Introduction
In June 1990, a team that consisted of 2 urologists (Lou Kavoussi and Ralph Clayman), a general surgeon (Nat Soper), an anesthesiologist (Terri Monk), and an interventional radiologist (Mike Darcy) from Washington University performed the first laparoscopic nephrectomy. It was performed in an 85-year-old woman with a 3-cm right midrenal tumor. In December 1990, the team from Washington University proceeded to perform the world's first retroperitoneal laparoscopic nephrectomy and laparoscopic nephroureterectomy. In 1995, Lloyd Ratner and Lou Kavoussi, from Johns Hopkins University, performed the first laparoscopic donor nephrectomy (LDN). This technique was later extended to include cyst excision, caliceal diverticulectomy, pyelolithotomy, and renal biopsy.
In the first clinical application of telesurgery, Marescaux and Gagner performed a transatlantic robotic cholecystectomy between France and New York using the ZEUS system. In 2001, Guillonneau performed the first robot-assisted laparoscopic nephrectomy in a human using the ZEUS system for nonfunctioning hydronephrotic right kidney due to uteropelvic junction obstruction.
Surgical Techniques
The two techniques for performing minimally invasive renal surgery are robotic (robot-assisted laparoscopic nephrectomy) and laparoscopic (laparoscopic nephrectomy). Both of these procedures can be performed transperitoneally or extraperitoneally and can both be performed with hand-port placement.
Currently, the da Vinci robotic surgical system (Intuitive Surgical, Mountain View, Calif) is the only telemanipulator approved by the US Food and Drug Administration (FDA) for cardiac and general abdominal procedures in the United States. In the past, the ZEUS robotic surgical system (Computer Motion, Goleta, Calif) was used in addition to the da Vinci surgical system.
The da Vinci surgical system consists of 2 primary components: (1) the surgeon's 3-dimensional viewing and control console and (2) the surgical arm unit that holds and manipulates the detachable surgical instruments. One arm holds the endoscope; the other 2 or 3 arms hold various EndoWrist instruments, which are tiny, computer-enhanced mechanical wrists with 7 degrees of freedom that provide the dexterity of the surgeon's hand and wrist at the operative site through 8-mm ports.
Surgical Approaches
Robotic transperitoneal approach
The transperitoneal approach as described by Hoznek is as follows (Hoznek, 2004):
- Positioning of patient and ports: In the completely robotic nephrectomy, the patient is positioned in the lateral kidney position (45-60°) with the ipsilateral side up. The bottom leg is flexed at the knee and the upper leg straight with padding under the bottom leg and pillows between the legs. The arms are separated with pillows rests on the arm rest. A Foley and an orogastric tube are inserted. A 12-mm camera port is placed in the midclavicular line lateral to the rectus muscle at the level of the umbilicus. Two 8-mm robotic ports are placed equidistantly, flanking the camera port in a right-angle configuration. Two additional assistant ports are placed for the patient-side assistant to provide irrigation and suction, clip placement, and retraction. The location of these ports is at the surgeon's discretion. The robotic arms are draped sterile and docked from the patient's back. The arms are attached to the ports, and the robotic camera is used after the black and white is balanced.
- Mobilization of the colon: Using EndoWrist long-tip forceps and hook cautery, the operation begins with medial mobilization of the colon along the white line of Toldt of the ascending or descending colon according to the side of the renal involvement. Distally, the colon is mobilized to the level of the iliac vessels and proximally to the level of the liver or spleen. For the right side, hepatic flexure is taken down and the Kocher maneuver is performed to expose the inferior vena cava (IVC). For the left side, the fascial attachment of the spleen is taken down and a plane is created between the superior pole of the kidney and spleen.
- Control of renal artery and vein: For the right side, the liver is elevated with a fan retractor. Alternatively, a 5-mm locking grasper is introduced without a port medial to the two cephalad ports and the liver is retracted by grasping the opposite body wall. The gonadal veins and the ureters are identified at the pelvic brim and are clipped and transected. The gonadal vein can be followed up to IVC. Dissection lateral to the IVC allows for identification of the right renal vein. The right renal artery is also delineated. In the process, lumbar, adrenal, and gonadal veins need to be controlled before the renal vessels are stapled and divided. The dissection of the left renal is similar to that of the right side, but the left adrenal vein needs to be identified and clipped prior to its transection. The renal vessels can be controlled with an endovascular stapler, with Hem-o-lok clips, or by tying the vessels.
