[Show abstract][Hide abstract] ABSTRACT: Objectives: Accurate tumor identification during partial nephrectomy is essential for successful tumor control. Intraoperative laparoscopic ultrasonography is useful for tumor localization, but the ultrasound probe is controlled by the assistant rather than the surgeon. We evaluated our initial experience using a robotic ultrasound probe that is controlled by the console surgeon. Methods: Partial nephrectomy was carried out in 22 consecutive patients between November 2010 and March 2011. A robotic ultrasound probe under console surgeon control was used in all the cases. All patients had at least 1 year follow up. Results: Mean patient age was 59 years and mean tumor size was 2.7 cm. There were six hilar tumors (27%) and 21 (95%) endophytic tumors. Mean R.E.N.A.L. nephrometry score was 6.9 (range 6-9). Mean operative time was 205.7 min and mean warm ischemia time was 17.9 min (range 6-28 min). All patients had negative tumor margins and were free of disease recurrence at a mean follow up of 13 months. Conclusion: The use of a robotic ultrasound probe during partial nephrectomy allows the surgeon to optimize tumor identification with maximal autonomy, and to benefit from the precision and articulation of the robotic instrument during this key step of the partial nephrectomy procedure.
International Journal of Urology 08/2012; · 1.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The advent of robotic partial nephrectomy (RPN) may help overcome some of the limitations encountered during laparoscopic
partial nephrectomy (LPN), namely, the longer warm ischemia time and higher rate of urologic complications. RPN is an advanced
surgical technique that should be performed by experienced surgeons on select patients, and with an adequately prepared assistant
bedside surgeon. A 3- or 4-arm approach may be utilized, although a 3-arm approach is recommended for those early in their
experience. Surgeons should be familiar with strategies for avoiding hemorrhage and other complications, and if encountered,
strategies for controlling bleeding, including suturing, additional clamping of unidentified arterial inflow, or venous unclamping.
Surgeons should also be familiar with strategies that minimize warm ischemia time, namely preemptive selective ligation of
involved arterioles and early unclamping. Strategies for achieving renal hypothermia primarily include retrograde injection
of ice-cold saline. Surgeons performing RPN need to be comfortable with laparoscopic dissection of the renal hilum. Anticipating
and preventing hemorrhage during hilar dissection, during warm ischemia time (WIT), and after hilar unclamping is a fundamental
technical skill that should be mastered to safely and consistently perform RPN in a quality fashion.
KeywordsChronic kidney failure-Kidney cancer-Laparoscopy-Minimally invasive surgical procedures-Nephron-sparing surgery-Renal cell carcinoma-Robotics-Urologic surgical procedures
[Show abstract][Hide abstract] ABSTRACT: Discovery of macroscopically positive lymph nodes (LN) during radical prostatectomy for clinically localized prostate cancer (PCa) is a rare event. We describe our experience of intraoperative finding of grossly positive LN during radical prostatectomy and evaluate outcomes and predictors. A total of 4,480 patients underwent robot-assisted radical prostatectomy (RARP) for clinically localized PCa from 2001 to 2010, and pelvic LN dissection was performed in 4,090 of these patients (91.3%). Patients with macroscopically positive LN discovered and confirmed intraoperatively were assessed, as was surgical decision (abort versus continue RARP). Patients with macroscopic LN-positive disease were also evaluated and oncologic outcomes were compared with patients with microscopic LN-positive disease on final pathology. LN-positive disease was found at final pathology in 87 patients (2.1%), of whom 13 (14.9%) had grossly abnormal LN confirmed intraoperatively by frozen section. RARP was aborted in nine cases and completed in four patients. All patients received adjuvant therapy with hormonal deprivation and/or radiation. Two patients in the aborted RARP subset died of PCa. All patients who underwent completion RARP are still alive at a mean follow-up of 57.2 months with one patient still alive at 95 months. Patients with macroscopically positive LN had a higher median preoperative prostate serum antigen (PSA) (17.2 vs. 6.7 μg/L, P = 0.002) and were more likely have biopsy perineural invasion (77.8 vs. 32.4%, P = 0.012). Intraoperative findings of macroscopically positive LN during RARP is a rare event that may occur in high-risk patients, particularly in those with a high PSA and biopsy perineural invasion. Long-term survival is possible after completion RARP.
[Show abstract][Hide abstract] ABSTRACT: Robot-assisted partial nephrectomy (RPN) has emerged as a viable approach to minimally invasive surgery for small renal tumors. There are few reports of RPN for tumors >4 cm. Our objective was to evaluate outcomes of RPN for tumors >4 cm compared with RPN for tumors ≤ 4 cm in a large multi-institutional study.
We reviewed data for 445 consecutive patients who underwent RPN by experienced surgeons at four academic institutions from 2006 to 2010. Patients were stratified into two groups according to radiographic tumor size. Patient demographics, perioperative outcomes, and oncologic outcomes were recorded.
A total of 83 of 445 (18.7%) patients had tumors >4 cm with a median radiographic tumor size of 5.0 cm (4.1-11 cm). Patients with tumors >4 cm had a higher proportion of hilar tumors (9.8% vs 4.7%, P<0.001), a higher mean R.E.N.A.L. nephrometry score (8.0 vs 6.3, P<0.01), longer warm ischemia time (WIT) (24 vs 17 min, P<0.001), and an increased rate of collecting system repair (72.2% vs 51.6%, P=0.006) compared with patients with tumors ≤ 4 cm. Functional outcomes and complications were similar between groups. There were no positive margins in patients with tumors >4 cm and only one recurrence.
In the largest multi-institutional series of RPN for tumors >4 cm, we demonstrate safety, feasibility, and efficacy of RPN for tumors >4 cm. Patients with tumors >4 cm had a higher nephrometry score, longer WIT, and slightly higher estimated blood loss compared with patients who had tumors ≤ 4 cm, but there was no increased risk of adverse outcomes in the hands of experienced surgeons.
Journal of endourology / Endourological Society 11/2011; 26(6):642-6. · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We evaluated the incidence of perioperative complications after robotic partial nephrectomy.
We retrospectively reviewed the records of patients treated with robotic assisted partial nephrectomy across the 4 participating institutions. Demographic, blood loss, warm ischemia time, and intraoperative and postoperative complication data were collected. All complications were graded according to the Clavien classification system.
A total of 450 consecutive robotic assisted partial nephrectomies were done between June 2006 and May 2009. Overall 71 patients (15.8%) had a complication, including intraoperative and postoperative complications in 8 (1.8%) and 65 (14.4%), respectively. Hemorrhage developed in 2 patients (0.2%) intraoperatively and in 22 (4.9%) postoperatively. Seven patients (1.6%) had urine leakage. As classified by the Clavien system, complications were grade I-II in 76.1% of cases and grade III-IV in 23.9%. Robotic assisted partial nephrectomy was converted to open or conventional laparoscopic surgery in 3 patients (0.7%) and to radical nephrectomy in 7 (1.6%). There were no deaths.
Current data indicate that robotic assisted partial nephrectomy is safe. Most postoperative complications are Clavien grade I or II, or can be managed conservatively.
The Journal of urology 06/2011; 186(2):417-21. · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Robot-assisted partial nephrectomy (RAPN) is an emerging technique for minimally invasive nephron-sparing surgery that may facilitate the technical challenges of sutured renorrhaphy. Barbed suture allows for knotless wound closure and improves suturing efficiency. We present the first clinical study of barbed suture for renorrhaphy during RAPN in human patients and compare perioperative outcomes to RAPN with polyglactin suture.
Thirty consecutive patients underwent RAPN by a single surgeon; 15 using polyglactin suture for renorrhaphy followed by 15 using the V-Loc 180 wound closure device. Renorrhaphy was performed in two layers, with a continuous running closure of deep vessels and the collecting system, followed by a running closure of the renal capsule, using the sliding Hem-o-lok clip technique. Operative characteristics and complications were compared between groups.
Renorrhaphy was successfully completed in all 30 consecutive RAPN procedures. V-Loc and conventional groups were equivalent in demographic and tumor characteristics. Mean operative and console time were equivalent; warm ischemia time was significantly shorter in the V-Loc group (18.5 vs 24.7 min, P = 0.008). There were no instances of suture slippage or tearing in the barbed suture group. The barbs held the sliding clip renorrhaphy intact without the need for redundant clips to prevent backsliding. Conclusion: Use of barbed suture simplifies the renorrhaphy technique during RAPN and improves efficiency, allowing for reduced warm ischemia times. We demonstrate feasibility and safety of this suture technique in human patients undergoing minimally invasive partial nephrectomy.
Journal of endourology / Endourological Society 02/2011; 25(3):529-33. · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To report our experience with robot-assisted partial nephrectomy (RAPN) in obese patients compared with a contemporary cohort of nonobese patients.
We defined obesity as a body mass index (BMI) ≥ 30 kg/m(2). From June 2004 to September 2009, 97 patients underwent RAPN at our institution, of whom 49 were obese (group 1) and 48 were nonobese (group 2, BMI <30 kg/m(2)). We compared demographics, operative data, complications, and pathological outcomes between these two groups.
The average BMI for the obese group was 36.2 kg/m(2) (range 30.3-49) compared with 25.7 kg/m(2) (range 20.5-29.7) for the nonobese group. Median tumor size was 2.5 versus 2.3 cm for obese and nonobese groups, respectively. Obese patients had a larger median estimated blood loss (150 vs.100 mL, p=0.027) and a trend toward a longer median operative time (265 vs. 242.5 minutes, p=0.085) and median warm ischemia time (26.5 vs. 22.5 minutes, p=0.074), but this did not achieve statistical significance. An intraoperative complication occurred in one patient in each group. The postoperative complication rate was not statistically significant between the two groups (8.3% vs. 4.3%, p=0.377). The median hospital stay was 2 days for both groups.
RAPN is safe and feasible in obese patients. Obese patients had a higher estimated blood loss and a trend toward greater operative time and warm ischemia time, which did not achieve statistical significance.
Journal of endourology / Endourological Society 01/2011; 25(1):101-5. · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The need for a skilled assistant to perform hilar clamping during robotic partial nephrectomy is a potential limitation of the technique. We describe our experience using robotic bulldog clamps applied by the console surgeon for hilar clamping.
A total of 60 consecutive patients underwent robotic partial nephrectomy, 30 using laparoscopic bulldog clamps applied by the assistant and 30 using robotic bulldog clamps applied with the robotic Prograsp instrument. Perioperative outcomes were compared between groups.
All 30 patients underwent successful hilar clamping during robotic partial nephrectomy using robotic bulldog clamps with no intraoperative complications and without the need for readjustment/reclamping. Robotic bulldog clamps provided adequate ischemia even for tumors >4 cm, hilar, endophytic, multiple tumors, and multiple renal arteries. Both groups had similar baseline characteristics. Perioperative outcomes with robotic bulldog clamps were at least comparable to the laparoscopic bulldog group, with a trend to lower console time, warm ischemia time, and estimated blood loss.
Use of robotically applied bulldog clamps is a safe and feasible method of hilar occlusion during robotic partial nephrectomy; they perform at least as well as laparoscopic bulldog clamps while allowing the console surgeon greater autonomy and precision for hilar clamping.
JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 01/2011; 15(4):520-6. · 0.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: • To evaluate our experience with robotic partial nephrectomy in patients with previous abdominal surgery and evaluate the effect of previous abdominal surgery on perioperative outcomes. We also describe a technique for intraperitoneal access for patients with prior abdominal surgery utilizing the 8 mm robotic camera for direct-vision trocar placement.
