Robot-assisted Laparoscopic Nephrectomy Research Articles

Robot-assisted laparoscopic nephrectomy: early outcome measures with the implementation of multimodal analgesia and intrathecal morphine via the acute pain service

PurposeThe objective of this study was to perform a retrospective cohort analysis, in which we measured the association of an acute pain service (APS)-driven multimodal analgesia protocol that included preoperative intrathecal morphine (ITM) compared to historic controls (i.e., surgeon-driven analgesia protocol without ITM) with postoperative opioid use.MethodsThis was a retrospective cohort study in which the primary objective was to determine whether there was a decrease in median 24-h opioid consumption (intravenous morphine equivalents [MEQ]) among robotic nephrectomy patients whose pain was managed by the surgical team prior to the APS, versus pain managed by APS. Secondary outcomes included opioid consumption during the 24–48 h and 48–72 h period and hospital length of stay. To create matched cohorts, we performed 1:1 (APS:non-APS) propensity score matching. Due to the cohorts occurring at the different time periods, we performed a segmented regression analysis of an interrupted time series.ResultsThere were 76 patients in the propensity-matched cohorts, in which 38 (50.0%) were in the APS cohort. The median difference in 24-h opioid consumption in the pre-APS versus APS cohort was 23.0 mg [95% CI 15.0, 31.0] (p < 0.0001), in favor of APS. There were no differences in the secondary outcomes. On segmented regression, there was a statistically significant drop in 24-h opioid consumption in the APS cohort versus pre-APS cohort (p = 0.005).ConclusionsThe implementation of an APS-driven multimodal analgesia protocol with ITM demonstrated a beneficial association with postoperative 24-h opioid consumption following robot-assisted nephrectomy.

Analgesic effect of the ultrasound-guided thoracolumbar paravertebral block in patients undergoing robot-assisted laparoscopic nephrectomy: a randomized controlled trial.

Paravertebral block has similar effect as epidural anesthesia, and has good somatic and visceral analgesic effect. Paravertebral block is widely used in thoracic surgery, but rarely used in abdominal surgery. This study aimed to evaluate the analgesic effect of thoracolumbar paravertebral block in patients undergoing robot-assisted laparoscopic nephrectomy. One hundred patients undergoing elective robot-assisted laparoscopic nephrectomy were included in this study. Based on whether the thoracolumbar paravertebral block was performed, the patients were randomly divided into the thoracolumbar paravertebral block combined with general anesthesia group (TL-PVB group) and simple general anesthesia group (NO-PVB group). Oxycodone was administered for patient-controlled intravenous analgesia (PCIA). The primary outcomes included the amount of remifentanil used during surgery, the amount of oxycodone used in 24 and 48h after surgery. Secondary outcomes included the changes of heart rate (HR) and mean arterial pressure (MAP), time for the first analgesia administration, visual analog score (VAS) of pain during rest and movement, and time of postoperative recovery. Compared to the NO-PVB group, the amount of remifentanil used during surgery in patients with TL-PVB group was significantly reduced (1.78 ± 0.37mg vs. 3.09 ± 0.48 mg, p < 0.001), the amount of oxycodone used 24h after surgery was significantly reduced (8.70 ± 1.70mg vs. 13.79 ± 2.74 mg, p < 0.001), and the amount of oxycodone used 48h after surgery was remarkably reduced (21.83 ± 4.28mg vs. 27.27 ± 4.76 mg, p < 0.001). There were significant differences in the changes of HR and MAP between the two groups (p < 0.001). The first analgesic requirement time of TL-PVB group was significantly longer than that of NO-PVB group (468.56 ± 169.60min vs. 113.48 ± 37.26min, p < 0.001). The postoperative VAS during rest and movement of TL-PVB group were significantly lower than that of NO-PVB group (p < 0.01). Compared with NO-PVB group, patients in TL-PVB group needed shorter time to awaken from anesthesia, leave the operating room, anal exhaust, get out of bed, and had shorter length of postoperative hospital stay (p < 0.001). The incidence of postoperative adverse reactions were lower in the TL-PVB group than that in the NO-PVB group (p < 0.05). Ultrasound-guided thoracolumbar paravertebral block significantly reduces intraoperative and postoperative opioid consumption, and provides better analgesia in patients undergoing robot-assisted laparoscopic nephrectomy, which is a recommendable combined anesthesia technique. ChiCTR2200061326, 21/06/2022.

