Ronney Abaza

Initial Series of Robotic Radical Nephrectomy with Vena Caval Tumor Thrombectomy

Laparoscopy has become a standard modality for most renal tumors but not as yet for renal cell carcinoma (RCC) involving the inferior vena cava (IVC). Robotic technology may facilitate such complex procedures. We report the first series of robotic nephrectomy with IVC tumor thrombectomy including the first cases requiring cross-clamping of the IVC in a minimally invasive fashion. Five patients underwent robotic nephrectomy with IVC tumor thrombectomy including one patient having two renal veins, each with an IVC thrombus, for a total of six IVC thrombi. The IVC was opened in all patients, and tumor thrombi were delivered intact, followed by sutured closure. The mean patient age was 64 yr (53-70 yr) with a mean body mass index of 36.6 kg/m(2) (22-43 kg/m(2)). Thrombi protruded 1 cm, 2 cm, 4 cm, and 5 cm into the IVC in five patients and 3 cm and 2 cm in the patient with two thrombi. The mean estimated blood loss was 170 ml (50-400 ml). Mean operative time was 327 min (240-411 min). Mean length of stay was 1.2 d. There were no complications, transfusions, or readmissions. This early series represents a limited experience by a single surgeon with a new procedure and may not be reproducible in larger numbers or by all surgeons. Further experience is necessary to validate this application.

Quality of Lymphadenectomy is Equivalent With Robotic and Open Cystectomy Using an Extended Template

PURPOSEnExtended lymph node dissection for bladder cancer provides better staging, cancerous node removal and potentially survival. Minimally invasive techniques have been criticized about the ability to adequately perform extended lymph node dissection. We compared the extended lymph node dissection quality of robotic and open cystectomy by assessing node yield and positivity.nnnMATERIALS AND METHODSnWe compared extended lymph node dissection in 120 open and 35 robotic cystectomy cases. Extended lymph node dissection included skeletonization of structures in each nodal group below the aortic bifurcation (common iliac, external iliac, obturator, hypogastric and presacral nodes). Nodes were processed identically but submitted as 1 or 2 packets for robotic cases and as 10 or more packets for open surgery cases.nnnRESULTSnThe mean±SD node count in the open group was 36.9±14.8 (range 11 to 87) and in the robotic group the mean yield was 37.5±13.2 (range 18 to 64). Only 12 of 120 open (10%) and 2 of 35 robotic (6%) cases had fewer than 20 nodes. A total of 36 open (30%) and 12 robotic (34%) cases were node positive. Open extended lymph node dissection identified 80% and 90% confidence of accurate staging as pN0 when obtaining 23 and 27 nodes, respectively. A node count of 23 or 27 was achieved in 87% and 77% of open cases, and in 91% and 83% of robotic cases, respectively. Of patients with open surgery 36% received neoadjuvant chemotherapy compared to 31% of those with robotic surgery.nnnCONCLUSIONSnNo difference was identified in the lymph node yield or the positive node rate when comparing open and robotic extended lymph node dissection. Local recurrence and survival data are needed to confirm whether the 2 techniques are oncologically equivalent.

Completely intracorporeal robotic renal autotransplantation.

PURPOSEnWe describe a technique of complete intracorporeal renal autotransplantation with donor nephrectomy and transplantation performed in a minimally invasive fashion without extracting the kidney.nnnMATERIALS AND METHODSnWe developed this technique of a completely intracorporeal robotic renal autotransplantation and determined the feasibility of this novel procedure. This includes a method of intracorporeal transarterial hypothermic renal perfusion using a perfusion catheter through a laparoscopic port. The procedure was successfully applied in a 56-year-old man with extensive left ureteral loss after failed ureteroscopy for ureterolithiasis.nnnRESULTSnRobotic donor nephrectomy was performed with a warm ischemia timexa0of 2.3 minutes. Subsequently cold ischemia was achieved by intracorporeal hypothermic renal perfusion for 95.5 minutes. Vascular anastomoses and ureteroureterostomy in the ipsilateral pelvis were completed afterxa0donor nephrectomy with a total overall surgeon console time of 334 minutes. Venous and arterial anastomosis times were 17.3 and 21.3 minutes, respectively. Estimated blood loss was less than 50 ml. There were no complications and the patient wasxa0discharged home on postoperative day 1 after normal Doppler transplant renal ultrasound. Postoperative renal scan at 6xa0weeks, intravenous urogram atxa08xa0weeks and computerized tomography urography atxa05 months revealed normal function and successful ureteral reconstruction.nnnCONCLUSIONSnWe report the feasibility of a technique of a completely intracorporeal robotic renal autotransplantation. This operation may be considered inxa0select patients in the hands of experienced robotic surgeons. However, furtherxa0refinement is required as this novel procedure is cautiously reproduced and adopted by others.

