robot assisted laparoscopic partial nephrectomy

Special Article

ROBOT ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY: TECHNIQUES AND OUTCOMES

Fatih Altunrende, Riccardo Autorino, Humberto Laydner, Michael A. White, Bo Yang, Rakesh Khanna, Shahab Hillyer, Wahib Isac, Gregory Spana, Robert J. Stein, Georges-Pascal Haber y Jihad H Kaouk.

Section of Laparoscopic and Robotic Surgery. Glickman Urological & Kidney Institute. Cleveland Clinic. Cleveland OH. USA.

Resumen.- La cirugía conservadora se considera el tratamiento “Gold estándar” para los tumores renalesT1. Como la nefrectomía parcial laparoscópica (NPL) repre-senta un procedimiento técnicamente difícil la cirugía robótica se ha utilizado de forma creciente durante los últimos años en el campo de la cirugía conservadora de riñón. El objetivo de esta revisión es analizar las técnicas y resultados de la nefrectomía parcial robótica (NPR).

La evidencia actualmente disponible muestra que la NPR es un procedimiento viable y seguro para tumores pequeños localizados y también en tumores complejos seleccionados. Los estudios tempranos comparando NPR y NPL han demostrado similares resultados perio-peratorios, con una tendencia hacia una isquemia más corta en la NPR. Sin embargo, el seguimiento oncoló-gico es limitado y se esperan nuevos ensayos clínicos prospectivos para confirmar los beneficios del abordaje robótico durante la nefrectomía parcial.

@ CORRESPONDENCE

Riccardo Autorino, MD, PhD, FEBUGlickman Urological & Kidney InstituteCleveland Clinic9500 Euclid Av., 44195Cleveland, OH, (USA)

[email protected]@ccf.org

Accepted for publication: October 22nd, 2010

Palabras clave: Tumor renal. Nefrectomía par-cial. Laparoscopia. Cirugía robótica.

Summary.- Nephron-sparing surgery is currently con-sidered the gold standard treatment for T1 renal tumors. As laparoscopic partial nephrectomy (LPN) represents a technically challenging procedure, robotic surgery has been increasingly used during the last few years in the field of nephron-sparing surgery. The aim of this review is to analyze the techniques and outcomes of robotic partial nephrectomy (RPN).

Arch. Esp. Urol. 2011; 64 (4): 325-336

Keywords: Kidney tumor. Partial Nephrectomy. Laparoscopy. Robotic surgery.

Currently available evidence shows that RPN is a feasi-ble and safe procedure for small localized renal tumors and also for selected complex renal tumors. Early com-parative studies have demonstrated similar perioperative outcomes between RPN and LPN, with a trend towards a shorter ischemia time for RPN. However, oncological follow-up remains limited and further prospective trials are awaited to confirm the benefits of robotic approach for partial nephrectomy.

F. Altunrende, R. Autorino, H. Laydner, et al.

INTRODUCTION

In the last two decades, nephron sparing surgery (NSS) has been increasingly adopted for the management of small renal tumors (1, 2). Open partial nephrectomy (OPN) is currently accepted as the gold standard treatment for T1 renal tumors (3).

To overcome the morbidity associated with open surgery, minimally invasive NSS approaches have been developed. Among them, laparoscopic partial nephrectomy (LPN) allows smaller incisions, shorter convalescence and recovery time, with similar oncologic and functional outcomes as compared to OPN (4,5). However, widespread acceptance of the LPN has been limited by the technical challenges encountered during tumor resection, hemostasis, and renal reconstruction. Thus, LPN is mainly performed by experienced laparoscopic surgeons (6).

Robotic technology is being increasingly applied in urological surgery (7). It provides some advantages, such as 3-D vision, articulating instruments, scaling of movement and tremor filtration, fourth robotic arm assistance and, more recently, the TilePro™ software (Intuitive surgical, Sunnyvale, CA), a live intra-operative ultrasound platform (8). All these features are helpful during complex procedures such as partial nephrectomy.

Since the first report by Gettman et al in 2004 showing the feasibility of robotic assisted partial nephrectomy (RPN) (9), a steadily increasing number of series have been reported in urological literature (Figure 1). Additionally, indications for RPN have significantly expanded to include RPN for complex renal tumors (10).

At our Institution, a RPN program has been started in 2006 (11) and it has been consistently implemented since then (12). Herein, we describe the technique and critically analyze the outcomes of RPN based on a literature review and experience at our Institution.

METHODS

A comprehensive literature electronic search was conducted in August 2010, using Medline database, either through PudMed or Ovid as search engine, to identify all publications relating to RPN. English language articles were included for review and foreign language articles were included if they added any additional, relevant information.

