Robotic-assisted Laparoscopic Partial Nephrectomy: Resection of Multiple Renal Masses and Demonstration of the Sequential Pre-placed Suture Technique
CUA Online Library. Samarasekera D. 06/22/13; 31390; UP-11
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Abstract
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Objective: The incidence of multifocal RCC is increased in patients with hereditary syndromes (eg. VHL). Patients are typically managed with staged resection or thermal ablative therapies. Simultaneous resection of multiple tumors is beneficial because it obviates the need for repeated general anesthetic and hilar dissection. Because of the longer warm ischemia time (WIT) multifocal resection has typically been carried out by the open approach. However increasing experience with robotic partial nephrectomy has allowed for resection of more complex solitary tumors with comparable WIT. Our aim was to demonstrate a technique for robotic partial nephrectomy for multifocal RCC. We also demonstrate our technique for the resection of tumors with the hilum unclamped (sequential pre-placed suture).
Methods: A 28 yo female with VHL presented with 3 left sided enhancing renal masses. Her BMI was 18.72 kg/m2, serum creatinine was 0.65 mg/dL, and eGFR was >60 mL/min/1.73m2. A CT scan with contrast showed a 2.1 cm upper pole mass (R.E.N.A.L. 5x), a 2.1 cm lateral inter-polar mass (R.E.N.A.L. 7p), and a 2.0 cm lateral lower pole mass (R.E.N.A.L. 7x). The upper and inter-polar masses were resected on clamp, and the lower pole mass was resected off clamp, using our sequential pre-placed suture technique.
Results: Operative time was 210 minutes, and estimated blood loss (EBL) was 250 cc. WIT was 26 minutes. There were no intra-operative or post-operative complications. Serum Cr on post-operative day 2 was 0.62 mg/dL. The final pathology of all 3 masses was grade 2 Clear Cell RCC. All margins were negative.
Conclusion: Robotic-assisted partial nephrectomy for multifocal RCC is technically feasible with an acceptable WIT. We encountered no complications with minimal blood loss. Additionally all resection margins were negative, and short-term renal function was not affected. The use of an un-clamped sequential pre-placed suture technique can be used to facilitate a decreased WIT. Eleven patients at our center have had a partial nephrectomy with this technique (3 with multiple tumors) and results are comparable to our clamped technique.
Methods: A 28 yo female with VHL presented with 3 left sided enhancing renal masses. Her BMI was 18.72 kg/m2, serum creatinine was 0.65 mg/dL, and eGFR was >60 mL/min/1.73m2. A CT scan with contrast showed a 2.1 cm upper pole mass (R.E.N.A.L. 5x), a 2.1 cm lateral inter-polar mass (R.E.N.A.L. 7p), and a 2.0 cm lateral lower pole mass (R.E.N.A.L. 7x). The upper and inter-polar masses were resected on clamp, and the lower pole mass was resected off clamp, using our sequential pre-placed suture technique.
Results: Operative time was 210 minutes, and estimated blood loss (EBL) was 250 cc. WIT was 26 minutes. There were no intra-operative or post-operative complications. Serum Cr on post-operative day 2 was 0.62 mg/dL. The final pathology of all 3 masses was grade 2 Clear Cell RCC. All margins were negative.
Conclusion: Robotic-assisted partial nephrectomy for multifocal RCC is technically feasible with an acceptable WIT. We encountered no complications with minimal blood loss. Additionally all resection margins were negative, and short-term renal function was not affected. The use of an un-clamped sequential pre-placed suture technique can be used to facilitate a decreased WIT. Eleven patients at our center have had a partial nephrectomy with this technique (3 with multiple tumors) and results are comparable to our clamped technique.
Objective: The incidence of multifocal RCC is increased in patients with hereditary syndromes (eg. VHL). Patients are typically managed with staged resection or thermal ablative therapies. Simultaneous resection of multiple tumors is beneficial because it obviates the need for repeated general anesthetic and hilar dissection. Because of the longer warm ischemia time (WIT) multifocal resection has typically been carried out by the open approach. However increasing experience with robotic partial nephrectomy has allowed for resection of more complex solitary tumors with comparable WIT. Our aim was to demonstrate a technique for robotic partial nephrectomy for multifocal RCC. We also demonstrate our technique for the resection of tumors with the hilum unclamped (sequential pre-placed suture).
Methods: A 28 yo female with VHL presented with 3 left sided enhancing renal masses. Her BMI was 18.72 kg/m2, serum creatinine was 0.65 mg/dL, and eGFR was >60 mL/min/1.73m2. A CT scan with contrast showed a 2.1 cm upper pole mass (R.E.N.A.L. 5x), a 2.1 cm lateral inter-polar mass (R.E.N.A.L. 7p), and a 2.0 cm lateral lower pole mass (R.E.N.A.L. 7x). The upper and inter-polar masses were resected on clamp, and the lower pole mass was resected off clamp, using our sequential pre-placed suture technique.
Results: Operative time was 210 minutes, and estimated blood loss (EBL) was 250 cc. WIT was 26 minutes. There were no intra-operative or post-operative complications. Serum Cr on post-operative day 2 was 0.62 mg/dL. The final pathology of all 3 masses was grade 2 Clear Cell RCC. All margins were negative.
Conclusion: Robotic-assisted partial nephrectomy for multifocal RCC is technically feasible with an acceptable WIT. We encountered no complications with minimal blood loss. Additionally all resection margins were negative, and short-term renal function was not affected. The use of an un-clamped sequential pre-placed suture technique can be used to facilitate a decreased WIT. Eleven patients at our center have had a partial nephrectomy with this technique (3 with multiple tumors) and results are comparable to our clamped technique.
Methods: A 28 yo female with VHL presented with 3 left sided enhancing renal masses. Her BMI was 18.72 kg/m2, serum creatinine was 0.65 mg/dL, and eGFR was >60 mL/min/1.73m2. A CT scan with contrast showed a 2.1 cm upper pole mass (R.E.N.A.L. 5x), a 2.1 cm lateral inter-polar mass (R.E.N.A.L. 7p), and a 2.0 cm lateral lower pole mass (R.E.N.A.L. 7x). The upper and inter-polar masses were resected on clamp, and the lower pole mass was resected off clamp, using our sequential pre-placed suture technique.
Results: Operative time was 210 minutes, and estimated blood loss (EBL) was 250 cc. WIT was 26 minutes. There were no intra-operative or post-operative complications. Serum Cr on post-operative day 2 was 0.62 mg/dL. The final pathology of all 3 masses was grade 2 Clear Cell RCC. All margins were negative.
Conclusion: Robotic-assisted partial nephrectomy for multifocal RCC is technically feasible with an acceptable WIT. We encountered no complications with minimal blood loss. Additionally all resection margins were negative, and short-term renal function was not affected. The use of an un-clamped sequential pre-placed suture technique can be used to facilitate a decreased WIT. Eleven patients at our center have had a partial nephrectomy with this technique (3 with multiple tumors) and results are comparable to our clamped technique.
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