558 Comparison of Length of Post-Operative Hospital Stay Following Robot-Assisted Laparoscopic Nephrectomies with Traditional Laparoscopic Nephrectomies: A Single-Centre Retrospective Study

Abstract Aim The study aims to compare the length of post-operative hospital stay following robot-assisted laparoscopic (RAL) nephrectomies with stays following traditional laparoscopic (LAP) nephrectomies at a district general hospital. Method This study retrospectively compares the post-operative length of hospital stay using information documented on patient’s paper notes scanned onto an online system. Between January 2021 and December 2021, 25 patients underwent LAP nephrectomies in this unit. Following the introduction of RAL at our unit, all patients requiring a nephrectomy had this procedure done using RAL. Between January 2022 to November 2022, 33 patients underwent a RAL, 3 of which required conversion to open and excluded from this study. Additionally, data on age, BMI, tumour size and ASA score was collected to identify any evidence of systemic bias. Results Mean post LAP hospital stay was 3.60 (±3.24) nights, while post RAL was shorter at 2.07 (±1.44) nights to a statistically significant degree (p-value = 0.0357). There was no significant difference in any of the demographic factors between the two groups (LAP and RAL). When including data for partial nephrectomies (n = 20; LAP = 11, RAL = 9) and pyeloplasties (n = 9; LAP = 5, RAL = 4), length of post-operation hospital stay was still significantly shorter for patients who had undergone robot-assisted laparoscopy. Mean post-LAP hospital stay was 3.56 (±2.62) nights, while post-RAL was shorter at 2.21 (±1.68) nights to a statistically significant degree (p-value = 0.00666). Conclusions The use of robot-assistance during laparoscopic nephrectomies was associated with significantly shorter post-operative hospital stays over traditional laparoscopic procedures in this cohort of patients.

ThTP6.2 Comparison of length of post-operative hospital stay following robot-assisted laparoscopic nephrectomies with traditional laparoscopic nephrectomies: a single-centre retrospective study

Abstract Aim The study aims to compare the length of post-operative hospital stay following robot-assisted laparoscopic (RAL) nephrectomies with stays following traditional laparoscopic (LAP) nephrectomies at a district general hospital. Method This study retrospectively compares the post-operative length of hospital stay using information documented on patient’s paper notes scanned onto an online system. Between January 2021 and December 2021, 25 patients underwent LAP nephrectomies in this unit. Following the introduction of RAL at our unit, all patients requiring a nephrectomy had this procedure done using RAL. Between January 2022 to November 2022, 33 patients underwent a RAL, 3 of which required conversion to open and excluded from this study. Additionally, data on age, BMI, tumour size and ASA score was collected to identify any evidence of systemic bias. Results Mean post LAP hospital stay was 3.60 (±3.24) nights, while post RAL was shorter at 2.07 (±1.44) nights to a statistically significant degree (p-value=0.0357). There was no significant difference in any of the demographic factors between the two groups (LAP and RAL). When including data for partial nephrectomies (n=20; LAP=11, RAL=9) and pyeloplasties (n=9; LAP=5, RAL=4), length of post-operation hospital stay was still significantly shorter for patients who had undergone robot-assisted laparoscopy. Mean post-LAP hospital stay was 3.56 (±2.62) nights, while post-RAL was shorter at 2.21 (±1.68) nights to a statistically significant degree (p-value=0.00666). Conclusions The use of robot-assistance during laparoscopic nephrectomies was associated with significantly shorter post-operative hospital stays over traditional laparoscopic procedures in this cohort of patients.

ANESTHETIC MANAGEMENT OF A PATIENT UNDERGOING ROBOTIC ASSISTED LAPAROSCOPIC NEPHRECTOMY FOR NON-FUNCTIONING LEFT KIDNEY.

Robotic assisted laparoscopic surgeries are a recent advancement in minimal access surgeries that guarantee faster recovery and minimal life altering choices to the patients. However, the advent of robotic laparoscopic surgeries has placed and increasing amount of responsibility on the anaesthesiologist to maintain intra-operative stability as robotic procedures have a unique set of general consideration and their own plethora of physiological changes in the patient. This case repost describes the anaesthetic management of a 57-year-old Female patient who underwent Robotic assisted laparoscopic nephrectomy of a non-functioning left kidney

