Robot-assisted Nephron-sparing Surgery Research Articles

Renal artery pseudoaneurysm following robot assisted nephron sparing surgery: two case reports

BackgroundRenal artery pseudoaneurysm following partial nephrectomy is a rare entity, the incidence of this entity is more common following penetrating abdominal injuries, percutaneous renal interventions such as percutaneous nephrostomy(PCN) or Percutaneous nephrolithotomy (PCNL). Although rare, renal artery pseudoaneurysm can be life threatening if not managed timely, they usually present within two weeks postoperatively with usual presenting complains being gross haematuria, flank pain and/or anaemia.Case presentationWe report case of two female patients 34 and 57 year old respectively of South Asian ethnicity, presenting with renal artery pseudoaneurysm following left sided robot assisted nephron sparing surgery for interpolar masses presenting clinically with total, painless, gross haematuria with clots within fifteen days postoperatively and their successful treatment by digital subtraction angiography and coil embolization.ConclusionRenal artery aneurysm is a rare fatal complication of minimally invasive nephron sparing surgery however considering the preoperative and intraoperative risk factors for its development and prompt suspicion at the outset can be life saving with coil embolization of the bleeding arterial aneurysm.

The initial experience of robot-assisted nephron-sparing surgery in patients with renal cell cancer

Purpose of the study: analysis of our experience in performing robotic-assisted nephron-sparing surgeries using the da robotic system. Material and Methods. The retrospective study included the first 37 consecutive patients who underwent robot-assisted partial nephrectomy from May 2020 to december 2022. Results. To assess the surgical outcomes in patients undergoing partial nephrectomy, three parameters associated with trifecta achievement were analyzed. The trifecta was assessed according to the standard criteria, whereas the quadfecta, which in addition to the trifecta included preservation of >90 % of the glomerular filtration rate (calculated according to Cockroft–Gault) in the postoperative period (3–7 days), did not assess the stage of chronic renal failure one year after surgery, thus probably demonstrating the high percentage of its achievement (54.1 %). A positive surgical margin was observed in 1 (2.7 %) patients. Warm ischemia time of more than 25 minutes was used in 8 patients (21.6 %). Complications in the postoperative period (Clavien–dindo II and higher) were observed in 1 (2.7 %) patient. Trifecta and quadfecta rates were 78.4 % and 54.1 %, respectively. To analyze the surgeons’ experience, 37 renal cell cancer patients were divided into two subgroups with first 20 and subsequent robotic partial nephrectomies. There were no differences in gender, age and calculated RENAL value between 2 subgroups. depending on the surgeons’ experience, statistically significant differences in the duration of surgery (p=0.035) and blood loss during surgery (p=0.007) were found. Conclusion. Considering the extensive experience of surgeons in the field of laparoscopic surgery for tumors of the renal parenchyma, the outcomes of robotic partial nephrectomies performed in 37 patients seem to be satisfactory and successful. The accumulated experience of surgeons after 20 robotic-assisted nephron-sparing surgeries makes it possible to significantly reduce surgery time and blood loss. The technique of robotic-assisted partial nephrectomy requires further improvements.

Technologic advances in robot-assisted nephron sparing surgery: a narrative review.

Nephron sparing surgery (NSS) is the preferred management for clinical stage T1 (cT1) renal masses. In recent years, indications have expanded to larger and more complex renal tumors. In an effort to provide optimal patient outcomes, urologists strive to achieve the pentafecta when performing partial nephrectomy. This has led to the continuous technologic advancement and technique refinement including the use of augmented reality, ultrasound techniques, changes in surgical approach and reconstruction, uses of novel fluorescence marker guided imaging, and implementation of early recovery after surgery (ERAS) protocols. The aim of this narrative review is to provide an overview of the recent advances in pre-, intra-, and post-operative management and approaches to managing patients with renal masses undergoing NSS. We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010 to 2022 without limitation on study design. We included only full-text English articles published in peer-reviewed journals. Partial nephrectomy is currently prioritized for cT1a renal masses; however, indications have been expanding due to a greater understanding of anatomy and technologic advances. Recent studies have demonstrated that improvements in imaging techniques utilizing cross-sectional imaging with three-dimensional (3D) reconstruction, use of color doppler intraoperative ultrasound, and newer studies emerging using contrast enhanced ultrasound play important roles in certain subsets of patients. While indocyanine green administration is commonly used, novel fluorescence-guided imaging including folate receptor-targeting fluorescence molecules are being investigated to better delineate tumor-parenchyma margins. Augmented reality has a developing role in patient and surgical trainee education. While pre-and intra-operative imaging have shown to be promising, near infrared guided segmental and sub-segmental vessel clamping has yet to show significant benefit in patient outcomes. Studies regarding reconstructive techniques and replacement of reconstruction with sealing agents have a promising future. Finally, ERAS protocols have allowed earlier discharge of patients without increasing complications while improving cost burden. Advances in NSS have ranged from pre-operative imaging techniques to ERAS protocols Further prospective investigations are required to determine the impact of novel imaging, in-vivo fluorescence biomarker use, and reconstructive techniques on achieving the pentafecta of NSS.