• From a prospective cohort of 197 consecutive patients who underwent robotic renal surgery at a single academic institution, a total of 95 patients underwent transperitoneal robotic partial nephrectomy (RPN). • Patients with and without previous abdominal surgery were compared. Patients with prior abdominal surgery were subcategorized into two groups: upper midline or ipsilateral upper quadrant scar or lower abdominal, contralateral, or minimally-invasive scar. • Demographic and perioperative variables were compared between the surgery and no surgery groups. Access was obtained using a Veress needle or Hassan technique. • We utilized a technique of direct vision placement of the initial trocar on our 10 most recent cases, using an 8 mm robotic camera placed through the obturator of 12 mm clear-tipped trocar. • Lysis of adhesions was performed as needed to allow for placement of additional robotic ports.
• A total of 95 patients underwent transperitoneal RPN, of which 41 (43%) had a history of prior abdominal surgery and six had upper midline or ipsilateral upper quadrant scars. • There were no statistically significant differences between patients with previous abdominal surgery and patients with no previous abdominal surgery in BMI (30.4 vs 29.4 kg/m(2) ), median tumor size (2.5 cm vs 2.3), median total operative time (246 vs 250 min), median warm ischemia time (21 vs 16 min), median EBL (150 vs100 ml), clinical stage, transfusion rate, or complications. • A total of six patients underwent 7 previous upper midline or ipsilateral upper quadrant surgeries, including open cholecystectomy-2 patients (33%), open partial gastrectomy-2 patients (33%) and exploratory laparotomy-1 patient (17%). • Complications in this group were an enterotomy during lysis of adhesions that was repaired robotically without sequelae and a mesenteric hematoma during Veress needle placement. A total of 35 patients underwent 16 other prior abdominal surgeries, including abdominal hysterectomy-10 patients (29%), umbilical/inguinal hernia repair-9 patients (26%) and appendectomy-7 patients (20%). There were no access related injuries in the 10 cases in which the robotic 8 mm camera was used for initial trocar placement.
• Transperitoneal robotic partial nephrectomy is feasible in the setting of prior abdominal surgery. The majority of these patients can have their procedure performed safely without an increase in complications. • Direct-vision intraperitoneal placement of initial trocar may be achieved by using an 8 mm robotic camera, without the need to switch between conventional and robotic cameras.
BJU International 12/2010; 108(3):413-9. · 3.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Minimally invasive approaches to partial nephrectomy have been rapidly gaining popularity but require advanced laparoscopic surgical skills. Renal hilar tumors, due to their anatomic location, pose additional technical challenges to the operating surgeon.
We compared the outcomes of robot-assisted partial nephrectomy (RPN) for hilar and nonhilar tumors in our large multicenter contemporary series of patients.
We retrospectively reviewed prospectively collected data on 446 consecutive patients who underwent RPN by renal surgeons experienced in minimally invasive techniques at four academic institutions from June 2006 to March 2010. Patients were stratified into two groups: those with hilar lesions and those with nonhilar lesions.
Patient demographics, operative outcomes, and postoperative outcomes, including oncologic outcomes, were recorded.
Forty-one patients (9%) had hilar renal masses; 405 patients (91%) had nonhilar masses. There was no statistical differences in patient demographics except for larger median tumor size in the hilar cohort (3.2 cm vs 2.6 cm; p=0.001). The only significant difference in operative outcomes was an increase in warm ischemia times for the hilar group versus the nonhilar group (26.3±7.4 min vs 19.6±10.0 min; p=<0.0001). There were no differences in postoperative outcomes; however, there was a trend for increased risk of malignancy and higher stage tumors in the hilar lesion group. Final pathologic margin status was similar in both groups. Only one patient in the nonhilar group had evidence of recurrence at 21 mo. The study was limited by the lack of standard anatomic classification of renal tumors and the potential influence of the surgeons' prior robotic experience.
The data represent the largest series of its kind and strongly suggest that RPN is a safe, effective, and feasible option for the minimally invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared with nonhilar tumors in the hands of experienced robotic surgeons.
European Urology 11/2010; 59(3):325-30. · 10.48 Impact Factor