V07-03: Robot-assisted heminephrectomy using an Image-guided anatomical tumor devascularization technique
Conservative management of high volume kidney tumors has several goals : optimal sparing of healthy parenchyma, free margin tumoral excision and avoidance of extended ischemia. The objective of this video was to illustrate the image-guided anatomical tumor devascularization technique through an heminephrectomy case.
Synapse 3D Software (Fujifilm) was used for pre-operative CT Scan segmentation. The resulting 3D-model of the kidney displaying the vascular and collecting system anatomy allowed the selection of third and forth-order clamping spots with prediction of the related parenchymal ischemia. The surgery was performed with the Da-Vinci surgical robot (Intuitive Surgical) and intra-operative assistance for image-guidance comprised 3D model and ultrasound, both relayed on the console screen. Clinical data were collected in the French kidney cancer prospective database UroCCR after patient consent.
The patient, a 41 year-old male, BMI 38, presented with a 8cm hilar tumor on the upper and mid-pole of the right kidney. It was rated as a highly complex tumor regarding RENAL (10ph) and PADUA (13p). Pre-operative screening of third and fourth-order tumor-feeding arterial branches permitted to plan the devascularization of the tumor with a minor effect on the healthy parenchyma. The tumor limits were compared with the pattern of ischemia using an intra-operative doppler ultrasound. Once all tumor-feeding arteries were clipped, an off-clamp minimal margin tumor excision was performed. The length of surgery was 240 minutes and blood loss was 150ml. Pathologic examination confirmed a Fuhrman grade 4 clear-cell renal carcinoma, stage pT3a with negative surgical margin. The patient was discharged on post-operative day one without any complication. Based on post-operative month 3 CT-scan, the volume of spared parenchyma was 95ml and 82% of tumor-free parenchymal volume (115ml). The CT-scan showed a harmonious enhancement of the spare kidney.
The anatomical tumor devascularization technique for high-volume tumors combines safe tumor removal with minimal ischemia. Intra-operative image-guidance with endoscopic US and 3D model make the surgery achievable.