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V7-04 COMPLETELY INTRACORPOREAL ROBOTIC RENAL AUTOTRANSPLANTATION
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THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Monday, May 19, 2014
V7-03
V7-05
ROBOTIC POST-CHEMOTHERAPY RETROPERITONEAL LYMPHNODE DISSECTION WITH ASSOCIATED DUPLICATED INFERIOR VENA CAVA
A SINGLE SURGEON EXPERIENCE WITH ROBOT-ASSISTED IVC THROMBECTOMY INCLUDING SYNTHETIC CAVAL PATCH REPAIR
Erik Castle, Christopher Keel*, Benjamin Woodson, Benjamin Lee, Raju Thomas, New Orleans, LA
Ziho Lee*, Blake W. Moore, Lindsey A. Parkes, Eric T. Choi, Jack H. Mydlo, Daniel D. Eun, Philadelphia, PA
INTRODUCTION AND OBJECTIVES: Robotic Retroperitoneal Lymphnode Dissection (RPLND) is an emerging option for those undergoing both primary and post-chemotherapy treatment. While open RPLND has previously been the standard of care, however, as surgeons have become more accomplished utilizing robotic assistance so to has this procedure evolved. The post-chemotherapy patient usually presents a specific challenge due to the dense fibrosis associate with this. In this video we present particularly unique case in a patient with duplicated inferior vena cava. Our objective is to demonstrate an interesting and safe means of RPLND utilizing robotic assistance. METHODS: A robotic approach was utilized to perform a bilateral template dissection of the retroperitoneum sparing the right sympathetic chain and superior hypogastric plexus. RESULTS: Further studies are needed to validate the oncologic efficacy of the approach against the standard open approach. CONCLUSIONS: Robotic RPLND in the post-chemotherapy is a safe and feasible alternative to open RPLND with reduced morbidity.
INTRODUCTION AND OBJECTIVES: Although robot-assisted radical nephrectomy and IVC thrombectomy has been shown to be feasible, the literature is limited. We present our initial experience with robot-assisted radical nephrectomy and IVC thrombectomy that includes one case that involved a synthetic vena caval patch repair. METHODS: Six patients underwent robot-assisted radical nephrectomy and IVC thrombectomy by a single surgeon (DDE) between October 2009 and January 2012. The limit of tumor extension was level I in 3 (50.0%) patients, level II in 1 (16.7%) patient, and level III in 2 (33.3%) patients. Cavotomy was required in 5 (83.3%) patients, and 1 (16.7%) patient required a synthetic caval patch repair. RESULTS: Mean age of patients was 53.3 years (range 43-61), mean BMI was 25.3 kg/m2 (range 25.0-29.3). Mean IVC cross clamp time was 24.8 minutes (range 0-69), mean operative time was 192.2 minutes (range 151-257), mean estimated blood loss was 466.7 milliliters (range 200-900), and mean hospital length of stay was 6.3 days (range 5-7). On pathologic analysis, mean tumor size was 8.2 cm (range 5.8-12). There were no intraoperative or postoperative complications. CONCLUSIONS: In appropriately selected candidates, robotassisted radical nephrectomy with IVC thrombectomy is feasible. Vena caval reconstruction utilizing a synthetic patch may be performed using the robotic platform.
