V11-07: Robotic Partial Nephrectomy in a Pelvic Kidney Mass: Surmounting Anatomic Challenges
VideoIntroductions and Objectives
Surgical management of renal tumors arising in ectopic kidneys are often complicated by the presence of supernumerary arteries and veins. In our case, we present our experience with a 59-year-old male, who had an incidental finding of a left pelvic kidney and underwent a robot-assisted partial nephrectomy to excise an upper pole, posterior located renal mass with 5 renal arteries.
The patient presented with abdominal pain and on CT was found to have a 2 cm solid renal mass in a left pelvic kidney. He was counseled on the options of partial nephrectomy, ablative therapies, and surveillance, and opted for a robotic partial nephrectomy. Trocars were placed in an inverted U-shaped configuration similar to a robotic prostatectomy setup. The patient was noted to have multiple anomalous vessels: a large artery emanating from the aortic bifurcation, two additional arteries stemming from this large artery, a 4th artery off the left common iliac, and a 5th artery off the retroperitoneum. The mass was identified at the superior aspect of the kidney and skeletonized. Because the kidney was attached to the retroperitoneum by the 5th posterior artery, we were unable to rotate the kidney to gain better exposure of the mass. Laparoscopic ultrasonography was used to delineate the tumor margins. 12.5 g of mannitol were administered intravenously and arteries supplying the upper pole of the kidney were selectively occluded using laparascopic bulldog clamps. The 4th and 5th arteries were left unclamped to allow perfusion to the lower pole of the kidney. The mass was excised with visually clean margins and the defect closed in a two-layered fashion. After completion of the renorrhaphy, the bulldog clamps were removed with excellent pulsations noted in all arteries as well as perfusion to the upper pole of the kidney.
Total OR time was 4.5 hours, with an EBL of 50 mL and selective upper pole warm ischemia time at 27 minutes. The patient’s length of stay was 3 days. There were no intraoperative complications. His preoperative creatinine was 0.9 (eGFR 89) and was the same at discharge. At 6 months follow up, his creatinine was 1.0 (eGFR 76). Surgical pathology revealed a 2.2 cm grade 3 papillary renal cell carcinoma, with a 2 mm negative margin.
We believe that robotic partial nephrectomy is an ideal technique for excising tumors arising within an ectopic kidney, due to the superior visualization and ergonomic advantages offered by the wristed instrumentation. In our case, this technique allowed for successful resection of the tumor despite its challenging location and complex vasculature.