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Volume 55, issue 3, pages 533-760, March 2009Surgery in Motion
Robotic Partial Nephrectomy with Sliding-Clip Renorrhaphy: Technique and Outcomes
Brian M. Benway, Agnes J. Wang, Jose M. Cabello, Sam B. Bhayani 
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Accepted 28 December 2008, Published online 7 January 2009, pages 592 - 599
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Abstract
Background
Robotic partial nephrectomy (RPN) is emerging as an alternative to traditional laparoscopic partial nephrectomy (LPN). Despite the potential advantages of the robotic approach, renorrhaphy remains a challenging portion of the procedure.
Objective
To present our technique and outcomes for RPN, including sliding-clip renorrhaphy.
Design, setting, and participants
Between 2007 and 2008, 50 patients underwent RPN performed by a single attending surgeon.
Surgical procedure
In this paper, we describe our technique for RPN, including a sliding-clip renorrhaphy, which is distinguished by the use of Weck Hem-O-Lock clips that are slid into place under complete control of the surgeon seated at the console and secured with a LapraTy clip. For the first 13 procedures, traditional tied-suture or assistant-placed clip closures were performed; sliding-clip renorrhaphy was performed in the remaining 37 cases.
Results and limitations
Mean tumor size was 2.5 cm. Mean operative time was 145.3 min, and mean overall warm ischemia time was 17.8 min. Mean estimated blood loss was 140.3 ml. The learning curve for overall operative time was 19 cases; the learning curve for portions of the case performed under warm ischemia (including tumor resection and renorrhaphy) was 26 cases. The introduction of a sliding-clip renorrhaphy produced significant reductions in overall operative time and warm ischemia time, while blood loss and hospital stay remained stable over our experience. Limitations of RPN include cost and increased reliance on the bedside assistant.
Conclusions
Sliding-clip renorrhaphy provides an efficient and effective repair that is under nearly complete control of the surgeon. This technique appears to contribute to significantly shorter overall operative times and, perhaps most critically, to shorter warm ischemia times. The learning curve for RPN using this technique appears to be foreshortened compared with LPN.
Keywords: Robotic partial nephrectomy, Renorrhaphy, Renal reconstruction, Partial nephrectomy, Robotics, Nephron-sparing, Renal cell carcinoma.
Article Outline
1. Introduction
Robotic partial nephrectomy (RPN) is an evolving technique that attempts to address the technical challenges of a pure laparoscopic approach. Despite the enhanced visualization and control afforded by the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), renorrhaphy remains a technically challenging aspect of the procedure. Consequently, there has been growing interest in exploring alternatives to traditional tied-suture renorrhaphy [1], [2], [3], and [4]. Recently, a refinement for knotless renorrhaphy was introduced, which affords the surgeon precise control over the tension placed on the repair while minimizing reliance on the assistant [5].
In this paper, along with the accompanying video material, we illustrate our technique for RPN, emphasizing our technique for sliding-clip renorrhaphy, and describe our experience and outcomes with our first 50 patients who have undergone RPN at our institution.
2. Methods
2.1. Patient selection and demographics
Fifty patients underwent RPN performed by a single attending surgeon at the Washington University School of Medicine. As the experience progressed, senior-level residents were also direct participants in the procedures. Because patient selection was based on tumor characteristics and patient preference, our patient population was not randomized. Patient demographics and perioperative data are summarized in Table 1.
Table 1 Perioperative data for 50 patients undergoing robotic partial nephrectomy
| Patient age, yr | 60.0 ± 10.6 (range: 35–76) |
| Tumor size on imaging, cm | 2.7 ± 1.2 (range: 1.0–10.0) |
| Body mass index | 29.6 ± 6.3 (range: 16–44.9) |
| Total operative time, min | 145.3 ± 34.0 (range: 69–219) |
| Warm ischemia time, min | 17.8 ± 11.6 (range: 0–40) |
| Estimated blood loss, ml | 140.3 ± 97.6 (range: 25–450) |
| Collecting system entry | 47% |
| Open conversions | 1 (2%) |
| Conversions to ablation | 1 (2%) |
| Aborted procedures | 1 (2%) |
| Complications | 5 (10%) |
| 1 deep venous thrombosis | |
| 1 myocardial infarction | |
| 1 readmission for hypertensive crisis | |
| 1 perirenal hematoma | |
| 1 postoperative anemia | |
| Transfusions | 2 (4%) |
| Hospital stay, d | 2.5 ± 1.0 (range: 1–7) |
2.2. Surgical technique
2.2.1. Patient positioning, access, port placement, and docking
The patient is secured in a flank position. A Veress needle is used to establish pneumoperitoneum. A three-arm approach is generally used; however, a four-arm approach can be utilized when difficulty with dissection is anticipated due to redundant tissues or excess perirenal fat. Port placements for each approach are illustrated in Fig. 1.
