KIDNEY CANCER: ROBOTIC PARTIAL NEPHRECTOMY
Contraindications
- Contraindications to laparoscopic surgery
- History of extensive abdominal or pelvic surgery
- Morbid obesity
- Extremely large tumor
Advantages to robotic approach
- Reduced blood loss, less pain, and shorter hospital stays
Pre-operative Preparation
- Hold/bridge anticoagulation medications prior to surgery
Steps of procedure
-
Venous thromboembolism prophylaxis
- Compression stockings
- No heparin
Antibiotics
- 2g cefazolin (900 mg clindamycin, if penicillin allergic)
- Transperitoneal approach
- Position: 60-90° ipsilateral (tumor side up) flank. Flex table slightly, at umbilicus. Slight Trendelenburg.
- Cuatery: 35 while dissecting bowel, then 40. Consider 60 if toxic fat around kidney.
- Surgical plan:
- Ports
- Variations possible, depending on patient characteristics, surgeon preference, and institution equipment
- With Xi robot, all ports can be in straight line.
- Number of ports: 4-5 (5-6 if right-sided)
- Location of ports:
- Port placement medial to the rectus border risks injury to the epigastric vessels.
- Configuration 1 (Xi)
- All ports are placed in a straight line at the lateral border of the ipsilateral rectus abdominus muscle.
- Camera (12 mm): 3 cm above the umbilicus
- Robotic Arm 1 (8 mm): 1 fingerbreadths below the costal margin
- Robotic Arm 2 (8 mm): 8 cm inferior to camera port (alternative configuration: 1 hand breadth medially and inferiorly to the camera port)
- Robotic Arm 3 (8 mm): superior and medial to the anterior superior iliac spine (optional) (1 hand breadth away from Robotic arm 2 in alternative configuration)
- Assistant 1 (12 mm): between camera trocar and Robotic Arm 1 or 3, in midline
- If right-sided, additional 5 mm trocar placed just inferior to xiphoid process to retract liver. Use Allis clamp to hold on abdominal wall and retract liver away from surgical field.
- Port configuration can vary based on tumor location to optimize the working angles.
- For upper pole tumors, all the ports can be shifted 1- to 2-cm cephalad.
- An extra 5-mm assistant port between the camera and the right robot port can be placed to allow the assistant better access to the operative field. Consider for complex tumours.
- For posterior tumors, all the ports can be shifted medially, as the kidney needs to be mobilized to allow access to its posterior aspect.
- For obese tumors, all ports can be shifted medially, including liver retractor
- Variations possible, depending on patient characteristics, surgeon preference, and institution equipment
- Step by step:
- Patient positioning, antiseptic preparation, draping. Insert foley catheter. Position patient. Pressure points should be padded. Axillary roll should be placed to prevent neuropraxia.
- Veress needle access.
- Location
- Commonly where camera port will be.
- Palmer's point (3 cm below the left costal margin and in the midclavicular line) is another option.
- Make incision in skin with cautery. Use cautery to get through subcutaneous fat. Use S-curve retractors to expose fascia. Use Kocher clamp to lift up on fascia. Use to right hand to steady varess needle and feel (usually) 2 pops until you are in abdomen. Confirm appropriate placement with saline test.
- Location
- Achieve pneumoperitoneum. Have gas on low flow and determine opening pressure. If pressures are low (< 10 mmg Hg), increase to high flow. As the pressure slowly rises to 20, the port sites are prepared.
- Insert ports. Once at 20mm Hg, the first port, the camera port is placed through a 12 mm transverse incision followed by the remaining ports all under direct vision. Once all ports are positioned, AirSeal is installed and activated and the pneumoperitoneum is reduced to 12-15 mm Hg for the procedure.
- Dock robot
- If Xi
- Attach camera port to robot. Insert and attach camera. A 30° robotic camera looking upward facilitates placement of the other trocars. Target camera to hilum/tumor. Hold camera port steady and allow robot to adjust. Attach remaining ports to robot.
- Insert instruments into arms (Arm 1 - monopolar scissors, Arm 2 - bipolar Maryland graspers, Arm 3 - Prograsp fenestrated graspers). Connect cords. Advance arms under vision.
- If Xi
- Medialize bowel to expose retroperitoneum. Grasp tissue lateral to the ascending/descending colon and incise peritoneum lateral to the white line of Toldt. Look for different colours of fat between mesocolon and pararenal fat. Use blunt and sharp dissection to develop avascular plane anterior to Gerota fascia and posterior to the mesocolon. If you encounter vessels/bleeding, you are in the wrong plane. Release attachments to the spleen and liver as needed.
- On the right side, goal is to identify IVC
- No need for extensive mobilization of the bowel to expose the renal hilum (left side requires more mobilization)
- After ascending colon has been medialized, identify the duodenum.
