3D Clampless Robot-Assisted Partial Nephrectomy for Endophytic Hilar Renal Mass

Nephron sparing surgery for endophytic and/or hilar renal masses, as well as for mass with contact or involvement of intraparenchymal structures such as vessels or calyces, represents a very challenging procedure in terms of localization and resection of the mass. Robot-assisted partial nephrectomy (RAPN) in the surgical management of these type of renal masses exponentially increased reducing postoperative morbidities. To date, different imaging tools have been adopted to improve preoperative planning, the quality of RAPN, and intraoperative navigation. An innovative tool is the three-dimensional (3D) model of the kidney and tumor based on preoperative computer tomography (CT). Herein we present our experience with 3D model-assisted RAPN in the complex case of a single-kidney patient with posterior, completely endophytic, and hilar renal mass. We described the case of a single kidney 63-year-old man who diagnosed a left renal mass of 4.5 cm at follow-up. The patient underwent right radical nephrectomy in 2002 for a clear cell renal cell carcinoma (ccRCC), involving the renal capsule (pT3aNxM0). R.E.N.A.L. nephrometry score was 10-x-h. For this totally endophytic hilar tumor, 3D-RAPN was performed by a highly experienced robotic surgeon using The da Vinci Xi® surgical system. A dissection of the intraparenchymal artery (just below the mass) is performed to preserve the clampless procedure. Total operative time and estimated blood loss were 140 min and 170cc, respectively. The drain was removed on post-operative day (POD) 3. The patient was discharged home on POD 4 without catheter in place and draining clear urine. Laboratory analyses at discharge revealed creatinine and estimated glomerular filtration rate (eGFR) of 1.02 mg/dl and 78 ml/min/1.73m 2 , respectively. Creatinine and eGFR were stable at 1 and 6 months of follow-up. Pathological showed ccRCC pT3aNx, grade 2, without positive surgical margin. No local and distant metastasis was diagnosed at 6 months. 3D reconstruction during robotic partial nephrectomy can improve the preoperative assessment, the quality of the resection phase, and a reduction in postoperative complications, with optimal functional recovery especially in challenging scenarios. All these efforts are made to be RAPN a real mini-invasive procedure.