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European Urology - Da Vinci-Assisted Robotic Partial Nephrectomy: Technique and Results at a Mean of 15 Months of Follow-Up

Thursday, 01 February 2007

Volume 51, Issue 1, Pages 186-192 (January 2007)

1. Introduction:

The widespread use of computed tomography as a diagnostic procedure has led to an increase in the detection of small asymptomatic renal masses. Partial nephrectomy is the standard of care for the treatment of these tumours and laparoscopic partial nephrectomy is gaining acceptance as the preferred approach [1], [2]. Technical difficulty associated with laparoscopic intracorporeal suturing and pressure to minimise warm ischemia time render this procedure within the purview of a few laparoscopically adept surgeons [2]. The advent of the da Vinci robot, with multijointed endowristed instruments and stereoscopic vision, decreases the technical difficulty of intracorporeal suturing [3] and may bring minimally invasive partial nephrectomy into the repertoire of the laparoscopically novice urologist. Despite several centres performing robotic radical prostatectomy, only two reports of robotic partial nephrectomy appear in the literature [4], [5]. We have performed >2000 da Vinci radical prostatectomy procedures at our institution and we used our experience with the robotic system to evaluate feasibility and safety of da Vinci-assisted partial nephrectomy for incidentally detected renal tumours. We present our early experience of 10 patients with a follow-up of 6–28 mo.

2. Patients and methods

2.1. Patients

From September 2003 to March 2005, 10 patients with incidentally detected unilateral small (<4cm) renal masses underwent da Vinci-assisted partial nephrectomy at our institution. All patients had a normal contralateral kidney. Nine patients had a solid enhancing renal mass and one patient had a complex cystic mass. All procedures were performed transperitoneally following the principles of open partial nephrectomy. Preoperative evaluation included, among other routine tests, serum creatinine and a three-dimensional computed tomography scan to accurately delineate the relationship of the mass to the renal vasculature and collecting system. A note was made of the number of renal arteries and aberrant renal vasculature.

2.2. Surgical technique

The patients were placed in flank position with a 45° lateral tilt. A Veress needle was introduced in the ipsilateral hypochondrium and pneumoperitoneum of 20mm Hg established to place the ports. The 12-mm camera port was placed 2 inches below the subcostal margin at the anterior axillary line. The two 8-mm robotic instrument ports were placed 8–10cm from the camera port and more medially toward the umbilicus. An assistant 12-mm port was placed below the umbilicus in the midline and for right-sided procedures an additional 5-mm port was placed to retract the liver (Fig. 1). A 30° lens looking up was used to place the ports and a 30° lens looking down was used for the operation. The standard technique was used to expose the kidney. The modified camera port placement that we use provides excellent vision of the renal hilar anatomy and obviates the need for an assistant to retract the colon. The renal artery and veins are dissected and the Gerota fascia is dissected off the surface of the kidney (leaving the perirenal fat intact over the area of the tumor). Intraoperative ultrasound was used to accurately plan the resection margin 10mm beyond the tumor margin (Fig. 2). The proposed line of resection was marked on the parenchyma with the da Vinci monopolar hook. Prior to clamping the pedicle, mannitol (12.5mg) was administered intravenously.

Fig. 1. Template of port placement for robotic partial nephrectomy. Note that the camera port (12mm) is placed more lateral and the robotic arm ports (8mm) are closer to the midline.

Fig. 2. Intraoperative ultrasound used to define site of incision on renal parenchyma.

The renal artery was occluded with laparoscopic bulldog clamps and time of warm ischemia was noted (Fig. 3). The renal parenchyma was resected with da Vinci round tip scissors. Visible arterioles were sutured or coagulated with da Vinci bipolar forceps. Frozen sections were obtained from the base of the parenchyma. Indigo carmine was administered intravenously to detect entry into the collecting system, which was closed with 3-0 Vicryl sutures. Gelfoam and Surgicel (oxidised regenerated cellulose) were used as adjuncts for hemostasis. The bulldog clamps were released and careful inspection performed to note any bleeding points, which were managed with additional FLOSEAL. The parenchymal surface was sutured close over Gelfoam pledgets (Fig. 4). A 15F Jackson-Pratt drain was placed via the 8-mm port and removed after 24h in the absence of significant drainage.

