Robotic-Assisted Laparoscopic Partial Nephrectomy 

Updated: Sep 10, 2021
Author: E Jason Abel, MD; Chief Editor: Edward David Kim, MD, FACS 

Overview

Background

Localized kidney cancer treatment overview

Kidney cancer (most commonly renal cell carcinoma) is one of the top ten commonly diagnosed cancers in men and women.[1]

While the incidence of renal cell carcinoma is increasing, there is also an increased rate of cancer detection because of the common use of cross-sectional imaging. As a result, many cancers are detected at earlier stages,[2] increasing the available treatment options.[3]

Evidence also shows that many small kidney cancers may be indolent and may progress slowly,[4] but there is no reliable method for predicting which patients will develop metastatic cancer. Although several systemic treatments have been developed in the last decade, the outcomes for metastatic renal cell carcinoma remain poor.[5] As a result, aggressive treatment is usually recommended in patients who do not have serious medical comorbidities.[6]

Surgery for localized renal cell carcinoma

In patients with renal cell carcinoma confined to the kidney (pathologic stage T1 or T2), surgery is effective treatment, with 5-year cancer-free rates of around 95% in large series.[1]

For 5 decades, the recommended treatment was complete removal of the kidney (radical nephrectomy),[2] which was effective but associated with an increased risk of chronic renal failure.[3]

Historically, partial nephrectomy was not offered as a standard treatment to otherwise healthy patients but was reserved for patients with a solitary kidney, poor renal function, or bilateral tumors.[4] However, in the 1990s, preserving renal function by removing only the tumor was popularized and accepted for selected patients with small renal masses.

To date, the vast majority of studies have shown equivalent cancer control in patients treated with complete removal of the kidney or removal of the tumor only,[6] with only rare exceptions.[7] In the American Urological Association (AUA) guidelines for small renal masses, when technically feasible, partial nephrectomy is the standard option for treatment of tumors less than 4 cm in otherwise healthy patients.[8]  The National Comprehensive Cancer Network (NCCN) recommends partial nephrectomy for a T1a renal mass, stating that radical nephrectomy should not be used when nephron-sparing approaches are possible. For T1b tumors, the NCCN guideline states that the standard of care is either radical nephrectomy or partial nephrectomy (when possible).[9]

In efforts to reduce the morbidity of open surgery, surgeons developed laparoscopic partial nephrectomy, with the initial large series showing excellent cancer-specific outcomes[10] but higher complication rates than open surgery.[11]

Other techniques that limit the morbidity of treatment for small renal cell carcinomas include active surveillance and laparoscopic or percutaneous ablation (cryoablation, radiofrequency ablation, and microwave ablation).[5] However, ablation techniques and surveillance have not demonstrated equivalent cancer outcomes to surgery and are not generally offered to otherwise healthy patients as first-line treatment.

With improvements in robotic technology for surgery, robotic-assisted partial nephrectomy (RPN) has emerged as a preferred technique, with excellent short-term cancer and functional outcomes and decreased morbidity in selected patients.[12]

Evolution of minimally invasive surgery for kidney cancer

Open nephrectomy for kidney tumors can be performed through a flank, subcostal, or midline abdominal incision.

The kidneys are located in the retroperitoneum deep to the colon and other peritoneal organs that may require a larger incision for proper access. In the 1980s and 1990s, reports of the feasibility of laparoscopic renal surgery were published,[13, 14] with the first hand-assisted laparoscopic nephrectomy performed in 1997.[15]

Laparoscopic techniques allowed smaller incisions, reduced postoperative pain, and hastened recovery. Multiple series have now demonstrated excellent long-term cancer outcomes for laparoscopic nephrectomy.[16] As laparoscopic techniques evolved, several authors demonstrated the feasibility[17] and favorable outcomes with laparoscopic partial nephrectomy performed by experienced laparoscopic surgeons.[18]

With the evolution of robotic technology for surgery, robotic-assisted partial nephrectomy has evolved as a technique that offers similar outcomes to laparoscopic or open techniques but that may have the advantage of improved maneuverability and precision to decrease ischemia times and improve postoperative renal function.[12]

Potential advantages and disadvantages of robotic assistance

The kidneys filter 10%-20% of an individual’s blood volume per minute. Therefore, partial nephrectomy requires precise control for excision and prompt repair to minimize bleeding and to decrease ischemic time to the kidney.

