V5-02: Robotic Partial Nephrectomy for Highly Complex Renal Masses
The indications for partial nephrectomy are expanding. The AUA guidelines state that partial nephrectomy is a standard option for healthy patients with clinical T1b renal masses. For many complex renal masses, urologists will perform radical nephrectomy which risk future development of CKD with its associated morbidity and mortality. In this video, we demonstrate our technique of robotic partial nephrectomy for patients with highly complex renal masses.
Since 2008 we have performed over 450 robotic partial nephrectomies, 68 of which were on T1b or greater renal masses. Our port placement for the da Vinci Si and Xi are in figures 1 and 2. The use of adjunctive technologies to aid in surgical planning is paramount with complex renal masses. The use of intraoperative ultrasound to delineate tumor margins, the use of indocyanine green to help identify hilar vasculature and tumor margins, and obtaining high quality axial and 3D reconsturctions to assess proximity to critical structures are all necessary to aid in performance of this difficult procedure. For these masses renorrhapy is performed in multiple layers using monocryl for the collecting system and small vessels, and interrupted vicryl for the medulla and cortex.
The median age of our series was 58 (48-73). The median warm ischemia time was 18 minutes. There was one conversions to open but none in the past four years. Postoperatively, 75% of the tumors were malignant with a mean decrease in eGFR of 12% (-37% - 0%) at a median follow up of 32 months.
Partial nephrectomy in patients with complex renal masses including T2 and completely endophytic renal masses is a safe and feasible. The continued spread of technology and techniques may allow more patients to undergo nephron sparing techniques decreasing the risk of CKD and long term morbidity and mortality.