Robotic Partial Nephrectomy

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Transperitoneal

Retroperitoneal

Contraindications

  1. Contraindications to laparoscopic surgery
  2. History of extensive abdominal surgery (contraindication for transperitoneal approach)
  3. Morbid obesity
  4. Extremely large tumor

Advantages to Robotic Approach

  • Compared to laparoscopic approach (2014 meta-analysis[1])
    • Significantly lower rate of conversion to open surgery, conversion to radical surgery, shorter warm ischemia time, smaller change of estimated glomerular filtration rate, and shorter length of stay
    • No significant differences in complications of Clavien-Dindo classification grades 1-2, Clavien-Dindo classification grades 3-5, change of serum creatinine, operative time, estimated blood loss, and positive surgical margins
  • Compared to open approach (2022 meta-analysis [2])
    • Significantly lower rates of blood loos, length of stay, and postoperative complications
    • No significant differences in operative time, warm ischemia time, positive surgical margins, preoperative eGFR, postoperative eGFR and intraoperative complications

Pre-operative Preparation

  • Pre-operative imaging
    • Primary tumor
      • Endophytic vs. exophytic tumour
        • If endophytic tumor, obtain pre-operative ultrasound.
          • If tumour not visible on pre-operative ultrasound, consider radical nephrectomy as intra-operative ultrasound to identify tumour will unlikely be successful.
      • Proximity to collecting system
      • Vasculature
    • Staging
  • Hold/bridge anticoagulation medications prior to surgery
    • ASA 7 days
    • Clopidogrel 5 days
    • Apixaban 2 days
  • Pre-operative testing
    • Urinalysis +/- culture
    • CBC
    • Serum creatinine/GFR

Steps of procedure

  • Equipment
    • Specimen Retrieval Pouch
      • Endo Catch™ Gold device 10 mm
        • Volume 220mL
    • Sutures
      • Renorrhaphy
        • 22 cm (or 15 cm if smaller defect) 2-0 Stratafix on a CT-1 needle with Hem-o-lok Weck clip in the loop of the suture, x2
        • Alternatively[3]
          • 3-0 V-loc suture on a V-20 needle for the deep layer
          • 2-0 V-loc on a GS-21 needle for the outer capsular layer
      • Closing
        • 0 Vicryl on UR6 x 2
        • 4-0 monocryl on PS-Z
        • 0 silk for drain
      • Rescue stitches
        • 4-0 Prolene on RB1 (in case of vascular injury), cut to 10cm
        • 2-0 Vicryl on CT-1 needle, cut to 10cm
  • Venous thromboembolism prophylaxis
    • Compression stockings
    • Heparin[4]
  • Antibiotics
    • 2g cefazolin (900 mg clindamycin, if penicillin allergic)[5]