The robot offers two main advantages over conventional laparoscopy. First, the binocular camera allows the surgeon depth perception to easily operate in 3 dimensions. Second, the “wrist” of the robotic arms has 7 degrees of freedom, which allow the surgeon better control over certain aspects of the operation, most importantly precise suturing with minimal tissue manipulation. The technological advantages of robotic-assisted partial nephrectomy over conventional laparoscopy may allow novice surgeons a shorter learning curve.[19]

Several authors speculate that the technical difficulty of laparoscopic partial nephrectomy has precluded its widespread acceptance, whereas the technical improvements of robotic-assisted partial nephrectomy may allow even novice laparoscopic surgeons to safely perform minimally invasive partial nephrectomies.[20]

The most notable disadvantage of robotic-assisted partial nephrectomy is the added cost of purchasing and maintaining a surgical robot. In 2012, a new robot cost approximately $1.75 million, with a yearly service agreement of $150,000 (da Vinci Surgical System, Intuitive Surgical, Sunnyvale, CA). However, future research is needed to evaluate whether the increased cost of using the surgical robot may be offset by increased utilization of nephron-sparing surgery and better patient outcomes.[21, 22]

History of robotics in urology

The first use of a surgical robot was in orthopaedics in 1983, and the first use of robotics for urologic surgery was in 1988. Initial robots in urology were designed for transurethral surgery, laparoscopic camera holding, or endoscopic applications.[23] In 2000, the da Vinci robotic surgical system was approved by the US Food and Drug Administration, and the first robotic prostatectomy was performed the same year.[24] Surgeons quickly adopted this technique, and, by 2007, it is estimated that 60%-70% of all prostatectomies were performed using robotic assistance.[25]

For kidney surgery, robot assistance has been used for various types of surgery but has particular application to partial nephrectomy[26] and pyeloplasty[27] because of the ease of laparoscopic suturing compared to conventional laparoscopy.

Optimal patient selection for robotic assisted partial nephrectomy

As the understanding of renal cell carcinoma has evolved, the role of partial nephrectomy has expanded. Partial nephrectomy was originally offered only to patients with a solitary kidney, bilateral masses, or poor renal function. Gradually, partial nephrectomy became the standard of care among patients with renal masses smaller than 4 cm, and many surgeons argue that partial nephrectomy is currently the standard of care regardless of tumor size, when technically feasible.[28]  [29]

When deciding whether partial nephrectomy is feasible, the ability to safely remove all tumor completely is the primary consideration. The position of the tumor within the kidney with respect to the blood vessels and collecting system are of paramount importance when considering partial nephrectomy. Multiple systems have been developed to help standardize and make this judgement more objective.[30, 31]  [32]

The use of robotic assistance may facilitate better control when excising tumors and faster repair of the defect when the tumor is removed. Ideal tumors for robotic excision are exophytic and smaller than 4 cm. Larger tumors and those closer to hilar vessels decrease the ability to successfully perform robotic partial nephrectomy. However, larger central tumors may also be removed robotically based on the location of the tumor and experience of the surgical team.[32, 29, 33]

Other patient factors such as severe heart or lung disease may make the robotic approach less suitable.

Preoperative screening

Potential advantages of robotic-assisted partial nephrectomy include a 3-dimensional stereoscopic vision, articulating instruments, and scaled-down movements, reducing tremor. Such articulating instruments and increased freedom of movement may also allow the surgeon to quickly replicate the well-established open surgical maneuvers.[34] However, robotic-assisted partial nephrectomy is a technically challenging procedure because of the time constraints posed by hilar clamping. When the renal hilum is clamped, every minute of ischemia may decrease the patients subsequent renal function.[35] Therefore, the surgeon should be well versed with handling and troubleshooting the robotic interface.[36]

The preoperative screening for this relatively complex robot-assisted laparoscopic procedure is identical to that of a laparoscopic nephrectomy/partial nephrectomy. The evaluation is largely based on anesthesia risk and tumor stage, size, and location; any candidate suitable for a laparoscopic partial nephrectomy is suitable for a robot-assisted laparoscopic partial nephrectomy.

Preoperative evaluation should include stratification of cardiovascular risks, serum laboratory studies, and 3-dimensional imaging (CT or MRI) to accurately delineate the relationship of the mass to the renal vasculature and collecting system.[37] The number of renal vessels and any aberrant vasculature should be noted and may be further delineated with MRI.

Perioperative antibiotics may be given as per standard laparoscopic nephrectomy.

Indications

Nephron-sparing surgery is an established treatment for renal tumors smaller than 4 cm in diameter.[38] The standard open approach to partial nephrectomies has been permeated in recent years by laparoscopic surgery, allowing for a minimally invasive approach to this surgery. Furthermore, the indications for laparoscopic nephron-sparing surgery have expanded over the years, largely facilitated by robotic assistance. This technology has enabled overcoming the technical challenges and steep learning curve inherent to laparoscopic partial nephrectomies,[39] and several reports indicate that similar functional and oncologic outcomes can be achieved when compared to the standard open approach.[40, 37]

The general indications for an open partial nephrectomy apply to the robotic approach—bilateral synchronous or metachronous tumors, tumor in a solitary or solitary functioning kidney, or renal tumors as a manifestation of syndromes such as von Hippel-Lindau (VHL) disease or Birt-Hogg-Dubé (BHD) syndrome, given their multifocality and bilaterality.

