Introduction: Wilms tumor is the most common pediatric renal neoplasm, affecting approximately one in 10,000 children. In cases of bilateral Wilms tumor, partial nephrectomy is the preferred treatment, to preserve renal parenchyma capacity while still achieving complete surgical excision with adequate margins. Partial nephrectomy for complex, endophytic renal masses is challenging and often involves complicated parenchymal reconstruction secondary to the deep cavity left behind by the excised tumor. Recent technological and surgical advances, including the three-dimensional model Iris, intraoperative indocyanine green fluorescence (ICG) imaging, selective clamping, and the daVinci robotic system, can assist during these technically challenging cases. This report describes how these systems and techniques can facilitate the treatment of a complex, endophytic Wilms tumor.
Methods: The patient was a 9-year-old male with Beckwith-Wiedemann Syndrome and metachronous bilateral Wilms tumors status post left partial nephrectomy. Histopathology was consistent with stage II favorable histology Wilms tumor. The patient completed chemotherapy as per NWTS-5 EE4A within five months of initial surgery. One year later, an abdominal MRI revealed a right kidney mass suspicious for a Wilms tumor. After no response to the initial DD4A chemotherapy regimen, the decision was made to proceed with right partial nephrectomy.
Results: The patient tolerated the procedure well. Total operative time was 175 minutes with a warm ischemia time of 40 minutes. There were no perioperative complications, and the patient was discharged home on postoperative day 3. The final pathology revealed blastemal predominant Wilms tumor without anaplasia and was staged as NWTS stage II. Surgical margins were negative. At his five-month follow-up visit, the patient had completed chemotherapy as per protocol AREN0534. Abdominopelvic MRI and chest X-ray showed no evidence of disease. Serum creatinine remained at baseline.
Conclusions: A robotic approach to partial nephrectomy is a safe and effective treatment for complex, endophytic renal tumors in pediatric patients. The efficacy of the robotic approach is further enhanced by technological and surgical advances such as the Iris 3D model, ICG imaging, and selective clamping technique.