Angiomyolipoma (AML) is the most common benign renal tumor, with an incidence of 0.3% to 3%. AMLs larger than 4 cm, especially those over 10 cm, carry a higher risk of hemorrhage and are difficult to treat due to their vascularity and proximity to vital structures. Renal cell carcinoma (RCC) accounts for 90% of kidney cancers. Large RCCs, particularly those involving the upper pole, present surgical challenges due to their proximity to the renal hilum and surrounding organs. Robotic-assisted partial nephrectomy has become a preferred approach for complex renal tumors, offering superior visualization and precision. This report discusses two challenging cases, demonstrating the feasibility and safety of nephron-sparing surgery in such cases.

Both cases involved patients with extensive prior abdominal surgeries, dense adhesions, distorted renal anatomy, and tumors near the renal hilum. Case 1: A 45-year-old female with no comorbidities had a 10 cm upper pole AML, complicated by dense adhesions, omental wrapping, and aberrant vasculature. The tumor extended towards the splenic flexure and pancreatic tail, with a slim body habitus restricting visualization and maneuverability. Case 2: A 45-year-old male with a history of open splenectomy for abdominal trauma presented with a 7 cm upper pole RCC. Dense adhesions, a splenunculus, and fibrotic Gerota’s fascia made dissection around the renal hilum challenging. Preoperative planning included detailed cross-sectional imaging reviewed in a multidisciplinary conference, with patients informed of the complexity and potential need for conversion to radical nephrectomy.

Robotic partial nephrectomy was performed using the Da Vinci Si system with a five-port transperitoneal configuration, customized to individual patient anatomy. Intraoperative ultrasound and meticulous dissection were instrumental in delineating tumor margins and preserving vital structures. In the AML case, surgery commenced with lateral-to-medial adhesiolysis, bowel mobilization via the line of Toldt, and stepwise dissection of adhesions. Aberrant arterial anatomy was carefully managed, with bulldog clamps applied to tagged branches to enable precise vascular control. In the RCC case, extensive adhesiolysis was performed to release the splenunculus and omental entrapment. Sharp and suction-assisted dissection techniques were employed to navigate through fibrotic planes. The tumor was resected aided by intraoperative imaging. Both surgeries were completed robotically. blood loss ranged between 600–700 mL. Operative time was 4 hours. Postoperative renal function was preserved, surgical margins were negative, they discharge on postoperative day five.

Robotic-assisted partial nephrectomy is a safe and feasible nephron-sparing approach for large, anatomically complex renal tumors. Success relies on careful preoperative planning, surgical adaptability, and multidisciplinary expertise, highlighting the expanding role of robotics in advanced urologic oncology.