Renal cell carcinoma is a leading cause of death in individuals with Von Hippel–Lindau (VHL) syndrome, typically presenting with multiple bilateral lesions that often require several renal surgeries. These repeated surgeries can impair kidney function, potentially leading to end-stage renal disease. To reduce the risk of renal dysfunction, preserving adequate functional parenchyma is a priority which is achieved through nephron-sparing surgery.

In this video, we demonstrate robotic enucleation of renal tumours in a 27-year-old man with a history of VSD repair, done six years ago. His father had VHL disease and died of metastatic RCC. His DTPA scan showed good bilateral renal function. 3D modelling of the CT dynamic renal study showed multiple tumours in bilateral kidneys, with the largest being 6.5 cm in the left kidney. After discussing treatment options, the patient wanted to proceed with robotic enucleation of the renal tumours. The procedure was performed using the da Vinci Xi robotic system. Initially, to save warm ischaemia time and prevent ischaemic damage to the kidney, several cysts were enucleated “off the clamp” and hemostasis was achieved using various methodologies including cautery, compression and suturing. Solid and cystic masses were removed and during the removal of one such cystic mass, there was bleeding which required clamping of the renal artery to proceed with the larger tumours. The goal of the procedure was to enucleate as many tumours as possible “off clamp”. Enucleation helped us preserve maximal renal parenchyma, possibly with better renal functional outcomes. Studies have shown it to be equivalent to resection with respect to oncological results.

The warm ischemia time was 42 minutes with approximately 1200ml blood loss. On postoperative day 4, he was discharged in stable condition. The histopathology report suggested clear cell carcinoma with multiple tumorlets in the renal cyst and two simple cysts.

In patients with VHL and multiple bilateral renal masses, a nephron-sparing surgical approach is recommended to minimise the risk of impaired kidney function. Additionally, an advanced technique such as the “off-clamp” surgery method is safe and can enhance functional outcomes, making it a viable option when technically and anatomically appropriate.