V579: Robotic-Assisted Laparoscopic Surgery for Pediatric Renal Cell Carcinoma Allows for both Nephron-Sparing Surgery and Extended Lymph Node Dissection
VideoIntroduction and Objectives
Partial nephrectomy (PN) has been reported as safe and effective in appropriately selected children with renal cell carcinoma (RCC). However, there are only limited reports of laparoscopic or robotic PN for oncologic surgery in children. Additionally, lymph node (LN) involvement is relatively common in pediatric RCC, and may present even with small tumors. Some suggest that LN dissection provides therapeutic benefit. Herein, a case of pediatric RCC is presented to demonstrate how robotic-assisted laparoscopy can permit excellent exposure for PN as well as extended LN dissection.
The submitted video describes a 14yr female with an incidentally noted 1cm left lower-pole renal mass. Physical exam, history, and labs were unremarkable. Abdominal Computed Tomography and other staging imaging demonstrated no sites of metastasis. After discussion about potential occult LN involvement, as well as the risks and benefits of PN and minimally-invasive approaches, the family elected for robotic-assisted laparoscopic PN with extended LN dissection.
In a modified flank position, a camera port, 3 robotic ports, and an assistant port were placed. The colon was mobilized past the splenic flexure allowing for aortic visualization. As suggested for the LN dissection advocated in high-risk adult RCC, an aortic and hilar LN dissection was completed. The kidney was then mobilized to expose the mass and using ultrasound guidance the extent of the tumor was delineated. The renal vessels were controlled with laparoscopically-applied clamps. The mass was resected using cold scissors. Hemostatic control was obtained by applying thrombin gel, a surgical cellulose bolster, and 2 renorrhaphy sutures using the “sliding-clip” technique. The clamps were removed for a total warm ischemia time of 26 min. The mass and LNs were placed in a bag and removed via the assistant port. Specimens were sent for frozen analysis which revealed RCC with negative margins and LNs. The case was completed with a console time of 180 min. The patient recovered uneventfully and was discharged home 2 days later. Final pathology revealed a 1.5cm clear-cell RCC, Fuhrman Grade 2, with 6 benign LNs.
In appropriately selected children and adolescents with RCC, the excellent exposure provided by laparoscopy can allow for experienced laparoscopic and robotic surgeons to perform both the LN dissection and tumor excision with the associated benefits of minimally-invasive surgery.