Source of Funding: None
Source of Funding: None
V7-04 COMPLETELY INTRACORPOREAL ROBOTIC RENAL AUTOTRANSPLANTATION Dan Gilbert*, Dublin, OH INTRODUCTION AND OBJECTIVES: Totally intracorporeal robotic donor nephrectomy with autotransplantation has not been previously described. We present a video demonstration of this novel procedure. METHODS: A 56 year old man who suffered extensive ureteral loss after infectious complications of a perforated ureter presented for surgical management and was offered nephrectomy, ileal interposition, or renal autotransplantation with ureteroureterostomy. As a stone former, he chose the latter. This was performed with a total of 5 ports, including three 8mm robotic ports for robotic instruments. The donor nephrectomy was performed first robotically with cold perfusion of the renal artery intracorporeally with a catheter through the assistant port while the kidney was moved to the pelvis for vascular anastomosis to the external iliac vessels. A ureteroureterostomy was then performed over a stent. RESULTS: Console time was 5 hours and 43 minutes, and the entire procedure was performed intracorporeally with only 5 port incisions. Venous anastomosis time was 17 minutes during which the kidney was cold perfused, and arterial anastomosis time was 21 minutes. Blood loss was 25cc, and the patient was discharged on the first postoperative day with no complications. Doppler ultrasound showed excellent flow prior to discharge, and renal scan at 6 weeks confirmed excellent graft function. Ureteral patency was confirmed at 3 months by IVP. CONCLUSIONS: We present the first report of a completely intracorporeal robotic donor nephrectomy and renal autotransplantation. This complex procedure should be offered selectively but with caution by highly experienced robotic renal surgeons. Source of Funding: None
V7-06 RECIPIENT ROBOT ASSISTED KIDNEY TRANSPLANT LEARNING STEPS: FRAME-BY-FRAME VIDEO ANALYSIS Mahendra Bhandari, Deepansh Dalela*, Akshay Sood, Detroit, MI; Rajesh Ahlawat, Gurgaon, India; Pranjal Modi, Ahmedabad, India; Ronney Abaza, Columbus, OH; Mani Menon, Khurshid Ghani, Wooju Jeong, Detroit, MI INTRODUCTION AND OBJECTIVES: Transplant surgeons learning robot-assisted kidney transplant (RAKT) should master skills specific to robotic vascular anastomoses in the dry and wet laboratory before proctoring on a patient. We compared the video recordings of the vascular anastomoses done by two groups of RAKT-performing transplant surgeons: one with extensive robotic experience, and other with minimal robotic orientation. We aimed to identify specific domains that require training to ensure safe and efficient performance of RAKT. METHODS: 41 patients undergoing recipient RAKT were classified into two groups based on the transplant surgeon’s robotic experience: Group 1 (n¼27) with extensive robotic experience (>2000 cases), and Group 2 (n¼14) with minimal robotic orientation (<10 cases). Surgeons in both groups had extensive open kidney transplant experience (>2000 cases for each). Measures of surgical process and functional patient outcomes were recorded for all 41 patients. Experienced robotic and transplant surgeons proctored all the operations to minimize compromise in functional patient outcomes. Two independent reviewers retrospectively analyzed the video recordings of venous and arterial anastomoses of 6 cases from each group (3 initial cases and 3 final cases in each group). RESULTS: The results are summarized in Tables 1 and 2. There was no significant difference in the baseline characteristics of patients in both the groups. Console camera modulation to optimize magnification of the operating field, tissue handling in absence of tactile feedback, and coordination of the robotic needle driver and forceps with the needle and suture were recognized as vital training points for vascular anastomoses.
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Monday, May 19, 2014
V7-03
V7-05
ROBOTIC POST-CHEMOTHERAPY RETROPERITONEAL LYMPHNODE DISSECTION WITH ASSOCIATED DUPLICATED INFERIOR VENA CAVA
A SINGLE SURGEON EXPERIENCE WITH ROBOT-ASSISTED IVC THROMBECTOMY INCLUDING SYNTHETIC CAVAL PATCH REPAIR
Erik Castle, Christopher Keel*, Benjamin Woodson, Benjamin Lee, Raju Thomas, New Orleans, LA
Ziho Lee*, Blake W. Moore, Lindsey A. Parkes, Eric T. Choi, Jack H. Mydlo, Daniel D. Eun, Philadelphia, PA
INTRODUCTION AND OBJECTIVES: Robotic Retroperitoneal Lymphnode Dissection (RPLND) is an emerging option for those undergoing both primary and post-chemotherapy treatment. While open RPLND has previously been the standard of care, however, as surgeons have become more accomplished utilizing robotic assistance so to has this procedure evolved. The post-chemotherapy patient usually presents a specific challenge due to the dense fibrosis associate with this. In this video we present particularly unique case in a patient with duplicated inferior vena cava. Our objective is to demonstrate an interesting and safe means of RPLND utilizing robotic assistance. METHODS: A robotic approach was utilized to perform a bilateral template dissection of the retroperitoneum sparing the right sympathetic chain and superior hypogastric plexus. RESULTS: Further studies are needed to validate the oncologic efficacy of the approach against the standard open approach. CONCLUSIONS: Robotic RPLND in the post-chemotherapy is a safe and feasible alternative to open RPLND with reduced morbidity.
