V9-09: Robotic Resection of Locally Recurrent Renal Cell Carcinoma
For localized small renal masses, partial nephrectomy has evolved as the standard of care. Over the last decade, contemporary series of open and laparoscopic partial nephrectomy have shown positive margins ranging from 0 to 4%, local recurrence between 0 to 4.2%, and mean time to recurrence from 12 to 43.3 months. This video will review and describe our robotic experience in the management of locoregional recurrence of renal cell carcinoma (RCC) after prior partial nephrectomy.
Two cases are presented. The first case is a 71 year old male who originally underwent right robotic partial nephrectomy for pT1b clear cell RCC with negative margins 3 years previously. Surveillance imaging demonstrated a recurrent right renal mass with associated renal vein thrombus. He underwent right robotic radical nephrectomy with excision of renal vein thrombus. The second case demonstrates a 73 year old male who originally underwent left robotic partial nephrectomy for pT1b clear cell RCC with negative margins 1.5 years previously. Surveillance imaging demonstrated recurrent left peri-hilar mass with an additional lesion adjacent to the hilum and aorta. A percutaneous biopsy of this lesion was negative. However, the mass continued to grow with clinical suspicion for recurrent tumor. He underwent left robotic radical nephrectomy with excision of the peri-aortic mass.
Technical steps, emphasized in the video, include the following: 1) lysis of adhesions; 2) mobilizing the colo-renal ligaments; 3) releasing adjacent organs (e.g., spleen, duodenum); 4) identification of the ureter; 5) identification of the renal hilum; 6) use of ultrasound with Power Doppler to identify vasculature and delineate the extent of the thrombus; 7) division of the renal vasculature with visualization of thrombus retracting proximally within the renal vein; 8) use of ultrasound to identify additional tissue to remove to ensure negative surgical margin.
This video demonstrates that in select patients with locoregional recurrence of RCC after prior partial nephrectomy, robotic radical nephrectomy can be safely performed. Keys in the success of performing this procedure: carefully delineation of the surgical planes and use of intraoperative ultrasound to define hilar vasculature and great vessels. Given complete resection of recurrent disease, close surveillance imaging will continue, and if distant disease develops, patients would be candidates for tyrosine kinase inhibitor therapy at that time.