Robotic-Assisted Laparoscopic Partial Nephrectomy: A Hybrid Technique
Anne M. Suskind, MD1, Ryan C. Jackson, none2, Stuart S. Kesler, MD2, Steven J. Shichman, MD2.
1University of Connecticut, Farmington, CT, USA, 2Hartford Hospital, Hartford, CT, USA.
Introduction and Objective: Nephron-sparing surgery has replaced radical nephrectomy as the gold standard for the treatment of small renal tumors. The newest technique in the field of nephron-sparing surgery is robotic-assisted laparoscopic partial nephrectomy (RALPN). Robotic assistance facilitates tumor resection and intracorporeal suturing; shortening the learning curve for a procedure that previously required a high degree of laparoscopic proficiency. In this video we demonstrate the efficacy of our hybrid technique for robotic-assisted laparoscopic partial nephrectomy (RALPN) and analyze our initial experience, which represents the largest reported series.
Methods: A single surgeon at our institution performed 75 RALPN’s from October 2007 to March 2009. This surgeon uses a hybrid technique combining laparoscopic and robotic approaches. First, the kidney and renal vasculature are adequately exposed and skeletonized via a laparoscopic approach. Once this is accomplished, the robot is docked. Hilar vessels are clamped and tumors are then resected using sharp excision. The resected tumor is bagged and removed intraoperatively for immediate pathologic confirmation of negative frozen margins. Simultaneously, the renal defect is repaired in the standard fashion using robotic assistance. We reviewed our operative technique and initial case series in this video.
Results: The average tumor size was 2.4 cm with a mean operative time of 191.5 minutes and an average warm ischemic time of 30.3 minutes. Mean blood loss was 257 cc and the average length of hospital stay was 3.1 days. There was one intraoperative complication where a lower pole renal artery was clipped. Post operative course was complicated for 10 patients. One patient required conversion to a standard laparoscopic procedure due to the inability to completely occlude the renal artery. One patient required a re-operation for hemorrhage, one patient developed a pseudoaneurysm/AV fistula, one patient was readmitted for an ileus, five patients experienced post-operative urinary retention, one patient developed renal failure and one patient was readmitted with a urine leak, hemorrhage, PE/DVT, and retention. Final pathology reports revealed negative margins in 74/75 patients (98.6%). 53 patients had T1a disease (70.7%), 4 had T1b disease (5.3%), 3 had T3a disease (4%), and 15 (20%) had benign pathology.
Conclusions: Our hybrid RALPN technique has been demonstrated to be both safe and effective as an alternative to the standard laparoscopic approach. Review of the initial 75 patients in our series proves comparable results to those studies published in the literature; however our series represents the largest of such series. Using this technique, we have been able to resect larger, more endophytic, centrally located tumors than we would have been able to accomplish using a standard laparoscopic technique.