Robotic renal surgery: Radical nephrectomy (including inferior vena cava thrombectomy)

Introduction

This chapter describes techniques for transperitoneal and retroperitoneal robotic-assisted laparoscopic nephrectomy. Robotic assistance facilitates a minimally invasive approach and avoids the need for open surgery particularly for larger and more challenging tumors, including those with inferior vena caval tumor thrombi.

Indications/patient selection

Indications for robotic nephrectomy include both benign and malignant conditions of the kidney. Benign conditions include those that result in chronic infection, pain or hypertension due to chronically obstructed, minimally functional kidneys, large polycystic kidneys, or large arteriovenous malformations not amenable to endovascular treatment. Malignancy is a far more common indication for nephrectomy due to renal parenchymal tumors deemed not amenable to nephron sparing treatment.

Alternative approaches such as open surgery, pure laparoscopy, and hand-assisted laparoscopy may be selected based on the individual surgeon’s experience, comfort level, and institutional availability of the robotic platforms. When a robotic platform is already available, considerations as to cost to the patient and hospital system do not clearly favor one approach over the other due to routine use of expensive disposable instruments (i.e., GelPort and advanced energy vessel-sealing devices) in laparoscopy. Circumstances that may result in a laparoscopic surgeon favoring an open approach such as concern for possible inferior vena cava (IVC) involvement, local invasion, or large tumors may potentially be approached robotically and are not absolute contraindications. Similarly, prior abdominal surgery resulting in adhesions may extend operative time but is not an absolute contraindication to robotic surgery.

Preoperative preparation

A complete history and physical should be taken prior to surgery. Preoperative imaging must include adequate axial imaging with either a contrast computed tomography (CT) scan of the abdomen and pelvis or a magnetic resonance imaging (MRI) with or without contrast if possible. This is essential to characterize the hilar anatomy and check for potential local invasion. Chest imaging with either a radiograph or CT scan should be performed to evaluate for pulmonary metastases, and brain imaging should be performed when indicated. If metastatic disease is found, patients should be counseled on alternatives to cytoreductive nephrectomy such as systemic therapy or palliative therapy, and appropriate referrals should be made. Laboratory evaluation should include a comprehensive metabolic panel, complete blood count, and type and screen when transfusion may be anticipated.

Patient preparation for robotic nephrectomy is similar to other intraperitoneal robotic surgery. Anticoagulation should be discontinued preoperatively to the extent possible. Oral contraceptives should generally be avoided due to the risk of thrombotic events with general anesthesia and abdominal surgery. Bowel preparation is optional, and can be avoided, but should be considered in patients with concern for bowel invasion or colonic distension on imaging (e.g., chronic constipation). Patients should be counseled on the potential need for open conversion and possible complications.

Robotic platform

Multiple generations of the da Vinci robotic platforms (Intuitive Surgical, Inc., Sunnyvale, CA) have been used for nephrectomy. Older generation platforms typically require that the patient-side cart be docked from the patient’s ipsilateral shoulder to facilitate instrument triangulation or over the patient’s head for retroperitoneal surgery. The fourth robotic arm on these previous robotic systems is more prone to external arm collisions and may be challenging to utilize.

The newer Xi robot has a rotating tower deploying the robotic arms from above and thereby allowing docking from any side with more tolerance for closer port placement and easier use of the fourth arm with fewer collisions. The newest generation is the Single Port (SP) platform. The unique considerations for this platform include limited instrument availability and limited retraction capability due to the coupling of all the arms through a common sheath and smaller diameter arms with limited strength compared to the multiport systems.

Patient positioning, ports, and docking

Patients should have adequate venous access, an orogastric tube for bowel decompression (particularly for duodenal decompression on the right), and a Foley catheter for bladder drainage and monitoring of urine output. Patients are positioned in lateral decubitus. Large gel chest rolls or a bean bag may be used to secure the patient. We favor full lateral decubitus positioning at 90 degrees to maximize gravity-assisted bowel mobilization, although others describe partial decubitus at 45 or 60 degrees. An axillary roll (rolled towel, saline bag, or gel pad) should be placed under the rib cage to avoid compression of the brachial plexus. A kidney rest should be avoided due to the risk of rhabdomyolysis. Bed flexion is not necessary for the transperitoneal approach but may facilitate placement of the fourth arm. Some favor flexion and a less steep angle to facilitate open conversion, but this is uncommon and may result in an increased need for retraction by the assistant or fourth arm for adequate visualization.

We prefer obtaining access via Veress needle with visual placement of a 12-mm trocar using a port with a visual obturator. Alternatively, blind port placement after needle insufflation or Hasson technique for access can be used. We favor a triangulated three-port configuration without an assistant port, but typical port configurations described by other authors often include an assistant port for suction or retraction, a 5-mm port for liver retraction on the right, and potentially a port for use of the robotic fourth arm, depending on the complexity of the case.

Robotic instruments

We use a 30-degree down endoscope for the duration of the surgery and robotic instruments that include the curved monopolar scissor instrument and fenestrated Maryland bipolar forceps. Additional options include hook cautery, other types of bipolar forceps, or the robotic vessel sealer (advanced bipolar). A fourth arm is generally not required but, if elected, may be used for the ProGrasp forceps.

We additionally use the robotic Weck clip applier for vascular ligation as well as to retract the kidney laterally if needed. A vascular stapler can be used as an alternative to clipping the vessels either laparoscopically through an assistant port or robotically through a 12-mm robotic trocar.