- Carefully medialize the duodenum. Avoid cautery.
- After the duodenum has been medalized, identify the IVC.
- Dissect along the IVC to identify the renal vein.
- Renal artery is usually in the crotch between renal vein and IVC.
- Note that this anterior approach provides quick access to the hilum but does not dissect the kidney inferiorly. Alternatively, can identify ureter to approach the hilum inferiorly.
- On the left side, goal is to identify ureter
- Identify the mid-ureter along the anterior aspect of the psoas.
- Once identified, dissection a plane is created medial to the ureter, with careful identication of the gonadal vein. The plane is developed superiorly along the psoas muscle with anterior elevation of the ureter and/or gonadal vein to identify the renal hilum. The 3rd robotic arm with the Prograsp fenestrated graspers being is used for retraction.
- The gonadal vein is an important anatomic landmark when proceeding toward the renal hilum; the renal vein can be identified by tracing the gonadal vein proximally to its insertion in the renal vein on the left side or to its insertion in the inferior vena cava just caudal to the hilum on the right side.
- On the right side, the gonadal vein is kept medially toward the vena cava, whereas on the left side, the gonadal vein is lifted along with the left ureter to expose the lower margin of the left renal hilum.
- Dissect hilum. Dissect the renal hilum meticulously to clearly delineate the vascular structures and allow adequate placement of bulldog clamps. One vessels are dissected, place vessel loops around them and secure them in place.
- Be careful of potential early arterial branching that is more common on the right side, especially if a venous occlusion is planed, as this may lead to kidney congestion and may result in more bleeding.
- Dissect around tumor. Gerota’s fascia is opened in an area far from the tumor to find the capsule, and dissection is performed along the renal capsule until the mass is exposed. The exposure is kept wide; a clue that one is approaching the tumor area is the presence of adhesions. The fat is then cleared circumferentially around the mass, allowing for visualization of 1–2 cm of normal parenchyma for future renal reconstruction. All attempts should be made to leave the overlying Gerota’s fascia atop the mass to assist in histopathologic staging and also to use as a handle for retraction.
- Plan incision. Use ultrasound probe to evaluate the location, depth, and borders of the tumor and plan the excision margins.
- To define the border of the tumor, the ultrasound probe is oriented parallel to the tumor border.
- Margins of resection of the renal capsule are scored with cautery to delineate the resection boundaries.
- Ensure all supplies ready for tumor excision and repair. All necessary material, including sutures and instruments, are confirmed to be at hand, including:
- Bulldog clamps
- Renorraphy sutures
- Hemostatic agents (Floseal, Surgiflo, etc.)
- Hilar control. Apply bulldog clamp to renal artery, and then vein. Start warm ischemia timer.
- In selected cases, resection may be performed by clamping the renal artery only.
- Excise tumor. Resect tumour along the previously scored margin using cold scissors. The bedside assistant uses suction to clear the resection bed, enabling improved visualization while applying slight counter retraction, as needed. If in the right plane, blunt dissection can be used. Cauterize arteries if you see them. Adjust retraction frequently.
- Renorraphy. Switch to robotic needle drivers. Performed in two layers. Variations in materials used.
- Oversew excision bed. 20-cm suture should have a knot and Hemo--o-Lok clip applied to the free end. Take outside-bite into cortex. Suture excision bed in running manner to oversew larger vessels and entries into the collecting system. Avoid deep bites! Deep bites risk pseudoaneurysm! When oversewing the resection bed is complete, the suture is brought through the renal capsule with the final throw and secured with two sliding Hem-o-Lok clips.
- Sutures options:
- 20-cm 2-0 Vicryl suture on an SH-1 needle (Ethicon Endo-Surgery, Somerville, NJ, USA)
- 3-0 V-lock
- Sutures options:
- Renal capsule
- Continuous, horizontal mattress 0-Vicryl suture on a CT-1 needle with a sliding Hem-o-Lok clip placed after each suture is passed through the capsule.
- Simple-interupted 0-Vicryl suture on a CT-1 needle with a sliding Hem-o-Lok clip
- Apply hemostatic agents and tighten Hem-o-Lok clips.
- Oversew excision bed. 20-cm suture should have a knot and Hemo--o-Lok clip applied to the free end. Take outside-bite into cortex. Suture excision bed in running manner to oversew larger vessels and entries into the collecting system. Avoid deep bites! Deep bites risk pseudoaneurysm! When oversewing the resection bed is complete, the suture is brought through the renal capsule with the final throw and secured with two sliding Hem-o-Lok clips.
- Unclamp hilum. After the completion of renorraphy, the hilum is unclamped and the warm ischemic time is noted (ideally <25 minutes).
