Simultaneous Bilateral Robotic Partial Nephrectomy: The Description of Our Technique

Abstract

Introduction: The robot-assisted partial nephrectomy (RAPN) is becoming an increasingly common procedure due to the published encouraging outcomes. Very few articles have been reported concerning simultaneous bilateral RAPN1,2. In this video, we report our first case of simultaneous bilateral RAPN to show the feasibility of our technique and critically discuss both the advantages and disadvantages of this procedure. Run time: 7.36 minutes. Materials and Methods: A 69-year-old male patient visited our department due to incidental finding of bilateral mesorenal small renal masses (2.5 cm on the right and 3.5 cm on the left) suspicious for malignancy. The procedure was performed using a three-arms Da Vinci robot. We started from the right side with the patient in flank position. Port placement: a 12-mm periumbilical camera port, two 8-mm robotic ports in a wide V configuration centered on the renal tumor, an additional 12-mm assistant port on the midline between the umbilicus and symphysis pubis. A right RAPN without hilar clamping was performed. Renorraphy was performed with running outside-in monocryl 4/0 and 2/0 sutures preloaded with Hem-o-lok clips. After completing the right RAPN, the trocars were removed and the robot was undocked. Without interrupting the anesthesiological procedures, the patient was placed in a supine position and, after a 180° rotation of the surgical bed, was newly placed in a contralateral flank position. Using both the previous periumbilical and midline ports, two other 8-mm robotic trocars were placed centered on the left renal tumor. The robot was then redocked and a left RAPN without hilar clamping was also performed. Results and Conclusions: Total operation time: 285 minutes (total console time: 240 minutes). Estimated blood losses: 150 mL. Postoperative period: uneventful. Pathological examination: bilateral renal cell carcinoma (pT1aG1), negative surgical margins. Our technique is noteworthy for some aspects. We minimize the number of the ports (six overall). The disposition of the operatory room allows the rotation of the patient's bed and the quick redock of the robot. The operative time was acceptable for a bilateral procedure. The unclamping technique decreased the risk of postoperative renal insufficiency, which is more frequent after a bilateral procedure. The cost for two nephrectomies was decreased because we did not shut the robot down and used the same instruments. In conclusion, our experience was encouraging and confirmed the feasibility and safety of this procedure. The planning of our technique was time and cost effective with a cosmetic benefit for the patient. However, we think that an appropriate selection of the patients (mainly, regarding the size, the location of the tumors, or the preexisting condition of chronic renal insufficiency) and a very good skill in renal robotic surgery are really advisable before approaching this type of surgery. This is an original work that has never been published before and has not been submitted simultaneously to any other journal. All the authors have made a significant contribution to the findings and methods in the article. All the authors have read and approved the final draft. All the authors have no financial or commercial interests and did not receive any funding for their research. The corresponding author takes on the above responsibilities on behalf of the other authors. Runtime of video: 7 mins 36 secs