Robotic Partial Nephrectomy Technique

Arieh L. Shalhav

Nimrod Barashi Research Fellow

Management of Challenging Renal Masses:

Advanced Techniques in RAPNx FOI 2018

The presenter has no relevant financial

relationships to disclose for this session

My Guiding Principles for Complex RAPNx

• It always looks easier in clinic, discuss realistic expectations with patient

• Verify US detectability preop

for Completely Endophitic tumors

• Plan the dissection/Excision – Study preop imaging well, Note irregular/infiltrating tumors, stranding

(Not all SRM are equal)

– Perform thorough intraop US as

your spatial image based on CT/MRI only may misguide you

– Build a mental 3D image in relation to collecting system and vessels

My Guiding principles for complex RAPNx

• Transperitoneal – my preferred approach

• For complex cases, whatever is needed

• A Radical Nephrectomy or Open partial are preferred

to oncological compromise or major complication,

especially in patient with 2 kidneys and good GFR

Master and Teach Intraop UltraSound

• Know the hook up and use the US keyboard

• Learn to use Tile Pro (PIP)

• Know how to use the Laparoscopic probe

• Completely delineate endophytic tumors

• Recognize vessels close to excision line (Doppler)

• Mark the excision line on the capsule

Case 1

• 47 y/o male,

• incidental 4 cm

Completely endophytic right lower pole

• no previous abdominal surgeries

• eGFR= 92, Hg= 15 g/l.

Plan your dissection

Setup and ports placement

“The way you make your bed determines how you sleep”

Grandma 1961

• Flank position with care to pad all pressure points

• Patient must be secured (taped) to the table (XI)

• Determine optimal bed position and final port

placement after lap view established

• If you think about repositioning/adding trocars do it.

Setup and port placement (Rt)

Legs

Head

Reflect the colon and get hilar control

🎯

Complete dissection of perinephric fat ( Nice case)

🎯 🎯 🎯 🎯

Dissection of perinephric fat ( Nasty case)

Precise tumor delineation with ultrasound

🎯 🎯

Hilar cinching and clamping

Cold Scissors Tumor Excision

Suturing renal parenchyma and capsule

🎯 🎯 🎯

Unclamping and hemostasis assurance

Endo-bag, Nephropexy, Drain

Outcomes

• OR time: 160 min, Warm ischemia : 26 min

• EBL: 50 cc, Hg stable at 13.4 g/l

• Post operative eGFR= 59

• Follow-up at 3 months: eGFR= 76

• Pathology Clear cell Fuhrman Grade 2, margins -

• Catheter removed at 6am, drain at 2pm on POD1

discharged at 3pm POD 1

Thank You