Robotic Retroperitoneoscopic Partial Nephrectomy: 4-Arm Technique

• Although kidney surgery has historically been performed in an open fashion with good results, the minimally invasive approach has become the gold standard for most kidney and ureteral surgery in the current era. Surgeries ranging from renal cyst decortication and pyeloplasty to more complex cases such as radical nephrectomy with IVC thrombectomy have been performed via a minimally invasive approach. In addition, robotic-assisted surgery has significantly increased the capabilities of most surgeons, and has facilitated even the most skilled laparoscopic surgeons to push the envelope for kidney surgery.

• Renal cell carcinoma remains the most lethal urologic malignancy and accounts for ~3% of all cancers diagnosed among men and women worldwide. For locally confined small renal masses and amenable larger masses, the standard of care for surgical management is partial nephrectomy. The minimally invasive options for access to the kidney are the traditional transperitoneal laparoscopic approach and the retroperitoneoscopic approach. The retroperitoneoscopic approach offers direct access to the kidney without the need to enter the peritoneal cavity, which is especially helpful in patients with multiple prior abdominal surgeries or a hostile abdomen, or in cases in which proper port placement would be difficult due to patient anatomy. In addition, certain renal masses that are located posteriorly are better accessed from a retroperitoneal approach rather than transperitoneal approach.

• Although the minimally invasive approach is applicable to nearly all kidney surgeries including partial nephrectomies, very select situations may necessitate an open approach. Very large tumors or those with extensive tumor thrombus may be better dealt with via open surgery. While the transperitoneal approach is contraindicated in patients with extensive prior abdominal surgery or a hostile abdomen, the retroperitoneal approach is still applicable. However, in patients with multiple percutaneous renal procedures, the retroperitoneum may be scarred and hence not allow adequate working space for the retroperitoneal approach.

Laparoscopic Ultrasound Probe
Robotic Surgical System

Full flank position with slight flexion. Robot docked over contralateral shoulder.

Pre-operative assessments
• A contrast enhanced CT or MRI with and without IV contrast is critical to preoperative assessment of renal masses and also in planning a partial nephrectomy. Renal mass biopsy, although not routinely indicated, may be beneficial in decision-making for potential active surveillance candidates, or in cases of in which a diagnosis of renal cell carcinoma is questionable. Once the decision is made for surgery, the size and location of the renal mass on preoperative imaging and patient comorbidities help determine whether to proceed with radical versus partial nephrectomy. Finally, tumor location and prior abdominal surgery play a major role in the decision for transperitoneal versus retroperitoneal approach.

1. Spacemaker hernia balloon used to open retroperitoneal cavity
2. Surgical landmarks identified and peritoneum Is swept medially for safe extraperitoneal port placement
3. Para-renal fat excised from Gerota’s fascia
4. Gerota’s fascia opened and peri-renal fat dissected off kidney
5. Renal hilum including artery and vein identified and dissected out
6. Tumor localized and depth/margins are delineated with drop-in laparoscopic ultrasound probe
7. Renal artery (and possibly vein) clamped with laparoscopic bulldog clamp
8. Tumor enucleated or resected using combination of sharp and blunt dissection
9. Collecting system repaired and bleeding vessels suture ligated, and renal parenchymal defect closed using bolsters
10. Clamp removed from hilar vessels and hemostatic agent applied
11. Drain placed if concern for urine leak due to collecting system entry

• Intraoperative complications include hemorrhage and injury to ureter, major vessels, bowel, and other surrounding organs
• Postoperative complications include retroperitoneal hematoma, urine leak, and A-V fistula or pseudoaneurysm formation

• Intraoperative complications include hemorrhage and injury to ureter, major vessels, bowel, and other surrounding organs
• Postoperative complications include retroperitoneal hematoma, urine leak, and A-V fistula or pseudoaneurysm formation

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