1. clamp. In our experience with hilar lesions, only the renal artery is
clamped while the renal vein remains open throughout the procedure.
Reconstruction of the kidney is performed with care not to obstruct the
renal pelvis post operatively.
CONCLUSIONS: Robotic-assisted laparoscopic partial ne-
phrectomy is a safe and feasible option for the treatment of complex
renal masses including hilar tumors.
Source of Funding: none
V5-03
MINIMIZING WARM ISCHEMIA DURING ROBOTIC ASSISTED
PARTIAL NEPHRECTOMY
ALAA HAMADA*, Janice C. Santos, Alan M. Nieder, Akshay Bhandari,
Miami Beach, FL
INTRODUCTION AND OBJECTIVES: To evaluate the efficacy
of our approach in minimizing warm ischemia during robotic assisted
partial nephrectomy (RAPN).
METHODS: We retrospectively evaluated data of patients who
underwent RAPN at a single institution by a single surgeon. After IRB
approval patient charts were queried for all pertinent patient data which
included demographic and perioperative data. Nephrometry score was
calculated for all patients. Pathologic data and postoperative compli-
cations were also recorded. Patients who underwent an off clamp partial
nephrectomy were excluded from analysis. With the intent to minimize
warm ischemia VÀloc suture was used to over sew the resection bed as
well as a single running VÀloc suture was used to reapproximate the
kidney parenchyma (renorrhaphy) in a horizontal mattress fashion using
the sliding hemÀoÀlok technique.
RESULTS: From September 2011 to August, 2013 a total of 48
patients underwent RAPN. The mean age was 67.2 years. Male to fe-
male ratio was: 2:1. The average ASA score was 2.6z3: The mean
nephrometry score was 6. The median warm ischemia time was 14
minutes and mean estimated blood loss was 129cc. There were no
conversions to open however, the procedure was converted to a radical
nephrectomy in 3 cases due to concern for incomplete tumor resection.
Clear renal cell carcinoma (RCC) was the predominant pathology
(68.8%). Positive margin was recorded in 1 (2%) patient. Overall there
were two complications (4%) e delayed hemorrhage with negative
angiogram and a delayed urinary fistula requiring percutaneous drain
placement. By using linear regression analysis, no significant predictive
effect of nephrometry score on duration of WIT in our patients (odds
ratio: 0.8, 95% CI (À0.145 to 1.7), p¼0.094.
CONCLUSIONS: Single suture renorrhaphy using VÀloc suture
performed during robotic partial nephrectomy is helpful in shortening the
warm ischemia time with no increased risk of bleeding or urine leak.
Source of Funding: None
V5-04
ROBOTIC-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY
WITH INTRACORPOREAL COOLING FOR A RENAL MASS
Dinesh Samarasekera*, Homayoun Zargar, Luis Felipe Brandao,
Oktay Akca, Jihad Kaouk, Cleveland, OH
INTRODUCTION AND OBJECTIVES: The application of ro-
botics to renal surgery has allowed for re-creation of open surgical
principles in a minimally invasive fashion. From open surgery it is
known that in-situ renal hypothermia prevents renal ischemic injury
during prolonged hilar clamping. A renal temperature of 18-20
C
is required for optimal preservation. The aim of this video is to
describe our technique for intracorporeal cooling with ice slush during
robotic partial nephrectomy, with real time parenchymal temperature
monitoring.
METHODS: A 74 year-old male presented with an enhancing 3
cm endophytic hilar right renal mass. The R.E.N.A.L. nephrometry
score was 8a. Pre-operative serum Creatinine was 1.32 mg/dL. Deci-
sion was made to proceed with a robotic right partial nephrectomy with
intracorporeal cooling, given the high complexity of the tumor. The
kidney was mobilized and the hilum was dissected. The kidney was
then surrounded with an18x4 inch sponge. Ice slush was introduced
through an additional 12 mm laparoscopic port placed posterior to the
mid axillary line. Ice was placed posterior to the kidney then the hilum
was clamped. Additional ice was placed over the medial aspect. After
cooling, which was monitored by a thermocouple introduced into the
normal kidney parenchyma, tumor excision was initiated, keeping ice
covering most of the normal kidney at all times.
RESULTS: Operative time was 183 minutes. Total ischemia
time was 27 minutes and estimated blood loss was 50 cc. The low-
est parenchymal temperature was 14.1
C. The patient’s temperature
only dropped by 0.6
C during cooling. There were no intraoperative
or perioperative complications. Serum Creatinine one week post-
operatively was 1.43 mg/dL. The final pathology was a 2.5cm clear cell
renal cell carcinoma, Fuhrman grade 4. The resection margins
were negative.
