Manish N. Patel

Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes.

PURPOSE Robot assisted partial nephrectomy is rapidly emerging as an alternative to laparoscopic partial nephrectomy for the treatment of renal malignancy. We present the largest multi-institution comparison of the 2 approaches to date, describing outcomes from 3 experienced minimally invasive surgeons. MATERIALS AND METHODS We performed a retrospective chart review, evaluating 118 consecutive laparoscopic partial nephrectomies and 129 consecutive robot assisted partial nephrectomies performed between 2004 and 2008 by 3 experienced minimally invasive surgeons at 3 academic centers. Perioperative data were recorded along with clinical and pathological outcomes. RESULTS The robot assisted and laparoscopic partial nephrectomy groups were equivalent in terms of age, gender, body mass index, American Society of Anesthesiologists classification (2.3 vs 2.4) and radiographic tumor size (2.9 vs 2.6 cm), respectively. Comparison of operative data revealed no significant differences in terms of overall operative time (189 vs 174 minutes), collecting system entry (47% vs 54%), pathological tumor size (2.8 vs 2.5 cm) and positive margin rate (3.9% vs 1%) for robot assisted and laparoscopic partial nephrectomy, respectively. Intraoperative blood loss was less for robot assisted vs laparoscopic partial nephrectomy (155 vs 196 ml, p = 0.03) as was length of hospital stay (2.4 vs 2.7 days, p <0.0001). Warm ischemia times were significantly shorter in the robot assisted partial nephrectomy series (19.7 vs 28.4 minutes, p <0.0001). Subset analysis based on complexity revealed that tumor complexity had no effect on operative time or estimated blood loss for robot assisted partial nephrectomy, although complexity did affect these factors for laparoscopic partial nephrectomy. In addition, for simple and complex tumors robot assisted partial nephrectomy provided significantly shorter warm ischemic time than laparoscopic partial nephrectomy (15.3 vs 25.2 minutes for simple, p <0.0001; 25.9 vs 36.7 minutes for complex, p = 0.0002). There were no intraoperative complications during robot assisted partial nephrectomy vs 1 complication during laparoscopic partial nephrectomy. Postoperative complication rates were similar for robot assisted and laparoscopic partial nephrectomy (8.6% vs 10.2%). CONCLUSIONS Robot assisted partial nephrectomy is a safe and viable alternative to laparoscopic partial nephrectomy, providing equivalent early oncological outcomes and comparable morbidity to a traditional laparoscopic approach. Moreover robot assisted partial nephrectomy appears to offer the advantages of decreased hospital stay as well as significantly less intraoperative blood loss and shorter warm ischemia time, the latter of which may help to provide maximal preservation of renal reserve. In addition, operative parameters for robot assisted partial nephrectomy appear to be less affected by tumor complexity compared to laparoscopic partial nephrectomy. Interestingly while the advantages of robotic surgery have historically been believed to aid laparoscopic naïve surgeons, these data indicate that robot assisted partial nephrectomy may also benefit experienced laparoscopic surgeons.

Robotic Partial Nephrectomy for Renal Tumors Larger Than 4 cm

BACKGROUND Minimally invasive partial nephrectomy (PN) is most commonly performed for renal tumors < or =4 cm in size. Robotic PN (RPN) for tumors >4 cm has not been assessed. OBJECTIVE To evaluate the safety and feasibility of RPN for tumors >4 cm in the context of patients undergoing RPN for tumors < or =4 cm. DESIGN, SETTING, AND PARTICIPANTS We reviewed data for 71 consecutive patients who underwent transperitoneal RPN at a tertiary care center between August 2007 and September 2009 by a single surgeon. Patients were stratified into two groups: 15 with tumors >4 cm on preoperative imaging (group 1) and 56 patients with tumors < or =4 cm (group 2). INTERVENTION All patients underwent transperitoneal RPN by a single surgeon. MEASUREMENTS Preoperative, perioperative, pathologic, and functional outcomes data were analyzed and compared between groups. We used chi(2) and student t tests for categorical and continuous variables, respectively. A p value <0.05 was considered statistically significant. RESULTS AND LIMITATIONS Mean radiographic tumor size was 5.0 cm (4.1-7.9) for group 1 and 2.1cm (0.7-3.8) for group 2. No significant differences were found between groups for estimated blood loss, total operative time, hospital stay, complication rates, and change in estimated glomerular filtration rate. Patients with larger tumors had longer median warm ischemia times (25 vs 20 min; p=0.011). Limitations of our study include the retrospective nature the analysis, small sample size, and single-surgeon experience. CONCLUSIONS In our initial experience, RPN for tumors >4 cm is safe and feasible, showing comparable outcomes to RPN for smaller tumors, although with longer warm ischemia times. Future studies with extended follow-up are necessary to determine the viability of RPN for large tumors as an effective form of treatment.

Robotic-assisted partial nephrectomy.

Surgical resection is the standard for treatment for RCC and partial nephrectomy (PN) is the treatment of choice for tumours < 4 cm [1]. Laparoscopic PN (LPN) is a viable alternative to traditional open PN, giving good oncological and functional outcomes [2–4]. LPN is a challenging procedure, particularly with intracorporeal suturing under the time constraints of warm ischaemia. The introduction of the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) with wristed instruments and magnified, three-dimensional vision, can facilitate the technical challenges of minimally invasive PN. The technique of robotic PN (RPN) is still developing and several institutions have recently reported their results [5–11]. Here we present our technique for RPN using a transperitoneal approach.

