BJUI. Robotic nephrectomy for the treatment of benign and malignant disease

Transcription

1 . JOURNAL COMPILATION 2008 BJU INTERNATIONAL Laparoscopic and Robotic Urology ROGERS et al. BJUI BJU INTERNATIONAL Robotic nephrectomy for the treatment of benign and malignant disease Craig Rogers, Rajesh Laungani, Louis Spencer Krane, Akshay Bhandari, Mahendra Bhandari and Mani Menon Henry Ford Hospital, Vattikuti Urology Institute, Detroit, MI, USA Accepted for publication 15 May 2008 Study Type Therapy (case series) Level of Evidence 4 OBJECTIVES To report our experience and describe our technique of robotic nephrectomy. PATIENTS AND METHODS We retrospectively evaluated 42 patients who underwent robotic nephrectomy at our institution from January 2004 to March Variables assessed included patient age, body mass index, operative duration, estimated blood loss (EBL), complications, hospital stay, analgesia requirements and specimen pathology. Radical nephrectomy (RN) was performed for suspected malignant disease and simple nephrectomy (SN) was performed for benign disease. RESULTS In all, 42 patients with a mean (range) age of 59.4 (17 38) years, underwent robotic nephrectomy (RN 35, SN seven) using a transperitoneal (39) or retroperitoneal (three) approach. The mean operative console time was 158 min, mean EBL was 223 ml, mean tumour size was 5.1 cm, and the mean hospital stay was 2.4 days. Renal hilar vessels were controlled using robotic suture ligation (25), robotic haemolock clips (12), or laparoscopic staplers (five). No patients required open conversion. One morbidly obese patient developed a wound dehiscience (complication rate 2.6%). On final tumour pathology, the RN specimens included 34 renal cell carcinomas (clear cell 23, papillary nine, chromophobe two) and an oncocytoma. The SN specimens showed chronic xanthogranulomatous pyelonephritis (four) and atrophic kidneys (three). All surgical margins were negative for malignancy with no evidence of tumour recurrence at a mean (range) follow-up of 15.7 (1 51) months. CONCLUSIONS Robotic nephrectomy is a safe and feasible option for minimally invasive surgical removal of the kidney for benign and malignant conditions and can be performed through a transperitoneal or retroperitoneal approach. KEYWORDS robotics, surgery, minimally invasive, renal cancer, radical nephrectomy INTRODUCTION Minimally invasive kidney surgery is being utilized more frequently and may offer potential benefits including decreased blood loss, decreased hospital stay, quicker recovery, and decreased pain [1,2]. Laparoscopic radical nephrectomy (RN) has shown favourable long-term oncological outcomes [3,4]. Robotic assistance has been described for kidney procedures, including pyeloplasty [5], partial nephrectomy [6 11], and donor nephrectomy [12]. Few reports discuss robotic nephrectomy and these are based on small patient cohorts [13,14]. We describe our experience with robotic nephrectomy in a larger cohort of patients for suspected malignancy and benign disease. PATIENTS AND METHODS We retrospectively evaluated all patients who underwent robotic nephrectomy at our institution by two surgeons (M.M. and C.R.) from January 2004 to March Preoperative variables for all patients were reviewed, including mean patient age, body mass index (BMI), preoperative creatinine, haemoglobin, and medical comorbidities. Intraoperative variables reviewed included estimated blood loss (EBL), total operative time, console time, complications, and surgical techniques of access and renal hilar ligation. The total operative time included time for skin incision, port placement, robotic docking and wound closure. Postoperative variables reviewed included hospital stay, analgesia requirements, complications and final tumour pathology. SURGICAL TECHNIQUE Surgical approach for robotic nephrectomy included both transperitoneal and retroperitoneal approaches. Figure 1 shows our port configuration for a transperitoneal approach (Fig. 1a) and a retroperitoneal approach (Fig. 1b). Transperitoneal approach Patients were positioned in flank position and pneumoperitoneum (15 mmhg) was established with the use of the Veress needle. Port placement and docking of the robot were performed as previously described [8,9] with 1660 JOURNAL COMPILATION 2008 BJU INTERNATIONAL 102, doi: /j x x

