Since the new millennium, robotic surgery has been increasingly utilized for a variety of procedures including robotic partial nephrectomy (RPN). Compared to laparoscopic partial nephrectomy, RPN is technically less difficult and is associated with less chance of conversion to radical nephrectomy [
Beginning May 2014, patients who were found to have clinical stage 1 renal masses were offered surgery, surveillance, or ablative therapy, in concordance with the AUA 2009 guidelines for the clinical stage 1 renal mass [
The Da Vinci Xi Surgical Platform (Figure
Da Vinci Xi patient cart.
A Foley catheter and nasogastric tube are placed prior to positioning. The patient is then placed in a modified lateral decubitus position at 45 degrees with a gel roll supporting the lower back. The anterior abdomen is placed on the lateral edge of the bed to minimize interference with the operative table. All pressure points are padded. An axillary role is placed and the upper arm is secured over the torso with pillows (see Figure
Patient positioning for left robotic partial nephrectomy.
The assistant port is placed first using an open Hasson technique. We use an Airseal (SurgiQuest Inc., Milford, CT) port placed in the midline, three to four centimeters above the umbilicus. After pneumoperitoneum is achieved, the laparoscope is inserted and the peritoneal cavity is inspected for injuries or adhesions. Four robotic ports are placed under direct vision in a linear fashion at the lateral border of the rectus muscle (Figure
Port placement for left robotic partial nephrectomy.
When the patient cart is driven for docking, the laser guidance is activated to facilitate precise positioning. The laser crosshairs projected from the overhead boom are aligned with the designated camera port. The camera port (port #2) is then mounted to the robotic arm and the camera is inserted. We focus the camera on the anticipated location of the renal hilum and then activate the autotargeting feature. Since the renal hilum is not visible on initial port placement, we have used external cues (subcostal region) in addition to internal cues (posterior to lower liver on the right side, or several inches caudad to the spleen on the left). The autotargeting allows for optimal boom rotation and robotic arm placement, to maximize access and minimize collision. After autopositioning, the remaining cannulas are docked and the robotic instruments are placed. The robotic arms are moved close together to minimize clashing (Figure
XI robot docked for right robotic partial nephrectomy.
The camera is routinely placed in port #2. The remaining robotic instruments include a fenestrated bipolar, monopolar scissors, and a ProGrasp in ports 1, 3, and 4, respectively. In order to expose Gerota’s fascia, we divide the white line of Toldt and retract the colon medially. The inferior aspect of Gerota’s is developed until the ureter is identified. The ProGrasp in the 4th arm is used to elevate the ureter off the psoas muscle, allowing a clear path to the renal hilum. Next, we expose the renal vessels. All major arterial branches are identified and mobilized from surrounding structures. We then focus on identifying our tumor. The perirenal fat is gently elevated from the kidney capsule to create wide exposure. For posteriorly based tumors, we will separate the perirenal fat around the entire kidney, in order to reflect the kidney 180 degrees. Once the tumor is identified, we introduce an ultrasound probe to identify the depth and margins of the tumor. Using the cautery, the margins of the tumor are scored. For hilar control, Reliance bulldog clamps (Scanlan International, St. Paul, MN) are introduced laparoscopically and passed to the ProGrasp. All major arterial branches are clamped with the Reliance bulldog clamps initiating renal ischemia. The 4th arm is used to keep the kidney rotated in the optimal position. The scissors are used to cut the tumor without cautery, while the fenestrated bipolar is used to retract the tumor. Liberal use of laparoscopic suction is critical in maintaining excellent vision and ensuring benign-appearing tumor margins. Once the tumor is completely excised, it is placed above the liver or spleen. A biopsy of the deep margin of the tumor base and any suspicious areas are then taken and passed off immediately, as per custom institutional practice. The left and right robotic instruments are then changed to large robotic needle drivers. Any discrete bleeding vessels or defects in the collecting system are closed with a 2-0 barbed suture. The kidney defect is then closed in two layers using the sliding renorrhaphy technique with barbed suture and hem-o-lok clips [
From May to July 2014, 15 patients with clinical stage 1 renal masses underwent RPN with the Da Vinci Xi surgical system. RPN was able to be performed successfully in all patients without conversion to radical nephrectomy or conversion to open partial nephrectomy. Table
Demographic and preoperative characteristics.
Age (yrs) | Sex | BMI | Preop eGFR (mL/min/1.73 m2) | Side | Imaging size (cms) | RENAL score | RENAL complexity |
---|---|---|---|---|---|---|---|
61 | F | 31 | 117.27 | Right | 3.9 | 9 | Moderate |
65 | F | 23 | 88.33 | Right | 2.8 | 8 | Moderate |
76 | F | 32 | 91.87 | Left | 2.4 | 5 | Low |
30 | M | 26 | 67.19 | Left | 1.7 | 7 | Moderate |
66 | M | 23 | 94.00 | Right | 3.2 | 10 | High |
79 | M | 25 | 41.90 | Right | 1.6 | 4 | Low |
49 | M | 36 | 79.41 | Left | 1.8 | 6 | Low |
62 | F | 34 | 72.68 | Left | 5.4 | 10 | High |
44 | F | 39 | 106.54 | Left | 2.0 | 7 | Moderate |
63 | F | 32 | 34.28 | Left | 3.6 | 4 | Low |
84 | M | 27 | 80.39 | Right | 2.1 | 6 | Low |
49 | M | 28 | 71.90 | Left | 2.6 | 10 | High |
71 | M | 35 | 51.22 | Left | 3 | 4 | Low |
57 | F | 23 | 97.40 | Right | 1.9 | 9 | Moderate |
54 | M | 37 | 47.31 | Left | 3 | 4 | Low |
For operative parameters (Table
Operative and pathologic outcomes.