Robotic partial nephrectomy in the setting of prior abdominal surgery

Study Type – Therapy (case series)

The Impact of Previous Inguinal or Abdominal Surgery on Outcomes After Robotic Radical Prostatectomy

OBJECTIVES To evaluate our experience with robotic radical prostatectomy (RRP) in the setting of previous inguinal or abdominal surgery. METHODS From a prospective cohort of 3950 consecutive patients who underwent transperitoneal RRP between September 2001 and September 2008, we identified 1049 (27%) patients with a history of abdominal or inguinal surgery. Demographic data including body mass index, age at the time of surgery, serum prostate-specific antigen, and clinical stage were prospectively recorded. Clinical endpoints measured included estimated blood loss (EBL), console time, total operative time, and perioperative complications. Degree of adhesiolysis at the time of surgery was graded into minor, moderate, or large. RESULTS In comparing patients with previous abdominal or inguinal surgery with no surgery, there were no differences in EBL (150 vs 151 mL, P = .79), total operative time (158 minutes v second 155 minutes, P = .15), body mass index (27.8 vs 27.4, P = .2), preoperative prostate-specific antigen (6.1 vs 6.3, P = .07) and clinical stage (P = .71). A total of 243 (24%) of patients with previous surgery required adhesiolysis vs 246 (8%) of patients with no previous surgery (P <.001). Appendectomy was the most common previous surgery identified (11%). Patients with a previous history of colectomy had the highest incidence of adhesiolysis (72%). A total of 5 bowel injuries were recorded in the cohort of 3950 patients; of these 3 patients had a history of prior abdominal surgery. CONCLUSIONS Previous abdominal or inguinal surgery is not a contraindication to RRP. The majority of these patients can have their procedure safely performed without an increased risk of complications.

Robot-Assisted Management of Congenital Renal Abnormalities in Adult Patients

INTRODUCTION Congenital anomalies of the genitourinary tract are usually diagnosed and corrected in childhood. Robot-assisted management of congenital urologic abnormalities in adult patients has not been described previously. We present a series of patients with congenital renal abnormalities diagnosed in adulthood and managed using a robotic approach. METHODS Four patients at our institution were identified with congenital renal abnormalities diagnosed in adulthood. One had a duplicated collecting system with hydronephrosis of a thinned out upper pole moiety and underwent heminephroureterectomy. A second had right hydronephrosis, complete atrophy of the right renal cortex, and a dilated tortuous ureter with obstructing ureterocele and underwent simple nephrectomy. A third patient had a duplicated system with distal ureteral reflux and an ureterocele and underwent ureteroureterostomy and distal ureterectomy. The fourth had a duplicated collecting system with ureterovaginal fistula of the upper pole moiety. Perioperative variables were collected including operative time, estimated blood loss, length of hospital stay, and change in estimated creatinine clearance. RESULTS Mean age was 35 years (range 16-54), mean body mass index was 30.9 kg/m(2) (21.8-42.5), and mean baseline estimated creatinine clearance was 147.7 mL/minutes (107.7-214.6). Mean operative time was 258 minutes (151-374) and mean estimated blood loss was 44 mL (25-50). Postoperative estimated creatinine clearance was 133.1 mL/minutes (115.9-160.9), which was not statistically different from preoperative values (p = 0.608). All patients were discharged by postoperative day 2. There were no perioperative complications. CONCLUSIONS Robot-assisted management of congenital renal abnormalities is a feasible and efficacious treatment modality in adult patients with low morbidity and good outcomes.

Robotic-assisted partial nephrectomy: has it come of age?

Surgical resection is the gold standard for the treatment of renal cell carcinoma, and partial nephrectomy (PN) is the treatment of choice for tumors smaller than 4 cm in size. A laparoscopic PN is a viable alternative to a traditional open PN, demonstrating good oncologic and functional outcomes. A laparoscopic PN is a challenging procedure, particularly performing intracorporeal suturing under the time constraints of warm ischemia. The introduction of the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA) with wristed instruments and magnified, 3-dimensional vision may facilitate the technical challenges of a minimally invasive PN. The technique of robotic partial nephrectomy (RPN) is still evolving and a number of institutions have recently reported their results. In this article, we present a review of the literature and our technique for robotic PN using a transperitoneal approach.

Robotic partial nephrectomy: A comparison to current techniques

The bar has been set high for nephron sparing surgery by experts in both open and laparoscopic approaches. Robotic partial nephrectomy has emerged as an option for minimally invasive nephron sparing surgery. We discuss the current literature for robotic partial nephrectomy in the context of reported outcomes for open and laparoscopic partial nephrectomy.

Robotic Urologic Surgery: Robot-Assisted Partial Nephrectomy

For renal masses smaller than 4 cm, open partial nephrectomy (OPN) has been the preferred surgical procedure to preserve renal function and minimize the long-term complications associated with renal insufficiency. Laparoscopic partial nephrectomy (LPN) has emerged as a viable alternative to OPN with comparable long-term oncologic and functional outcomes, but with the convalescence benefits of a minimally invasive approach. However, LPN is a technically challenging procedure, particularly in regard to intracorporeal sutured renal reconstruction under the time constraints of warm ischemia. Robotic assistance for partial nephrectomy with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) may facilitate some of the technical challenges of LPN by giving the surgeon three-dimensional stereoscopic vision, a tremor-free platform, and wristed instruments which help recapitulate the open technique.

Robotic Assisted Radical Nephroureterectomy with Bladder Cuff Excision and Regional Lymphadenectomy

Radical nephroureterectomy is a challenging operation as it combines both an extirpative and reconstructive procedure in both the upper and lower urinary tracts. In the past, most surgeons elected to do this procedure either entirely open or with a large open incision to peform the bladder cuff excision and reconstruction. In this chapter, we aim to describe our technique for completely robotic assisted nephroureterectomy with bladder cuff excision and regional lymphadenectomy with tips and tricks to help surgeons perform this procedure easily and efficiently.