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Robotic-Assisted Laparoscopic Partial Nephrectomy Periprocedural Care

  • Author: E Jason Abel, MD; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Dec 03, 2015
 

Patient Education & Consent

Once a decision has been made to proceed with surgery, the patient must be carefully counseled on all options available, including open partial nephrectomy, open or laparoscopic radical nephrectomy, percutaneous procedures such as cryoablation and thermal ablation, and observation. Risks and benefits attendant to each procedure should be explained and placed honestly in the context of the surgeon’s individual experience and outcomes.

Patient Instructions

The authors’ preference is to request that each patient drink one bottle of magnesium citrate the night before surgery to decompress the bowel and facilitate colon mobilization. The authors do not routinely employ a full bowel preparation.

As appropriate, patients are requested to stop smoking well in advance of surgery, to stay active, and to maintain a good diet. Platelet inhibitors are stopped well in advance of surgery. A set of specific instructions detailing each expected step of the hospitalization, discharge, and postoperative period is given to each patient; this should be specific to the surgeon and the patient, including details such as likelihood of drain placement, type of incision closure, recommendations for postoperative activity, and an estimate of the patient’s postoperative functional ability to allow appropriate support planning.

Elements of Informed Consent

Specific risks that require careful and complete discussion during informed consent for robotic-assisted partial nephrectomy include bleeding, infection, urinary leak, acute kidney injury secondary to ischemia, the likelihood and implication of positive oncologic margins, bowel injury, and significant vascular injury. These factors should be personalized to each patient and each tumor and should include a discussion of the possibility of conversion to open or laparoscopic radical nephrectomy and the renal functional implications thereof. General risks to be discussed include transfusion, deep venous thrombosis/pulmonary embolism, neuropathy, rhabdomyolysis, and pneumonia.

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Pre-Procedure Planning

Robot-assisted partial nephrectomy requires an emphasis on the team approach to surgery. The primary assistant and the operating room nursing staff are vital to the success of the procedure.

The assistant is responsible for critical tasks such as hilar clamp application, introduction of the sutures and clips, and provision of suction and countertraction during the tumor excision.[43]

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Equipment

The robotic console for da Vinci surgical robot

The user interface for the surgeon consists of the display system, master arms, control/touchpad, and footswitch panel.

Display system: The current system provides a 3-dimensional stereoscopic high-definition display with up to 10X magnification for the surgeon in the console, and additional 2-dimensional displays are available for the rest of the operating room team. The Si model also has dual console capabilities to facilitate training, with a second console with 3-dimensional vision and ability to take control of the instruments.

Master arms: The master controls take input from the surgeon’s finger and thumb and translate the operator’s movements in real time to the robotic arms and EndoWrist instruments. Some basic force feedback is also provided to the surgeon. Motion-scaling settings allow the scaling of hand-to-instrument movement ratios.

Control/touchpad: At the surgeon console, an integrated surgeon interface allows control of the video, audio, and system settings for the console surgeon. These include toggling between 2-dimensional and 3-dimensional display, adjusting motion scaling, and choosing camera perspectives. Unique user settings can be stored in each surgeon’s user profile, and the surgeon can benefit from the available ergonomic settings to minimize fatigue. The newer Si model features a programmable touchpad.

Footswitch panel: Moving the camera, swapping between different types of energy, and deploying diathermy is controlled with a clutch mechanism and foot switches.

Robotic arms

The da Vinci system consists of 2 or 3 arms for mounting surgical instruments, and a separate camera arm is dedicated for the camera.

The robotic arms are mounted on a mobile platform that is draped and secured in place alongside the patient once the patient is appropriately positioned.

The arms are mounted to 8-mm trocars placed through the patient’s abdominal wall.

The arms are controlled by the surgeon within the console, and instrument exchange, suctioning, and suture delivery is performed by the assisting surgeon at the bedside, alongside the robotic arms.

Port placement and installation of the robot is obviously an important aspect of this procedure. It is important to consider the timing of docking the robot, as table rotation will not be possible with the robot docked.

