V3-05: Robotic assisted laparoscopic tumor enucleation with artery hypothermic perfusion combined with neoadjuvant target therapy for a multifocal solitary kidney cancer
Our patient is a 61 year old female who underwent radical nephrectomy on the right side 8 years ago. Multiple renal masses were found by ultrasound during the latest follow up. Subsequent imaging confirmed 3 tumors in the left kidney with 5.5cm in the greatest dimension.
This patient underwent 3 circles of neoadjuvant target therapy with Axitinib. All of three tumors shrinked after therapy with decreased enhancement and clearer tumor capsule in the CT imaging. A balloon was placed into the left renal artery by an interventional radiologist before surgery. We began the procedure by mobilizing the colon. Then we identified the renal vein and all of its branches. After the lumbar vein was disconnected, the renal artery can easily be dissected. After defat, the kidney was totally mobilized. After occlusion of the artery, the renal vein was clamped. During infusion of cold Ringer’s solution, we started enucleation from the largest tumor. The parenchyma close to the tumor was resected until the capsule was identified. The tumor was enucleated by combining sharp and blunt dissection using tumor capsule as the anatomical landmark, with no visible rim of normal parenchyma. Tumor thrombosis was find invading into the branch of the renal vein and was separated from the tumor. The second tumor was identified at the edge of the first tumor and was enucleated with the same technique. The thrombosis was resected and no visible tumor was left on the tumor bed. Collecting system was found ruptured and was closed by running suture with 3-0 monofilament. No additional suture was performed on the tumor bed. The parenchyma defect was closed with horizontal interrupted 2-0 Monocryl sutures with Hem-o-lok clips placed on the kidney capsule. The third tumor at the upper pole was enucleated similarly. Once the stitches were placed, the clamp of the renal vein was removed and occlusion of the artery was released.
Perioperative date revealed estimate blood loss of 200 ml and warm ischemia time of 68 minutes. The patient underwent anuria for 2 hours and the serum creatinine elevated to 3.4 mg/dl 48 hours after surgery and dropped down to 1.5mg/dl after one month. Final pathology revealed a pT3a clear cell carcinoma. No residue tumor was revealed in the enhanced CT during follow up.
In summary, complicated renal cancer, especially solitary cancer need individualized treatment. Tumor enucleation assisted with target therapy and robotic technique seems like a feasible strategy to realize tumor free and maintain renal function.