Console time (min) | Ischemia time (min) | EBL (mls) | Intraop. comp. | Pathological subtype | Tumor size (cms) | T stage | Surgical margin |
---|---|---|---|---|---|---|---|
99 | 40 | 100 | No | Clear cell | 3.2 | 1a | Neg. |
98 | 19 | 50 | No | Oncocytoma | 2.5 | n/a | Neg. |
132 | 14 | 50 | No | Chromophobe | 2 | 1a | Neg. |
77 | 20 | 100 | No | Clear cell | 1.6 | 1a | Neg. |
111 | 20 | 100 | No | Chromophobe | 3.5 | 1a | Neg. |
67 | 0 | 50 | No | Benign cyst | n/a | n/a | Neg. |
85 | 11 | 50 | No | Papillary type 1 | 1.7 | 1a | Neg. |
123 | 27 | 200 | No | Clear | 5 | 1b | Neg. |
73 | 9 | 50 | No | Chromophobe | 2 | 1a | Neg. |
96 | 15 | 100 | No | Clear cell | 3 | 1a | Neg. |
106 | 22 | 200 | No | Oncocytoma | 2.5 | n/a | Neg. |
182 | 18 | 150 | No | Clear cell | 2.5 | 1a | Neg. |
51 | 10 | 400 | No | Papillary type 1 | 2.8 | 1a | Neg. |
44 | 18 | 100 | No | Clear cell | 2 | 1a | Neg. |
176 | 20 | 100 | No | Clear cell | 2.5 | 1a | Neg. |
12 of 15 patients had renal cell carcinoma on final pathology (seven with clear cell, two with papillary type 1, and three with chromophobe). Three patients had benign disease with one having benign cystic disease and two patients with oncocytoma. All surgical margins were negative and all patients had pT1 disease. All deep base biopsies were negative as well. All patients were discharged by POD #3 and 66% were discharged by POD #2. Two perioperative complications were noted. One 30-year-old male patient had a drop in hemoglobin on the first postoperative day (POD) from 14 to 6 gm/dL. Angiogram showed a pseudoaneurysm in a small artery at the lower margin of the defect. This was embolized with success. He was transfused 2 units and discharged on POD #3. The second complication was a readmission for possible UTI in a forty-year-old woman on POD #4. Cultures and imaging were negative and she was discharged home.
For the experienced robotic surgeon, the RPN could be performed seamlessly on the XI with several notable differences. Port placement is significantly different on the XI with this procedure compared to the Si. The XI is designed for parallel movement, which means the instruments work best when they are working in a near parallel configuration. This makes port placement ideal when the ports are in a line. In contrast, with the Si, the 4th arm port is typically placed lateral to the other ports. This lateral placement often would cause external or internal collision. For the RPN, the 4th arm port placement in the midline is advantageous and provides more functionality with minimal collision. On the XI, we are able to utilize the 4th arm for multiple tasks including bowel retraction, elevation of the lower pole of the kidney, and holding the kidney in position during the extirpative and reconstructive phases of the surgery.
In addition, the ports can (and should) be significantly closer together compared to the Si. There should be 6 cm between ports on the XI, compared to 8–10 cm for the Si. When the ports are closely spaced, the arms are allowed to work in parallel with each other. Furthermore, the camera is 8 mm on the XI, which allows it to be placed in any of the robotic ports. Camera port hopping is thus far an exclusive feature of the Da Vinci Xi; however, we have not found it necessary for an RPN.
Perhaps the most pronounced difference in the XI is in the docking phase.
The XI patient cart occupies a different physical space than the Si. One major benefit is the addition of the boom, which allows the robotic arms to extend and rotate, in order to facilitate docking from multiple angles. This allows the patient to console more flexibility in positioning within the operative theatre. One drawback of the boom is that it creates additional height to the patient cart. In our operating rooms, this means navigating ceiling attachments more carefully. We have docked the robot both from the feet (with 90-degree boom rotation) and from the patient’s side (perpendicular to the operative table). The side docking offers the most reliable targeting in our experience, irrespective of the patient’s height.
Most of the operative technique for an RPN on the XI is similar to that on the Si. We have noted several changes with camera. The XI video camera is autofocusing, which can save time. However, the fidelity of tissue color on the camera can fluctuate, especially when there is blood in the field, sometimes giving an orange hue. Also, the smoke from the cautery is more obtrusive than on the Si. We have used the valveless Airseal port with continuous smoke suction to address this limitation. As a distinct advantage, the instruments for the XI are 1.75 inches longer, which facilitates longer reach and has aided upper pole kidney mobilization for the RPN.
Our console time and ischemia time were relatively short, even in the face of moderately complex tumors. Our mean ischemia time of 17.5 minutes and estimated blood loss (EBL) compare favorably to other large series of robotic partial nephrectomy with prior Da Vinci models [
Overall, surgeons felt that the XI offered significant improvements over the Si for the RPN. Docking was more precise and instrument clashing was minimal. In particular, the XI added usefulness to the 4th arm and generally made the case flow more smoothly. Due to technological changes in the robot, the port placement and docking procedure are markedly different than typical procedures with the previous versions of the robot. Console time and ischemia time were expectedly short. Perioperative outcomes and pathologic outcomes were similar to our prior experience with RPN.
RPN with the Da Vinci Xi system can be performed in a safe and reproducible fashion. This latest upgrade provides several advantages over the previous system that can facilitate a more efficient procedure but further studies are required to fully elucidate performance outcomes in multiple settings.
George J. S. Kallingal, Sanjaya Swain, Fadi Darwiche, Sanoj Punnen, Murugesan Manoharan, Mark L. Gonzalgo, and Dipen J. Parekh declare they do not have any personal or institutional conflict of interests.