Laparoscopic and Robotic Surgery in Urology 9811337373, 9789811337376

Citation preview

Daniel J. Mollura Xu Zhang Matthew Editor P. Lungren Michael R.B. Evans Editors

Laparoscopic Clinical Medicine and Robotic Surgery Covertemplate in Urology Subtitle for Clinical Medicine Covers T3_HB Second Edition

13 2

123

Laparoscopic and Robotic Surgery in Urology

Xu Zhang Editor

Laparoscopic and Robotic Surgery in Urology

Editor Xu Zhang Department of urology The First Medical Center Chinese PLA General Hospital Beijing China

ISBN 978-981-13-3737-6    ISBN 978-981-13-3738-3 (eBook) https://doi.org/10.1007/978-981-13-3738-3 Jointly published with People’s Medical Publishing House, PR of China The print edition is not for sale in China. Customers from China please order the print book from: People’s Medical Publishing House, PR of China. © Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 This work is subject to copyright. All rights are reserved by the Publishers, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publishers, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publishers nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publishers remain neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Preface

Laparoscopic surgeries in urology have begun since the nineties and have taken a big leap over the years. The exponential improvement of 3D laparoscopy and robotic surgical system has resolved myriad of technical difficulties during minimal invasive surgeries. These breakthroughs have led to widen implementation of minimally invasive surgeries around the globe. Although the inception of laparoscopic urology in China started a bit late than the West, our surgical approach greatly differs from the West. While they prefer intraperitoneal approach, our key approach to upper tract surgeries is retroperitoneal. My first book Laparoscopic Surgery in Urology was published in 2008. It encompasses my cumulative experiences of over 4000 laparoscopic urological surgeries. It rapidly become the blueprint for urologists and trainees in China, and over 10,000 copies have been sold. It has played an important role in promoting the popularization of laparoscopic technology in China. In 2008, I was transferred to one of the largest general hospitals in China—PLA General Hospital in Beijing—which is the pioneer hospital of minimally invasive surgeries. It is the first hospital in China to own a robotic surgical system, and currently it has 14 robotic surgical systems. As the chief urologist of this hospital, I am excited to lead my team to become one of the highest volume centres in Asia for minimally invasive surgeries. By year 2015, I have completed over 4000 robotic surgeries and 10,000 laparoscopic surgeries. With further experiences, I have decided to publish my second book Laparoscopic and Robotic Surgery in Urology to share my vast experiences and latest development in minimally invasive surgeries. This book has also swiftly become the most favourite reference book for the urologists. My relationship with Springer Publishing dated back to the nineties. At that time, I was fortunate to be nominated by my respected mentor, the late Professor Qiu FaZu, who was known as the “father of Chinese surgery”, to attend one-year fellowship in Heidelberg University under the sponsorship of Springer Publishing. I was lucky to get Dr. Heinz Götze’s support in Heidelberg, who was publisher and former managing partner of Springer-Verlag. Hence, I was excited when Springer Publishing in year 2017 offered a great opportunity to work on the English version of Laparoscopic and Robotic Surgery in Urology. This book consists of three parts: upper urinary tract surgeries, lower urinary tract surgeries and urological related lymphadenectomies. Great emphasis has been put on detailing patient selection, perioperative management, important techniques and post-operative care. More important, we highlighted critical steps in the surgeries, and addressed intraoperative challenges that surgeons may face during surgeries. Our aim is to aestheticize simple surgeries and simplify complicated surgeries. To improve content readability, we have included more than 1000 comprehensive illustrations and real-time capture figures that we have taken during our surgeries. Every operative step was accompanied by clear intraoperative images to improve readers’ understanding. Through the combination of texts and pictures, we hope to provide our readers with panorama view for each surgical procedure. In addition, there are 40 live surgery videos with online access to facilitate learning. We have kept the video editing to the minimal to maintain the originality of the surgeries. Enormous efforts have been put in to convey complex concepts clearly and simplify the surgical planning and techniques without watering down the message.

v

vi

Preface

With these efforts, we hope that we can connect with our readers and this book will serve as a reference for urologists who are interested in these techniques. I am grateful to have the full and invaluable supports of my enthusiastic team to assist with the researches, gathering of illustration and capture figures, video editing and proof reading of this book. It has been a great honour to work with Springer Publishing Group for the publication of this book. I hope that this book will excite readers and promote the development of laparoscopic and robotic surgery in China and all over the world. We welcome any discussion and feedback for further improvement. Thank you and hope you enjoy the reading. Beijing, China

Xu  Zhang

Contents

Part I Adrenal Gland, Kidney and Ureter 1 Patient Position and Trocar Placement for Upper Urinary Tract Surgery�����������   3 Qingbo Huang, Kan Liu, Xin Ma, and Xu Zhang 2 Retroperitoneoscopic Anatomical Adrenalectomy���������������������������������������������������  11 Bin Fu, Xin Ma, Hongzhao Li, Tao Zheng, and Xu Zhang 3 Robotic Adrenalectomy ���������������������������������������������������������������������������������������������  25 Bin Fu, Hongzhao Li, Xin Ma, and Xu Zhang 4 Retroperitoneal Laparoscopic Simple Nephrectomy�����������������������������������������������  35 Songliang Du, Xin Ma, Tao Zheng, and Xu Zhang 5 Retroperitoneal Laparoscopic Radical Nephrectomy���������������������������������������������  41 Chao Wang, Hongzhao Li, Baojun Wang, and Xu Zhang 6 Robotic Inferior Vena Cava Thrombectomy �����������������������������������������������������������  53 Baojun Wang, Xin Ma, Hongzhao Li, and Xu Zhang 7 Retroperitoneal Laparoscopic Nephroureterectomy�����������������������������������������������  67 Dan Shen, Xin Ma, Hongzhao Li, and Xu Zhang 8 Robotic Nephroureterectomy�������������������������������������������������������������������������������������  71 Dan Shen, Xin Ma, Hongzhao Li, and Xu Zhang 9 Retroperitoneal Laparoscopic Donor Nephrectomy�����������������������������������������������  75 Jianwen Chen, Xin Ma, Tao Zheng, and Xu Zhang 10 Robotic Donor Nephrectomy�������������������������������������������������������������������������������������  83 Jianwen Chen, Xin Ma, and Xu Zhang 11 Retroperitoneal Laparoscopic Partial Nephrectomy�����������������������������������������������  89 Songliang Du, Hongzhao Li, Xin Ma, and Xu Zhang 12 Robot Assisted Laparoscopic Partial Nephrectomy������������������������������������������������ 107 Xiangjun Lyu, Xin Ma, Hongzhao Li, and Xu Zhang 13 Retroperitoneal Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction ������������������������������������������������������������������������������������������������� 127 Guoxi Zhang, Taoping Shi, Hongzhao Li, and Xu Zhang 14 Robotic Dismembered Pyeloplasty for Ureteropelvic Junction Obstruction ������� 137 Ying Li Lin, Baojun Wang, Xin Ma, Hongzhao Li, and Xu Zhang 15 Retroperitoneal Laparoscopic Ureterolithotomy����������������������������������������������������� 145 Yang Fan, Taoping Shi, Baojun Wang, and Hongzhao Li 16 Retroperitoneal Laparoscopic Ureteroureterostomy for Retrocaval Ureter��������� 151 Guoxi Zhang, Yongji Yan, Taoping Shi, Hongzhao Li, and Xu Zhang vii

