Introduction: Management of renal masses in solitary kidneys can pose a challenging dilemma. Important considerations include feasibility of mass resection with adequate renorrhaphy, limiting ischemia time, and preservation of nephrons to avoid dialysis. We present a complex robot-assisted partial nephrectomy (RAPN) in a 55 year-old female with a solitary left kidney, incidentally found to have a 5.7cm left renal mass that was centrally located, completely endophytic, with a R.E.N.A.L Nephrometry score of 11, and a baseline creatinine of 1.06 mg/dL.
Methods: The patient was placed in right lateral decubitus position with the left flank flexed. Pneumoperitoneum was achieved with a Veress needle, and four robotic 8 mm ports were placed in a straight line along the lateral edge of the rectus with a 12 mm assistant port in the midline. A remotely operated suction irrigation (ROSI) system was utilized. After the colon was medialized, hilar dissection was started with identifying the renal vein (RV), and immediately posterior and cephalad was the renal artery (RA). Intraoperative ultrasonography was performed to demarcate borders of mass excision, since the mass was completely endophytic. Approximately 50% of mass excision was performed with selective clamping of the artery supplying the tumor, but the main RA was eventually clamped to help control bleeding. The mass, along with a segment of tumor thrombus, was grossly excised to completion. Renorrhaphy was started with a 3-0 v-lock suture over-sewing the base of mass excision to control bleeding followed by simple interrupted 0-vicryl suture to bring edges of resection together. These were secured with two Hem-o-lok clips. Gerota’s fascia was re-approximated with a 3-0 v-lock suture, and the specimen was placed in a Endocatch bag for extraction through a Gibson incision.
Results: Procedure time was 5 hours and 13 minutes. Estimated blood loss (EBL) was 1,500 mL. Pathology showed clear cell RCC, Furhman grade 3, with lymphovascular invasion and a positive surgical margin at the RV. Post-operatively, the patient experienced a oliguric renal failure, with creatinine (Cr) peaking at 8.5 mg/dL on postoperative day 4 . Following that, urine output increased to over 2 liters daily, and Cr fell to 5.5 mg/dL by POD#9, at which time the patient was discharged. At one month follow-up, Cr was 1.49 mg/dL. At no point did the patient have any dialysis needs.
Conclusions: A number of difficult challenges exist for complex RAPN in solitary kidneys. Performing as much of the procedure as possible without clamping the main renal artery may increase blood loss but will also facilitate renal recovery.