A Single Overnight Stay Is Possible for Most Patients Undergoing Robotic Partial Nephrectomy

OBJECTIVEnTo evaluate establishment of overnight stay only as sufficient after robotic partial nephrectomy (RPN).nnnMETHODSnStated benefits of minimally invasive surgery include reduced hospitalization, but published hospital stays after laparoscopic or robotic partial nephrectomy are not significantly less than with open surgery. We developed a clinical pathway targeting discharge on postoperative day (POD) 1 after RPN of any complexity. We reviewed all RPNs by a single surgeon since instituting our clinical pathway, including ambulation and diet the night of surgery, avoidance of intravenous narcotics and drains, and catheter removal on POD 1 before discharge. Targeted discharge was not modified regardless of RPN complexity.nnnRESULTSnA total of 150 consecutive patients underwent 160 RPNs with 35 hilar tumors and 26 with segmental, and 33 with no artery clamping. Three had solitary kidneys, and 8 underwent multiple (range, 2-4) RPNs. Mean patient age was 57 years (range, 22-89 years), and body mass index was 32 kg/m(2) (range, 18-54 kg/m(2)). Mean tumor size was 3.6 cm (range, 1.0-11.0; median, 3.2 cm), and the RENAL (radius, exophytic/endophytic, nearness to collecting system, anterior/posterior, and location) nephrometry score was 8 (range, 4-12; median, 8). Mean warm ischemia time was 12.1 minutes (range, 0-30.0 minutes). Mean preoperative and discharge creatinine were 0.9 mg/dL (range, 0.43-2.79 mg/dL) and 1.13 mg/dL (range, 0.56-2.93 mg/dL). All patients ambulated on POD 0. One patient required one dose of intravenous narcotic. Mean length of stay was 1.1 days, with 145 (97%) discharged on POD 1, of which only 4 (2.7%) were readmitted within 30 days.nnnCONCLUSIONnDischarge on POD 1 is feasible in most RPN patients regardless of complexity. Readmission rate was low, indicating that longer admissions may not prevent complications when patients meeting discharge criteria go home on POD 1.

Drain Placement Can be Safely Omitted After the Majority of Robotic Partial Nephrectomies

PURPOSEnDrain placement after partial nephrectomy is considered standard but it is based on routine and not on evidence. With experience we performed robotic partial nephrectomy and routinely omitted a drain even with significant collecting system violation. We have rarely used drains after robotic partial nephrectomy for several years, and we report our outcomes.nnnMATERIALS AND METHODSnWe reviewed a single surgeon, prospective database of all robotic partial nephrectomies from February 2008 to March 2012, including the characteristics of those with and without a drain.nnnRESULTSnThe 150 patients underwent a total of 160 robotic partial nephrectomy procedures with a drain used in 11 patients and omitted in 93%. Mean patient age was 57 years (range 22 to 89), mean American Society of Anesthesiologists score was 2.8 (range 2 to 4) and mean body mass index was 32 kg/m(2) (range 18 to 54). Values were similar in patients with and without a drain. In patients without a drain and in those with a drain mean tumor size was 3.5 cm (range 1.0 to 11.0) and 4.6 cm (range 1.1 to 8.6), and mean R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines, hilar tumor touching main renal artery or vein) nephrometry score was 7.8 (range 4 to 12) and 8.8 (range 6 to 11), respectively. Collecting system violation occurred in 88 patients (59%), including 78 without a drain. Two patients (1.3%) required transfusion with no intervention for bleeding. All except 5 patients (97%) were discharged home on postoperative day 1 with all drains removed before discharge. In 2 patients (1.3%) without a drain small urinomas without infection developed more than 2 weeks postoperatively, which were treated with a week of Foley catheter drainage and percutaneous drainage, respectively.nnnCONCLUSIONSnDrain placement after robotic partial nephrectomy can be routinely omitted with a low rate of urine leaks, which can be managed safely when they rarely occur.

