V9-11: Robotic partial nephrectomy for completely endophytic renal masses: variations in surgical technique
Robotic partial nephrectomy (RPN) for completely endophytic renal masses is feasible with increased robotic surgical experience. In this video we demonstrate our surgical technique for robotic partial nephrectomy, focusing on the technical variations for RPN for completely endophytic tumors.
Between June 2006 and August 2015, our institution performed 1,123 partial nephrectomies. 130 were performed for completely endophytic renal tumors. We present 2 patients with completely endophytic, central renal masses who underwent RPN, one in the left kidney and one in the right. Our approach to surgical removal of completely endophytic renal tumors includes the use of intraoperative ultrasound to delineate the margins of the mass, initial shallow angle of resection to improve visualization of the parenchymal margin and tumor base, and correction of excision trajectory at the renal sinus. This technique is described in detail in our video presentation.
Of the 1,123 RPN performed at our institution over the last 10 years, 11.6% were performed for completely endophytic renal masses. Mean operative time, warm ischemia and estimated blood loss in this cohort were 180 minutes, 24.5 minutes, and 197 cc, respectively. Minor complicate rate in this group was 13.9%, while major complication rate was 13.9%. 7 patients in this group had positive margins (5.4%). Successfully surgical extirpation of completely endophytic renal masses is optimized by an initially shallow incision in order to obtain a clear view of the parenchymal edge and base of tumor. Once the sinus fat and collecting system are exposed, the trajectory of the excision is corrected and the sides and back of the tumor are excised in a step-wise, circumferential fashion.
RPN for completely endophytic renal tumors is feasible and necessitates technical variations in excision in order to optimize outcomes. Excision of the tumor should be performed in a step-wise systematic fashion with a shallow initial incision to improve visualization into the renal defect and to avoid cutting into the tumor.