EAU 2018: Immediate and Late Complications of Robotic Partial Nephrectomy
Dr. Dasgupta introduces the session by showing videos of common complication associated with robotic partial nephrectomy. Too much of our surprise, the videos focused on complications that occurred during laparoscopic accesses rather than the procedure itself. Dr. Dasgupta emphasizes that complication free laparoscopic access is the most important determinant in a successful laparoscopic/robotic procedure, as most of the complications associated with minimally invasive approaches occur during access. He shares some thoughts on how to prevent such complications, like the early transition to Hassan technique if the Veress needle fails, avoidance of placing ports blindly and careful identification of the abdominal wall vasculature during trocar placement.
During surgery the most common complications are bleeding, tumor violation and injury to adjacent organs. He advocates for a wide mobilization of the colon to allow for proper identification of the vascular structures. Careful and deliberate dissection of the hilum is key, as any injury during this portion increases the likelihood of conversion into a radical nephrectomy. Often considered a mundane part of the case, he cautions on inadvertent tumor manipulation with the robotic instruments during the de-fatting process as robotic instruments tend to exert more force that we can read visually. This is especially important for cystic tumor or those with evidence of intra-tumoral necrosis where a capsular violation can occur easily and unexpectedly. In regard to tumor resection, he advocates for whichever technique (resection or enucleation) the surgeon is comfortable with, as long as sound oncological principles are used (minimization of surgical margins and avoidance of tumor spillage). Dr. Dasgupta favors early unclamping not for minimization of ischemia but for identification of potential arterial bleeders before capsular closure. Lastly, he reminds the audience of the dire consequences of port seeding from poor endo-bag manipulation.
In summary, minimally invasive PN, with or without robotic assistance, is performed according to the same principles as open PN. Although early to intermediate experience with laparoscopic PN suggested increased urologic complications compared with open PN, subsequent experience with robotic PN have substantially reduced perioperative morbidity. Tumor complexity remains a major predictor of intraoperative and postoperative complications, regardless of surgical approach, and open PN should be considered for particularly challenging situations.
Presented by: Prokar Dasgupta MD, Professor and Chair of Urology at King's College London
Written by: Andres F. Correa, Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark