**5. Surgical technique**

Evidence from a meta-analysis reveals similar surgical outcomes and complications between transperitoneal and retroperitoneal robot-assisted partial nephrectomies. The retroperitoneal approach may have a specific role in selected cases including posterior tumours and in patients with pervious significant transperitoneal surgery. Absence of the need to mobilise bowel and easy access to the hilar vessels, leads to a shorter operative time [26]. However, the choice between retroperitoneal or transperitoneal approach lies based on surgeon's expertise and patient factors [17].

We recommend a trans-peritoneal approach, particularly in the early phase of the learning curve. This will ensure that adjacent structures can be adequately mobilised away from the kidney. In addition, operative space is optimised when within the peritoneum. This will avoid injury to sensitive structures such as the duodenum on the right and the spleen; tail of the pancreas and duodeno-jejunal junction on the left. The authors recommend using a 0° camera lens in the early learning curve period, unless experienced in 30° downward scope lens from laparoscopic surgery [23]. Use of 30° downward lens has a role in the later stages of dissecting posterior tumours [24]. A pneumoperitoneum of 10–12 mmHg is established. In almost all cases the kidney can be adequately mobilised to expose renal masses to perform a partial nephrectomy successfully in the trans-peritoneal approach. However, some surgeons transferring from retroperitoneal laparoscopic surgery may feel suitably experienced in translating skills to perform retroperitoneal robotic surgery. Guides are available on performing retroperitoneal RAPN [27, 28].

A wide array of instruments and preferences exist in performing a RAPN. The authors perform the procedure with the surgeon holding the EndoWrist® Fenestrated Bipolar Forceps and the EndoWrist® Hot Shears™ monopolar curved scissors in the non-dominant and dominant hand robotic ports respectively. Sharp dissection is performed along the white line of Toldt. Sharp and blunt dissection is used to reflect the large bowel off the anterior surface of Gerota' fascia [24]. Dissection is directed to the inferior border of Gerota's fascia in order to locate the ureter. Release of attachments from adjacent structures including liver or spleen may be performed to characterise the planes clearly. The psoas major muscle is used as a landmark to help identify the ureter, similar to a laparoscopic approach. The ureter is then dissected cranially to identify the renal hilum [23]. Specific care should be taken to control, or avoid injury to the gonadal vessels. The additional robotic arm, holding the ProGrasp™ forceps can now be deployed to retract the kidney laterally, thereby creating space to dissect the hilum safely away from sensitive medial structures (such as the duodenum or inferior vena cava). The Force Bipolar™ is a new instrument which combines the ProGrasp™ grasping qualities with bipolar diathermy and may be incorporated instead for efficiency. In right sided tumours, the hilum can be approached from a cranial to caudal direction, enabling earlier access to the renal artery. The Inferior Vena Cava just below the liver can be easily identified and followed caudally to reach the renal pedicle in right sided tumours.

the usage of Mannitol in view of its limited evidence in minimising loss of renal function post

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To minimise the dangers associated with, the next step is performed after unanimous readiness of the theatre staff. A Scanlan® Reliance Bulldog Clamp (Scanlan® International, St. Paul, MN, USA) is applied to the renal artery, in selected cases this is followed by another on the renal vein [23]. Satinsky clamp is an option in the rare difficult dissections when bleeding from the renal pedicle impairs ability to clamp the vessels with a bulldog clamp [31]. The