INTRODUCTION AND OBJECTIVES: Although robot-assisted radical nephrectomy and IVC thrombectomy has been shown to be feasible, the literature is limited. We present our initial experience with robot-assisted radical nephrectomy and IVC thrombectomy that includes one case that involved a synthetic vena caval patch repair. METHODS: Six patients underwent robot-assisted radical nephrectomy and IVC thrombectomy by a single surgeon (DDE) between October 2009 and January 2012. The limit of tumor extension was level I in 3 (50.0%) patients, level II in 1 (16.7%) patient, and level III in 2 (33.3%) patients. Cavotomy was required in 5 (83.3%) patients, and 1 (16.7%) patient required a synthetic caval patch repair. RESULTS: Mean age of patients was 53.3 years (range 43-61), mean BMI was 25.3 kg/m2 (range 25.0-29.3). Mean IVC cross clamp time was 24.8 minutes (range 0-69), mean operative time was 192.2 minutes (range 151-257), mean estimated blood loss was 466.7 milliliters (range 200-900), and mean hospital length of stay was 6.3 days (range 5-7). On pathologic analysis, mean tumor size was 8.2 cm (range 5.8-12). There were no intraoperative or postoperative complications. CONCLUSIONS: In appropriately selected candidates, robotassisted radical nephrectomy with IVC thrombectomy is feasible. Vena caval reconstruction utilizing a synthetic patch may be performed using the robotic platform.
Source of Funding: None
Source of Funding: None
V7-04 COMPLETELY INTRACORPOREAL ROBOTIC RENAL AUTOTRANSPLANTATION Dan Gilbert*, Dublin, OH INTRODUCTION AND OBJECTIVES: Totally intracorporeal robotic donor nephrectomy with autotransplantation has not been previously described. We present a video demonstration of this novel procedure. METHODS: A 56 year old man who suffered extensive ureteral loss after infectious complications of a perforated ureter presented for surgical management and was offered nephrectomy, ileal interposition, or renal autotransplantation with ureteroureterostomy. As a stone former, he chose the latter. This was performed with a total of 5 ports, including three 8mm robotic ports for robotic instruments. The donor nephrectomy was performed first robotically with cold perfusion of the renal artery intracorporeally with a catheter through the assistant port while the kidney was moved to the pelvis for vascular anastomosis to the external iliac vessels. A ureteroureterostomy was then performed over a stent. RESULTS: Console time was 5 hours and 43 minutes, and the entire procedure was performed intracorporeally with only 5 port incisions. Venous anastomosis time was 17 minutes during which the kidney was cold perfused, and arterial anastomosis time was 21 minutes. Blood loss was 25cc, and the patient was discharged on the first postoperative day with no complications. Doppler ultrasound showed excellent flow prior to discharge, and renal scan at 6 weeks confirmed excellent graft function. Ureteral patency was confirmed at 3 months by IVP. CONCLUSIONS: We present the first report of a completely intracorporeal robotic donor nephrectomy and renal autotransplantation. This complex procedure should be offered selectively but with caution by highly experienced robotic renal surgeons. Source of Funding: None
V7-06 RECIPIENT ROBOT ASSISTED KIDNEY TRANSPLANT LEARNING STEPS: FRAME-BY-FRAME VIDEO ANALYSIS Mahendra Bhandari, Deepansh Dalela*, Akshay Sood, Detroit, MI; Rajesh Ahlawat, Gurgaon, India; Pranjal Modi, Ahmedabad, India; Ronney Abaza, Columbus, OH; Mani Menon, Khurshid Ghani, Wooju Jeong, Detroit, MI INTRODUCTION AND OBJECTIVES: Transplant surgeons learning robot-assisted kidney transplant (RAKT) should master skills specific to robotic vascular anastomoses in the dry and wet laboratory before proctoring on a patient. We compared the video recordings of the vascular anastomoses done by two groups of RAKT-performing transplant surgeons: one with extensive robotic experience, and other with minimal robotic orientation. We aimed to identify specific domains that require training to ensure safe and efficient performance of RAKT. METHODS: 41 patients undergoing recipient RAKT were classified into two groups based on the transplant surgeon’s robotic experience: Group 1 (n¼27) with extensive robotic experience (>2000 cases), and Group 2 (n¼14) with minimal robotic orientation (<10 cases). Surgeons in both groups had extensive open kidney transplant experience (>2000 cases for each). Measures of surgical process and functional patient outcomes were recorded for all 41 patients. Experienced robotic and transplant surgeons proctored all the operations to minimize compromise in functional patient outcomes. Two independent reviewers retrospectively analyzed the video recordings of venous and arterial anastomoses of 6 cases from each group (3 initial cases and 3 final cases in each group). RESULTS: The results are summarized in Tables 1 and 2. There was no significant difference in the baseline characteristics of patients in both the groups. Console camera modulation to optimize magnification of the operating field, tissue handling in absence of tactile feedback, and coordination of the robotic needle driver and forceps with the needle and suture were recognized as vital training points for vascular anastomoses.