Fig. 3. Clamping of renal artery with laparoscopic bulldog clamp.

Fig. 4. Suturing closes the cut surface of the kidney over FLOSEAL and gel-foam bolsters.

Patients were given ketorolac for the first 24h and paracetamol/codeine for breakthrough pain; no opioids were administered. Serum creatinine estimation was performed in the recovery room and on postoperative days 1 and 14. Ambulation and clear liquids were encouraged on the evening of surgery and patients were discharged when they tolerated a regular diet.

3. Results

Seven men and three women (average age, 61 yr) underwent unilateral transperitoneal da Vinci-assisted partial nephrectomy on an elective basis. Six masses were located on the right kidney and four on the left. The average size of the tumour was 2.3cm (range, 1.0–3.5cm). The average operative time was 155min (range, 120–185min) and average time for patient positioning and robotic system setup was 20min. The mean blood loss was 92ml (range, 50–150ml). Seven patients required clamping of the renal artery and the mean warm ischemia time was 21min (range, 18–27min). No patients experienced an elevation of serum creatinine postoperatively and there were no intraoperative complications. Postoperative complications were observed in two patients; one patient experienced a urinary leak and the other patient required urgent re-exploration due to persistent bleeding. One patient required blood transfusion postoperatively. Nine of 10 patients were discharged within 48h. Pathologic examination revealed renal cell carcinoma in eight, oncocytoma in one, and lipoma in one patient. All resection margins were excised and submitted for frozen section analysis and were found to be negative for residual malignancy. At a mean follow-up of 15 mo (range, 6–28 mo) no tumour recurrences have been observed.

4. Discussion

Nephron-sparing surgery for renal cell carcinoma has steadily gained acceptance among urologists. Originally reserved for patients with solitary kidney, bilateral tumours, or renal insufficiency, partial nephrectomy has become the standard of care even in the face of a normal contralateral kidney [6]. Several studies have demonstrated that disease-free survival and oncologic outcomes of partial nephrectomy are equivalent to radical nephrectomy in carefully selected patients [7]. Despite the advantages laparoscopic partial nephrectomy enjoys over conventional open surgery in terms of perioperative morbidity, blood loss, operative time, and hospital stay, the technical difficulty of intracorporeal laparoscopic suturing has prevented the widespread use of laparoscopic partial nephrectomy. The main concern is the potential for prolonged warm ischemia time and subsequent renal dysfunction [8]. Robotic surgery is in the forefront of minimally invasive surgery and has been successfully applied to radical prostatectomy. The use of da Vinci robotic assistance has significantly decreased the learning curve for complex laparoscopic tasks, especially intracorporeal suturing. At our institution we have performed >2000 robotic radical prostatectomies and we reasoned our experience with the da Vinci system would enable us to explore the feasibility of da Vinci-assisted partial nephrectomy. Table 1 outlines the demographics, operative parameters, complications, and pathology outcomes in our patients. Because this represented our initial experience, we carefully selected the patients undergoing robotic partial nephrectomy. We were able to complete all cases using the da Vinci system and there were no conversions. The mean operative time of 171min included patient positioning and robotic setup time. Thus far, only two centres have reported on the feasibility of robotic partial nephrectomy. Phillips et al. [4] reported on their experience of 12 robotic partial nephrectomy procedures. However, they performed the initial dissection laparoscopically and used the robot for hilar dissection and suturing. Their mean operative time was 265min and warm ischemia time averaged 26min. The mean blood loss was 240ml and patients were hospitalised for 3 d. Three cases required conversion to open approach secondary to brisk bleeding. They concluded that the robotic approach was feasible and safe and that the endowristed instruments made the surgery technically easier. Gettman et al. [5] reported on 13 robotic partial nephrectomy procedures. They used an intra-arterial catheter to cool the kidney in eight patients. They reported mean operative time of 215min and mean warm and cold ischemia times of 22min and 33min, respectively. One patient in their series had a positive frozen section and underwent radical nephrectomy. However, neither reported on oncologic results or provided a long follow-up (Table 2). In our series the mean operative time was 155min and the mean warm ischemia time was 21min. The median hospital stay was 1.5 d. One patient, who had a negative frozen section intraoperatively, had a positive surgical margin at final pathologic analysis. He was offered a radical nephrectomy but chose to undergo surveillance instead. At 12 mo of follow-up he has had no recurrence of the cancer.

