V08-09: Image-guided robot-assisted partial nephrectomy (IGRAPN): combining 3 imaging techniques to perform an anatomical zero ischemia hemi-nephrectomy.
Nephron sparing management of big renal masses is a challenging procedure due to the difficulties in optimal preservation of healthy parenchyma, maintaining an acceptable warm ischemia time, achieving negative surgical margins and controlled risk of complications. Our objective with this video is to report our experience using different imaging techniques to perform a zero ischemia hemi-nephrectomy with anatomic tumor excision for a complex tumor.
3D modeling of the tumor was performed using Synapse 3D (Fujifilm). This modeling allowed to select clamping points for 3rd order arteries in order to avoid global ischemia during resection. TilePro function of the DaVinci Si robot was used to access 3D modeling during surgery. Intraoperative US was used to delimitate tumor’s margin before resection. Indocyanine green was injected intraoperatively to control exact devascularisation area before tumor resection. Clinical data, collected after consent, were extracted from the french national database on kidney cancer UroCCR.
We’ve demonstrated the technique on the case of a 40 yo man with a 6 cm upper pole, endophytic, centrally located and hilar tumor of the left kidney(RENAL score 10ph and PADUA score 11p). The arterial branches of 2nd and 3rd order vascularizing the tumor were detected preoperatively and ligated before tumor resection to avoid unnecessary bleeding. Similarly, was done for the venous branch draining from the tumor area and the upper calyx. Intraoperative US was used to determine the exact boundaries of the lesion in order to avoid positive surgical margins. The use of indocyanine green permitted to verify the correspondence between the devascularisation and tumor area, demonstrating that a minimal margin resection was possible and that healthy renal parenchyma was not in the ischemic area. Total operative time was 150 min and estimated blood loss of less than 200 ml. The patient was discharged at post-operative day 3 without complication. At final pathology the mass resulted a pT1b papillary renal tumor with sarcomatoide components. 6 months after surgery no tumor recurrence was found at CT scan, sCr was 84 µmol/L and GFR 89 mL/min.
Image-guided anatomic zero-ischemia partial nephrectomy resulted safe and feasible. This technique combines best healthy parenchyma preservation with an anatomic control of the extent of ischemia and excessive bleeding. It allowed to perform nephron sparing surgery also in the case of large masses without compromising oncological and functional outcomes.