Transperitoneal

  • Position: Ipsilateral (tumor side up), modified flank/lateral decubitus at approximately 60-90° (if left sided, 90° so that spleen can fall; if right-sided, less than 90°; alternatively, 45° has been described[6]). Gel roll supporting the lower back. Bottom leg flexed. Top leg straight. Pillows between legs. Ipsilateral arm on side of body, contralateral arm out on arm board.
    • Some surgeons prefer to flex operating table. If flexing table, position patient so that midpoint of inferior aspect of ribcage and superior aspect of pelvic bone is at break of bed
  • Surgical plan:
    • Number of ports: 5 (6 if right-sided) (variations possible, depending on institution equipment and surgeon preference)
      • 4 robot ports + 1 assistant port +/- 1 liver retractor for right-sided tumors
        • Arm 1: fenestrated bipolar graspers
        • Arm 2: camera
        • Arm 3: monopolar curved scissors
        • Arm 4: Prograsp graspers
    • Location of ports:
      • General considerations for robotic port placement
        • Port placement through the rectus muscle risks damage to the epigastric vessels.[10]
          • The epigastric vessels travel near the lateral edge of the rectus muscles in the lower abdomen and travel closer to the midline in the upper abdomen where they join the internal mammary arteries.[11]
          • Generally if trocars are not placed in the midline, they should be placed at least 6cm lateral to the midline to prevent epigastric injury.[12]
        • >8 cm distance is recommended between robotic ports[1]
          • 10-20 cm distance should be maintained between the ports and target anatomy
            • 10 cm distance from TA is good but 20 cm distance is better
      • Configuration 1: Straight line configuration (if Xi)[7]
        • All robotic ports are placed in a straight line lateral to the the lateral border of the ipsilateral rectus abdominus muscle. This line may translate laterally (obese patient, lateral tumor) or medially (skinny patient, medial tumor), depending on patient and tumour characteristics
        1. Robotic Arm 1 (8 mm): 2 fingerbreadths below the costal margin
        2. Camera/Robotic Arm 2 (8 mm (12 mm if Si)): 6 cm inferior to Robotic Port 1
        3. Robotic Arm 3 (8 mm): 6 cm inferior to Robotic Port 2
        4. Robotic Arm 4 (8 mm): 6 cm inferior to Robotic Port 3
        5. Assistant (12 mm): half-way between camera and Robotic Arm 1, medial to these ports, in midline
      • If right-sided, additional 5 mm trocar placed just inferior to xiphoid process for liver traction. Use Allis clamp to hold on abdominal wall and retract liver away from surgical field.
        • Depending on liver anatomy, liver retractor may need to be placed in contralateral side.
    • Step by step:
      • General anesthesia and insertion of lines. Use naso/orograstric tube for gastric decompression during case.
      • Patient positioning, antiseptic preparation, draping. Insert foley catheter and have tubing go over contralateral leg. Slide patient laterally to tumor side of table. Roll patient so that the anterior abdomen is placed on the contralateral edge of the table. Position patient. Pressure points should be padded. Axillary roll should be placed (under the upper chest, at a level inferior to the tip of the scapula, rather than under the axillary region[8]) to prevent neuropraxia. An axillary roll is not required if the patient is tilted at the 45° angle and not lying directly on his or her axilla[9]. Secure patient to operating table. Prepare surgical area and drape to expose umbilicus, xiphoid, costal margin, and ASIS.
      • Outline landmarks. Use a marking pen to outline costal margin, iliac crest, and lateral border of rectus.
      • Abdominal access with transumbilical Veress needle. Apply penetrating towel clamps superior and inferior to umbilicus. With fingers under clamp, gently lift (as excessive elevation can cause separation of the abdominal layers and increase risk of pre-peritoneal placement). Insert Veress needle at 90 degrees. Feel or hear (usually) 2 (corresponding to the penetration of the abdominal fascia and parietal peritoneum) clicks/pops (the protective sheath clicking when it recoils), indicating that the abdominal cavity has been entered.
        • If transumbilical unsuccessful (3 attempts) or contraindicated (presence of umbilical pathology such as adhesions or herniations, peri-umbilical scars, aortic pulsations, thin patient), consider left upper quadrant (also known as Palmer’s point) entry.
          • Palmer’s point: 3cm below the left subcostal border in the mid-clavicular line
            • Contraindications to Palmer’s entry include splenomegaly, hepatomegaly, portal hypertension, gastric or pancreatic masses, history of a splenic or gastric surgery and presence or suspicion of left upper quadrant adhesions.
            • If Palmer’s point contraindicated, consider a point that is in middle of ASIS and umbilicus and translate this point superiorly to the level of the umbilicus
            • If not transumbilical entry, use cautery/knife to make incision at planned entry point. Dissect down through fat to expose fascia. Use Kocher clamp to lift up on fascia. Insert Veress needle.
            • In patients with potential of significant abdominal adhesions, consider open (Hassan) entry
      • Test Veress needle and insufflate, if appropriate. Aspirate and inspect for blood or fecal content. If negative, inject saline for drop test (though not reliable). Aspirate the needle again. If successful on initial testing, gently advance the needle 0.5cm. Turn on insufflation to high flow (no need to begin at low flow because the size of the Veress needle limits flow to 1.5-2L/min). Check for 3 consecutive pressure readings below 10mmHg. If pressure >10 mm, withdraw needle slightly. If pressure decreases <10 mm, this indicates that needle tip was against an intra-abdominal structure such as the intestine or omentum. If the pressure remains ≥10 mm Hg, the needle is not properly placed. Achieve pneumoperitoneum to 15 (or 20; 20 facilitates port placement by increasing abdominal resistance, but have to remember to decrease after ports inserted) mm Hg.