Table 1.

Demographic, operative parameters, and complications in 10 patients undergoing robotic partial nephrectomy


No.	Sex	Age, yr	Side	Site	Tumor size, cm	Operative time, ^amin	Warm ischemia time, min	Follow-up, mo	Hospital stay, d	Complication
1	M	74	Rt	Lower pole	3.0	140	24	28	2	Nil
2	F	66	Lt	Anterior lateral	2.0	185	NA	24	2	Blood transfusion
3	F	68	Lt	Upper pole	1.0	160	NA	15	2	Nil
4	M	73	Rt	Lower pole	1.5	120	NA	14	1	Nil
5	M	54	Rt	Posterior lateral	2.0	130	19	14	1	Nil
6	M	48	Lt	Posterior lateral	2.5	180	23	13	1	Nil
7	M	58	Rt	Upper pole	2.5	160	22	12	1	Positive margin, urine leak
8	M	69	Lt	Inferior lateral	2.0	180	27	12	2	Nil
9	F	43	Rt	Anterior lateral	3.0	150	14	11	2	Nil
10	M	61	Rt	Upper pole	3.5	150	18	6	21	Re-exploration nephrectomy

NA=not applicable.

^a Excludes mean setup time of 20min.

Table 2.

Comparison of contemporary series of robotic partial nephrectomy


Series	No. of patients	Mean tumor size, cm	Operative time, min	Warm ischemia time, min	Median hospital stay, d	Mean blood loss, ml	Mean Follow-up, mo	Recurrence
Gettman et al.	13	3.5	215	22	4.3	170	NR	NR
Phillips et al.	12	1.4	265	26	2.7	240	NR	NR
Present study	10	2.3	155	21	1.5	92	15	0

NR=not reported.

The robotic approach to renal surgery, specifically partial nephrectomy has some inherent challenges. These relate to familiarity with the da Vinci robotic system including effective use of the camera and of the clutch as well as an understanding of the range of motion of each of the robotic arms. The robot design does not permit significant side-to-side movement and hence accurate port placement is extremely important. The traditional port placement template requires the camera port to be placed at the umbilicus and two robotic arm ports more laterally [4], [5]. Using this template, the range of motion of the robotic arms is restricted and it is necessary to have an assistant retract the colon, especially during dissection of the renal pedicle. We have modified the port placement template (Fig. 5) for robotic partial nephrectomy, placing the camera port laterally and the robotic instruments closer to the umbilicus. Using this template, retraction of the colon is unnecessary and because the plane of motion of the robotic arms is different from that of the camera arm, the range of motion of the former is enhanced. This improved range of motion facilitates dissection of the upper and lower poles of the kidney and adjacent organs such as liver and duodenum on the right and the spleen on the left. The role of the assistant is critical especially during warm ischemia because the operating surgeon is not at the table side. The assistants involved with the da Vinci-assisted partial nephrectomy are crucial to the success and outcome of the case, because they control not only basic retraction and suctioning, but also provide the console surgeon the suture and bolster material and are responsible for pedicle clamping and initiation of warm ischemia.

Fig. 5. The modified port placement template depicting the distinct planes of movement for the camera and robotic ports increasing the range of movement.

