Robot-assisted resection of renal tumour – our current most common technique – video

Czech version

Authors: Milan Hora ¹; Ivan Trávníček ¹; ; Petr Stránský ¹; Adriena Bartošveselá ¹; ; Tomášpitra ¹; Hana Sedláčková ¹; Petr Stránský Jr ¹; Dominika Šiková ¹; Kseniia Khomenko ¹; Blanka Drápelová ¹; Jitka Voráčková ¹; Jiří Ferda ²; Kristýna Pivovarčíková ³
Authors‘ workplace: Urologická klinika, LF UK a FN Plzeň 2 Klinika zobrazovacích metod, LF UK a FN Plzeň 3 Šiklův ústav patologie, LF UK a FN Plzeň ¹
Published in: Ces Urol 2025; 29(1): 9-11
Category: Video
doi: https://doi.org/10.48095/cccu2025004

Overview

Aim: To present on video our current most used technique of robot-assisted resection of renal tumour (RR). Material: We performed 274 RRs between June 2020 and November 2024. Our technique is based on a modification of conventional laparoscopic renal resection, of which we performed 599 between August 2004 and May 2020. RRs currently account for over one third of the surgical procedures for kidney cancer at our institution. Laparoscopic (rarely robotic assisted) nephrectomy is almost as frequent. Open resection accounts for about 17% and open nephrectomy for slightly less. Open resections are mainly indicated for more complex tumours, for tumors with significant “toxic” fat capsule, and when combined with other procedures, mostly for intestinal malignancies. RR is routinely performed by two console surgeons, occasionally by two additional ones. Operation technique: General anaesthesia. Optional urinary catheter inserted. Lateral position 60– 70°. Upper limbs extended in front, close together. Operative field prepared for eventual lumbotomy. Transperitoneal approach. The capnoperitoneum is created with a Veres needle, CO₂ pressure 12 mmHg. Assist port 12 mm slightly lateral to the umbilicus. Four 8-mm robotic ports are inserted pararectally under visual control. Four-arm daVinci Xi robotic system is inserted. Ports craniocaudally: 1. ProGrasp, 2. bipolar grasper (bipolar forceps Maryland or more often fenestrated) or monopolar curved scissors (Hot shears) according to the operated side and the dominant hand of the operator, 3. camera 30°, 4. the second of the mentioned instruments from port 2. The scissors are alternated with a needle driver, usually the Large SutureCut needle driver. In the Toldt line, the peritoneum is opened, the colon is retracted medially, and the Gerota fascia is opened medially from the kidney. The necessary part of the kidney is dissected from the fat capsule for good access to the tumour. The tumour is verified sonographically with a drop-in probe inserted through the assistant port. Scissors can be used to mark the line of resection on the kidney. The ureter is verified and the hilar vessels are released. The artery(s) or necessary branch is bypassed with tubing and clamped with the SCANLAN® robotic endo-bulldog. Only in central tumours is the vein also clamped. Knowledge of the topographic anatomy of the vessels from two-phase CT angiography is very helpful at this stage. The effectiveness of ischemia is verified by Doppler; exceptionally (especially in selective clamping of the artery branches) by NIR imaging with FireFly® with administration of indocyanine green – Verdye® 1.25– 2.5 mg. The tumour is resected with cold scissors with a rim of healthy tissue. Suturing of the base is performed with an absorbable self-anchoring barbed suture (V-Loc® 90, size 3-0, 1/ 2 needle 26 mm). The edges of the kidney are mattress sutured with another suture, tightened with Absolok™ AP300 absorbable clips (polydioxanone PDS, size ML) – “sliding clips” technique. The second layer of the parenchyma is sewn with simple continuation stitches, mostly without continuous anchoring. For more superficial tumours, a straight suture of the parenchyma is performed, including anchoring of the base. The hilar vessels are released. Eventual residual bleeding is usually treated with a larger needle – V-Loc® 90, size 2-0, needle 37 mm. Exceptionally, woven cellulose Surgicel® is applied to the suture. We have eliminated tissue adhesives from the armamentarium. The Gerota fascia defect is closed with V-Loc® 90, size 3-0 suture. The tumour is placed in an Endocatch® Gold extraction bag. A drain is usually not used. If used, then Penrose inserted after the robotic port 1 or 2 (taken craniocaudally). The tumour is extracted through the dilated port in the lower abdomen after the robotic port 3 and closed with Vicryl® suture introduced with a Berci fascial port closure forceps. Smaller tumours are extracted at the assist port site without the need for closure. The patient is mobilized early, only if it is necessary to release the whole kidney is he left on bed rest for 2– 3 days. The slide is stained with black ink at the base. Video: Lasting 6 min 17 sec, it shows the above technique for left-sided resection, the surgeon has left hand dominance. Procedure combined with fenestration of parapelvic cysts. Clamping of the main artery used, single layer suture of the resected kidney with treatment of residual bleeding. Conclusion: It has completely replaced the laparoscopic approach. The key points are predominant transperitoneal approach, knowledge of vascular anatomy from CT angiography, extent of renal release according to tumour localization, clamping of the artery with endo-bulldog, verification of ischemia efficiency with Doppler, cold scissors, absorbable self-anchoring sutures and absorbable PDS clips, suture of Gerota’s fascia, no use of drainage, staining of the base of the specimen.

Keywords:

kidney tumour, resection, laparoscopy, robot

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