机器人PN第一次报道

ROBOTIC-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY:TECHNIQUE AND INITIAL CLINICAL EXPERIENCE WITH DA VINCI ROBOTIC SYSTEM MATTHEW T.GETTMAN,MICHAEL L.BLUTE,GEORGE K.CHOW,RICHARD NEURURER,GEORG BARTSCH,AND REINHARD PESCHELABSTRACTObjectives.To develop and assess the feasibility of laparoscopic partial nephrectomy performed using the daVinci robotic system.Methods.Between November2002and August2003,13patients with solid or suspicious cystic renal masses underwent robotic-assisted laparoscopic partial nephrectomy.In8cases,an intra-arterial catheter was inserted for renal cooling before occlusion of the renal artery.The remaining5patients underwent partial nephrectomy after the renal hilum had been clamped.Tumor excision and intracorporeal suturing were performed entirely with telerobotics.The perioperative data and pathologic results were retrospec-tively reviewed.Results.The mean lesion diameter was3.5cm(range2.0to6.0).The mean operative time was215minutes (range130to262),and the mean blood loss was170mL(range50to300).The mean warm ischemia was 22minutes(range15to29),and the mean cold ischemia time was33minutes(range18to43).The length of hospital stay averaged4.3days(range2to7).The resected lesions included renal cell carcinoma in10, oncocytoma in2,and a complex renal cyst in1.In1case,a positive margin occurred despite negative frozen sections;laparoscopic nephrectomy was performed and showed no residual tumor.One patient experienced postoperative ileus.At2to11months of follow-up,no recurrence had been observed.Conclusions.Robotic-assisted partial nephrectomy is feasible.Robotic partial nephrectomy can be safely performed using a transperitoneal or retroperitoneal approach.A second scrubbed assistant is mandatory to provide assistance using conventional laparoscopic instruments with this technique.UROLOGY64: 914–918,2004.©2004Elsevier Inc.I ncreased use of transaxial imaging has led to the incidental discovery of small renal masses amenable to partial nephrectomy.In the pres-ence of a normal contralateral kidney,nephron-sparing surgery is increasingly performed,with proven efficacy and long-term patient-related benefits.1–3One concern,possibly limiting wide-spread use of laparoscopic partial nephrectomy (LPN),has been the lack of technically friendly and reliable methods for hemostasis.4The hemo-static modalities currently used during LPN in-clude argon beam coagulation,electrocautery, gelatin sponges,ultrasound dissection,radiofre-quency ablation,andfibrin glue.4–9Laparo-scopic techniques that mimic open partial ne-phrectomy and provide more reliable hemostasis have also been described;however,intracorpo-real suturing and concerns of warm renal isch-emia have remained limitations.10,11 Recently,telerobotic surgical systems have been introduced with a goal of decreasing tech-nical difficulty of intracorporeal suturing;how-ever,to our knowledge,an experience with LPN has not yet been published.We hypothesized that telerobotics would facilitate performance of LPN using a suture closure method of hemosta-sis that recapitulates the steps of open partial nephrectomy.In this investigation,we report our initial experience with LPN performed using the daVinci telerobotic system.From the Department of Urology,Mayo Clinic,Rochester, Minnesota;and Department of Urology,University of Innsbruck, Innsbruck,AustriaReprint requests:Matthew T.Gettman,M.D.,Department of Urology,Gonda7,Mayo Clinic,200First Street,Southwest, Rochester,MN55905Submitted:November10,2003,accepted(with revisions):June 21,2004ADULT UROLOGYLSEVIER NCMATERIAL AND METHODSP ATIENTSBetween November2002and August2003,13patients un-derwent robotic-assisted transperitoneal or retroperitoneal LPN(Table I).All patients had been evaluated with computed tomography to define the mass clearly preoperatively.The inclusion criteria were solitary,enhancing,predominantly ex-ophytic solid or suspicious cystic renal lesions(Bosniak cate-gory III or IV)that were found to be satisfactory candidates for LPN,similar to those indications previously described by Gill et al.12Preoperatively,all patients had a normal contralateral kidney and normal renal function.The exclusion criteria were completely endophytic or central renal lesions or extensive prior intra-abdominal surgery precluding an attempt with LPN.The mean tumor size on the preoperative computed tomography scan was3.5cm(range2to6).In11patients,a transperitoneal approach was used.In the remaining2pa-tients with a posterior and lateral tumor,a retroperitoneal