V14-04 Overcoming Challenges in Redo Robot- Assisted Partial Nephrectomy

You have accessJournal of UrologyAdrenal/Renal Oncology II (V14)1 May 2024V14-04 OVERCOMING CHALLENGES IN REDO ROBOT- ASSISTED PARTIAL NEPHRECTOMY Adriana M. Pedraza Bermeo, Nicolas Soputro, Roxana Ramos-Carpinteyro, Jaya Chavali, Carter Mikesell, and Jihad Kaouk Adriana M. Pedraza BermeoAdriana M. Pedraza Bermeo , Nicolas SoputroNicolas Soputro , Roxana Ramos-CarpinteyroRoxana Ramos-Carpinteyro , Jaya ChavaliJaya Chavali , Carter MikesellCarter Mikesell , and Jihad KaoukJihad Kaouk View All Author Informationhttps://doi.org/10.1097/01.JU.0001008704.74547.03.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Partial nephrectomy is the preferred treatment for T1a and T1b tumors, with a recurrence rate of 1-2%. Most recurrences occur within five years at the initial treatment site. This video aims to address unique challenges in Redo Robot-Assisted Partial Nephrectomy (RAPN). METHODS: Effective planning for surgery involves assessing baseline renal function, understanding the previous PN approach, evaluating tumor location, and identifying anatomical variations. We utilize the Hassan technique for access, ensuring that new ports are placed at least 1 inch away from pre-existing scars. A significant challenge arises from the lack of perirenal fat and pronounced adhesions, attributed to prior manipulation of Gerota's fascia. This situation complicates the surgery, increasing the risk of breaching the subcapsular plane. Aiming to minimize ischemia while preserving kidney functionality, we prioritize secure access to and control of the hilum. The choice between individual or en bloc clamping depends on intraoperative findings. Various access options exist. In this case, given the severe vessel-encasing fibrosis, we accessed the hilum within Gerota's fascia to reach a previously undissected area. It's worth noting that this approach might increase the likelihood of encountering additional arterial branches, as demonstrated in the video. Once the tumor was exposed, we performed the hilum dissection using Bulldog clamps for vascular control and confirmed ischemia with Doppler ultrasound; alternatively, Near-Infrared Fluorescence can be used. We then excised the tumor and carried out a two-layer renorrhaphy. During reconstruction, we used a barbed suture and a sliding-clip technique. RESULTS: This 71-year-old female presented with stage 3a chronic kidney disease and a history of left RAPN in 2010 for a pT1b clear cell renal cell carcinoma (ccRCC). In 2023, she underwent a redo RAPN due to a 4.5 cm mass, which revealed a pT3a ccRCC with negative margins. The procedure, lasting 120 minutes with a 13-minute warm ischemia, was complication-free. The estimated glomerular filtration rate two months after the surgery remained stable at 46 ml/min/1.73 m2. CONCLUSIONS: Redo RAPN requires surgical planning to achieve cancer removal and kidney function preservation. Surgeons must prepare for handling perinephric fibrous tissue, employing various hilum approaches, and maintaining vascular control. This procedure should be carried out in institutions with experienced surgical teams. Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e1228 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Adriana M. Pedraza Bermeo More articles by this author Nicolas Soputro More articles by this author Roxana Ramos-Carpinteyro More articles by this author Jaya Chavali More articles by this author Carter Mikesell More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF downloadLoading ...