INTRODUCTION: Radical nephrectomy with IVC thrombectomy is a challenging procedure. A crucial step is the control of the cranial edge of the thrombus, which can be made with the assistance of indocyanine green (ICG) guidance.
METHODS: Preoperative embolization of right renal arteries was performed. Liver was mobilized to expose the retrohepatic IVC. IVC was prepared, cranially and distally to the neoplastic thrombus. All lumbar veins, visible short hepatic veins and right gonadal vein were secured, while left renal vein was isolated for tourniquet encircling.
Right renal arteries were transected and previously applied tourniquets were synched down after confirming with near infrared fluorescence (NIF) the proper control of cranial thrombus edge. Cavotomy was performed and the thrombus delivered and secured into an endo catch bag. IVC lumen was copiously irrigated with heparin saline solution and IVC suture performed. After tourniquets removal, NIF was used to confirm proper restoration of IVC flow. Finally, nephrectomy was completed.
RESULTS: Operative time was 300 minutes. EBL was 350 ml. Patients was discharged on 7th postoperative day. Postoperative course was uneventful.
CONCLUSIONS: NIF imaging represents a significant technical advancement in management of level III IVC tumor thrombi, to improve control of cranial thrombus edge and to confirm proper restoration of IVC flow after cava suture.
INTRODUCTION: we highlight surgical steps of a left adrenalectomy and left renal vein tumor thrombectomy.
METHODS: preoperative CT scan highlights a 7 cm left adrenal mass with a tumor thrombus extending into the left renal vein. Left renal vein was prepared and encircled with tourniquet distally to the renal vein branch. After left renal artery identification, left renal vein was furtherly prepared and a tourniquet was placed proximally to the left renal vein branch. Left adrenal vein was hence isolated and encircled with tourniquet. Left renal vein and left adrenal vein tourniquets were cinched down and a renal vein was incised and the thrombus meticulously removed, in conjunction with the adrenal vein ostium. Left adrenal vein was stapled and the specimen secured into an endocatch bag. The left renal vein was sutured and all tourniquets removed, without any blood leakage. The adrenal mass was then progressively dissected and secured in an endobag.
RESULTS: Operative time was 170 minutes. Perioperative course was uneventful and patient was discharged in postoperative day 5. The pathologic report showed a primary adrenocortical carcinoma. Post operative CT scan was negative.
CONCLUSIONS: robot-assisted left adrenalectomy with left renal vein tumor thrombectomy is a feasible and safe treatment option in a tertiary referral center, with favourable perioperative outcomes.
INTRODUCTION: In this video, we highlight surgical tips and tricks for: extensive retrohepatic IVC dissection during level 3 thrombus IVC thrombectomy, thrombus cranial margin control, and intraoperative complications management that can occur during IVC thrombus dissection.
METHODS: The following surgical tips and trips were highlighted: an extensive retrohepatic IVC dissection, with liver mobilization,essential for a wide exposure of retrohepatic IVC; the use of an occluding balloon fogarty catheter under transesophageal control, and, alternatively, ICG guidance,to better identify and control level 3 IVC tumor thrombi cranial edge;management of intraoperative complications during IVC opening and thrombus dissection.
RESULTS: An extensive retrohepatic IVC dissection,the use of an occluding balloon fogarty catheter under transesophageal control, and ICG guidance, represent very useful tools, to better identify and control level 3 IVC tumor thrombi cranial edge.
The management of unforeseen intraoperative complications, during IVC opening and thrombus excision, is a crucial point, during robotic IVC surgery.
CONCLUSIONS: Robotic IVC thrombus surgery represents a challenging procedure, and requires highly expertise skills in advanced urologic robotic surgery.
INTRODUCTION: We describe a novel technique to mark endophytic renal tumors with transarterial superselective delivery of indocyanine green (ICG)-lipiodol mixture, in patients selected for purely off clamp (OC) robotic partial nephrectomy (RPN).
METHODS: Between September 2017 and October 2017, 10 consecutive patients with predominantly or totally endophytic renal masses underwent superselective transarterial tumor ICG marking and bland embolization immediately before OC-RPN. Preoperative transarterial bland embolization was performed with superselective delivery of lipiodol-indocyanine green mixture (1 to 2 by volume, mixing 1.5 millilitres of indocyanine green with 3 millilitres of lipiodol) into tertiary order arteries feeding the tumor. Purely OC-RPN was performed.
RESULTS: Median PADUA nephrometry score was 10 (IQR 9-11). Median operative time was 75 minutes (IQR 65-85), median estimated blood loss was 250 mL (IQR 200-350). Bland embolization was uneventful in all patients. Hilar clamp was not necessary in any case. Perioperative course was uneventful for all patients and median hospital stay was 3 days (IQR 2-3).Surgical margins were negative in all cases. Eight (80%) patients had renal cell carcinoma histology at final pathology.
CONCLUSIONS:Key benefits of this technique include a quick identification of the mass, avoiding any use of intraoperative ultrasound imaging, and a real time control of resection margins thanks to an improved visualization of tumor.
