Precise Clamping of Renal Artery With Endovascular Stents During Robotic Partial Nephrectomy: Technical Hints to Optimize Outcomes.

OBJECTIVE

To describe our surgical technique for robotic partial nephrectomy, focusing on specific technical hints for vascular clamping on patients with renal masses and endovascular stent (ES) in the renal artery.

METHODS

We reviewed the records of 3 patients that underwent robotic partial nephrectomy in our institution with precise clamping of renal arteries due to previous placement of ES. Perioperative outcomes were recorded. In our video, we present the case of 73-year-old Caucasian with a 10-cm left renal neoplasm and associated fenestrated endograft due to endovascular aorta repair. After preoperative imaging was reviewed, a robotic approach was planned.

RESULTS

Key hints for outcomes optimization during nephron sparing surgery on patients with ES on the renal arteries: (1) preoperative computed tomography scan is crucial for surgical planning on dissection of the renal pedicle, (2) an additional multiplanar volume rendering of the computed tomography scan may allow better 3-dimensional visualization and orientation of the renal vasculature and anatomy, (3) precise renal artery clamping distal from the renal artery stent is required to avoid renal stent occlusion, (4) extensive and meticulous dissection of the renal pedicle is mandatory to dictate correct clamping, and (5) an intraoperative Doppler ultrasound after clamping release confirms the blood flow through the renal arteries. From the patients analyzed, median age was 69.6 years, median body mass index was 31.3, and mean estimated glomerular filtration rate was 36.6 mL/min. No cases were converted to open procedures. Perioperative outcomes are described in Table 1.

CONCLUSION

Partial nephrectomy in patients with renal artery stents requires distal dissection of the renal artery beyond the stent. Our described technique provides feasible, reproducible, and valuable surgical suggestions for outcomes optimization during nephron-sparing surgery on patients with endovascular graft stents.