      • Outline port sites. Use marking pen to denote incisions for robotic (8mm) and assistant (12mm) ports. Robotic ports should be at least 6cm (approx. 3 fingerbreadths; 8cm if Si[10]) from each other and, within appropriate distance to target anatomy (15-20cm). Make sure assistant has good access to field from assistant port.
      • Insert assistant port using visual obturator. Twist assistant port into abdomen. Twisting is more important than pushing. Once in, remove trocar (should hear air coming out when opening valve on port), and insert camera (30 degrees). Switch gas to this port.
      • Inspect abdomen. Check that no injury made to the bowel during insertion of Veress needle. Check for adhesions that may interfere with port placement.
      • Insert remaining ports. Point camera towards patient’s head. Begin insertion of most superior port (facilitates visualization of inserting other ports). Use knife to make an 8mm transverse incision in this area. Twist port into incision under vision. Take out obturator and advance trocar until black line. Repeat steps for other ports. On right side, setup liver retractor with Allis clamp through 5-mm subxiphoid port.
      • Dock robot and insert instruments. Attach camera port to robot. Insert and attach camera. Target camera to renal hilum; use external cues (subcostal region) in addition to internal cues (posterior to lower liver on the right side, or several inches caudad to the spleen on the left). Hold camera port steady and allow robot to adjust. Attach remaining ports to robot. Insert monopolar scissors in right robot arm, bipolar Prograsp graspers in left robotic arm, and Prograsp graspers in inferior robotic arm. Connect monopolar and bipolar electric cords. Look at right side first, push Prograsps and then scissors into position under vision. Repeat for left side. Rotate the patient clearance joints on arms #1 and #4 toward the patient to maximize arm movement[11].
        • At patient clearance is increased, the arm joints rotate axially clockwise away from the patient and the preceding arm, resulting in the external arm assuming a steeper angle and creating more space between the arm and the patient[12]
      • Lysis of adhesions, if needed. Check for adhesions and take any down if needed.
      • Medialize bowel to expose retroperitoneum. Use 30 degrees down camera. Incise peritoneum lateral to the white line of Toldt. Use blunt and sharp dissection to develop plane anterior to Gerota fascia and posterior to the mesocolon. Release attachments to the spleen and liver as needed.
        • On the right side, goal is to identify the IVC; there is no need for extensive mobilization of the bowel to expose the renal hilum.
          • Caution: To avoid duodenal injury, use minimal cautery during the medialization of the duodenum.
        • On the left side, mobilize the spleen completely to avoid potential splenic injury. Be careful of splenic artery and pancreas. When developing space between spleen and kidney, use left hand under spleen to protect spleen. Use hand over hand motion. For efficiency, develop this space completely, before continuing to mobilize the colon.
        • Use the 4th arm to retract the kidney laterally after sufficient medialization of the bowel.
      • Identify ureter and gonadal vein. Use 30 degrees up camera. The mid-ureter is identified along the anterior aspect of the psoas. Once identified, a dissection plane is created medial and parallel to the ureter, with careful identification of the gonadal vein. The plane is developed superiorly along the psoas muscle towards the renal hilum with anterior elevation of the ureter and/or gonadal vein with the 4th arm
        • 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
          • 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.
        • Proximally, the gonadal vessels are medial to the ureter. The gonadal vessels descend laterally and cross anterior to the ureter, “water under the bridge”, a third of the way to the bladder.
          • On the left side, the gonadal vessels cross the left ureter after running parallel to it for a small distance
      • Identify renal hilum. During hilar dissection it is important to place the kidney on stretch, to improve identification and to facilitate dissection of the hilar vessels. Identify renal artery. The renal artery is posterior to the renal vein. The renal artery only needs enough dissection to allow bulldog to clamp it i.e. circumferential dissection is not needed. Place clamp(s) in the vicinity of the renal artery.
        • Caution: do not to miss early arterial branching that is more common on the right side, especially if a venous occlusion is planned, as this may lead to kidney congestion and may result in more bleeding.
        • Consider renal vein clamping for (3) right-sided tumors, central tumors, and large tumors.
          • Advantages of renal vein clamping: decreased bleeding during tumor resection
          • Disadvantage of renal vein clamping: more dissection needed, potentially increasing risk.
        • If needed, the left gonadal vein can be ligated and divided to increase mobility of the renal vein and potentially improve exposure of the renal artery.
      • Identify tumour and defat kidney. Make an incision in Gerota's fascia and dissect through fat in an area far from the tumor to find the kidney capsule. When near capsule, grasp fat and use cautery on edge of fat plane, not kidney edge. Continue to clear fat off renal surface, aiming to work in fat planes. A clue that one is approaching the tumor area is the presence of adhesions. Stay superficial to capsule since capsule is strength layer of repair. Sticky fat can be tedious. Bipolar helpful for vessels in fat. Use ultrasound to confirm location of tumor (green dot indicates proximal aspect of probe). Use ultrasound to identify location, depth, and borders of tumor. To define the border of the tumor, the ultrasound probe is oriented parallel to the tumor border. 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. Increase cautery settings to 50/50 and score edges of tumor + margin with scissors intermittently, not circumferentially. Check with doppler ultrasound that there is flow in multiple places. Consider how 4th arm will be used to keep the kidney in position during tumour excision and renorrhaphy.
