PMC8200488_01
Hyperaccuracy three-dimensional (HA3D) virtual model of the two renal masses in a patient with a horseshoe kidney (HSK). The snapshots (A-E) show the anatomical relationships of the two renal masses (colored orange) with the extra- and intra-renal vascular (veins, in blue; arteries, in red) and urinary structures (in yellow). Simple renal cysts are colored violet. A linked video clip is available scanning the QR code on the right side of the image. For apple users: open the Camera app from your devices. Hold your device so that the QR code appears in the Camera app's viewfinder. Your device recognizes the QR code and shows a notification. Tap the notification to open the link associated with the QR code. For Android users: download a QR code scanner app and follow the above instructions.
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F1
After reconstruction of the anatomy of the HSK and of the two renal masses, careful evaluation of the renal vasculature and urinary collecting system was performed (Figure 1). Notably, the opportunity to navigate the HA3D virtual model (Figure 1) allowed the surgeon to take advantage of the knowledge of the anatomical relationships of the tumor with the vascular and urinary systems to tailor the surgical strategy for tumor resection both preoperatively and intraoperatively.
Vascular anatomy of our case with focus on the main renal arteries feeding the left-sided portion of the horseshoe kidney (HSK) and on the clamping strategy adopted by the surgeon. A selective delayed clamping strategy was performed for resection of the larger renal mass (A,B) while a clampless strategy was chosen for resection of the smaller renal mass. A linked video clip is available scanning the QR code on the right side of the image. For Apple users: open the Camera app from your devices. Hold your device so that the QR code appears in the Camera app's viewfinder. Your device recognizes the QR code and shows a notification. Tap the notification to open the link associated with the QR code. For Android users: download a QR code scanner app and follow the above instructions.
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F2
In particular, the 3D model allowed us to appreciate the anatomy of the three renal arteries originating from the aorta and feeding the left kidney, orienting the surgeon toward a selective clamping strategy for resection of the larger mass and a clampless strategy for resection of the smaller mass (Figure 2). After delineation of its contours, and once the "enucleation" plane has been identified, the two renal arteries feeding the tumor-bearing portion of the left kidney were clamped (Figure 2) and tumor resection was carried out using an enucleative resection strategy, as previously described (Figure 4).
Overview of port placement in our case of robot-assisted partial nephrectomy (RAPN) for two complex renal masses in a patient with a horseshoe kidney. The da Vinci Si robotic platform with a 30  lens, a three-arm configuration plus two assistant ports [both 12-mm ports, of which one for the AirSeal  system (SurgiQuest, ConMed Corporation, Milford, CT)] was adopted. (A) Placement of the camera port using the Hasson technique plus two robotic ports and two 12-mm assistant ports. (B) Overview of the final port placement. (C) Docking of the robot.
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F3
Port placement was performed following established principles, with a few technical modifications allowing to optimize the access to the HSK and to mobilize the left kidney properly (Figure 3). Pneumoperitoneum was set at 12 mmHg and maintaining constant during the procedure thanks to the Air Seal system.
Intraoperative snapshot showing the main steps of robot-assisted partial nephrectomy (RAPN) in our case. (1-4) Development of the enucleation plane for resection of the larger renal mass (before clamping the renal hilum), with inadvertent capsulotomy of the tumor during tumor enucleation after clamping of the renal hilum (2); the surgeons recognized the wrong plane of dissection and continued the enucleation through the real anatomic plane between the tumor and the healthy renal parenchyma with no macroscopic positive margins; (5) double-layer renorrhaphy to close the renal defect after tumor enucleation of the larger renal mass; (6) enucleation of the smaller hilar renal mass, which was in contact with both vascular structures and the sinus fat. A linked video clip is available scanning the QR code on the right side of the image. For Apple users: open the Camera app from your devices. Hold your device so that the QR code appears in the Camera app's viewfinder. Your device recognizes the QR code and shows a notification. Tap the notification to open the link associated with the QR code. For Android users: download a QR code scanner app and follow the above instructions.
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F4
After delineation of its contours, and once the "enucleation" plane has been identified, the two renal arteries feeding the tumor-bearing portion of the left kidney were clamped (Figure 2) and tumor resection was carried out using an enucleative resection strategy, as previously described (Figure 4).