While standard laparoscopic partial nephrectomy has been limited to relatively small exophytic tumors, robotic assistance permits nephron-sparing surgery for larger, more central, endophytic, and complex tumors that would otherwise be relegated to an open approach.

In experienced centers, robot-assisted laparoscopic partial nephrectomies have been performed for tumors larger than 4 cm[41] and central masses.[42] The main advantage with robotic assistance is its added dexterity and improved manipulation of the tumor, allowing for rapid control of postexcisional bleeding and renorrhaphy while minimizing blood loss and ischemia time. Accordingly, the indications for contemporary robotic partial nephrectomy are very similar to those of open partial nephrectomies in experienced hands, with comparable ischemic times, blood loss, and oncologic outcomes. Note that, while ischemic times approach those of open surgery, intraoperative parenchymal cooling cannot be applied during ischemia and tumor excision.

Contraindications

In general, robotic nephron-sparing surgery should not be offered for higher-stage tumors that are located in the hilum (ie, >T2, extension into vena cava, or with obvious nodal involvement). These parameters are generally assessed with preoperative CT- or MRI-based abdominal imaging.

When nephron-sparing surgery is absolutely indicated (ie, solitary kidney, bilateral tumors, renal insufficiency), some of these contraindications can be overlooked, especially in the hands of highly experienced surgeons. It should be kept in mind that the threshold to use the open approach or conversion to open should be held low in these complex scenarios. In addition, the standard relative contraindications to laparoscopic surgery (eg, significant prior abdominal surgeries, bowel obstruction) still apply to robot-assisted surgery.

Technical Considerations

The robotic approach to renal surgery, particularly partial nephrectomy, has some inherent challenges, and some familiarity with the da Vinci robotic system is necessary. The surgeon must gain an understanding of the robotic arm movements and range of motion, especially in relation to the clutch and camera.

Procedure Planning

In preparation for nephron-sparing surgery, the patient must undergo a complete metastatic workup, which involves abdominal imaging with CT or MRI, chest radiography, and blood work (complete blood cell count [CBC], electrolytes, liver and coagulation profile). The abdominal imaging should include reconstructed series to clearly delineate the vasculature, specifically the number and course of renal arteries and veins. This is critical to plan intraoperative hilar dissection and clamping.

In addition, tumor size, location, endophytic nature, and proximity to the collecting system are examined on preoperative imaging, and a renal nephrometry score is determined.[43] Arrangements should also be made for intraoperative ultrasonography to more precisely mark out the tumor prior to resection.

Of equal importance to the console surgeon is the bedside assistant, especially when applying the vascular clamps extra corporally. Sufficient assist ports must be placed prior to beginning dissection. All instruments, sutures, and pledgets should be carefully prepared prior to commencing the tumor excision; it would be prudent to “walk through” the procedure in detail with the bedside assistant, scrub nurse, and other operating-room personnel involved in the case.

Outcomes

Since 2004, more than 65 published articles have documented outcomes of robotic-assisted laparoscopic partial nephrectomy. Until recently, most studies were from a single institution and comprised small patient numbers. However, as the experience with the surgery has improved, so have outcomes. Furthermore, as surgeons have become more adept at performing this procedure, the ability to safely surgically remove renal masses in the hilar, endophytic, and multiple tumor locations has also improved.[44]

In the data in Table 1, the vast majority of renal masses excised were smaller than 4 cm (pT1a), and, as would be expected, approximately 70% were malignant. Operative times were longer than would be expected for open partial nephrectomy, and blood loss is similar across the series.

Table 1. Overall Demographics of Robotic-Assisted Laparoscopic Partial Nephrectomy (Open Table in a new window)

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)[45]

13

13

7

215

4.3

170

3.5

10 (76.9)

Kaul et al (2007)[37]

10

10

15

155

1.5

92

2.3

8 (80)

Rogers et al (2008)[34]

8

14

3

192

2.6

230

3.6

8 (60)

Rogers et al (2008)[46]

11

11

NR

202

2.6

220

3.8

11 (100)

Benway et al (2009)[47]

50

50

NR

145.3

2.5

140

2.7

28 (56)

Wang et al (2009)[48]

40

40

NR

140

2.5

136

2.5

25 (62)

White et al (2009)[49]

20

20

NR

197

4.05

220

2.72

NR

Patel et al (2010)[41]

