Robotic-assisted partial nephrectomy nightmare: poor clamping and tumor rupture

Abstract

An 82-year-old Caucasian male patient was referred to our center because of the incidental finding of a nodule in the middle third of the right kidney during a screening abdominal ultrasound. No local or systemic symptom could be associated with the renal mass on initial evaluation. The patient underwent an abdominal contrast-enhanced CT scan, which revealed a mass in the outer middle third of the right kidney measuring 4.5 × 3.5 cm, predominantly exophytic, with contact to the collecting system and an enhancement pattern suspicious for primary renal malignancy. Tumor complexity was classified as PADUA score 9 and Renal Score 9x. Clinical stage was cT1bN0M0. Total procedure time was 130 min. Estimated blood loss was 800 mL and warm ischemia time was 24 min. Intraoperative complications were tumor rupture and increased bleeding. The postoperative course was uneventful. Meticulous preoperative planning including contrast-enhanced CT with 1 mm thick slices and 3D reconstruction imaging is critical. Comprehensive dissection of the renal hilum must be performed to access the exact number of vessels vascularizing the kidney and to provide adequate ischemia of the renal parenchyma for clean visualization during tumor resection to avoid nightmares such as positive margins and tumor rupture.

Keywords: Partial nephrectomy, robotic surgery, complications