Renal Mass with Renal Stones: A Challenging Scenario Managed with Robotic Assistance

Introduction: A renal mass with a concurrent stone is a complex challenge. The challenge is to tackle both pathologies using a single anesthetic without compromising the oncologic or renal functional outcomes. This video demonstrates two cases using robot-assisted nephron-sparing surgery (RA-NSS) and provides tips for effective management to maintain the oncologic and functional safety. Methods: Simultaneous RA-NSS with stone retrieval was performed with DaVinci SiHD system using three robotic arms in two cases after obtaining due consent as per our previously described technique.1 Case 1 was a 66-year-old man, whereas the second case was a 56-year-old woman. In Case 1, during resection of the tumor the renal stone was identified through the opening in the pelvicaliceal system (PCS), which was further extended and three stones were retrieved intact. For Case 2, after dissecting the hilum, the renal pelvic dissection was performed followed by a pyelotomy to retrieve the stones. This mimics a previous published technique by Garisto et al.2 The PCS was closed with 3-0 polygalactin sutures over a Double-J stent (DJS), in both cases. Results: The warm ischemia time (WIT) was 27 minutes in Case 1 and the renal hilum was not clamped in Case 2. The estimated blood loss was 800 and 200 mL and the length of hospital stay was 7 and 5 days for Cases 1 and 2, respectively. The histopathology report in both the cases was clear cell with negative margins. The DJS were removed at 4 weeks. No adjuvant treatment was offered in both the cases. Both the patients were recurrence free with normal renal function at a follow-up of >5 years. Conclusions: During RA-NSS the focus is to limit WIT and maintain the oncologic margins. In a situation where a renal stone is large and the tumor is close to PCS (index Case 1), the NSS is performed initially followed by an incision further into pelvis for stone extraction. However, when the stone is in the pelvis and the tumor is in the periphery (index Case 2), pyelolithotomy should be performed first followed by NSS to decrease or avert the WIT. Patient consent statement: Both the patients of this video submission gave full consent for recording the surgical procedure and its use for publication. The authors have received and archived patient consent for video recording/publication None of the authors have any competing financial interests. Runtime of video: 8 mins 10 secs

Application of Contrast-Enhanced Ultrasonography (CEUS) in the Assessment of Kidney Wound Recovery After Nephron-Sparing Surgery.

PurposeTo investigate feasibility, repeatability and usefulness of contrast-enhanced ultrasonography (CEUS) in the assessment of kidney wound recovery after laparoscopic nephron-sparing surgery (LNSS) or robot-assisted nephron-sparing surgery (RANSS) and preliminarily research the clinical factors associated with the length of extravasation (LOE).Patients and MethodsFrom April 2019 to January 2020, 130 patients that underwent LNSS or RANSS in our hospital were included, and 90 patients (90/130) received CEUS examinations each one day from the postoperative day 1. The discovery of the cessation of contrast medium extravasation from the renal wound was the primary endpoint named “ultrasonic healing”, and LOE ranged from the day of surgery to “ultrasonic healing”. Patient, tumor, perioperative factors and LOE were collected. Univariate analysis and multivariate linear regression analysis were applied for the determination of factors associated with LOE.ResultsThe average postoperative LOE was 1.76 days (standard deviation, 1.115; 95% confidence interval: 1.52–1.99). Ultrasonic healing within three days was observed in 95.6% patients (86/90). Univariable and multivariable analyses showed that R and A components in R.E.N.A.L. nephrometry score were associated with LOE. Anterior location and R component score of 2 (tumor size>4cm) were related to longer LOE than posterior location and R score of 1 (tumor size<4cm). The incidence of complications in patients with LOE over one day was higher than those with LOE of one day.ConclusionCEUS was feasible, repeatable and useful in the assessment of kidney wound recovery. Tumor size and location were related to LOE after minimally invasive nephron-sparing surgery (MINSS). Length of stay after MINSS within three days might be relatively safe.