71

71

6.8

245.9

2

100

2.71

51 (72)

Gong et al (2010)[50]

29

29

15

197

2.5

220

3

21 (72)

Petros et al (2011)[51]

95

95

NR

248.3

2

122

2.39

68 (72)

Laydner et al (2011)[52]

8

19

14

199

4.75

250

2.2

16 (84)

Abreu et al (2011)[53]

7

7

NR

237

4

229

3.4

6 (86)

Dulabon et al (2011)[42]

446

446

NR

188.1

2.88

213

3.02

333 (75)

Spana et al (2011)[54]

450

NR

NR

188

NR

206

2.91

NR

Kaouk et al (2011)[55]

187

NR

6

181.4

3.64

248

3.15

171 (69)

Guillotreau et al (2012)[56]

210

212

4.8

180

3

200

2.4

156 (74)

NR = not recorded

Concerning the data in Table 2, it should be noted that clamp times improved during the experience for each institution and averaged approximately 20 minutes overall.

Unlike traditional open partial nephrectomy, in which a kidney is normally cooled with ice for 10 minutes following clamping, laparoscopic and robotic partial nephrectomies are often performed with warm ischemia. Gettman et al[45] performed intra-arterial cooling of the renal artery in a few select patients. As the experience improved, some institutions began performing selective renal hilar arterial clamping or off clamp completely. Positive margin rates are similar to those reported for open partial nephrectomy.

Table 2. Warm Ischemia Time Associated With Renal Arterial Clamping and Positive Margin Rate (Open Table in a new window)

Series

Arterial clamping (%)

Clamp Time, Minutes

Positive Margin (%)

Gettman et al (2004)[45]

5 (38.5)

22

1 (7.7)

Kaul et al (2007)[37]

7 (70)

21

0 (0)

Rogers et al (2008)[34]

NR

31

0 (0)

Rogers et al (2008)[46]

11 (100)

28.9

0 (0)

Benway et al (2009)[47]

NR

17.8

1 (2)

Wang et al (2009)[48]

40 (100)

19

1 (2)

White et al (2009)[49]

20 (100)

23.8

NR

Patel et al (2010)[41]

57 (80)

21.1

3 (4)

Gong et al (2010)[50]

29 (100)

25

0 (0)

Petros et al (2011)[51]

NR

17.7

NR

Laydner et al (2011)[52]

13 (68)

21

0 (0)

Abreu et al (2011)[53]

0 (0)

NA

0 (0)

Dulabon et al (2011)[42]

NR

20.22

7 (1)

Spana et al (2011)[54]

NR

20.2

NR

Kaouk et al (2011)[55]

NR

18

NR

Guillotreau et al (2012)[56]

NR

17

3 (1)

NR = not recorded; NA = not applicable

In Table 3, grade 1 and 2 complications included postoperative bleeding requiring transfusion, infection, and ileus. The most common Clavien 3 complications included urinoma requiring cystoscopy and stent placement and angioembolization.

Intraoperative complications were also rare and were primarily seen during procedures in which patients had prior abdominal procedures. Examples include enterotomy primarily repaired without sequelae and conversion to an open procedure. Tumor recurrences were uncommon across the board; however, most series had a limited follow-up.

Table 3. Postoperative Complications as Classified With the Clavien-Dindo system. (Open Table in a new window)

Series

Intraoperative Complications (%)

Clavien-Grade 1 and 2 (%)

Clavien-Grade 3 and 4 (%)

Transfusion (%)

Recurrences (%)

Gettman et al (2004)[45]

0 (0)

1 (7.7)

0 (0)

0 (0)

0 (0)

Kaul et al (2007)[37]

0 (0)

2 (20)

1 (10)

1 (10)

0 (0)

Rogers et al (2008)[34]

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

Rogers et al (2008)[46]

0 (0)

0 (0)

2 (18)

0 (0)

NR

Benway et al (2009)[47]

3 (6)

4 (8)

1 (2)

2 (4)

0 (0)*

Wang et al (2009)[48]

2 (5)

7 (18)

1 (2)

2 (5)

NR

White et al (2009)[49]

0 (0)

4 (20)

1 (5)

3 (15)

NR

Patel et al (2010)[41]

1 (1)

4 (6)

3 (4)

2 (3)

0 (0)*

Gong et al (2010)[50]

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

Petros et al (2011)[51]

2 (2)

4 (4)

3 (3)

2 (2)

NR

Laydner et al (2011)[52]

0 (0)

1 (5)

0 (0)

0 (0)

NR

Abreu et al (2011)[53]

0 (0)

2 (29)

0 (0)

1 (14)

NR

Dulabon et al (2011)[42]

10 (2)

16 (4)

1 (0.2)

18 (4)