viii

17 Retroperitoneal Laparoscopic Heminephrectomy for Duplex Kidney Anomaly� 157 Yang Fan, Hongzhao Li, Taoping Shi, Baojun Wang, and Xu Zhang 18 Retroperitoneal Laparoscopic Renal Pedicle Lymphatic Disconnection for Chyluria����������������������������������������������������������������������������������������������������������������������� 163 Xintao Li, Xin Ma, Hongzhao Li, and Xu Zhang Part II Bladder and Prostate 19 Patient Position and Trocar Placement for Lower Urinary Tract Surgery����������� 173 Qingbo Huang, Fam Xeng Inn, Hongzhao Li, Baojun Wang, and Xu Zhang 20 Laparoscopic Radical Cystectomy in Male Patients and Urinary Diversion ������� 179 Tao Zheng, Xin Ma, Hongzhao Li, Fam Xeng Inn, and Xu Zhang 21 Robotic Radical Cystoproatatectomy and Intracorporeal Neobladder����������������� 193 Xing Ai, Hongzhao Li, Xin Ma, and Xu Zhang 22 Laparoscopic Radical Cystectomy for Female Patients ����������������������������������������� 207 Kai Xu, Hongzhao Li, Xin Ma, Fam Xeng Inn, and Xu Zhang 23 Laparoscopic Partial Cystectomy����������������������������������������������������������������������������� 217 Baojun Wang, Tao Zheng, Hongzhao Li, and Xu Zhang 24 Laparoscopic Ureteral Reimplantation ������������������������������������������������������������������� 225 Taoping Shi, Kan Liu, Tao Zheng, Fam Xeng Inn, Xin Ma, and Xu Zhang 25 Robot-Assisted Laparoscopic Ureteral Reimplantation����������������������������������������� 229 Taoping Shi, Hongzhao Li, Fam Xeng Inn, and Xu Zhang 26 Extraperitoneal Laparoscopic Radical Prostatectomy������������������������������������������� 233 Qing Ai, Hongzhao Li, Xin Ma, and Xu Zhang 27 Robotic Radical Prostatectomy��������������������������������������������������������������������������������� 249 Qing Ai, Hongzhao Li, Xin Ma, and Xu Zhang 28 Robotic Excision of Seminal Vesicle Tumor������������������������������������������������������������� 263 Xintao Li, Xin Ma, and Xu Zhang Part III Lympadenectomy 29 Laparoscopic Retroperitoneal Lymph Node Dissection ����������������������������������������� 273 Dong Ni, Xin Ma, Tao Zheng, and Xu Zhang 30 Robotic Retroperitoneal Lymph Node Dissection��������������������������������������������������� 285 Dong Ni, Hongzhao Li, Xin Ma, and Xu Zhang 31 Laparoscopic Pelvic Lymph Node Dissection for Bladder Cancer������������������������� 299 Yu Gao, Hongzhao Li, Xin Ma, and Xu Zhang 32 Robotic Pelvic Lymph Node Dissection for Bladder Cancer ��������������������������������� 309 Yu Gao, Hongzhao Li, Xin Ma, and Xu Zhang 33 Femoraloscopic Inguinal Lymphadenectomy����������������������������������������������������������� 317 Qingbo Huang, Tao Zheng, Taoping Shi, Xin Ma, and Xu Zhang

Contents

Editors and Contributors

Associate Editors Hongzhao Li, MD  Professor, Vice Chief, Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Xin  Ma, MD Professor, Vice Chief, Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Tao  Zheng, MD Professor, Chief, Department of Urology, Wuhan Fourth Hospital, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

Contributors Qing  Ai, MD Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Xing Ai, MD  Professor, Chief, Department of Urology, The Seventh Medical Center, Chinese PLA General Hospital, Beijing, China Jianwen  Chen, MD Department of Nephrology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Songliang Du, MD  Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Yang  Fan, MD  Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Bin Fu, MD  Professor, Vice Chief, Department of Urology, The First Hospital Affiliated to Nanchang University, Nanchang, China Yu  Gao, MD Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Qingbo Huang, MD  Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Fam  Xeng  Inn, MD Dr., Urology Unit, Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia Ying  Li  Lin, MD Associate Professor, Department of Urology, Xuzhou Cancer Hospital, Xuzhou, Jiangsu, China Kan  Liu, MD Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China ix

x

Xintao  Li, MD  Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Xiangjun Lyu, MD  Associate Professor, Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Dong Ni, MD  Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China Dan  Shen, MD  Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Taoping  Shi, MD Associate Professor, Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Baojun Wang, MD  Associate Professor, Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China Chao Wang, MD  Professor, Department of Urology, The First People’s Hospital of Jining, Jining, China Kai  Xu, MD Associate Professor, Department of Urology, Zhujiang Hospital of Southern Medical University, Guangzhou, China Yongji  Yan, MD  Professor, Chief, Department of Urology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China Guoxi  Zhang, MD Professor, Vice Chief, Department of Urology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China

Editors and Contributors

Part I Adrenal Gland, Kidney and Ureter

1

Patient Position and Trocar Placement for Upper Urinary Tract Surgery Qingbo Huang, Kan Liu, Xin Ma, and Xu Zhang

1

Establishment of Retroperitoneal Approach for Adrenal Gland and Upper Urinary Tract Laparoscopic Surgery