V03-10 ACUTE HEMORRHAGE MANAGEMENT SIMULATOR

You have accessJournal of UrologyCME1 Apr 2023V03-10 ACUTE HEMORRHAGE MANAGEMENT SIMULATOR Michael Kheshvadjian, Michael Nazmifar, Peris Castaneda, Eman Dadashian, Jeremiah Dallmer, John Heard, Eric Lo, Aurash Naser-Tavakolian, and Michael Ahdoot Michael KheshvadjianMichael Kheshvadjian More articles by this author , Michael NazmifarMichael Nazmifar More articles by this author , Peris CastanedaPeris Castaneda More articles by this author , Eman DadashianEman Dadashian More articles by this author , Jeremiah DallmerJeremiah Dallmer More articles by this author , John HeardJohn Heard More articles by this author , Eric LoEric Lo More articles by this author , Aurash Naser-TavakolianAurash Naser-Tavakolian More articles by this author , and Michael AhdootMichael Ahdoot More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although encountering a major vascular injury such as the partial transection of a renal artery during robot-assisted laparoscopic nephrectomy is rare, when it does occur, the consequences can be devastating. Practice resources and fully immersive simulations are primarily virtual in nature and difficult to access. We sought to create a hands-on training simulation designed to train medical residents on the management of acute hemorrhage during robot-assisted laparoscopic nephrectomy. METHODS: We placed a submersible utility pump into a receptacle containing 5L of artificial blood made from corn starch, water and red dye. The pump was then connected to a pressure gauge and flow control valve to accurately set a flow rate of 1 L/min. The artificial blood was pumped through the closed-loop system via a series of silicone tubes attached to an artificial vessel with the dimensions of an average renal artery. The artificial vessel was then placed in an artificial terrain made from flour, water, and silicone rubber to emulate the pliability of organic tissue. This apparatus was then placed in a basin that fit within the Intuitive abdominal dome trainer, allowing for the robot arms of the da Vinci surgical system to dock. RESULTS: The machine pump was able to maintain a flow rate of 1 L/min, and the system was able to reproducibly simulate a major vascular injury without complications. The concavity of the artificial terrain allows for the pooling of blood, simulating the realistic challenge of maintaining visualization during acute hemorrhage, while the collateral flow effectively simulates back-bleeding after vascular clamping. CONCLUSIONS: Our simulation proved to be successful in simulating a realistic environment for trainees to practice their skills in managing acute hemorrhage. This simulation is not only a training tool for medical residents to practice, but also allows attending physicians to assess their trainee’s skill level and provide feedback on critical decision-making during crisis, and communication skills. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e248 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Kheshvadjian More articles by this author Michael Nazmifar More articles by this author Peris Castaneda More articles by this author Eman Dadashian More articles by this author Jeremiah Dallmer More articles by this author John Heard More articles by this author Eric Lo More articles by this author Aurash Naser-Tavakolian More articles by this author Michael Ahdoot More articles by this author Expand All Advertisement PDF downloadLoading ...

The effect of hyperoxia on ventilation during recovery from general anesthesia: A randomized pilot study for a parallel randomized controlled trial

Study objectiveWhile supplemental O2 inhalation corrects hypoxemia, its effect on post-anesthesia ventilation remains unknown. This pilot trial tested the hypothesis that hyperoxia increases the time spent with a transcutaneous PCO2 (TcPCO2) > 45 mmHg, compared with standard O2 supplementation. DesignSingle-blinded, parallel two-arm randomized pilot trial. SettingUniversity hospital. Patients20 patients undergoing robotic-assisted laparoscopic nephrectomy. MeasurementsAfter institutional approval and informed consent, patients were randomized to receive O2 titrated to arterial saturation (SpO2): 90–94% (Conservative O2, N =10), or to SpO2 > 96% (Liberal O2, N = 10) for up to 90 min after anesthesia. Continuous TcPCO2, respiratory inductance plethysmography (RIP), and SpO2, were recorded. We calculated the percentage of time at TcPCO2 > 45 mmHg for each patient and compared the two groups using analysis of covariance, adjusting for sex, age, and body mass index. We also estimated the sample size required to detect the between-group difference observed in this pilot trial. RIP signals were used to calculate apnea/hypopnea index (AHI), which was then compared between two groups. Main resultsThe mean percentage of time with a TcPCO2 > 45 mmHg was 80.6% for the Conservative O2 (N=9) and 61.2% for the Liberal O2 (N=10) group [between-group difference of 19.4% (95% CI: −18.7% to 57.6%), P = 0.140]. With an observed effect size of 0.73, we estimated that 30 participants per group are required, to demonstrate this difference with a power of 80% at a two-sided alpha of 5%. Means SpO2 were 94.5% and 99.9% for the Conservative O2 and the Liberal O2 groups, respectively. AHI was significantly higher in the Conservative O2, compared with the Liberal O2 group (median AHI: 16 vs. 3; P = 0.0014). ConclusionsHyperoxia in the post-anesthesia period reduced the time spent at TcPCO2 > 45 mmHg and significantly decreased AHI, while mean SpO2 ranged inside the a priori defined limits. Trial registrationClinicalTrials.gov identifier: NCT04723433

Cost Implications of Routine Preoperative Blood Typing and Crossmatching Prior to Robot-Assisted Laparoscopic Partial Nephrectomy.

