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Objective: To demonstrate the utility of cold ischemia during robotic-assisted laparoscopic partial nephrectomy (RAPN). Patients and surgical procedure: Patients that are eligible for nephron-sparing surgery for management of renal neoplasms include those with solitary anatomical or functioning kidney, chronic kidney disease (CKD) and bilateral renal masses. The utilization of hilar clamping and resultant ischemia time is an inherent limitation of partial nephrectomy. We present a case of a large, complex unilateral renal mass in a patient with stage III CKD that required hilar clamping. In an effort to maximally preserve post-operative renal function, we performed RAPN utilizing cold ischemia for definitive surgical management. Finding an optimal method for laparoscopic ice delivery to induce ischemia has been challenging with many mechanisms proposed (Ramani et al., 2006). To date, a general consensus has not been reached on which method supersedes others. Results: Cold ischemia was accomplished using a modified 10 cc syringe to deliver 300 cc of ice through a dedicated 12 mm trocar. A clamp time of 32 min was necessary for tumor enucleation and renorraphy. Estimated blood loss was 200 cc and final pathology showed Fuhrman grade 3 clear cell RCC (pT1aNxM0) with negative margins. The patient was discharged after an uneventful hospitalization on post-operative day 3. At 2-week follow-up his renal function was comparable to preoperative values. Conclusions: Cold ischemia during RAPN is feasible and may facilitate prolonged ischemia time in the setting of a complex renal mass and the decision to pursue nephron-sparing surgery.

A patient with germline von Hippel-Lindau (VHL) gene alteration and history of multiple tumors present with classical paraneoplastic syndrome (PNS) associated with renal cell carcinoma (RCC). She underwent open nephron sparing surgery with resolution of symptoms. She remained without recurrence of RCC for the initial 2 years of her follow-up. To the best of our knowledge, this case represents the first in which PNS was specifically resolved using a partial nephrectomy in a patient with VHL. This case report provides initial evidence for the potential role of nephron sparing surgery in the management of paraneoplastic symptoms associated with hereditary RCC.