01503-0/assets/gr1.jpg)
Fig. 1 (a) Trocar positioning for the three-arm approach—the assistant port can be placed in one of two locations, based on surgeon preference; (b) trocar positioning for the four-arm approach. R = robotic trocar; C = camera port; A = assistant port.
The robot is then docked at an angle, centered along the line defined by the camera port and the renal hilum. A 30° downward lens is used throughout the case.
2.2.2. Bowel mobilization, hilar dissection, and tumor identification
The working arms are outfitted with robotic scissors, with monopolar cautery, and the ProGrasp forceps. If a fourth arm is utilized for retraction, it is outfitted with either a dual-blade arterial retractor or a double-fenestrated grasper.
The bowel is reflected medially to expose the retroperitoneum. For right-sided tumors, liver retraction may be necessary and can be provided by the assistant using a laparoscopic suction device or a similarly blunt instrument. The renal vasculature is exposed using the closed robotic scissors. Gerota's fascia is incised, and the fat should be reflected circumferentially with a wide margin around the visible tumor—a critical step that will aid visualization during renal reconstruction. Intraoperative ultrasound is then employed to define the gross margins of the mass.
2.2.3. Hilar control and tumor excision
Mannitol 12.5 gm IV is administered shortly before vascular clamping to reduce ischemic injury [6]. While a laparoscopic Satinsky may be used to clamp the vessels en bloc, we prefer to clamp each vessel individually with laparoscopic bulldog clamps [7], [8], and [9], often clamping the artery doubly to ensure complete occlusion. The kidney should quickly blanch; if it does not, consideration should be given to the presence of an unseen accessory vessel that may serve the upper pole or may be a branch of the main renal artery, if the first clamp was placed distal to a bifurcation.
The tumor is excised sharply. The ProGrasp forceps can be used to gently spread the tissues to aid dissection. Once dissection is complete, the specimen is placed above the liver or spleen for later retrieval.
2.2.4. Renal reconstruction with a sliding-clip renorrhaphy
The robotic scissors are exchanged for robotic needle drivers. Only one needle driver is necessary; the ProGrasp forceps should remain on the nondominant hand.
If the collecting system has been entered or if large vessels remain patent, repair with absorbable suture materials will be required prior to proceeding with renorrhaphy. We generally coagulate the cortex with monopolar cautery. A bolster may be used for shallow defects but is unnecessary in most cases.
For the renorrhaphy, all sutures are first prepared on the back table. A knot is tied at the end of a 15-cm 0 or 1 polyglactin suture. Above the knot, a LapraTy (Ethicon, Cincinnati, OH, USA) clip is placed, and above that, a 10-mm Weck Hem-o-Lock (Teleflex, Research Triangle Park, NC) clip is placed (Fig. 2).
01503-0/assets/gr2.jpg)
Fig. 2 The prepared suture: A 0 or 1 polyglactin suture is cut to 15 cm; a knot is tied at the end, followed by a LapraTy clip, then a Weck Hem-O-Lock clip.
The sutures are then placed through the renal capsule at intervals of 1 cm. As the final throw of each suture is placed, the assistant places a second Hem-o-Lock clip on the loose end; every effort should be made to center the suture within the jaws of the clip, which helps the clip to slide smoothly. All sutures should be placed and clipped before attempting to tighten any of the sutures.
To tighten, the loose end of each suture is grasped with the ProGrasp forceps, and tension is applied perpendicular to the capsule in order to minimize the risk of tearing. Using the robotic needle driver with the jaws slightly open, the surgeon slides the clip toward the kidney. Proper tension has been applied when the surface of the kidney is slightly dimpled. A LapraTy clip is placed by the assistant to secure the closure (Fig. 3).