      • Pre-clamp checklist
        • Confirm cautery settings (usually 40/40)
        • Confirm stable patient status with anesthesia
        • Confirm sufficient gas in tank
        • Ensure bedside assist has access to field and all ports are not displaced
        • Confirm all sutures/rescue sutures are available
        • Get all sutures in the field (Two 22 or 15 cm (depending on defect size) 2-0 Stratafix on a CT-1 needle with Hem-o-lok Weck clip in the loop of the suture)
        • Increase pneumoperitoneum to 20 mm Hg
        • Announce sequence of steps to team
      • Cut tumour
        • Apply bulldog(s).
        • Reposition 4th arm to optimize tumour excision and renorrhaphy.
        • Use ultrasound with Doppler to confirm absence of flow in multiple places. If still flow, need to identify additional arterial inflow. After confirming absence of flow, assistant removes doppler and replaces with suction.
        • Start cutting tumor around 5-6 o clock with cold scissors (may need to use heat over fat that covers edge). Use one scissor length excursions. Use left hand to retract the tumour. If excessive bleeding, may have missed an artery. Continue cutting tumor circumferentially, if possible, as allows more mobility. Initially, closer to edge, cut with cold scissors to enter enucleation plane. Be careful not to remove too much capsule, as this is the strength layer for repair. Once plane entered, use peel and lift. Some attachments/vessels may need bipolar/coagulation and then cut with scissors. Use left hand to retract tumor. The bedside assistant uses suction to clear the resection bed, enabling improved visualization while applying slight counter retraction, as needed.
        • After excising tumor, place tumor in medial lower quadrant or immediately in bag.
        • Use bipolar or hot scissors for any active vessels. 
      • Renorrhaphy
        • Switch to needle drivers. Use one hand to compress bleeding while other hand is changed to needle driver. When needle driver in, replace compression and switch other hand to needle driver.
        • Consider renorrhaphy approach. Which direction will you want to place Hem-o-lok Weck clips for superficial layer? Want them to be placed easily by assistant and away from ureter. Which direction should needles travel to avoid injury to blood vessels? Which direction is most ergonomic for the deep layer?
        • Deep layer closure. Use 22 cm (or 15 cm if smaller defect) 2-0 Stratafix on a CT-1 needle with Hem-o-lok Weck clip in the loop of the suture. Anchor on the renal capsule outside of the defect by taking outside-in bite. Inside bite should be at the distal apex of deeper bed.
          • Using same stitch, perform deep layer closure by passing suture through cortical layer of the renal defect. Bite is with right hand from one side to another, big bites taken in 1 (some situations may require this to be done backhand). Use right hand to first anchor stitch in position, then regrab proximally to manipulate in good direction. Slow, controlled movements avoid tearing. Use left hand to lift prior suture but not too tight. DO NOT TIGHTEN. First throw is taken on opposite side of anchor. Keep running until proximal aspect of deep defect. 2-3mm travel. If entry into collecting system, incorporate these into the bites. Exit the contralateral side. Secure with a Hem-o-lok Weck clip. Tighten slightly and break needle and ensure assistant removes needle.
        • Superficial layer closure. Use 22cm 2-0 Stratafix on a CT-1 needle with Hem-o-lok Weck clip in the loop of the suture. Anchor on the renal capsule outside of the defect by taking outside-in bite. Then inside-out bite. Enter and exit outside the renal defect beyond the distal apex of defect. Place hem-o lock. Cinch slightly. Take next bite, and place hem-o-lock. Put aside superficial stitch.
        • Tighten deep layer. Gradually tighten deep layer suture starting distally and working towards proximal apex. Advance suture with right hand, hold in place with left. Repeat then move onto next suture. Tighten hemolock on exit +/- entry of deep layer. Consider placing additional hemolock for vicryl, not needed for braided sutures such as stratafix.
        • Continue superficial layer. Tighten superficial layer. When tightening hem-o-locks, advance suture so that it slides in middle. The ultimate (last) hem-o-lok may be held in place by spreading the needle driver tips, but for all penultimate ones the hem-o-lock should be held in center with grasp of needle driver. Subsequent bites should be taken in two, outside-in, inside-out. Ensure bites are not superficial as this suture should close both the cortical and medullary layers. After existing parenchyma, secure layer with Hem-o-lok Weck clips. Slightly tighten ultimate suture, but only cinch penultimate suture. Continue running to proximal edge of defect and exit on contralateral side.
        • Tighten superficial layer.
        • Tighten further.
        • Tighten deep layer Hem-o-Loks at distal ends of renorrhaphy  
        • Remove clamp. Assess kidney for bleeding and obtain additional hemostasis as needed.
          • If bleeding after unclamping, apply direct pressure immediately increase the insufflation pressure. Re-tighten and cinch down the renorrhaphy clips.
          • Open conversion is usually indicated for uncontrolled bleeding and the surgical team should be ready for such an eventuality.
        • Decrease pneumoperitoneum 10 mm Hg and reassess for bleeding.
        • Cut and remove remaining needles. Ensure assistant removes all needles.
        • Remove bulldogs. Ensure assistant removes all bulldogs.
        • Obtain further hemostasis, may need scissors to coagulate in some areas
      • Closure
        • Deliver specimen. A laparoscopic entrapment sac is introduced by the assistant; the specimen is placed in the sac and removed from camera port, if small, or assistant port, if larger. Care must be taken to make the extraction incision large enough to avoid fracturing the specimen, possibly preventing accurate histopathologic examination for margin status and staging.
        • +/- insert drain through arm 4
        • Undock robot.
        • Close port sites and extraction site. Consider closing fascia for extraction site

