ROBOTIC PARTIAL NEPHRECTOMY: 15 YRS LATER

Transcription

1 ROBOTIC PARTIAL NEPHRECTOMY: 15 YRS LATER Clayton Lau, MD Chief, Division of Urology/Urologic Oncology City of Hope Medical Center Current Trends in Urologic Oncology 2019 Beaver Creek Resort, CO

2 Disclosures Consultant and Speaker for Intuitive Surgical 2.

3 Epidemiology 62K Estimated (NEW CASES) 13K Kidney Cancer related deaths 40% of new tumors that are found Incidentally are SRM RCC accounts for 3% of adult malignancies Incidence rising 2% annually since 1975 Lifetime risk of developing RCC -1/63(1.6%) Average age at diagnosis is 64 Men:Female(1.6 : 1) Most are asymptomatic Triad: Hematuria Flank Pain Abdominal Mass J Natl Compr Canc Network. 2017:15: Hollingsworth J Natl Cancer Inst 2006 Cooperberg J Urol

4 Kidney Cancer NCCN 2017 J Natl Compr Canc Network. 2017:15:

5 Open Partial Nephrectomy A. Novick Variety of techniques: early vascular control vs off clamp partial minimize ischemic damage mannitol diuresis regional hypothermia complete tumor excision with free margins closure of collecting system and renal defect Uzzo, Novick. J Urol 2001, 166(1):

6 Renal MIS Timeline LRN LPN RRN Clayman J Urol 1990 Winfield J Urol 1993 Guilloneau J Urol 2001 Gettman 2004 Urology RPN 6.

7 1 st Case series of Robotic Partial Nephrectomy N=13 11/2002 to 8/03 n 13 mean diameter WIT OPTime 3.5cm 22 mins 215 mins LOS 4.3 Gettman, et al. Urology

8 Tanagho et al Urology

9 EBL(mean)=206ml( ) WIT =20.3 mins(0-83) OP Time= mins(59-472) Nephrotomy Scores=6.9 Complications Overall 15.6% Hemorrhage Intraop 9(0.2%) Hemorrhage Postop 41(4.6%) Urinary Leakage 10 (0.11%) Lymphatic Leak 10(0.11%) Embolization rate 1.1% No reoperations or deaths within 90 days Tanagho et al Urology

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11 E V O L U T I O N O F M I S T E C H N O L O G Y Coming Soon da Vinci SP Single Port Multi-quadrant access Crystal clear 3D HD vision da Vinci Xi Multi-quadrant access Crystal clear 3D HD vision Platform for future technologies FIREFLY 1999 da Vinci Si Dual Console option Enhanced HD Vision (1080i) Upgradable architecture FIREFLY XI SKILLS SIMULATOR INTEGRATED ENERGY VESSEL SEALER da Vinci Eliminates lap compromises Introduction of 4 th arm (2003) Simple instruments da Vinci S 3D HD Vision (720p) Cross-quadrant access Streamlined set-up SINGLE-SITE SKILLS SIMULATOR ADVANCED INSTRUMENTATION STAPLER 45 & 30 CURVED TIP (WHITE, BLUE, GREEN) FUTURE INNOVATION SINGLE PORT SURGERY PATIENT CART 11.

12 COH Robotic Partial Nephrectomy Yuh et al

13 COH Robotic Partial Nephrectomy 13.

14 COH Partial Nephrectomy 14.

15 Preventing Complications/Lessons Learned Positioning Access Understanding Anatomy Prevent Bleeding Prevent R1 resection Minimize Urine Leak Prevent Renal Failure 15.

16 Renal Surgery Postioning /Access #Flank position(80-90 degrees) #Maximal Flexion #No Bean bag/krause Arm(Airplane) Support #Orthopedic Hip Jelly Positioners and Rolled Blankets #Arm Protector from The Pink Pad- Pigazzi Pink Pad(Medline) #Cloth Tape 3 inch across chest and hips 16.

17 head Feet DICE 5 Left sided renal surgery 17.

18 head STRAIGHT LINE Right Renal Surgery 18.

19 Understanding the Anatomy-Preplanning Understanding Anatomy Prepare to Mobilize Prepare for Accurate Vascular Control Meticulous Closure/early unclamping 19.

20 Preventing Intraoperative Bleeding Expose hilum proximally Use firefly to confirm arterial control Free the upper part of kidney from Adrenal Gland Check vein if full, kidney plump and purple 20.

21 CONFIRMING ISCHEMIA 21.

22 Preventing R1 resection Tumor localization Preop imaging Ultrasound Kidney Mobilization Prepare before cutting Depth Angle of Entry Irregularly shaped tumor Carefully of inadvertant resction entry or traction entry 22.

23 ULTRASOUND us 23.

24 Tumor Resection and Renorrhaphy When cutting the tumor out, use blunt dissection to efficiently to removed the mass Don t work in a hole Take your time, but be efficient and exact in securing arteries/arterioles and collecting system When clamp comes off and repair is done. Pack it with minilap if it is still oozing. May need additional interrupted sutures. 24.

25 R1 associated with Increased Local recurrence Retrospective multi-instutional review patients( )-rpn LIJ,UCI, Uof Chicago, USC Median FU 33 months R1(97(7.8%) Local Recurrence 5.6% (low risk T1 Grade 1/2) 10.3% (T1 grade 3, or T2/3) Journal of Urology

26 Minimizing Urine Leak/Post op Bleeding/Aneurysm Make sure the kidney is mobilized well enough were you can easily reconstruct Don t cut deep with cautery in deep tumors Meticuolous Renorrhaphy /closure Vlock Vicyl Early enclamping 26.

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28 RENAL SINUS 28.

29 EUN RENORRHAPHY: Double-armed suture INNER LAYER: VLOC on CV 23 needle Running baseball stitch Closes open vessels and collecting system Early unclamping OUTER LAYER: 12 0 VLOC on GS21 needle Running horizontal mattress Laproclip on all needle exits from capsule Slide Laproclip to close defect and compress parenchyma/capsule VLOC on CV23 needle Sutures interlocking 12 0 VLOC on GS21 needle 29.

30 INNER LAYER 30.

31 EARLY UNCLAMP 31.

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34 NO GAPS 34.

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36 Minimizing Ischemia/Renal Failure The correct Operation RN vs PN Open vs Robo Learning curve/support Reduce warm ischemia CKK, Solitary kidney, multiple lesions Off Clamp Selective clamping Spaliviero, Coleman, et Al Euro Urol Jan

37 Key points for Setup/Mobilization Dissect The Renal hilum off as proximal as possible(ivc/aorta) Mobilize the kidney outside of Gerota s fascia first Defat the Perirenal fat at least 2 cm from edge of tumor For deeper tumors, cut till you get to renal sinus fat and/or collecting system 37.

38 Video big partial 38.

39 Video Horseeshoe 39.

40 Advanced technology -Video 40.

41 ICG uses 41.

42 Final Thoughts Complications will happen, key maneuver is preparation Mobilization is key, invest the time into it Use the advanced technology/suture Urine Leak: Maximal Drainage Bleeding: Selective Angioembolization 42.

43 Thank you Questions: 43.