Introduction: Robot-assisted laparoscopic partial nephrectomy (RALPN) is the gold standard in treating small renal masses when anatomy allows. Pelvic kidneys pose a unique challenge when performing RALPN due to the kidneys’ deep position and variable arterial supply. The feasibility of laparoscopic surgeries, such as pyeloplasty and nephrectomy, on pelvic kidneys have been previously described. We performed a successful RALPN in a patient with a right pelvic kidney.
Methods: A 66-year-old female who presented with abdominal pain was found to have an incidental 1.1 cm enhancing anteriorly located mass on a right sided pelvic kidney. Preoperative angiography with 3D reconstruction allowed for identification of all arterial supply to the kidney. Ports were placed in a supra-umbilical position, similar to a robotic prostatectomy and the patient was placed in the Trendelenburg position. The pelvic kidney was distal to the aortic bifurcation, and a peritoneal incision was made on the kidney’s right lateral side. The bowel was difficult to retract, so the lateral peritoneal flap was hitched to the anterior abdominal wall, greatly improving operative exposure. Preoperative imaging guided the careful dissection to identify the vascular anatomy. The peritoneum was opened to expose the parenchyma and allow for continued dissection of the renal vessels and ureter. Intraoperative ultrasound confirmed the borders of the mass. The mass was successfully excised as in standard partial nephrectomy.
Results: Length of time on console was 267 minutes. Estimated blood loss was 50cc. Total warm ischemia time was 12 minutes and 46 seconds. There were no postoperative complications and the patient was discharged on postoperative day 2. Final pathology was T1a clear cell, renal cell carcinoma.
Conclusions: RALPN in a pelvic kidney is safe and feasible. A CT angiogram obtained prior to surgery may be beneficial to delineate the altered anatomy. A technique of hitching the lateral peritoneal flap to the anterior abdominal wall may assist with bowel retraction and widen the surgical field.
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