V3-08: Partial nephrectomy of an Endophytic Mass in a Horseshoe Kidney
Nephron sparing surgery, specifically robotic assisted laparoscopic partial nephrectomy, has become a widely accepted treatment choice for small renal masses. Renal fusion abnormalities, such as horseshoe kidney, are uncommon congenital findings with a frequency of approximately 1 in 200 in the general population. Renal fusion abnormalities change the position and orientation of the kidney, and complicate the treatment of renal disorders. We demonstrate our technique for the management of a complex, endophytic cT1b renal mass in a horseshoe kidney.
A 73-year-old African-American gentleman with a history of CHF as well as COPD and a 50-pack-year history of cigarette smoking had an incidentally discovered horseshoe kidney on a contrasted CT scan of the abdomen ordered for abdominal pain, as well as an endophytic, complex cystic mass within the superior pole of the left portion of the kidney measuring 4.7 x 4.5 x 3.7 cm. This mass was assigned a 10AH on the nephrometry scoring scale. He placed in the modified flank position and the da Vinci Xi surgical system was used to target the left flank. After dropping the colon and the colorenal ligaments, we were able to identify the hilum, including the renal hilum, and the complex vascular anatomy. We used endoscopic ultrasound to target the tumor, and we undertook a circumferential resection of the mass. Final warm ischemia time was 24 minutes 32 seconds. We performed a two layer renorrhaphy, which was hemostatic at the conclusion of the procedure.
The patient did well postoperatively. His serum creatinine preoperatively was 1.3, and at the time of his discharge on postoperative day 3, it had returned to baseline. Final pathology showed papillary renal cell carcinoma type 1, Fuhrman nuclear grade 3, 4.2cm in maximal dimension. The surgical margin was negative for malignancy. The patient is currently awaiting follow up cross sectional imaging.
Robotic assisted laparoscopic partial nephrectomy can be a valuable addition to the urologist’s armamentarium for the treatment of complex renal masses identified in horseshoe kidneys.