Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 33  |  Issue : 1  |  Page : 5-8

Robotic partial nephrectomy for multiple renal masses: A case series


Department of Urology, National and Kapodistrian University of Athens, Greece

Date of Submission07-Jun-2021
Date of Decision22-Jun-2021
Date of Acceptance28-Jun-2021
Date of Web Publication15-Feb-2022

Correspondence Address:
Konstantinos G Stravodimos
Department of Urology, Laiko Hospital, National and Kapodistrian University of Athens, Agiou Thoma Street, Athens, 115 27
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HUAJ.HUAJ_24_21

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  Abstract 


Background: Partial nephrectomy is strongly recommended by the EAU guidelines as the primary treatment option for T1 Renal Cell Carcinoma. Robotic assisted partial nephrectomy has been gaining ground as an approach with similar oncological results to open and laparoscopic approaches, while outperforming them in secondary endpoints, such as functional and perioperative results. Materials and Methods: We present our cohort of multiple renal tumors treated with robotic partial nephrectomy. 4 patients were treated for double kidney tumours. We demonstrate patients' demographics and tumour preoperative assessment, our surgical technique, operative details, such as the perioperative outcomes and complications. Conclusion: Our experience in the treatment of multiple renal masses with robotic partial nephrectomy suggests favourable outcomes for our patients extending the oncological, functional and perioperative results of RAPN.

Keywords: Multiple masses, partial nephrectomy, robot


How to cite this article:
Stravodimos KG, Moulavasilis N, Manousakis E, Fragkiadis E. Robotic partial nephrectomy for multiple renal masses: A case series. Hellenic Urology 2021;33:5-8

How to cite this URL:
Stravodimos KG, Moulavasilis N, Manousakis E, Fragkiadis E. Robotic partial nephrectomy for multiple renal masses: A case series. Hellenic Urology [serial online] 2021 [cited 2022 Oct 4];33:5-8. Available from: http://www.hellenicurologyjournal.com/text.asp?2021/33/1/5/337778




  Introduction Top


Partial nephrectomy is strongly recommended by the EAU guidelines as the primary treatment option for T1 renal cell carcinoma,[1],[2],[3],[4],[5],[6],[7],[8],[9] as robotic technology plays an increasingly important role in surgery worldwide. Surgical patterns in Greece confirm the rapid adoption of the technique in everyday practice, as in the rest of the world.[10] Concerning the treatment of renal masses, oncological outcomes such as progression-free survival are comparable between radical and nephron-sparing approach, while partial nephrectomy better preserves kidney function and protects from cardiovascular disorders and mortality. Nonetheless, a slightly higher complication rate is associated with nephron-sparing techniques. Anatomic considerations regarding tumor site, size, multifocality, and complexity are also important factors in decision-making.

Robotic-assisted partial nephrectomy (RAPN) has been gaining ground as an approach with similar oncological results to open and laparoscopic approaches,[1],[11] while outperforming them in secondary endpoints such as warm ischemia time (WIT), intraoperative blood loss, transfusion rates, minor and major complications, and hospital stay.[12],[13],[14],[15]

Multiple tumors in the same kidney, comprise a somewhat niche cohort of patients of increased complexity and special surgical challenges, that has been scarcely reported in the literature.[16],[17],[18],[19] The increased dexterity of the Da Vinci robotic system (Intuitive Surgical, USA) allows to offer the full benefits of the robotic approach while treating multiple tumors in the same kidney. We would like to present our case series of multiple renal tumors treated with robotic partial nephrectomy.


  Materials and Methods Top


From 2013 to 2021, a total of 76 robotic partial nephrectomies were performed in our Department, while four among them were for double kidney tumors. All RAPNs were performed by an experienced surgeon (K. S.) through a transperitoneal approach. Patients were placed in a modified flank position at 60°. Three robotic arms were used and two extra ports for the bedside assistant were placed (5 and 12 mm). The AirSeal system (ConMed, USA) was used to provide stable pneumoperitoneum, continuous smoke evacuation, and valve-free access to the abdominal cavity. After mobilization of the colon and the identification of the hilum, the renal vessels were prepared and positively identified. Tumor was identified and the boundaries were marked with cautery; only the renal artery was clamped using a bulldog and tumors were excised. A combination of cold and cautery excision was used. A two-stage renorrhaphy was performed on the defect using the sliding-clip technique.[20]

We declare that we have obtained the consent of the participants to make the data public.


