Robot-assisted deferred cytoreductive nephrectomy in metastatic renal cell carcinoma following immune checkpoint inhibitors plus tyrosine-kinase inhibitor

Objective: This video aims to demonstrate the safety and feasibility of performing deferred cytoreductive ne- phrectomy (dCN) using robotic assistance in patient treated with immunotherapy for metastatic renal cell carcinoma (mRCC). Patients and surgical procedure: A 62-year-old woman, affected by right metastatic renal cell carcinoma, showed partial response after 4 cycles of Pembrolizumab and Axitinib. Multidisciplinary team consultation decided for cytoreductive right radical nephrectomy with adrenalectomy. After anatomical landmarks identification, inferior vena cava (IVC) was progressively exposed, until identifying the renal hilum. During surgery, small bleeding occurred, and Weck-clips were placed to control the arterial flow. Nephrectomy proceeded without complica- tions. Right adrenal gland, suspected of metastasis, was removed. Results: No intra- and post-operative high-grade Clavien-Dindo complications occurred, and the patient was discharged in post-operative day 3. Final pathology revealed clear cell renal cell carcinoma with sarcomatoid features, Furhman grade 4, with metastatic lesion in the omolateral adrenal gland (pT3a pM1) Conclusion: Robot-assisted dCN is feasible and safe after immune checkpoint inhibitor-based combination therapy in patients affected by mRCC.