CONCLUSIONS: Robotic partial nephrectomy with intra-
corporeal ice slush cooling is technically feasible. We present our
simplified technique with real-time renal parenchymal temperature
monitoring. We have performed this technique in 4 patients and were
able to achieve renal temperatures of 18
C consistently during hilar
clamping. No post-operative ileus 2 days was observed. However,
further improvements in the ice delivery system are required for uni-
versal adaptation of this method. Finally long-term renal functional
outcome data is needed to fully validate this technique.
Source of Funding: none
V5-05
INTRAOPERATIVE PERIPROSTATIC NERVE ACTION POTENTIAL
MONITORING DURING ROBOTIC PROSTATECTOMY
Ashutosh Tewari, Ketan Badani*, Paras Singhal, Adnan Ali,
Robert Leung, Brian Antonucci, Ruslan Korets, Michael Rothberg,
Ari Bergman, Trushar Patel, New York, NY; Dean Myers, Hutchinson,
MN; Carol Campbell, Cabot, PA; Wenjeng Li, Bryan Courtney,
Jacksonville, FL; Marc Zimmerman, Santa Barbara, CA;
Sonny Yamasaki, Jacksonville, FL
INTRODUCTION AND OBJECTIVES: Prostate cancer surgery
involves interplay between the competing goals of extirpation of cancer,
nerve sparing, and postoperative recovery of potency and continence. A
surgeon’s task is further complicated by the complexity of periprostatic
neuroarchitecture and fine nerves that are not readily visible, which
places them at risk of inadvertent injury. Better intra-operative detection
of nerve location in the peri-prostatic space can help in better nerve
preservation, which is critical for improved functional outcomes after
radical prostatectomy. We present a video of an ongoing feasibility
clinical study to determine whether intraoperative nerve monitoring can
locate these microscopic nerves during robotic radical prostatec-
tomy (RP).
METHODS: 28 patients with a Sexual Health Index for Men
(SHIM) questionnaire score of 17 or higher were prospectively enrolled
into a single study-arm. All study patients received robotic RP with
intraoperative nerve monitoring. A bipolar ball-tip probe directed by
robotic needle drivers stimulated the periprostatic nerves. A modified
Foley catheter with ring electrodes recorded the evoked nerve activity
from within the urethra, distal to the apex of the prostate. The nerves
were mapped circumferentially in the transverse plane of the prostate.
Mapping was also attempted by reversing stimulating and recording
electrodes: Stimulating from the Foley catheter ring electrodes and
recording the retrograde nerve action potentials from the bipolar ball-tip
probe. Following mapping, spontaneous nerve activity during dissection
was monitored with the modified Foley catheter.
RESULTS: All 28 enrolled patients underwent robotic RP ac-
cording to the nerve monitoring protocol. In 3 patients (11%), evoked
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2. nerve action potentials were noted in response to stimulation. In 26
patients (93%), spontaneous nerve activity was recorded from the
modified Foley catheter as the surgeon progressed with dissection.
Spontaneous nerve activity was found to increase following surgical
steps involving cautery or traction.
CONCLUSIONS: To our knowledge, this is the first study in
which nerve action potentials have been recorded directly from the
periprostatic nerves. The demonstrated increase in spontaneous nerve
activity following cautery and traction supports use of athermal and
traction-free dissection techniques. Further research and improvements
in technology are needed to consistently record from these fine nerve
fibers and to avoid potential false negatives.
Source of Funding: This feasibility study was sponsored and
funded by Medtronic, Inc.
V5-06
THE FIRST REPORT OF ROBOTIC ASSISTED RADICAL
NEPHRECTOMY WITH RETROHEPATIC VENA CAVAL TUMOR
THROMBECTOMY AND EXTENDED RETROPERITONEAL LYMPH
NODE DISSECTION
Jed-Sian Cheng*, Boston, MA; Gennady Bratslavsky, Syracuse, NY
INTRODUCTION AND OBJECTIVES: Robotic assisted kidney
surgery has become a common treatment modality for renal cell car-
cinoma. However, there is less than handful of reports describing the
experience of performing a robotic assisted radical nephrectomy with
inferior vena caval (IVC) tumor thrombectomy. In this video, we present
the first report of a robotic assisted radical nephrectomy with retro-
hepatic vena caval tumor thrombectomy (11cm) and extended retro-
peritoneal lymph node dissection for renal cell carcinoma.
METHODS: A 52 year old female with large renal mass, 11cm
IVC thrombus, and negative metastatic workup presented to our clinic
and was consented to undergo robotic assisted radical nephrectomy.
After the DaVinci robot was docked, mobilization of the colon and du-
odenum, followed by mobilization of the liver with division of several
short hepatic veins was performed. Intraoperative US confirmed the
presence of the retrohepatic tumor thrombus. After the division of the
renal artery the control of the inferior vena cava above and below the
tumor thrombus and contralateral renal vein was achieved with the
removal of the level III IVC thrombus extending to the retrohepatic
portion of the vena cava. Additionally, an extended retroperitoneal
lymph node dissection for renal cell carcinoma was performed with
robotic assistance.