The surgical treatment of small renal masses has shifted from open to minimally invasive approaches. Preoperative blood typing and product orders often mirror the practices of the open era. We aim to define the rate of transfusion after robot-assisted partial laparoscopic nephrectomy (RAPN) at an academic medical center and the costs associated with current practice. A retrospective review of an institutional database was utilized to identify patients who underwent RAPN and transfusion of blood products. Patient, tumor and operative variables were identified. From 2008 to 2021, 804 patients underwent RAPN, with 9 (1.1%) patients requiring a transfusion. Comparison of the transfused group with nontransfused patients yielded a significant difference in mean operative blood loss (527.8 ml vs 162.5 ml, p <0.0001), R.E.N.A.L. (for radius, exophytic/endophytic, nearness of tumor to collecting system, anterior/posterior, location relative to polar line) nephrometry score (7.1 vs 5.9, p <0.05), hemoglobin (11.3 gm/dl vs 13.9 gm/dl, p <0.05) and hematocrit (34.2% vs 41.4%, p <0.05). The variables associated with transfusion on univariate analysis were examined for predictive capacity using logistic regression. Operative blood loss (p <0.05), nephrometry score (p=0.05), hemoglobin (p <0.05) and hematocrit (p <0.05) remained associated with a transfusion. The hospital charge for blood typing and crossmatching was $1,320 USD per patient. With the maturity of RAPN techniques and outcomes, the extent of preoperative testing related to blood products should evolve to better reflect current procedural risks. Prioritizing testing resources for patients at increased complication risk can be based on predictive factors.

Comparison of Postoperative Renal Function between Non-Steroidal Anti-Inflammatory Drug and Opioids for Patient-Controlled Analgesia after Laparoscopic Nephrectomy: A Retrospective Cohort Study.

Non-steroidal anti-inflammatory drugs (NSAIDs) can be used as opioid alternatives for patient-controlled analgesia (PCA). However, their use after nephrectomy has raised concerns regarding possible nephrotoxicity. This study compared postoperative renal function and postoperative outcomes between patients using NSAID and patients using opioids for PCA in nephrectomy. In this retrospective observational study, records were reviewed for 913 patients who underwent laparoscopic or robot-assisted laparoscopic nephrectomy from 2015 to 2017. After propensity score matching, 247 patients per group were analyzed. Glomerular filtration rate (GFR) percentages (postoperative value divided by preoperative value), blood urea nitrogen (BUN)/creatinine ratios, and serum creatinine percentages were compared at 2 weeks, 6 months, and 1 year after surgery between users of NSAID and users of opioids for PCA. Additionally, postoperative complication rates, postoperative acute kidney injury (AKI) incidences, postoperative pain scores, and lengths of hospital stay were compared between groups. Postoperative GFR percentages, BUN/creatinine ratios, and serum creatinine percentages were similar between the two groups. There were no significant differences in the rates of postoperative complications, incidences of AKI, and pain scores at 30 min, 6 h, 48 h, or 7 days postoperatively. The length of hospital stay was significantly shorter in the NSAID group than in the opioid group. This study showed no association between the use of NSAID for PCA after laparoscopic nephrectomy and the incidence of postoperative renal dysfunction.

Nefrectomia simple laparoscópica robot asistida con extracción de pieza transvaginal. Reporte de caso