When surgery is performed through retroperitoneal approach, lateral position or prone position can be selected [1–3] Lateral position with retroperitoneal approach is our preferred choice [4–6] and will be further described. Patient Position: Patient is positioned to lateral decubitus position with extended flank. A gel cushion is inserted under the waist to elevate the waist and maximize the flank extension. Gel cushion or soft pillow should be put under the head and axillary to prevent brachial plexus injury. Lower limb of non-operating side should be flexed in 90 degree; while the lower limb of operating side should be straightened, a soft pillow is placed in between the lower limbs. Cushions should be placed under the elbow and ankle for protection. Restraining straps are strapped at the chest and pelvic to fix the patient at the position (Fig. 1.1). Creation of retroperitoneal working space and trocar insertion: The retroperitoneal space is a potential space posterior the peritoneum and can be developed into a surgical space. There are mainly two ways to develop and expand the retroperitoneal space:

neum anteriorly. A balloon expander that is made by tying index finger of a size 8 latex glove around 16F catheter (Fig. 1.2), is inserted into the retreoperitoneal space. The balloon expanded is inflated with 600~800 mL of air to expand the retroperitoneal space (Fig.  1.3). Subsequent insertion of trocars will be guided by index finger from the retroperitoneal space (Fig. 1.4). A 10 mm camera trocar is inserted two fingers breadths above the iliac crest on midaxillary line; second trocar is inserted at the just below the subcostal margin on anterior axillary line; third trocar is inserted via the initial skin incision and the skin

Fig. 1.1  Extended lateral decubitus

1. Hasson open technique: 2  cm longitudinal incision is made inferior to edge of the twelfth rib on posterior axillary line. This incision must be big enough to facilitate insertion of index finger. The muscle and lumbodorsal fascia are bluntly dissected by using a long hemostatic forceps until entering the retroperitoneal space. Index finger is inserted into the retroperitoneal space, and bluntly dissects the adipose tissue from superior to inferior and from posterior to anterior, at same time pushes the peritoQ. Huang · K. Liu · X. Ma · X. Zhang (*) Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China e-mail: [email protected], [email protected]

Fig. 1.2  Balloon expanded

© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 X. Zhang (ed.), Laparoscopic and Robotic Surgery in Urology, https://doi.org/10.1007/978-981-13-3738-3_1

3

4

Q. Huang et al.

Fig. 1.3  Expansion of retreoperitoneal space with the balloon expander

Fig. 1.5 Trocar configuration for retreoperitoneal laparoscopy surgery

Fig. 1.4  Trocar insertion under the guidance of index fingers

incision is sutured to fix the trocar. 12 mm trocar will be inserted on the side of dominant hand (Fig. 1.5). For some thin patients, blunt finger dissection of the retroperitoneal space able to mobilized most of the adipose tissue and push away the peritoneum, creating a sufficient retroperitoneal working space without balloon expander (Fig. 1.6). 2. Veress needle technique: Veress needle is punctured into retroperitoneal space at two finger breadths superior to iliac crest, on midaxillary line. Insufflator is connected to Veress needle to insufflate and expand the retroperitoneal. Subsequently, camera trocar inserted at the needle puncture point, laparoscope is inserted through this tro-

1  Patient Position and Trocar Placement for Upper Urinary Tract Surgery

car. Retroperitoneal space is bluntly dissected with laparoscope. The other working trocars are inserted under direct vision. Mobilization of the retroperitoneal adipose tissue and identification of structures within retroperitoneal space. Only Adipose tissue will be seen upon entering retroperitoneal space. This adipose tissue need to mobilized to expose structures within the retroperitoneal. An indentation can be seen at the meeting of point of peritoneal reflection and psoas muscle. The adipose tissue is mobilization from the indentation superiorly to iliac fossa inferiorly; from peritoneal reflection medially to psoas muscle laterally (Fig. 1.7). The dissected adipose tissue can be placed into the iliac fossa to avoid interruption to subsequent surgery (Figs.  1.8 and 1.9). Supplying vessels (Fig. 1.10) of the adipose tissue that will be encountered along dissection can be divided with Harmonic scalpel. Structures within the retroperi-

5

Fig. 1.7  Mobilization of adipose tissue within the retroperitoneal space (RAT retroperitoneal adipose tissue; dotted line showing the dissection direction)

Fig. 1.8  Mobilization of adipose tissue with exposure of Gerota’s fascia (GF Gerota’s fascia)

Fig. 1.6  Finger dissection of retroperitoneal space

Fig. 1.9  Adipose tissue was mobilized toward iliac fossa (IF iliac fossa)

6

Q. Huang et al.

Fig. 1.10  Supplying vessel of adipose tissue (GF Gerota’s fascia)

Fig. 1.12  DM diaphragm

Fig. 1.11  GF Gerota’s fascia

toneal including Gerota’s fascia (Fig. 1.11), diaphragm (Fig.  1.12), psoas muscle (Fig.  1.13), anterior peritoneal reflection (Fig.  1.14), posterior peritoneal reflection (Fig. 1.15) can be recognized after mobilization of adipose tissue.

2

Fig. 1.13  PM psoas muscle

Establishment of Transperitoneal Approach for Adrenal Gland and Upper Urinary Tract Robotic Surgery

Adrenal gland and upper ureter tract robotic surgeries that can be performed via transperitoneal approach include adrenal gland neoplasms excision, radical nephrectomy, partial nephrectomy, pyeloplasty and living donor nephrectomy [7, 8]. The body position and distribution of trocars in these surgeries are accommodated to robotic docking systems.

Fig. 1.14  APF anterior peritoneal reflection

1  Patient Position and Trocar Placement for Upper Urinary Tract Surgery

Patient position: After induction of general anesthesia and insertion of nasogastric tube and urinary catheter, patient is positioned to 60–70 degree lateral recumbent position with flank extension supported by gel cushion. A pillow is placed under the waist to elevate the waist and maximize the flank extension. Head and neck should be maintained in natural position with pillows. Soft pillow is placed under the axilla to prevent brachial plexus injury, all the bony prominents should be protected. Restraining straps is strapped at the chest and pelvic to fix the patient at the position (Fig. 1.16). Establishment of pneumoperitoneum: Transumbilical insertion of Veress needle is the safest as the entire anterior abdominal fascia is fused into single layer at umbilical 3 mm transverse incision is made at the umbilical, both lateral edge of umbilical is clipped with towel clips and ele-

