Retroperitoneal single-site robot-assisted partial nephrectomy using Lapsingle Vision advanced access platform: initial three case reports

Abstract

Robot-assisted partial nephrectomy is currently the standard for treatment of small renal mass. Recently, robot-assisted single site surgery has been introduced. However, there have been few reports of retroperitoneal approaches. Herein, we report initial case series of retroperitoneal single-site robot-assisted partial nephrectomy using the da Vinci Xi surgical system using the Lapsingle Vision advanced access platform. Three patients have undergone retroperitoneal single-site robot-assisted partial nephrectomy due to incidental finding of renal mass. Operation duration, estimated blood loss, warm ischemia time, estimated glomerular filtration rate (eGFR) change, and complication were evaluated. Renal cell carcinoma of the two clear cell type and one chromophobe was diagnosed based on the pathological examination. Initial two cases were successfully completed with minimal bleeding and warm ischemic time within 25 minutes. The last 3rd case has been converted to multiport operation due to limited retroperitoneal space and difficulty in managing upper pole renal mass. Retroperitoneal single-site robot-assisted partial nephrectomy is a feasible treatment modality for treatment of posterior or lateral renal masses. Additional cases are needed to confirm the safety and efficacy of this technique.

Keywords: Kidney cancer; nephrectomy; retroperitoneal; robotics; single site case reports.

Figure 1

Computed tomography imaging of the tumors in three cases, 1 (A), 2 (B), and 3 (C).

Figure 2

Retroperitoneal space creation. (A) The incision was 3 cm, which was two fingers above the iliac crest just lateral to the triangle of Petit; (B) the external oblique muscle was separated using retractors to expose the lumbo-dorsal fascia; (C) a PDB balloon dilator (Tyco, Princeton, NJ, USA) was placed into the retroperitoneal space.

Figure 3

The port placement and docking procedure of retroperitoneal single-site robotic surgery using Lapsingle Vision advanced assess platform. (A) After retroperitoneal space creation; (B) lap single vision configuration for left side retroperitoneal single-site robot-assisted partial nephrectomy; (C,D) robotic arm installation and docking of robot during retroperitoneal surgery. Robot is docked over the patient’s head, parallel to the spine.

Figure 4

The step by step surgical procedure of retroperitoneal single-site robot-assisted partial nephrectomy. (A) Retroperitoneal anatomic relationships. The robotic scope is rotated for the psoas muscle in horizontal position. The ureter peristalsis is identified after balloon dissection of the retroperitoneum; (B) arterial pulsations are helpful to identify the renal artery, which is skeletonized in anticipation of hilar vascular control; (C) planning the excision margins by allowing accurate identification of the location, depth, and borders of the tumor; (D) hilar clamping can be performed using laparoscopic bulldog clamps; (E) the tumor is resected along the previously scored margin using cold scissors; (F) renorrhaphy is performed in two layers using robotic needle-drivers.

Video 1

Retroperitoneal single-site robot-assisted partial nephrectomy.