V10-04: Trans-Retro Robotic Partial Nephrectomy: A Novel Hybrid Approach for Challenging Posterior Tumors
Retroperitoneal nephrectomy has been associated with shorter operative time, ischemia time, and hospital stay, as well as less blood loss and fewer readmissions compared to a transperitoneal approach. Nevertheless, its use has typically been limited to tumors with lower complexity, likely due to the fact that the retroperitoneum is a smaller and less familiar space with limited visibility and maneuvering capacity. Here we discuss a robotic technique that combines the trans and retroperitoneal approaches, allowing for direct access to posterior renal masses without sacrificing maneuverability.
A 42-year-old woman presented with a 4.5 cm Bozniak type 4 mass located in the upper pole of the left kidney, near the hilum. After discussing treatment options, she elected to undergo robotic laparoscopic partial nephrectomy. The trans-retro approach was conducted with a da Vinci Xi robot. Transperitoneal: The camera was placed at the lateral border of the rectus muscle across from the 12th rib. Three 8 mm robot ports were placed: one 3 cm below the costal margin, one along the lateral border of the rectus muscle in the left lower quadrant, and one 5 cm cephalad to the anterior superior iliac spine. The transperitoneal portion was performed in its usual fashion. The colon was mobilized to enter the retroperitoneum followed by dissection to isolate the ureter and renal vessels. Retroperitoneal: An additional port was added for direct access to the posterior tumor. It was placed 3 cm above the anterior superior iliac spine lateral to the left midaxillary line. The camera was repositioned into the lower quadrant port, allowing for visualization from an inferior angle. Intraoperative ultrasound was used to confirm tumor location. The renal artery was clamped and the tumor was excised using cold scissors.
Operative console time was 3 hours, 30 minutes with an ischemia time of 20.5 minutes and estimated blood loss of 100 ml. The path report showed a 4.5 cm pT1b clear cell renal cell carcinoma, ISUP grade 1. The patient was discharged on post-op day three with no change in EGFR.
The trans-retro robotic partial nephrectomy approach is particularly useful for challenging posterior tumors, though its utility can be extended to less complex tumors. It allows for direct retroperitoneal access with ample maneuvering space, which is particularly beneficial for those less familiar with the retroperitoneal approach. We believe it is easily learned and a valuable option when assessing treatment of challenging posterior renal tumors.
Funding: Climb 4 Kidney Cancer