Fig. 1.15  PPF posterior peritoneal reflection

Fig. 1.16  Schematic view for upper urinary tract approach

7

vated. Veress needle is hold with dominant hand between thumb and index finger, at about 4  cm distance from the tip of needle. The needle is punctured perpendicularly to the abdominal wall. A breakthrough sensation and bouncing of inner core of Veress needle indicate successfully penetration into abdominal cavity. Veress needle is hold in situ after successful puncture. Gas is insufflated at low flow rate (1 L/min) until the abdominal pressure achieves 12~15  mmHg. Failure of gas insufflation may be due to insufficiency of muscle relaxation or Veres needle blockage by omentum or intestinal wall, which can be resolved by readjustment of needle position. For patients who are at high risk of peritoneal adhesion due to previous abdominal infection or abdominal surgery history, the establishment of pneumoperitoneum should be performed via open Hasson technique. Trocars configuration: robotic surgery of upper urinary tract can be divided into the lateral approach, the transumbilical approach and the paraumbilical approach; based on location of robotic camera trocar is inserted. Paraumbilical approach is recommended based on our experience (Fig.  1.17). After pneumoperitoneum is established, an 10  mm incision is made on semilunalis 2-finger breadths above the umbilical, a 12 mm trocar is inserted as the camera trocar. Veress needle is removed; gas is insufflated via camera trocar. Subsequent trocar insertions are performed under direct vision of camera. First 8-mm robotic trocar is inserted a palm width distance above the camera trocar, second 8-mm robotic trocar is inserted 2 finger breadths above and lateral to ASIS, with a palm width distance from the camera trocar. Angle between the axis from first robotic trocar to camera trocar, and the axis from camera trocar to second robotic trocar should be 120 degree. Third robotic trocar can be inserted just above the pubic tubercle on the semilunalis,

8

Q. Huang et al.

first working arm; bipolar Maryland is installed as second working arm, Prograsp grasper is installed as third arm. After all working arm are docked, surgical field is viewed in far vision; distances between each working arm are assess for the possibility of collision among the working arm.

3

Fig. 1.17 Trocar configurations of upper urinary tract robotic surgeries

Fig. 1.18  Location of robotic working arms in upper urinary tract surgeries

with a palm width distance from second robotic trocar. Third trocar is optional based surgeon preference. For right-sided operation, an additional 5 mm port is inserted just below the xiphoid for liver retraction. Robot system docking: Imaginary line from camera trocar to midpoint between first and second trocar is the axis reference for docking of robotic system. Robotic system is approached from the back. Camera trocar is docked to robotic camera arm; the camera arm is adjusted to ensure the triangle indicator on the camera arm locating within the blue strip; hence working field will be shown middle in the screen. Subsequently, robotic arms are docked to their paired trocars (Fig. 1.18). Monopolar scissor is installed as

Establishment of Retroperitoneal Approach for Upper Urinary Tract Robotic Surgery

Patient position: Patient is positioned in lateral decubitus position with extended flank. A pillow should be put under the waist to elevate the waist and maximize the flank extension. Establishment of pneumoperitoneum and Trocar configuration: 3 cm transverse incision is made 2 cm above the iliac crest on middle axillary line. A long hemostatic clamp is inserted into the incision and bluntly dissect lumbodorsal fascia until entering into the retroperitoneal space. Index finger is inserted into the retroperitoneal space, and bluntly d­ issects the adipose tissue. Subsequently, balloon expander is inserted into the retroperitoneal space, and inflated to expand the retroperitoneal space. An 8 mm robotic trocar is inserted at midpoint between costal margin and iliac crest on the posterior axillary line, under guidance of index finger. This trocar is for insertion of second robotic arm. A 12 mm camera trocar is inserted into the 3 cm incision, the incision is sutured. Gas is insufflated via camera trocar, pressure is maintained between 12 and 15 mmHg. A suction device is inserted through second arm trocar to push the peritoneum away. Trocar for first robotic arm is inserted at 1–2 cm medial to anterior axillary line, same level of second robotic arm, under direct vision. A 12  mm assistant trochar is inserted at midpoint between first arm trocar and camera trocar (Fig.  1.19). Angle between robotic arm trocars and camera trocar should be more than 90°. Docking: Robotic system is approach from the head of the patient align with the long axis of body. Camera trocar is docked to robotic camera arm; the camera arm is adjusted to ensure the triangle indicator on the camera arm locating within the blue strip; hence working field will be shown middle in the screen. Subsequently, robotic arms are docked to their paired trocars (Fig. 1.20). Monopolar scissor is installed as first working arm; bipolar Maryland is installed as second working arm. After all the working arm are docked, surgical field is viewed in far vision; distances between each working arm are assess for the possibility of collision among the working arm. The assistant works from front side of the patient.

1  Patient Position and Trocar Placement for Upper Urinary Tract Surgery

Fig. 1.19  Trocar configurations of retroperitoneal robotic upper urinary tract surgery

9

Fig. 1.20  Location of robotic system during retroperitoneal approach, upper urinary tract robotic surgery

4. Zhang X, Fu B, Lang B, Zhang J, Xu K, Li HZ, Ma X, Zheng T.  Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases. J Urol. 2007;177(4):1254–7. 5 . Lang B, Fu B, OuYang JZ, Wang BJ, Zhang GX, Xu K, Zhang J, References Wang C, Shi TP, Zhou HX, Ma X, Zhang X. Retrospective comparison of retroperitoneoscopic versus open adrenalectomy for pheo 1. Capelouto CC, Moore RG, Silverman SG, Kavoussi LR.  Retro-­ chromocytoma. J Urol. 2008;179(1):57–60; discussion 60 peritoneoscopy: anatomical rationale for direct retroperitoneal 6. Zhang X, Li HZ, Ma X, Zheng T, Li LC, Ye ZQ. Retroperitoneal access. J Urol. 1994;152(6 Pt 1):2008–10. laparoscopic nephron-sparing surgery for renal tumors: report of 32 2. Bannenberg JJ, Garibiyan H, Vijverberg P, De Wit L, Meijer DW, cases. Urology. 2005;65(6):1080–4; discussion 1084–85. Kurth KH, Rademaker BP. Initial experiences with the retroperito- 7. Su L-M.  Atlas of robotic urologic surgery. New  York: Humana neal approach for endoscopic nephrectomy with the patient in the Press; 2011. p. 120–214. prone position. J Laparoendosc Adv Surg Tech A. 1998;8(1):25–32. 8. Ghavamian R. Atlas of laparoscopic and robotic urologic oncologi 3. Gill IS, Rassweiler JJ.  Retroperitoneoscopic renal surgery: our cal surgery. New Delhi, India: Jaypee Brothers Medical Publishers approach. Urology. 1999;54(4):734–8. (P) Ltd; 2013. p. 60–87.

2

Retroperitoneoscopic Anatomical Adrenalectomy Bin Fu, Xin Ma, Hongzhao Li, Tao Zheng, and Xu Zhang

1

Overview

More than 90% of adrenal tumors are benign lesions and small in size. It has a complex anatomy due to the deep location and closely related to many important structures including liver, spleen, pancreas, inferior vena cava and renal vessels. Open adrenectomy requires 20–30  cm length skin incision to resect a 2–3  cm tumors. This is a complicated surgery with high risk of mortality when injury to major vessels and vital organs. Laparoscopic technology, has gained great popularity worldwide for its prominent minimally invasive advantages including less traumatic, quick recovery, minimal postoperative pain, shorter hospital stay and small scar. With the evidences from large number of clinical trials and multi-center comparative analysis, it has replaced the open surgery as the mainstream surgical approach in the era of minimally invasive surgery due to its safety and reliability [1]. Laparoscopic adrenalectomy can be performed either transperitoneally or retroperitoneally. At present, surgeons from foreign countries such as Europe and United States prefer transperitoneal approach Adrenal exposure is the main problem for transperitoneal laparoscopic adrenalectomy that involves mobilization of few vital organ. This surgery is relatively complicated, and prone to adjacent organs injury. Although lower than open adrenectomy, its reported complication rate is approaching 10.3%. Furthermore it consumes long operation duration and requires long learning curve B. Fu Department of Urology, The First Hospital Affiliated to Nanchang University, Nanchang, China X. Ma · H. Li · X. Zhang (*) Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China e-mail: [email protected], [email protected] T. Zheng Department of Urology, Wuhan Fourth Hospital, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

[2, 3]. In China, most laparoscopic adrenalectomies are performed through retroperitoneal approach [4, 5]. In comparison to transperitoneal approach, studies have shown that retroperitoneal approach have the advantages of less bleeding, faster recovery, and less postoperative ileus [6]. However, limitations of retroperitoneal laparoscopic adrenalectomy include small operative space, difficulty in locating the adrenal gland, especially obese patients, and poor blood vessels exposure [1]. The author had systematically studied anatomy of adrenal gland within the retroperitoneal space and its surgical application since 2000, to improve surgical dissection of adrenal gland retroperitoneally. There are three relatively avascular spaces around the three surfaces of the adrenal gland, which are ventral, dorsal and renal surface. Retroperitoneal laparoscopic anatomical adrenalectomy was described; these three anatomical planes were sequentially dissected to expose the adrenal gland. By dissecting these anatomical planes, vital organs and major vessels adjacent to adrenal gland can be clearly identified, adrenal gland and vessels will be fully exposed, operation time can be shortened and complication rate is significantly reduced. Principles that should be comply when performing adrenalectomy include early localization and complete exposure of adrenal gland, dissection along the adrenal capsule, and minimal direct contact with adrenal gland and tumor and exposure of suprarenal vein [4, 7]. Up to date, our center had completed about 3000 retroperitoneal laparoscopic adrenalectomies with variety of adrenal diseases.

2

Indications and Contraindications

1. Indications Retroperitoneal laparoscopic anatomical adrenalectomy is suitable for most adrenal surgical diseases, including: (a) Hypercortisolism and primary hyperaldosteronism due to adrenocortical carcinoma or hyperplastic diseases;

© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 X. Zhang (ed.), Laparoscopic and Robotic Surgery in Urology, https://doi.org/10.1007/978-981-13-3738-3_2

11

12

(b) Hypercatecholaminism due to adrenal medullary hyperplasia and adrenal pheochromocytoma; (c) Nonfunctioning incidentaloma bigger than 3  cm, including adrenal cyst, adrenal medullary lipoma, ganglioneuroma, etc.; (d) Localized adrenal malignant carcinoma without obvious local invasion on capsule or vessel; • Solitary metastatic adrenal carcinoma with specific primary lesion [8]. 2. Contraindications Common contraindications including (a) Obvious invasion into surrounding organs or distant metastasis is detected before the surgery; (b) Patient with uncorrected coagulopathy. (c) Patient who are medically unfit for surgery [8]. Giant adrenal tumor with abundant of blood supply are challenging for laparoscopic approach. Adrenal tumors more than 10 cm in diameter, was once considered as a contraindication of laparoscopic surgery [3, 9]. But with the accumulation of experience in laparoscopic adrenalectomy, case reports regarding successful resection of large adrenal tumor are increasing in number. Other relative contraindications include obesity, pregnancy and previous upper abdomen surgery. The largest tumor that was resected by author was 14 cm in diameter, high level of laparoscopic was required to performed such operation [2, 4, 10, 11].

