V33 THE SURGICAL TECHNIQUE OF ROBOTIC-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY

V33 THE SURGICAL TECHNIQUE OF ROBOTIC-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY

V6 LAPAROSCOPIC NEPHRECTOMY Friday, 20 March, 12.15-13.45, eURO Auditorium V33 The surgical technique of robotic-assisted laparoscopic partial nep...

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V6 LAPAROSCOPIC NEPHRECTOMY Friday, 20 March, 12.15-13.45, eURO Auditorium

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The surgical technique of robotic-assisted laparoscopic partial nephrectomy



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Simplified method of robotic-assisted laparoscopic nephroureterectomy: Adequate position of the trocars

Ho H.S.S., Harbicher M., Neururer R., Steiner H., Bartsch G., Peschel R.

Palou J., Gausa L., Rengifo D., Peña J., Dominguez A., Villavicencio H.

Medical University of Innsbruck, Dept. of Urology, Innsbruck, Austria Introduction & Objectives: Laparoscopic partial nephrectomy provided the benefits of minimally-invasive surgery for small renal tumour. However, its associated technical difficulties could be challenging. Since 2003, we had been utilizing robotic-assisted laparoscopic partial nephrectomy (RLPN) for these tumours. In this video, we described in details our evolved technique of RLPN for renal tumours of less than 7-cm. Material & Methods: From February 2003 till September 2008, we included all consecutive RLPN performed for enhancing renal mass on CT scan. We excluded patients with tumours more than 7 cm and those with abdominal surgery that precludes transperitoneal approach. Tumours in the dorsal aspect of the upper pole were also excluded. A 3-arm Da Vinci robot was used in a 4-ports approach with warm ischemic time. The vascular occlusion was achieved with self-made Rummel tourniquets to renal artery and vein, applied by the console surgeon. After tumour excision and pelvicalyceal (PC) closure, the tumour bed was lined with Floseal® and the capsule was closed with a continuous absorbable suture, reinforced by Hem-o-Lok® clips. A single surgeon performed all the surgery with a patient-side assistant. Ultrasound surveillance for complications were on the fourth post-op day and at 3 months. Oncological surveillance was done with 6 to 12-monthly contrast CT scan. Serum creatinine was measured at every follow-up visit. We recorded the following: operating time (OT) which included robot setting-up, warm ischemic time (WIT), pelvicalyceal system closure and estimated blood loss (EBL). Results: Of the 75 patients, 49 were men. Their mean age was 59.5 years-old with a mean pre-op serum creatinine of 0.73 mg/dL. The mean tumour size was 2.9 cm. 53 of them were exophytic and 18 were central; less than 1 cm from the PC or renal vessels. The mean OT and WIT were 106 and 24.1 minutes respectively. The mean EBL was 91.5 ml. There were two conversions to open surgery and ten patients needed blood transfusion. We had three positive surgical margins, early in our series. There was one case of post-op bleeding that was managed conservatively. There was one case of urinary leak which resolved with ureteral stenting. Twenty-two tumours (29.3%) were benign. Majority (81.1%) of the malignant tumours were of the clear cell subtype. Forty-five of the tumours were pathological T1a.

Fundació Puigvert, Dept. of Urology, Barcelona, Spain Introduction & Objectives: Neprhoureterectomy is the gold standard of the treatment of the upper urinary tract tumors. Laparoscopic surgery has become an alternative to open surgery due to improvement and refinement of the technique, and to avoid cell seeding and also the management of the distal ureter. Robotic surgery is a well established technique and facilitates the performance of laparoscopic surgery. The difficulty in the appliance of robotics in nephrouretectomy is the position of the trocars and the placement of the robot. We present our technique with a simple position of the trocars that allows an easy procedure without repositioning of the robot. Material & Methods: A 65 year old man, heavy smoker, presented with hematuria. Ultrasonography revealed left hydronephrosis and the cystoscopy was normal. The CTscan disclosed the presence of a tumor of the renal pelvis with secondary hydronephrosis, no lymph node enlargement. The patient was placed in the lumbotomy position and the robot on the contralateral side in the line between the umibilicus and the iliac crest. The trocars were located as follows: One camera port at the level of the umbilicus, 10 cm lateral to the midline, the 2nd and 3rd robotic ports at the level of anterior axillary line and the assistant port at the umbilicus. We proceeded first to standard nephrectomy with division of the renal artery and vein. Then the ureter wass identified and occluded with a Hem-o-lock clip and mobilized to the level of the bladder. The distal part of the ureter was dissected with both electrocautery and blunt sweeping. The final attachments of Waldeyer´s sheath were divided. Then, before the section of the ureter a 3-0- Prolene suture was placed to allow traction and final closure of the orifice defect of the bladder. An endobag was used for the specimen. An ipsilateral lower-abdominal trocar site was extended to a small Gibson incision to deliver the specimen. Results: Total operative time was 2.5 hours, the pathology revealed an Urothelial cell carcinoma of the renal pelvis pT2G3, with no positive margins. The recovery was uneventful, the drainage was removed 24 hours after the procedure and bladder indwelling catheter 48 hours and the patient discharged 2 days after the procedure

