Is robotic surgery safe and feasible for horseshoe kidneys? A multicentre case series

Abstract

Introduction & Objectives: Horseshoe kidneys (HSK) are the most common renal fusion abnormality. However, they are only present in 0.2% of the population. Due to anatomical variation in vasculature, ectopia and malrotation, surgery has traditionally been performed via an open approach. Robotic surgery has been widely adopted for other urological procedures due to the superior ergonomics; high definition, 3D stereoscopic vision; and 7 degrees of freedom, providing a viable, less invasive surgical option. We aimed to assess the safety and feasibility of robot-assisted surgery for HSK. Materials & Methods: Retrospective data were collected for consecutive patients with HSK undergoing robotic surgery between 2016 and 2020 across two high-volume centres by experienced robotic surgeons. 3D reconstruction using CT renal angiograms were used to help identify vasculature and tumour location, where appropriate. Results: Seven patients underwent robotic surgery for HSK including three partial nephrectomies and one nephroureterectomy for renal masses and three benign nephrectomies for non-functioning kidneys. The median age was 53 years (IQR 44-57) and median BMI was 25 (IQR 25-26.5). Median tumour size in four patients with renal masses was 36 mm (IQR 25-45). Median console time was 120 minutes (IQR 118-215), median operating time was 170 minutes (IQR 155-247) and median estimated blood loss was 150 mL (IQR 125-250). The median pre-operative eGFR was 76 (IQR 72-90) and median post-operative eGFR was 71 (IQR 60-81). There was no grade III or higher Clavien-Dindo complication. There was one Clavien-Dindo II, wound infection complication, requiring a five-day length of stay. All other operations were uneventful and median length of stay was two days. Negative margins were achieved in 75% of tumour resections, and final histology demonstrated clear cell renal cell carcinoma (RCC), RCC, urothelial sarcomatoid and angiomyolipoma. Conclusions: We report one of the largest series of robotic-assisted surgery on HSK. Robotic surgery is safe and feasible for HSK in centralised high centres with acceptable perioperative outcomes, early oncological outcomes and morbidity comparable to standard renal surgery. A further prospective, multi-centre study is required to evaluate the role of robotic surgery in renal fusion anomalies.