Concurrent Robotic Kidney and General Surgery Procedures

Abstract

Introduction: When kidney tumors are found incidentally during evaluation of a general surgery condition, patients may request concurrent robotic surgeries to address both issues simultaneously.1,2 This video shows two such cases: first a concurrent robotic nephrectomy and cholecystectomy and second a concurrent robotic partial nephrectomy with partial gastrectomy. Methods: Robotic nephrectomy and cholecystectomy: A 46-year-old woman with right upper quadrant pain was found to have cholelithiasis and a 7.1 cm right renal mass. The procedure was performed with the daVinci Si system with a four-arm approach and flank position with no redocking. Ports were placed for robotic kidney surgery with a 5 mm subxiphoid port for a liver retractor. The upper pole attachments of the kidney were mobilized, facilitating cranial retraction of the liver and exposure of the gallbladder. The nephrectomy was done first and hilar vessels were ligated with specimen being placed in a retrieval bag. Attention was turned to the cholecystectomy, and the cystic duct and artery were dissected and ligated with robotic hemlock clips. The remaining gallbladder attachments were freed and the specimen was removed through retrieval bag. Robotic partial nephrectomy and partial gastrectomy: A 66-year-old woman with gastrointestinal symptoms was found to have a 3.1 cm enhancing mass off the gastric fundus consistent with a gastrointestinal stromal tumor (GIST) and an incidental 4 cm renal mass of the left lower pole. The procedure was performed with the daVinci Si system with a four-arm transabdominal approach in flank position and no redocking. Ports were placed for robotic kidney surgery with a Gelpoint for the assistant port to allow intraoperative assessment of the specimens. The partial gastrectomy was performed first, using the robotic vessel sealer to expose the gastric fundus. The endoGIA stapler was used to remove the lesion at its base with negative margins, which was removed through a retrieval bag through the Gelpoint. Partial nephrectomy was performed next. The colon was mobilized and the renal hilar vessels were dissected. Intraoperative ultrasound was used to delineate tumor margins and the tumor was excised through sharp and blunt dissection. Results: Robotic nephrectomy and cholecystectomy: operating room (OR) time was 170 minutes, estimated blood loss (EBL) was 30 mL, and hospital stay was 1 day. Final pathology report confirmed a 7.1 cm chromophobe renal-cell carcinoma (RCC) with sarcomatoid differentiation (pT2a). Gallbladder pathology report showed acute cholecystitis and cholelithiasis. Robotic partial nephrectomy and partial gastrectomy: OR time was 150 minutes, EBL was 200 mL, and hospital stay was 3 days. Final pathology report confirmed a 4 cm papillary RCC type 1 (pT1a), grade 3. Partial gastrectomy pathology report confirmed a 3.1 cm GIST tumor. An additional two cases were performed, including a nephrectomy showing clear RCC (pT4) with partial hepatectomy caused by RCC extension into the liver. The second case involved a nephrectomy demonstrating clear RCC (pT1b) alongside a right hemicolectomy because of tubulovillous adenoma. All procedures documented had negative margins and no complications. Conclusion: This video demonstrates the feasibility of concurrent robotic kidney procedures in conjunction with robotic general surgery procedures. With careful planning and proper technique, robotic kidney and robotic general surgery procedures may be performed simultaneously with favorable outcomes. No competing financial interests exist. Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 7 mins 47 secs This video was presented at the North American Robotic Urology Symposium, February 2017, in Las Vegas, Nevada.