Next Dr. Mihir Desai took the stage next and discussed his technique of robotic IVC thrombectomy. Dr. Desai first touched on pre-operative planning that included imaging details and instrument selection. His imaging assessment included details such as the width of the thrombus, the length of the thrombus, the distance of the thrombus from upper part of renal vein and lower part of the renal vein, and diameter of the vena cava, which is important if a balloon is required for proximal IVC control. In terms of specialized instruments, Dr. Desai recommends having a robotic stapler due to unusual vessel angles encountered, a robotic Hemolock clip applier to easily clip lumbar and short hepatic veins, and a double fenestrated grasper that has the length to get behind the infra- and supra-hilar vena cava.
Dr. Desia then described his technique on the right side that included IVC control, thrombus extraction, and IVC repair before turning attention to the kidney. He recommended working midline to lateral with meticulous hemostasis while minimally disturbing the IVC. Some tips included using vessel loops with adequate strength to ensure control throughout the case, begin control with the distal IVC followed by the renal vein, and clip the short hepatic veins to get additional IVC length, if needed, prior to proximal control. If the tumor is thought to be more proximal, then a small veinotomy can be made and an appropriately sized balloon can be placed well above the thrombus because the IVC diameter was measured pre-operatively. Dr. Desai mentioned knowing how much to inject into the balloon to get once cm more than the size measured on imaging. Next the renal vein is transected with a stapler so there is no tumor spillage and for optimal exposure to the posterior IVC and lumbar veins. Then the IVC is opened and the thrombus extracted, the IVC is sutured with Goretex, and heparinized saline is added prior to complete IVC closure. Finally, the balloon is deflated and removed before the veinotomy is closed with a figure of 8.
Dr. Erik Castle presented his experience and thoughts regarding retroperitoneal lymph node dissection. He considers robotic surgery as a great advancement over laparoscopic surgery because laparoscopic surgery does not allow the surgeon to adequately dissect behind the great vessels and there were incidents of recurrence, making it more of a biopsy technique. Dr. Castle gave insight into the nerve sparing approach highlighting the four to five post ganglionic fibers in the interaortocaval region as the primary nerves to spare because other nerves may be sacrificed during the more extensive dissection of the left renal hilum done to prevent recurrence. He shared a post-RPLND photo, highlighting the sympathetic chain trunk (large arrow), the post ganglionic fibers (small arrows), a lumbar vein (L), and the great vessels as an example of how robotic approach allows dissection behind the vessels in contrast to a laparoscopic approach.
Next Dr. Castle compared the two of the current robotic platforms. The Davinci Xi has advantages over the Davinci Si in that the robot can be brought in laterally rather than over the patient’s shoulder and direction of dissection, distal and proximal, can be easily done by rotating the boom rather than moving the entire robot. Another tip was that Dr. Castle sutures the mesenteric window to the anterior abdominal wall with a v-lock rather than passing stay sutures through the abdominal wall.
Dr. Castle stressed that there is still a role for open surgery for complex or some post-chemotherapy cases and another tip that he shared was that during a complex case where the tumor is invading the IVC, the surgeon can take up to 50% of the IVC prior to primarily repair or patch the IVC if a larger resection is required as long as vascular control is present. As far as which urologist should be performing the robotic RPLND, Dr. Castle recommends that surgeons with a high open RPLND volume perform the surgery because they have the best understanding of anatomy, which is crucial during complex cases.
Dr. Castle ended his presentation urging urologists to set proper patient expectations in terms of expected antegrade ejaculation rates that are 80-85% with a bilateral nerve sparing approach with the caveat that post-chemotherapy the surgeon can not preserve the nerves as frequently but should try by looking for the 4-5 interaortocaval fibers previously described and staying above the IMA if the nerve sparing is aggressive.
Dr. Wooju Jeong closed the session by discussing robotic renal transplantation. Dr. Jeong began by describing the process leading to the development of the robotic renal transplant utilizing pelvic hypothermia in his institution. First, the concept was simulated in a radical prostatectomy model and safety factors were established in cadavers to provide factors to evaluate safety in patients with Shewart control charts. The surgeon learning curve was also examined with the cumulative summation method. Outcomes were assessed and were comparable to the open series with 95% pf graft survival in three years and with decreased complications of wound infection and lymphocele development in the robotic series (shown in the picture below). Dr. Jeong did caution that the robotic renal transplant with pelvic hypothermia had a 10% delayed graft function.
Dr. Jeong concluded that the advent of robotic kidney transplant could provide urologists with added benefit of developing the surgical skills for auto-transplants and procedures that require vascular manipulation, and, in addition, the pelvic hypothermia technique might be useful for renal surgeries such as partial nephrectomy. One audience member was curious to know the technique to introduce pelvic hypothermia and Dr. Jeong mentioned that ice slush was introduced with a syringe through a gel port to reach the area of interest.
Presented by:
- Sammy E. Elsamra, MD, Department of Surgery, Rutgers Health
- Mihir Desai, MD, Keck Hospital of USC, Norris Cancer Hospital, Verdugo Hills Hospital
- Erik P Castle, MD, Professor of Urology, Tulane University, New Orleans, Louisiana
- Wooju Jeong, MD, Senior Staff Urologist, Henry Ford Health, Detroit, Michigan
Written by: Zachary E Tano, MD Endourology Fellow, Department of Urology, University of California, Irvine during the 39th World Congress of Endo urology and Uro-Technology (WCET), Oct 1 - 4, 2022, San Diego, California.