B. Fu et al.

images for pheochromocytoma through the high intensity transient signals on the tumor with T2-weighted images. 131I-MIBG (131 meta-­ iodobenzyl guanidine) examination is confirmation test for bilateral pheochromocytoma and atypical pheochromocytoma [3]. 2. Special preparation Patients with functional adrenal tumors always have varying degrees of endocrine and metabolic disorders that will increase the risk general anesthesia, due to complex pathophysiological changes caused by endocrine dysfunction. (a) Preoperative preparation of primary hyperaldosteronism patients The principles include blood pressure control, correction of electrolyte imbalance and hypokalemic alkalosis, maintain normal serum potassium level and normal ECG tracing. The approaches are: (1) Oral intake of spironolactone, 40~60 mg, tds or qid. (2) Oral intake of potassium 4~6 g od (3) Antihypertensive drugs should be started for patients with severe hypertension to control blood pressure. Generally, patient undergoes tumor resection and unilateral adrenalectomy due to aldosteronoma or adrenal hyperplasia does not require hormone supplements [12]. (b) Preoperative preparation of patients with 3 Perioperative Management Cushing’s syndrome Hormone supplements are given to control blood 1. General preparations include routine preoperative pressure and blood glucose, to correct electrolyte turinvestigations, qualitative and localization examinations bulence and acid-base disturbance; prophylaxis antirequired for a definite diagnosis: biotic is prescribed as well. Hormonal replacement (a) Routine preoperative investigations include full blood therapy is the most important treatment, IM cortisone count, renal profile, liver function test, coagulation acetate 100–200 mg is injected at the night before surprofile, serum blood glucose, blood cross match and gery and morning of surgery day. Another 100  mg urine FEME. cortisone acetate injection is given again soon after (b) Qualitative and localization examinations: The diagthe surgery. Intramuscular cortisone acetate injection nosis of adrenal disease requires both of these examiis given every 8 h for the first 2 days after the surgery, nations. This part of the examination can be completed then once for every 12  h for the next 2 days. with the co-management from endocrinologist colSubsequently, cortisone acetate 25 mg is given orally league. Currently in our centre, endocrine examinatwice a day as maintenance dose, together with fluorotions are performed by endocrinologist. Patient will cortisone 0.1 mg Qd for 1 month or longer [5, 13, 14]. be transferred to urology ward for adrenal surgery (c) Preoperative preparation of patients with hyperafter fully investigated. Qualitative diagnosis is comcatecholaminism: The principles of preparation are bination of patient’s clinical presentation, physical vascular bed expansion, control of blood pressure and examination, and selective adrenal hormone levels. plasma volume expansion. Corticosteroid tests include the serum cortisol level The approaches are: and its metabolites, serum ACTH, aldosterone, renin-­ (1) α adrenergic receptor blocker is given preoperaangiotensin-­aldosterone, and other Medulla hormone tively to expand the peripheral blood vessels. tests include serum adrenaline, norepinephrine, cateOral prazosin tds is given for 10–14 days before cholamine, 24-h urine VMA and other. Localization surgery; phenoxybenzamine 10 mg tds or qid can diagnosis can be done with color Doppler ultrasound, be given and gradually increased to the sufficient multiphases CT scan and MRI. MRI provides better dose to prevent the hypertensive episode.

2  Retroperitoneoscopic Anatomical Adrenalectomy

(2) Patients with tachycardia or arrhythmia, can be added with cardiovascular selective β receptor blocker when the effect of α adrenergic receptor blocker is stable. Preoperative heart rate should be controlled at less than 90/min. (3) Expanding the plasma volume and controlling the blood pressure before operation can prevent intraoperative fluctuations of blood pressure, promote postoperative stabile blood pressure recovery. Intravenous volume can be expanded by giving 1000~2000 mL intravenous fluid with crystalloid colloid ratio of 2:1. (4) Atropine should be avoided during surgery due to its vagal inhibition effect that can increase the heart rate and induce arrhythmias [3].

4

Operating Procedure

(1) Anesthesia and patient position Operation is performed under general anesthesia with tracheal intubation, nasogastric tubes and urinary catheter are inserted. Patient is positioned to lateral decubitus position with extended flank. For the patients with suspected hypercatecholaminism, central venous line and arterial line should be inserted to monitor central venous pressure and radial artery pressure; big bore intravenous line should be inserted for medication infusion and fluid resuscitation. (2) Right adrenectomy (all the images are taken from one patient) (a) Preparation of retroperitoneal space and trocars configuration are described in detail in Chap. 1. (b) Mobilization of retroperitoneal adipose tissue from Gerota’s fascia is described in detail in Chap. 1 (Fig. 2.1).

Fig. 2.1  Mobilization of retroperitoneal adipose tissue

13

(c) Gerota’s fascia is incised longitudinally just posterior to peritoneal reflection, superiorly from the indentation that is the meeting point of peritoneal reflection and psoas muscle to iliac fossa inferiorly (Fig. 2.2). (d) Avascular space between the perirenal fat capsule and the anterior layer of prerenal fascia is dissected as first anatomical plane; the white loose areolar tissues should be identified for entering the correct plane. (e) First anatomical plane is bluntly dissected; blood vessel is divided with ultrasonic apparatus. The dissection is advanced medially to expose the anterior surface of adrenal gland or tumor. This step is critical for the early localization of adrenal tumors. For right sided adrenectomy, dissection should be medially advanced from the adrenal gland to expose the inferior vena cava (Figs. 2.3, 2.4, and 2.5).

Fig. 2.2  Longitudinal incision at the Gerota’s fascia

Fig. 2.3  Dissection of the first anatomical plane and identification of white loose areolar tissue

14

B. Fu et al.

Fig. 2.4  Medial dissection of first anatomical plane and exposure of facies ventralis of the adrenal grand

Fig. 2.6  Second anatomical plane dissection and tumor exposure

Fig. 2.7  Adipose tissue excision at the upper pole of kidney Fig. 2.5  Medial dissection of first anatomical plane is advanced until identification of inferior vena cava

(f) The second anatomical plane is a relatively avascular space posterior to the kidney, which is located between the perirenal fat capsule and posterior perirenal fascia. This plane is dissected superiorly to meet the first separation layer, and dissected medially to the medial surface of upper pole of kidney. Blood vessels from the psoas muscle can be divided with ultrasonic apparatus, or ligated with Hem-O-­ Lok clips. The vessels do not need to be divided if they do not affect the surgery. Dissection of this plane is to expose the facies lateralis of the adrenal gland and enlarge the operating space. Some tumors are posteriorly located, and can only be exposed by separating this plane (Fig. 2.6). (g) Part of the perirenal fat at the upper pole is excised to expose the kidney surface. This step is important

to identify the third anatomical plane, especially for obese patients; this step can be skipped for thin patient (Fig. 2.7). (h) Space between the surface of upper pole and periadrenal adipose tissue at the base of adrenal gland is identified as the third anatomical plane, the periadrenal adipose tissue is retracted upward gently, and dissected from the surface of upper pole. Right suprarenal vein will be expose after the base of adrenal gland is fully dissected and retracted. The right suprarenal vein travels obliquely into the vena cava. Suprarenal vein is ligated with Hem-O-Lok clip and divided (Fig. 2.8). (i) There are many adrenal artery branches at the base of adrenal gland. The base of adrenal gland is dissected with combination of blunt and sharp dissection, blood vessel must be isolated, ligated and divided (Fig. 2.9).