- Mobilization of the kidney: Dissection outside the Gerota fascia is performed, releasing the superior and inferior poles. The posterior attachments are then performed. In patients with a kidney tumor, the adrenal gland is taken down en bloc; otherwise, a plane is created between the superior pole of the kidney and the adrenal gland.
- Specimen retrieval: The specimen is placed in an EndoCatch bag, and hemostasis is achieved. One of the port sites is enlarged and the specimen is retracted.
Robotic transperitoneal approach with hand-port placement
Most commonly used for donor nephrectomy, this involves a lower midline incision for the hand port. Four trocars are placed. A 12-mm port for the camera is placed at the level of renal hilum; this is flanked by an 8-mm robotic port placed equidistantly in a V-shaped fashion. Another 12-mm assistant port is placed close to the midline at the pubic level. An assistant retracts the tissues and helps the surgeon at the console to proceed with the dissection. The dissection is performed similarly to the above description and involves medial mobilization of the colon followed by identification of the ureter; the renal hilum is then traced from the gonadal vein. The renal attachments are taken down; the renal hilum is then secured and transected. The specimen is retracted through the midline incision.
Laparoscopic nephrectomy
Positioning of patient and ports: This technique was developed by Flowers et al using a full decubitus position (Flowers, 1997). The patient is placed in the full lateral position (right side down for left nephrectomy), with arms separated with pillows and rested on the arm rest. The first port is placed on the lateral border of the rectus sheath; this is followed by the semi-elliptical placement of 3 other ports around the target organ. The ports are separated by at least 10 cm. A 30° camera is used. The camera port is positioned farthest cephalad, followed by the left and right working-port sites; the most caudal is the assistant port.
Dissection of the renal vein, artery, and superior pole: The dissection begins with the medial mobilization of the colon along the white line of Toldt, with the distal extent at the level of the iliac vessels and the proximal extent lateral to the spleen. The Gerota fascia is incised at the superior pole, creating a dissecting plane between the adrenal gland and the kidney. The adrenal vein is identified and secured. The renal vein and its branches are identified when the Gerota fascia is entered, usually directly caudad to the adrenal gland. Another approach would be to follow the gonadal vein to the renal hilum. The renal artery is usually located behind and slightly inferior to the renal vein.
Ureteral and inferior pole dissection: The ureter is identified with blunt dissection lateral to the gonadal vein. The ureter is dissected along with a good amount of periureteral tissue and fat up to the iliac vessels. The ureter is retracted superiorly and anteriorly, exposing the triangle of tissue between the renal vessels, ureter, and retroperitoneum. The kidney and the perinephric fat are dissected from the iliopsoas and lateral abdominal wall.
Division of renal hilum: The ureter is clipped and transected. The arterial supply is stapled prior to transection; this is followed by renal vein control. A midline incision is made, and the specimen is extracted.
Hand-assisted laparoscopic nephrectomy
In this technique, a hand port is inserted through an abdominal incision at the beginning of the procedure. Two other ports are placed—one for the camera and one for the working port. An additional assistant port is optional. The dissection is very similar to the above description.
Surgical Pearls
The following are suggestions for surgeons who are interested in implementing the robotic and laparoscopic renal surgery into their practice:
- The robotic/laparoscopic team should be trained and dedicated.
- An experienced surgeon should be present to supervise the initial few cases.
- The Intuitive Surgical representative should be present for initial robotic cases.
- The team should become experienced initially with the hand-assisted technique before advancing to the totally robotic/laparoscopic technique.
- The initial tumor nephrectomies should be limited to small tumors that are not over the renal hilum.
- In the initial learning phase, cases that involve enlarged nodes and renal vein or IVC thrombosis should be avoided.
- Large exophytic tumors that extend close to the Gerota fascia should be avoided for the initial retroperitoneal laparoscopic nephrectomy.
- Any devices that provide a thermal effect should be used cautiously to avoid injury to bowels or the cava.
- During left-sided nephrectomies, attention should be paid to the lumbar vein, which may drain into the renal vein posteriorly.
- If a bag is used to remove the specimen, the incision should be large enough to avoid breaking the bag.
- The author avoids nonlocking clips on large vessels and instead recommends locking clips or endovascular staples.
