Robot-assisted laparoscopic partial nephrectomy: step-by-step contemporary technique and surgical outcomes at a single high-volume institution.
BACKGROUND
Robotic technology is being increasingly adopted in urologic surgery.


OBJECTIVE
To describe a contemporary surgical technique and report cumulative surgical outcomes of robot-assisted laparoscopic partial nephrectomy (RALPN) at our tertiary care institution.


METHODS
Medical charts of consecutive patients who underwent RALPN between June 2006 and November 2011 were reviewed from a prospectively maintained, institutional review board-approved database.


METHODS
The main steps of our current surgical technique are described in this video tutorial: patient positioning and trocar placement; bowel mobilization; hilar dissection; tumor identification and demarcation; clamping of the hilum; tumor excision; renorraphy; hilar unclamping; and tumor retrieval.


METHODS
Patients' characteristics and main surgical outcomes were analyzed.


CONCLUSIONS
A total of 400 patients (mean age: 58.5 yr, mean body mass index: 30.7 kg/m(2)) were included in this analysis. Mean renal tumor size was 3.17 cm (standard deviation [SD]: 1.64) and mean RENAL score was 7.2 (SD: 2). Six patients (1.5%) presented with a solitary kidney. Mean total operative time was 190.3 min (SD: 57), and mean warm ischemia time was 19.2 min (SD: 10.72). In 36 cases (9%), an unclamped hilum technique was used. After a mean follow-up of 12.4 mo (SD: 12.2), there was a decline of -9.2 ml/min per 1.73 m(2) (SD: 26.56) in estimated glomerular filtration rate. Most renal masses were malignant (74.5%), and the overall mean tumor size was 3.05 cm (SD: 1.66). Renal cell carcinoma with a clear cell histology represented the most frequent malignant diagnosis (64.4% of cases). A positive margin was observed in nine cases (2.25%). A total of 11 intraoperative complications (2.7%) occurred, and a conversion to open or laparoscopic PN was required in six cases (1.5%). A postoperative complication occurred in 61 cases (15.3%), the majority of them being low grade.


CONCLUSIONS
The standardization of each surgical step has allowed for optimization of RALPN and ultimately improved its outcomes and expanded its indications.
Section of Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA. kaoukj@ccf.org
Jihad H
JH
Kaouk
Ali
A
Khalifeh
Shahab
S
Hillyer
Georges-Pascal
GP
Haber
Robert J
RJ
Stein
Riccardo
R
Autorino
D000368:Aged; D005260:Female; D061847:Hospitals, High-Volume; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery*; D010535:Laparoscopy / Q000009:adverse effects / Q000295:instrumentation; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D009820:Ohio; D056888:Patient Positioning; D012371:Robotics / Q000295:instrumentation; D025321:Surgery, Computer-Assisted / Q000009:adverse effects / Q000295:instrumentation; D013525:Surgical Instruments; D062606:Tertiary Care Centers; D016896:Treatment Outcome