V3-11: Robotic partial nephrectomy involving intracorporeal cold ischemia for post cryoablation failure
The reference standard treatment for small renal masses is partial nephrectomy, and the robotic approach has become rapidly adopted in this setting. However, minimally invasive approach to partial nephrectomy can be complicated by previous surgery or percutaneous renal ablative therapy. The ideal approach to partial nephrectomy is unknown in this setting. We present a surgical video of a 62 year old female with a previous left renal cryoablation, who developed an ipsilateral recurrent left renal mass in the previous ablative zone. We performed a robotic partial nephrectomy utilizing intracorporeal cold ischemia. Our surgery is technically innovative in that we introduce a method for providing cold ischemia through a minimally invasive robotic approach in the setting of cryotherapy failure.
The Da Vinci Xi (Intuitive Inc, Sunnyvale, CA, USA) robotic platform was utilized with a 4 arm approach. Robotic ports were placed in a linear configuration lateral to the rectus muscle and an assistant port near the umbilicus. An additional 15mm accessory port is placed near the 12th rib for introduction of ice slush. Modified 20mL syringes are used to deploy ice slush through the 15mm accessory port. The renal artery is clamped and the tumor completely excised. Renorrhaphy was performed with adequate hemostasis.
Estimated blood loss was 50mL Cold ischemia time was 83 minutes. Final pathology revealed clear cell renal cell carcinoma, Fuhrman grade 2, 2.0cm, with negative margins, pT1a. Follow up renal functional studies showed a GFR >60 mL/min/1.73m2 at 6 month follow up.
Robotic partial nephrectomy in the setting of percutaneous ablative failure is technically feasible and can be performed with the addition of ice slush cold ischemia. Further study is requisite to confirm these results.