Robotic Partial Nephrectomy for Complex Hilar Tumors: Step by step

Objective: To report our step-by-step technique and provide tips and tricks for robotic partial nephrectomy (RPN) in a highly complex renal mass. Robotic surgery has widened the indications of the conservative treatment for renal masses. With increasing experience, larger deeply infiltrative tumors, or tumors involving the renal hilum can be treated with robotic partial nephrectomy. Materials and methods: A 78-year-old male came to our attention for a complex right renal mass. Past medical history included severe hypertension and a myocardial infarction with subsequent stent placement in 2014. Baseline renal function assessed by serum creatinine was 0.93 mg/dl. The preoperative computed tomography scan and magnetic resonance showed a right enhancing posterior renal mass, 7.6 cm in diameter, cT2a, and RENAL score 12. The patient was scheduled for robotic partial nephrectomy. Transperitoneal approach with three arms robotic configuration was chosen. Results: Operative time including robot's docking was 195 minutes. Warm ischemia time was 19 minutes. Blood losses were negligible, with no transfusions required. Serum creatinine at discharge was 1.15 mg/dl. Final pathology revealed a clear cell renal cell carcinoma, pT3b, and ISUP grade 3, involving the sinus fat and the renal vein. Surgical margins were negative. Conclusion: Robotic partial nephrectomy can be successfully performed in cases of completely endophytic central, hilar masses. Consistent experience is needed before embarking on this surgery. Future studies are needed to determine the long-term outcomes for partial nephrectomy for these complex tumors.