Risk and Prevention of Acute Urinary Retention After Robotic Prostatectomy

PURPOSEnAcute urinary retention after catheter removal is a recognized complication following open or robot-assisted radical prostatectomy. We evaluated patient and surgery related risk factors to determine whether acute urinary retention could be prevented. To our knowledge this has not previously been investigated for prostatectomy done by any technique.nnnMATERIALS AND METHODSnWe reviewed a single surgeon, robot-assisted radical prostatectomy database of patients treated between February 2008 and June 2011 for acute urinary retention after catheter removal, which was routinely performed 3 to 7 days postoperatively. We compared the characteristics of patients with and without acute urinary retention.nnnRESULTSnOf 1,026 patients 25 (2.4%) experienced acute urinary retention. There was no difference between patients with and without acute urinary retention in mean age, body mass index, blood loss or prostate size, and no difference in the frequency of bladder neck reconstruction or nerve sparing. The catheter was removed an average of 4.1 vs 5.7 days postoperatively in patients with vs without acute urinary retention. Of 25 patients with acute urinary retention 22 (88%) underwent catheter removal on postoperative day 3 or 4. Although only 3 of 381 patients (0.8%) had a leak on cystogram on postoperative day 3 or 4, the acute urinary retention rate when the catheter was removed on day 3 or 4 was 5.8% (22 of 381). This was several times higher than the rate in patients who retained the catheter for greater than 4 days (3 of 645 or 0.5%).nnnCONCLUSIONSnAcute urinary retention develops infrequently after robotic prostatectomy. No patient related risk factors were identified beyond catheterization time. Although the catheter may be removed after 3 or 4 days with rare leaks, the acute urinary retention risk was much less when the catheter was left in place at least 5 days.

Techniques for Laparoscopic and Robotic Localization of Intraluminal Ureteral Pathology

OBJECTIVESnImprovements in endoscopic technology have made open ureteral surgery uncommon. There remain cases of ureteral disease not amenable to ureteroscopic treatment, but laparoscopy allows even these complicated cases to be treated in a minimally invasive fashion. Laparoscopic and robotic surgical treatment of the ureter requires the ability to localize the diseased segment laparoscopically, even when the defect is within the lumen and cannot be seen externally or palpated as in open surgery. We describe 3 techniques to localize the disease within the ureter during laparoscopy and robotic surgery and the benefits and limitations of each technique.nnnMETHODSnThree cases of laparoscopic and robotic ureteral surgery illustrate 3 different techniques used to localize disease within the ureteral lumen. The first case illustrates a ureteral occlusion balloon catheter used to identify a stricture by distending the collecting system proximal to the obstruction and cinching the balloon against the stricture. The second case illustrates a flexible ureteroscope introduced through a 5-mm port and into the incised ureter to guide excision of extensive polyposis. The third case, involving a polyp and stricture, illustrates a technique involving retrograde ureteroscopy with cutting to the light laparoscopically.nnnRESULTSnThree techniques are demonstrated to successfully localize intraluminal ureteral disease that could not be identified visually by laparoscopic inspection alone. These techniques also can minimize the extent of ureteral dissection to preserve blood supply.nnnCONCLUSIONSnLaparoscopy and robotic surgery can be successfully applied to benign ureteral disease not amenable to ureteroscopic treatment. Three cases are presented to illustrate 3 techniques for laparoscopic or robotic localization of intraluminal ureteral disease.

Prevention and Treatment of Transitional Cell Carcinomatosis With Intraperitoneal Chemotherapy in a Rat Model

PURPOSEnTumor spillage from bladder perforation during transurethral bladder tumor resection or cystectomy risks seeding the peritoneum with transitional cell carcinoma. We determined the lowest effective mitomycin C dose to prevent tumor implantation and the potential efficacy of delayed therapy. Additionally, we investigated the effect of tumor debulking combined with intraperitoneal mitomycin C.nnnMATERIALS AND METHODSnUsing our established murine model of intraperitoneal transitional cell carcinoma implantation mitomycin C was instilled at decreasing concentrations to find the lowest effective dose. To evaluate the effectiveness of delayed therapy mitomycin C was administered on day 3 or 7 after tumor implantation. Finally, surgical debulking of established tumors with or without mitomycin C was performed.nnnRESULTSnAll control animals had disseminated carcinomatosis. The lowest effective intraperitoneal mitomycin C dose to prevent implantation was 0.3125 mg/m(2). Administration of mitomycin C on day 3 after instillation resulted in tumor-free status in 50% of the animals, although no rats were tumor-free when treated on day 7. Tumor debulking only for established disease cured 40% of the animals, whereas debulking combined with mitomycin C had a 100% cure rate.nnnCONCLUSIONSnIntraperitoneal mitomycin C prevents tumor growth after transitional cell carcinoma implantation. Delayed therapy is not as effective as immediate treatment but cure is still possible, particularly when combined with surgical debulking, in a rat model.