approach was used.The surgical specimen was processed us-ing standard techniques,and the pathologic assessment was performed using the1997TNM staging system.S URGICAL T ECHNIQUEIn all cases,robotic-assisted LPN was performed using the daVinci telerobotic surgical system.Technical details regard-ing the daVinci robotic system have been previously de-scribed.13For the8most recent patients in the series,an intra-arterial renal catheter was placed by radiology intraoperatively by way of groin access to facilitate cooling of the kidney with iced saline during LPN.14,15Patients undergoing a transperi-toneal approach were placed in a45°modifiedflank position, as used for standard LPN,and the ports were placed after pneumoperitoneum was established with a Veress needle.A 12-mm trocar was initially placed at the umbilicus to serve as the assistant port during the robotic ing the robotic endoscope,the peritoneal cavity was then inspected to determine the generalized location of the kidney and the renal lesion.An additional12-mm trocar for the robotic endoscope was then placed at a midclavicular,infraumbilical position in line with the perceived location of the renal tumor.Trocars for the two additional robotic arms(8-mm ports,Intuitive Surgi-cal)were then placed medially and laterally such that the distance between the camera port and each working port was at least7cm.In addition,the robotic ports were ideally placed such that the angle created between the working ports and the camera port was obtuse(Fig.1).For patients undergoing a retroperitoneal approach,a fullflank position was used.After the working space had been created,the camera port was placed below the tip of the12th rib,the working ports were similarly placed such that the angle between the working ports and camera was obtuse.The daVinci-assisted LPN followed the steps of open partial nephrectomy and conventional LPN,as previously de-scribed.10–12,15The initial dissection was performed with a hook electrode on the lateral working robotic arm and a Pro-grasp or Cadiere forceps on the medial working robotic arm. During the transperitoneal approach,the line of Toldt was incised,the bowel mobilized medially,and Gerota’s fascia in-cised.During the retroperitoneal approach,Gerota’s fascia was likewise identified and incised.The scrubbed assistant facilitated dissection by using conventional laparoscopic in-struments to provide countertraction and suction.The kidney was completely mobilized within Gerota’s fascia to identify the renal lesion and exclude the possibility of additional lesions. Fat overlying the renal lesion was not dissected and was in-cluded as part of the pathologic specimen.The renal hilum was then dissected to permit occlusion during partial nephrec-tomy.In preparation for daVinci-assisted LPN,the assistant intro-duced a2-0Vicryl suture(15to20cm in length)through the 12-mm assistant port.A bolster composed of Gelfoam and Surgicel was also placed intra-abdominally in preparation for suturing after tumor excision.Before tumor excision,12.5g of mannitol was administered.For patients undergoing resection of tumors in the presence of warm renal ischemia,renal artery and vein occlusion was performed with a laparoscopic bulldog clamp.Alternatively,for patients undergoing intra-arterialTABLE I.Patient characteristics Patient total(n)13Age(yr)Mean68 Range51–78 Sex(n)Male8 Female5 Preoperative serum creatinine(mg/dL)Mean 1.1 Range0.7–1.4 Side of involvement(n)Right7 Left6 Tumor location(n)Anterior lateral6 Posterior lateral3 Anterior medial2 Posterior medial2 Upper pole3 Middle pole5 Lower pole5 Pathologic stage*pT1aNxMx9pT1bNxMx1*Final pathologic examination revealed renal cell carcinoma in10of13partial nephrectomy specimens(seetext).FIGURE1.Position of trocars during robotic-assisted LPN using transperitoneal approach.catheter placement for delivery of iced saline,renal artery oc-clusion was performed using the intra-arterial catheter bal-loon,as previously described.14,15In these cases,continuous infusion of iced saline prevented venous backflow during ing cold,round tip scissors,LPN was then per-formed.During tumor excision,the assistant used a suction/ irrigator or conventional laparoscopic grasper for counter traction and to optimize visualization of the surgicalfield.The excised tumor was temporarily placed adjacent to the kidney, and the assistant placed large needle drivers on the robotic arms.Collecting system violations and larger bleeding vessels were controlled with2-0Vicryl sutures.Entry into the collect-ing