2 FIG. 1. a, Port configuration for transperitoneal robotic nephrectomy utilizing a lateral camera port, fourth arm, and medial 12-mm assistant port. b, Port configuration for retroperitoneal approach for robotic nephrectomy. a Robotic suture ligation of the renal hilum was performed using a 0-silk suture and robotic needle drivers (Fig. 3b). The kidney was mobilized and placed in a 15-mm endocatch bag for removal. The specimen was extracted by extending inferiorly the peri-umbilical incision used for the 12 mm assistant port. Morcellation of the specimen was not performed. Retroperitoneal approach b A retroperitoneal approach was used in three cases due to extensive prior abdominal surgery (two patients) or peritoneal dialysis (one). The patient was positioned in full flank position with slight table flexion. An incision was made between the 12th rib and the iliac crest to access the retroperitoneum. A preperitoneal dissection balloon (PDB TM, Autosuture, Inc.) was used to dilate the retroperitoneal space as described by others [15] and a 12-mm balloon trocar (Autosuture, Inc.) was placed for the robotic camera. The two robotic instrument ports and a lateral 12- mm assistant port were placed under vision with a distance of at least 3 cm between ports (Fig. 1b). The robot was docked at a steep angle over the shoulder and head of the patient. The kidney was retracted anteriorly and dissection proceeded along the psoas muscle with robotic assistance until pulsations in the retroperitoneal fat were identified, denoting the underlying renal vessels. The renal hilum was dissected and ligated using suture ligation and/or robotic haemolock clips. the camera in a lateral position (Fig. 1). The robotic instruments used included the robotic hook (right arm) and the robotic Maryland graspers (left arm). A 12-mm port was placed medially for the assistant to perform tasks such as suctioning, retraction, and placing a laparoscopic specimen bag. The fourth robotic arm was used in 10 cases by placing a robotic trocar 4 5 cm medial to the inferior robotic instrument port, with a dual blade retractor or Prograsp retractor used as a fourth-arm instrument. The colon was mobilized with robotic assistance by incising along the white line of Toldt and medially reflecting the bowel to expose the kidney. The gonadal vein and ureter were identified and dissection proceeded toward the renal hilum. The fourth arm was used to retract the kidney and place the renal hilum on stretch during dissection of the renal hilum (Fig. 2). The renal vessels were controlled using suture ligation, robotic haemolock clips, or a laparoscopic stapler. Robotic haemolock clips were placed with a robotic haemolock clip applier (Fig. 3a). RESULTS In all, 42 patients with a mean (range) age of 59 (17 83) years underwent robotic nephrectomy (RN 35, simple nephrectomy [SN] seven). Patient demographics and perioperative outcomes for patients who underwent robotic SN and RN are shown in Table 1. The surgical approach was transperitoneal in 39 cases and retroperitoneal in three cases. All patients were started on a clear liquid diet on postoperative day 1 and were tolerating a regular diet and ambulating at the time of discharge. All patients reported by 1 month follow-up that they had resumed normal activities. Overall, the mean total operative time was 294 min, mean console time was 158 min, JOURNAL COMPILATION 2008 BJU INTERNATIONAL 1661

3 ROGERS ET AL. mean EBL was 223 ml, and mean hospital stay was 2.4 days. Renal hilar vessels were controlled using robotic suture ligation (25 cases), robotic haemolock clips (12), or laparoscopic staplers (five). The fourth robotic arm was utilized in 10 cases. No patients required open conversion. One morbidly obese patient developed a wound dehiscence of the extraction site for a perioperative complication rate of 2.6%. Of the seven SNs performed, three were for nonfunctional renal units and four showed chronic xanthogranulomatous pyelonephritis on final pathology. FIG. 2. Kidney retraction utilizing fourth arm. Robotic double fenestrated instrument (solid arrow) being used to elevate kidney to place renal hilum (dashed arrow) on stretch for subsequent dissection. Analysis of the 35 patients who underwent robotic RN, had a mean total operative time of 291 min, mean console time of 153 min, mean EBL of 221 ml, mean tumour size of 5.1 cm, and mean hospital stay of 2.5 days. On final tumour pathology of the 35 RN specimens, there were 34 RCCs (clear cell 23, papillary nine, chromophobe two) and an oncocytoma. All surgical margins were negative for malignancy with no evidence of tumour recurrence at a mean (range) followup of 15.7 (1 51) months. DISCUSSION Laparoscopic RN was first described by Clayman et al. [16]. Although robotic assistance has been utilized in multiple reports of urological procedures, involving the upper urinary tract [5 12], only a few reports exist regarding robotic nephrectomy [13,14]. These are comprised of small patient cohorts. Our robotic nephrectomy series includes a larger cohort of patients undergoing RN for malignancy as well as patients undergoing SN for benign disease. Potential advantages of robotic assistance for RN include a magnified, three-dimensional view and the articulating robotic instruments that can facilitate precise dissection and ligation of the renal hilar vessels. The question might be asked Why do a robotic nephrectomy when it can be done laparoscopically? We recognize that robotic assistance for RN may not be practical or necessary for all patients. We do not claim superiority of robotic nephrectomy over conventional laparoscopy and we are not necessarily advocating a robotic approach for all nephrectomy cases. However, we offer a few examples of potential benefits of robotic assistance: The fourth robotic arm can be used to provide upward retraction on the kidney, placing the renal hilum on stretch to facilitate two-handed, precise dissection of the renal hilar vessels. With robotic assistance, suture ligation of the renal vessels can be performed, similar to an open approach. Hemolock clips can be placed robotically under control of the console surgeon for precise ligation of renal hilar or collateral vessels that may be at an angle that is difficult to reach with a conventional laparoscopic haemolock-clip applier. A robotic nephrectomy may serve as a useful training platform for acquiring the robotic skill and experience required for more complex robotic kidney surgery cases, such as a partial nephrectomy, in which robotic assistance may facilitate tumour excision and renal reconstruction for complex tumours [11]. Robotic assistance may also facilitate a retroperitoneal approach for robotic RN, offering precise dissection in a confined working space. in the present series a retroperitoneal approach for robotic nephrectomy was used for three patients: two patients who had undergone extensive prior abdominal surgery, one of which was discharged the day after RN, and one patient on peritoneal dialysis in whom peritoneal dialysis was able to be resumed the night of surgery. Klingler et al. [13] described the feasibility of robotic RN for a small cohort of five patients. In another study, this same group compared robotic RN in six patients to laparoscopic (33 patients) and open (18 patients) approaches [14]. The open surgery group had a larger EBL but shorter operative time than the other groups, but there was no statistically significant difference in hospital cost or operative variables between robotic or laparoscopic approaches other than a longer operative time (345 min vs 265 min). The longer operative time for a robotic approach was attributed to the learning curve for robotic techniques as well as port placement and robot dock time. These studies did not specify differences between operative console time and total operative time. Our mean 1662 JOURNAL COMPILATION 2008 BJU INTERNATIONAL