3D-printed models and virtual reality as new tools for image-guided robot-assisted nephron-sparing surgery: a systematic review of the newest evidences.

Nowadays, kidney cancer surgery has been focusing on a patient-tailored management, expanding the indication to nephron-sparing surgery (NSS). Starting from computer tomography images, 3D models can be created, allowing a never experienced before understanding of surgical anatomy. Once obtained the models can be printed or virtually visualized with the aid to assist the surgeon in preoperative planning and simulation or intraoperative navigation. The aim of this systematic review is to assess the preoperative and intraoperative impact of 3D printed and virtual imaging for robotic NSS. Ten articles were found to meet the inclusion criteria and reviewed. An 'intermediate' score was assessed to the overall articles' quality. A moderate/high risk of bias was recorded for all the studies. 3D-printed models were considered to be more useful during both preoperative simulations and patients' counseling. These models guaranteed a better comprehension of anatomical structures and surgical procedure. Costs and quality of the materials available represent the two main limits of this developing technology.Instead, in a virtual reality setting the preoperative planning was enhanced by using 3D virtual models in a mixed reality environment. Intraoperatively, the possibility to overlap the 3D model to real anatomy allowed augmented reality procedures. This technology is still a 'newborn' and is constantly evolving, expanding day by day the range of its potential applications.

1058 - The influence of robot-assisted nephron sparing surgery on blood pressure of patients with hypertension: The preliminary results

1058 - The influence of robot-assisted nephron sparing surgery on blood pressure of patients with hypertension: The preliminary results

The application of renal sinus anatomy based tension-free reconstruction technique for robot-assisted nephron-sparing surgery of hilar tumors: a single center report and follow-up of 286 cases

Objective To describe our renal sinus anatomy based tension-free reconstruction step by step and report perioperative data and long-term outcomes of patients undergoing robot-assisted nephron-sparing surgery for hilar tumors. Methods From June 2013 to December 2016, data of 286 consecutive patients with hilar tumor who underwent RAPN in single center were retrospectively reviewed.There were 202 males and 84 females, aged(56.2±9.2)years.The body mass index was(26.8±3.5)kg/m2.The median diameter of tumor was 2.6 cm(0.8-6.0 cm), and R. E.N.A.L.score was 8.2±1.8. The anatomy-based Garland specialized in protecting the large hilar vessels and minimizing the tension of trans/retroperitoneal defect suturing approach for anterior/posterior lip hilar tumor respectively. Patient′s perioperative complications and long-term follow-up including renal function and oncological outcomes were analyzed. Results Garland technique was successfully applied in 284 patients, the warm ischemia time (WIT) was (18.2±4.1) min. Median estimated blood loss (EBL) for RAPN was 100 ml (range: 10-600 ml). Median operative time was 120 min (range: 60-230 min). No patient was converted to open surgery. Postoperative hospital stay was 4.0 d (range: 2.0-9.0 d). Three patients (1.1%) had positive surgical margins. Of all the pathological results, 260 cases (91.5%)were clear renal cell carcinoma, 8 cases (2.8%)were chromophobe renal carcinoma, 7 cases (2.5%)were papillary type renal cell carcinoma, 5 cases(1.8%) were oncocytoma, 3 cases (1.1%)were angiomyolipoma, one case (0.3%)was mucinous tubular and spindle cell carcinoma. Two patients underwent blood transfusion. Three patients(1.0%) had local recurrence.284 patients were alive at a median follow-up of 36 months (range: 12-54 months). Conclusions Garland technique is safe and feasible for hilar tumor resection and reconstruction with less surgical complications. Large renal vessel injury was avoided and tension of wound closure was minimized. The trans/retroperitoneal approaches are capable for anterior/posterior hilar tumor. Patients with hilar tumor could benefit from robotic surgery with a well preserved renal function and good oncological outcomes. Key words: Kidney neoplasms, renal hilum; Robot; Nephron-sparing surgery; Renal sinus anatomy; Kidney reconstruction