Objetivo: Minimizar la morbilidad en la nefrectomía laparoscópica robot asistida con la extracción de la pieza por orificios naturales, asi como estandarizar la técnica quirúrgica laparoscópica robot asistida con extracción de pieza transvaginal a fin de identificar los pasos críticos y posibles complicaciones de este abordaje.&#x0D; Materiales y métodos: Se trata de una paciente femenina de la cuarta década de la vida, multípara, con antecedente de infección de vías urinarias recurrentes, secundaria a hipoplasia renal derecha, documentando la exclusión renal funcional mediante gamagrama renal, se propuso el manejo mediante técnica quirúrgica tradicional, realizando abordaje transperitoneal laparoscópico robot asistido, con el uso de 2 trocares robóticos, un trocar accesorio abdominal y un trocar transvaginal.&#x0D; Resultados: Se utilizaron 2 trocares robóticos, un trocar accesorio en el fondo de saco de Douglas y uno abdominal, con un tiempo operatorio de 45 minutos posterior al acoplamiento robot-paciente, con un sangrado transoperatorio cuantificado en 30 ml. El tiempo de estancia hospitalaria fue de 2 días, con un tiempo promedio de uso de analgésicos de 5 días; en el post operatorio mediato la paciente presentó como complicación la presencia de infección de vías urinarias que ameritó tratamiento mediante antibioticoterapia, sin otras complicaciones.&#x0D; Conclusiones: El abordaje laparoscópico robot asistido con la utilización de orificios naturales para la extracción de la pieza quirúrgica, reduce el costo y la morbilidad trans y post operatoria de las pacientes sometidas a este tipo de abordaje, así mismo reduce el tiempo quirúrgico, el sangrado transoperatorio, la estancia hospitalaria y el uso de analgésicos.

Néphrectomie laparoscopique assistée par robot dans le cadre du donneur-vivant : étude chez les donneurs et les receveurs à partir de 155 cas

To evaluate morbidity and renal function of the donor and recipient during a robotic-assisted laparoscopic nephrectomy procedure. It is a retrospective study of 155 consecutive patients by robot-assisted laparoscopy in the living donor. Mean operating time, warm ischemia time, blood loss, complications according to the Clavien classification and evolution of creatinine clearance were analyzed in the donors. Recovery of graft function, complications and changes in creatinine clearance were observed in recipients. The mean operating time was 176 (±23) minutes. The mean warm ischemia time was 4.8 (±0.6) minutes. Twenty seven complications were noted. The loss of renal function was 19% at 5 years in donors. Renal recovery was immediate for 153 recipients. Two were delayed due to sepsis. Two patients lost their graft at 15 and 18 months. Seventeen complications have been identified. The mean kidney function of the recipients is measured at 63ml/min at 5 years. Robotic-assisted laparoscopic nephrectomy procedure appears to provide the donor with low morbidity and a moderate decrease in creatinine clearance at 19% at 5 years. Morbidity is also low in recipients with very satisfactory 5-year mean renal function. The technique should promote donation. 4.

Robotic-assisted Laparoscopic Nephrectomy with Vein Thrombectomy: Initial Experience and Outcomes from a Single Surgeon.

This study was designed to explore the safety and feasibility of robotic-assisted laparoscopic nephrectomy with vein thrombectomy (RAL-NVT) for the treatment of renal cell carcinoma (RCC) with venous tumor thrombus (VTT). Clinical data of 6 patients treated with RAL-NVT between July 2016 and November 2017 in our hospital were retrospectively collected and analyzed. There were 5 males and 1 female with their age ranging from 48 years to 68 years. Five renal tumors were right-sided and one left-sided. Three cases fell in level 0 VTT, one in level I and two in level II. Preoperative imaging revealed lymph node involvement in 1 case and distant metastasis in 2 cases. For RCC with level 0 VTT, the renal vein of the affected side was adequately and carefully dissected around the thrombus to the proximity of inferior vena cava (IVC) and was ligated with Hem-o-loks without cross-clamping the IVC. For level I and II VTT, the IVC was crossclamped cephalically and caudally around the tumor thrombus and all tributaries were sequentially blocked to ensure the safe retrieval of VTT. All operations were successfully completed without conversion to open operation. The mean operative time was 150 (115-230) min. Cross-clamping of the IVC happened in 3 cases, and the blocking time was 14, 19 and 20 min, respectively. The mean estimated blood loss during the operation was 400 (200-580) mL. The peritoneal drainage tube was removed 5 to 9 days after the operation, and all patients were postoperatively discharged at 6 to 11 days. Postoperative pathological analysis confirmed that the RCCs were comprised of 4 clear cell RCCs, 1 papillary cell RCC, and 1 medullary cell RCC; 2 cases were Fuhrman grade II, 3 cases grade III, and 1 case undefined grade. No recurrence or progression was observed during the follow-up of 4.2 (3-6) months. We concluded that RAL-NVT is highly challenging but safe and feasible for the treatment of RCC with VTT.

