Robot-assisted Laparoscopic Partial Nephrectomy: Step-by-step Contemporary Technique and Surgical Outcomes at a Single High-volume Institution

Abstract

BackgroundRobotic technology is being increasingly adopted in urologic surgery. ObjectiveTo describe a contemporary surgical technique and report cumulative surgical outcomes of robot-assisted laparoscopic partial nephrectomy (RALPN) at our tertiary care institution. Design, setting, and participantsMedical charts of consecutive patients who underwent RALPN between June 2006 and November 2011 were reviewed from a prospectively maintained, institutional review board-approved database. Surgical procedureThe main steps of our current surgical technique are described in this video tutorial: patient positioning and trocar placement; bowel mobilization; hilar dissection; tumor identification and demarcation; clamping of the hilum; tumor excision; renorraphy; hilar unclamping; and tumor retrieval. Outcome measurements and statistical analysisPatients’ characteristics and main surgical outcomes were analyzed. Results and limitationsA total of 400 patients (mean age: 58.5 yr, mean body mass index: 30.7kg/m2) were included in this analysis. Mean renal tumor size was 3.17cm (standard deviation [SD]: 1.64) and mean RENAL score was 7.2 (SD: 2). Six patients (1.5%) presented with a solitary kidney. Mean total operative time was 190.3min (SD: 57), and mean warm ischemia time was 19.2min (SD: 10.72). In 36 cases (9%), an unclamped hilum technique was used. After a mean follow-up of 12.4 mo (SD: 12.2), there was a decline of −9.2ml/min per 1.73 m2 (SD: 26.56) in estimated glomerular filtration rate. Most renal masses were malignant (74.5%), and the overall mean tumor size was 3.05cm (SD: 1.66). Renal cell carcinoma with a clear cell histology represented the most frequent malignant diagnosis (64.4% of cases). A positive margin was observed in nine cases (2.25%). A total of 11 intraoperative complications (2.7%) occurred, and a conversion to open or laparoscopic PN was required in six cases (1.5%). A postoperative complication occurred in 61 cases (15.3%), the majority of them being low grade. ConclusionsThe standardization of each surgical step has allowed for optimization of RALPN and ultimately improved its outcomes and expanded its indications.