Data_Sheet_2_Case Report: Optimizing Pre- and Intraoperative Planning With Hyperaccuracy Three-Dimensional Virtual Models for a Challenging Case of Robotic Partial Nephrectomy for Two Complex Renal Masses in a Horseshoe Kidney.docx

Objective: To report a case of robot-assisted partial nephrectomy (RAPN) for two highly complex renal tumors in a patient with a Horseshoe kidney (HSK), focusing on the utility of hyperaccuracy three-dimensional (HA3D) virtual models for accurate preoperative and intraoperative planning of the procedure.
Methods: A 74-year-old Caucasian male patient was referred to our Unit for incidental detection of two complex renal masses in the left portion of a HSK. The 50 × 55 mm, larger, predominantly exophytic renal mass was located at the middle-lower pole of the left-sided kidney (PADUA score 9). The 16 × 17 mm, smaller, hilar renal mass was located at the middle-higher pole of the left-sided kidney (PADUA score 9). Contrast-enhanced CT scan images in DICOM format were processed using a dedicated software to achieve a HA3D virtual reconstructions. RAPN was performed by a highly experienced surgeon using the da Vinci Si robotic platform with a three-arm configuration. A selective delayed clamping strategy was adopted for resection of the larger renal mass while a clampless strategy was adopted for the smaller renal mass. An enucleative resection strategy was pursued for both tumors.
Results: The overall operative time was 150 min, with a warm ischemia time of 21 min. No intraoperative or postoperative complications were recorded. Final resection technique according to the SIB score was pure enucleation for both masses. At histopathological analysis, both renal masses were clear cell renal cell carcinoma (ccRCC) (stage pT1bNxMx and pT3aNxMx for the larger and smaller mass, respectively). At a follow-up of 7 months, there was no evidence of local or systemic recurrence.
Conclusions: Surgical management of complex renal masses in patients with HSKs is challenging and decision-making is highly nuanced. To optimize postoperative outcomes, proper surgical experience and careful preoperative planning are key. In this regard, 3D models can play a crucial role to refine patient counseling, surgical decision-making, and pre- and intraoperative planning during RAPN, tailoring surgical strategies and techniques according to the single patient's anatomy.

研究目的：报告1例针对马蹄肾（Horseshoe kidney, HSK）患者的2枚复杂肾肿瘤实施机器人辅助肾部分切除术（robot-assisted partial nephrectomy, RAPN）的病例，重点探讨超高精度三维（hyperaccuracy three-dimensional, HA3D）虚拟模型在该手术精准术前及术中规划中的应用价值。
方法：1例74岁高加索男性患者因偶然发现马蹄肾左侧部存在2枚复杂肾肿物就诊于我科。其中较大肿物尺寸为50×55 mm，以向外生长为主，位于左肾中下极，PADUA评分（PADUA score）为9分；较小肿物尺寸为16×17 mm，为肾门旁肿物，位于左肾中上极，PADUA评分为9分。采用专用软件处理DICOM格式的增强CT影像，生成HA3D虚拟重建模型。由经验丰富的外科医师采用达芬奇Si手术机器人平台的三臂构型完成RAPN手术：针对较大肾肿物采用选择性延迟阻断血流策略，针对较小肾肿物则采用无阻断血流策略，2枚肿瘤均采用剜除术式进行切除。
结果：总手术时长为150分钟，热缺血时间为21分钟。术中及术后均未出现并发症。根据SIB评分，最终2枚肿物均采用纯剜除术式完成切除。病理组织学检查显示，2枚肾肿物均为透明细胞肾细胞癌（clear cell renal cell carcinoma, ccRCC）；较大肿物分期为pT1bNxMx，较小肿物分期为pT3aNxMx。术后7个月随访期间，未发现局部或远处复发征象。
结论：针对马蹄肾患者的复杂肾肿物实施外科治疗极具挑战性，手术决策需兼顾诸多细节。为优化术后结局，丰富的手术经验与细致的术前规划是关键。就此而言，三维模型可发挥关键作用，有助于优化RAPN术中的患者沟通、手术决策及术前与术中规划，可根据患者个体解剖结构定制手术策略与操作技术。