Iatrogenic aortic and iliac artery transections during robotic nephrectomies requiring emergent open vascular repair.

Background: Robotic and laparoscopic radical nephrectomy are widely performed and are generally considered safe. Major vascular injuries are rare but potentially life-threatening, most often involving extrarenal visceral arteries. In contrast, injury to the aortoiliac axis during minimally invasive nephrectomy is exceptionally rare, and complete intraoperative transections have been seldom documented. Methods: We report three cases of major aortoiliac vascular injury occurring during robotic nephrectomy between 2021 and 2024. Clinical presentation, mechanism of injury, intraoperative management, vascular reconstruction, and postoperative outcomes were reviewed. Results: Two patients sustained complete infrarenal aortic transections and one sustained a right common iliac artery transection. All injuries occurred during stapled division of a misidentified renal vessel, requiring emergent conversion to open surgery with interposition graft reconstruction. Distal perfusion was restored in all cases, and the patients experienced uncomplicated postoperative recoveries without further vascular compromise. Conclusions: Life-threatening arterial injuries during robotic or laparoscopic nephrectomies commonly result from anatomic misperception of distorted planes rather than proximity to major vessels alone. Prevention requires a structured review of preoperative imaging to confirm anatomic landmarks and intraoperative verification of vessel origin and course before division. In addition, there should be a low threshold for conversion to open surgery when anatomy is uncertain. In the event of major vascular injury, rapid conversion, prompt proximal and distal vascular control, and early intraoperative collaboration with vascular surgery are critical to achieving favorable patient outcomes.