01503-0/assets/gr3.jpg)
Fig. 3 The robotic needle driver is used to slide the Weck Hem-O-Lock clip over the suture to tighten the renorrhaphy. A LapraTy clip is used to secure the repair.
If necessary, the tension may be readjusted by sliding the clips again; however, readjustment of the LapraTy clip is somewhat difficult, so care should be taken to avoid applying excessive force during this maneuver.
Once renorrhaphy is complete, the clamps are removed and the defect is inspected to verify hemostasis. If necessary, additional sutures or thrombogenic material may be used. If significant bleeding is encountered on unclamping, we recommend against hasty action. As the kidney expands with the return of blood flow, the repair may further tamponade. Should bleeding persist, the repair can be retightened as described above or more sutures may be placed. Other possible considerations are conversion to radical nephrectomy or open partial nephrectomy, although we did not encounter significant hemorrhage in the present series.
2.2.5. Specimen retrieval and closure
The specimen is placed in a retrieval sac and extruded through one of the caudal robotic ports, which may be enlarged if necessary. The fascia at the extraction site should be closed with a thick dissolvable suture. The remaining trocar sites do not require fascial closure, as the risk of herniation is low [10].
3. Results
3.1. Operative data
A total of 30 left-sided and 20 right-sided tumors were treated with RPN. On imaging, tumors ranged from 1 to 10 cm. Mean total operative time was 145.3 min (range: 69–219 min), and mean warm ischemia time across the entire series was 17.8 min (range: 0–40 min). Limiting the data to cases in which clamping was performed, mean warm ischemia time was 22.8 min (range: 11–40 min). The collecting system was entered in 47% of cases. Mean blood loss was 140.3 ml (range: 25–450 ml).
The first 13 patients underwent traditional clip or tied-suture renorrhaphy. Starting with the 14th case and throughout the remaining 37 cases, a sliding-clip technique was used.
3.2. Pathology and outcomes
Tumor pathology is outlined in Table 2. Mean pathologic tumor size was 2.5 cm (range: 0.3–7.5 cm). For tumors with available pathologic data, 28 (56%) were malignant and 17 (34%) were benign. Five cases (10%) demonstrated atypical pathology. There was one focally positive margin in a patient with a 2.1-cm papillary renal cell carcinoma.
Table 2 Summary of pathology
| Malignant (%) | 28 (56) |
| Pathologic subtype (%) | |
| Clear cell | 18 (36) |
| Papillary | 7 (14) |
| Chromophobe | 2 (4) |
| Mixed | 1 (2) |
| Pathologic stage (%) | |
| pT1a | 22 (44) |
| pT1b | 5 (10) |
| pT2 | 0 (0) |
| pT3a | 0 (0) |
| pT3b | 1 (2) |
| pT4 | 0 (0) |
| Benign (%) | 17 (34) |
| Pathologic subtype (%) | |
| Angiomyolipoma | 8 (16) |
| Oncocytoma | 3 (6) |
| Cyst | 4 (8) |
| Cystic nephroma | 1 (2) |
| Metanephric adenoma | 1 (2) |
| Miscellaneous (%) | 5 (10) |
| Other benign | 2 (4) |
| Castleman's disease | 1 (2) |
| Schwannoma | 1 (2) |
| Indeterminate | 1 (2) |
| Pathologic tumor size (cm) | 2.5 ± 1.4 (0.3–7.5) |
| Positive margin (%) | 1 (2%) |
Although there was a significant decrease in postoperative hemoglobin (13.6 to 11.8, p < 0.0001), there was no change in creatinine 24 h postoperatively (1.02 to 1.14, p = 0.068).
For patients with 1-yr follow-up, there have been no recurrences and no changes in creatinine (mean: 1.12 preoperative vs 1.12 at last follow-up).
3.3. Conversions and complications
There was one conversion to open partial nephrectomy for a prohibitive amount of adhesions in a patient with a prior esophagectomy and reconstruction. Additionally, there was one patient converted to robotic-assisted cryoablation for densely adherent perirenal fat that prevented adequate exposure of the capsule. Finally, one case for a suspected 1.5-cm mass was aborted after the tumor was unable to be located intraoperatively. A biopsy of the suspected area was benign. Follow-up imaging showed the lesion to be a resolving infection.
