V2154: Robotic-assisted Laparoscopic Partial Nephrectomy for a Complex Cystic Tumor: Tips, Tricks, and Troubleshooting
VideoIntroduction and Objectives
Increasing experience with robotic-assisted partial nephrectomy has allowed for the resection of increasingly more complex tumors. New suturing techniques (eg. knotless sliding heme-o-lock) and hemostatic agents have lead to lower warm ischemia times (WIT) and decreased blood loss (EBL). However, resection of these masses can still be technically challenging, resulting serious complications such as hemorrhage and urine leak. Our objective was to present some maneuvers that we have found to be helpful when removing these tumors. We feel that these techniques may reduce WIT, allow for the resection of larger and more complex masses, improve visualization during resection, and minimize positive margins.
A 69 yo female was found to have a 3.6cm Bosniak IV right renal mass (R.E.N.A.L. 9x). There was an associated sub-capsular hematoma extending caudally to the mass. Additionally, the mass was seen to extend into the renal sinus, and abutted an upper pole calyx. A Tc 99m MAG3 renogram showed 38% split function in the right kidney. Her baseline serum Cr was 0.75 mg/dL and eGFR was > 60 mL/min/1.73m2. We used a three-armed approach with our standard port placement for robotic partial nephrectomy which has previously been described.
Our first tip describes the use of intra-operative Doppler ultrasound to carefully plan the resection, which we feel is essential. Next we present troubleshooting methods for persistent arterial hemorrhage during resection. This is likely due to a missed accessory artery, a bulldog placed too laterally on the renal artery (actually placed on a segmental branch), and failure of the bulldog to completely occlude the artery. Tip#2 includes maneuvers for dealing with this problem such as further hilar dissection to find all accessory arteries, unclamping the vein, more proximal clamping of the renal artery (to ensure the main trunk is occluded), or placing an extra bulldog on the artery to ensure adequate closure. Tip#3 describes techniques for controlling bleeding vessels as they are encountered during the resection. Finally, Tip#4 stresses the importance of pre-operative imaging to guide the resection, and not solely relying on visual cues. OR time was 150 min, EBL was 300cc, and WIT was 33 mins. Final pathology was a benign renal cyst. We encountered no peri-operative complications.
We present some tips for robotic partial nephrectomy that are helpful in achieving optimal oncologic and functional outcomes, while minimizing complications during the resection of a complex cystic renal mass.