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.
Operative steps
After access and docking of the robot, the surgery is initiated by mobilizing the colon medially. On the right side, the duodenum is Kocherized on approach to the IVC. The liver can be mobilized off of Gerota’s fascia early in the procedure to provide mobility or later after hilar control. A laparoscopic locking grasper can be used as a liver retractor through a 5-mm subxiphoid port. Alternatively, the shaft of the right robotic instrument can be used to lift the liver out of the way but typically is performed in this fashion by more experienced robotic surgeons, while those less experienced benefit from a liver retractor. If using a liver retractor, care should be taken to avoid internal or external collisions with this grasper to prevent displacement or tearing of the tissue to which it is secured, particularly if grasping the diaphragm.
On the left side, the spleen and pancreas should be mobilized as one unit along with the descending colon. This is generally uncomplicated but does require deliberate identification and care to avoid injury to the splenic vessels, the pancreas, or the spleen.
Robotic Weck clips may be used to secure the anterior Gerota’s fascia to the lateral abdominal wall and provide lateralization of the kidney for hilar visualization and to place the hilum on stretch. As mentioned previously, we prefer clipping of the renal artery and vein over stapling. Once the renal vein is found, the renal artery is generally immediately posterior to it. We favor a medial dissection keeping the gonadal vein lateral and usually medial to lumbar veins inserting on the renal vein when present. Working closer to the aorta in this fashion allows the dual benefit of finding the main renal artery before any potential early branches and also preparing for retroperitoneal lymph node dissection when planned.
On the left side, consideration should be taken to ensure that a renal artery suspected to be in an unusual location (i.e., more cranial) is not actually the superior mesenteric artery, as ligation of this is uniformly fatal if not recognized.
The renal artery should be controlled with at least two clips on the stay (aortic) side leaving a gap between them and a stump of artery distal to the second clip to prevent the possibility of clip slippage from the high-pressure blood flow in the aorta. In 2007, the United States Food and Drug Administration (FDA) issued a black-box warning regarding the use of Weck clips on the renal artery for donor nephrectomy due to reports of this occurring since, in donor nephrectomy, the artery is divided close to the aorta to preserve renal artery length for transplantation.
When the artery is difficult to access behind the renal vein, a single clip can be placed on the renal artery and then the renal vein ligated and divided before placing the remaining clips on the renal artery. The renal vein may be wider than the Weck clips, but the renal vein compresses easily and is never too large for clipping. Alternatively, vascular staplers can be used, but care must be taken to ensure that it is appropriately loaded, as misfires can be disastrous and challenging to recover robotically without open conversion. Lastly, the vessels can be suture ligated as an additional option, although this would require use of robotic needle drivers and may not be cost effective.
Following renal hilar control, attention is turned to the upper pole and preservation or resection of the adrenal gland when indicated. Small adrenal arteries between the upper pole and adrenal must be adequately controlled to prevent postoperative hemorrhage but, typically, bipolar cautery and not clipping is adequate. Dissection is then carried superolaterally toward the abdominal sidewall where care must be taken to not injure the diaphragm. The ureter is clipped and transected, and the lateral attachments are released, thereby freeing the kidney for placement in a large specimen bag for extraction.
Extraction through the midline avoids muscle splitting, but Pfannenstiel extraction is also commonly performed.
Postoperative care
Long-acting bupivacaine, either administered through a pain pump or liposomal formulation, is a nonnarcotic adjunct along with intravenous ketorolac (renal function permitting) that can reduce or eliminate the need for narcotics postoperatively. The Foley catheter can be removed prior to reversal of anesthesia as this helps with early ambulation and minimizes risks of catheter-associated urinary tract infection.
Special considerations
Large tumors
Minimally invasive surgery for extremely large renal tumors is most often limited by a lack of space within the insufflated abdomen. When a tumor is large enough that it fills a large proportion of the abdomen (e.g., crosses the midline), even with pneumoperitoneum, the space needed to allow dissection and mobilization of the extremely large mass and access to the renal vessels can be severely limited. The typical flank positioning for laparoscopic or robotic surgery will cause the tumorous kidney to droop over the aorta and vena cava, and the colon will often be “buried” in a crevice lateral to the tumorous kidney, as the line of Toldt will tether the colon to the abdominal sidewall as the tumor grows below (with its mesentery potentially severely thinned out) rather than displacing the colon medially.
In such settings, access to the renal vessels requires lateral retraction of the tumorous kidney that is often difficult to achieve due to the sheer weight of the specimen. Hand-assisted surgery can also be limited in these cases since there may not be adequate space in the abdomen for the surgeon’s hand. Robotic surgery allows a unique combination of factors aiding in these procedures. These include an ability to access tight locations with wristed instrumentation, and the strength of a robotic fourth arm to lift the large tumorous kidney to be able to reach the hilum. Also, the robotic laparoscope is stable and surgeon controlled such that it can be driven by the surgeon into narrow locations.
Critics of robotic surgery for large tumors maintain that such procedures require a large extraction incision to remove the tumorous kidney and therefore laparoscopic surgery is no less morbid than open. There remain advantages to the robotic approach despite this. For one, an open approach will often require a larger incision for exposure than would be needed for extraction of the specimen after internal robotic hilar division and complete mobilization. Unlike the open approach where the incision site will be dictated by the size and location of the tumor (e.g., large flank or chevron incision), with the robotic approach the tumorous kidney can be extracted at any site, including a midline incision to avoid cutting muscle. Also, large tumors often have significant neovascularity and parasitic vessels that are friable and can bleed easily. With open surgery such vessels can result in substantial blood loss, which can be significantly reduced with pneumoperitoneum and meticulous robotic dissection.
When these two advantages of robotic surgery for very large tumors are combined, patients can undergo nephrectomy with minimal or low blood loss and tumor extraction with less pain to allow earlier discharge (postoperative day 0 to 1) and return to normal activities ( Fig. 18.1 ). In the setting of cytoreductive nephrectomy, expeditious recovery is important in order to not delay systemic therapy.
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