ABSTRACT
Purpose:
Robot-assisted partial nephrectomy (RAPN) is rapidly increasing its role in the nephron-sparing surgery setting (11 Di Maida F, Grosso AA, Sforza S, Mari A, Lambertini L, Nardoni S, et al. Surgical Management of Synchronous, Bilateral Renal Masses: A 1-decade Referral Center Experience. Eur Urol Focus. 2022:S2405-4569(22)00033-5.). The recent introduction of technological advancements is leading more experienced surgeons to approach complex renal mass with a conservative intent (22 Minervini A, Grosso AA, Di Maida F. How To Deal with Renal Cell Carcinoma Tumors >7 cm: The Role of Nephron-sparing Surgery. Eur Urol Open Sci. 2021;33:42-44., 33 Campi R, Di Maida F, Lane BR, De Cobelli O, Sanguedolce F, Hatzichristodoulou G, et al. Impact of surgical approach and resection technique on the risk of Trifecta Failure after partial nephrectomy for highly complex renal masses. Eur J Surg Oncol. 2022;48:687-93.).
In particular, three-dimensional reconstruction and the use of intraoperative ultrasonography are gaining attention as crucial tools to safely and effectively approach complex cases (44 Minervini A, Grosso AA, Di Maida F, Mari A, Vittori G, Muto G, et al. How far is too far? Exploring the indications for robotic partial nephrectomy in a highly complex kidney tumor. Int Braz J Urol. 2020;46:871-2., 55 Grosso AA, Di Maida F, Tellini R, Mari A, Sforza S, Masieri L, et al. Robot-assisted partial nephrectomy with 3D preoperative surgical planning: video presentation of the florentine experience. Int Braz J Urol. 2021;47:1272-3.).
We aimed to video-report the management of highly complex renal mass treated with RAPN, focusing on preoperative surgical planning and intraoperative technical nuances.
Materials and methods:
A 73-year-old male patient was referred to our institution for an incidental detection of a 70 mm diameter, completely endophytic, hilar renal mass (PADUA score 13, RENAL score 11a). Contrast-enhanced CT scan images were processed by M3DICS (Turin, Italy) and used to obtain a 3D virtual model. RAPN was performed by a highly experienced surgeon using Da Vinci Si robotic platform with a three-arm configuration.
Results:
The overall operative time was 114 min, with a warm ischemia time of 16 min. No intraoperative or postoperative complications were recorded. According to the SIB score, the pure enucleation excision strategy was performed. Histopathological analysis revealed a pT3a low-grade oncocytic kidney tumor with negative surgical margins. with negative surgical margins. At 24-months follow up, no local or systemic recurrence was detected.
Conclusions:
Conservative management of complex renal masses is challenging with a highly nuanced decision-making process. In this regard, preoperative 3D models and intraoperative ultrasound (US) guidance play a pivotal role to develop a tailored surgical strategy according to patient’ and tumor's characteristics.