|Year : 2021 | Volume
| Issue : 1 | Page : 5-8
Robotic partial nephrectomy for multiple renal masses: A case series
Konstantinos G Stravodimos, Napoleon Moulavasilis, Emmanouil Manousakis, Evangelos Fragkiadis
Department of Urology, National and Kapodistrian University of Athens, Greece
|Date of Submission||07-Jun-2021|
|Date of Decision||22-Jun-2021|
|Date of Acceptance||28-Jun-2021|
|Date of Web Publication||15-Feb-2022|
Konstantinos G Stravodimos
Department of Urology, Laiko Hospital, National and Kapodistrian University of Athens, Agiou Thoma Street, Athens, 115 27
Source of Support: None, Conflict of Interest: None
Background: Partial nephrectomy is strongly recommended by the EAU guidelines as the primary treatment option for T1 Renal Cell Carcinoma. Robotic assisted partial nephrectomy has been gaining ground as an approach with similar oncological results to open and laparoscopic approaches, while outperforming them in secondary endpoints, such as functional and perioperative results. Materials and Methods: We present our cohort of multiple renal tumors treated with robotic partial nephrectomy. 4 patients were treated for double kidney tumours. We demonstrate patients' demographics and tumour preoperative assessment, our surgical technique, operative details, such as the perioperative outcomes and complications. Conclusion: Our experience in the treatment of multiple renal masses with robotic partial nephrectomy suggests favourable outcomes for our patients extending the oncological, functional and perioperative results of RAPN.
Keywords: Multiple masses, partial nephrectomy, robot
|How to cite this article:|
Stravodimos KG, Moulavasilis N, Manousakis E, Fragkiadis E. Robotic partial nephrectomy for multiple renal masses: A case series. Hellenic Urology 2021;33:5-8
| Introduction|| |
Partial nephrectomy is strongly recommended by the EAU guidelines as the primary treatment option for T1 renal cell carcinoma,,,,,,,,, as robotic technology plays an increasingly important role in surgery worldwide. Surgical patterns in Greece confirm the rapid adoption of the technique in everyday practice, as in the rest of the world. Concerning the treatment of renal masses, oncological outcomes such as progression-free survival are comparable between radical and nephron-sparing approach, while partial nephrectomy better preserves kidney function and protects from cardiovascular disorders and mortality. Nonetheless, a slightly higher complication rate is associated with nephron-sparing techniques. Anatomic considerations regarding tumor site, size, multifocality, and complexity are also important factors in decision-making.
Robotic-assisted partial nephrectomy (RAPN) has been gaining ground as an approach with similar oncological results to open and laparoscopic approaches,, while outperforming them in secondary endpoints such as warm ischemia time (WIT), intraoperative blood loss, transfusion rates, minor and major complications, and hospital stay.,,,
Multiple tumors in the same kidney, comprise a somewhat niche cohort of patients of increased complexity and special surgical challenges, that has been scarcely reported in the literature.,,, The increased dexterity of the Da Vinci robotic system (Intuitive Surgical, USA) allows to offer the full benefits of the robotic approach while treating multiple tumors in the same kidney. We would like to present our case series of multiple renal tumors treated with robotic partial nephrectomy.
| Materials and Methods|| |
From 2013 to 2021, a total of 76 robotic partial nephrectomies were performed in our Department, while four among them were for double kidney tumors. All RAPNs were performed by an experienced surgeon (K. S.) through a transperitoneal approach. Patients were placed in a modified flank position at 60°. Three robotic arms were used and two extra ports for the bedside assistant were placed (5 and 12 mm). The AirSeal system (ConMed, USA) was used to provide stable pneumoperitoneum, continuous smoke evacuation, and valve-free access to the abdominal cavity. After mobilization of the colon and the identification of the hilum, the renal vessels were prepared and positively identified. Tumor was identified and the boundaries were marked with cautery; only the renal artery was clamped using a bulldog and tumors were excised. A combination of cold and cautery excision was used. A two-stage renorrhaphy was performed on the defect using the sliding-clip technique.
We declare that we have obtained the consent of the participants to make the data public.
| Results|| |
Four patients (two females and two males, and one with Von Hippel-Lindau [VHL] disease) of a mean age of 52.5 (35–73) were treated for double kidney tumors and are presented in our cohort. We present the patients' demographics and tumor preoperative assessment utilizing the RENAL score in [Table 1]. The average value for body mass index was 26.85 kg/m2.
