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ENDOUROLOGY
& LAPAROSCOPY
Initial
experience with robot assisted partial nephrectomy for multiple renal
masses
Boris R, Proano M, Linehan WM, Pinto PA, Bratslavsky G
Urologic Oncology Branch, Center for Cancer Research, National Cancer
Institute, National Institutes of Health, Department of Health and Human
Services, Bethesda, Maryland, USA
J Urol. 2009; 182: 1280-6
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Purpose:
We evaluated the feasibility of performing robot assisted partial
nephrectomy in patients with multiple renal masses and examined the
results of our initial experiences.
Materials and Methods: We reviewed the records of 10 patients with
multiple renal masses who underwent attempted robot assisted partial
nephrectomy within the last 2 years. Demographic information, and
intraoperative, perioperative and renal function outcome data on these
patients were reviewed.
Results: A total of 24 tumors in 9 patients were removed with robot
assistance. There was 1 open conversion with successful completion
of partial nephrectomy. Of the patients 70% had a known hereditary
renal cancer syndrome and the remainder had multifocal disease with
unknown germline genetic alterations. Frozen section from the tumor
bed evaluated in 5 of 10 cases was negative. One patient experienced
urinary leak postoperatively, which resolved by postoperative day
9 without intervention. Of the 24 robotically resected masses 22 were
malignant. Our most recent 3 patients underwent successful partial
nephrectomy without hilar clamping, obviating the need for warm ischemia.
Overall renal function was unchanged at most recent followup with
a minimal decrease in operated kidney differential function.
Conclusions: Robot assisted partial nephrectomy for multiple renal
masses was feasible in our early experience. Patient selection is
paramount for successful minimally invasive surgery. Robot assisted
partial nephrectomy without hilar clamping, especially in the hereditary
patient population in which repeat ipsilateral partial nephrectomy
may be anticipated, appears promising but requires further evaluation.
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Editorial
Comment
Since the first laparoscopic partial nephrectomy was performed to
by Winfield et al. and subsequently perfected by Kavoussi, Gill and
others, the nephron-sparing surgery evolved with better technology,
i.e. intra-operative ultrasound, vascular clamps, articulating needle
holders, absorbable clips, etc. Ultimately, the use of robotic assisted
surgery has been performed by the authors with comparable results
as the laparoscopic partial nephrectomy. The advantages of the robot
seem clear in terms of the intuitive use of the robot for intracorporeal
suturing and the 7 degree of freedom of the laparoscopic devices,
but one should be aware of the cost involved and the learning curve
that could be different from surgeon to surgeon if the previous laparoscopic
experience is minimal, which is not the case in this particular report.
Furthermore, other methods of nephron-sparing surgery may be used
to manage small renal masses, i.e. cryoablation or other ablative
techniques that may yield the same oncological and functional outcomes
as partial nephrectomies. The strength of this manuscript is the large
experience of this group with previous management of malignant renal
masses and complex laparoscopic oncological procedures performed laparoscopically
in a single institution. Moreover, the complication rates of robotic
assisted partial nephrectomies are comparable to open technique even
when the complexity of the cases increased.
Dr.
Fernando J. Kim
Chief of Urology, Denver Health Med. Ctr.
Associate Professor, Univ. Colorado Health Sci. Ctr.
Director of Minimally Invasive Urol. Oncology, UCHSC
Denver, Colorado, USA
E-mail: fernando.kim@dhha.org
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