Needle in a haystack: lost in transition

A lost needle during minimally invasive surgery is a cause of undue anxiety to the entire surgical team and also causes prolongation of surgical time. There is no literature reporting follow-up of any patient with needle left behind as they are considered as a 'never event' during a surgical procedure. Preventing such events needs vigilance on part of the surgeon and assistant. Here, we report a case of lost needle during performance of a robot-assisted nephron sparing surgery. The robot needed to be de-docked and converted to laparoscopy. After a thorough search, the needle was found to be lodged at an unusual place. A brief review of available literature is also provided alongside.

Robot Assisted Nephron Sparing Surgery in a L-Shaped Fused Ectopic Pelvic Kidney: Reproducibility of the Procedure and Technical Considerations

Crossed fused ectopia of the kidneys is a rare anomaly and tumours arising in them are rarer still. We report a case of a renal cell carcinoma arising in an L shaped crossed fused ectopic kidney in a 38 year old man for whom a robot assisted nephron sparing surgery was done. Our report highlights the importance of preoperative contrast enhanced computerized tomography (CECT) with arterial 3D reconstruction for preoperative surgical planning and the use of daVinci robot (Intuitive Surgical Inc., Sunnyvale, CA, USA) in performing the heminephrectomy with utmost precision. We have earlier reported the use of the robot for heminephrectomy in a patient with chromophobe renal cell carcinoma in a crossed fused ectopic kidney and this report highlights the technical aspects of the surgical procedure and establishes the reproducibility of the same.

Anaesthetic management of a patient with Huntington's chorea undergoing robot-assisted nephron-sparing surgery.

Anaesthetic management of a patient with Huntington's chorea undergoing robot-assisted nephron-sparing surgery.

V5-04 RESECTABLE PHYSICAL 3-D MODELS UTILIZING 3-D PRINTER TECHNOLOGY FOR ROBOTIC PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: We constructed high fidelity individualized physical three-dimensional (3-D) models of renal units made with materials that approximate the properties of renal tissue to allow surgeons to use robotic platforms to resect the models prior to performing robot assisted nephron sparing surgery. METHODS: Specialized software was utilized to import patient’s diagnostic computerized tomography cross sectional imaging into 3-D printers and create physical 3-Dmodels of renal unitswith enhancing in situ lesions. Sterolithography additive manufacturing, a technique in which an ultraviolet laser is used to cure a photosensitive resin in sequential, horizontally oriented layers was employed to build the models (Medical Modeling Inc., Golden, CO). Two 3-D models were constructed using flexible materials, which maintained high fidelity but whose physical properties approximated renal tissue. Models were resected using the Da Vinci surgical platform prior to operating on the patient for surgical simulation. RESULTS: Both patients on whom the models were constructed successfully underwent partial nephrectomy. Average ischemic time was 21 minutes, nephrometry score was 6.8, and all margins were negative. Models themselves as well as the individualized surgical simulation they allowed were believed by surgeons to aid in identification, dissection and resection of renal lesions. CONCLUSIONS: Pre-operative resectable physical 3-D models can be constructed and used as individualized surgical simulation for improved outcomes of trainees and surgeons alike.

Do We Need to Clamp the Renal Hilum Liberally during the Initial Phase of the Learning Curve of Robot-Assisted Nephron-Sparing Surgery?

