V3-07: Salvage Robotic Partial Nephrectomy After Cryoablation
Focal therapy with cryoablation (CA) or radiofrequency ablation (RFA) is a treatment option for small renal masses, however reported recurrence rates are 10-13% (Novick, 2009). Salvage partial nephrectomy after CA is challenging due to significant desmoplastic reaction and scarring, which has been noted to be more severe than RFA. Increased complications have also been reported in post CA versus RFA patients. Robotic salvage partial nephrectomy is uncommonly reported. We describe a unique case of salvage robotic partial nephrectomy 5 years after CA.
A 60 year old healthy male was found to have a 2.8 cm right lower pole mass and he was treated with cryoablation therapy. He was asymptomatic, but remained on surveillance with periodic imaging. Five years later, he was found to have a 3.2 cm enhancing renal mass with calcifications, concerning for malignancy. He was referred to us for salvage robotic partial nephrectomy.
We utilized a standard transabdominal approach using a 6 port robotic technique. The colon was reflected medially. The inferior vena cava was identified. The ureter was significantly scarred and was in close proximity to the mass. Hilar dissection revealed a single renal artery and two renal veins. The kidney and mass were exposed. The ureter was adherent to the tumor and was carefully freed. Ultrasound guidance was used to demarcate the tumor. After hilar clamping, the mass was excised using a monopolar scissors. 3-0 v-loc suture was used to repair the calyceal openings and oversew the tumor bed. A 2-0 V-loc suture was used for the renorraphy using the running sliding hem-o-lok clip technique. Clamps were removed and good hemostasis was confirmed. Surgicel and Tisseel were applied to the defect. A JP drain was placed. Operative time was 162 minutes with 34 minutes of warm ischemia time. _x000D_ _x000D_ The foley catheter was removed the day after surgery. The patient was discharged home on postoperative day 1 with the drain despite drain creatinine being consistent with serum. It was removed in the office on postoperative day 3. Final pathology was grade 2 pT1a clear cell renal cell carcinoma with negative margins. Renal function was normal at four and 6 month follow up. Imaging did not reveal any evidence of recurrence.
In experienced hands, salvage robotic partial nephrectomy after cryoablation is challenging but feasible with acceptable warm ischemia time. As demonstrated in the video, robotic approach allows for adequate visualization and meticulous renorrhaphy.