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Ces Urol 2016; 20(1): 13–15
VIDEO
tion (since that time more than 120 laparoscopic
partials were done). The number of patients treated
is still growing due to the increasing number of
small renal masses detected and our increasing
experience with more advanced tumours (size and
location). We are now able to resect even some
unpleasantly located kidney tumours.
Our technique
: Partial nephrectomies were
done using 2nd generation DaVinci® S™ system.
We are performing transperitoneal approach with
4–5 ports and standard patient positioning (flank
position, slightly bent). We start with open ac‑
cess for the 12mm camera port. Then we use two
8mm ports for the robotic arms and 12mm and
sometimes another 5mm port for the assistant.
The abdomen is insufflated with CO2 to 12 mmHg.
We mobilise the colon, open Gerota fascia and re‑
move the perirenal fat to expose the tumour. The
tumour margins are identified using ultrasound.
They are then scored circumferentially by electro
cautery. Then we prepare the renal hilum. A vessel
loop is put around the renal artery, which is then
clamped using a bull dock. We do not usually do
selective clamping. But in selected cases (small
tumour, favourable location) we resect the kid‑
ney without clamping the artery (zero ischemia).
Dissection of the tumour is done using blunt and
sharp technique. Electro cautery is not used, for
it would impair the visual control. The tumour is
placed in an endobag. We then use plasma argon
coagulation for the resected margin. The resected
kidney is closed in two layers. We start with braided
absorbable Safil 3–0 suture with a knot and clip at
one end. This suture goes from outside in, several
turns are done to close the major vessels or calices,
then it goes out so another clip can be placed at
the end and the suture tightened. The second
suture is done using sliding clips technique. Hae‑
mostatic agents are used if necessary. We also try to
close the Gerota fascia. At the end we always place
a Redon drain. Urinary catheter is removed on the
first post-operative day. Surgery is performed un‑
der standard general anaesthesia with commonly
used postoperative analgesics.
Results
: Mean console time was 59 min
(45–120 min), warm ischemia time was 12 min, in
30 cases there was zero ischemia time. This could
be done due to small size and favourable loca‑
tion of the tumour. Mean blood loss was 120 ml
(20–300 ml). There were no conversions to open
surgery and there were no major complications
requiring surgery (Clavien IIIb). In 2 cases we had to
insert DJ stent due to urinoma (Clavien IIIa). RCC was
found in 82 cases and in 3 cases oncocytoma. The
mean size of the tumour was 3.9 cm (1.5–10 cm).
The surgical margins were negative in all cases, and
so far there has been no relapse of tumour.
Conclusion
: RAPN showed very good results,
enhanced the visual control and manoeuvrability,
thus extending the number of tumours that can
be managed using minimally invasive technique.
Using the novel techniques (sliding clips) both
warm time ischemia and complication rates can
be reduced.
KEY WORDS
Kidney tumour, Renal cell carcinoma, partial ne‑
phrectomy, robot-assisted partial nephrectomy.