#344 Clampless And Sutureless RAPN For The Mgt. of Multiple Lesions In Von Hippel Lindau Syndrome

This is one of the 2023 KS International Innovation Awards videos selected for inclusion in the Vattikuti Foundation – ORSI Humans at the Cutting Edge of Robotic Surgery Conference, October 6, 7 & 8, 2023 in Ghent, Belgium. Posting does not imply that is has been selected as a Finalist, just that the content will be discussed at the Conference.

Dr. Nicola Frego

From the entry: Clampless and Sutureless Robot-Assisted Partial Nephrectomy for the Treatment of Fifteen Bilateral Renal Lesions in a Patient with Von Hippel-Lindau Syndrome.

Introduction Patients with Von Hippel-Lindau (VHL) disease have higher risk of developing renal cell carcinomas. In these patients, given the frequent presence of multiple masses and the high risk of recurrence, nephron-sparing approaches are essential to preserve renal function. In this context, technical refinements such as 3D reconstruction, off-clamp, selective suturing or sutureless techniques can be helpful to improve functional outcomes. Herein, we described our surgical management for a patient with VHL syndrome with multiple bilateral renal lesions applying these innovative techniques.

Methods A 27-year-old man affected by VHL disease presented with 8 and 7 masses on the right and left kidney, respectively. Diameters ranged from 5 to 54 mm on the right, and from 4 on 57 mm on the left. His baseline creatinine was 1.11 mg/dl. First, the patient underwent a left RAPN which revealed 5 clear cell renal cell carcinomas (ccRCC) – the biggest one pT1bR0 – and 2 benign cysts. Six weeks later, the patient underwent a right RAPN. Both procedures were performed using a clampless and sutureless technique; when a completely sutureless resection was not possible, a selective suturing technique was utilised. Preoperative surgical planning included 3-D imaging reconstruction (Figure 1). We here described the surgical procedure for right RAPN and its peri- and post-operative outcomes.

Results Operative and console time were 205 and 175 minutes, respectively. Blood loss was 650 ml. An off-clamp enucleation of all 8 renal masses was performed with a sutureless technique, applying an haemostatic agent (Veriset) to the resection beds. Only for the biggest lower pole mass a selective suture was required in the resection bed. There was no need for intra-operative transfusions, and no perioperative complications occurred. The patient was discharged on the second postoperative day with a creatinine of 0.99 mg/dL. The pathologic assessment revealed 8 ccRCC, the biggest one being pT1bR0.

Conclusions In patients with multiple renal masses requiring surgical treatment, the use of innovative approaches such as clampless approach, sutureless and/or selective suturing techniques can help preserving healthy parenchyma during RAPN. Further studies with longer functional follow-up are awaited to confirm these findings at long-term.

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