system was based on visual inspection of the renal defect after tumor resection.Suture closure of the renal defect was then performed using bolsters.After closure of the renal de-fect,the pedicle clamp was removed,and the excised renal tumor was placed into a retrieval bag.For patients undergoing intra-arterial cooling,the balloon occluding the renal artery was released after suture closure of the renal defect.Frozen section evaluation was performed in all cases.Gerota’s fascia was then reapproximated over the kidney with2-0Vicryl su-ture,and the bowel was brought back into anatomic position.A Jackson-Pratt drain was placed through the more lateral 8-mm trocar site.The tumor was then retrieved intact,and all ports were closed in standard fashion.RESULTSThe patient-related demographic data and re-sults are summarized in Table I.In all cases,LPN was performed on an elective basis in the pres-ence of a normal contralateral kidney.A total of 13daVinci-assisted LPN procedures were per-formed,with a mean operative time of215min-utes(range130to262).The mean operative time included the time required for installation of the robot.In all cases,the initial setup of the robot was performed before initiation of the pneumoperitoneum.Overall,the mean esti-mated blood loss was170mL(range50to300). Closure of the collecting system was required in 2cases.In general,three U sutures were required to approximate the renal parenchyma.For patients undergoing LPN after clamping of the renal hilum,the overall mean warm renal isch-emia time was22minutes(range15to29).For patients undergoing LPN after placement of an in-tra-arterial cooling catheter,the mean cold isch-emia time was33minutes(range18to43).Of these cases,placement of the angiocatheter was al-ways successful,and the angiocatheter was never dislodged during dissection.In all cases,the angio-catheter provided effective occlusion of the renal artery and prevented venous backflow during e of intra-arterial cooling did not com-plicate excision of the renal mass in any case. Complete hemostasis was attained intraopera-tively in all cases without open conversion.No in-traoperative complications were encountered.One patient experienced postoperative ileus,which re-solved spontaneously without adverse conse-quences,except for a prolonged7-day hospitaliza-tion.The mean length of hospital stay was4.3days (range2to7).Pathologic examination revealed renal cell carcinoma in10cases,oncocytoma in2 cases,and a benign complex cyst in1case.In the case of a6-cm lower pole tumor,a positive margin occurred despite negative frozen section analysis; laparoscopic radical nephrectomy was subse-quently performed and showed no evidence of re-sidual tumor.At2to11months of follow-up,no recurrence had been observed.COMMENTBecause intracorporeal suturing is perceived by many urologists as technically difficult and time consuming,a variety of alternative hemostatic techniques have been introduced for LPN.3–8How-ever,the alternative techniques have at times been less reliable than what is possible with suture clo-sure of the renal defect.A technique of LPN has also been described using intracorporeal suturing with conventional laparoscopic instruments.This approach is increasingly preferred by urologists who have learned intracorporeal suturing and are comfortable with the technique,but this method can represent a significant challenge for those urol-ogists who are unskilled with intracorporeal sutur-ing or are not comfortable with the technique.9–11 Although robotic technology appears targeted to urologists with minimal laparoscopic skills,the performance-enhancing features of telerobots may also augment the performance of experienced lapa-roscopists.In a variety of open surgical procedures, for example,use of performance-enhancing tech-nologies by experienced surgeons(ie,surgical loupes)is thought to improve surgical outcomes. Our goal,therefore,was to evaluate the role of tel-erobotics on the performance of LPN.We found that with telerobotics,LPN was feasible and that suture closure of the renal defect was possible.In our initial experience,the technique provided re-liable hemostasis and operative times comparable to those times reported for other techniques of LPN.We also found that telerobotics could be per-formed using either a transperitoneal or a retroper-itoneal approach.At this time,case selection appears a very impor-tant consideration when using telerobotics for LPN.We would recommend the use of robotic-assisted LPN for predominantly exophytic renal