  Results Top


Four patients (two females and two males, and one with Von Hippel-Lindau [VHL] disease) of a mean age of 52.5 (35–73) were treated for double kidney tumors and are presented in our cohort. We present the patients' demographics and tumor preoperative assessment utilizing the RENAL score in [Table 1]. The average value for body mass index was 26.85 kg/m2.
Table 1: Demographics

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Tumor characteristics and final pathology report (all patients had at least one malignant tumor) are presented in [Table 2]. The size of the tumors excluded was from 6 mm to 45 mm and the RENAL score was valued 4–8. Two left and two right kidneys were operated. Only one tumor was recorded as T1b stage at the histology report, while all other tumors were recorded as T1a. None positive margins were found at any tumor excision. The histopathology findings include papillary tumors for patient 1, clear cell renal cell carcinoma (CRCC) and angiomyolipoma (AML) for patient 2, both CRCC for patient 3, and for patient 4 chromophobe renal cell carcinoma and AML.
Table 2: Tumor characteristics

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Operative details, including operative time, WIT, and blood loss are presented in [Table 3]. No use of hemostatic agents was needed and a drain was placed upon completion of all cases. No conversion to open procedure or radical nephrectomy (lap or open) was necessary. No blood transfusion was needed, while only one patient had a prolonged hospital stay due to respiratory infection treated with antibiotics and having a delayed discharged at 9 days postoperative. Hemoglobin and creatinine level changes, postoperative complications graded with the Clavien-Dindo system and hospital stay are presented in [Table 4]. We took into account, the laboratory values of the preoperative examination performed 1 day before the surgery and the laboratory values on the 1st postoperative day. The fluctuation of the estimated glomerular filtration rate value that showed a decrease or an increase was attributed to the different conditions (fasting time) for each case under which the preoperative examination was performed. During follow-up, three patients are free of recurrence while the patient with VHL disease has a new tumor and is under active surveillance.
Table 3: Operative details

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Table 4: Perioperative outcomes and complications

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  Discussion Top


Robotic partial nephrectomy offers the combined advantages of excellent long-term oncological results, less intra and postoperative complications, and the fast recovery time of a minimal approach surgery.[21],[22] Multiple factors attributing to those excellent results have been identified by various groups, such as the three-dimensional visualization, the effect of pneumoperitoneum on blood loss, but the most substantial factor is the increased dexterity and high precision of robotic instrument movements toward expanding the indication of partial nephrectomies to more complex cases. Therefore, we have a rapidly growing literature regarding case series of larger T2 tumors, of advanced complexity and higher RENAL score tumors.[23],[24] Complicated combined surgeries, such as partial nephrectomy and cholecystectomy, have been performed by our team owing to the same reasons.[25]

Multifocality of renal cell carcinoma may range between 4.3% and 25%.[26] Radical nephrectomy or nephron-sparing surgery does not contribute to differences in cancer-specific survival in this subgroup of patients with renal carcinoma.[27] Multiple tumors are definitely a smaller group of patients and difficult to be studied in large numbers, but could also comprise younger patients and patients of hereditary syndromes, as patient 3 in our series (35 years old with VHL disease). These patients would benefit the most from renal function preservation and decrease of cardiovascular disorders. Cohorts similar to ours,[16],[17],[18],[19] report encouraging results, with comparable operative time (mean 183.75 min in our series) and WIT (mean 24.25 min in our series). With developing experience, all the techniques described to reduce WIT (early unclamping, select clamping, and off-clamp)[18] can be facilitated when operating multiple tumors. In our cases, early unclamping was achieved in one patient where the tumors were excised consecutively and the inner renorrhaphy was performed for both before unclamping and performing the approximation of the renal parenchyma.

The RENAL score is a well-accepted method that can be used to correlate with intra and postoperative complications in nephron-sparing surgery although tumor size may be used equally for the same purpose.[28]

Due to the small size of our series, we did not attempt any correlation between scores or tumor size and outcomes. Nonetheless. multiplicity poses by itself a significant factor of surgical complexity. Robotic assistance helps to avoid surgical complications[18],[19] and in our series, we did not have any intra or postoperative surgical complication or conversion.

Robotic assistance has been proven to achieve equal trifecta results in multifocal tumors with less morbidity when compared to open partial nephrectomy and be safe and feasible even in cases in solitary kidneys.[29],[30]

We would like to stress that RAPN, although easier than the laparoscopic counterpart, is an operation with a difficult learning curve, especially in such complicated cases requires a well experienced team of surgeons, bedside assistants, nurses, and anesthesiologists. Meticulous preoperative assessment with contrast-enhanced computed tomography or Magnetic Resonance Imaging is of utmost importance regarding hilum anatomy, tumor anatomy, and preoperative planning in all of partial nephrectomy cases.