Our initial experience of 10 cases with da Vinci robotic partial nephrectomy is encouraging. The pressure of completing the procedure within the safe 30-min limit of warm ischemia in the face of risk of renal dysfunction, coupled with the extreme difficulty of laparoscopic intracorporeal suturing prevented the laparoscopic approach being used more widely. We believe that the intuitive design, stereoscopic vision, and endowristed instrumentation of the da Vinci robotic system has made a significant impact on how we approach laparoscopic partial nephrectomy and permitted us to accurately suture both the pelvicalyceal system and renal parenchyma without exceeding maximum safe warm ischemia time. We wish to stress certain caveats. Although these patients were carefully selected, as additional experience is gained, it is expected that operative and warm ischemia times will decrease, larger and more complex tumours resected, and standard approaches developed depending on the location and size of the tumour. Such a transition has been described previously for laparoscopic nephrectomy and by us and others for robotic radical prostatectomy [9], [10]. Although our experience suggests that robotic partial nephrectomy is feasible for carefully selected small renal masses, the cost of the robot is currently prohibitive and remains a limitation. Additional evaluation is necessary to evaluate whether the advantages will justify the higher cost.

5. Conclusion

Our series indicates that robotic-assisted partial nephrectomy is a viable alternative to open or laparoscopic approach in appropriately selected patients with small renal masses and provides durable long-term results. The modified port placement template described by us facilitates dissection and expands range of motion of the robot. The attributes of the robot reduce technical difficulty associated with intracorporeal suturing and permit urologists inexperienced with laparoscopic procedures to complete the procedure within reasonable warm ischemia time. Whether robotic assistance can permit more widespread use of laparoscopic partial nephrectomy requires additional evaluation by multiple centers. We further emphasise that such investigation into the feasibility of such procedures should initially be performed by surgeons who are facile with both robotics and laparoscopic techniques to reduce patient morbidity during the learning phase.

Editorial comment

Francesco Porpiglia, Department of Urology, San Luigi Hospital, Regione Gonzole 10, 10043, Orbassano, Torino, Italy

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Laparoscopic partial nephrectomy (LPN) is considered a challenging procedure.

More than a 1000 cases have been described in literature. Some studies demonstrate oncological efficacy [11], [12], [13] while in terms of safety, it is evident that good results are only obtained after adequate and specific experience [14].

This is why there is a constant search for solutions to obtain better results and robotic assisted laparoscopic partial nephrectomy (RALPN) could be considered as one of them.

In their study, the authors, who must be congratulated for their effort, report their first experience using the robot for this procedure (the third in literature). They here describe a template organization of trocars, renal artery control using bulldog clamp, parenchyma resection with da Vinci round tip scissors and haemostasis by means of suture and FloSeal®, which exactly duplicates LPN.

The limited number of treated cases, for a centre already known for its robotic experience, does not enable us to draw any conclusions. In terms of positive surgical margins, complications, operative time, blood loss, ischemia time, and length of hospital stay, these results are comparable to those recorded with LPN. However, it is important to underline that the mean size of lesions was 2.3cm and the cases selected. We also noted that the main complications were encountered in patients with upper pole lesions, a fact that is probably linked to some limitation of the robot and which makes us consider that other problems could arise in larger studies. Furthermore, another limitation could be the cost, as mentioned by the authors, even though an economic analysis was not performed.

Having analysed all these facts, it is very difficult to recognise any advantages of RALPN over LPN. One thing that is sure is that, from an overall point of view, the use of RALPN does not make things much easier!

Editorial comment

Libor Safarik, Department of Urology, 1st School of Medicine, Charles University Prague, Ke Karlovu 6, Praha 2, 128 00, Czech Republic

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Robotic laparoscopic procedures in urology have been gaining more and more popularity among the urological surgeons, particularly among the younger ones. Not only they have brought advanced technology into the manual surgery, they have also simplified and shortened the learning curves for surgeons [15], [16]. The only setback is still the considerable price for equipment, which might prevent some departments, particularly those which are constricted to a tight budget, to be lured.

In the presented paper, the authors suggest to expand the use of the already well-known “da Vinci” system to the interesting area of partial kidney resection [17]. Apart from the previously multiple cited advantages of using robotic system in prostate surgery, in this area of time-minded warm ischemia, the robotic suturing could be of extraordinary importance mimicking the sewing machine speed in experienced hands.

Since the incidence of small renal masses during routine U/S or CT/MRI imaging is considerably high and with the high-definition machines is likely to mount further up, it indicates a good pool of new cases for generations-to-come urologists to go this way and set the robotic partial nephrectomy as a new standard in urological oncology.

