V04-05: Robot-assisted partial nephrectomy and bilateral pyelolythotomy of ectopic pelvic kidneys
Ectopic kidney is congenital abnormality of position and rotation, frequently associated with urolithiasis. In case of large stones, the percutaneous treatment has some specific difficulties related to the anatomy of the kidneys and the pelvis, that viceversa represents the ideal condition for a transperitoneal surgical access. The case here presented, in addition was affected by a bilateral renal lithiasis and an enhancing parenchymal mass of the right lower pole: with the aim to perform a “one-stage” treatment, we planned a robotic surgery.
A 44-years old male admitted because of recurrent left back pain. Past medical history was consistent bilateral pelvic kidneys and ureteral lithiasis spontaneously passed 1 year before. Abdominal contrast enhanced CT scan showed a 17 mm stone in the left renal pelvis, a 12 mm stones in the right pelvis and a 34x27 mm enhancing right lower pole renal mass, with a strict relationship with the prevesical ureter; the angiographic phases revealed a vascular supply to the right kidney from the common iliac artery. A robotic surgery was indicated. Patient was placed in trendelenburg position with Da Vinci® port configuration as for transperitoneal radical prostatectomy, using a 30° lens. The right kidney was firstly approached: after complete isolation of the ureter and its dissection from the tumor, suspension of the renal artery at its emergence from the iliac, a clampless partial nephrectomy was performed; then through a longitudinal pyelotomy was extracted the renal stone. To minimize the opening in the posterior peritoneum and the sigmoid mesentery, covering the left kidney, the site of the pelvis and stone were identified by an intraoperative ultrasound; then, through a longitudinal pyelotomy the stone was extracted. At the end, the peritoneum was sutured. A Jackson-Pratt drainage was place through the inferior robotic port
The operative time was 240 minutes, with 190 minutes of console time. Estimated blood loss was 50 mL. No intra or post-operative complications were reported. The drain was removed on the second postoperative day and the length of stay was 4 days. At discharge, the patient had serum creatinine of 0.93 mg/dL and haemoglobin of 12.5 g/dL. Final histopathology showed a pT1a G2 clear cell renal cell carcinoma with a negative surgical margin, while stone analysis showed calcium oxalate stones
With the availability of robotic technology, the indications for minimally invasive surgery may be safely expanded to include concomitant morbidities in uncommon presentations.