  Conclusion Top


Our experience in the treatment of multiple renal masses with robotic partial nephrectomy suggests favorable outcomes for our patients extending the oncological, functional, and perioperative results of RAPN to a very special group of patients that may benefit the most. These complicated cases although demanding, should not be excluded from the robotic approach, but a dedicated and experienced surgical team is needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
MacLennan S, Imamura M, Lapitan MC, Omar MI, Lam TB, Hilvano-Cabungcal AM, et al. Systematic review of perioperative and quality-of-life outcomes following surgical management of localised renal cancer. Eur Urol 2012;62:1097-117.  Back to cited text no. 1
    
2.
Kunath F, Schmidt S, Krabbe LM, Miernik A, Dahm P, Cleves A, et al. Partial nephrectomy versus radical nephrectomy for clinical localised renal masses. Cochrane Database Syst Rev 2017;5:CD012045.  Back to cited text no. 2
    
3.
Thompson RH, Boorjian SA, Lohse CM, Leibovich BC, Kwon ED, Cheville JC, et al. Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy. J Urol 2008;179:468-71.  Back to cited text no. 3
    
4.
Huang WC, Elkin EB, Levey AS, Jang TL, Russo P. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors – is there a difference in mortality and cardiovascular outcomes? J Urol 2009;181:55-61.  Back to cited text no. 4
    
5.
Miller DC, Schonlau M, Litwin MS, Lai J, Saigal CS; Urologic Diseases in America Project. Renal and cardiovascular morbidity after partial or radical nephrectomy. Cancer 2008;112:511-20.  Back to cited text no. 5
    
6.
Capitanio U, Terrone C, Antonelli A, Minervini A, Volpe A, Furlan M, et al. Nephron-sparing techniques independently decrease the risk of cardiovascular events relative to radical nephrectomy in patients with a T1a-T1b renal mass and normal preoperative renal function. Eur Urol 2015;67:683-9.  Back to cited text no. 6
    
7.
Scosyrev E, Messing EM, Sylvester R, Campbell S, Van Poppel H. Renal function after nephron-sparing surgery versus radical nephrectomy: Results from EORTC randomized trial 30904. Eur Urol 2014;65:372-7.  Back to cited text no. 7
    
8.
Kates M, Badalato GM, Pitman M, McKiernan JM. Increased risk of overall and cardiovascular mortality after radical nephrectomy for renal cell carcinoma 2 cm or less. J Urol 2011;186:1247-53.  Back to cited text no. 8
    
9.
Van Poppel H, Da Pozzo L, Albrecht W, Matveev V, Bono A, Borkowski A, et al. A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2007;51:1606-15.  Back to cited text no. 9
    
10.
Deligiannis D, Anastasiou I, Mygdalis V, Fragkiadis E, Stravodimos K. Change of practice patterns in urology with the introduction of the Da Vinci surgical system: The Greek NHS experience in debt crisis era. Arch Ital Urol Androl 2015;87:56-61.  Back to cited text no. 10
    
11.
Chang KD, Abdel Raheem A, Kim KH, Oh CK, Park SY, Kim YS, et al. Functional and oncological outcomes of open, laparoscopic and robot-assisted partial nephrectomy: A multicentre comparative matched-pair analyses with a median of 5 years' follow-up. BJU Int 2018;122:618-26.  Back to cited text no. 11
    
12.
Alimi Q, Peyronnet B, Sebe P, Cote JF, Kammerer-Jacquet SF, Khene ZE, et al. Comparison of short-term functional, oncological, and perioperative outcomes between laparoscopic and robotic partial nephrectomy beyond the learning curve. J Laparoendosc Adv Surg Tech A 2018;28:1047-52.  Back to cited text no. 12
    
13.
Masson-Lecomte A, Yates DR, Hupertan V, Haertig A, Chartier-Kastler E, Bitker MO, et al. A prospective comparison of the pathologic and surgical outcomes obtained after elective treatment of renal cell carcinoma by open or robot-assisted partial nephrectomy. Urol Oncol 2013;31:924-9.  Back to cited text no. 13
    
14.
Peyronnet B, Seisen T, Oger E, Vaessen C, Grassano Y, Benoit T, et al. Comparison of 1800 robotic and open partial nephrectomies for renal tumors. Ann Surg Oncol 2016;23:4277-83.  Back to cited text no. 14
    
