Learning Objectives

At the conclusion of the activity, participants will be able to:

• Manage bleeding complications of robotic partial nephrectomy.
• Describe the algorithm of immunotherapy treatment of advanced renal cell carcinoma.
• Minimize positive margin rates of robotic partial nephrectomy.

Recent Advances in Systemic Therapy for Renal Cancer

Medical management of renal cell carcinoma continues to be a rapidly evolving area. As of August 2021, a new anti-HIF-2alpha approach is now U.S. Food and Drug Administration (FDA) approved for nonmetastatic von Hippel-Lindau-associated tumors not requiring immediate surgery.¹ This agent (belzutifan) is a new class of agent and will be assessed in future clinical trials as well.

New FDA approvals in 2021 have also occurred in treatment of metastatic clear cell renal cell carcinoma. Nivolumab + cabozantinib has shown improvements in survival as compared to sunitinib,² and the FDA has now approved this regimen. In addition, lenvantinib + pembrolizumab is now FDA approved, again with a clear survival improvement relative to sunitinib.³

Clinical trials in advanced papillary renal cell carcinoma demonstrated cabozantinib is a relatively active agent in the setting.⁴ This agent either alone or plus nivolumab has clear activity in advanced papillary renal cell patients.

In the adjuvant space there is a new trial that likely will result in a new FDA approval. This trial examined adjuvant pembrolizumab after nephrectomy in clear cell renal cell carcinoma. Patients were included if they were determined to have (after nephrectomy) pathological stage T3 or higher tumors (or node positive tumors) or pathological T2 tumors with nuclear grade 4, or T2 tumors with sarcomatoid differentiation. The adjuvant use of pembrolizumab clearly improved disease-free survival⁵ and likely this will be FDA approved during the year ahead.

Partial Nephrectomy for T1b and Hilar Renal Masses

Nephron-sparing surgery is recommended when surgery is indicated in T1a renal masses. For T1b renal masses, partial nephrectomy results in improved postoperative renal function with equivalent oncologic outcomes, though the complication rate and blood loss are expected to be greater.⁶ Overall survival of patients with T1b tumors may also be better when compared to radical nephrectomy based on data from the National Cancer Database.⁷ Hence partial nephrectomy may be performed in these patients after considering tumor location and complexity, patient factors such as comorbidities, and renal function and surgeon experience. The robotic and open approach for partial nephrectomy is based on surgeon experience and can have equivalent oncologic outcomes. Partial nephrectomy for T1b tumors is expected to be complex and must have good preoperative imaging to determine the location of the mass in relation to the hilar vessels. The collecting system in most of these patients will be entered and will need to be closed. We prefer a 2-layer renorrhaphy in these patients. Segmental venous involvement with tumor thrombus on preoperative imaging as well as during surgery must be looked for and managed appropriately, if present for T1b and T2 neoplasms.

Hilar masses can also present surgical challenges that must be managed. The relationship of the mass to adjacent blood vessels must be determined. Endophytic masses will need a preoperative ultrasound to determine its echogenicity to enable optimal intraoperative imaging. The vessels will need to be dissected to include the branches as they enter the renal sinus and branches that are close to the mass. Often the dissection will have to be on the capsule of the mass to prevent vascular injury. Selective clipping or diathermy of branches as they enter the mass may be required. Enucleation of hilar masses may also be considered to prevent vascular injury. After excision of the hilar mass, renal reconstruction will have to be individualized based on the configuration of the defect. A traditional 2-layer renorrhaphy may not be possible or recommended. When the collecting system is not violated, a horseshoe defect can be managed with a single-layer renorraphy. Double pigtail indwelling ureteral stents are not recommended even in complex partial nephrectomies. Drains and tissue sealants are not required in the vast majority of partial nephrectomies but may be considered in complex scenarios.