Robotic assisted anatrophic nephrotomy “oyster-pearl extraction technique” for deep and centrally located endophytic renal mass

Endophytic renal tumors pose challenge in achieving the purpose of Nephron sparing surgery (NSS) owing to their lack of visibility over kidney surface. Among these, deep & centrally located variants are notorious as their surgical management involves loss of more nephrons and relatively more compromised vascularity of the spared renal parenchyma. With advent of robotic-assisted interventions, increasing in-depth knowledge on safe ischemia time of kidney, multiple approaches to manage endophytic tumors offer swift post-operative renal recovery. The present video aims to demonstrate the Robotic-assisted ‘Oyster-pearl extraction technique’ via anatrophic nephrotomy in managing deep and centrally located endophytic tumors. An elderly female with morbid obesity, presented with a completely endophytic, centrally located left renal mass, size of 25 × 23 × 22 millimeter, with nephrometric score of 10a. On evaluation her Serum creatinine was 0.70 mg/dl, on DTPA scan, GFR of the right and the left kidney was 38 milliliter/minute and 35 milliliter/minute respectively, with no local or distant recurrence. Robotic-assisted ‘Oyster pearl extraction technique’ via anatrophic nephrotomy was performed for excision of the mass. The operating time and warm ischemia time were 165 min and 35 min respectively, with blood loss of 200 ml. The post-operative hospital stay was of 2 days. Histopathology revealed conventional renal cell carcinoma and margins were free of tumor. At 3 months, Serum creatinine was 0.80 mg/dl, GFR of right and left kidney were 35 milliliter/minute and 31 milliliter/minute respectively, with no local or distant recurrence. Robotic-assisted ‘Oyster-pearl extraction technique’ via anatrophic nephrotomy offers a promising approach to manage centrally endophytic renal masses in patients with or without comorbidities with preservation of functional renal parenchyma, swift post-operative recovery along with accepted oncological outcome.