- Obtain hemostasis. The renal excision bed is inspected for hemostasis with pneumoperitoneum pressure lowered to 6 mm Hg. Gerota’s fascia is closed by using Hem-o-Lok clips.
- Delver specimen. A laparoscopic entrapment sac is introduced by the assistant through the 12 mm assistant trocar; the specimen is placed in the sac and removed from an existing trocar site. If large tumour, the most lateral trocar site can be used and the incision is extended medially (avoid injury to the inferior epigastric vessels) to form either a Gibson or Pfannensteil incision (more cosmetic). Otherwise, extract the scan from the camera port as the fascia should be well dissected here from initial access.
- Gibson: 3 cm above and parallel to the inguinal ligament.§
- Pfannenstiel: transverse lower abdominal incision, superior to the pubic ridge. Dissection is made through the skin and subcutaneous fat; the anterior rectus sheath is divided transversely. The rectus muscle is open vertically in the midline sparing the muscle fibers from being divided. The peritoneum is then entered through a vertical incision. Be careful of branches from the inferior epigastric branches as well as the superficial epigastric.§
- Care must be taken to make a large enough incision to prevent disruption of the specimen; this enables proper histopathological examination.
- Insert drain, if needed. A Jackson-Pratt drain is placed through a lower lateral port.
- Undock robot.
- Closure. All 12-mm incisions are closed with 0-Vicryl suture by using the Carter-Thomason device (Inlet Medical Inc., Eden Prairie, MN, USA).
- Ports
- Retroperitoneal approach
- See video (retroperitoneal access, Dr. James Porter)
- See video (full case, Dr. James Porter)
- See video #2 (full case, Dr. James Porter)
- Advantages over transperitoneal approach
- Access to the hilum is quick and direct
- Shorter operative times for posterior tumours, as the kidney does not need to be cmpletely mobilized
- May reduce the risk of ileus due to lack of bowel mobilisation, particularly in the context of a urine leak
- Tumours in the upper pole may be easier than those in the lower pole, as the upper pole location ensures the tumour is further away so there is more room to work.
- Also, a posterior lower pole tumour can be dealt with fairly easily with a transperitoneal approach by mobilising and medialising the lower pole to allow access to the backside of the kidney without having to flip and twist the kidney, as one would with an upper pole posterior tumour transperitoneally.
- Use transperioneal approach for retroperitoneal approach
- Can be used in patients with history of abdoinal surgery or adhesions
- Position: full 90° flank, and the table is fully flexed to increase the space between the 12th rib and iliac crest.
- In some patients, a prominent hipbone may limit the potential space, and in such cases, ensure the hip is below the break.
- A rolled blanket is placed as a support on either side of the patient.
- Spine and hip must be positioned in a straight line, and the spine fully exposed to allow space for placement of the lateral robotic arm.
- Dependent arm is padded and secured to an arm-board, which is tilted towards the head as much as possible. Pillows or blankets are placed in between the arms, which are then secured together with tape. Elbows should be placed forwards, so that the robotic arms do not collide with the arms.
- Tape is placed across the chest and hip and the patient secured with straps.
- Surgical plan:
- Number of ports: 5 (if XI, 4 if SI) (variations possible, depending on institution equipment and surgeon preference)
- Location of ports:
- Camera (12 mm): ≈1.9 cm (1 fingerbreadth) above the iliac crest, in mid-axillary line
- Robotic Arm 1 (8 mm): 7–8 cm superior and lateral to the camera port. This is placed just above the indentation of the erector spinae muscles in the space under the 12th rib.
- Robotic Arm 2 (8 mm): in posterior axillary line
- Robotic Arm 3 (8 mm):
- Assistant 1 (12 mm): in the anterior axillary line just cephalad to the anterior superior iliac spine and 7–8 cm caudal to the medial robotic port
- A fourth arm can also be used especially in cases where perinephric fat is abundant. If so, the robotic port is placed in the most medial and inferior aspect of the field ≈7–8 cm beyond and 2 cm below the medial robotic port. The advantage of the fourth arm is that the kidney can be elevated using a ProGrasp™, thus freeing both working robotic instruments.
- In contrast to a laparoscopic approach, all ports are shifted inferiorly towards the iliac crest.
- If the camera port is too close to the 12th rib, this may put the robotic instruments too close to the kidney.
- The triangle of Petit (composed of the iliac crest inferiorly, latissimus dorsi posteriorly and external oblique anteriorly) is identified, and serves as an important landmark.
- Step by step:
- Patient positioning, antiseptic preparation, draping. Insert foley catheter. Position patient. Pressure points should be padded.