1 (0.2)

Spana et al (2011)[54]

1 (0.2)

54 (12)

17 (4)

18 (4)

NR

Kaouk et al (2011)[55]

3 (1)

42 (17)

6 (2)

17 (9)

NR

Guillotreau et al (2012)[56]

7 (3)

36 (17)

6 (3)

NR

0 (0)

NR = not recorded

*None at 12 months follow-up

In Table 4, not all studies provided baseline and postoperative creatinine assessments. Some studies reported both 1-month and 6-month measurements overall. The estimated glomerular filtration rate (eGFR) was provided in several of the more recent studies and averaged a decrease of 5%. Overall, effects on renal function were minor, even in patients with multiple tumors. None of the studies reported the need for hemodialysis postoperatively.

Table 4. Assessment of Renal Function (Open Table in a new window)

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)[34]

0.9

84.9

0.93

79.3

0.03

5.6

Rogers et al (2008)[46]

NR

82.7

NR

74.7

NR

8

Benway et al (2009)[47]

1.12

NR

1.12

NR

0

NR

White et al (2009)[49]

0.86

NR

1.02

NR

0.16

NR

Patel et al (2010)[41]

NR

76.2

NR

73.9

NR

2.3

Gong et al (2010)[50]

NR

NR

NR

NR

NR

4.5

Laydner et al (2011)[52]

1.08

74

1.2

70.25

0.12

3.75

Abreu et al (2011)[53]

1.1

65.6

1.3

67

0.2

-1.4

Kaouk et al (2011)[55]

0.89

86.3

86.35

82.08

0.05

4.22

Guillotreau et al (2012)[56]

0.94

86.3

NR

76

NR

10.3

NR = not recorded

Summary

Robotic partial nephrectomy achieves similar oncologic outcomes, less blood loss, minimal effects on renal function, and an excellent safety profile when performed at high-volume centers. Further studies with long-term cancer and functional outcomes may establish robotic-assisted partial nephrectomy as the standard of care for selected patients with small renal masses.

 

Periprocedural Care

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.

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.[45]

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.

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.[57]

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°.[58] 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.[36] 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.[37] 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.

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[59] 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.

 

Technique

Approach Considerations

The robotic approach to renal surgery, particularly partial nephrectomy, has some inherent challenges, and some familiarity with the da Vinci robotic system is necessary. The surgeon must gain an understanding of the robotic arm movements and range of motion, especially in relation to the clutch and camera.

The advent of robotically assisted prostatectomy in 2001[24] paved the way for widespread accessibility to the da Vinci robotic unit and its application to renal surgery. Since that time, at least one multi-institutional survey has demonstrated superiority of the robotic approach when compared to laparoscopic for outcomes of blood loss, hospital stay and a substantially shorter warm ischemia time, while maintaining equivalence in positive margin rate, operative time and complications.[12]

A transperitoneal approach is most commonly used. Prior abdominal operation is not necessarily a contraindication to this procedure, but access should be approached with regard for previous operation(s) by an experienced team.

See Positioning for a discussion of patient positioning and abdominal access.

Robotic Transperitoneal Approach

The patient is placed in a partial flank position with the table moderately flexed at the level of the contralateral kidney. The authors’ preference is not to use the kidney rest, and the upper arm is adducted along the side and hip, as described by Rashid et al.[60] In the authors’ experience, this position simplifies patient positioning and provides much better space for robotic arm movement in front of the patient (see image 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.

After induction of general anesthesia, placement of urinary catheter, and gastric drainage, the patient is positioned and the camera port is placed roughly 8-10 cm below the costal margin on an axis 90° to the costal margin; one simple rule of thumb is that the camera port is placed one average male hand’s breadth away from the costal margin, perpendicular to it. Numerous different strategies can be used for camera and port position, but the authors find this approach to be easy and intuitive.

For the novice surgeon, it is useful to use an approach that minimizes the likelihood of disorientation, and the authors feel that positioning the operative arms on the long axis of the torso avoids this risk and allows unhampered vision in the caudal direction.

The abdomen may be insufflated via Veress needle placement before camera port insertion, or direct port placement may be used in the decompressed abdomen; the direct visual placement approach can be used without prior insufflation (see video below).

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 technique of peritoneal entry and insufflation should be determined by the surgeon; no single approach has been shown superior, although direct entry techniques are associated with a decrease in failed entry, omental injury, and extraperitoneal insufflation compared to Veress needle insertion in a meta-analysis.[61]

Depending on patient habitus, the camera may be placed above the lateral margin of the rectus muscles or in the midline superior to the umbilicus in the very thin patient. Correlation of the tumor location on imaging studies to the bony anatomy and planned approach may suggest modification of this scheme as appropriate to give the surgeon unfettered access to the renal hilum and tumor. In the authors’ practice, the right and left robotic ports are placed in roughly the anterior axillary line, again with attention to ensuring good triangulation for both hilar and tumor access.

