Robot-assisted Partial Nephrectomy for Complex (PADUA Score ≥10) Tumors: Techniques and Results from a Multicenter Experience at Four High-volume Centers.

BACKGROUND: Robot-assisted partial nephrectomy (RAPN) represents a widely accepted minimally invasive alternative to open and laparoscopic surgery for the treatment of clinically localized renal tumors. OBJECTIVE: To assess the feasibility of RAPN in a contemporary series of patients with highly complex tumors (PADUA score ≥10) treated at four high-volume robotic surgery institutions. DESIGN, SETTING, AND PARTICIPANTS: Data from a prospectively maintained multi-institutional database on patients subjected to RAPN between 2010 and 2017 were reviewed. For the scope of this analysis, only patients with highly complex renal tumors, defined as a PADUA score between 10 and 14, were included. SURGICAL PROCEDURE: RAPN was performed with the da Vinci Si or Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) using novel technologies such as TilePro and near-infrared fluorescence imaging. MEASUREMENTS: Intraoperative, postoperative, surgical, and oncological outcomes were collected. Predictors of optimal surgical outcomes defined according to the Margin Ischemia and Complications binary system (absence of Clavien-Dindo >2 complications, warm ischemia time [WIT] <20min, and absence of positive surgical margins) were determined using logistic regression models (LRMs). RESULTS AND LIMITATIONS: Overall, 255 patients with complex renal tumors were included. The mean operative time was 165min and mean WIT was 18.6min. Overall, WIT was longer than 20min in 86 (33.7%) individuals, while a Clavien-Dindo >2 complication and positive surgical margins were observed in 13 (5.1%) and four (out of 211 patients with malignant histotypes; 1.9%) individuals, respectively. Optimal surgical outcomes were achieved in 158 (62.0%) patients. At a median follow-up of 28mo, one (0.4%) local and two (0.8%) distant recurrences of the disease were observed. In multivariable LRMs, extremely complex tumors (PADUA score 12-13) were associated with an increased likelihood of not achieving optimal outcomes (odds ratio: 2.31; p=0.024). Besides tumor complexity, male gender was also associated with a two-fold higher risk of not achieving optimal surgical outcomes (p=0.029). CONCLUSIONS: In experienced hands, RAPN can be considered as an effective treatment option even in cases of complex renal lesions. However, increasing tumor complexity may affect the surgical outcomes in this highly selected patient population. PATIENT SUMMARY: We reported our multicentric experience with robot-assisted partial nephrectomy (RAPN) in patients with complex renal tumors. We demonstrated that, in experienced hands, RAPN is a feasible and safe treatment option even in such patients. Novel technologies applied to RAPN may further extend the indications without compromising the outcomes.

Tumor enucleoresection in robot-assisted partial nephrectomy.

The objective of this study is to describe our technique and results of the enucleoresection technique in robot-assisted partial nephrectomy. The patient is positioned in full flank position. Three robotic arms of a da Vinci system and an assistant's port are used. The renal hilus is freed, the kidney mobilized and the site of the partial excision prepared. The vessels are clamped with a bulldog. The capsula of the kidney is incised circular about 5 mm around the tumor. A pseudocapsula of compressed healthy tissue around the tumor is found and mainly blunt dissection is done with the cold scissors. At the base of the dissection, the resection is completed sharply. Possible calyceal defects and major vessels are stitched. Fibrinogen coagulation enhancer and cellulose coagulation sponge are used to lessen the gap and the renal defect is closed with absorbable suture. The kidney is re-perfused and observed for bleeding. We have performed 17 cases with warm ischemia time 16-35 min (mean 24 min) and tumor size 2.2-5.3 cm (mean 3.8 cm). All surgical margins were tumor free. No postoperative complications were identified except one clot retention. Robot-assisted enucleoresection of kidney tumors is a feasible and very promising technique that needs to be further evaluated for results.

Failure of a robotic arm during da Vinci prostatectomy: a case report.

We report a rare case of a da Vinci robotic arm failure during a laparoscopic robot-assisted radical prostatectomy. The articulation joint of an Endowrist needle driver was broken and positioned at such an angle that made it impossible to remove through the trocar. In addition, it was later discovered that a small piece of the instrument was detached and remained inside the abdomen of the patient without even having been identified on subsequent radiological evaluation. In order to remove the broken instrument, we had to uninstall it from the robot arm and a bigger incision had to be made in the abdominal wall of the patient. The operation was completed without any other incidents. Testing the broken instrument for integrity is recommended to avoid this rare complication.