# Repeat robotic nephron-sparing surgery for metachronous multifocal tumors in a solitary kidney: a case report

## TL;DR

A patient with a single kidney underwent two robotic surgeries to remove multiple kidney tumors, showing that repeat procedures are possible without significant loss of kidney function.

## Contribution

Demonstrates the feasibility of repeat robotic partial nephrectomy in a solitary kidney with metachronous tumors.

## Key findings

- The second robotic surgery was successfully performed with selective clamping of the renal artery.
- Postoperative renal function remained stable despite increased surgical complexity.
- Both tumors were confirmed as clear cell renal carcinomas with negative surgical margins.

## Abstract

We report the case of a 58-year-old male with metachronous renal tumors and a solitary kidney who had previously undergone an open right radical nephrectomy with extended lymphadenectomy for an invasive renal cell carcinoma (RCC) (pT3a N0M0) in November 2013. In May 2022, during routine surveillance, a left lower pole lesion measuring 2.5 × 2 × 1.6 cm was detected, and the patient was submitted to robot-assisted partial nephrectomy (RAPN). The histopathological study confirmed the presence of a pT1a Fuhrman grade 3 clear cell renal carcinoma. In October 2024, follow-up imaging revealed a new upper pole lesion measuring 4 × 3 × 2.3 cm in the left kidney. The patient was submitted to a novel robot-assisted partial nephrectomy, which was successfully completed using selective clamping of the renal artery. The clamping time was 28 minutes (versus 17 minutes during the initial procedure), and the estimated blood loss increased to approximately 300 mL compared to about 100 mL previously, with a console time of 98 minutes. The patient was discharged after the second surgery in good functional status. The final pathology revealed clear cell RCC, Fuhrman grade 2/nucleolar grade 2 (WHO/ISUP 2016), and pT1a, with negative margins. Despite increased technical challenges during reoperation, postoperative renal function remained stable, underscoring the feasibility of repeat RAPN in a solitary kidney.