Advantages and Disadvantages of Robotic/Laparoscopic Nephrectomy
The advantages of laparoscopy include decreased pain, hospital stay, convalescence time, wound infection risk, and pulmonary complications and improved cosmesis. However, despite well-established advantages of laparoscopy over conventional surgery, laparoscopy has a steep learning curve. Despite the advances in laparoscopy, this technique has the following inherent limitations:
- Limited range of motion due to the fulcrum
- Inferior ergonomic design of laparoscopic instruments
- Two-dimensional image of the operative field and indirect visibility of the operative field by the camera assistant
- Relative lack of tactile feedback (However, experienced laparoscopists can develop a mild tactile feedback sensation that improves surgical dissection and decreases complications, but this may take time to develop.)
- Natural hand tremor (Gill, 2000)
The da Vinci system is equipped with 3-dimensional vision with magnification X10 and X15, 7° of freedom of movement, and an articulating robotic EndoWrist, which mimics the surgeon's hand movements. Robotic assistance significantly reduces the technical challenge and learning curve and extends the potential for an open surgeon to embrace these developments easily. The robotic articulating wrist allows precise dissection. Robot-assisted procedures are increasingly being used; however, the robot-assisted technology is expensive. The EndoWrist instruments can be used only 10 times, requiring constant replacement. This technique requires a dedicated operating department team with special training in handling robot equipment.
Results
The superiority of laparoscopy over conventional surgery is well established. Presently, the trend is to evaluate the superiority of laparoscopic nephrectomy in transplant surgery. Table 1 summarizes the outcomes of laparoscopic donor nephrectomy (LDN) compared with open nephrectomy in 5 large series, as outlined by Alston et al (2005).
Table 1. The Outcomes of LDN Compared With Those of Open Nephrectomy
Open table in new window
Table
*WIT indicates warm ischemia time.
†EBL indicates estimated blood loss.
‡DGF indicates donor graft failure.
§SCr indicates serum creatinine.
The application of robot in clinical application is relatively new and lacks controlled randomized studies that compare the outcomes with those of laparoscopic nephrectomy. Kumar et al summarized a series of papers with the author's remarks regarding robotic nephrectomy (Kumar, 2005).
Table 2. Robot-Assisted Nephrectomy
Open table in new window
Table
| Reference | Subjects | Cases, No. | Type | Technical Success | Remarks |
| Gill, 2000 | Swine | 5 | Simple | All | Technical feasibility of telerobotics |
| Long operative time; learning curve | |||||
| Sung, 2001 | Swine | 11 | Simple | All | Comparison of ZEUS and da Vinci systems |
| Guillonneau, 2001 | Human | 1 | Simple | All | ZEUS and AESOP systems |
| Marella (2004) | Human | 18 | Simple | Unreported | Compared with hand-assisted laparoscopy |
| Hubert, 2003 | Human | 12 | Simple | 11/12 | Moderate laparoscopy experience |
| 2 | Radical | ||||
| 2 | Donor | ||||
| Pedraza, 2004 | Human | 1 | Nephroureterectomy | All | |
| Horgan, 2002 | Human | 12 | Donor | All | Longer vessels retrieved; shorter hospitalization |
| Reference | Subjects | Cases, No. | Type | Technical Success | Remarks |
| Gill, 2000 | Swine | 5 | Simple | All | Technical feasibility of telerobotics |
| Long operative time; learning curve | |||||
| Sung, 2001 | Swine | 11 | Simple | All | Comparison of ZEUS and da Vinci systems |
| Guillonneau, 2001 | Human | 1 | Simple | All | ZEUS and AESOP systems |
| Marella (2004) | Human | 18 | Simple | Unreported | Compared with hand-assisted laparoscopy |
| Hubert, 2003 | Human | 12 | Simple | 11/12 | Moderate laparoscopy experience |
| 2 | Radical | ||||
| 2 | Donor | ||||
| Pedraza, 2004 | Human | 1 | Nephroureterectomy | All | |
| Horgan, 2002 | Human | 12 | Donor | All | Longer vessels retrieved; shorter hospitalization |
Multimedia
 | Media file 1: Robot console and surgical cart. |
 | Media file 2: Surgeon's console with the master arms. |
 | Media file 3: Robotic instrument tray with EndoWrist instruments. |
 | Media file 4: Surgical cart with robot arms. |
 | Media file 5: Surgeon's console. |
 | Media file 6: Surgeon's console. |
Keywords
minimally invasive nephrectomy, laparoscopic nephrectomy, laparoscopic donor nephrectomy, LDN, radical nephrectomy, partial nephrectomy, simple nephrectomy, hand-assisted nephrectomy, hand-assisted donor nephrectomy, laparoscopic renal surgery, robotic nephrectomy, robot-assisted laparoscopic nephrectomy, robotic renal surgery, retroperitoneal laparoscopic nephrectomy, laparoscopic nephroureterectomy, telesurgery, da Vinci robotic surgical system, telemanipulator, ZEUS robotic surgical system, telerobotics
More on Robotic and Laparoscopic Renal Surgery |
| References |
References
Alston C, Spaliviero M, Gill IS. Laparoscopic donor nephrectomy. Urology. May 2005;65(5):833-9.