The authors have used the standard “endowristing motion” for knotting, which could be replaced or accompanied with the tail pre-clipped running PDS sutures finished with another resorbable clip. It is quicker during multiple bites in fragile kidney parenchyma and it is safer from ripping off. Clipped sutures execute higher superficial flat compression to the cut vessels and give the temporary support for the sealing glue to finish the most challenging part of the surgery in time [18], [19].

For the beginners with this smart procedure I would recommend to place the urethral catheter prior to surgery, since the application of 4°C N/S coolant through it may extend the time of “warm” ischemia to prevent the future damage to the kidney and not accurately sewn and sealed small openings to the collecting system could be healed on it within 2–3 days after operation.

References

1. Finelli A, Gill IS. Laparoscopic partial nephrectomy: contemporary technique and results. Urol Oncol. 2004;22:139–144.

2. Link RE, Bhayani SB, Allaf ME, et al.. Exploring the learning curve, pathological outcomes and perioperative morbidity of laparoscopic partial nephrectomy performed for renal mass. J Urol. 2005;173:1690–1694.

3. Maniar H, Council M, Prasad S, Prasad S, Chu C, Damiano R. Comparison of skill training with robotic systems and traditional endoscopy: implications on training and adoption. J Surg Res. 2005;125:23–29.

4. Phillips CK, Taneja SS, Stifelman MD. Robot-assisted laparoscopic partial nephrectomy: the NYU technique. J Endourol. 2005;19:441–445.

5. Gettman MT, Blute ML, Chow GK, Neururer R, Bartsch G, Peschel R. Robotic assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology. 2004;64:914–918.

6. Abukora F, Nambirajan T, Albqami N, et al.. Laparoscopic nephron sparing surgery: evolution in a decade. Eur Urol. 2005;47:488–493.

7. Allaf ME, Bhayani SB, Rogers C, et al.. Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome. J Urol. 2004;172:871–873.

8. Desai MM, Gill IS, Ramani AP, Spaliviero M, Rybicki L, Kaouk JH. The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy. BJU Int. 2005;95:377–383.

9. Kaul S, Shah NL, Menon M. Learning curve using robotic surgery. Curr Urol Rep. 2006;7:125–129.

10. Phillips J, Catto JW, Lavin V, et al.. The laparoscopic nephrectomy learning curve: a single centre's development of a de novo practice. Postgrad Med J. 2005;81:599–603.

References

11. Moindazeh A, Gill IS, Finelli A, Kaouk J, Desai M. Laparoscopic partial nephrectomy: 3 year follow-up. J Urol. 2006;175:459–462.

12. Albqami N, Janetschek G. Laparoscopic partial nephrectomy. Curr Opinion Urol. 2005;15:306–311.

13. Porpiglia F, Fiori C, Terrone C, Bollito E, Fontana D, Scarpa RM. Assessment of surgical margins in renal cell carcinoma after nephron sparing: a comparative study: laparoscopy versus open surgery. J Urol. 2005;173:1098.

14. Haber GP, Gill IS. Laparoscopic partial nephrectomy: contemporary technique and outcomes. Eur Urol. 2006;49:660–665.

References

15. Miyake O, Kiuchi H, Yoshimura K, et al.. Urological robotic surgery: preliminary experience with the Zeus system. Int J Urol. 2005;12:928–932.

16. Gettman MT, Blute ML, Chow GK, et al.. Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology. 2004;64:914–918.

17. Haber GP, Gill IS. Laparoscopic partial nephrectomy: contemporary technique and outcomes. Eur Urol. 2006;49:660–665.

18. Wille AH, Tullmann M, Roigas J, et al.. Laparoscopic partial nephrectomy in renal cell cancer–results and reproducibility by different surgeons in a high volume laparoscopic center. Eur Urol. 2006;49:337–342.

19. Koninger J, Bottinger P, Redecke J, et al.. Laparoscopic repair of perforated gastroduodenal ulcer by running suture. Langenbecks Arch Surg. 2004;389:11–16.

Sanjeev Kaul, Rajesh Laungani, Richard Sarle, Hans Stricker, James Peabody, Ray Littleton, Mani Menon

Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA

Accepted 5 June 2006 published online 22 June 2006.

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