Robotic Partial Nephrectomy for Tumors that Invade Sinus Fat (Video)

Achieving local cancer control without radical nephrectomy

By Jihad Kaouk, MD

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In this era of robotic surgery, indications for partial nephrectomy (PN) are being widened to more complex renal masses.

In this video, we provide technical hints for achieving local cancer control during transperitoneal robotic PN (RPN) for T3 tumors that invade the sinus fat.

Technique

Our refined robotic technique entails a thorough examination of preoperative imaging and intraoperative renal ultrasound. Excision of the tumor is planned in such a way to shift retraction to the sinus fat. Such retraction allows for delineation of the fat involved with the tumor versus normal sinus fat away from the tumor.

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We base our enthusiasm for this technique on a study of masses that underwent RPN at our institution. Of the 1,497 renal masses, 512 were suspected to have sinus fat invasion (RENAL score 3 for nearness to the sinus). Of these, 69 (13.5 percent) had pT3a tumor involving sinus fat at final pathology, representing the analyzed cohort. Twenty-four robotic transperitoneal PN were performed by our refined technique described in this video and 45 PNs were performed by our standard institutional technique.

Overall positive surgical margin (PSM) rate for the analyzed cohort (69 patients) was 11.6 percent. In patients operated on by our standard technique, the PSM rate was higher (0 percent versus 17.8 percent, P = 0.031). We were able to practically eliminate positive margins by refining our technique (P = 0.031). In patients operated on with the revised robotic technique presented on this video, trifecta achievement (no positive margins, no complications and excellent kidney function) was even higher compared to the standard technique (54.2 percent versus 20 percent, P = 0.005).

Differences in PSMs were not reflected in early oncological outcomes. Retrospective analysis and limited follow-up represent study limitations.

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Conclusion

With consistent experience in robotic surgery, optimal cancer control can be achieved with this customized robotic approach, especially in cases when tumors involve the renal sinus, which would otherwise require a radical nephrectomy.

Clinical fellow Juan Garisto, MD, and research fellow Riccardo Bertolo, MD, assisted in the production of this video.