AUA 2018: Surgical Techniques: Tips & Tricks: Robotic Partial Nephrectomy

San Francisco, CA (UroToday.com) Three renowned experts in the field of robotic partial nephrectomy were present at AUA 2018 to discuss surgical techniques, tips, and tricks related to successfully and efficiently performing this growingly common procedure. Each had representative videos of index cases. Below is a concise summary of the main points they expressed. 

Gennady Bratslavsky, MD discussed the standard transperitoneal approach and provided a demonstration of the normal anatomy encountered via the transperitoneal robotic approach and how an efficient partial nephrectomy should be conducted.

Duke Herrell, III, MD discussed complex hilar tumors and emphasized that patient and case selection is key to having success with complex renal masses. He recommends obtaining thin cut CT renal angiograms, and MRI may help differentiate depth of lesions for better preoperative planning. Of key importance when dealing with hilar masses is to get excellent vascular control. He uses multiple Scanlon clamps on the renal artery and also clamps the vein. In this way, he demonstrated that a relatively bloodless dissection around the hilum can be conducted safely.

James Porter, MD discussed the retroperitoneal robotic approach and highlighted several important aspects related to successfully performing a retroperitoneal robotic partial nephrectomy.


Position: The patient should be in full flank and fully flexed. Maximize space between the 12th rib and iliac crest. The hip and shoulder should be in line.

Port configuration: Arms should be about 6-8cm apart and the assistant placed underneath the 4th arm; The Si allows for 3 arms to be used but can lead to “one-handed surgery” at times. In that regard, the Xi may be superior because it allows for getting 4 arms into the space with relative ease. 

Space Creation: A dilating balloon is used (he prefers the football-shaped balloon) on the psoas to push the kidney anteriorly.

Docking: The Si robot needs to come over the head; whereas the Xi robot can dock from different directions. Again, this is a likely advantage of the newer robot.

Fat management: This is an extremely important part of the retroperitoneal approach. The first move is to remove paranephric fat off the posterior layer of Gerota’s fascia. The surgeon then enters Gerota’s fascia directly above psoas to gain access to the kidney and hilum and improve orientation.

All of the panelists were asked about specific scenarios related to vascular control. If one encounters significant bleeding during tumor excision, it is likely that an artery was missed and/or that the vein needs to be unclamped. Airseal ports may be helpful in maintaining high-pressure pneumoperitoneum during the excision to avoid excessive bleeding. Prompt suturing is also key.

Tumor spillage (especially with necrotic and papillary tumors) can also be difficult to manage. There is no definitive indication to convert to an open procedure or perform a radical nephrectomy if this occurs. However, every attempt should be made to clear the spilled tumor material and get negative margins. “The solution to pollution is dilution,” argued Gennady, and liberal use of irrigation should be employed.

Although robotic partial nephrectomy can be a straightforward case, it can also be complex and challenging. Keeping some of these key pieces of advice in mind can significantly improve the efficiency and outcomes as surgeons increase their experience.


Moderator: Mihir Desai, MD
Panelists:
Gennady Bratslavsky, MD, SUNY Upstate Medical University
James Porter, MD, University of Washington Medical Center
Duke Herrell, III, MD, Vanderbilt University

Written by: Shreyas Joshi, MD Fox Chase Cancer Center, Philadelphia, PA @ssjoshimd at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA