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V9-03 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS
e860
THE JOURNAL OF UROLOGYâ
using a novel three dimensional (3d) printing and silicone casting technology. METHODS: Using standard preoperative imaging, 3d reconstruction of renal parenchyma and tumor was performed to generate solid models suitable for rapid fabrication. Leveraging a novel prototyping process that utilizes 3d extrusion printing and subsequent polymer casting we generated pre-surgical models out of a silicone-based material. To determine how well these patientspecific models simulated actual operative experience, we compared enucleation times between model and actual tumor using the same robotic platform. For the final model, we performed 3d laser scans of both the enucleated model and tumor comparing their spatial characteristics. All surgical rehearsals were performed prior to the actual procedure. RESULTS: We generated patient-specific pre-surgical models for 3 patients. R.E.N.A.L. nephrometry scoring for the pre-surgical models was 7a, 8p, 8a and tumor sizes were 3.5x3.4x3.5 cm, 4.1x3.8x3.5 cm, and 1.5x1.4x1.4 cm. Time of enucleation was similar between the patient-specific pre-surgical models and the actual surgery (6:24 vs. 5:58, 3:11 vs. 3:43, 4:55 vs. 6:09 mins). For case #3, the surgical model enucleation volume measured 6.4 mm3 and the actual excised specimen 12.8 mm3. A 3d-reconstructed visual overlay demonstrated a high level of coherence in the shape of the excised tumor and allowed measurement of the difference in the volume of excised normal renal parenchyma between the model and the actual patient specimen. CONCLUSIONS: We have developed a patient-specific presurgical simulation for robotic partial nephrectomy. Our model provides accurate representation of enucleation time and volume of resected tissue. This highly reproducible simulation platform has the potential to alter surgical decision-making and allow for preoperative rehearsal in complex cases. Furthermore it may become a valuable tool for resident training. Source of Funding: none
V9-03 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS Matthew J. Maurice*, Daniel Ramirez, Peter A. Caputo, Ryan J. Nelson, Onder Kara, Ercan Malkoc, Jihad H. Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: Hilar tumors are challenging due to their centrality and proximity to the renal hilum, increasing the complexity of tumor excision and renal reconstruction. We sought to highlight these challenges and demonstrate techniques for successful execution and excellent outcomes. METHODS: Using our retrospective robotic partial nephrectomy database, we abstracted data on patients who were treated between 2006 and 2015. Videos demonstrating robotic partial nephrectomy for two particularly challenging hilar tumors were selected for presentation. For all cases, patients were positioned in full 45-degree flank, and surgery was performed with four working ports. Intraoperative ultrasound was used to identify tumor margins and guide excision. The renorrhaphy was performed in a minimum of two layers, including a deep layer closed with 2-0 polyglactin 910 in a running fashion and a capsular layer closed with 0 polyglactin 910 suture in a horizontal mattress fashion. RESULTS: Of 1123 total operations, 97 (8.9%) were performed for hilar tumors. Median tumor size was 3.7 cm (IQR, 3.04.6), and median RENAL score was 9 (IQR, 8-10). Median estimated blood loss was 200 cc (IQR, 100-300). Median operative and warm ischemia times were 3.3 hours (IQR, 2.7-4.3) and 26 minutes (IQR, 21-33), respectively. The overall complication rate for all tumors was 22.2% (249/1,123), including 183 (16.3%) minor and 66 (5.9%) major complications. For hilar tumors, the complication rate was 30.9% (30/97), including 21 (21.6%) minor and 9 (9.3%) major complications.
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
CONCLUSIONS: Robotic partial nephrectomy is technically feasible for highly complex hilar tumors. Operative times and warm ischemia may be prolonged. For select cases, clinical, oncological, and functional outcomes are excellent. Source of Funding: None
V9-04 ROBOTIC PARTIAL NEPHRECTOMY IN THE SETTING OF IDIOPATHIC IVC OBSTRUCTION: A MULTIDISCIPLINARY APPROACH Matthew J. Maurice*, Daniel G. Clair, Maria del Pilar Bayona Molano, Daniel Ramirez, Peter A. Caputo, Ryan J. Nelson, Onder Kara, Ercan Malkoc, Christine N. Tran, Georges-Pascal Haber, Jihad H. Kaouk, Robert J. Stein, Cleveland, OH INTRODUCTION AND OBJECTIVES: A renal mass in the setting of pararenal vascular anomaly is an unusual presentation that increases the complexity of robotic partial nephrectomy. We highlight important surgical considerations and discuss our preoperative and intraoperative management. METHODS: The patient was a 39-year-old woman with a 4.1-cm posterior hilar renal mass (RENAL score: 11). She also was noted to have suprarenal inferior vena cava stenosis causing a large retroperitoneal aneurysm posterior to the mass and extensive pararenal collateralization. She was healthy and otherwise a good candidate for robotic partial nephrectomy, but she was deemed high risk for aneurysmal rupture or other serious bleeding due to the vascular anomaly. Robotic partial nephrectomy was performed via a transperitoneal approach using four working ports with the patient positioned in full flank. Intraoperative ultrasound was used for tumor identification. A two-layer renorrhaphy was performed of the deep and capsular layers. The deep layer was closed in a running fashion with 2-0 polyglactin 910 suture. Due to insufficient tissue, the outer edge of cortex was oversewn with 0 polyglactin 910 suture in a running horizontal mattress fashion using the sliding clip technique. RESULTS: Preoperatively, Vascular Surgery was consulted, and endovascular stenting of the caval stenosis was performed. The lumbar aneurysm and collaterals decreased substantially in size. Surgical strategies employed during robotic partial nephrectomy included meticulous dissection of the hilum, complete mobilization of the kidney within Gerota’s fascia to create space between the aneurysm and renal mass, and artery-only hilar clamping to provide venous drainage in the event of an unidentified arterial branch. Operative time was 3.6 hours; warm ischemia time was 26 minutes; and estimated blood loss was 200 cc. Seventy percent of the kidney was preserved, and there were no complications. The patient was discharged on postoperative day 3. Pathology showed T1a clear cell renal cell carcinoma with negative margins. Short-term glomerular filtration rate preservation was 86&. CONCLUSIONS: Pararenal aneurysm and collateral formation can occur with suprarenal caval stenosis, increasing the risk of rupture and bleeding during right-sided robotic partial nephrectomy. Surgery can be performed safely using a multidisciplinary approach and meticulous surgical technique. Source of Funding: none
V9-05 RETROPERITONEAL ACCESS FOR ROBOTIC RENAL SURGERY Barrett Anderson*, Alec Wright, Aaron Potretzke, R. Sherburne Figenshau, St. Louis, MO INTRODUCTION AND OBJECTIVES: Retroperitoneal access for robotic renal surgery is an effective alternative to the commonly used
THE JOURNAL OF UROLOGYâ
using a novel three dimensional (3d) printing and silicone casting technology. METHODS: Using standard preoperative imaging, 3d reconstruction of renal parenchyma and tumor was performed to generate solid models suitable for rapid fabrication. Leveraging a novel prototyping process that utilizes 3d extrusion printing and subsequent polymer casting we generated pre-surgical models out of a silicone-based material. To determine how well these patientspecific models simulated actual operative experience, we compared enucleation times between model and actual tumor using the same robotic platform. For the final model, we performed 3d laser scans of both the enucleated model and tumor comparing their spatial characteristics. All surgical rehearsals were performed prior to the actual procedure. RESULTS: We generated patient-specific pre-surgical models for 3 patients. R.E.N.A.L. nephrometry scoring for the pre-surgical models was 7a, 8p, 8a and tumor sizes were 3.5x3.4x3.5 cm, 4.1x3.8x3.5 cm, and 1.5x1.4x1.4 cm. Time of enucleation was similar between the patient-specific pre-surgical models and the actual surgery (6:24 vs. 5:58, 3:11 vs. 3:43, 4:55 vs. 6:09 mins). For case #3, the surgical model enucleation volume measured 6.4 mm3 and the actual excised specimen 12.8 mm3. A 3d-reconstructed visual overlay demonstrated a high level of coherence in the shape of the excised tumor and allowed measurement of the difference in the volume of excised normal renal parenchyma between the model and the actual patient specimen. CONCLUSIONS: We have developed a patient-specific presurgical simulation for robotic partial nephrectomy. Our model provides accurate representation of enucleation time and volume of resected tissue. This highly reproducible simulation platform has the potential to alter surgical decision-making and allow for preoperative rehearsal in complex cases. Furthermore it may become a valuable tool for resident training. Source of Funding: none
V9-03 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS Matthew J. Maurice*, Daniel Ramirez, Peter A. Caputo, Ryan J. Nelson, Onder Kara, Ercan Malkoc, Jihad H. Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: Hilar tumors are challenging due to their centrality and proximity to the renal hilum, increasing the complexity of tumor excision and renal reconstruction. We sought to highlight these challenges and demonstrate techniques for successful execution and excellent outcomes. METHODS: Using our retrospective robotic partial nephrectomy database, we abstracted data on patients who were treated between 2006 and 2015. Videos demonstrating robotic partial nephrectomy for two particularly challenging hilar tumors were selected for presentation. For all cases, patients were positioned in full 45-degree flank, and surgery was performed with four working ports. Intraoperative ultrasound was used to identify tumor margins and guide excision. The renorrhaphy was performed in a minimum of two layers, including a deep layer closed with 2-0 polyglactin 910 in a running fashion and a capsular layer closed with 0 polyglactin 910 suture in a horizontal mattress fashion. RESULTS: Of 1123 total operations, 97 (8.9%) were performed for hilar tumors. Median tumor size was 3.7 cm (IQR, 3.04.6), and median RENAL score was 9 (IQR, 8-10). Median estimated blood loss was 200 cc (IQR, 100-300). Median operative and warm ischemia times were 3.3 hours (IQR, 2.7-4.3) and 26 minutes (IQR, 21-33), respectively. The overall complication rate for all tumors was 22.2% (249/1,123), including 183 (16.3%) minor and 66 (5.9%) major complications. For hilar tumors, the complication rate was 30.9% (30/97), including 21 (21.6%) minor and 9 (9.3%) major complications.
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
CONCLUSIONS: Robotic partial nephrectomy is technically feasible for highly complex hilar tumors. Operative times and warm ischemia may be prolonged. For select cases, clinical, oncological, and functional outcomes are excellent. Source of Funding: None
V9-04 ROBOTIC PARTIAL NEPHRECTOMY IN THE SETTING OF IDIOPATHIC IVC OBSTRUCTION: A MULTIDISCIPLINARY APPROACH Matthew J. Maurice*, Daniel G. Clair, Maria del Pilar Bayona Molano, Daniel Ramirez, Peter A. Caputo, Ryan J. Nelson, Onder Kara, Ercan Malkoc, Christine N. Tran, Georges-Pascal Haber, Jihad H. Kaouk, Robert J. Stein, Cleveland, OH INTRODUCTION AND OBJECTIVES: A renal mass in the setting of pararenal vascular anomaly is an unusual presentation that increases the complexity of robotic partial nephrectomy. We highlight important surgical considerations and discuss our preoperative and intraoperative management. METHODS: The patient was a 39-year-old woman with a 4.1-cm posterior hilar renal mass (RENAL score: 11). She also was noted to have suprarenal inferior vena cava stenosis causing a large retroperitoneal aneurysm posterior to the mass and extensive pararenal collateralization. She was healthy and otherwise a good candidate for robotic partial nephrectomy, but she was deemed high risk for aneurysmal rupture or other serious bleeding due to the vascular anomaly. Robotic partial nephrectomy was performed via a transperitoneal approach using four working ports with the patient positioned in full flank. Intraoperative ultrasound was used for tumor identification. A two-layer renorrhaphy was performed of the deep and capsular layers. The deep layer was closed in a running fashion with 2-0 polyglactin 910 suture. Due to insufficient tissue, the outer edge of cortex was oversewn with 0 polyglactin 910 suture in a running horizontal mattress fashion using the sliding clip technique. RESULTS: Preoperatively, Vascular Surgery was consulted, and endovascular stenting of the caval stenosis was performed. The lumbar aneurysm and collaterals decreased substantially in size. Surgical strategies employed during robotic partial nephrectomy included meticulous dissection of the hilum, complete mobilization of the kidney within Gerota’s fascia to create space between the aneurysm and renal mass, and artery-only hilar clamping to provide venous drainage in the event of an unidentified arterial branch. Operative time was 3.6 hours; warm ischemia time was 26 minutes; and estimated blood loss was 200 cc. Seventy percent of the kidney was preserved, and there were no complications. The patient was discharged on postoperative day 3. Pathology showed T1a clear cell renal cell carcinoma with negative margins. Short-term glomerular filtration rate preservation was 86&. CONCLUSIONS: Pararenal aneurysm and collateral formation can occur with suprarenal caval stenosis, increasing the risk of rupture and bleeding during right-sided robotic partial nephrectomy. Surgery can be performed safely using a multidisciplinary approach and meticulous surgical technique. Source of Funding: none
V9-05 RETROPERITONEAL ACCESS FOR ROBOTIC RENAL SURGERY Barrett Anderson*, Alec Wright, Aaron Potretzke, R. Sherburne Figenshau, St. Louis, MO INTRODUCTION AND OBJECTIVES: Retroperitoneal access for robotic renal surgery is an effective alternative to the commonly used