326

Search was conducted by using a free-text protocol including the following terms: robotic, robot assisted, robotic assisted, partial nephrectomy, nephron sparing surgery, renal tumor, renal cell carcinoma. These were arranged by a variable combinations of the Boolean operators “AND” and “OR”. Editorials were not included. Review articles and case reports were considered only if relevant. Studies published as abstracts only and reports from meetings were not included. Additional significant studies cited in the reference lists of the selected papers were evaluated. Publications reporting on the same cohort group from the same institution were limited to the most recent publication. In addition, experience with RPN at our own Institution was considered.

SURGICAL TECHNIQUE: AN OVERVIEW

Patient positioning The procedure is initiated with the patient in the supine position, under general endotracheal anesthesia. The patient is then placed in a 45-60° modified flank position. The table is flexed and positioned in slight Trendelenburg. The patient is secured to the table and all pressure points are padded. Pneumoperitoneum is established with a Veress needle.

Trocar placement Port configuration is based on the triangulation principle and might be modified according to robot models, surgeon’s preference and patient’s anatomy (Figure 2). An incision is made superolateral to the umbilicus (pararectal) for the 12 mm camera port. An 8 mm port is placed at the lateral border of the ipsilateral rectus muscle, about 3cm below the costal margin. A second 8mm port is placed about 5-7

FIGURE 1. Number of RPN series reported inurological literature.


cm cephalad to the anterior superior iliac spine. An assistant 12mm port is placed along the lateral border of the rectus muscle in the lower abdominal quadrant. If additional retraction is needed, retract the liver, a 5mm port is placed in the sub-xiphoid area. The robot is then positioned over the patient’s shoulder with the camera oriented in line with the kidney.

In a paper from Detroit, the authors modified port placement to facilitate dissection and to expand range of motion of the robot (13). They place the 12 mm camera port more lateral and the 8 mm robotic arm ports closer to midline.

Medial mobilization of the bowel A 30 degree down scope is utilized along with the ProGrasp™ (Intuitive Surgical, Sunnyvale, CA) robotic grasper in the left hand for retraction and either the monopolar scissors or hook is used in the right hand. The peritoneum is sharply incised along the white line of Toldt. The bowel is mobilized medially, developing a plane anterior to Gerota’s fascia and posterior to the mesocolon. Dissection continues cephalad to mobilize the spleen or liver.

Hilar identification and dissection The gonadal vein is identified along with the ureter and traced superiorly up to the renal area. The peri-renal fat is incised in the non-involved part of the kidney. Dissection then turns toward the renal hilum. Renal vein/artery is dissected by a combination of blunt dissection and electrocautery. Complete and thorough dissection of the renal hilum is very important before attempting vascular control. The value of a

gentle handling of the tissues needs to be pointed out as the lack of tactile feedback in the robotic system might contribute to potential injury of major vessels. Lee et al reported an injury of the posterior segmental artery, requiring conversion to radical nephrectomy (14).

Tumor identification Gerota’s fascia is opened and dissection is carried out along the renal capsule until the mass is exposed. The fat is then cleared circumferentially around the mass, allowing for visualization of at least 1-2cm of normal parenchyma for renal reconstruction. All attempts are made to leave the overlying Gerota’s fascia atop the mass to assist in histopathologic staging and also to utilize as a handle for retraction. The laparoscopic ultrasound probe is used to plan excision margins. The renal capsule is scored to delineate the boundaries of resection.

Hilar clamping Tumor excision can be performed with or with out renal clamping. Intravenous injection of 12.5 g of Mannitol is administered prior to clamping of the renal vessels for the osmotic diuresis. Renal hilum can be clamped with either bulldog or Satinsky clamps. Both are placed by the assistant through an accessory port. Bulldog clamps can be applied separately to the artery and vein, minimizing the inclusion of surrounding tissues. Disadvantages include the requirement of an experienced assistant and optimal alignment (15). Satinsky clamp allows for en-bloc clamping of the renal hilum without the need for full dissection. Though excellent occlusion can be obtained, the Satinsky clamp carries the added disadvantages of port occupancy and potential vascular damage from accidental external collision (16).

Ho et al used a device consisting of a vascular loop and a rubber tube held in place by a Hem-o-Lok clip, avoiding the disadvantages of bulldogs and Satinsky clamps, of maintaining vascular control with the console surgeon (17).

For selected tumors, excision and reconstruction can be attempted without hilar clamping. Our institution successfully described an offclamp technique. In this study, operative time was significantly shorter, but blood loss was greater in the off clamp group. However, there was no significant difference of transfusion rates (18).

Nadler et al reported off–clamp radiofrequency ablation RPN. An avascular plane of tissue from coagulation necrosis was achieved with

327

FIGURE 2. Port placement for RPN at Cleveland Clinic (A-C 8 mm port, B-D 12 mm port).


the RFA system. The tumor was sharply excised with a negative margin using robotic scissors, without hilar clamping. Sixteen patients underwent partial nephrectomies with this technique. No complications were observed, with a follow-up of three months (19).

Recently, selective renal parenchymal clamping during RPN has been described by Viprakasit et al in three patients. Mean selective clamp time was 37 minutes. Mean change in preoperative and postoperative creatinine was 0.1 mg/dL (20).

