Focal segmental glomerulosclerosis (FSGS) is a histological pattern that is associated with nephrotic syndrome in children and adults and represents an important cause of end-stage renal disease worldwide. The underlying podocytopathy is a consequence of multiple pathways, either individually or collectively. The associated heavy proteinuria represents a perioperative risk factor for complications after transplantation. Therefore, a bilateral nephrectomy before transplantation is recommended to stop protein loss by the kidneys.
A 19-year-old woman with therapy-resistant FSGS had a persistently low serum albumin level requiring 70g human albumin supplementation each week. A bilateral kidney embolisation or surgical removal before listing for a kidney transplantation was required. To improve perioperative outcomes and cosmesis in a young female patient, she was scheduled for a robotic subumbilical access to avoid scar tissue in the upper abdomen.
The patient was positioned in a supine position with 30° head down. Four robotic 8-mm trocars were placed in a subumbilical line and a 5-mm and 12-mm assistant trocars were positioned laterally of the medial umbilical ligaments. No repositioning of the patient during the whole case was required.The peritoneum was incised at the level of the ileocecal valve up to the ligament of Treitz. A hammock-like barrier was created by suturing both lateral edges of the parietal peritoneum to the anterior abdominal wall. Subsequently, the renal hilus was dissected and the kidney mobilised. The renal vessels were clipped. An 18-mm laparoscopic morcellator was introduced after extending the 12-mm assistant trocar incision, and the kidneys were removed through the morcellator. Blood loss was <50 mL,and the theatre time was 325 minutes. After the surgery the patient had mild bruises on both shoulders because of the longperiod in the Trendelenburg position, but these resolved without further treatment.Postoperative length of stay was 4 days. After successful removal of both kidneys, the patient was listed for a kidney transplant with priority given due to her age being < 20 years.
Bilateral robotic nephrectomyusing a subumbilical accessand removal of the kidney using a morcellator is technically demanding but feasible.