El-Galley R, Hood N, Young CJ, et al. Donor nephrectomy: A comparison of techniques and results of open, hand assisted and full laparoscopic nephrectomy. J Urol. Jan 2004;171(1):40-3.
Flowers JL, Jacobs S, Cho E, et al. Comparison of open and laparoscopic live donor nephrectomy. Ann Surg. Oct 1997;226(4):483-9; discussion 489-90. [Medline].
Gill IS, Sung GT, Hsu TH, Meraney AM. Robotic remote laparoscopic nephrectomy and adrenalectomy: the initial experience. J Urol. Dec 2000;164(6):2082-5. [Medline].
Guillonneau B, Jayet C, Tewari A, Vallancien G. Robot assisted laparoscopic nephrectomy. J Urol. Jul 2001;166(1):200-1. [Medline].
Hemal AK, Menon M. Robotics in urology. Curr Opin Urol. Mar 2004;14(2):89-93.
Horgan S, Vanuno D, Benedetti E. Early experience with robotically assisted laparoscopic donor nephrectomy. Surg Laparosc Endosc Percutan Tech. Feb 2002;12(1):64-70. [Medline].
Hoznek A, Hubert J, Antiphon P, et al. Robotic renal surgery. Urol Clin North Am. Nov 2004;31(4):731-6.
Hubert J, Feuillu F. Robotic (da Vinci) remote laparoscopic nephrectomy feasibility and results in 16 cases. Eur Urol. 2003;198.
Jacobs SC, Cho E, Foster C, et al. Laparoscopic donor nephrectomy: the University of Maryland 6-year experience. J Urol. Jan 2004;171(1):47-51. [Medline].
Kumar R, Hemal AK, Menon M. Robotic renal and adrenal surgery: present and future. BJU Int. Aug 2005;96(3):244-9.
Marella V, Wise G. Adjunctive technologies in laparoscopic nephrectomy-comparison of hand-assisted and robotic techniques. J Urol. 2004;171 (suppl):339.
Marescaux J, Leroy J, Gagner M, et al. Transatlantic robot-assisted telesurgery. Nature. Sep 27 2001;413(6854):379-80.
Pedraza R, Palmer L, Moss V, Franco I. Bilateral robotic assisted laparoscopic heminephroureterectomy. J Urol. Jun 2004;171(6 Pt 1):2394-5.
Ratner LE, Montgomery RA, Kavoussi LR. Laparoscopic live donor nephrectomy. A review of the first 5 years. Urol Clin North Am. Nov 2001;28(4):709-19. [Medline].
Rawlins MC, Hefty TL, Brown SL, Biehl TR. Learning laparoscopic donor nephrectomy safely: a report on 100 cases. Arch Surg. May 2002;137(5):531-4; discussion 534-5. [Medline].
Simforoosh N, Bassiri A, Ziaee SA, et al. Laparoscopic versus open live donor nephrectomy: the first randomized clinical trial. Transplant Proc. Nov 2003;35(7):2553-4. [Medline].
Sung GT, Gill IS. Robotic renal and adrenal surgery. Surg Clin North Am. Dec 2003;83(6):1469-82. [Medline].
Sung GT, Gill IS. Robotic laparoscopic surgery: a comparison of the DA Vinci and Zeus systems. Urology. Dec 2001;58(6):893-8. [Medline].
Taylor GD, Cadeddu JA. Applications of laparoscopic surgery in urology: impact on patient care. Med Clin North Am. Mar 2004;88(2):519-38.
Further Reading
Keywords
minimally invasive nephrectomy, laparoscopic nephrectomy, laparoscopic donor nephrectomy, LDN, radical nephrectomy, partial nephrectomy, simple nephrectomy, hand-assisted nephrectomy, hand-assisted donor nephrectomy, laparoscopic renal surgery, robotic nephrectomy, robot-assisted laparoscopic nephrectomy, robotic renal surgery, retroperitoneal laparoscopic nephrectomy, laparoscopic nephroureterectomy, telesurgery, da Vinci robotic surgical system, telemanipulator, ZEUS robotic surgical system, telerobotics