2  Retroperitoneoscopic Anatomical Adrenalectomy

Fig. 2.8  Dissection of the third anatomical plane

Fig. 2.9  Ligation of suprarenal vein with Hem-O-Lok clips

(j) Adrenal gland along tumor margin is clipped with Hem-O-Lok clips and tumor is excised from adrenal gland. Adrenal gland should be preserved as much as possible during the excision. For upper pole adrenal tumor, adhesive tissue between the upper pole of adrenal gland and diaphragm for complete tumor exposure and excision. Pneumoperitoneum pressure is reduced to 3~5 mmHg to check and secure hemostasis. Tumor is removed through skin incision from third trocar incision within a specimen bag (Fig. 2.10). ( 3) Left adrenalectomy (a) Preparation of retroperitoneal space and trocars configuration are described in detail in Chap. 1. (b) Mobilization of retroperitoneal adipose tissue from Gerota’s fascia is described in detail in Chap. 1 (Fig. 2.11).

15

Fig. 2.10  Adrenal gland along tumor margin was clipped with Hem-­ O-­Lok clips and tumor was excised from adrenal gland

Fig. 2.11  Mobilization of retroperitoneal adipose tissue

(c) Gerota’s fascia is incised longitudinally just posterior to peritoneal reflection, superiorly from the indentation that is the meeting point of peritoneal reflection and psoas muscle to iliac fossa inferiorly (Fig. 2.12). (d) Avascular space located between the perirenal fat capsule and the anterior layer of prerenal fascia is dissected as the first anatomical plane; the white loose areolar tissues should be identified when entering the correct plane. The dissection is advanced medially to expose the anterior surface of adrenal gland or tumor. This step is critical for the early localization of adrenal tumors (Figs. 2.13 and 2.14). (e) The second anatomical plane is the relatively avascular space posterior to the kidney, which is located between the perirenal fat capsule and posterior perirenal fascia. This plane is dissected superiorly to

16

B. Fu et al.

Fig. 2.12  Longitudinal incision at the Gerota’s fascia

Fig. 2.15  Dissection of second anatomical plane

Fig. 2.13  Dissection of the first anatomical plane and identification of white loose areolar tissue

Fig. 2.16  Dissection of the third separation plane

Fig. 2.14  Tumor exposure at the first anatomical plane

meet the first anatomical plane and dissected medially to the medial surface of the upper pole of kidney. Dissection of this plane is to expose the facies lateralis of the adrenal gland and enlarge the operating space. Some tumors are posteriorly located, and can only be exposed after separating this plane (Fig. 2.15). (f) Space between the surface of upper pole and the adipose tissue at the base of adrenal gland is identified as the third anatomical plane. The periadrenal adipose tissue is retracted upward gently, and dissected from the surface of upper pole. Left suprarenal vein will be expose after the base of adrenal gland is fully dissected and retracted. The adhesive tissue between the upper pole of adrenal gland and diaphragm tissue is preserved for suspension of the adrenal gland (Fig. 2.16). (g) There are many adrenal artery branches under the adrenal gland. The base of adrenal gland is dissected

2  Retroperitoneoscopic Anatomical Adrenalectomy

with combination of blunt and sharp dissection; blood vessel must be isolated, ligated and divided. Suprarenal vein is completely exposed. The left suprarenal vein that travels vertically into the renal vein is ligated and divided as indicated. Ligation of suprarenal vein is not indicated when it does not affect the tumor excision (Fig. 2.17). (h) Adrenal gland along tumor margin is clipped with Hem-O-Lok clips and tumor is excised from adrenal gland. Adrenal gland should be preserved as much as possible during the excision. For upper pole adrenal tumor, adhesive tissue between the upper pole of adrenal gland and diaphragm for complete tumor exposure and excision. Pneumoperitoneum pressure is reduced to 3~5 mmHg to check and secure hemostasis. Tumor is removed through skin incision for third trocar within a specimen bag (Figs. 2.18 and 2.19).

17

Fig. 2.19  Incision of the adhesive tissue between the upper pole of adrenal gland and diaphragm

5

Precautions

1. The adrenal gland located at the subdiaphragmatic area is high in position, retroperitoneal adipose tissue should be mobilized until subdiaphragmatic area for better exposure of the adrenal. 2. The retroperitoneal surgery space should be fully prepared for maximum working space. Retroperitoneal anatomical landmarks such as peritoneum reflection, psoas muscle, and diaphragm must be accurately identified. Perirenal fascia should be incised as high as possible for maximum exposure of adrenal. 3. Important steps of anatomical laparoscopic adrenalectomy includes sequent dissection of the three relatively Fig. 2.17  Complete exposure of the left suprarenal vein avascular spaces and early localization of adrenal gland. Early localization of adrenal gland can provide good guidance on subsequent dissection to avoid contact and incision on adrenal gland [15]. 4. Identification of loose white areolar tissue is crucial to ensure dissecting at the correct anatomical plane [4, 7]. 5. Avascular anatomical plane should be dissected with combination of blunt and sharp dissection. Blood vessels should be divided with ultrasonic apparatus, surgical field should be kept clear from blood [16]. 6. Arteriar suprarenales superiors is the adhesive tissue between the adrenal upper pole and diaphragm that can maintain superior retraction of adrenal gland; it should only be incised after adrenal vein ligation. 7. For patients with less perirenal fat, it is relatively easier to identify the adrenal gland during dissection of first anatomical plane, dissection of second anatomical plane can be started from upper pole of kidney to the facies Fig. 2.18  Adrenal gland along tumor margin was clipped with Hem-­ O-­Lok clips and tumor was excised from adrenal gland lateralis of adrenal gland.

18

B. Fu et al.

8. The adrenal tissue is brittle and fragile; it should be avoided from direct clamping to prevent surface bleeding, rupture of adrenal gland or tumor and adjacent tumor seeding. Retraction should be done by clamping periadrenal adipose tissue. 9. Suprarenal vein must be clearly expose for ligation. It should be ligated with Hem-o-Lok clips. Right suprarenal vein is short; attention of care must be given during dissection. Author had experience with adrenal tumor which was encased by suprarenal vein and infiltrated inferior vena cava. This tumor was excised en-bloc with the wall of vena cava by using linear cutter stapler. 10. Anatomical planes must be fully dissected to maximize the potential anatomical space around the kidney and adrenal gland. The adrenal gland and tumor must be fully exposed to accurately assess the characteristics of tumor for the decision of total or partial resection of adrenal. Adjacent organ must be clearly identified to avoid injury [17–19]. 11. The primary aims in preoperative preparation of pheochromocytoma are to control blood pressure and blood volume. The patient should be given plasma volume expansion before the surgery to prevent hypotension caused by postoperative vasoconstriction. Good communication and cooperation with anesthetic colleague intraoperatively is important for stabilizing the intraoperative blood pressure [3].