Tumor excision The tumor is resected by the using cold scissors and the bedside assistant uses suction to clear the resection bed and allow for improved visualization.

Renal tumor is excised en-bloc with the overlying perinephric fat with a small margin of normal renal parenchyma. Mottrie et al were the first to describe a tumor enucleoresection technique in RPN. They performed 17 RPN (including 5 complex tumors), identifying a plane 0.5 cm away of the tumor. After the tumor is recognized, the renal capsule is incised with cold scissors, and dissection continues bluntly. No recurrence was noticed with a mean follow-up of 19 months

Renal reconstruction (Figure 3). The technique for renal reconstruction has significantly evolved since the landmark study by Benway et al. reporting the description of the sliding –clip renorrhaphy (21). Nowadays, the renorrhaphy is usually performed by applying hem-o-lok clips to

328

FIGURE 3. Renorraphy after tumor excision: technique at the Cleveland Clinic in 2010.

ROBOT ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY: TECHNIQUES AND OUTCOMES329

hold and obtain the ideal tension on the parenchimal sutures.

At our institution, the renal reconstruction is performed using an 8 inch 2-0 vicryl suture with a knot and hem-o-lok clip fixed to the opposite end is used to place a running suture of the tumor excision bed to achieve hemostasis and closure of the collecting system. The hilum is unclamped and the renal excision bed is inspected for hemostasis. The renal parenchyma defect is approximated using 0 Vicryl sutures Figure 3. The defect is covered with oxidized cellulose (Surgicel, Johnson and Johnson, Somerville, NJ, USA) and a fibrin sealant (Evicel, Johnson and Johnson, Somerville, NJ, USA or Vitagel, Orthovita, Malvern, Pa, USA).

Moreover, several materials can be used with the aim to aid in achieving a complete hemostasis: oxidized cellulose bolsters, gelatin matrix, fibrin, hydrogel-based adhesive, and glutaraldehyde-based adhesive.

Specimen extraction and closure The specimen is placed in a laparoscopic entrapment sac and is removed from a lower quadrant port site. Care must be taken to make the extraction incision large enough to avoid fracturing the specimen, which could impair an accurate histopathologic examination for margin status and staging. A flank drain is placed in the renal bed and all the ports are removed under vision.

Initial single-institution RPN series (Table I)

In their initial series, Gettman et al reported thirteen patients with an exophytic small renal mass undergoing RPN (9). A transperitoneal approach was used in 11 patients, whereas in the remaining 2 patients with a posterior tumor, a retroperitoneal approach was preferred. At 2 to 11 months of follow-up, no recurrence was noted. Authors concluded that RPN was feasible and allowed to recapitulate the steps of open partial nephrectomy and conventional LPN. However, they recommended this technique only for small, exophytic renal lesion.

Since this first report, authors from other Institutions have also demonstrated that the early outcomes of RPNs are comparable to the LPNs ones (16, 21-23).

Overall, they were able to show the feasibility and the safety of the procedure in selected cases (small, exophytic renal lesion). Oncological outcomes

are promising, positive surgical margins being a rare event. On the other hand, representing the initial experience with the technique, they were limited by the small sample size and the limited follow-up.

Expanding indications for RPN: complex tumors With improved visibility and reconstructive ability, the indications of RPN have expanded to include the management of complex, larger and endophytic lesions (24, 25, 26).

The first reported series on RPN for complex cases was published in 2008. It included hilar, endophytic, and multiple tumors, with a total of 14 tumors resected. All patients had negative surgical margins, and no tumor recurrence was observed with follow-up of 3 months. The authors concluded that RPN is a safe and feasible approach for select patients with complex renal tumors (10).

Another series concerning extended indications was published by Boris et al. In a group of nine patients with multiple ipsilateral renal masses, 24 tumors were removed with an enucleation technique. Average follow up was 9.4 months. Mean EBL was 360 cc and mean warm ischemia time 29.6 minutes. They concluded that RPN for multiple renal masses was safe and the renal function was minimally affected (27).

The RPN technique was also demonstrated to be safe and feasible for renal tumors >4 cm. It has comparable outcomes to RPN for smaller tumors, although with longer warm ischemia times (28).

Recently, the largest published single–instution RPN series to date was published, including 100 patients, 7 of which with multi focal tumors (29). They applied the RENAL nephrometry scoring system (30) to objectify the complexities of the lesions. All cases had negative surgical margins and no recurrences were evidenced with a mean follow-up of 12.7 months.

Multi-institutional series Two institutions reported together their outcomes of 11 RPNs for tumors abutting the renal artery and/or renal vein on preoperative imaging. The mean size of tumor resected was 3.8 cm with a mean operative time of 202 minutes and a WIT of 28.9 minutes. The mean EBL was 220 ml and the mean LOS was 3 days (31).