- Enter retroperitoneal space. Mark the iliac crest, ribs, and axillary lines. A 12–15 mm length incision for the camera port is made ≈1.9 cm (1 fingerbreadth) above the iliac crest just lateral to the triangle of Petit. The external oblique muscles are separated using retractors to expose the lumbodorsal fascia. A Kelly forceps is used to penetrate the fascia and enter the retroperitoneal space. The index finger is then inserted into this space. One should be able to feel the tip of the 12th rib, the psoas muscle and sometimes the lower pole of the kidney. Using gentle blunt finger dissection, the peritoneum is carefully swept away.
- Insert balloon dissector. A kidney-shaped balloon dissector is then placed into the retroperitoneal space. To do this correctly, the trocar is inserted with the port facing the anterior abdomen towards the assistant. As the trocar is inserted, the obturator is removed and the folded balloon glides into the retroperitoneal space, in a Seldinger type fashion. This is a crucial step, so that the kidney-shaped balloon unfolds and expands in a cephalo-caudal orientation, outside the Gerota’s fascia, and does not create shearing forces that may inadvertently cause a peritoneal breach.
- Expand retroperitoneal space. A 30 ° laparoscope is inserted into the balloon dissector, and the retroperitoneal space created by expanding the balloon under direct vision using the pump provided. Normally, 40 compressions are performed, although one can go up to 50 or 60. Landmarks are superiorly, the transversus abdominis muscle and the anterior layer of the peritoneum, and inferiorly, the psoas tendon and ureter. The lower pole of the kidney within the Gerota’s fascia can also be identified. The degree to which the peritoneum has been dissected off the anterior abdomen is noted for subsequent placement of ports. The balloon is then deflated and replaced with a 12-mm port for the robotic camera.
- If hole in peritoneum, can use the 4th transperitoneally and through the hole to retract kidney with prograsp
- Insert ports. The position of the camera port within the retroperitoneal space is crucial, as all other port placements are based on this.
- All ports should be placed with at least 6-cm space between them; final measurements are not taken until pneumo-retroperitoneum has been created.
- The camera port is attached to CO2 to maintain pneumo-retroperitoneum at 15 mmHg. Use of lower pressures is possible when using valveless pressure barrier insufflators (Airseal®, SurgiQuest Inc., Milford, CT, USA).
- A 30 ° up-facing lens is helpful for placement of remaining ports.
- The lateral robotic port is inserted first. A Veress needle can be inserted to confirm the site before the port is inserted under vision.
- Next, the 12-mm assistant and medial robotic port sites are marked. A laparoscopic Kittner through the lateral robotic port can be used to gently sweep away peritoneum, if more space is needed.
- The medial robotic port is inserted followed by the assistant port.
- Docking. Once docked, insert the camera into the assistant port and adjust the robotic ports so that they are closer to the skin, allowing your instruments with greater working space. Then, insert the robotic instruments (right arm, monopolar scissors; left arm, fenestrated bipolar grasper) and advance them under vision. Now place the camera in the robotic camera port. The assistant then assesses access to the kidney via the 12-mm port. Some prefer a 0 ° robotic scope for the rest of the operation, although it is also possible to use a 30 ° scope.
- Management of the ‘para-nephric’ fat. Carefully dissect the para-nephric fat off the Gerota’s fascia. Care is taken medially and anteriorly where the peritoneum can be entered. The excised fat is placed in the lower retroperitoneum.
- Expose perinephric fat. Gerota’s fascia is incised just above the psoas muscle exposing the perinephric fat and kidney. For this, an incision is made parallel to the psoas muscle 2 cm above the psoas tendon. Dissection is then carried along the psoas muscle elevating the kidney and perinephric fat. On the right side, be careful of the IVC.
- Identify hilum. Once the hilar vessels are identified, the rest of the operation follows standard steps of robotic partial nephrectomy (see above). In retroperitoneal approach, you encounter artery first. Dissecting the renal vein is more difficult with the retroperitoneal approach, though most do not clamp the vein during partial nephrectomy.
- Deliver specimen through the camera port.
Post-operative care
- Remove Jackson-Pratt drain prior to discharge if output appropriate.
Complications
- Intra-operative
- Bleeding
- Injury to adjacent organ (bowel, diaphragm, liver, spleen, pancreas)
- Early post-operative
- Infection
- Urine leak
- Re-operation due to
- Bleeding, including pseudoaneurysm
- Wound dehiscence
- Late post-operative
- Incisional hernia
References
- Kaouk, Jihad H., et al. "Robot-assisted laparoscopic partial nephrectomy: step-by-step contemporary technique and surgical outcomes at a single high-volume institution." European urology 62.3 (2012): 553-561.
- Ghani, Khurshid R., et al. "Robotic retroperitoneal partial nephrectomy: a step‐by‐step guide." BJU international 114.2 (2014): 311-313.