Management of a Major Complication of Robotic Partial Nephrectomy

Abstract

Robotic partial nephrectomy (RPN) offers faster recovery time, shorter hospital stays, and decreased intraoperative blood loss. Thus, it has become a frequently preferred technique. Different major and minor complications may occur in RPN. However, there are insufficient data regarding the management of robotic surgery-related complications. A 62-year-old man presented with an incidental left renal mass. Magnetic resonance imaging demonstrated a 3.3x3.1x3.8 cm solid and contrast-enhanced renal mass localized at the lower pole of the left kidney. The PADUA score was 7. We performed robotic left partial nephrectomy (PN). Perioperative bleeding, warm ischemia time, and operation time were 100 cc, 26 min, and 180 min, respectively. There were no unexpected events during the operation. During the postoperative 2nd hour in the recovery room, the patient had syncope, hypotension, and tachycardia. Urgent ultrasonography demonstrated a 7x6 cm retroperitoneal hematoma. The selective renal angiography and embolization (SRAE) technique was preferred to manage the complication. Intra-arterial access was provided by femoral artery cannulation in the supine position under local anesthesia. Pseudoaneurysm was observed as a sign of bleeding in the lower pole segmental artery. An endovascular coiling procedure was performed on the pseudoaneurysm originating from the lower pole renal artery. The patient’s post-angioembolization course was uneventful, with no other complications after the intervention. The patient was discharged after five days of follow-up. Complications following RPN performed by experienced surgeons can be acceptably low. However, postoperative arterial malformation leading to hemorrhage can be life-threatening. It has been reported that minimally invasive PN increases the risk of arterial malformation compared with open PN, and the reported incidence varies by approximately 3-10%. In our case, we preferred SRAE because surgical exploration had a potential risk of nephrectomy. SRAE is a technically feasible and safe option for managing arterial hemorrhage after RPN.

Keywords

• arterial embolization
• complication
• endourology
• radiology
• robotic partial nephrectomy
• urooncology