3D Uro-oncology: Resection of endophytic hilar tumor
Dr. Gonzalo Vitagliano
Hospital Alemán de Buenos Aires - Argentina
✔ Understand in detail the anatomy involved
✔ Plan a safe approach
✔ Avoid radical nephrectomy
✔ Be a real-time consultation tool within the operating room
✔ Decrease surgical time
A 62-year-old male patient was found to have a right incidental renal mass with a large part of its volume within the renal parenchyma.
The diagnostic images show the location of the tumor in the hilar area, with endophytic character, evidencing a highly complex case. Knowing this, the surgical team decided to perform a 3D biomodel to accurately define the vasculature involved and plan how to resect the tumor mass with the least possible damage.
3D anatomic model
◾ Technology: FDM
◾ Material: PLA
◾ Resolution: 0.2 mm
◾ Finish: Multiple colors
Surgical planning and results in the operating room
The anatomical model showed that the tumor was responsible for dividing the renal pedicle and was located in a very important vascular confluence zone. In addition, it clearly showed how the renal vein was divided presenting a branch below the tumor.
It was very important for the surgeon to know the vascular structure, not only to be able to perform an adequate clamping and a careful resection, but also to be attentive and cautious when placing the stitches, since any repair could frustrate the preservation performed.
The biomodel was taken to surgery providing real-time support during the approach.
"During surgery, when the kidney is already presented, the only thing we are looking at is the 3D model. We absolutely stop looking at the CT and MRI. We put the model in the same location that we have the anatomic structures and start navigating the anatomy," explains Dr. Vitagliano about his experience using biomodels in the operating room.
The 3D planning also allowed characterization of the tumor mass and lesion site, resulting in much faster and effective intraoperative identification.
For the treatment of the patient, a laparoscopic partial nephrectomy was performed with a transperitoneal approach and total arterial and partial venous clamping. From the renal artery, two arteries derived that gave a lower frame but there was also another bifurcation of the renal artery that gave a higher frame, therefore, the only way to have a vascular control of the three branches that could be nourishing the tumor was with a total clamping. However, the venous clamping was partial only in the vein passing under the tumor.
The patient was operated successfully in a total time of 107 min and with an ischemia time of 15 min. He was discharged 40 hours after surgery. The pathological anatomy indicated a 3x2 cm oncocytoma with free margins.
"How important it is to analyze this case, because if we were to transfer it to a few years ago, and perhaps with other expertise, with other technical capabilities and without 3D reconstruction, no one could object that this patient did not end up in a radical nephrectomy. Especially, given the characteristics of the tumor: mesorenal and 3cm. Clearly, today we know that the patient benefited by having nephron sparing surgery. We removed a tumor that did not have the capacity to metastasize, but it did have the capacity to cause him to lose the kidney because if that oncocytoma had grown, it could easily become unresectable, compromising the whole kidney and making it unpreservable", reflects Dr. Vitagliano.
Bonus track - How to train resections of complex renal tumors?
In MIRAI 3D we developed the UROTRAINER training system for simulation in laparoscopic partial nephrectomy. It is a fully operable kidney with 11 tumors and 2 cysts with different RENAL Score. It was specially designed to develop hands-on skills in uro-oncology in both initial and advanced stages of medical training.
More information: https://www.urotrainer.com/
Do you want to know more about Uro-Oncology? "3D Urology: Resection of renal tumors in critically ill patients" Dr. Claudio Koren, from Churruca Hospital, used 3D models to plan the surgery of a single patient with a tumor and aneurysmal dilatation of the abdominal aorta.