Several surgical strategies have been described to reduce the parenchymal damage in course of robot assisted partial nephrectomy (RAPN), including selective clumping. The “classic” Brodel’ arterial organization into four to five branches is present in about 40% of cases. INFACT about 35% of cases initially managed with selective clamping may require the subsequent clamping of the main artery because of excessive bleeding for 2 main reasons: first, the tumor can run over different renal segments , second,a single renal segment is supplied by different segmental arterial branches with collateral circulation. Recently, 3D modelling and printing have been shown to improve the surgeon’s knowledge of the renalanatomy and to influence the surgical planning.
We report a case of 62 years old male patient diagnosed with 28x25 mm partially endophytic lesion in the upper right renal pole. Two 3D-model were elaborated by two different software allowing the surgical team a better comprehension of renal, vascular and tumour’s anatomy before surgery. A single main artery was found, supplying three anterior and one posterior main segmental branches. Moreover, the model showed two small, interlobar arteries originating respectively by posterior segmental and the upper anterior branches that probably supplied the upper pole and the tumour.The patient underwent RAPN using the DaVinci Xi with transperitoneal approach.The renal mass is than visualizedby using intraoperative ultrasound (TILEPRO®) as well,tobetter delineate the morphology of the tumour. For selective clamping, we firstly clamped the upper anterior segmental branch and evaluated the tumour’s vascular supply with i.v. injection of 10 mg of Indocyanine green and near-infrared fluorescence imaging. However, the tumour and the upper pole showed an important residual vascularization. Thus,we clamped also the posterior segmental artery, resulting in a complete ischemia of the upper pole of the kidney.A sharp enucleoresection of the lesion was performed.After the placement of the inner suture, an early unclamping was adopted. Finally, a further injection of 5 mg of indocyanine green showed a complete vascularization of the entire kidney.
Console time and estimated blood loss were 150 min and 110 cc, respectively. No intra- and postoperative complications, neither renal function impairment (ΔVGFR: 7 ml/min) were recorded. The patient was discharged on 3th post-op day. Histological examination revealed a clear cell RCC, stage pT1a, nucleolar grade 3, with negative surgical margins.
3D-modeling was useful to identify the segmental arteries which supply the upper pole and the two renal segments involved by the tumor and allowed the surgeon to better understand the morphology of the mass and its depth into the renal parenchyma. 3-D modeling may change the surgical planning before RAPNthus improving perioperative outcomes.