The application of robotic nephrectomy, work bench surgery with robotic kidney autotransplantation in nephron-sparing surgery of complex renal tumors

Objective To investigate the safety and feasibility of robotic nephrectomy, work bench surgery with robotic kidney autotransplantation in the treatment of complex renal tumors. Methods The clinical data of 5 patients with renal tumors admitted from January 2018 to July 2018 were analyzed retrospectively. There were 4 males and 1 females. The median age was 49 years old, ranging 32-66 years. The median body mass index was 25.6 kg/m2, ranging 21.1-27.8 kg/m2. Serum creatinine level was 87.2 μmol/L, ranging 78.0-88.9μmol/L before bench surgery. 5 patients had multiple bilateral renal tumors and had undergone laparoscopic or robotic partial nephrectomy on the contralateral kidney. For bench surgery kidney, 4 cases were on the left side and 1 case was on the right side. Each kidney has more than 2 separate tumors, combined with complete endophytic tumors, tumors larger than 7 cm in diameter or hilar tumors. 5 patients were all performed robotic nephrectomy, work bench partial nephrectomy with robotic kidney autotransplantation under general anesthesia. The patient was first in a lateral decubitus position for robotic nephrectomy, and the kidney was removed through a median 6 cm periumbilical incision. After kidney removal, kidney tumors were resected and kidney was reconstructed on a hypothermic working table. Then the kidney was packed in a plastic bag, filling with ice slush. The corresponding parts of the plastic bag were cut to expose the renal artery and vein. Finally, the patient was moved to lithotomy position with Trendelenburg tilt of 20°, and the autologous kidney wrapped in the plastic bag was placed through the previous periumbilical incision into the abdominal cavity for robotic kidney autotransplantation. The renal artery and vein were anastomosed end-to-side with the right external iliac artery and vein. The ureter and bladder were anastomosed. Autologous kidneys were placed in abdominal cavity in 4 cases, and placed in right iliac fossa with retroperitonealization in 1 case. Ice slush on the surface of the autologous kidney did not completely melt before the blood supply was restored during the operation, and the autologous kidney immediately urinated after the blood supply was restored. Results All surgeries were performed successfully without conversion to open surgeries. The total operation time was 460 min, ranging(415-645 min), the time of robotic nephrectomy was 120 min, ranging(74-300 min), the time of robotic kidney autotransplantation was 135 min, ranging(103-163 min), the warm ischemia time was 3 min, ranging(1.5-6.0 min), the cold ischemia time was 182 min, ranging(135-210 min), the rewarming time was 50 min, ranging(45-55 min), the estimated blood loss during operation was 100 ml, ranging(50-300 ml), and the hospital stay was 6 d, ranging(5-9 d). The number of resected tumors was 4, ranging(2-6). The pathology reveals clear cell carcinoma in 3 cases and chromophobe cell carcinoma in 2 cases. The surgical margins were all negative. The serum creatinine levels were 111.1 μmol/L (87-217.6 μmol/L) and 106.1 μmol/L (87.1-172 μmol/L) on the 7th and 30th day after operation, respectively. One month after operation, CT showed that the function and morphology of the autologous kidneys were fine. No recurrence or metastasis was found in 5 patients during a median follow-up of 7 months, ranging (5.4-11.7 mon). Conclusions For patients with complex renal tumors who cannot undergo in situ partial nephrectomy, robotic nephrectomy, work bench surgery with robotic kidney autotransplantation can completely remove the tumors, maximize the preservation of renal function and minimize the trauma of patients, making the ultimate means of nephron-sparing surgery for patients with complex renal tumors more minimally invasive and safe. Key words: Complex renal tumors; Work bench surgery; Robotic kidney autotransplantation