V07-10: Robotic-Assisted Partial Nephrectomy with Intracorporeal Hypothermia after Pazopanib treatment in a Solitary Kidney with Segmental Vein Thrombosis
Partial nephrectomy (PN) is indicated for patients in whom loss of nephrons would place them at risk for renal replacement therapy, such as those with a solitary kidney. A variety of tyrosine kinase (TK) inhibitors, such as Pazopanib, have demonstrated the ability to decrease tumor volume in patients who may be amenable to PN. In this video, we demonstrate our surgical technique of robotic partial nephrectomy (RPN) in a patient with a solitary kidney who had received neoadjuvant Pazopanib, highlighting the multidisciplinary approach required to optimize renal parenchymal preservation.
In our video, we present the case of 77-year-old male, caucasian with 6.6 cm left renal neoplasm in a solitary kidney. An initial percutaneous biopsy from the mass revealed clear cell RCC ISUP 2. After a multidisciplinary tumor board meeting, Pazopanib (800mg once daily) was administered for 8 weeks with repeat imaging at completion of therapy. Post-TK-inhibitor image study was compared with the pre-TK-Inhibitor CT using the Morphology, Attenuation, Size, and Structure (MASS) criteria showing a favorable response to the treatment. Thereafter, a RPN was planned. Major steps of our robotic technique on this case included: 1) Colon mobilization, 2) Ureteral identification and mobilization, 3) Hilar dissection and control, 4) Kidney defatting, 5) Visualization and tumor demarcation, 6) Intracorporeal hypothermia using ice slush, 7) Excision of renal mass and segmental vein thrombosis clipping, 8) Renorraphy and, 9) Specimen retrieval. Perioperative outcomes including operative time, pathology, length of stay and complications were presented.
The procedure was performed without conversion to open. The operative time was 224 minutes with a cold ischemia time of 53 minutes. The estimated blood loss was 800ml and the length of hospital stay was 4 days. Pathology demonstrated an 8.6cm mass consistent with Clear Cell Renal Carcinoma ISUP 3 with a TNM staging pT2aNx. Postoperative GFR was maintained at 24 ml/min compared to the preoperative value of 33 ml/min.
A multidisciplinary approach is effective for patients in whom nephron preservation is critical, providing an opportunity to select those that may benefit from TK-inhibitor therapy. Pazopanib may allow for partial nephrectomy in a highly selective subgroup of patients who would otherwise require radical nephrectomy. Prospective data will be necessary before this strategy can be disseminated into clinical practice.