4 FIG. 3. Robotic assistance for ligation of the renal hilar vessels during robotic nephrectomy using a robotic haemolock clip (a) and suture ligation (b). a b successfully perform robotic nephrectomy even in patients with a BMI as high as 44 kg/ m 2. Although the feasibility of a laparoscopic nephrectomy for patients with an increased BMI has been shown [17 19], the present series is the first to show similar feasibility for robotic nephrectomy. Obesity has been shown to increase operative times for laparoscopic renal surgery, and this may have also caused an increase in operative times in our series of robotic nephrectomy. The mean hospital stay in the present series was influenced by pre-existing medical comorbidities. Five patients who underwent RN had a hospital stay of 4 days. These patients had medical comorbidities including end-stage renal disease, chronic renal insufficiency, and pulmonary disease, for which they underwent additional uneventful inpatient medical monitoring. Adjusting hospital stay for this additional, uncomplicated observation period, patients were ready for discharge at a mean of 2.2 days after RN. console operative time for those patients undergoing RN was 153 min and total operative time was 291 min. In the present series, the patients who underwent robotic RN had shorter operative times (291 min vs 345 min) and a lower complication rate (2.6% vs 18%) compared with previous reports on robotic RN. Our technique differs from these reports in that we used a lateral position for the camera, we used additional techniques for hilar control including robotic suture ligation and robotic haemolock clips, we utilized the fourth robotic arm, and we offered a retroperitoneal robotic approach in select patients. We had a relatively obese patient cohort (mean BMI of 31 kg/m 2 ), but we were able to Limitations of the present study include its small sample size. Potential disadvantages of robotic nephrectomy include the cost and the need for an experienced bedside assistant. A detailed comparative cost analysis is beyond the scope of this article. We feel that centres with high utilization of robotics by other surgeons and specialties may potentially develop an economy of scale, achieving more comparable overall costs. Although a skilled surgical assistant is beneficial, we feel that the role of the fourth arm may be further optimized to allow the console surgeon greater independence. The present study was not designed to compare robotic assistance with other approaches to nephrectomy, but rather to describe our experience and technique. A comparative analysis of open vs laparoscopic vs robotic nephrectomy, ideally in the form of a randomized clinical trial, would be useful as a follow-up study. Robotic nephrectomy is a safe and feasible option for minimally invasive surgical removal of the kidney for benign and malignant conditions and can be performed through a transperitoneal or a retroperitoneal approach. CONFLICT OF INTEREST None declared. JOURNAL COMPILATION 2008 BJU INTERNATIONAL 1663

