V9-10: Technical caveats in Robotic Partial Nephrectomy in upper polar renal tumor
Nephron sparing surgery has become the standard of care for T1a small renal masses. A robotic approach is being increasingly used to perform this complex oncologic reconstructive procedure in view of its distinct advantages. Partial nephrectomy in upper polar tumors represents a distinct surgical challenge in view of its anatomical location. Aberrant vascular anatomy adds to the intricacy. We hereby present a video of robot assisted partial nephrectomy for an upper polar right renal mass with an accessory upper polar artery and discuss a few points of technique in context to the tumor location.
A 47 year female was incidentally found to have 4 cm right upper polar renal mass. Multi-phasic CT revealed RENAL 7 x right upper polar mass with an accessory artery to the upper pole. Transperitoneal robot assisted partial nephrectomy was performed in standard nephrectomy position using total 7 ports, including three 8 mm robotic ports, one 12 mm camera port, two 12 mm assistant ports and one additional 5 mm port for liver retraction. Ports were placed cephalic to the usual location. Ureteric catheter was not used and only limited mobilization of the colon was done. Complete mobilization of the upper pole from the liver and adrenal was done till psoas muscle as an initial step. Ureter and gonadal vein complex was sparingly dissected just to identify the hilum. Laparoscopic ultrasound probe was used to delineate the tumor. Main renal vessels were clamped separately and as the accessory artery was directly going into the tumor, it was clipped and divided. After tumor excision and repair of pelvicalyceal system, vessels were unclamped early and renal defect was repaired in two layers.
Total console time was 130 minutes and warm ischemia time was 13 minutes and 27 seconds. Per urethral catheter and drain were removed on POD 1 and 2 respectively. Patient was discharged in stable condition on POD 2. Histopathology revealed grade 2 clear cell RCC with clear margins.
Upper polar renal tumors represent a distinct surgical challenge for partial nephrectomy. Slight cephalad port placement, limited mobilization of the colon and ureter gonadal vein complex and initiating the complete mobilization of the kidney from the upper pole, avoids unnecessary dissection and may decrease overall operative duration while facilitating access to and excision of upper pole renal masses.