V9-08: Robotic-assisted laparoscopic partial nephrectomy and ipsilateral pyelolithotomy in intrarenal pelvis

Video

Introductions and Objectives
Minimally invasive approaches to nephron sparing surgery have become increasingly utilized as the preferred approach to T1 tumors. In addition, robotic approaches have been used to treat large upper tract nephrolithiasis. Here we present an interesting case of a patient with a right renal mass and concurrent staghorn calculus in an intrarenal pelvis and describe our experience with robotic-assisted laparoscopic partial nephrectomy and pyelolithotomy.

Methods
A 59 year old male with an intrarenal pelvis (renal pelvic score >50%) and bilateral obstructing kidney stones causing renal failure requiring dialysis was found to have a 4.9 cm enhancing right renal mass (RENAL Nephrometry score 2+1+3+p+2=8p). Due to the large stone burden and ipsilateral mass, the decision was made to use a robotic-assisted laparoscopic approach to address both problems in a single setting. Highlights of our technique include planned extraction of large lower pole stones during tumor excision, the use of the 3rd robotic arm to lift renal parenchyma off the intrarenal pelvis gaining exposure for pyelolithotomy and the use of a ureteral access sheath to help guide and stabilize the flexible ureteroscope during pyeloscopy and stone extraction.

Results
Operative time was 330 minutes. Warm ischemia time was 39 minutes. Estimated blood loss was 250cc. There were no intra- or post-operative complications. The patient was discharged home on postoperative day 3. Pathologic analysis showed a lipid poor angiomyolipoma with negative margins and uric acid stones. At 2-month follow-up, a CT showed a well-healed renorrhaphy, a single 4 mm right mid-upper pole renal stone, and persistent 8mm left ureteropelvic junction stone despite potassium citrate therapy. Elective ureteroscopy to address the left stone and remove the small right residual stone is planned.

Conclusions
Robotic-assisted laparoscopic partial nephrectomy and pyelolithotomy is an effective and safe approach to treat patients presenting with concurrent renal masses and obstructing renal stones. In patients with an intrarenal pelvis, careful preoperative planning to use a 3rd robotic arm for retraction can aid significantly in the exposure needed to safely remove a staghorn calculi.

Funding: None