Background

Minimally-invasive surgery is gold-standard for the treatment of renal tumors below 7 cm. Nevertheless, the tumor position can be challenging for the laparoscopic approach. Robotic-assisted partial nephrectomy may overcome these difficulties. We present a case of a robotic-assisted right partial nephrectomy of a tumor adjacent to the renal hilum.

Case Presentation

Male patient, 58 years old, smoker (10 cigarettes/day) with no relevant medical history. Medicated with omeprazole. He was referred to us for an incidental finding a renal mass in an abdominal ultrasound. The CT showed a: “…solid lesion in the anterior aspect of the right kidney with 3,3 cm maximum width...”. The patient was asymptomatic.

The patient was proposed for a robotic-assisted right partial nephrectomy. Four ports were placed in the midclavicular line. One port for the assistant was placed just superior and lateral to the umbilicus, but medial to the midclavicular line. Another port was placed near the xiphoid for liver retraction. The ascending colon was mobilized and access to renal hilum was gained. Two renal arteries were dissected and referenced. The renal tumor was identified with a very close relation with the renal hilum. Arteries were clamped and tumor resection took place. Total ischemia time was 16 minutes. Suturing of the tumor bed was performed in two layers with an absorbable barbed 3/0 suture (sliding clip renorrhaphy). A platelet-rich fibrin glue obtained from autologous platelets was applied over the suture. The peritoneum was closed over the kidney. Total procedure time was 1h30min. Estimated blood losses were 100 mL. There were no complications in the post-operative period. Patient was discharged in the following day. Histology reveled a clear cell renal cell carcinoma, pT1a R0.

Conclusion

Renal masses in close proximity with the renal hilum are very difficult to address. Nevertheless, and experienced robotic surgeon may successfully perform partial nephrectomy in such cases. Further spread of robotic surgery may contribute to more nephron sparing surgeries in the future.