Objective. We aimed to compare the results of our initial robot-assisted nephron-sparing surgeries (RANSS) performed with or without hilar clamping. Material and Method. Charts of the initial RANSSs (n = 44), which were performed by a single surgeon, were retrospectively reviewed. R.E.N.A.L. nephrometry system, modified Clavien classification, and M.D.R.D. equation were used to record tumoral complexity, complications, and estimated glomerular filtration rate (eGFR), respectively. Outcomes of the clamped (group 1, n = 14) versus off-clamp (group 2, n = 30) RANSSs were compared. Results. The difference between the two groups was insignificant regarding mean patient age, mean tumor size, and mean R.E.N.A.L. nephrometry score. Mean operative time, mean estimated blood loss amount, and mean length of hospitalization were similar between groups. A total of 4 patients in each group suffered 11 Clavien grade ≥2 complications early postoperatively. Open conversion rates were similar. The difference between the 2 groups in terms of the mean postoperative change in eGFR was insignificant. We did not encounter any local recurrence after a mean follow-up of 18.9 months. Conclusions. Creating warm-ischemic conditions during RANSS should not be a liberal decision, even in the initial phases of the learning curve for a highly experienced open surgeon.

Morphometric profile of the localised renal tumors managed either by open or robot-assisted nephron-sparing surgery: the impact of scoring systems on the decision making process

BackgroundNephrometric scoring systems aim to improve the manner in which tumoral complexity is measured and reported. Each system provides a way to objectively measure specific tumor features that influence technical feasibility. In this study we aimed to determine how nephrometric scoring systems tailored our approach to the surgical treatment of localised renal masses.MethodsCharts of the patients with localised renal tumors, who were managed by either open or robot-assisted nephron-sparing surgery between May 2010 and June 2012, were retrospectively reviewed. Nephrometric scores [radius, exophytic/endophytic, nearness, anterior/posterior, location (R.E.N.A.L.) score, preoperative aspects and dimensions used for anatomic (P.A.D.U.A.) classification and centrality index (C-index)] were calculated based on preoperative imaging findings. Perioperative data were recorded. Morphometric characteristics of the renal masses were compared. Additionally, the difference between surgical alternative subgroups in terms of morphometric variables and the predictive power of each scoring system in determining the details of the surgical plan were investigated. Furthermore, surgical preferences in different nephrometric categories were compared.ResultsMean R.E.N.A.L. and P.A.D.U.A. scores of the tumors treated with robotic surgery were significantly lower than those managed by open surgery. R.E.N.A.L. nephrometry score showed significant differences between most of the surgical alternative subgroups. P.A.D.U.A. and C-index differences were significant only between robotic off-clamp and open clamped cases. Tumors that required open conversion had significantly higher mean R.E.N.A.L. and P.A.D.U.A. score. High R.E.N.A.L. score (cut-off: 6.5) and high P.A.D.U.A. score (cut-off: 7.5) were found to be significant predictors of the surgical route. Significantly more tumors with moderate R.E.N.A.L. score were managed through the open approach, while the significant majority of those with low R.E.N.A.L. and low P.A.D.U.A. score were operated by robotic assistance.ConclusionsR.E.N.A.L. and P.A.D.U.A. scores influenced our surgical treatment strategy for localized renal masses. High R.E.N.A.L. and P.A.D.U.A. scores increased the likelihood of an open NSS.

Nephron-Sparing Surgery for Renal Masses Measuring Larger Than 7 cm on Preoperative Imaging: A Single Surgeon, Single Center Experience

Objectives. To document the feasibility of nephron-sparing surgery (NSS) for the surgical treatment of renal masses measuring larger than 7 cm (cT2) on preoperative imaging. Methods. A total of 139 patients have undergone NSS between 2001 and 2012 by a single surgeon in our clinic. Of these, we identified 17 patients whose tumors were measuring greater than 7 cm on preoperative imaging studies and were limited to the kidney. Their charts were retrospectively reviewed. Results. Mean age of the study population was 49.8 ± 11.3 years. Thirteen patients were managed by open NSS, while 4 patients have undergone robot-assisted NSS. Mean diameter and mean R.E.N.A.L. score of the tumors that were enucleoresected were 8.2 cm and 8.5, respectively. A total of 5 Clavien grade 2 and higher complications were recorded within 30 days of surgery. Histopathologic examination revealed benign histology in almost 1/4 of the cases. After a median followup of 33 months, all of our patients were alive. Only one patient (5.8%) experienced local recurrence. Conclusions. NSS is a feasible and safe option for large (>7 cm) renal masses. It may be considered not only for imperative conditions but also for highly selected cases with a normal contralateral kidney.