The largest multi-institutional RPN series to date was reported by Benway et al. They analyzed the outcomes of 183 patients, with a mean tumor size

F. Altunrende, R. Autorino, H. Laydner, et al.330

References

Gettman, 2004

Phillips, 2005

Kaul, 2007

Rogers, 2008*

Rogers, 2008+

Bhayani, 2008

Ho, 2009

Michli, 2009

Wang, 2009

Mottrie, 2009

Patel, 2009

Kaouk, 2009++

Stein, 2009++

Nadler, 2009+++

Benway, 2009

Boris, 2009

White, 2009+++

Scoll BJ, 2010

Mottrie, 2010

Haseebuddin, 2010

Patel, 2010

Gong, 2010

Rogers, 2008#

Rogers, 2008+

Benway, 2009

Benway, 2010#

Study Size(n)

13

12

10

8

11

35

20

20

40

17

3

2

1

16

50

9

8

100

62

38

71

29

148

11

129

183

Tumor Size(cm)

3,.5

1,.8

2,.3

3.6

3.8

2.8

3.53

2.7

2.5

3.8

2.4

2

11

-

2.7

2.7

2.4

2.8

2.8

2.3

3.55

3.0

2.8

3.8

2.9

2.8

WIT(min)

22

26

21

31

28.9

21

21.7

28.1

19

24

17.3

-

-

-

17.8

29.6

-

25.5

20

22.8

22.5

25

27.8

28.9

19.7

23.9

OT (min)

215

265

155

192

202

142

82.8

142

140

133

NA

170

180

435

145.3

257

167

206

91

138.8

256.5

197

197

202

189

210

EBL(ml)

170

240

92

230

220

133

189

263

136

87

75

100

600

125

140.3

360

569

127

95

133.6

100

220

183

220

155

131.5

LOS(d)

4.3

2.7

1.5

2.6

2.6

2.5

4.8

2.8

2.5

5

1.7

3.5

2

2.6

2.5

4

3.75

3.2

5

2.5

2

2.5

1.9

2.6

2.4

NA

Single-Institution RPN series

Multi-Institution RPN series

TABLE I. PUBLISHED RPN SERIES: PERIOPERATIVE OUTCOMES.

Values expressed as mean. Complex cases,+ Hilar tumors, ++ Single port clampless surgery, +++ Clampless surgeryWIT=Warm ischemia time; OT=Operative Time; EBL=Estimated Blood Loss; LOS=Length of Stay


Refe

renc

es

Car

uso,

2006

Aro

n, 2

008

Dea

ne, 2

008

Wan

g, 2

009

Benw

ay, 2

009

Kura

l, 20

09

Del

ong,

201

0

Wu,

201

0

Hab

er, 2

010

Type

of s

tudy

Cas

e co

ntro

l

Mat

ched

pai

r

Mat

ched

pai

r

Cas

e se

ries

Cas

e co

ntro

l

Cas

e co

ntro

l

Cas

e co

ntro

l

Cas

e co

ntro

l

Mat

ched

pai

r

Stud

y gr

oups

NPR

NPL P

NPR

NPL P

NPR

NPL p NPR

NPL p NPR

NPL p NPR

NPL p NPR

NPL P

RF- N

PRN

PL P

NPR

NPL p

N o

f pts

.

10 10 12 12 11 12 40 62 129

118

11 20 13 15 36 42 75 75

Tum

or S

ize

(cm

)

1.95

2.18

0.46 2.4

2.9

0.06 3.1

2.3

>0.0

5

2.5

2.4

>0.0

5

2.9

2.6

>0.0

5

3.2

3.14

0.85 2.6

2.8

0.59

4

2.8

2.0

<0.0

07

2.75 2.5

0.25

WIT

(min

)

26.4

29.3

0.24 23 22 0.89

32.1

35.3

0.50

1

19 25 0.03

19.7

28.4

<0.0

001

27..3

35.8

0.02

29.7

39.9

0.00

006

-31

.1

18.2

20.3

0.27

Ope

rativ

e Ti

me

(min

)

279

253

0.11

242

256

0.60

228.

728

9.5

0.10

2

140

156

0.04

189

174

>0.0

5

185

226

0.07

352

253

<0.0

001

373

293

<0.0

0006

200

197

0.75

EBL

(ml)

240

200

0.90

329

300

0.84

115

198

0.16

9

136

173

>0.0

5

155

196

0.03

286.

438

7.5

0.3

100

150

0.62

8

337

250

<0.0

0002

323

222

0.01

LOS

(d)

2.60

2.65

0.89 4.7

4.4

0.77 2.0

3.1

0.03

9

2.5

2.9

0.03 2.4

2.7

<0.0

001

3.9

4.27

0.28 2 2

0.76 2.8

2.0

0.01

99

4.2

4.1

0.84

TABL

E II.

CO

MPA

RATI

VE S

TUDI

ES.