Tumor characteristics and final pathology report (all patients had at least one malignant tumor) are presented in [Table 2]. The size of the tumors excluded was from 6 mm to 45 mm and the RENAL score was valued 4–8. Two left and two right kidneys were operated. Only one tumor was recorded as T1b stage at the histology report, while all other tumors were recorded as T1a. None positive margins were found at any tumor excision. The histopathology findings include papillary tumors for patient 1, clear cell renal cell carcinoma (CRCC) and angiomyolipoma (AML) for patient 2, both CRCC for patient 3, and for patient 4 chromophobe renal cell carcinoma and AML.
Operative details, including operative time, WIT, and blood loss are presented in [Table 3]. No use of hemostatic agents was needed and a drain was placed upon completion of all cases. No conversion to open procedure or radical nephrectomy (lap or open) was necessary. No blood transfusion was needed, while only one patient had a prolonged hospital stay due to respiratory infection treated with antibiotics and having a delayed discharged at 9 days postoperative. Hemoglobin and creatinine level changes, postoperative complications graded with the Clavien-Dindo system and hospital stay are presented in [Table 4]. We took into account, the laboratory values of the preoperative examination performed 1 day before the surgery and the laboratory values on the 1st postoperative day. The fluctuation of the estimated glomerular filtration rate value that showed a decrease or an increase was attributed to the different conditions (fasting time) for each case under which the preoperative examination was performed. During follow-up, three patients are free of recurrence while the patient with VHL disease has a new tumor and is under active surveillance.
| Discussion|| |
Robotic partial nephrectomy offers the combined advantages of excellent long-term oncological results, less intra and postoperative complications, and the fast recovery time of a minimal approach surgery., Multiple factors attributing to those excellent results have been identified by various groups, such as the three-dimensional visualization, the effect of pneumoperitoneum on blood loss, but the most substantial factor is the increased dexterity and high precision of robotic instrument movements toward expanding the indication of partial nephrectomies to more complex cases. Therefore, we have a rapidly growing literature regarding case series of larger T2 tumors, of advanced complexity and higher RENAL score tumors., Complicated combined surgeries, such as partial nephrectomy and cholecystectomy, have been performed by our team owing to the same reasons.
Multifocality of renal cell carcinoma may range between 4.3% and 25%. Radical nephrectomy or nephron-sparing surgery does not contribute to differences in cancer-specific survival in this subgroup of patients with renal carcinoma. Multiple tumors are definitely a smaller group of patients and difficult to be studied in large numbers, but could also comprise younger patients and patients of hereditary syndromes, as patient 3 in our series (35 years old with VHL disease). These patients would benefit the most from renal function preservation and decrease of cardiovascular disorders. Cohorts similar to ours,,,, report encouraging results, with comparable operative time (mean 183.75 min in our series) and WIT (mean 24.25 min in our series). With developing experience, all the techniques described to reduce WIT (early unclamping, select clamping, and off-clamp) can be facilitated when operating multiple tumors. In our cases, early unclamping was achieved in one patient where the tumors were excised consecutively and the inner renorrhaphy was performed for both before unclamping and performing the approximation of the renal parenchyma.
The RENAL score is a well-accepted method that can be used to correlate with intra and postoperative complications in nephron-sparing surgery although tumor size may be used equally for the same purpose.
Due to the small size of our series, we did not attempt any correlation between scores or tumor size and outcomes. Nonetheless. multiplicity poses by itself a significant factor of surgical complexity. Robotic assistance helps to avoid surgical complications, and in our series, we did not have any intra or postoperative surgical complication or conversion.
Robotic assistance has been proven to achieve equal trifecta results in multifocal tumors with less morbidity when compared to open partial nephrectomy and be safe and feasible even in cases in solitary kidneys.,
We would like to stress that RAPN, although easier than the laparoscopic counterpart, is an operation with a difficult learning curve, especially in such complicated cases requires a well experienced team of surgeons, bedside assistants, nurses, and anesthesiologists. Meticulous preoperative assessment with contrast-enhanced computed tomography or Magnetic Resonance Imaging is of utmost importance regarding hilum anatomy, tumor anatomy, and preoperative planning in all of partial nephrectomy cases.
| Conclusion|| |
Our experience in the treatment of multiple renal masses with robotic partial nephrectomy suggests favorable outcomes for our patients extending the oncological, functional, and perioperative results of RAPN to a very special group of patients that may benefit the most. These complicated cases although demanding, should not be excluded from the robotic approach, but a dedicated and experienced surgical team is needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]