The tumour is excised with consideration of surgical margins, with the assistant surgeon ensuring the field is adequately exposed by suctioning away blood. The sliding-clip renorrhaphy principle is applied to close the renal defect, in multiple layers. The deep layer of the renorrhaphy is performed with the poliglecaprone 3–0 suture, with a Weck® Hem-o-lok® ligating clip already attached at one end. A continuous suture runs through the base of the defect closing any open collecting system and small vessels. If arterial bleeds are detected these can be closed individually with additional monofilament sutures to ensure meticulous haemostasis. Once the continuous running poliglecaprone suture is applied, a Hem-o-lok® clip is applied to the needle end. Traction is applied to the needle end to snug the clip down against the renal capsule, bringing the renal defect together. Larger defects will require multiple sutures. We use an early 'off-clamp' technique after the deep sliding-clip renorraphy is complete, in the order of release of renal vein, followed by the artery, where the vein has been clamped. This reduces the warm ischaemic time. We do not use a bolster. At this stage haemostasis is adequate to complete the superficial sliding-clip renorrhaphy suture with a large polyglactin suture. In this layer, clips are applied at every throw through the renal capsule to further close the defect. A second locking clip can be applied above every previous clip on the sliding suture to prevent slipping. Use of adjuncts to haemostasis is not essential but may provide added security and further minimise blood loss. This may be in the form of Floseal®, Surgicel® or Evicel®. The hilum and excision site are carefully inspected following this step, to ensure haemostasis is achieved. We recommend closing Gerota's fascia, which may minimise difficulty in future renal surgery from scarring [24]. An intra-abdominal drain is inserted through the lateral port. The specimen is removed using an endocatch pouch,

• A 'time-out' is taken to assess the tumour excision, the associated renal defect and the plan for renorraphy prior to the on-clamp time, will in our experience lead to better planning

• Use of intraoperative doppler ultrasound is widely recommended for use in partial

• Plan your incision on the Gerota's fascia carefully will help with closure after. Practice often on simulators to ensure that your suturing skills are adequate to perform renorrha-

phy under the pressure of limited time, whilst the clamp clock is ticking.

clamping marks the triggering of a stopwatch, to measure warm ischaemic time.

operatively in humans [30].

inserted through the assistant's port.

and a potentially safer procedure.

**5.1. Tips and tricks**

nephrectomy.

Hilar dissection requires sensitive movements to adequately expose all renal vessels (one at a time) to allow for application of clamps later in the operation. This enables precise control in case of unexpected haemorrhage. We recommend clamping the main renal artery early in the learning curve, rather than attempting to selectively clamp more distal segmental branches. Near-infrared fluorescence imaging system with indocyanine green is an available technology allowing identification of intraoperative parenchymal perfusion, thereby enabling selective vessel clamping for limiting ischaemia to the tumour alone. It has been shown to improve early functional outcomes, with better preservation of glomerular filtration rate of the resected kidney on renal scan with Tc 99 m-DTPA [29]. Once the main artery is exposed, a short sling can be placed and held in place by a suitable arterial clip (to the rubber sling ends alone), we use a Weck® Hem-o-lok® ligating clip.

At this stage exposure of the renal tumour proceeds by incising Gerota's fascia and 'defatting' the kidney adequately, preferably along the renal capsular plane. This will enable adequate exposure of the renal tumour and mobilise the kidney to achieve a wide surgical field to perform the excision. The drop-in ultrasound probe is introduced and manipulated by the surgeon using the ProGrasp™ forceps to distinguish tumour margins [17]. The tumour is marked superficially on the renal capsule with the Hot Shears™ curved monopolar diathermy scissors, leaving a 5 mm margin for oncological outcomes.

All accessory equipment is introduced through the assistant port, including the arterial clamps. Two absorbable monofilament sutures such as Poliglecaprone, e.g. Monocryl® 3–0 and two absorbable braided sutures such as Polyglactin, e.g. 0-Vicryl®, cut to size are strategically positioned in the abdomen for easy access during renorrhaphy.

At this stage a brief 'time-out' ensures that the surgeon and the surgical team are aware of the ensuing critical element of the operation—sometimes known as 'on-clamp time'. This provides ample opportunity to ensure that there is adequate insufflation gas in the tanks, that additional sutures are readily available and that the anaesthetist is prepared for potential haemorrhage. At this stage it is recommended to re-review the CT images to ensure that the shape of the renal mass can be translated to the operative field. The authors do not recommend the usage of Mannitol in view of its limited evidence in minimising loss of renal function post operatively in humans [30].

