Images in Clinical Urology Preoperative Fiducial Coil Placement Facilitates Robot-assisted Laparoscopic Excision of Retroperitoneal Small Solitary Metastasis of Kidney Cancer Vineet Agrawal, Ashwani Sharma, and Guan Wu Image-guided fiducial markers are being used in surgery, especially in spine and breast surgery, and radiotherapy, allowing localization of tumor sites precisely. We report a case of fiducial coil use in a man undergoing a robot-assisted laparoscopic resection of a metastatic nodule under the ipsilateral diaphragm after robot-assisted partial nephrectomy performed 2 years ago for a left upper pole renal tumor. The fiducial coil facilitated the localization of the lesion, which would otherwise have been challenging because of its small size and location. In addition, the fiducial coil was helpful to avoid cutting into the lesion directly. UROLOGY 84: e21ee22, 2014.  2014 Elsevier Inc.

Figure 1. Computed tomographic scan views after the placement of the fiducial coil. A, axial view; B, coronal view; C, sagittal view; fc, fiducial coil; le, lesion.

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53-year-old man, with a history of robot-assisted partial nephrectomy performed 2 years ago (5.5 cm left upper pole, pT1b, Fuhrman grade-2 conventional renal cell carcinoma with negative surgical Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, University of Rochester Medical Center, Rochester, NY; and the Department of Radiology, University of Rochester Medical Center, Rochester, NY Address correspondence to: Guan Wu, M.D., Ph.D., Department of Urology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 656, Rochester, NY 14642. E-mail: [email protected] Submitted: April 28, 2014, accepted (with revisions): July 7, 2014

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margins), underwent a robot-assisted laparoscopic resection of a 1.0-mm metastatic nodule under the ipsilateral diaphragm. A fiducial metal coil was placed 2 cm caudal to the tumor by an interventional radiologist under computed tomography guidance before the surgery to facilitate intraoperative identification of the tumor site (Fig. 1). The dissection was carried out from the area below the coil. When the coil was identified, the tumor location above the coil was therefore determined and the area resected (Figs. 2, 3). The fiducial coil was helpful to avoid cutting into the lesion directly. Postoperative http://dx.doi.org/10.1016/j.urology.2014.07.019 0090-4295/14

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Figure 2. Intraoperative view before the resection of the metastatic lesion. The fiducial coil is seen with the lesion above it. fc, fiducial coil; le, lesion.

Figure 3. Intraoperative view of resection of the lesion with a resultant defect in the diaphragm, which was suture repaired. d, diaphragm; le, lesion.

histology revealed 2 foci (1.4 and 0.6 cm) of Fuhrman grade-2 conventional renal cell carcinoma with negative margins. There were no associated complications. Image-guided fiducial markers are being used in surgery, especially in spine and breast surgery, and radiotherapy,1-4 allowing localization of tumor sites precisely. To our knowledge, this represents the first reported case of fiducial coil use during robot-assisted urologic surgery. The coil facilitated the localization of the lesion, which would otherwise have been challenging because of its small size and location.

References

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1. Omara AI, Wang M, Fan Y, et al. Anatomical landmarks for pointmatching registration in image-guided neurosurgery. Int J Med Robot. 2014;10:55-64. 2. Brouwer OR, Buckle T, Bunschoten A, et al. Image navigation as a means to expand the boundaries of fluorescence-guided surgery. Phys Med Biol. 2012;57:3123-3136. 3. Trovo M, Polesel J, Biasutti C, et al. Fiducial markers for imageguided partial breast irradiation. Radiol Med. 2013;118:12121219. 4. Shaikh T, Chen T, Khan A, et al. Improvement in interobserver accuracy in delineation of the lumpectomy cavity using fiducial markers. Int J Radiat Oncol Biol Phys. 2010;78:1127-1134.

UROLOGY 84 (5), 2014

Preoperative fiducial coil placement facilitates robot-assisted laparoscopic excision of retroperitoneal small solitary metastasis of kidney cancer.

Image-guided fiducial markers are being used in surgery, especially in spine and breast surgery, and radiotherapy, allowing localization of tumor site...
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