Scopo di questo video è presentare “step by step” la tecnica di chirurgia conservativa del surrene in pazienti affetti da S.me di Conn (adenoma secernente).
MATERIALI E METODI
Con il paziente in decubito laterale si posizionano i trocars secondo lo schema abituale della chirurgia transperitoneale della loggia renale. Si procede, attraverso la medializzazione del colon discendente, all’accesso al retroperitoneo e, previa incisione della fascia di Gerota, all’identificazione della ghiandola surrenalica. Isolamento dei vasi surrenalici, della ghiandola e dell’ adenoma che viene asportato mediante l’utilizzo di Ligasure ed hem-o-lok con ottimo controllo emostatico.
Il tempo operatorio è stato di circa 90 min, le perdite ematiche esigue (circa 100cc) e non abbiamo riscontrato complicanze perioperatorie. L’ospedalizzazione è stata di 4 giorni. Al follow-up dopo 12 mesi la sintomatologia era scomparsa.
Il trattamento della sindrome di Conn consiste generalmente nella surrenalectomia laparoscopica o Robot-assistita. Tuttavia la monolateralità pressoché esclusiva della malattia, generalmente le piccole dimensioni della tumefazione e la rarità estrema di malignità biologica depongo per la possibilità di un trattamento conservativo.
Il video proposto ha evidenziato come il trattamento laparoscopico conservativo dei tumori secernenti Aldosterone sia fattibile, riproducibile e sicuro. Questa procedura ha il vantaggio di preservare parenchima sano e di permettere un più rapido recupero post-operatorio.
SCOPO DEL LAVORO
Il video descrive step by step il trattamento crioablativo percutaneo imaging combinato (US/CT) di una lesione di 2cm all’interno di una cisti complessa in una paziente affetta da rene policistico.
MATERIALE E METODI
Nel nostro centro abbiamo trattato 53 pazienti con crioablazione percutanea TC guidata; in 4/53 abbiamo utilizzato un approccio combinato (US e CT); si trattava di pazienti con IR severa (eGFR <30) in cui era controindicata la somministrazione del mdc iodato.
Nella nostra esperienza il tasso di recidiva locale di malattia (4/53) è stato dello 7.5%. In tutti e 4 i pazienti trattati con approccio combinato non ci sono stati né residui, né recidiva di malattia. La preservazione della funzionalità renale permette di considerare tale tecnica sicura in quei pazienti ad elevato rischio di sviluppare un’IRC.
DISCUSSIONE E CONCLUSIONE
Il video proposto ha evidenziato come il trattamento crioablativo percutaneo con imaging combinato (US e CT) sia una metodica relativamente semplice nella guida della criosonda e che consente un approccio sicuro ed efficace specialmente in casi selezionati dove per la presenza di patologie preesistenti o anomalie anatomiche non sia possibile effettuare un trattamento chirurgico o ercutaneo esclusivamente CT guidato.
The video shows two patients underwent off-clamp laparoscopic tumor enucleation after a meticulous analysis of preoperative imagining. The first case is a 57 year old woman diagnosed with 3.4 cm right renal tumor, normal renal function, PADUA score 6, loacated on segment 9, 70% exophytic, 15 mm distant from collecting system, absence of feeding arteries and integrity of the pseudocapsule surrounding the tumor. The second case is a 50 year old gentleman with stage 3 CKD diagnosed with cm right oncocytoma involving segments 3 and 1, 30% exophytic, 3 mm distant from the collecting system, no feeding arteries identified and a complete pseudocapsule surrounding the tumor.
In the first case operative time was 115 minutes, estimated blood loss 250 ml and the patient was discharged on postoperative day 3. Final pathology showed pT1a cromophobe RCC.
In the second case operative time was 125 minutes, estimated blood loss 300 ml and the patient was discharged on postoperative day 3. Final pathology confirmed the diagnosis of oncocytoma.
Preoperative imaging of renal masses with a standardized report and a meticulous analysis of tumor characteristics can help urologists to offer patients a tailored surgical approach to maximize renal function preservation without undermining oncologic principles and safety.
This video describes the main steps of the robot-assisted laparoscopic retroperitoneal lymphadenectomy for lymph node metastasis occurred after radical nephrectomy for renal cell carcinoma. Previous laparoscopic right nephrectomy showed a renal clear cells adenocarcinoma with rhabdoid and sarcomatoid features (Fuhrman grade 3-4). With the patient in left lateral position five ports were placed transperitoneally. Open access technique was used for primary trocar. Three robotic trocars were placed on pararectal, the fourth port 2cm to the iliac crest. The laparoscopic Air-Seal port was placed between the central and the right port on the xifopubic line. The first step was the liberation of intense retroperitoneal adhesions due to previous surgery. Hem-o-lok clips were used to control peritumoral vessels. A large lymphatic retroperitoneal mass of about 10cm in diameter was en-bloc excised. The hemostasis was obtained with the use of Floseal and Tabotamp. The operative time was 120 minutes. Estimated blood loss was minimal. No intraoperative and postoperative complications occurred. The patient was discharged four days after surgery. The patology report confirmed lymphatic metastasis of renal clear cells carcinoma with rhabdoid/sarcomatoid features (Fuhrman grade 4). The Robot-assisted laparoscopic retroperitoneal lymphadenectomy is a feasible approach to treat metastatic lymphnodes.