lesions.This recommendation is based solely on our experience with robotic-assisted LPN to date. Initially,we chose tumors that were anterior in position and for this reason used a transperitoneal approach.For tumors located more posteriorly in the kidney,we have now also resected lesions us-ing a retroperitoneal approach.Although a retro-peritoneal approach is feasible,frequent modifica-tions of the robotic alignment are required by the assistant surgeon during this approach,and the optimal working environment with the current ro-botic systems seems better using a transperitoneal approach.Therefore,we believe that,at least ini-tially,patients with anterolateral-based tumors should be selected,and the approach should be transperitoneal.Compared with open surgery and standard lapa-roscopy,robotic-assisted LPN requires increased emphasis on a team approach.The experienced scrubbed assistant,for example,is critical to the success of the procedure.The assistant performs tasks vital to the procedure such as application of the pedicle clamp and introduction of suture and bolster material.The assistant is also responsible for providing countertraction and suction during tumor resection.Given the increased emphasis on the team approach,the learning curve for telero-botic procedures requires an adjustment even for surgeons familiar with conventional laparoscopy. One of the most important aspects of telerobotic surgery is port placement and installation of the robot.More so than with other telerobotic proce-dures,the position of the trocars must be tailored to the anticipated position of the renal tumor and the body habitus of the patient.Endoscopic visu-alization of the surgicalfield can assist with local-izing the general position of the kidney when plan-ning port placement at the beginning of the procedure.For optimal function of the robot,the angle created between each working robotic port and the camera port should be obtuse and the tra-jectory to the renal tumor should bisect this angle. Technical issues regarding robotic-assisted LPN also require comment.Because the daVinci-as-sisted procedures were initially performed using warm renal ischemia,the time required for tumor excision and repair should ideally be less than30 minutes.Although the mean warm ischemia time was within this period,we have now started using intra-arterial catheter placement in recent cases with iced saline renal cooling to extend the isch-emia time safely beyond30minutes.Increased re-liance on the team approach for the introduction of suture and bolster material did appear less advan-tageous from a time standpoint.At times,it can be quite challenging for the scrubbed surgeon to pro-vide effective assistance given the location and on-going movement of the robotic system,especially when the operativefield is magnified.The initial clinical results with daVinci-assisted LPN are encouraging,but limitations to this feasi-bility report require comment.First,larger clinical experience is needed to confirm our initialfindings and a comparison with a control group would be beneficial.More experience is also required to as-sess the benefits of the intra-arterial catheter that permits renal cooling during resection.Although our goal of telerobotics was to enable more effec-tive application of LPN,especially for larger diam-eter lesions,case selection to date has focused on small,predominantly exophytic,lesions.Thus,ad-ditional experience is required to assess the benefit of robotics on the resection of larger renal lesions. Additional experience and technical modifications will also be helpful for the retroperitoneal ap-proach to posterior lesions.Finally,the ability of telerobotics to bridge the technology gap between experienced and inexperienced laparoscopists re-quires further study.CONCLUSIONSIn our initial clinical experience,daVinci-as-sisted LPN was feasible and was able to recapit-ulate the steps of open partial nephrectomy and conventional LPN.Robotic-assisted LPN can be safely performed using a transperitoneal or ret-roperitoneal approach.A second scrubbed sur-geon is mandatory for this procedure to provide technical assistance using conventional laparo-scopic instruments.REFERENCESu W,Blute ML,Weaver AL,et al:Matched compari-son of radical nephrectomy vs.nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney.Mayo Clin Proc75:1236–1242,2000.2.Herr HW:Partial nephrectomy for unilateral renal car-cinoma and a normal contralateral kidney:10-year followup. 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