15.
Choi JE, You JH, Kim DK, Rha KH, Lee SH. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: A systematic review and meta-analysis. Eur Urol 2015;67:891-901.  Back to cited text no. 15
    
16.
Abreu AL, Berger AK, Aron M, Ukimura O, Stein RJ, Gill IS, et al. Minimally invasive partial nephrectomy for single versus multiple renal tumors. J Urol 2013;189:462-7.  Back to cited text no. 16
    
17.
Boris R, Proano M, Linehan WM, Pinto PA, Bratslavsky G. Initial experience with robot assisted partial nephrectomy for multiple renal masses. J Urol 2009;182:1280-6.  Back to cited text no. 17
    
18.
Laydner H, Autorino R, Spana G, Altunrende F, Yang B, Khanna R, et al. Robot-assisted partial nephrectomy for sporadic ipsilateral multifocal renal tumours. BJU Int 2012;109:274-80.  Back to cited text no. 18
    
19.
Yang J, Xia JD, Xue JX, Song NH, Liang C, Xi D, et al. Robotic-assisted partial nephrectomy with sequential clamping of segmental renal arteries for multiple ipsilateral renal tumors: Initial outcomes. BMC Urol 2019;19:31.  Back to cited text no. 19
    
20.
Benway BM, Wang AJ, Cabello JM, Bhayani SB. Robotic partial nephrectomy with sliding-clip renorrhaphy: Technique and outcomes. Eur Urol 2009;55:592-9.  Back to cited text no. 20
    
21.
Gul ZG, Tam A, Badani KK. Robotic partial nephrectomy: The current status. Indian J Urol 2020;36:16-20.  Back to cited text no. 21
[PUBMED]  [Full text]  
22.
Bertolo R, Garisto J, Dagenais J, Sagalovich D, Stein R, Fareed K, et al. Transperitoneal robot-assisted partial nephrectomy with minimum follow-up of 5 years: Oncological and functional outcomes from a single institution. Eur Urol Oncol 2019;2:207-13.  Back to cited text no. 22
    
23.
Abdel Raheem A, Alatawi A, Kim DK, Sheikh A, Alabdulaali I, Han WK, et al. Outcomes of high-complexity renal tumours with a Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score of ≥10 after robot-assisted partial nephrectomy with a median 46.5-month follow-up: A tertiary centre experience. BJU Int 2016;118:770-8.  Back to cited text no. 23
    
24.
Hennessey DB, Wei G, Moon D, Kinnear N, Bolton DM, Lawrentschuk N, et al. Strategies for success: A multi-institutional study on robot-assisted partial nephrectomy for complex renal lesions. BJU Int 2018;121 Suppl 3:40-7.  Back to cited text no. 24
    
25.
Stravodimos K, Katafigiotis I, Pournaras C, Dimitroulis D, Kousournas G, Fragkiadis E, et al. Combined robot assisted right partial nephrectomy and cholecystectomy with single docking. J Robot Surg 2019;13:167-9.  Back to cited text no. 25
    
26.
Tsivian M, Moreira DM, Caso JR, Mouraviev V, Madden JF, Bratslavsky G, et al. Predicting occult multifocality of renal cell carcinoma. Eur Urol 2010;58:118-26.  Back to cited text no. 26
    
27.
Minervini A, Serni S, Giubilei G, Lanzi F, Vittori G, Lapini A, et al. Multiple ipsilateral renal tumors: Retrospective analysis of surgical and oncological results of tumor enucleation vs radical nephrectomy. Eur J Surg Oncol 2009;35:521-6.  Back to cited text no. 27
    
28.
Khene ZE, Mazouin C, Larcher A, Peyronnet B, Gasmi A, Roumiguié M, et al. Predicting Complications After Robotic Partial Nephrectomy: Back to Simplicity. Eur Urol Focus. 2021:S2405-4569(21)00123-1. doi: 10.1016/j.euf.2021.04.017. Epub ahead of print. PMID: 33958318.  Back to cited text no. 28
    
29.
Yerram NK, Dagenais J, Bryk DJ, Nandanan N, Maurice MJ, Mouracade P, et al. Trifecta outcomes in multifocal tumors: A comparison between robotic and open partial nephrectomy. J Endourol 2018;32:615-20.  Back to cited text no. 29
    
30.
Miyake H, Motoyama D, Matsushita Y, Watanabe H, Ito T, Sugiyama T, et al. Robot-assisted partial nephrectomy for patients with multifocal renal tumors arising in a solitary kidney: Report of three cases. J Endourol Case Rep 2020;6:370-3.  Back to cited text no. 30
    



 
 
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