Radical robot-assisted laparoscopic nephrectomy with thrombectomy in the vena cava

BackgroundRenal cell carcinoma has a natural tendency to extend through the renal vein. When the thrombus reaches the vena cava, thrombectomy and the necessary reconstruction of the vena cava are typically performed by open pathway. Robot-assisted technology provides advantages for performing this complex technique, using a minimally invasive access. Material and methodsWe present the technique we employed in the first case performed in our department. After performing renal artery embolization, we conducted the surgery with the Vinci S robotic system. The main steps of the surgery are as follows: detachment and Kocher maneuver; release of the lower renal pole; clamping and sectioning of the renal artery; endocavitary ultrasound to locate the thrombus; placement of tourniquets in the vena cava below and above the renal veins and in the left renal vein; closure of the 3 tourniquets; opening of the vena cava; resection and extraction of the thrombus; suture of the vena cava; opening of the tourniquets; complete release of the kidney; bagging and extraction of the specimen. ResultsThe surgery was performed without complications. The patient required a transfusion of 2 units of packed red blood cells and was discharged with modest renal failure (creatinine level of 1.60mg/dl). ConclusionsRadical nephrectomy with thrombectomy in the vena cava is a technique susceptible to severe complications and has, to date, been performed in few centers. We believe that the technique is reproducible and has clear advantages for our patients.

Our experiences with robot- assisted laparoscopic surgery in pediatric patients: the first case series from Turkey.

Robotic surgery is a leading treatment option for minimally invasive surgery and has an increasing popularity in pediatric population, as well. In this article, we reported our case series of robot-assisted laparoscopic surgery in pediatric population. We retrospectively reviewed 29 consecutive pediatric patients who underwent robot- assisted procedures between May 2014 and October 2016. Patient demographics, hospitalization time, estimated blood loss, robotic time and total operative and peri-, and post-operative complications were evaluated. A total of 24 ureter units (18 patients) with grade 1-5 vesicoureteral reflux in 13 female and 5 male, 1 male patient with vesicoureteral stenosis were underwent robot- assisted laparoscopic ureteral reimplantation (RALUR). All patients had complete resolution after surgery. Robot-assisted laparoscopic pyeloplasty (RALP) was performed in 6 patients with ureteropelvic junction obstruction. All patients had complete resolution after surgery. Completely intracorporeal robotic assisted laparoscopic augmentation ileocystoplasty (RLAIC) was applied to two patients with neurogenic bladder. The symptoms and preoperative hydronephrosis were regressed on the first month of follow-up. Robot-assisted laparoscopic reduction cystoplasty (RALRC) was performed in 14-year-old boy with a bladder diverticula and recurrent urinary tract infection. The last case was eleven- year-old female patient with non-functioning kidney. She had recurrent urinary tract infections and was treated with robotic assisted laparoscopic nephrectomy (RALN). Robot-assisted laparoscopic surgery is safe and efficient in pediatric population. Although open surgery is still the gold standard for many pediatric diseases, inherent reconstructive advantages of robotic assisted laparoscopy have a chance to change this view.

Outcomes of Robotic Nephrectomy Including Highest-complexity Cases: Largest Series to Date and Literature Review

To review the outcomes of robot-assisted laparoscopic nephrectomy (RALN) after 101 consecutive cases, the largest reported series to date. The benefit of adding robotic technology to laparoscopic nephrectomy is unclear and controversial. We used robotics for nephrectomy routinely, including for simpler cases rather than laparoscopy, as well as for the most complex nephrectomies rather than open surgery. We reviewed a prospective database of 101 consecutive nephrectomy procedures by a single surgeon (R.A.). All were initiated as RALN regardless of complexity. Patient characteristics and outcomes were reviewed, including tumor complexity, conversion rate, transfusions, length of stay, and complications. Mean age was 60 years (19-86 years), and mean body mass index was 31 kg/m(2) (16-54 kg/m(2)). Ninety patients had tumors with mean size of 8.2 cm (2.2-25.8 cm). Eighty were malignant, including 31 pT3a tumors (39%), with 9 renal vein thrombi. Eight malignancies had caval tumor thrombi (10%). Local invasion required 1 bowel resection, 1 partial hepatectomy, and 1 distal pancreatectomy, all performed robotically with no conversions to open surgery. Ipsilateral retroperitoneal lymphadenectomy was performed in 40 patients removing 13.7 nodes (4-36). Mean operative time and blood loss were 172 minutes (57-411 minutes) and 67 mL (10-400 mL) with only 1 transfusion (1%). Mean length of stay was 1.1 days (0-7 days), with 94% discharged by postoperative day 1. Clavien grade III-IV complications occurred in 5% without deaths. Robotic nephrectomy allows for consistent outcomes regardless of procedure complexity. Completion of procedures without need for open conversion was possible even in the most complex procedures, including those with vascular and contiguous organ invasion.

