Preoperative 3D model guidance for robotic-partial nephrectomy: a case report of intraoperative vascular injury and its management

Abstract

Partial nephrectomy (PN) is increasingly used in the treatment of renal cell carcinoma and is now considered the “gold standard” treatment for T1 lesions. However, it is still considered a challenging procedure. Several imaging modalities have been tested to improve PN outcomes. One of the most intriguing is 3D reconstruction, which can be used for both preoperative planning and intraoperative decision making. In the following case, we describe an intraoperative vascular injury that occurred during robot-assisted PN (RAPN), despite accurate preoperative 3D-guided planning, and its management. The patient undergoing PN was 57 years old and had an incidental diagnosis of a 17 mm left-sided renal lesion located on the posterior surface of the kidney at the lower pole. Based on the CT scan, a virtual 3D reconstruction was obtained, which highlighted the presence of a saccular dilatation of the main artery. Selective clamping of a segmental artery feeding the posterior surface of the lower pole of the kidney was planned. The RENAL nephrometry and PADUA score were calculated with a value of 4p and 6, respectively. Despite a thorough preoperative planning, a lesion of the dilatation of the main artery was identified with a large bleeding which was managed by global clamping of the kidney followed by selective suturing. In conclusion, PN remains a challenging procedure even for experienced and skilled surgeons. The occurrence of intraoperative complications is not anecdotal. The introduction of the robotic console and new intraoperative tools such as 3D models have reduced the risk of adverse events, but their complete elimination is still utopian due to the extreme complexity of the procedure.

Keywords: Robotic partial nephrectomy, 3D models, nightmares, kidney cancer