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ROBOTIC ASSISTED RESECTION OF LOCALLY RECURRENT RENAL CELL CARCINOMA WITH PARA-AORTIC LYMPH NODE DISSECTION
Vol. 179, No. 4, Supplement, Sunday, May 18, 2008
and ureter are sequentially divided using the laparoscopic stapler. The remainder of the nephrectomy is performed, and the specimen is removed via the umbilical incision either morcellated (as in this case for benign disease) or intact (in cases of malignant disease). RESULTS: Keyhole umbilical nephrectomy was successfully completed with an operative time of 133 minutes. The blood loss was minimal, and the kidney was extracted through the solitary 2.0cm umbilical incision using specimen morcellation. The patient recovered well without perioperative complications and was discharged on hospital day 2 in stable condition. Final pathology was chronic pyelonephritis. CONCLUSIONS: Keyhole umbilical surgery is a novel WHFKQLTXHZKLFKPD\DIIRUGEHQH¿WVRYHUFRQYHQWLRQDOODSDURVFRS\:H are prospectively comparing short-term measures of convalescence to EHWWHUGH¿QHLWVUROH Source of Funding: None
V443 ROBOTIC ASSISTED RESECTION OF LOCALLY RECURRENT RENAL CELL CARCINOMA WITH PARA-AORTIC LYMPH NODE DISSECTION Ismail R Saad*, Rosalia Viterbo, David Y T Chen, Robert G Uzzo. Philadelphia, PA. INTRODUCTION AND OBJECTIVE: The da Vinci Robot® has been an important adjunct in laparoscopic urologic oncology. However, its role in complex upper urinary tract oncologic procedures has not been established. We present our initial experience using the robot for para-aortic lymph node (LN) dissection as well as resection of a local recurrence of renal cell carcinoma (RCC) following radical nephrectomy. METHODS: The patient is a 39 years old. male who presented 2.5 years following a left laparoscopic transperitoneal radical QHSKUHFWRP\ ZKLFK UHYHDOHG D S7 FOHDU FHOO 5&& 6WDJH VSHFL¿F VXUYHLOODQFHLPDJLQJLGHQWL¿HGDFPSDUDDRUWLF/1ZLWKDQDGMDFHQW area of soft tissue mass suggestive of local cancer recurrence. Salvage surgery was recommended, and robotic assisted para-aortic LN dissection with excision of local recurrence was performed as follows: 7KHSDWLHQWZDVSODFHGLQWKHÀDQNSRVLWLRQ7KUHHURERWDUPVZHUHXVHG including the camera port. The camera port was placed 6 cm above the umbilicus just off the midline using the radiographic location of the enlarged node as the remote center. Two daVinci® 8mm ports were triangulated 8cm off this location. During the procedure, two additional assistant ports were employed as needed. The procedure was comprised RIVWDQGDUGOHIWFRORQPRELOL]DWLRQLGHQWL¿FDWLRQRIWKHDRUWDFRPSOHWH dissection of para-aortic LN and area of questionable local recurrence, VSHFLPHQUHWULHYDODQG¿QDOO\DSSOLFDWLRQRIKHPRVWDWLFDLGV RESULTS: The operative time was 195 minutes (including robot docking time). Blood loss was minimal. Hospital stay was 2 days. Twenty-four lymph nodes were robotically harvested with 3 demonstrating metastatic RCC. CONCLUSIONS: The use of the da Vinci® surgical system for complex upper tract oncologic procedures is a safe and feasible alternative to conventional laparoscopy or traditional open surgery. While there are published reports of its use for radical and partial nephrectomy, ZHEHOLHYHWKLVLVWKH¿UVWUHSRUWRQXVLQJURERWLFDVVLVWHGVXUJHU\IRU retroperitoneal LN dissection following radical nephrectomy. Robotic resection of recurrent upper urinary tract tumors appears to be safe and may be associated with decreased post-operative morbidity. Source of Funding: None
V444 LAPAROSCOPIC INTERAORTOCAVAL METASTASECTOMY FOR RCC Andre Berger*, Monish Aron, Raj K Goel, David Canes, Kazumi Kamoi, Philippe Koenig, Georges-Pascal Haber, Leonardo G Lopes, Marcelo Miranda, Inderbir S Gill. Cleveland, OH. INTRODUCTION AND OBJECTIVE: Patients with metastatic renal cell carcinoma (RCC) have reported 5-year survival rates of 0% to 20%. With complete surgical excision of a solitary metastatic site, 5-year survival up to 40-50% may be expected. Untreated retroperitoneal metastasis from RCC carries a poor prognosis. Combination of judicious
THE JOURNAL OF UROLOGY®
157
surgery and newer systemic therapies may have potential to improve the outcomes in such situations. In this video we demonstrate laparoscopic excision of an interaortocaval metastasis from RCC. To our knowledge this is the first report of laparoscopic excision of interaortocaval metastasis from RCC. METHODS: An 84 year old female underwent to a right radical nephrectomy in 2002 for a pT3N0M0, grade 2 RCC. In 04/07, a 5 cm interaortocaval mass was noted on a routine follow-up CT (Fig 1a, Fig 1b). Detailed metastatic work-up did not reveal any other lesions. Given her excellent performance status, long disease free interval, and solitary metastasis, a laparoscopic transperitoneal excision of the mass was performed. RESULTS: A 5-port approach was employed (12 mm port x 4, 5 mm port x 1) (Fig 1c). Adhesions were detached and the great vessels ZHUHZLGHO\H[SRVHG7KHLQWHUDRUWRFDYDOPDVV )LJG ZDVLGHQWL¿HG A large venous communication between the mass and the cava was suture ligated. The mass was completely excised without complications. A large venous communication between the mass and the cava was suture ligated. Operative time was 174 mins. Estimated blood loss was 700 ml. Post-operative course was uneventful and hospital stay was 2 days. Histopathology revealed metastatic clear cell RCC with negative margins. At 4-months follow up, the patent remains disease free. CONCLUSIONS: A laparoscopic approach for excision of RCC metastases in the vicinity of the great vessels is technically feasible. However, it should be reserved for laparoscopists with advanced suturing skills.