Valu

es e

xpre

ssed

as

mea

n. R

PN=r

obot

ic p

artia

l nep

hrec

tom

y; LP

N=l

apar

osco

pic

parti

al n

ephr

ecto

my;

RF=

radi

ofre

quen

cy a

blat

ion;

WIT

=war

m is

chem

ia ti

me;

EBL

=esti

mat

ed b

lood

loss

; LO

S=le

ngth

of s

tay

F. Altunrende, R. Autorino, H. Laydner, et al.332

Refe

renc

ias

Aro

n 20

08

Benw

ay 2

009

Benw

ay 2

010

Bhay

ani 2

008

Boris

200

9C

arus

o 20

06

Dea

ne 2

008

Del

ong

2010

Get

tman

200

4G

ong

2010

Hab

er 2

010

Has

eebu

ddin

20

10

Ho

2009

TABL

E III.

REP

ORT

ED C

OM

PLIC

ATIO

N O

F RP

N.

RPN

: Rob

otic

Par

tial N

ephr

ecto

my,

LPN

: lap

aros

copi

c pa

rtial

nep

hrec

tom

y, O

PN: o

pen

parti

al n

ephr

ecto

my,

* a

ccor

ding

to C

lavi

en’s

clas

sifica

tion

Sam

ple

(n)

12 129

183

35 10 10 11 13 13 29 75 38 20

Type

of c

ompl

icat

ion

(n)

Con

gesti

ve h

eart

failu

re (1

), Sl

ow re

cove

ry o

f bow

el fu

nctio

n (1

)Bl

eedi

ng (1

)U

rine

leak

s (3

)Pu

lmon

ary

embo

lus

(1);

Myo

card

ial i

nfar

ctio

n (1

)Re

-exp

lara

tion

neph

rect

omy

(1)

Rect

us h

emat

oma

(1);

Arte

riove

nous

mal

form

atio

ns (2

)Bl

eedi

ng (2

); U

rine

leak

s (2

); M

yoca

rdia

l inf

arct

ion

(1)

Chy

lous

leak

s (2

)Ps

eudo

aneu

rism

(3)

Stro

ke (2

)Su

bcap

sula

r ren

al h

emat

oma

(1)

Dee

p ve

neou

s th

rom

bosis

(1),

hem

atom

a (1

),Hyp

erte

nsiv

e cr

isis

(1)

Myo

card

ial i

nfar

ctio

n (1

)U

rine

leak

s (1

)U

rinar

y re

tent

ion

(1)

Ileus

(1)

Posto

pera

tive

hem

orrh

age

(1)

Con

gesti

ve h

earth

faul

ire (1

),Urin

ary

tract

infe

ctio

n (1

),Ble

edin

g (1

)Ile

usN

one

Ileus

(2),T

rans

ient

syn

copa

l epi

sode

(1)

Atri

al fi

brill

atio

n (1

),DVT

(2),

Urin

oma

(1)

Blee

ding

(2)

Urin

ary

rete

ntio

n (1

)H

yper

tens

ive

crisi

s(1)

Urin

e le

aks

(1)

Myc

ordi

al in

farc

tion

(1),P

ulm

onar

y em

bolu

s (1

)N

one

Gra

de o

fco

mpl

icat

ion*

II IIIb

IIIa

IVa

IVa

Und

efine

dII IIIa

IIIb

IVa

Und

efine

dII IVa I I IIIa

IIIb II I I II IIIb I II IIIa

IVa

Conv

ersi

ons

2 to

LPN

2 to

OPN

2 to

OPN

0

1 to

OPN

1 to

han

d as

siste

d LP

N,

1 to

OPN

1 to

han

d as

siste

d LP

N 0 0 0

3 to

LPN

0 0

Posi

tive

mar

gin

(n)

1 5 7 0 0 0 0 0 1 0 0 1 0


Refe

renc

ias

Kaul

200

7

Kura

l 200

9M

ichl

i 200

9M

ottri

e 20

09M

ottri

e 20

10

Nad

ler 2

009

Pate

l 201

0

Phill

ips

2005

Roge

rs 2

008

Scol

l 201

0

Wan

g 20

09

Whi

te 2

009

Wu

2010

Sam

ple

(n)

10 11 20 17 62 16 71 12 148

100

40 8 42

Type

of c

ompl

icat

ion

(n)

Blee

ding

(1)

Urin

e le

ak (1

)Re

nal p

seud

oane

urys

m (1

)A

bsce

ss (1

) ,Pu

lmon

ary

embo

lism

(1)

Clo

t ret

entio

n (1

)Pe

riren

al h

aem

atom

a (5

)H

emat

uria

(2)

Non

eA

tele

ctas

is (1

)Urin

ary

rete

ntio

n (1

)U

rinar

y le

ak (

2), B

leed

ing

(2)

Blee

ding

(1)

Blee

ding

(1),

Pulm

onar

y em

bolis

m (1

)U

rine

leak

(1)

Hem

atom

a (1

)Ile

us (3

)Pul

mon

ary

embo

lus

(1)R

habd

omyo

lysis

(1)

Urin

e le

ak (1

)A

nem

ia (1

), Pu

lmon

ary

embo

lism

(1),

Col

itis

(1),

Rhab

dom

yoly

sis (1

), Py

elon

ephr

itis

(1)

Pulm

onar

y em

bolis

m (1

), Pe

rinep

hric

col

lect

ion

(1),

Hem

orrh

age

(1),

Urin

e le

ak (1

), Bl

eedi

ng (1

)D

eath

due

to m

yoca

rdia

l inf

arct

ion

Hem

atom

a (1

)U

rine

leak

(1)

Car

diop

ulm

onar

y (3

), Th

rom

boem

bolic

(1)

Dee

p ve

nous

thro

mbo

sis (1

),Ane

mia

(1)

Urin

e le

ak (7

)W

ound

infe

ctio

n (1

), co

litis

(1),

ileus

(1)

Gra

de o

fco

mpl

icat

ion*

IIIb

Und

efine

dIII

aIV

a I II IIIa I II IIIb

IVa

IIIa

IIIb

Und

efine

dI II IIIa V II IIIa

Und

efine

dII

I (3)

, IIIa

(4)

II

Conv

ersi

ons

1 to

OPN

01

to O

PN0 0 0

1 to

han

d as

siste

d, 1

to

OPN

, 1 L

PN2

to O

PN

2 to

OPN

1 to

OPN

1 to

cry

oabl

atio

n0 0

Posi

tive

mar

gin

(n)

0 0 0 0 0 3 NA 2 5 1 0 0

RPN

: Rob

otic

Par

tial N

ephr

ecto

my,

LP

N: l

apar

osco

pic

parti

al n

ephr

ecto

my,

O

PN: o

pen

parti

al n

ephr

ecto

my,

*a

ccor

ding

to C

lavi

en’s

clas

sifica

tion

TABL

E III.

REP

ORT

ED C

OM

PLIC

ATIO

N O

F RP

N.


of 2.87 cm. Mean operative time was 210 min and mean WIT 23.9 min. They concluded that RPN is a safe and efficacious approach, offering short ischemia times, as well as perioperative morbidity equivalent to other standard approaches (32).

Comparative studies: RPN versus LPN (Table II) The first study comparing RPN and LPN was published in 2006. There were no statistically significant differences in terms of mean ischemia time, operative time, blood loss, risk of conversion and hospital stay for between the two groups. Authors concluded RPN is a safe and feasible procedure, but without any advantage over LPN (33). Similarly, in another comparative series from the Cleveland Clinic, no statistically significant difference in the outcomes was detected (11).The first comparison showing some advantage for RPN was published in 2009. The mean operative time (140 versus 156 min), WIT (19 versus 25), and length of hospital stay (2.5 versus 2.9 days) were significantly shorter for RPN. On the other hand, the authors pointed out that RPN is associated with an increased cost and the primary surgeon needs a second experienced surgeon to perform control of hilar clamping (34).

Kural et al compared the results of 11 RPN and 20 LPN. The only major complication was a renal arterial pseudoaneurysm in the RPN group. In the LPN group, one patient had postoperative bleeding and underwent re-exploration. They found that the mean warm ischemia time was significantly shorter in the RPN group (27.3 minutes for the RAPN group and 35.8 for the LPN group) (p = 0.02). Preoperative and postoperative creatinine values were not different for both groups (35).

In a comparison of the outcomes in patients undergoing radiofrequency ablation-assisted clampless RPN and LPN, no difference was found in blood loss, complication rate, postoperative bleeding, renal function or recurrence rate (36).

A recent retrospective analysis compared RPN and LPN. They found significantly decreased WIT in the RPN group, however the operative time was longer (344 versus 254 minutes, p value <0.0001) (37).

In the largest single-surgeon series comparative study published so far, Haber et al demonstrated excellent renal functional and oncological outcomes. Operative outcomes were similar, with the only significant difference between the groups being less intra operative blood loss in the LPN (12).

In a multi-institutional analysis published in 2009, the authors compared 129 consecutive RPN and 118 standard LPN by 3 experienced minimally invasive surgeons at 3 academic centers. They did not find any significant differences in terms of overall operative time (189 vs 174 minutes), collecting system entry (47% vs 54%), pathological tumor size (2.8 vs 2.5 cm) and positive margin rate (3.9% vs 1%) for RPN and LPN, respectively. The advantages of the robotic cases were less blood loss (155 vs 196 mL: P=0.03) and earlier hospital discharge (2.4 vs 2.7 days; P=0.0001). Warm ischemia times were significantly shorter in the RPN group (19.7 vs 28.4 minutes, p < 0.0001). Tumor complexity had no effect on operative time or estimated blood loss for RPN, unlike what happened in the LPN group. In addition, for simple and complex tumors RPN provided significantly shorter warm ischemia time (15.3 vs 25.2 minutes for simple, p <0.0001; 25.9 vs 36.7 minutes for complex, p =0.0002) (39).