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Patient Preparation

Patient preparation is limited to administration of one bottle of magnesium citrate orally the night before surgery to decompress the bowel and administration of a second-generation cephalosporin antimicrobial prior to incision.

Anesthesia

General anesthesia is used.

Positioning

After general anesthesia is administered, an NG tube is placed, and a Foley catheter is inserted, the patient is placed in a modified lateral position with a gel roll behind the buttock and another behind the shoulder. Alternatively, a bean bag and cloth tape can be used to support the patient.[55]

Table flexion allows an increased working space for the instruments and avoids clashing of the robotic arms during the procedure, and most surgeons continue to prefer a flank position with the table moderately flexed.

An axillary roll may be placed to avoid brachial plexus injury, and all pressure points are padded and protected accordingly. The upper arm may be secured above the down arm or positioned in the "upper arm adducted" position along the patient's hip, as demonstrated below.

Positioning in the Upside Arm Adducted (UAA) posit Positioning in the Upside Arm Adducted (UAA) position. This position maximizes access to the abdomen while avoiding robotic interference with the patient's arm.

The table is flexed to about 20°.[56] Other authors suggest that inclining the operating table by 30°-45° provides more room on the side of the robot to accommodate the vision cart and the laparoscopic boom and monitors and to allow movement of personnel.[34] The patient is then secured to the table with heavy tape across the hips and shoulders.

The older "standard" Da Vinci robot design permits only minimal side-to-side movement, and precise port placement is essential. For this reason, Kaul et al have modified the traditional port placement template for robotic partial nephrectomy by placing the camera port laterally and the robotic instruments closer to the umbilicus when using this system.[35] This modification obviates the need for retraction of the colon, and an enhanced range of motion of the robotic arms is accomplished. Subsequently, dissection of the upper and lower poles of the kidney and adjacent organs such as liver and duodenum on the right and spleen on the left is facilitated.

Surgeons using the standard model Da Vinci unit may choose to perform portions of the dissection and renal mobilization laparoscopically, focusing on use of the robot for the resection and renorrhaphy. This approach takes full advantage of the vision and dexterity provided by the robotic platform for the critical portions of partial nephrectomy while avoiding the limitations of the first-generation system.

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Monitoring & Follow-up

Follow-up after surgery is similar to that after open partial nephrectomy. Patients undergo a history and physical examination, as well as laboratory tests, at intervals after surgery as outlined in the NCCN guideline[57] according to risk of recurrence as defined by the stage and grade of tumor. Local recurrence after surgery for pT1 renal cell carcinoma is very rare (< 5% in 5 years), and recurrence is most common in the lung.

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Contributor Information and Disclosures
Author

E Jason Abel, MD Assistant Professor of Urologic Oncology, Department of Urology, University of Wisconsin Hospital and Clinics, University of Wisconsin School of Medicine and Public Health; Attending Urologist, William S Middleton Memorial Veterans Hospital

Disclosure: Nothing to disclose.

Coauthor(s)

Michael B Williams, MD, MS Assistant Professor, Department of Urology, Leroy T Canoles, Jr, Cancer Research Center, Eastern Virginia Medical School

Michael B Williams, MD, MS is a member of the following medical societies: American Association for Cancer Research, American Urological Association, Society of Urologic Oncology, Texas Medical Association, American Society of Clinical Oncology, American Association of Clinical Urologists

Disclosure: Nothing to disclose.

Sri Sivalingam, MD, MSc, FRCSC Fellow in Endourology and Minimally Invasive Surgery, Department of Urology, University of Wisconsin School of Medicine and Public Health

Sri Sivalingam, MD, MSc, FRCSC is a member of the following medical societies: American Urological Association, Canadian Medical Association, Canadian Urological Association

Disclosure: Nothing to disclose.

