly experienced surgeon using Da Vinci Si robotic platform with a three-arm configuration. Results: The overall operative time was 114 min, with a warm ischemia time of 16 min. No intraoperative or postoperative complications were recorded. According to the SIB score, the pure enucleation excision strategy was performed. Histopathological analysis revealed a pT3a low-grade oncocytic kidney tumor with negative surgical margins. with negative surgical margins. At 24-months follow up, no local or systemic recurrence was detected. Conclusions: Conservative management of complex renal masses is challenging with a highly nuanced decision-making process. In this regard, preoperative 3D models and intraoperative ultrasound (US) guidance play a pivotal role to develop a tailored surgical strategy according to patient' and tumor's characteristics. INFORMED CONSENTInformed consent was obtained from all individual participants included in the study. All the procedures were in accordance with the ethical standards of the institutional and national research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Three-dimensional virtual model for robot-assisted partial nephrectomy: a propensity-score matching analysis with a contemporary control group

“…Interestingly, a different message emerged from a systematic review and meta-analysis conducted among comparative studies where no difference was observed in terms of eGFR for RAPN carried on with/without 3DVMs [ 28 ]. We also harbored skepticism on the unselected adoption of such technology when performing nephrons-sparing surgery, as mentioned in previous publications [ 29 , 30 ]. As such, we conducted a sensitivity analysis on different PADUA risk-categories (low-risk PADUA 6–7; intermediate-risk PADUA 8–9; high-risk PADUA ≥ 10) showing that the functional benefit was observed only the high-risk category masses (Fig.…”

Clinical safety and efficacy of microwave ablation for small renal masses

“…Future studies evaluating the association between nephrometry score and microwave ablation outcomes could be beneficial. Other enhanced decision-making processes for the conservative management of complex renal masses may include utilizing preoperative 3D models to develop a tailored strategy according to patient and tumor characteristics ( 24 ). In addition, identification of patients at risk for pathologic upstaging could improve treatment efficacy.…”

3D virtual model for robot-assisted partial nephrectomy in highly-complex cases (PADUA ⩾ 10)

“…For the study purpose Chronic kidney disease (CKD) stage was assessed according to the Kidney Disease Improvement Global Outcomes-KDIGO criteria. 11 Resection technique was visually classified by the surgeon as enucleation (SIB score 0-2), enucleoresection (SIB score [3][4] or resection (SIB score 5) according to the SIB score, as previously reported. [12][13][14] Outcomes Our primary endpoint was to evaluate whereas RAPNs with 3DVM were superior in terms of functional outcomes defined as 12-month creatinine serum level and 12-month eGFR in the overall cohort and in subgroup analysis.…”

“…1 Recently, the escalating utilization of robotic-assisted procedures has conferred advantages upon NSS patients, manifesting in diminished postoperative discomfort and morbidity, 2 alongside prolonged survival rates, notably in T1-T2 instances. 3 Nevertheless, the management of complex neoplasms (PADUA ⩾ 10), 4 which exhibit adjacency to or encroachment upon intraparenchymal elements like vessels or calyces, or those obscured upon kidney exposure (endophytic or posteriorly situated), persists as a challenge. In 3D virtual model for robot-assisted partial nephrectomy in highly-complex cases (PADUA ⩾ 10) this pursuit, innovative imaging technologies have been explored, such as highly accurate three-dimensional virtual models (3DVMs).…”