Final site selection is best determined once abdominal insufflation is obtained and relative relationships between the ports can be optimized. In general, robotic and camera ports should be at least 8 cm apart to minimize clashing when using the "S" or Si" systems.

As noted in Positioning, surgeons using the "standard" Da Vinci system may wish to consider performing initial abdominal entry, as well as kidney preparation and dissection, laparoscopically before docking the robot for the partial nephrectomy owing to the decreased operative field with the earlier model of robot.

Two assistant ports are placed next—the first in the midline inferior to the umbilicus and the second is in the superior lower quadrant in a lateral location that is selected to minimize interference with the robotic arms and the other assist port. Alternatively, the midline superior to the camera may be used, although this can complicate simultaneous port utilization by a single assistant if the robotic camera is in between (see image below).

This illustrates port placement with the second as 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.

It is important to select a port size adequate to accept a CT-1 needle, clip, and bulldog clamp appliers and mini-laparotomy pad, if desired. The authors use a 15-mm port for one of the assist ports and a 12-mm or 15-mm port for the secondary assist port. It is important to tailor assist-port placement to the abdomen after camera and robotic arm placement. The robotic “fourth arm” may be placed through a lower-quadrant lateral port placement, although the authors rarely find this useful and reserve it for extremely complex masses or the absence of a skilled assistant.

The robot is docked from behind the patient with care taken to minimize the potential for arm clashing during the extensive lateral movement necessary for renal mobilization. A 30° down lens is used. When operating on the right side, an additional 5-mm port may be placed in the subxiphoid region, if necessary, to allow a laparoscopic blunt grasper to be placed beneath the liver edge and secured to the body wall in order to retract the liver superiorly for improved upper-pole access (see video below).

The 5-mm subxiphoid port is used to place a blunt grasper under the liver for this right-sided case and elevate it.

Renal access

With a monopolar scissor in the right robotic hand and a bipolar grasper in the left hand, the lateral attachments of the colon are carefully taken down with care to avoid exposure of the bowel to electrocautery. Some surgeons may prefer the Maryland bipolar grasper in the left hand.

The assistant should traction bowel in a downward direction with the tip of the suction irrigator while the surgeon provides upward countertraction to maximize exposure of the intervening structures. As the colon is reflected medially to enter the anterior pararenal space, care should be taken to identify and selectively transect the ligamentous attachments to the upper-quadrant structures and thus minimize risk of traction injury to the spleen or liver. Lateral body wall attachments of the kidney are left intact, and Gerota fascia is not entered (see videos below).

The colon is released from the lateral abdominal wall.
The anterior pararenal space is defined. Gerota fascia is not entered at this point.

Hilar access

Once the colon is safely released and reflected, careful identification and dissection of the renal vasculature is undertaken.

Preoperative planning and understanding of this anatomy should be obtained through appropriate imaging studies with care to note all arterial and venous variations and duplications.

Access to the vessels of the hilum is obtained by direct approach or, if difficult by identification of the ureter, gonadal vein and inferior great vessel on the appropriate side with careful progression superiorly to the hilum. Care must be taken to identify and preserve any accessory lower-pole vessels. The duodenum is kocherized on the right side. Using lateral traction on the kidney to stretch the hilar attachments, the vessels are dissected free from all surrounding tissue to allow easy and unhindered placement of temporary occlusive vascular "bulldog" clamps. Complete circumferential freedom of the vessels is critical to the effectiveness of the vascular control. Inclusion of any excess tissue in the clamp may prevent complete occlusion and worsen both bleeding and visualization during tumor resection (see video below).

The renal artery is freed from periarterial tissue.

Renal mobilization

Once the hilum is appropriately freed, attention is turned to acquiring access to the tumor before clamping. Generous access in the region of the tumor is of great importance, and the authors recommend that at least 2-3 cm surrounding the margins of the proposed resection be freed of perirenal fat and accessible to the surgeon. For posterior or upper-pole tumors, complete freedom of the kidney will likely be required to allow the kidney to be flipped or rotated into a favorable orientation. Gerota fascia is entered and the plane on the renal capsule developed with attention to dividing the perirenal fat in an orientation that will allow simple reconstruction of the fat over the tumor resection bed at the conclusion of the case.

As renal freedom is obtained, the kidney can be repositioned into the optimal orientation for resection. Often, a mini-laparotomy pad (sponge) can be passed in through a 15-mm port and used to prop the kidney up and stabilize it while providing an absorptive medium for any bleeding that occurs (see video below).