Source of Funding: None
V445 ROBOTIC PARTIAL NEPHRECTOMY, FOUR ARM APPROACH: AN INSTRUCTIONAL VIDEO Agnes J Wang*, Sam B Bhayani. Saint Louis, MO. INTRODUCTION AND OBJECTIVE: Since the first laparoscopic nephrectomy was performed in 1991, improvements in surgical technique and the increased number of incidentally detected tumors have driven interest in a nephron-sparing operation. However, the laparoscopic approach can be technically challenging to perform, even for experienced laparoscopic surgeons. Robotic assistance can better facilitate the operation, possibly to decrease the conversion rate to a radical nephrectomy and reduce warm ischemia time. Using a fourth robotic arm allows placement of a retractor, further simplifying the dissection. A 7-minute instructional video will be presented to demonstrate the robotic assisted, laparoscopic partial nephrectomy XWLOL]LQJWKHIRXUDUPDSSURDFK METHODS: A 61-year-old white male presented with an LQFLGHQWDO FHQWLPHWHU OHIW ORZHU SROH UHQDO PDVV ZLWK D VLJQL¿FDQW LQWUDUHQDOFRPSRQHQW$VWKHWXPRUZDVVPDOODQGFOHDUO\ORFDOL]HGKH elected for a nephron-sparing procedure. RESULTS: The patient underwent a robot assisted, laparoscopic partial nephrectomy. A 45mm dual-blade atrial retractor was placed on the fourth robotic arm to assist in retraction and dissection. The
and ureter are sequentially divided using the laparoscopic stapler. The remainder of the nephrectomy is performed, and the specimen is removed via the umbilical incision either morcellated (as in this case for benign disease) or intact (in cases of malignant disease). RESULTS: Keyhole umbilical nephrectomy was successfully completed with an operative time of 133 minutes. The blood loss was minimal, and the kidney was extracted through the solitary 2.0cm umbilical incision using specimen morcellation. The patient recovered well without perioperative complications and was discharged on hospital day 2 in stable condition. Final pathology was chronic pyelonephritis. CONCLUSIONS: Keyhole umbilical surgery is a novel WHFKQLTXHZKLFKPD\DIIRUGEHQH¿WVRYHUFRQYHQWLRQDOODSDURVFRS\:H are prospectively comparing short-term measures of convalescence to EHWWHUGH¿QHLWVUROH Source of Funding: None
V443 ROBOTIC ASSISTED RESECTION OF LOCALLY RECURRENT RENAL CELL CARCINOMA WITH PARA-AORTIC LYMPH NODE DISSECTION Ismail R Saad*, Rosalia Viterbo, David Y T Chen, Robert G Uzzo. Philadelphia, PA. INTRODUCTION AND OBJECTIVE: The da Vinci Robot® has been an important adjunct in laparoscopic urologic oncology. However, its role in complex upper urinary tract oncologic procedures has not been established. We present our initial experience using the robot for para-aortic lymph node (LN) dissection as well as resection of a local recurrence of renal cell carcinoma (RCC) following radical nephrectomy. METHODS: The patient is a 39 years old. male who presented 2.5 years following a left laparoscopic transperitoneal radical QHSKUHFWRP\ ZKLFK UHYHDOHG D S7 FOHDU FHOO 5&& 6WDJH VSHFL¿F VXUYHLOODQFHLPDJLQJLGHQWL¿HGDFPSDUDDRUWLF/1ZLWKDQDGMDFHQW area of soft tissue mass suggestive of local cancer recurrence. Salvage surgery was recommended, and robotic assisted para-aortic LN dissection with excision of local recurrence was performed as follows: 7KHSDWLHQWZDVSODFHGLQWKHÀDQNSRVLWLRQ7KUHHURERWDUPVZHUHXVHG including the camera port. The camera port was placed 6 cm above the umbilicus just off the midline using the radiographic location of the enlarged node as the remote center. Two daVinci® 8mm ports were triangulated 8cm off this location. During the procedure, two additional assistant ports were employed as needed. The procedure was comprised RIVWDQGDUGOHIWFRORQPRELOL]DWLRQLGHQWL¿FDWLRQRIWKHDRUWDFRPSOHWH dissection of para-aortic LN and area of questionable local recurrence, VSHFLPHQUHWULHYDODQG¿QDOO\DSSOLFDWLRQRIKHPRVWDWLFDLGV RESULTS: The operative time was 195 minutes (including robot docking time). Blood loss was minimal. Hospital stay was 2 days. Twenty-four lymph nodes were robotically harvested with 3 demonstrating metastatic RCC. CONCLUSIONS: The use of the da Vinci® surgical system for complex upper tract oncologic procedures is a safe and feasible alternative to conventional laparoscopy or traditional open surgery. While there are published reports of its use for radical and partial nephrectomy, ZHEHOLHYHWKLVLVWKH¿UVWUHSRUWRQXVLQJURERWLFDVVLVWHGVXUJHU\IRU retroperitoneal LN dissection following radical nephrectomy. Robotic resection of recurrent upper urinary tract tumors appears to be safe and may be associated with decreased post-operative morbidity. Source of Funding: None