Surgical outcomes of robot-assisted nephrectomy for living-donor kidney transplantation in 12 cases

Objective To summarize the surgical experience about the robot-assisted laparoscopic nephrectomy for living-donor kidney transplantation,as well as its efficacy and safety.Methods From September 2013 to January 2014,the clinical data of 2 male and 10 female patients who were underwent robot-assisted nephrectomy for living-donor kidney transplantation in our hospital were analyzed.The mean age in those patients were 47 years old (range 38 to 60 years old).11 underwent a left nephrectomy and the 12th patient underwent a right nephrectomy.As to the receptor,all of them,including 8 male and 4 female patients,were suffered from the uremia due to the chronic glomerulonephritis.The mean age in those receptors were 26 years old (range 20 to 36 years old).The duration of hemodialysis in those patients ranged from 8 to 25 months (mean 14 months).Their transplanted kidneys were all donated from their parents.Operative time,bleeding volume,warm ischemia time,length of vein and artery preservation,surgical related complication and changing of renal function in donor were analyzed.Results All patients underwent totally robotic nephrectomy without open procedure conversion.The median console time was 140 minutes (range 110-195 min).Median intraoperative bleeding was 50 ml (range 30-120 ml).The median warm ischemia time was 170 s (range 100-280 s).The median length of vein preservation was 2.4 cm (range 1.9-3.0 cm) and 1.8 cm (range 1.4-2.3 cm) for artery.Spleen injuries occurred in two cases whcn the kidney was takcn out and splenorrhaphy was performed.The hospital stay of all donors was 5 days.None of the transplant recipients developed delayed graft functional recovery.Conclusions Robot-assisted laparoscopic nephrectomy is a safe,reliable,minimal invasive and effective procedure for living-donor kidney transplantation.More attention,however,should be paid to the spleen when the left kidney is taken out. Key words: Laparoscopic donor nephrectomy; Robotic surgery; surgical procedures; Renal transplantation

Robotic radical nephrectomy for renal cell carcinoma: a systematic review.

BackgroundLaparoscopic radical nephrectomy (LRN) is the actual gold-standard for the treatment of clinically localized renal cell carcinoma (RCC) (cT1-2 with no indications for nephron-sparing surgery). Limited evidence is currently available on the role of robotics in the field of radical nephrectomy. The aim of the current study was to provide a systematic review of the current evidence on the role of robotic radical nephrectomy (RRN) and to analyze the comparative studies between RRN and open nephrectomy (ON)/LRN.MethodsA Medline search was performed between 2000–2013 with the terms “robotic radical nephrectomy”, “robot-assisted laparoscopic nephrectomy”, “radical nephrectomy”. Six RRN case-series and four comparative studies between RRN and (ON)/pure or hand-assisted LRN were identified.ResultsCurrent literature produces a low level of evidence for RRN in the treatment of RCC, with only one prospective study available. Mean operative time (OT) ranges between 127.8-345 min, mean estimated blood loss (EBL) ranges between 100–273.6 ml, and mean hospital stay (HS) ranges between 1.2-4.3 days. The comparison between RRN and LRN showed no differences in the evaluated outcomes except for a longer OT for RRN as evidenced in two studies. Significantly higher direct costs and costs of the disposable instruments were also observed for RRN. The comparison between RRN and ON showed that ON is characterized by shorter OT but higher EBL, higher need of postoperative analgesics and longer HS.ConclusionsNo advantage of robotics over standard laparoscopy for the treatment of clinically localized RCC was evidenced. Promising preliminary results on oncologic efficacy of RRN have been published on the T3a-b disease. Fields of wider application of robotics should be researched where indications for open surgery still persist.

NEFRECTOMÍA ROBÓTICA DEL DONANTE VIVO PARA TRASPLANTE: PRIMER CASO EN LATINOAMÉRICA

Living robotic donor nephrectomy. The first case in Latin America Introduction: Living donor nephrectomy is the best alternative of treatment for patients with chronic renal disease. Even though open surgery remains the gold standard for donor nephrectomy, laparoscopic surgery has become a feasible alternative in referral centers. To minimize the long learning curve associated with this procedure, some centers have introduced robotic donor nephrectomy as a surgical option. Aim: To present the first robotic-assisted laparoscopic donor nephrectomy in Latin America. Clinical case: The donor is a 50 years old male, living-related to the recipient by affinity (husband/wife). The recipient is a 54 years old female with history of end-stage renal disease waiting to initiate dialysis program. A left transperitoneal robotic-assisted laparoscopic nephrectomy employing the da Vinci Si ® (Intuitive Surgical, Sunnyvale CA.) is performed. Mean operative time was 188 minutes with an estimated blood loss of 300 ml. Mean ischemia time was 6 minutes. The graft presented immediate function. Both patients were discharged at 72 h. Conclu- sion: Living donor robotic-assisted laparoscopic nephrectomy is a safe and viable procedure. Larger series are needed to establish its role.

Current controversies and challenges in robotic-assisted, laparoscopic, and open partial nephrectomies

Recent studies demonstrate that partial versus radical nephrectomy confers a survival advantage while lowering the risk of severe chronic kidney disease. Open partial nephrectomy remains the gold standard, but the use of minimally invasive approaches is expanding. Using a MEDLINE literature search, we reviewed all relevant literature between 2000 and 2014. Fifty-one articles were left for review after filtering for inclusion of trends, learning curve, perioperative outcomes, warm ischemia time, and costs. Partial nephrectomy use has increased over the past decade accounting for 24.7 % of all surgeries performed for the treatment of organ-confined renal masses in 2008. The introduction of robotic technology has continued to alter the landscape accounting for 47 % of all partial nephrectomies at academic US centers in 2011, though a center bias and publication bias likely exist. A slower adoption rate has been seen at non-academic centers and those in low-income areas. The learning curve for robotic-assisted laparoscopic nephrectomy has been shorter than for laparoscopic partial nephrectomy, explaining, in part, why the rate of partial nephrectomy remained relatively stagnant before the robotic-assisted laparoscopic nephrectomy, despite an increase in the detection of small renal masses. Operative and warm ischemia time remain shortest for open partial nephrectomy, though it is associated with the highest blood loss and longest hospital stay. Finally, open partial nephrectomy remains the least costly modality. Each approach to partial nephrectomy has its advantages and disadvantages, and continued effort must be applied to comparative effectiveness research for nephron-sparing treatments for renal cell carcinoma.

Robotic-assisted laparoscopic nephrectomy (right) combined with inferior vena caval thrombectomy for level Ⅱ tumor thrombus：the first clinical case in China

Objective To report the first clinical case of robotic-assisted laparoscopic nephrectomy(right)combined with inferior vena caval thrombectomy for levelⅡtumor thrombus in China.Methods A 73-year-old female patient presented with"gross hematuria and flank discomfort for 4 months"was admitted to our hospital.Preoperative CT scans revealed a 4.9cm×4.7cm right renal cancer,grossly extending into the inferior vena cava(IVC,length of the IVC tumor thrombus:4.6cm).After three months of neoadjuvant targeted molecular therapies(TKIs),the tumor size reduced to 4.3cm×4.4cm on CT and the IVC tumor thrombus length reduced to 3.3cm.IVC filter was placed cephalad 2 days before surgery under DSA intervention.The patient was placed in recumbent position during the operation;a 12-mm optical port was placed to the right of the rectus abdominis at 2cm above the umbilicus.Two 8-mm robotic ports and three 12-mm assistant ports were placed percutaneously under direct visualization through a stab incision.The robotic system was then docked,with the colon reflected medially and the duodenum kocherized.The IVC sheath was opened,and the IVC was dissected circumferentially above and below the insertion of the right renal vein to the extent dictated by the length of the thrombus.With the right renal artery dissected and transected,the vessel loops were used to create modified-Rummel tourniquets.The vena cava below and above tumor thrombus,and the left renal vein were cross-clamped.With the vessel loops cinched down completely and secured by hem-o-lok clips,the wall of the IVC was then incised longitudinally for approximately 5cm.The tumor thrombus was delivered intact along with the invaded IVC wall.The IVC was closed and tourniquet was loosened.After adequate hemostasis was achieved,the specimen was placed into an entrapment sac and incisions were closed by layers.Results The procedure was smoothly completed.The total operating time was 363min and the total IVC cross-clamp time was 47min.The estimated blood loss was 1 200mL.The amount of intraoperative transfusion was 1 200mL and 1 000mL postoperative blood transfusion was required for a low level of hemoglobin.The bowel function recovered at day 3 after operation and drainage was maintained for 3 days.The patient was discharged 16 days after operation.Conclusion We successfully completed the first clinical case of robotic-assisted laparoscopic nephrectomy combined with inferior vena caval thrombectomy for levelⅡ tumor thrombus in China;it is a safe and feasible procedure,but has great technical difficulty,so the patients should be chosen with great care.