The tumor is free of Gerota fascia with a generous margin of clear capsule surrounding it. Overlying fat is left attached.

Identification of the tumor

For exophytic masses, the tumor can generally be identified visually during careful dissection of Gerota fascia. Care should be taken to avoid inadvertent tumor entry and, if possible, to isolate the perirenal fat over the tumor and leave it attached as an island. Endophytic or intrarenal tumors often benefit from intraoperative ultrasonography to identify the tumor margins and goals of resection;[62] the authors find that scoring the renal capsule with the monopolar scissors to mark the planned resection can be of great assistance, especially as the appearance of the kidney changes during resection.

Tumor resection

While preparations for resection are being made, 12.5 g of mannitol is administered intravenously 10 minutes before clamping is anticipated. When ready, bulldog clamps are applied to the renal artery(s) and, if desired, to the renal veins. The authors often place a second bulldog to ensure complete occlusion of the artery.

Reasonable attempts on the part of the anesthesiologist to lower the blood pressure should be undertaken to decrease bleeding. Some evidence suggests that the deleterious effects of warm ischemia are somewhat mitigated by clamping only the arterial inflow without vein clamping;[63] however, this can increase venous back-bleeding and, in some cases, interfere with visualization. The authors consider venous occlusion on a case-by-case basis: for smaller and more peripheral tumors, it is unnecessary; for larger tumors, for central tumors, or for novice surgeons, it may prove beneficial (see video below).

The assistant places two "Bulldog" vascular clamps on the renal artery.

Once vascular clamps are placed, the time is noted and attention is rapidly turned to tumor resection. Using the scissors in a “cold” fashion to allow optimal visualization of the parenchyma, the capsule is cut and the subjacent normal parenchyma is rapidly entered. Maintaining an appropriate orientation of resection angle is of critical importance to ensuring negative margins; it is often useful to direct the scissor tips away from the mass initially (see video below).

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.

Excessive bleeding that interferes with visualization should be dealt with by first increasing the insufflation pressure to 20 mm Hg; suction is important but should be limited in order to maintain high insufflation pressure and not contribute to ongoing bleeding via abdominal decompression.

When an appropriate depth has been reached, the scissors can be turned “tips up” in order to prevent unnecessary diving into the kidney; knowledge that the Da Vinci monopolar scissors are 1 cm long can assist in assessing depth (see video below).

After reaching an appropriate depth, the scissors are turned and the base of the resection developed beneath the tumor.

Spot fulguration of areas of vigorous bleeding should be done with either monopolar or bipolar cautery as encountered, but resection should not be overly delayed. Entry into the collecting system should be noted; tumor resection is completed in less than 5 minutes, if possible. Reference to capsular scoring can be helpful during this resection, particularly with an indistinct mass. The authors start with roughly a 180° incision and complete the capsular incision on the "back" half as the tumor mass is becoming free. Margins are sent according to surgeon preference.

Renorrhaphy

When the renal mass is excised, it is set safely aside in a retrievable location and repair immediately commenced. Robotic instruments are exchanged for needle drivers on just the right hand or both, and the authors’ preference is to repair the tumor bed with a running 6-in, 3-0 V-Lok suture (Covidien, Dublin, Ireland) beginning outside the resection bed and with care taken to oversew vascular sinuses and repair collecting system violations as seen in the fashion originally reported by Shikanov et al.[64] The V-Lok suture may be simply cut once this running repair of the tumor bed is complete, taking advantage of its nonslipping qualities. This step may be unnecessary in smaller or uncomplicated resections (see video below).

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.

Capsular renorrhaphy is undertaken with 0 polyglactin on a CT-1 needle. These are generally precut to a 4-in length with either a knot holding a Hem-o-lok clip (Teleflex, Research Triangle Park, NC, USA) in place at the distal end or a Lapra-Ty (Ethicon, Somerville, NJ, USA), securing the clip as described by Benway et al.[47] The authors do not use preformed bolsters.

A small section of precut Surgicel (Ethicon, Somerville, NJ, USA) is placed in the resection bed, and a hemostatic agent such as Floseal (Baxter Biosurgery, Deerfield, IL, USA) may be dispensed on top; the sutures are then placed with a 1- to 2-cm margin from the edge of the resection bed, passed into the bed, placed again into the opposing side of the defect, and pulled up from the opposing margin.

Moderate upward traction is used to pull the suture through so that the clip engages the capsule and pulls the defect closed with slight capsular dimpling; care is taken to avoid tearing the renal capsule. A Hem-o-lok clip is applied to the second side, slid down, and then locked in place with a Lapra-Ty after pulling an appropriate amount of hemostatic tension across the defect. This is repeated to result in resection bed closure with suture spacing every 5-7 mm along the wound. Placement of the Hem-o-lok clips so that the center of the clip engages the suture is important to allow controlled slipping and broad distribution of tension across the kidney capsule (see videos below).