Granville L Lloyd, MD Assistant Professor of Urology, Department of Urology, University of Wisconsin School of Medicine and Public Health; Attending Urologist, Meriter Hospital, Madison, WI

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

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Positioning in the Upside Arm Adducted (UAA) position. This position maximizes access to the abdomen while avoiding robotic interference with the patient's arm.
This illustrates port placement with the second assist port placed above the umbilicus and slightly lateral of midline. The lower assistant port is in the lower midline. Final positions are always determined after abdominal access, insufflation and camera port placement.
Direct insertion trocar placement. The trocar is placed directly into the decompressed abdomen and connected to CO2 insufflation. Once the peritoneal cavity develops the port may be pushed further in to the abdomen. (ENDOPATH® XCEL™ Bladeless Trocar, Ethicon Endosurgery)
The 5-mm subxiphoid port is used to place a blunt grasper under the liver for this right-sided case and elevate it.
The colon is released from the lateral abdominal wall.
The anterior pararenal space is defined. Gerota fascia is not entered at this point.
The renal artery is freed from periarterial tissue.
The tumor is free of Gerota fascia with a generous margin of clear capsule surrounding it. Overlying fat is left attached.
The assistant places two "Bulldog" vascular clamps on the renal artery.
The initial phase of the resection is performed. Knowledge of the intrarenal anatomy of the tumor allows incision near the base; initial scissor orientation is straight down with tips away.
After reaching an appropriate depth, the scissors are turned and the base of the resection developed beneath the tumor.
A running suture, begun outside the resection bed, is placed to oversew collecting system and vascular structures. The authors prefer V-Lok suture, which is cut without tying.
Hemostatic agent and Surgicel are placed in the renal defect and 0 polyglactin on a CT-1 used to begin capsular closure.
Further capsular sutures are placed and tensioned with Hem-o-lok clips. Lapra-tys are then used to complete this "sliding-clip" renorrhaphy.
Table 1. Overall Demographics of Robotic-Assisted Laparoscopic Partial Nephrectomy
Series Number of Patients Total Number of Masses Follow-up Time, Months Operative Time, Minutes Mean Length of Stay Estimated Blood Loss, mL Tumor Size, cm Cancer (%)
Gettman et al (2004)[43] 13 13 7 215 4.3 170 3.5 10 (76.9)
Kaul et al (2007)[35] 10 10 15 155 1.5 92 2.3 8 (80)
Rogers et al (2008)[32] 8 14 3 192 2.6 230 3.6 8 (60)
Rogers et al (2008)[44] 11 11 NR 202 2.6 220 3.8 11 (100)
Benway et al (2009)[45] 50 50 NR 145.3 2.5 140 2.7 28 (56)
Wang et al (2009)[46] 40 40 NR 140 2.5 136 2.5 25 (62)
White et al (2009)[47] 20 20 NR 197 4.05 220 2.72 NR
Patel et al (2010)[39] 71 71 6.8 245.9 2 100 2.71 51 (72)
Gong et al (2010)[48] 29 29 15 197 2.5 220 3 21 (72)
Petros et al (2011)[49] 95 95 NR 248.3 2 122 2.39 68 (72)
Laydner et al (2011)[50] 8 19 14 199 4.75 250 2.2 16 (84)
Abreu et al (2011)[51] 7 7 NR 237 4 229 3.4 6 (86)
Dulabon et al (2011)[40] 446 446 NR 188.1 2.88 213 3.02 333 (75)
Spana et al (2011)[52] 450 NR NR 188 NR 206 2.91 NR
Kaouk et al (2011)[53] 187 NR 6 181.4 3.64 248 3.15 171 (69)
Guillotreau et al (2012)[54] 210 212 4.8 180 3 200 2.4 156 (74)
NR = not recorded
Table 2. Warm Ischemia Time Associated With Renal Arterial Clamping and Positive Margin Rate
Series Arterial clamping (%) Clamp Time, Minutes Positive Margin (%)
Gettman et al (2004)[43] 5 (38.5) 22 1 (7.7)
Kaul et al (2007)[35] 7 (70) 21 0 (0)
Rogers et al (2008)[32] NR 31 0 (0)
Rogers et al (2008)[44] 11 (100) 28.9 0 (0)
Benway et al (2009)[45] NR 17.8 1 (2)
Wang et al (2009)[46] 40 (100) 19 1 (2)
White et al (2009)[47] 20 (100) 23.8 NR
Patel et al (2010)[39] 57 (80) 21.1 3 (4)
Gong et al (2010)[48] 29 (100) 25 0 (0)
Petros et al (2011)[49] NR 17.7 NR
Laydner et al (2011)[50] 13 (68) 21 0 (0)
Abreu et al (2011)[51] 0 (0) NA 0 (0)
Dulabon et al (2011)[40] NR 20.22 7 (1)
Spana et al (2011)[52] NR 20.2 NR
Kaouk et al (2011)[53] NR 18 NR
Guillotreau et al (2012)[54] NR 17 3 (1)
NR = not recorded; NA = not applicable
Table 3. Postoperative Complications as Classified With the Clavien-Dindo system.
Series Intraoperative Complications (%) Clavien-Grade 1 and 2 (%) Clavien-Grade 3 and 4 (%) Transfusion (%) Recurrences (%)
Gettman et al (2004)[43] 0 (0) 1 (7.7) 0 (0) 0 (0) 0 (0)
Kaul et al (2007)[35] 0 (0) 2 (20) 1 (10) 1 (10) 0 (0)
Rogers et al (2008)[32] 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Rogers et al (2008)[44] 0 (0) 0 (0) 2 (18) 0 (0) NR
Benway et al (2009)[45] 3 (6) 4 (8) 1 (2) 2 (4) 0 (0)*
Wang et al (2009)[46] 2 (5) 7 (18) 1 (2) 2 (5) NR
White et al (2009)[47] 0 (0) 4 (20) 1 (5) 3 (15) NR
Patel et al (2010)[39] 1 (1) 4 (6) 3 (4) 2 (3) 0 (0)*
Gong et al (2010)[48] 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Petros et al (2011)[49] 2 (2) 4 (4) 3 (3) 2 (2) NR
Laydner et al (2011)[50] 0 (0) 1 (5) 0 (0) 0 (0) NR
Abreu et al (2011)[51] 0 (0) 2 (29) 0 (0) 1 (14) NR
Dulabon et al (2011)[40] 10 (2) 16 (4) 1 (0.2) 18 (4) 1 (0.2)
Spana et al (2011)[52] 1 (0.2) 54 (12) 17 (4) 18 (4) NR
Kaouk et al (2011)[53] 3 (1) 42 (17) 6 (2) 17 (9) NR
Guillotreau et al (2012)[54] 7 (3) 36 (17) 6 (3) NR 0 (0)
NR = not recorded