To minimise the dangers associated with, the next step is performed after unanimous readiness of the theatre staff. A Scanlan® Reliance Bulldog Clamp (Scanlan® International, St. Paul, MN, USA) is applied to the renal artery, in selected cases this is followed by another on the renal vein [23]. Satinsky clamp is an option in the rare difficult dissections when bleeding from the renal pedicle impairs ability to clamp the vessels with a bulldog clamp [31]. The clamping marks the triggering of a stopwatch, to measure warm ischaemic time.

The tumour is excised with consideration of surgical margins, with the assistant surgeon ensuring the field is adequately exposed by suctioning away blood. The sliding-clip renorrhaphy principle is applied to close the renal defect, in multiple layers. The deep layer of the renorrhaphy is performed with the poliglecaprone 3–0 suture, with a Weck® Hem-o-lok® ligating clip already attached at one end. A continuous suture runs through the base of the defect closing any open collecting system and small vessels. If arterial bleeds are detected these can be closed individually with additional monofilament sutures to ensure meticulous haemostasis. Once the continuous running poliglecaprone suture is applied, a Hem-o-lok® clip is applied to the needle end. Traction is applied to the needle end to snug the clip down against the renal capsule, bringing the renal defect together. Larger defects will require multiple sutures. We use an early 'off-clamp' technique after the deep sliding-clip renorraphy is complete, in the order of release of renal vein, followed by the artery, where the vein has been clamped. This reduces the warm ischaemic time. We do not use a bolster. At this stage haemostasis is adequate to complete the superficial sliding-clip renorrhaphy suture with a large polyglactin suture. In this layer, clips are applied at every throw through the renal capsule to further close the defect. A second locking clip can be applied above every previous clip on the sliding suture to prevent slipping. Use of adjuncts to haemostasis is not essential but may provide added security and further minimise blood loss. This may be in the form of Floseal®, Surgicel® or Evicel®. The hilum and excision site are carefully inspected following this step, to ensure haemostasis is achieved. We recommend closing Gerota's fascia, which may minimise difficulty in future renal surgery from scarring [24]. An intra-abdominal drain is inserted through the lateral port. The specimen is removed using an endocatch pouch, inserted through the assistant's port.

#### **5.1. Tips and tricks**

Sharp and blunt dissection is used to reflect the large bowel off the anterior surface of Gerota' fascia [24]. Dissection is directed to the inferior border of Gerota's fascia in order to locate the ureter. Release of attachments from adjacent structures including liver or spleen may be performed to characterise the planes clearly. The psoas major muscle is used as a landmark to help identify the ureter, similar to a laparoscopic approach. The ureter is then dissected cranially to identify the renal hilum [23]. Specific care should be taken to control, or avoid injury to the gonadal vessels. The additional robotic arm, holding the ProGrasp™ forceps can now be deployed to retract the kidney laterally, thereby creating space to dissect the hilum safely away from sensitive medial structures (such as the duodenum or inferior vena cava). The Force Bipolar™ is a new instrument which combines the ProGrasp™ grasping qualities with bipolar diathermy and may be incorporated instead for efficiency. In right sided tumours, the hilum can be approached from a cranial to caudal direction, enabling earlier access to the renal artery. The Inferior Vena Cava just below the liver can be easily identified and followed

Hilar dissection requires sensitive movements to adequately expose all renal vessels (one at a time) to allow for application of clamps later in the operation. This enables precise control in case of unexpected haemorrhage. We recommend clamping the main renal artery early in the learning curve, rather than attempting to selectively clamp more distal segmental branches. Near-infrared fluorescence imaging system with indocyanine green is an available technology allowing identification of intraoperative parenchymal perfusion, thereby enabling selective vessel clamping for limiting ischaemia to the tumour alone. It has been shown to improve early functional outcomes, with better preservation of glomerular filtration rate of the resected kidney on renal scan with Tc 99 m-DTPA [29]. Once the main artery is exposed, a short sling can be placed and held in place by a suitable arterial clip (to the rubber sling ends

