V7-11: Robotic-Assisted Laparoscopic Partial Nephrectomy for a Renal Mass in a Two-Year-Old
Robotic-assisted laparoscopic extirpative renal surgery has been well described for benign indications in children, primarily for resection of non-functioning renal moieties. However, it has rarely been described for resection of potentially malignant masses. The following clinical case demonstrates successful robotic-assisted laparoscopic partial nephrectomy (RALPN) for a renal mass in a two-year-old child. Because the methods used for neoplasms differ significantly from those employed for benign resection, they have been described in detail and demonstrated in the accompanying video.
The patient is a 15kg, otherwise healthy, two-year-old girl with an incidentally discovered 1.2cm left lower pole renal mass. The small size and polar location of the lesion made it particularly amenable to RALPN with plans for frozen section analysis and possible regional lymphadenectomy and conversion to radical nephrectomy.
The procedure was performed using an 8mm umbilical camera port, two 8mm robotic arm ports, and a 12mm assistant port. After medializing the descending colon, the ureter was traced up to the renal hilum. Renal vessels were encircled with vessel loops. The Gerota’s fascia and fat overlying the lower pole of the kidney was dissected and sent to pathology, exposing the underlying mass. Intra-operative ultrasound confirmed the presence and depth of the mass. The renal artery was clamped with laparoscopic bulldog. The mass was excised with cold scissors. Renorrhaphy was performed using sliding clip technique. Warm ischemic time was 32 minutes. Frozen sections showed narrow margins but was inconclusive regarding the tumor’s malignant potential and so a decision was made to defer further surgery until definitive diagnosis. Estimated blood loss was 10cc. The patient was discharged from the hospital on day two. Final pathology demonstrated adenomatous perilobar nephrogenic rest, a known precursor lesion to Wilms’ tumor. At last follow-up 3.5 months postoperatively, the patient is doing well with renal ultrasound demonstrating a normal appearing and symmetrical left kidney.
RALPN is a safe and effective modality for resecting potentially malignant renal masses, even in very small children. We believe it offers significant advantages over the large open incisions and radical resections often still utilized for small pediatric renal masses. The accompanying video further illustrates our technique.