ICG marked robot-assisted partial nephrectomy for totally endophytic renal masses

Abstract

Introduction: Contemporary guidelines recommend partial nephrectomy as the standard of care for localized kidney tumor. However, totally endophytic renal masses represent a challenge in terms of both intra-operative identification and surgical dissection. Beside intraoperative ultrasound, indocyanine green (ICG) has been presented as an alternative to accurately mark totally endophytic renal masses. In this video, we presented two cases of robotassisted partial nephrectomy (RAPN) performed for totally endophytic renal masses preoperatively marked with indocyanine green (ICG). Material and Methods: Preoperative super-selective trans-arterial delivery of a ICG-lipiodol mixture (1:2 volume ratio) into tertiaryorder arterial branches feeding the renal mass 24h prior to trans-peritoneal RAPN was performed. Either main renal artery or inferior polar artery was clamped and enucleo-resection of both renal masses was performed using white-light and firefly vision. Hemostatic agents either Tachosil or Floseal have been used. Renorraphy was performed with Monosyn 2/0 and sliding technique. Robotic DaVinci X platform and Airseal system were performed. Patient, tumor and preoperative characteristics were reported for each patients. Results: The first case in the video shows a left renal totally endophytic perihilar mass of 27 x 23 mm, with a RENAL score of 10ah. The second case shows a right mid-posterior renal totally endophytic mass of 40 x 34 mm, with a RENAL score of 10ah. Angiographic procedures for delivery of ICG-lipiodol mixture lasted 40 minutes with no complications. The operative time was 90 and 120 minutes, respectively. Warm ischemia time was 20 and 25 minutes, respectively. Neither intra-operative adverse events nor post-operative complications were recorded. Both patients were discharged on post-operative day 2. Final pathology reported a clear cell carcinoma of renal cells (ccRCC) grade 2 sec. Fuhrman, pT1a, R0 in the first case and an oncocytoma in the second case. Conclusion: RAPN for endophytic renal masses using preoperative selective embolization with indocyanine green (ICG)- lipiodol mixture represents a feasible and reproducible technique. In comparison with intraoperative ultrasound, the ICG approach is more intuitive for the surgeons without the need of a learning curve to interpret ultrasound nor to handle ultrasound probe.