Robotic Surgery in Urology Robotic Partial Nephrectomy
The widespread use of imaging techniques has revolutionised therapy modalities for small renal masses. Small renal lesions are excellent candidates for nephron-sparing surgery. Open partial nephrectomy for patients with renal cell carcinoma
Studies also showed that radical nephrectomy is associated with a lower overall survival rate for patients
Huang et al. looked at the glomerular filtration rate in 622 patients after radical and partial nephrectomy and concluded that radical nephrectomy is a massive risk factor for the development of chronic kidney disease. Therefore, this group of authors questioned radical nephrectomy’s status as the gold standard for small renal cortical tumours.55
Nephron-sparing surgery goes along with the need for a bloodless field during tumour resection within a limited warm ischaemia time followed by haemostatic renorhaphy. Factors associated with better functional outcome following nephron-sparing surgery are hilar clamping, adjunctive use of haemostatic agents and renal parenchymal closure by suture ligation.57
20 minutes of warm ischaemia time59 and cold ischaemia should be
kept as short as possible and ideally should not exceed 35 minutes.66 Blood loss during nephron-sparing surgery is typically less than 200ml. Complications are reported in 0–17% of cases, rarely with a need to convert robotic laparoscopic surgery into open surgery. PSMs are found in 0–2.3% of patients and, to date, there has only been one reported recurrence following robot-assisted laparoscopic nephron-sparing surgery.67
Benway et al.68 Laparoscopic nephron-sparing surgery shows
equivalent results to the open approach, but its role is still under debate because of an average 10-minute longer warm ischaemia time than with open procedures (30.7 versus 20.1 minutes).58
Laparoscopic robotic surgery demands a more complex cooling of the kidney during surgery compared with conventional open surgery. Several methods have been described to optimise and facilitate cold ischaemia because mean ischaemia times tend to be significantly longer than during open partial nephrectomies. The techniques used include surface cooling using ice slush,59 irrigation using ice-cold solutions60 using ice-cold saline.61
renal artery and ureteral retrograde irrigation The first two cooling methods require the
intravenous application of mannitol before clamping the renal vessels in order to avoid any parenchymal oedema or damage to nephrons.
Control of haemostasis is an important factor during nephron-sparing surgery. The use of the gelatine matrix thrombin sealant FloSeal® during partial nephrectomy has shown a significant reduction in overall complication rates. Positive tendencies could be observed regarding post-operative haemorrhagic complications and urine leakage.62
Since that time it has steadily gained acceptance as a viable alternative to the conventional open and laparoscopic therapy modalities. Initial reports on robotic nephron-sparing surgery did not show clear benefits of the new surgical method, but recent studies demonstrated that robotic-assisted partial nephrectomy seems to be a safe and technically feasible minimally invasive approach to nephron-sparing surgery with acceptable pathological and renal function outcome.64
In 2004, robot-assisted partial nephrectomy was first reported by Gettman et al.63
Most robotic series report on a hybrid technique, with the initial steps of the nephron-sparing surgery carried out with standard laparoscopic transperitoneal dissection.65
The current
literature shows that warm ischaemia times range from 18 to 22 minutes, with overall operative times ranging from 83 to 170 minutes. The historical cut-off for warm ischaemia times is commonly thought to be 30 minutes; until this point recovery of full renal function is expected. However, a recent review of the current literature suggests that if ischaemia is required, the tumour should be removed within
EUROPEAN UROLOGICAL REVIEW
recently published the largest multicentre robot-assisted partial nephrectomy experience to date. Four high-volume centres were included in the study design. A total of 183 patients who underwent robotic partial nephrectomy were retrospectively evaluated. The reported mean age at the time of surgery was 59.3 years. Mean tumour size was 2.87cm. Mean total operative time was 210 minutes, while mean ischaemia time was 23.9 minutes. Calyceal repair was required in 52.1% of cases. Mean estimated blood loss was 131.5ml. In total, 69% of excised tumours were malignant, of which 2.7% exhibited PSMs. The incidence of major complications was 8.2%. After 26 months of follow-up, no recurrence has been reported and no change in serum creatinine (1.03 versus 1.04mg/dl; p=0,84) and no significant change in estimated glomerular filtration rate (eGFR) from baseline could be observed (82.2 versus 79.4mg/ml; p=0.74).68
These results are very
encouraging and show almost equal data compared with conventional open and laparoscopic partial nephrectomies.
Robotic Adrenalectomy
The first description of surgical resection of the adrenal gland goes back to 1914.69
first laparoscopic transperitoneal adrenalectomy.70
In 1992 Gagner et al. reported the results of the Since then,
laparoscopic surgery has become a widely accepted therapy modality for both benign and malignant adrenal lesions. In 2001, Horgan and Vanuno published their results of the first robotic adrenalectomies ever to be performed.71
Indications for robotic as well as laparoscopic adrenalectomy are very similar, but not the same. The bigger an adrenal mass, the higher the risk of malignancy, therefore resection of this mass should be the primary goal. Size is still the best indicator for malignant processes in the adrenal gland, although its sensitivity and specificity are imperfect.72
The current literature on robotic adrenalectomy shows that this technique is well tolerated and effective. The short-term outcomes are similar to those of laparoscopic adrenalectomy. The advantages of the robotic approach described at the beginning of this article are also being reported for robotic adrenalectomy. The conversion rates of current series as well as hospitalisation times are similar to those of laparoscopic studies.75
The literature on robotic radical or partial adrenalectomy is very scarce; however, there have been several case series of the robotic approach.73,74
However, operative
times have been reported to be longer compared with the conventional approach.76
published the results of their prospective randomised controlled trial in which 20 patients were randomly assigned to undergo laparoscopic (n=10) or robotic (n=10) adrenalectomy. Operative times were longer for the robotic group (169 versus 115 minutes). No difference in hospitalisation was reported, but a
Morino et al.77 73
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