The overall complication rate of the RPN series seems to be similar to LPN. The most frequently described complications are urinary leak and hematoma (Table III).

All the comparisons published so far in the literature are retrospective, non- randomized series. This can lead to selection bias, limiting any further conclusions. However, this is currently the best evidence available in the literature and it is unlikely that randomized prospective studies will be done in the near future to fill this gap, due to the highly complex logistics required to apply such study design in this setting.

Robotic laparoendoscopic single site surgery (R-LESS) partial nephrectomy Recently, the addition of the da Vinci Surgery System (Intuitive Surgical, Sunnyvale, CA, USA) to LESS allowed improving ergonomics currently limiting this newly introduced surgical approach (39). Seven single-port laparoscopic and robotic partial nephrectomies were reported by Kaouk et al in 2009. Patients with small, exophytic and solitary mass were selected. A multichannel port was used to obtain intra-abdominal access and the harmonic scalpel was used for tumor excision under normal renal perfusion. No complications were observed in two robotic cases (40).

In another report from the same Institution, the Gel Port laparoscopic system was used as an access platform for robotic R-LESS partial nephrectomy in a case of 11 cm angiomyolipoma, which was resected without renal hilar clamping and no complications (41).

334


Leibovich B, Blute M, Cheville J, et al. Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol, 2004; 171:1066. Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumors: A retrospective cohort stu-dy” Lancet Oncol 740;2006.Ljungberg B, Cowan NC, Hanbury DC, et al. EAU Guidelines on Renal Cell Carcinoma: The 2010 Update. Eur Urol, 2010; 13.Rozanec JJ, Ameri C, Holst P, et al. Nephron-sparing surgery: our experience in open and la-paroscopic approach in 254 cases. Arch Esp Urol, 2010; 63(1):62. Heuer R, Gill IS, Guazzoni G, et al. A critical analysis of the actual role of minimally invasive surgery and active surveillance for kidney cancer. Eur Urol, 2010; 57(2):223.Janetschek G. Laparoscopic partial nephrectomy: how far have we gone?. Curr Opin Urol, 2007; 17(5):316.Castillo O, Javier Ahualli C, Sánchez-salas R, et al. Robotically assisted urologic endoscopic sur-gery. Arch Esp Urol, 2008; 61(7):809.Shapiro E, Benway BM, wang AJ, and Bhayani SB. The role of nephron-sparing robotic surgery in the management of renal malignancy. Current opinion Urol, 2009; 19:76.Gettman MT, Blute ML, Chow GK, et al. Robotic-assisted laparoscopic partial nephrectomy: techni-que and initial clinical experience with DaVinci robotic system. Urol, 2004; 64:914.Rogers CG, Singh A, Blatt AM, et al. Robotic par-tial nephrectomy for complex renal tumors: Sur-gical technique. Eur Urol, 2008; 53 :514.Aron M, Koenig P, Kaouk JH, et al. Robotic and laparoscopic partial nephrectomy: a matched-pair comparison from a high-volume centre. BJU Int, 2008; 102(1):86.

1.

2.

3.

4.

5.

6.

7.

8.

**9.

10.

*11.

REFERENCES AND RECOMMENDED READINGS(*of special interest, **of outstanding interest)

**12.

13.

14.

15.

16.

17.

**18.

19.

20.

**21.

22.

23.

24.

25.

26.

