V5-09: Robot Assisted Laparoscopic Partial Nephrectomy for a T2b lesion: Technique and Outcomes
Since the advent and integration of the robotic platform, more complex surgery is being performed via a minimally invasive approach. Reports of surgeons completing complex partial nephrectomies robotically have surfaced, but most focus on the location of a small tumor and very few, if any at all have presented data on ≥T2a lesions. We present the technique and successful outcomes for resecting a T2b renal mass with the robotic platform.
This is a 45 year old female patient who presented to the emergency department with chest pain. A chest CT scan did not reveal any pulmonary abnormalities, but did show the upper portion of a large, left renal mass. A subsequent CT scan of the abdomen and pelvis revealed a 13.5cm, cystic/solid renal mass, grade IV on the Bosniak grading system. The RENAL nephrometry score was 12x. She underwent a robot assisted laparoscopic partial nephrectomy. She was placed in a right lateral decubitus position. We utilized the da Vinci Xi system and performed a 3 arm procedure with a single, 12mm assistant port. During the procedure, care was taken to leave the upper pole/mass in situ and limit dissection around it because of its size and the cystic nature of the mass. We liberally utilized intraoperative ultrasound to ensure that the resection margins were negative for tumor.
The total operative time was 171 minutes. The warm ischemia time was 29 minutes. Estimated blood loss was 200mL. The patient was discharged home on post-operative day 2 and there have been no complications at > 30 days of follow up. Pre-operative creatinine was 0.79 and post-operative creatinine was 0.81. The final pathology was pT2a, Nx, Mx, Clear cell, Grade III, margins negative.
We present what we believe to be one of the first cases of a T2b, central, renal mass excised via a robot assisted laparoscopic partial nephrectomy. We believe that careful pre-operative planning, meticulous dissection and liberal use of intra-operative ultrasound can ensure success for complex lesions such as this and that size should not limit the utilization of nephron sparing surgery.