Minimally Invasive Surgical Management of Posterior Upper-Pole Renal Masses

Abstract

Introduction:

Posterior upper-pole renal masses are arguably among the most challenging to address in a minimally invasive fashion. ¹ In the accompanying video, we demonstrate our technique for minimally invasive partial nephrectomy via a retroperitoneal approach for these uniquely challenging cases, along with an overview of our results utilizing this approach. The runtime of this video is 7:39.

Materials and Methods:

A retroperitoneal approach is preferred owing to its ability to provide favorable working angles. Our illustrative case is a 65-year-old man with a right posterior upper-pole renal mass measuring 2 cm. The retroperitoneal space is expanded with a balloon dilator, and trocars are placed. The assistant port is placed low and anterior. The robot is docked over the patient's head. The retroperitoneal space is developed using the contour of the psoas muscle and arterial pulsations to maintain orientation and position sense. The tumor is identified and the surrounding kidney is defatted. The kidney may be further mobilized to maximize tumor observation. Ultrasonography confirms the tumor position and configuration. The tumor is excised under warm ischemia. Sliding-clip renorrhaphy is performed. ^2,3

Results and Conclusions:

The illustrated case was performed in 124 minutes, with a warm ischemic time of 15 minutes. Blood loss was<100 mL. Across our experience of 20 patients using this approach, the mean tumor size has been 2.5 cm. Mean operative time is 196 minutes (149–284 minutes), with a mean warm ischemic time of 25 minutes (0–55 minutes). Two patients were performed off-clamp. Mean intraoperative blood loss was 270 mL; one patient required transfusion. There were two postoperative complications: one patient with bleeding and one who developed a urinoma. At a mean follow-up of 6 months, there have been no recurrences. In this regard, our technique for retroperitoneal excision of posterior upper-pole renal masses appears to be a safe and efficacious approach for nephron-sparing surgery.

B.M.B.is a paid consultant, Viking Systems, Inc., Westborough, MA., A.J.R., K.G., T.M.R., S.B., and R.S.F. have nothing to disclose.

Runtime of video: 7 mins 39 secs