*None at 12 months follow-up



Table 4. Assessment of Renal Function
Series Preoperative Serum Creatinine level, mg/dL Preoperative eGFR, mL/min/1.73 m2 Postoperative Serum Creatinine level, mg/dL Postoperative eGFR, mL/min/1.73 m2 Increased



Postoperative Serum Creatinine level, mg/dL



Decreased



Postoperative eGFR, mL/min/1.73 m2



Rogers et al (2008)[32] 0.9 84.9 0.93 79.3 0.03 5.6
Rogers et al (2008)[44] NR 82.7 NR 74.7 NR 8
Benway et al (2009)[45] 1.12 NR 1.12 NR 0 NR
White et al (2009)[47] 0.86 NR 1.02 NR 0.16 NR
Patel et al (2010)[39] NR 76.2 NR 73.9 NR 2.3
Gong et al (2010)[48] NR NR NR NR NR 4.5
Laydner et al (2011)[50] 1.08 74 1.2 70.25 0.12 3.75
Abreu et al (2011)[51] 1.1 65.6 1.3 67 0.2 -1.4
Kaouk et al (2011)[53] 0.89 86.3 86.35 82.08 0.05 4.22
Guillotreau et al (2012)[54] 0.94 86.3 NR 76 NR 10.3
NR = not recorded
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