1721Vol. 11 | No. 03 | May - June 2014 |U R O LO G Y J O U R N A L Tumor Enucleation with Zero Ischemia for Renal Cell Carcinoma by Robotic Retroperi- toneal Approach Nicolae Crisan,1,2 Cristina Ivan,1 Vitalie Gherman,1 Calin Neiculescu,1 Ioan Coman1,2 Corresponding Author: Nicolae Crisan, MD 11 Tabacarilor Street, 400139, Cluj- Napoca, Romania. Tel: +47 3540 6101 E-mail: drnicolaecrisan@gmail.com Received October 2013 Accepted April 2014 1 Department of Urology, Clinical Municipal Hospital, Cluj-Napoca, Romania. 2 Iuliu Hatieganu University of Medicine and Pharmacy, Cluj- Napoca, Romania. CASE REPORT Keywords: kidney neoplasms; surgery; laparoscopy; robotics; methods. INTRODUCTION We present a surgical technique with zero ischemia enucleation of a right renal tumor using the robotic retroperitoneal approach (RA). CASE REPORT A 67 year-old male, with a 14 mm right upper pole renal tumor, located on the posterior kid- ney surface, discovered accidentally after a computer tomography (Figure 1). The Preopera- tive Aspects and Dimensions Used for an Anatomical (PADUA) score was 7. After general endotracheal anesthesia was administered, the patient was placed in the full flank position. The body was flexed to expand the distance between iliac crest and the tip of the 12th rib. The retroperitoneum was entered through a 12 mm incision (for 12 mm trocar) in the angle between the 12th rib and paravertebral muscles in Gaur manner.(1) At 9 cm of this trocar, above the iliac crest another 12 mm trocar was introduced under camera vision (optic trocar for robotic camera). At 9 cm distance from the second trocar, on the line obtained through extending the line from the 12th rib, an 8 mm robotic trocar was placed. This way a favorable triangular position for the robotic trocars resulted, avoiding the conflict between robotic arms and between robot and assistant surgeon. Two 10 mm trocars were placed for the assistant surgeon, laterally and medially from the optic trocar (Figure 2). Finally, the first 12 mm trocar 1722 | was replaced with an 8 mm robotic trocar. The da Vinci ro- bot was then docked over the patient's head and shoulders. The RA allows us a direct access to the ureter and renal hilum. We found three distinct renal arteries that were skel- etonized on the vessel loop, without using vascular clamps for the ischemia (Figures 3 and 4). After localization and preparation of the posterior aspect of the kidney, we per- formed a zero-ischemia enucleation of the tumor (Figure 5). Renography was performed using 2.0 Vicryl. The speci- men was then bagged and recovered at the end of the case through the camera-port incision. The retroperitoneal space was prepared in 10 minutes and the insertion of the five trocars took 15 minutes, with 5 minutes docking. The op- erative time was 90 minutes, with 250 mL blood-loss. No postoperative complication was noted. Surgical margins were negative, and a pT1a Fuhrman 1 grade was found. He was discharged on the 6th day after the procedure. DISCUSSION There are two issues regarding the presented case that need Figure 1. Renal tumor on the posterior side of the right kidney (CT aspect). Figure 3 . Renal pedicle with two renal arteries. Figure 4 . Renal vein and the third renal artery. Figure 2. Trocar placement for robotic retroperitoneal approach. Case Report 1723Vol. 11 | No. 03 | May - June 2014 |U R O LO G Y J O U R N A L Robotic Retroperitoneal Enucleation of a Renal Tumor | Crisan et al further discussion. The first concerns the robotic partial nephrectomy with RA and the second concerns the zero ischemia time with robotic approach. The favorable perio- perative results for RA (operative time, ischemia time) are explained through the rapid and direct access on the renal artery(2,3,4) and to the posterior side of the kidney, with a facile management of postoperative blood or urine loss.(5) The disadvantages for RA are related to the conflict among the robotic arms or between the robot and the assistant sur- geon and the difficulty of the surgeon in recognizing the anatomy while using RA.(6,7) The enucleation consists of blunt dissection in the avas- cular cleavage between the tumor pseudocapsule and the renal parenchyma without clamping the renal artery (zero ischemia). This technique is considered to follow the onco- logical principles imposed by the EAU guidelines.(8,9) In the literature there are few data about robotic renal enu- cleation with RA. Recently, the results of a multicenter study were published, which included 886 cases of robotic partial nephrectomies, but none with zero ischemia time.(10) CONCLUSION We concluded that this case is important by presenting two new aspects of surgical technique: robotic RA for perform- ing a renal tumor enucleation without ischemia time. CONFLICT OF INTEREST None declared. REFERENCES 1. Gaur DD. Laparoscopic operative retroperitoneoscopy: use of a new device. J Urol. 1992;148:1137-9. 2. Rogers C, Laungani R, Krane LS, Bhandari A, Bhandari M, Menon M. Retroperitoneal robotic renal surgery: technique and early results. J Robotic Surg. 2009;3:1-5. 3. Rogers C, Laungani R, Krane LS, Bhandari A, Bhandari M, Menon M. Robotic nephrectomy for the treatment of benign and malignant disease. BJU Int. 2008;102:1660-5. 4. Hughes-Hallett A, Patki P, Patel N, Barber NJ, Sullivan M, Thilaga- rajah R. Robot-assisted partial nephrectomy: a comparison of the transperitoneal and retroperitoneal approaches. J Endourol. 2013;27:869-74. 5. Patel M, Porter J. Robotic retroperitoneal partial nephrectomy. World J Urol. 2013;31:1377-82. 6. Gettman MT, Blute ML, Chow GK, Neururer R, Bartsch G, Peschel R. Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with da Vinci robotic system. Urology. 2004;64:914-8. 7. Krambeck AE, Gettman MT. Robotic renal surgery: radical and par- tial nephrectomy. Arch Esp Urol. 2007;60:462-70. 8. Ficarra V, Galfano A, Cavalleri S. Is simple enucleation a minimal par- tial nephrectomy responding to the EAU guidelines' recommenda- tions?. Eur Urol. 2009;55:1315-8. 9. Minervini A, Vittori G, Lapini A, et al. Morbidity of tumour enuclea- tion for renal cell carcinoma (RCC): results of a single-centre pro- spective study. BJU Int. 2012;109:372-7. 10. Tanagho YS, Kaouk JH, Allaf ME, et al. Perioperative complications of robot-assisted partial nephrectomy: analysis of 886 patients at 5 United States centers. Urology. 2013;81:573-9. Figure 5 . Robotic enucleation of renal tumor.