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.

Vascular bulldog clamps should be removed as soon as possible to minimize ischemic time. In a more peripheral or limited resection, this can be done as soon as the first parenchymal suture is placed, if desired; in general, the authors release the clamps as soon as the first 3 capsular sutures are in place. The goal should be to have the clamps released before 20 minutes of warm ischemia has elapsed; however, oncologic success should never be compromised to shorten ischemia time. Optimal results are achieved with clamp times that are under 25 minutes; renal function is more likely to be compromised with longer times, especially in the setting of other microvascular comorbidity such as diabetes or hypertension.[65]

Once the clamps are released, attention is immediately returned to the resection bed. Further sutures are placed as necessary to achieve complete hemostasis, and the insufflation pressure is lowered to allow appropriate survey for bleeding. Final tightening of the capsular sutures is done. A second layer of Surgicel and hemostatic agent may be placed if the desired. Gerota fascia is closed over the repair with a running 2-0 or 3-0 polyglactin using intermittent Hem-o-lok clips to take up tension.

The specimen in placed in a bag and secured. The robot is undocked after a final survey with the pressure decreased, and a drain is placed if significant collecting system entry was suspected or bleeding feared. Ports of 10 mm or greater are closed with a Carter-Thomason device or under direct vision; 8 mm or smaller ports are generally not closed in the authors’ practice.[66]

Notes

The use of the intravenous contrast agent indocyanine green (ICN) may provide advantages in identification of appropriate vascular branches for clamp application, as well as for assessing tumor margins before and after resection. At the present time, utility is being assessed, and availability of this technology is limited and costly.

 

Questions & Answers

Overview

What is the prevalence of renal cell carcinoma (RCC)?

How effective is surgery for renal cell carcinoma (RCC)?

How has laparoscopic nephrectomy evolved?

What are the advantages of robotic-assisted laparoscopic partial nephrectomy?

What is the history of robotic-assisted laparoscopic partial nephrectomy?

What are the factors in patient selection for robotic-assisted laparoscopic partial nephrectomy?

What is included in the preoperative screening for robotic-assisted laparoscopic partial nephrectomy?

When is robotic-assisted laparoscopic partial nephrectomy indicated?

What are the contraindications for robotic-assisted laparoscopic partial nephrectomy?

What are the challenges to successful performance of robotic-assisted laparoscopic partial nephrectomy?

What is included in the metastatic workup prior to performing robotic-assisted laparoscopic partial nephrectomy?

What is the role of preoperative imaging for robotic-assisted laparoscopic partial nephrectomy?

What is the role of the bedside assistant in the performance of robotic-assisted laparoscopic partial nephrectomy?

What are the expected outcomes of robotic-assisted laparoscopic partial nephrectomy?

How do the outcomes for robotic-assisted laparoscopic partial nephrectomy compare to other surgical approaches?

Periprocedural Care

What is included in patient education about robotic-assisted laparoscopic partial nephrectomy?

What are the preoperative patient instructions for robotic-assisted laparoscopic partial nephrectomy?

What are the elements of informed consent for robotic-assisted laparoscopic partial nephrectomy?

Who are the members of the surgery team for robotic-assisted laparoscopic partial nephrectomy?

What are the components of the da Vinci surgical console for robotic-assisted laparoscopic partial nephrectomy?

Which types of robotic arms are required to perform robotic-assisted laparoscopic partial nephrectomy?

How is the patient prepped for robotic-assisted laparoscopic partial nephrectomy?

What is the role of anesthesia in the performance of robotic-assisted laparoscopic partial nephrectomy?

How is the patient positioned for robotic-assisted laparoscopic partial nephrectomy?

What is included in the long-term monitoring following robotic-assisted laparoscopic partial nephrectomy?

Technique

What is the surgical approach used for robotic-assisted laparoscopic partial nephrectomy?

What are the initial steps in the performance of robotic-assisted laparoscopic partial nephrectomy?

What are the steps for renal access during robotic-assisted laparoscopic partial nephrectomy?

How is hilar access achieved during robotic-assisted laparoscopic partial nephrectomy?

How is renal mobilization obtained during robotic-assisted laparoscopic partial nephrectomy?

How is the tumor identified during robotic-assisted laparoscopic partial nephrectomy?

How is the tumor resected during robotic-assisted laparoscopic partial nephrectomy?

How is renorrhaphy performed during robotic-assisted laparoscopic partial nephrectomy?

What is the role of indocyanine green contrast agent in the performance of robotic-assisted laparoscopic partial nephrectomy?