At this stage exposure of the renal tumour proceeds by incising Gerota's fascia and 'defatting' the kidney adequately, preferably along the renal capsular plane. This will enable adequate exposure of the renal tumour and mobilise the kidney to achieve a wide surgical field to perform the excision. The drop-in ultrasound probe is introduced and manipulated by the surgeon using the ProGrasp™ forceps to distinguish tumour margins [17]. The tumour is marked superficially on the renal capsule with the Hot Shears™ curved monopolar diathermy

All accessory equipment is introduced through the assistant port, including the arterial clamps. Two absorbable monofilament sutures such as Poliglecaprone, e.g. Monocryl® 3–0 and two absorbable braided sutures such as Polyglactin, e.g. 0-Vicryl®, cut to size are strategi-

At this stage a brief 'time-out' ensures that the surgeon and the surgical team are aware of the ensuing critical element of the operation—sometimes known as 'on-clamp time'. This provides ample opportunity to ensure that there is adequate insufflation gas in the tanks, that additional sutures are readily available and that the anaesthetist is prepared for potential haemorrhage. At this stage it is recommended to re-review the CT images to ensure that the shape of the renal mass can be translated to the operative field. The authors do not recommend

caudally to reach the renal pedicle in right sided tumours.

240 Evolving Trends in Kidney Cancer

alone), we use a Weck® Hem-o-lok® ligating clip.

scissors, leaving a 5 mm margin for oncological outcomes.

cally positioned in the abdomen for easy access during renorrhaphy.


• An apron of Perinephric fat can be placed behind the posterior surface of the kidney, to anteriorly displace the kidney. This improves access to posterior and lateral tumours. If there is inadequate Perinephric fat, tonsil swabs can be placed instead.

as preoperatively planned in 90% of the cases [39]. The accuracy of the arterial reconstruction enabled preoperative simulation of vascular ischaemia by selective clamping. This enabled

Near-infrared fluorescence (NIRF) technology using an intravenous contrast medium (e.g. Indocyanine green) enables identification of the segmental vessels perfusing the renal tumour, by switching between white light and fluorescence enhanced views intraoperatively [40]. NIRF RAPN has been found to have a lower loss in renal scan confirmed renal function in the operated unit and a lower reduction in Glomerular Filtration Rate (GFR of 8%)compared to standard RAPN without selective vessel clamping. In three of the 15 NIRF RAPN cases, selective clamping was converted to standard clamping as incomplete ischaemia of the tumour was identified. This demonstrates NIFRs growing benefit over non-NIFR selective clamping. Urologists participating in a study on 3D (Three Dimensional) printed models of the kidney, favoured its use in preoperative planning, patient counselling and surgical training [41]. The authors report maximal benefit of these models in patients with complex renal

Our technique offers a standardised approach to aspiring urologists in performing roboticassisted partial nephrectomies. We expect urologists to have the appropriate level of training and supervision prior to performing this procedure. We highlight a variety of tips and tricks that have benefitted our team in performing safer and easier surgery. We describe the stance of guidelines of robotic surgery in partial nephrectomies. We highlight emerging technologies

which may become incorporated into the future practice of robotic surgery.

\*, Edward Ramez Latif<sup>1</sup>

[1] Kang SK, Kim D, Chandarana H. Contemporary imaging of the renal mass. Current

, Milan Thomas1

, Ben Eddy<sup>1</sup>

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,

reduction of global ischaemia from 81–24% with the use of the HA3D technology [39].

vasculature [42].

**8. Conclusion**

**Author details**

Elio Mazzone<sup>2</sup>

**References**

Mohammed Kamil Quraishi1

2 O.L.V. Hospital, Aalst, Belgium

and Alexandre Mottrie<sup>2</sup>

1 Kent and Canterbury Hospital, Canterbury, UK

\*Address all correspondence to: mkquraishi@doctors.org.uk

Urology Reports. 2011;**12**:11. DOI: 10.1007/s11934-010-0148-y

This is our summarised technique that is performed in our practice, which can be adopted by departments interested in developing a robotic partial nephrectomy service.
