Overcoming Challenges in Redo Robot-Assisted Partial Nephrectomy with Ultrasound Guidance

Partial nephrectomy is the preferred treatment for T1a and T1b tumors, boasting a recurrence rate of 1-2%, with most recurrences occurring within five years at the initial treatment site. This video highlights the unique challenges associated with Redo Robot-Assisted Partial Nephrectomy (RAPN). Effective surgical planning begins with assessing baseline renal function, understanding the previous nephrectomy approach, evaluating tumor location, and identifying any anatomical variations. Utilizing the Hassan technique for access, we ensure that new ports are positioned at least one inch from existing scars. A significant challenge is posed by the lack of perirenal fat and extensive adhesions resulting from previous manipulation of Gerota’s fascia, which complicates the surgical procedure and heightens the risk of breaching the subcapsular plane. To minimize ischemia while preserving kidney function, secure access to and control of the hilum is prioritized. The choice between individual or en bloc clamping is determined by intraoperative findings. In this case, due to severe vessel-encasing fibrosis, we accessed the hilum within Gerota’s fascia to reach an undissected area, increasing the likelihood of encountering additional arterial branches. Once the tumor was exposed, hilum dissection was performed using Bulldog clamps for vascular control, and ischemia was confirmed with Doppler ultrasound. The tumor was excised, followed by a two-layer renorrhaphy using a barbed suture and a sliding-clip technique. The case involved a 71-year-old female with a history of left RAPN in 2010, who underwent redo RAPN in 2023 for a 4.5 cm mass, revealing a pT3a clear cell renal cell carcinoma (ccRCC) with negative margins. The procedure was completed in 120 minutes with 13 minutes of warm ischemia and no complications, and her estimated glomerular filtration rate remained stable two months post-surgery.