5 ROGERS ET AL. TABLE 1 Demographics and perioperative outcomes of 42 patients undergoing robotic nephrectomy Variable SN RN Total N Sex, n: Male Female Surgical approach, n: Transperitoneal Retroperitoneal Side, n: Right Left Mean (range): Age, years 48.7 (17 79) 61.5 (31 83) 59.4 (17 83) BMI, kg/m (17 42) 30.5 (23 44) 30.4 (17 44) Total op. time, min 300 ( ) 291( ) 294 ( ) Console time, min 172 (69 280) 153 (90 300) 158 (69 300) EBL, ml 233 ( ) 221 ( ) 223 ( ) Change in Hb, g/dl 2.4 ( ) 1.6 ( ) 1.3 ( ) Change in Cr, mg/dl 0.4 ( ) 0.5 ( ) 0.48 ( ) Hosptial stay, days 1.8 (1 5) 2.5 (1 8) 2.4 (1 8) Pain score (0 10; visual analogue scale) POD0 3.5 (0 5) 4 (0 8) 3.7 (0 8) POD1 2.8 (0 6) 2.5 (0 6) 2.6 (0 6) POD2 3 (0 5) 2.7 (0 6) 2.8 (0 6) Narcotic usage (morphine equivalents, mg) POD0 6.5 (5 8) 7.2 (2 14) 6.8 (2 14) POD1 6.7 (0 9) 7.2 (0 19) 6.9 (0 19) POD2 3.8 (0 6) 4.1 (0 11) 4 (0 11) Tumor size, cm* 5.1 (1 10.5) Pathological stage, n pt1a 10 pt1b 16 pt2 3 pt3a 2 pt3b 3 Hb, haemoglobin; Cr, creatinine; Op.; operative; POD, postoperative day; *mean tumour size for 35 patients undergoing RN for kidney tumours; pathological stage for 34 RN patients undergoing RN for RCC. REFERENCES 1 Dunn MD, Portis AJ, Shalhav AL et al. Laparoscopic versus open radical nephrectomy: a 9-year experience. J Urol 2000; 164: Gill IS, Meraney AM, Schweizer DK et al. Laparoscopic radical nephrectomy in 100 patients: a single center experience from the United States. Cancer 2001; 92: Permpongkosol S, Chan DY, Link RE et al. Long-term survival analysis after laparoscopic radical nephrectomy. J Urol 2005; 174: Portis AJ, Yan Y, Landman J et al. Longterm followup after laparoscopic radical nephrectomy. J Urol 2002; 167: Patel V. Robotic-assisted laparoscopic dismembered pyeloplasty. Urology 2005; 66: Caruso RP, Phillips CK, Kau E, Taneja SS, Stifelman MD. Robot assisted laparoscopic partial nephrectomy: initial experience. J Urol 2006; 176: Gettman MT, Blute ML, Chow GK, Neururer R, Bartsch G, Peschel R. Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology 2004; 64: Kaul S, Laungani R, Sarle R et al. Da Vinci-assisted robotic partial nephrectomy: technique and results at a mean of 15 months of follow-up. Eur Urol 2007; 51: Badani KK, Muhletaler F, Fumo M et al. Optimizing robotic renal surgery: the lateral camera port placement technique and current results. J Endourol 2008; 22: Phillips CK, Taneja SS, Stifelman MD. Robot-assisted laparoscopic partial nephrectomy: the NYU technique. J Endourol 2005; 19: Rogers CG, Singh A, Blatt AM, Linehan WM, Pinto PA. Robotic partial nephrectomy for complex renal tumors: surgical technique. Eur Urol 2008; 53: Horgan S, Benedetti E, Moser F. Robotically assisted donor nephrectomy for kidney transplantation. Am J Surg 2004; 188: 45S 51S 13 Klingler DW, Hemstreet GP, Balaji KC. Feasibility of robotic radical nephrectomy initial results of single-institution pilot study. Urology 2005; 65: Nazemi T, Galich A, Sterrett S, Klingler D, Smith L, Balaji KC. Radical nephrectomy performed by open, laparoscopy with or without handassistance or robotic methods by the same surgeon produces comparable perioperative results. Int Braz J Urol 2006; 32: Gill IS, Rassweiler JJ. Retroperitoneoscopic renal surgery: our approach. Urology 1999; 54: Clayman RV, Kavoussi LR, Soper NJ et al. Laparoscopic nephrectomy: initial case report. J Urol 1991; 146: Anast JW, Stoller ML, Meng MV et al. Differences in complications and outcomes for obese patients undergoing laparoscopic radical, partial or simple nephrectomy. J Urol 2004; 172: Gong EM, Orvieto MA, Lyon MB, Lucioni A, Gerber GS, Shalhav AL. Analysis of impact of body mass index on outcomes of laparoscopic renal surgery. Urology 2007; 69: JOURNAL COMPILATION 2008 BJU INTERNATIONAL

6 19 Kapoor A, Nassir A, Chew B, Gillis A, Luke P, Whelan P. Comparison of laparoscopic radical renal surgery in morbidly obese and non-obese patients. J Endourol 2004; 18: Correspondence: Craig Rogers, Henry Ford Hospital, Vattikuti Urology Institute, 2799 West Grand Boulevard, Detroit, MI 48202, USA. crogers2@hfhs.org. Abbreviations: (R)(S)N, (radical) (simple) nephrectomy; EBL, estimated blood loss; BMI, body mass index. JOURNAL COMPILATION 2008 BJU INTERNATIONAL 1665