There were five complications (10%). One patient suffered a postoperative myocardial infarction. One patient was readmitted for hypertensive crisis after noncompliance with antihypertensive medication. One patient developed a deep venous thrombosis. Since this complication, we have given all patients a preoperative dose of enoxaparin; there have been no further thromboembolic events in our series. Two patients required transfusion, one for a drop in hematocrit related to a perirenal hematoma and another for an unrelated medical indication.
3.4. Learning curve
An analysis of overall operative time and warm ischemia time appears in Fig. 4, and Fig. 5. A line of best fit was drawn against the scatter plot to identify the learning curve in terms of reaching maximal overall efficiency and maximum efficiency for portions of the case performed under warm ischemia, which include tumor dissection and renorrhaphy.
01503-0/assets/gr4/gr4_584x342.jpg)
Fig. 4 Learning curve with respect to overall operative time. The upswing in the curve after the initial 19 cases represents increasingly more challenging tumors being addressed robotically, as well as greater resident involvement in the procedures.
01503-0/assets/gr5/gr5_584x342.jpg)
Fig. 5 Learning curve with respect for warm ischemia time. Procedures in which clamping was not implemented, including conversions, are excluded from this plot. Again, the upswing after 26 cases likely represents more difficult cases being performed robotically later in the experience.
The present data indicate that the learning curve with respect to overall operative time is 19 cases, whereas the learning curve for portions of the case performed under warm ischemia is 26 cases. After this learning curve was reached, there was a slight upswing in both curves. We believe this is due to the increased complexity of the tumors treated by the robotic approach and greater direct resident involvement with the procedures as our institutional experience progressed.
3.5. Potential impact of sliding-clip renorrhaphy on operative parameters
Subset analysis of our first 13 cases, performed using traditional renorrhaphy techniques, and of our last 37 cases, which employed a sliding-clip renorrhaphy, reveals interesting trends. Mean operative time decreased from 169.8 min to 136.8 min, a difference that was significant (p = 0.0018). Additionally, for cases where the vessels were clamped, mean warm ischemia times decreased significantly, from 28.3 min to 20.6 min (p = 0.0029). There was also a significant decrease in the number of robotic trocars used (p = 0.036), indicating a shift from a four-arm to a three-arm approach as the technique matured. There was no significant difference with regard to blood loss or length of hospital stay.
4. Discussion
Over the past 2 decades, the role of partial nephrectomy has been expanding. By providing oncologic outcomes equivalent to radical nephrectomy, along with improved preservation of renal function, partial nephrectomy has become established as a standard of care for small renal masses, even in patients with a normal contralateral kidney [11], and [12].
The introduction of laparoscopic partial nephrectomy (LPN) [13] further refined the approach to nephron-sparing surgery, offering oncologic outcomes equivalent to open partial nephrectomy while offering patients a shorter hospital stay and overall recovery time [14], [15], [16], and [17]. Despite these clear advantages, LPN has struggled to gain a foothold outside of academic centers of excellence [18], possibly due to the considerable technical demands of the procedure.
RPN is an emerging technique that offers a number of potential advantages, including magnified stereoscopic vision, elimination of tremor, and fully articulating instruments. These refinements may, in turn, help to reduce the technical challenge associated with a pure laparoscopic approach.
Although the experience is admittedly early, RPN appears to be a viable alternative to LPN, boasting, at the very least, equivalent operative parameters in terms of ischemic time as well as excellent early oncologic outcomes [9], [19], [20], [21], [22], [23], [24], and [25]. Five-year follow-up is not presently available; however, in three series with intermediate outcome data, there have been no reported recurrences up to 28 mo [21], [23], and [25]. Additionally, our data show no negative impact on renal function, which corroborates the outcomes of Rogers et al [23].
Our data examining the learning curve of the robotic approach suggest that for an experienced minimally invasive surgeon, RPN is a technique that is rapidly learned. Overall, the learning curve for RPN was surpassed in 19 cases. We were also able to identify a learning curve of 26 cases for tumor dissection and renorrhaphy, portions of the case that are performed under the duress of warm ischemia. This compares favorably to LPN data from Link et al, who found that although overall operative time did decrease with experience, the learning curve for portions of the case performed under warm ischemia was never surpassed, even after >200 cases [26].