V444 LAPAROSCOPIC INTERAORTOCAVAL METASTASECTOMY FOR RCC Andre Berger*, Monish Aron, Raj K Goel, David Canes, Kazumi Kamoi, Philippe Koenig, Georges-Pascal Haber, Leonardo G Lopes, Marcelo Miranda, Inderbir S Gill. Cleveland, OH. INTRODUCTION AND OBJECTIVE: Patients with metastatic renal cell carcinoma (RCC) have reported 5-year survival rates of 0% to 20%. With complete surgical excision of a solitary metastatic site, 5-year survival up to 40-50% may be expected. Untreated retroperitoneal metastasis from RCC carries a poor prognosis. Combination of judicious
THE JOURNAL OF UROLOGY®
157
surgery and newer systemic therapies may have potential to improve the outcomes in such situations. In this video we demonstrate laparoscopic excision of an interaortocaval metastasis from RCC. To our knowledge this is the first report of laparoscopic excision of interaortocaval metastasis from RCC. METHODS: An 84 year old female underwent to a right radical nephrectomy in 2002 for a pT3N0M0, grade 2 RCC. In 04/07, a 5 cm interaortocaval mass was noted on a routine follow-up CT (Fig 1a, Fig 1b). Detailed metastatic work-up did not reveal any other lesions. Given her excellent performance status, long disease free interval, and solitary metastasis, a laparoscopic transperitoneal excision of the mass was performed. RESULTS: A 5-port approach was employed (12 mm port x 4, 5 mm port x 1) (Fig 1c). Adhesions were detached and the great vessels ZHUHZLGHO\H[SRVHG7KHLQWHUDRUWRFDYDOPDVV )LJG ZDVLGHQWL¿HG A large venous communication between the mass and the cava was suture ligated. The mass was completely excised without complications. A large venous communication between the mass and the cava was suture ligated. Operative time was 174 mins. Estimated blood loss was 700 ml. Post-operative course was uneventful and hospital stay was 2 days. Histopathology revealed metastatic clear cell RCC with negative margins. At 4-months follow up, the patent remains disease free. CONCLUSIONS: A laparoscopic approach for excision of RCC metastases in the vicinity of the great vessels is technically feasible. However, it should be reserved for laparoscopists with advanced suturing skills.
Source of Funding: None
V445 ROBOTIC PARTIAL NEPHRECTOMY, FOUR ARM APPROACH: AN INSTRUCTIONAL VIDEO Agnes J Wang*, Sam B Bhayani. Saint Louis, MO. INTRODUCTION AND OBJECTIVE: Since the first laparoscopic nephrectomy was performed in 1991, improvements in surgical technique and the increased number of incidentally detected tumors have driven interest in a nephron-sparing operation. However, the laparoscopic approach can be technically challenging to perform, even for experienced laparoscopic surgeons. Robotic assistance can better facilitate the operation, possibly to decrease the conversion rate to a radical nephrectomy and reduce warm ischemia time. Using a fourth robotic arm allows placement of a retractor, further simplifying the dissection. A 7-minute instructional video will be presented to demonstrate the robotic assisted, laparoscopic partial nephrectomy XWLOL]LQJWKHIRXUDUPDSSURDFK METHODS: A 61-year-old white male presented with an LQFLGHQWDO FHQWLPHWHU OHIW ORZHU SROH UHQDO PDVV ZLWK D VLJQL¿FDQW LQWUDUHQDOFRPSRQHQW$VWKHWXPRUZDVVPDOODQGFOHDUO\ORFDOL]HGKH elected for a nephron-sparing procedure. RESULTS: The patient underwent a robot assisted, laparoscopic partial nephrectomy. A 45mm dual-blade atrial retractor was placed on the fourth robotic arm to assist in retraction and dissection. The