Haber GP, White WM, Crouzet S, et al. Robotic Versus Laparoscopic Partial Nephrectomy: Sin-gle-surgeon Matched Cohort Study of 150 Pa-tients. Urol, 2010; 76(3):754-8. Kaul S, Laungani R, Saqrle R, et al. Da Vinci – Assisted robotic partial nephrectomy:technique and results at a mean of 15 monts of follow. Eur Urol, 2007; 51: 186.Lee JW, Yoon YE, Kim DK. et al. Renal artery injury during robot-assisted renal surgery. J Endo-urol, 2010; 24(7):1101.Hsieh T, Jarrett T, Pinto P. Current status of ne-phron-sparing robotic partial nephrectomy. Curr Opin Urol, 2010; 20:65.Phillips C, Taneja S, Stifelman M. Robot-assisted laparoscopic partial nephrectomy: the NYU tech-nique. J Endourol, 2005; 19:441.Ho HS, Peschel R, Neururer R, et al. Another no-vel application of Hem-o-Lok clips for transient vascular occlusion in robot-assisted laparoscopic partial nephrectomy: an alternative to laparos-copic bulldog and Satinsky clamps. J Endourol, 2008; 22(8):1677.White WM, Goel RK, Haber GP, Kaouk JH. Ro-botic partial nephrectomy without renal hilar oc-clusion. BJU Int, 2010; 105(11):1580.Nadler RB, Perry KT, Smith ND. Hybrid lapa-roscopic and robotic ultrasound-guided radio-frequency ablation-assisted clampless partial ne-phrectomy. Urol, 2009; 74(1):202.Viprakasit DP, Altamar HO, Miller NL, Herre-ll SD. Selective renal parenchymal clamping in robotic partial nephrectomy: initial experience” Urol, 2010; 76(3): 750-3. Benway BM, Wang AJ, Cabello JM, et al. Robotic partial nephrectomy with sliding –clip renorrha-phy:technique and outcomes. Eur Urol, 2009; 55: 592.Michli EE, Parra RO. Robotic-assisted laparosco-pic partial nephrectomy: initial clinical experien-ce. Urol, 2009; 73(2):302.Yang CK, Chiu KY, Su CK, et al. Initial clinical experience with surgical technique of robot-assis-ted transperitoneal laparoscopic partial nephrec-tomy. J Chin Med Assoc, 2009; 72(12):634.Bhayani SB, Das N. Robotic assisted laparoscopic partial nephrectomy for suspected renal cell carci-noma: retrospective review of surgical outcomes of 35 cases. BMC Surg, 2008; 8:16.Ho H, Schwentner C, Neururer R, et al. Steiner H, Bartsch G, Peschel R. Robotic-assisted lapa-roscopic partial nephrectomy: surgical technique and clinical outcomes at 1 year. BJU Int, 2009; 103(5):663.Gong Y, Du C, Josephson DY, et al. Four-arm ro-botic partial nephrectomy for complex renal cell carcinoma. World J Urol, 2010; 28(1):111.

CONCLUSIONS

Based on currently available evidence, RPN seems to be as an effective and safe alternative to LPN in patients elected to NSS. Surgical technique for RPN has evolved and indications have been expanded in the last two years. Currently available comparative studies are retrospective and with a limited follow-up. Prospective trials are awaited to confirm encouraging findings from early reported series.

335

Boris R, Proano M, Linehan M, Pinto PA. Initial experience with robot assisted partial nephrec-tomy for multiple renal masses. J Urol, 2009; 182:1280. Patel MN, Krane S, Bhandari A, et al. Robotic partial nephrectomy for renal tumors larger than 4 cm. Eur Urol, 2009; 57(2):310.Scoll BJ, Uzzo RG, Chen DYT. Robot assisted partial nephrectomy: A large single-instutional experience. Urol, 2010; 75:1328.Kutikov A, Uzzo RG. The R.E.N.A.L nephrome-try score:a comprehensive standardized system for quantitating renal size, location, and depth. J Urol, 2009; 182;844.Rogers CG, Metwalli A, Blatt AM. et al. Robotic partial nephrectomy for renal hilar tumors: a multi-institutional analysis. J Urol, 2008; 180(6):2353.Benway BM, Bhayani SB, Rogers CG. et al. Ro-bot-Assisted Partial Nephrectomy: An Internatio-nal Experience. Eur Urol Jan 22:Epub ahead of print; 2010.Caruso RP, Phillips CK, Kau E, et al. Robot as-sisted laparoscopic partial nephrectomy: initial experience. J Urol,2006; 176:36.Wang AJ, Bjayani SB, et al. Robotic partial ne-phrectomy versus laparoscopic partial nephrec-tomy for renal cell carcinoma: single-surgeon analysis of >100 consecutive procedures. Urol,

2009; 73:206.Kural AR, Atug F, Tufek I. et al. Robot-assisted partial nephrectomy versus laparoscopic partial nephrectomy: comparison of outcomes. J Endo-urol, 2009; 23(9):1491.Wu S, Viprakasit DP, Cashy J. et al. Radiofre-quency Ablation–Assisted Robotic Laparoscopic Partial Nephrectomy Without Renal Hilar Vessel Clamping Versus Laparoscopic Partial Nephrec-tomy: A Comparison of Perioperative Outcomes. J Endourol, 2010; 24( 3):385.Delong JM, Shapiro O, Moinzadeh A. Compari-son of laparoscopic versus robotic assisted partial nephrectomy: one surgeons’s initial experience. Can J Urol, 2010; 17:5201.Benway BM, Bhayani SB, Rogers CG, et al. “Robot assisted partial nephrectomy versus lapa-roscopic partial nephrectomy for renal tumors: A multi-instutional analysis of perioperative outco-mes. J Urol, 2009; 182(3):866-872.White MA, Haber GP, Kaouk JH. Robotic single-site surgery. Curr Opin Urol, 2010; 20 (1): 86.Kaouk JH, Goel RK. Single-port laparoscopic and robotic partial nephrectomy. Eur Urol, 2009; 55(5):1163;.Stein RJ, White WM, Goel RK, et al. Robotic lapa-roendoscopic single-site surgery using Gel Port as the access platform. Eur Urol, 2010; 57(1):132.

27.

*28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

*39.

**40.

41.

336

robot assisted laparoscopic partial nephrectomy

Documents