The future of "Retro" robotic partial nephrectomy

Abstract

Partial nephrectomy (PN) is the gold standard treatment for appropriately selected renal masses. Recent surgical advancements and adoption of the robotic technique has led to greater adoption of nephron-sparing surgery. Robotic PN was initially described via the transperitoneal (TP) approach, however, retroperitoneal (RP) access is possible and in some cases more desirable. In the RP approach, the kidney is accessed from its posterior surface and the intraperitoneal space is avoided. The RP approach to PN has the benefit of avoiding intraperitoneal viscera and colonic mobilization in patients with extensive prior abdominal surgery. The technique also eliminates the need for renal unit rotation in patients with posterior tumors and affords access to masses directly posterior to the renal hilum. The RP and TP approach to PN have shown similar oncologic and perioperative outcomes. Several recent studies have reported shorter operative times and lengths of stay (LOS) with comparable warm ischemia times for the RP approach when compared to transperitoneal PN (tPN). Given the indispensable deliverables of this approach in select patients, robotic retroperitoneal PN (rPN) should be in the armamentarium of a versatile urologic kidney surgeon. This review describes the current state of rPN and compares the indications and outcomes of the TP and RP approaches.

Keywords: Retroperitoneoscopic; partial nephrectomy (PN); renal mass; robotic partial nephrectomy; transperitoneal partial nephrectomy.

Figure 1

Patient positioning for rPN. Patient is placed in the lateral decubitus position and the OR table is placed in flexion to expand distance between the costal margin and iliac crest. Robot is docked at the patient’s head. rPN, retroperitoneal partial nephrectomy; OR, operating room.

Figure 2

rPN port placement. The iliac crest and costal margin at the 12th rib are marked. A 12-mm camera port is placed at the posterior axillary line between the marked anatomic landmarks. Robotic 8-mm ports are placed 6–8 apart, two medial to the camera port and one lateral to the camera port. A 12-mm assistant port is placed just off the iliac crest between the 12-mm camera port and the most medial 8-mm robotic port. rPN, retroperitoneal partial nephrectomy.

Figure 3

Patient positioning for tPN. Patient is placed in a modified lateral decubitus position. Robot is docked from the patient’s side. tPN, transperitoneal partial nephrectomy.

Figure 4

tPN port placement. The costal margin is marked. A 12-mm Camera port is placed cephalad to the umbilicus and lateral to the rectus muscle. The 8-mm robotic ports are placed along a straight line, cephalad to caudad, from the camera port, approximately one hand-breadth apart, starting just underneath the costal margin. A 12-mm assistant port is placed cranial and lateral to the umbilicus. tPN, transperitoneal partial nephrectomy.

Figure 5

Retroperitoneoscopic robotic partial nephrectomy for a patient with “hostile abdomen”. Patient with a colostomy, such as the one pictured, is an appropriate candidate for retroperitoneal access for kidney surgery, as intraabdominal adhesions and pathology are completely avoided.