Even for inexperienced laparoscopic surgeons, it appears that the learning curve for RPN is nevertheless diminished, although the exact number of cases to surpass the learning curve has not been precisely defined [27].
Renal reconstruction, however, remains a challenging portion of the procedure, and multiple techniques to eliminate the need for knot tying during renorrhaphy have been described [1], [2], [3], [4], [5], and [28]. Many of these techniques may place the surgeon at a disadvantage because they often rely on an inexperienced assistant to determine the tension to be placed on the repair. While all available methods report good results, sliding-clip renorrhaphy offers a number of potential advantages.
Sliding-clip renorrhaphy uses sliding Hem-o-Lock clips, which are under complete control of the surgeon seated at the console. This method affords the surgeon precise control over the tension placed on the renorrhaphy and allows the tension to be readjusted, if deemed necessary. While other authors employ a Hem-O-Lock clip-only closure [3], and [28], our experience has been that these clips have a tendency to slide after placement, as evidenced by the laxity we have noted in completion nephrectomy specimens. Therefore, we provide additional security to our closure by using a LapraTy to backstop the Hem-O-Lock clip, thus preventing loosening of the tension on the repair.
A recent series from our institution comparing a single-surgeon experience of LPN with RPN demonstrated equivalence in terms of positive margin status, collecting system disruption, and estimated blood loss; however, overall operative time and warm ischemia times were significantly shorter in the RPN group [19]. This compares favorably to the experiences of Caruso et al and Deane et al, whose overall operative and warm ischemic times did not differ between LPN and RPN [22], and [27], and of Aron et al, who found warm ischemia times during RPN to be significantly longer than for LPN [29]. Because the main distinguishing feature between our experience and those reported by others is the technique for renal reconstruction, it may indeed be the case that sliding-clip renorrhaphy proves to be the critical difference.
Some concerns have been raised about leaving durable clip material in close contact with the renal parenchyma; it is unknown whether these clips are prone to migration or erosion over an extended period of time. Orvieto et al found that after LapraTy clip closure, analysis at 8 wk revealed all clips to be well encapsulated, with no evidence of migration or erosion [1]. Presently, however, long-term data on the nondegradable Hem-O-Lock clips are lacking.
Despite its ease, the robotic approach does carry a few disadvantages worth considering. RPN requires more trocar sites than LPN. While comparative data regarding pain, cosmesis, and patient satisfaction are lacking, it is likely that the effects of placing an additional trocar are negligible. Also, because the surgeon is not scrubbed, an experienced assistant and support staff are required. Finally, despite increasing utilization, RPN remains a costly operation compared with LPN, with a high capital expenditure to purchase and maintain the robotic system. One must, however, also consider other factors that may contribute to the overall financial value of the robotic approach, including a shorter hospital stay and a decrease in complications that require a secondary procedure [19].
5. Conclusions
RPN is an emerging alternative to LPN, providing equivalent early oncologic outcomes while offering a modest learning curve. Despite the advantages of a robotic approach, renorrhaphy remains a challenging portion of the case. The technique for renorrhaphy described in this paper employs sliding Hem-O-Lock clips secured by a LapraTy clip, providing a highly efficient and effective repair that is quickly learned and easily implemented. Adoption of a sliding-clip technique appears to reduce overall operative times significantly and, perhaps most critically, provides a significant reduction in warm ischemia times.
Author contributions: Brian M. Benway and Sam B. Bhayani had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Benway, Wang, Cabello, Bhayani.
Acquisition of data: Benway, Wang, Bhayani.
Analysis and interpretation of data: Benway, Wang, Bhayani.
Drafting of the manuscript: Benway, Wang, Bhayani.
Critical revision of the manuscript for important intellectual content: Benway, Cabello, Bhayani.
Statistical analysis: Benway, Wang, Bhayani.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Bhayani.
Other (specify): None.
Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/ affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: Sam B. Bhayani is a consultant for Intuitive Surgical Corp., Sunnyvale, CA, USA. B.M. Benway, A.J. Wang, and J.M. Cabello have nothing to disclose.
Funding/Support and role of the sponsor: None.
Appendix A. Supplementary data
Download video References
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Footnotes
Washington University School of Medicine, Department of Surgery, Division of Urologic Surgery, Saint Louis, MO, USA
Corresponding author. Tel. +1 314 362 2612; Fax: +1 314 454 5244.
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