Il video descrive il trattamento laparoscopico di una voluminosa massa renale sinistra polare inferiore di oltre 8 cm, in paziente donna di anni 29.
Vengono inquadrate le sedi dei trocars transperitoneali e gli steps chirurgici:
mobilizzazione del colon discendente ed esposizione del rene,
isolamento dell’ilo vascolare e posizionamento di vessel loop sull’arteria renale sinistra principale,
extrarotazione del rene,
preparazione dell’adipe perirenale,
identificazione della massa e marcatura della linea di sezione,
enucleazione della massa,
trattamento di vaso arterioso diretto alla massa neoplastica,
sliding suture emostatica,
posizionamento di surgiflo,
dissezione della massa dall’adipe perirenale,
posizionamento della massa in endobag.
I tempi chirurgici sono stati 120 min, le perdite ematiche 400 ML. Non sono state registrate complicanze perioperatorie.
l’esame istologico è esitato in clear cell carcinoma ISUP III, necrosi presente, capsula presente e continua, margini chirurgici negativi.
Nonostante la sede della neoplasia, sita sulla superficie posteriore del rene, nel caso trattato è stato adottato l’accesso transperitoneale per ridurre al minimo la manipolazione della massa, operando di fatto una dissezione del rene dalla neoplasia, che sarebbe invece comparsa nel campo operatorio subito frontalmente, se fosse stato adottato l’accesso lomboscopico.
In this study of factibility, ee tested and review our technique of robot-assisted laparoscopic renal cyst removal using a new robotic device (SenHance) on human patients.
We set up an operating theatre to test SenHance on consecutive laparoscopic robot assisted renal cyst removal to be performed in total anesthesia. The console incorporates the following main components: an ergonomic seat, the Robotic Master (RM) with haptic handles, a 3D-HD monitor, an eye-tracking system (ETS), a keyboard and a touchpad, and one foot pedal. The ETS is an infrared-based eye tracking system that detects which point the surgeon is looking at. There was one surgeon placed at computer-console and one surgeon placed at the surgical table. We adapted the laparoscopic technique to perform the procedure. The haptic sensation can be used for pushing or pulling to estimate elasticity and consistency of tissues and controlling the tensility of the sutures when tying. Low-cost disposable or reusable instruments were used.
To date, we performed 8 renal cyst removal with SenHance robot. Three robot’s arms were used. 5 procedures were on the right kidney, while 3 were on the left one. The mean surgical time was 45.77 minutes (range 31-72 min). The mean diameter of the cysts was 9.4 cm (range 7.5-15 cm). The mean blood loss was 58.6 ml (range 20-100 ml). Mean cost per intervention was 950 Euros.
Range of competing robotic surgical systems is expected to enter the market in the next 5 years. The new technology offered has the potential to improve surgical ergonomics. With the market dominated by the high-performing but expensive generations of the da Vinci for almost 20 years, newer, economic machines may make robotic surgery accessible to wider populations. The high cost associated with robotic surgery was partly explained by Intuitive Surgical being the sole producer of commercial robotic surgical systems. In 2019 a number of their intellectual property patents are due to expire. Competing master-slave system Telelap Alf-X by TransEnterix has now entered the market with sales made in Italy and Japan, and has an application with the U.S. Food and Drug Administration pending. Several other systems are also expected to be marketed within the next 5 years . Increased competition, reusable instruments, and a resulting reduction in cost will lead to a stronger economic argument for robotic-assisted surgery, and expansion to more centers and regions is likely.
The closed console of da Vinci envelops the surgeon’s face and compromises his or her situational awareness within the operating theatre. Telelap Alf-X and the newer Revo-I, currently undergoing trials in Korea , promise open surgeon consoles with the potential to improve operating ergonomics. The Telelap Alf-X monitor requires the surgeon to wear 3D glasses and incorporates eye-tracking, whereas Revo-I boasts a 3D high definition monitor .
A major limitation of robotic surgical systems was the lack of haptic feedback compared to traditional laparoscopic technique. Telelap Alf-X is the first commercial robotic platform to incorporate haptic feedback technology. Via counter-movement of the console handles, the surgeon receives tactile information regarding force and its direction applied at the surgical site. Haptic feedback while operating increases surgical awareness and improves security .
Robot-assisted laparoscopic renal cyst removal using SenHance is safe, feasible and reproducible procedure. Moreover it offers a good perception when instruments touch each other avoiding collision between robotic arms. It also offers a reduction of costs per intervention.
1. Hannah Warren, Prokar Dasgupta
The future of robotics
Investig Clin Urol. 2017 Sep; 58(5): 297–298