Retroperitoneal

  • Factors to consider for retroperitoneal approach
    • Tumor factors
      • Tumor location
        • In axial plane, bisect kidney obliquely resulting in two equal segments. Retroperitoneal approach favours tumours posterior to bisection while transperitoneal approach favours tumours anterior to bisection.
        • Retroperitoneal approach may also be favoured for lateral posterior tumours (even if slightly anterior to bisection line), upper pole, and posteromedial (even if slightly anterior to bisection line)
        • Lower pole tumours are harder with retroperitoneal approach, though may not be as much of a problem with Xi robot compared to Si
        • Anteromedial tumours also difficult with retroperitoneal approach
    • Patient factors
      • Retroperitoneal fat
        • In patients with significant retroperitoneal fat, retroperitoneal approach can be difficult to dissect through large quantities of fat without familiar anatomic landmarks
  • Advantages
    • Avoids potential injury of intraperitoneal contents
  • Position: Ipsilateral (tumor side up), lateral decubitus at approximately 90°. Bottom leg flexed. Top leg straight. Pillows between legs.
  • Surgical plan:
    • Number of ports:
    • Location of ports:
    • Step by step:

Complications

Population-based data is preferentially described, rather than data from few surgeons.

  • Overall rate of any complications: ≈10-25%[13][14]
    • Rates of major complications (Clavien grades 3-5): ≈4%[15]
  • Median length of stay: ≈3 days[16]
    • ≈25% have LOS > 4 days[17]

Intra-operative

  • Bleeding
  • Injury to adjacent organ (bowel, diaphragm, liver, spleen, pancreas, ureter, bladder)
    • Bowel injury
      • Intraoperative intestinal injury rates: ≈4%
      • May occur during trocar placement or from cautery injury
      • All injuries recognized intraoperatively require immediate repair and intraoperative general surgery consultation should be considered
      • In the postoperative period, signs of a bowel injury could include port-site pain, nausea, vomiting, abdominal distension, fever and leucocytosis.
    • Intraoperative ureteral or bladder injury rates: ≈4%
  • Conversion to open surgery
  • Conversion to radical nephrectomy
  • Risks of general anesthesia
    • DVT/PE rates: ≈1%

Early post-operative

  • Infection
  • Re-operation due to
    • Bleeding
    • Wound dehiscence
  • Urine leak
    • Should be suspected postoperatively if the drain output is elevated with elevated drain creatinine levels. The drain should be left in place and the urine output monitored.
    • A CT urogram may be ordered for continued leakage or symptoms to assess for a urinoma.
    • A percutaneous drain may need to be placed if there is a collection or the existing drain may need to be adjusted.
    • Resolution of the urinoma should be confirmed with follow-up imaging.
    • Retrograde placement of a ureteric stent should be an option if there is continued output or evidence of obstruction.

Late post-operative

  • Incisional hernia
  • Pseudoaneurysm
  • Failure to cure
    • Positive surgical margin ≈10%[20]
  • Need for secondary procedure e.g. to manage urine leak or pseudoaneurysm

References

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