Trans-retro partial nephrectomy: A novel approach for posterior kidney tumors

Abstract

IntroductionThe approach to surgery in Robot Assisted Partial Nephrectomy (RAPN) should be largely determined by tumor location (1) with anterior and lateral tumors approached through a transperitoneal approach and posterior tumors by a retroperitoneal approach. However, due to the unfamiliarity of the retroperitoneal approach as well as the concerns for a limited working space, most urologists are still hesitant from performing a retroperitoneal RAPN even for posterior renal tumors (2). We have developed a novel approach that combines the benefits of an increased working space of the transperitoneal RAPN with improved tumor and hilar visualization of retroperitoneal RAPN for posterior tumors. In this hybrid approach, we start transperitoneally and then transition to a retroperitoneal viewing approach. This video highlights the important steps of this surgery with an index case utilizing benefits of the da Vinci Xi (Intuitive Surgical Inc., Sunnyvale, California, USA) robot. MethodsA total of 9 patients have undergone Trans to Retroperitoneal RAPN since June 2018. We start by positioning the patient on full flank position and flex the table to open up the space between 12th rib and iliac crest. Three 8 mm robotic ports are placed as per a standard Trans-peritoneal RAPN. 12 mm air seal port is used as the assistant port between the robotic ports 2 and 3. A fourth 8 mm robotic port is placed, after initial trans-peritoneal dissection into the retroperitoneal space, just lateral to the tip of the 12th rib. The camera is changed from arm 2 to arm 3 and arm 1 is used for medial kidney retraction with a prograsp forceps. Arms 2 and 3 house the fenestrated bipolar and the monopolar scissors respectively. Hilar clamping, tumor resection and renorrhaphy is completed from this approach. ResultsThe total duration of the surgery was 5 h and 19 min, and a significant amount of this time was spent on mobilization of the colon and initial trans-peritoneal dissection due to the excessive perinephric fat and dissection of the second and third order renal artery and vein branches. The clamp time was 20.5 min and no drains were left. She was discharged on POD 3 without any significant complications. Margins were negative, final path revealed clear cell Renal Cell Carcinoma, ISUP grade 1. ConclusionThe trans to retroperitoneal approach to RAPN can be an alternative approach to retroperitoneal RAPN for posterior renal tumors and can obviate the need for an open approach or even preclude a possible laparoscopic nephrectomy for those unfamiliar with the retroperitoneal approach.