RESULTS: Total operative time was 6 hours and 6 minutes.
Estimated blood loss was 1200cc. The final pathology demonstrated
8.5 cm, Fuhrman grade 3, ccRCC with sarcomatoid features and
negative surgical margins. All 44 lymph nodes removed (hilar, para-
caval, precaval, preaortic and interaortocaval) were negative for meta-
static RCC. Final staging was pT3b, N0, M0. Patient was discharged to
home 36 hours postoperatively and had experienced no perioperative
or postoperative complications.
CONCLUSIONS: Robotic assisted radical nephrectomy with
retrohepatic vena caval tumor thrombectomy and extended retroperi-
toneal lymph node dissection is technically feasible and has potential
benefits. Given the magnitude of the surgery, the postoperative pain
and ileus can be greatly reduced allowing for discharge to home 36
hours after surgery. The robotic assistance may allow for improved
intracorporal repair of the IVC, shortened recovery time, while main-
taining oncological principles.
Source of Funding: None
V5-07
DIRECT APPROACH FOR LEFT NEPHRECTOMY WITH
THROMBUS IN RENAL VEIN : KEEPING IN MIND A CLASSIC
LAPAROSCOPIC ACCES
Jose Antonio Bellido Petti*, Barcelona, Spain;
Yolanda Santos Gutierrez, Vic, Spain; Josep Dinares Prat, vic, Spain;
Alejandro Garcia Navarro, Juan Uría Gonzalez Tova, Vic, Spain
INTRODUCTION AND OBJECTIVES: We describe and
demonstrate the feasibility of early ligature of the renal artery and vein
using a direct access to the renal pedicle at the level of the Treitz lig-
ament during left transperitoneal radical laparoscopic nephrectomy in a
patient with thrombus in left renal vein very near of the renal Cava vein
METHODS: To reproduce the principles of open radical ne-
phrectomy and in order to achieve early ligature for the treatment of left
RCC withtransperitoneal approach, we used thedirect accessto the renal
artery at the level of the Treitz ligament. The advantage of this access
signifies a total lack of manipulation of the renal mass and the thrombus.
RESULTS: the patient and trocars are placed in convencional
position. The procedure begins with the identification of the fourth part
of the duodenum and the inferior mesenteric vein. An incision of Treitz
ligament and posterior peritoneum is performed along the route of the
inferior mesenteric vein. The anterior-lateral surface of the aorta is
identified. The aorta is carefully dissected from paraaortic nodal tissue
and its wall clearly exposed. The dissection continues upwards from the
mesenteric inferior artery, in this phase lumbar arteries and the gonadal
artery are identified and clipped. The renal vein which crosses over the
aorta is retracted, the renal artery identified and carefully dissected up
to its origin. The renal artery is secured with a laparoscopic Hem-o-
Lok.The renal vein identified, isolated, secured with Hem-o-lock and
sectioned. The nephrectomy is completed by dissection of the Gerota’s
fascia from the muscle fibres of the diaphragm. The Gerota’s fascia and
entire contents are removed using a endobag
CONCLUSIONS: This technique permits the surgeon to follow
the classic steps and principles of radical nephrectomy, which have
driven open surgery techniques for several years. It also ensures liga-
ture of the renal artery and vein for anatomic variations, in the presence
of large renal masses and thrombus.
Source of Funding: self-funded
V5-08
LAPAROSCOPIC RADICAL NEPHRECTOMY FOR RENAL CELL
CARCINOMA WITH LEVEL 1 IVC THROMBUS
George Abraham*, Avinash Siddaiah, Krishnamohan Ramaswami,
Datson George, Oppukeril Thampan, Kochi, India
INTRODUCTION AND OBJECTIVES: Laparoscopic approach
is becoming the standard of care for managing renal tumors. Renal
masses with a renal vein and inferior vena cava (IVC) thrombus present
a technically challenging situation. Left sided tumors present an addi-
tional challenge as getting an access to the junction of the vein with the
vena cava is difficult. We present video demonstration of our technique
of laparoscopic radical nephrectomy for renal cell carcinoma (RCC) with
level 1 IVC thrombus.
METHODS: All patients who underwent laparoscopic man-
agement of RCC with level 1 thrombus were included in this retro-
spective study. Right radical nephrectomy was performed with standard
5 ports technique. For left side tumor, patient was first positioned in right
lateral position and 4 ports technique was used for left radical ne-
phrectomy. Then patient was positioned in left lateral decubitus and 3
ports were placed to get an access to left renal vein and vena caval
confluence. Renal vein was suture ligated close to IVC after milking the
thrombus in to renal vein. After completion of procedure drain was
placed and specimen was retrieved through pfennenstiel incision.
Operative and postoperative details were recorded.
RESULTS: Total 5 patients with RCC with IVC thrombus were
managed with laparoscopic approach, 3 on right side and 2 on left side.
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