Conclusions: Our technique of RLPN has shown to be a feasible treatment option for small renal tumours with acceptable OT and minimal complication. Its simplicity in surgical approach and technical steps ensure that it is achievable and replicable. Team co-ordination is also pivotal in the early experience, particularly during warm ischemia.

Conclusions: This approach makes robotic nephroureterectomy a safe oncological procedure, feasible and reproducible. The adequate position of the trocars and the robot allows and facilitates the access from the upper pole of the kidney to the lower distal ureter and without no need of redocking.





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Laparoscopic heminephroureterectomy for duplex kidney anomalies in children

Laparoscopic management of a renal mass with type I venous thrombus

Seibold J.1, Nagele U.1, Schilling D.1, Anastasiadis A.G.2, Sievert K.D.1, Stenzl A.1, Corvin S.3

Rodríguez Faba O., Palou J., Rosales A., Huguet J., Parada R., Villavicencio H.

1 University of Tübingen, Dept. of Urology, Tübingen, Germany, 2Hospital of Großburgwedel, Dept. of Urology, Burgwedel, Germany, 3Dept. of Urology, Eggenfelden, Germany

Fundació Puigvert, Dept. of Urology, Barcelona, Spain

Introduction & Objectives: In this video we demonstrate our experiences of laparoscopic heminephroureterectomy in duplex kidney anomalies in children. Material & Methods: 5 laparoscopic heminephroureterectomies were performed in 4 girls with a mean age of 41 (9 to 67) months. In all cases, a non-functioning upper pole with an obstructive (n=4) or refluxing (n=1) megaureter was found. The upper pole was resected laparoscopically enbloc with the megaureter using 3 to 4 trocars. Results: Laparoscopic heminephroureterectomy is demonstrated in this video in a four year old girl. Trocar positioning (difference of right and left side) is shown. Important steps of the procedure are highlighted. There was no conversion to open surgery, mean operative time was 190 (170 to 210) min, blood loss was minimal and no intraoperative complications occurred. Despite chronic inflammation in the resected specimens, the patients showed no clinical signs of infection postoperatively. The average length of hospital stay was 5, 6 days (range 4 – 7 days). Conclusions: This video shows that laparoscopic heminephroureterectomy in children is feasible and associated with minimal morbidity, an excellent cosmetic result and a short hospital stay. The main disadvantage of the laparoscopic approach is the long operative time. Laparoscopic heminephroureterectomy is a technically demanding procedure and should be performed only at specialized centers.

Introduction & Objectives: The disruption of the renal vein occurs between 5-10% of patients with renal cell carcinoma and generally represents a relative contraindication for laparoscopic approach. All reported cases since 2003 include a small number of patients and most with hand-assisted. Laparoscopic management of renal vein is possible by direct control with hemologs or cava vein clamping and posterior suturing. Material & Methods: We present the case of a 79 years old man that following an episode of back pain and hematuria in TC scan was reported a tumour of superior pole of the right kidney 5.8x4, 3x5, 7 cm. with type I tumour thrombus affecting the renal vein until its entry into the cava. Extension study was negative. A laparoscopic approach was performed by mini laparotomy, initially with 3 trocars and separation of the liver by pincer grip. Once exposed the pedicle and sectioned the main artery, was found that the thrombus was in the vein and did not affect the cava therefore hemologs were placed after finding that the total thrombus was inside the renal vein. Results: The operative time was 180 minutes and the bleeding minimal. Being a large mass was necessary the placement of a trocar to lift the lower kidney pole. In addition to the main artery and vein were found another extra vein and artery. It is important the good exposure of the front of the cava vein round the thrombus and check that all of the thrombus remains within the renal vein to decide the type of clamps that in this case was through hemologs. Conclusions: In selected cases, laparoscopic resection of renal tumors with thrombus in vein type I is feasible technically. Is necessary a preoperative planning of the management of thrombus and the possibility of conversion to open surgery. Long-term evaluation of the oncological results is necessary.

Eur Urol Suppl 2009;8(4):391