V9-04: ROBOTIC PARTIAL NEPHRECTOMY IN THE SETTING OF IDIOPATHIC IVC OBSTRUCTION: A MULTIDISCIPLINARY APPROACH
A renal mass in the setting of pararenal vascular anomaly is an unusual presentation that increases the complexity of robotic partial nephrectomy. We highlight important surgical considerations and discuss our preoperative and intraoperative management.
The patient was a 39-year-old woman with a 4.1-cm posterior hilar renal mass (RENAL score: 11). She also was noted to have suprarenal inferior vena cava stenosis causing a large retroperitoneal aneurysm posterior to the mass and extensive pararenal collateralization. She was healthy and otherwise a good candidate for robotic partial nephrectomy, but she was deemed high risk for aneurysmal rupture or other serious bleeding due to the vascular anomaly. Robotic partial nephrectomy was performed via a transperitoneal approach using four working ports with the patient positioned in full flank. Intraoperative ultrasound was used for tumor identification. A two-layer renorrhaphy was performed of the deep and capsular layers. The deep layer was closed in a running fashion with 2-0 polyglactin 910 suture. Due to insufficient tissue, the outer edge of cortex was oversewn with 0 polyglactin 910 suture in a running horizontal mattress fashion using the sliding clip technique.
Preoperatively, Vascular Surgery was consulted, and endovascular stenting of the caval stenosis was performed. The lumbar aneurysm and collaterals decreased substantially in size. Surgical strategies employed during robotic partial nephrectomy included meticulous dissection of the hilum, complete mobilization of the kidney within Gerota's fascia to create space between the aneurysm and renal mass, and artery-only hilar clamping to provide venous drainage in the event of an unidentified arterial branch. Operative time was 3.6 hours; warm ischemia time was 26 minutes; and estimated blood loss was 200 cc. Seventy percent of the kidney was preserved, and there were no complications. The patient was discharged on postoperative day 3. Pathology showed T1a clear cell renal cell carcinoma with negative margins. Short-term glomerular filtration rate preservation was 86&[permil]._x000D_
Pararenal aneurysm and collateral formation can occur with suprarenal caval stenosis, increasing the risk of rupture and bleeding during right-sided robotic partial nephrectomy. Surgery can be performed safely using a multidisciplinary approach and meticulous surgical technique.