6

Postoperative Management

Vital signs are closely monitored; nasogastric tube and urinary catheter can be removed soon postoperatively. The retroperitoneal drain can be removed when minimal output. Electrolyte imbalance and blood pressure should be closely monitored for patients with primary aldosteronism. Electrolyte imbalance must be promptly rectified. Blood pressure can be manifest as following scenarios: 1 . Blood pressure stabilizes in normal range after surgery. 2. Blood pressure normalizes, subsequently has a paradoxical rise. This situation can be effectively controlled with antihypertensive drugs are effective. 3. Electrolyte imbalance is corrected, however, blood pressure is not significantly reducing, antihypertensive drugs need to be started. If the symptoms of aldosterone cannot be alleviated significantly after surgery, daily spironolactone 200~400 mg can be given. The symptoms are generally will be controlled [12]. Patients with hypercatecholaminism may have risk of acute hypotension after surgery, especially during position chance. Blood pressure should be monitored continuously.

During episode of hypotension, intravenous fluid and inotropic drugs are given to maintain the blood pressure. Blood glucose should be monitored to prevent harmful impact from hypoglycemic attack [20]. Patients with Cushing’s syndrome may have acute adrenal insufficiency after the surgery. Steroidal hormone can be given under a strict protocol; serum electrolytes and sugar must be regularly checked. During Addison’s crisis, patient must be resuscitated and the dosage of steroidal hormone should be increased. For patients with hypercortisolism, the ability of tissue healing is low and wound is susceptible to infections, that will subsequently lead to poor wound healing. Patient should be encouraged to perform regular lung exercise to avoid atelectasis and pulmonary infection [13].

7

Complications

The overall complications rate is lower for laparoscopic adrenal surgeries in comparison to open approach as intraabdominal organs and large vessels injury can be avoided in laparoscopic retroperitoneal adrenal surgery. Intraoperative or postoperative bleeding is a common complication [21–23]. 1. Trochar insertion-related complications: These complications usually occur during creation of pneumoperitoneum and insertion of first trocar. Epigastric vessels, major vessels, solid organs and bowels are at risk of injury. (a) Epigastric vein injury. Bleeding from epigastric vein is usually self-limiting through compression of trocars. (b) Intraperitoneal organ injury: Liver and spleen injuries are the commonest. Small intestine injury commonly happens as well. Intestine injury can be primary closed with interrupted suturing by using 4-0 absorbable suture under sufficient bowel preparation. Other solid organ injuries are managed according to respective principle of organ injury management. (c) Injury of blood vessels: Major vessels injury due to trocar penetration require conversion to open surgery. Vessels are repaired according to the principle of vascular surgery. The following precaution steps should be taken to prevent major vessels injury. (1) Competent training for laparoscopic surgery (2) Familiarity with surface anatomy (3) Preoperative insertion of nasogastric tube and urinary catheter to avoid the distention of hollow viscous (4) Sufficient pneumoperitoneum pressure (5) Anterior retraction of abdominal wall to keep the abdominal wall away from bowel

2  Retroperitoneoscopic Anatomical Adrenalectomy

(6) For patients with previous history of abdominal surgery, trocars should be inserted through Hasson technique [14]. 2. CO2 pneumoperitoneum-related complications It occurred in 2~3.5% of patients, and the incidence is higher when pneumoperitoneum duration is over 4  h. Complications include subcutaneous emphysema, hypercapnia, pneumothorax and others. There complications are less in robotic assisted adrenal surgery because robotic assisted adrenal surgery usually can be completed within 2 h. (1) Subcutaneous emphysema: A common complication with crepitus or feeling of grasp the snow when touching it; it is self-limiting. (2) Hypercapnia: Hypercapnia can occur in patients with background history of pulmonary disease; pneumoperitoneum pressure should be reduced when patient is hypercapnic. (3) Pneumothorax: Pneumothorax occurred when dia phragm or pleura is injured. Diaphragm defect must be repaired promptly; Chest drain must be inserted. Precaution steps must be taken to prevent CO2 pneumoperitoneum related complications. (1) Strict control of surgical indications, especially for patients with chronic obstructive pulmonary diseases When operating on COPD patient, surgeon must maintains good communication with anesthesiologists; lung function test and blood gas analysis should be completed before the surgery. (2) Intraoperative pneumoperitoneum pressure should be maintained between 10~14  mmHg. COPD patients should be operated by experience surgeon to shorten the operation time. (3) Airway pressure, arterial blood gas and haemodynamic parameters should be closely monitored for patients with pulmonary or cardiovascular diseases. Surgery should be converted to open or terminated when patient cannot tolerate with CO2 pneumoperitoneum. 3. Injuries of blood vessels: Blood vessels injury are common complications with 0.7~5.4% incidence. (1) Injuries of adrenal arteriole: Electrocoagulation or titanium clipping can secure this bleeding. (2) Injury of suprarenal vein: Injury of suprarenal vein may involve the vena cava or left renal vein. The suprarenal vein should be carefully mobilized. Increasing the pneumoperitoneum pressure can provide temporally tamponade for the bleeding from left renal vein or vena cava to repair the defect. When bleeding unable to be secured laparoscopically, ­surgery must be converted to open surgery without hesitation. Blood transfusion rate can be used as an indicator for intraoperative and postoperative

19

bleeding, reported blood transfusion rate of laparoscopic adrenal surgery is from 2 to 10% (3) Injury of renal veins: Left renal vein is at higher risk of injury due to insertion left suprarenal vein into the left renal vein. The defect usually can be repaired laparoscopically. (4) Injuries of vena cava: This complication occurs in right adrenal surgery; the right suprarenal vein travers vertically and inserts into the vena cava. Vena cava may be injured during mobilization of right suprarenal vein (5) Splenic vessels injury: It can occur in left adrenal surgery. Some of the splenic vein injury can be repaired; while splenectomy is required for splenic artery injury [24]. 4. Adjacent organs injury include injury to liver, spleen, pancreas, kidney, and large bowel. (1) Liver and spleen injury: Liver and spleen can be injured during mobilization for adrenal exposure. Liver injury may occur during of trocar insertion. Most of the injuries are superficial and can be secured with electrocautery. Liver excision is required for en bloc removal of adrenal tumor when there is liver infiltration, liver defect need to be repaired to secured the hemostasis. (2) Pancreatic tail injury: Pancreatic tail may be presumed and excised as adrenal specimen by beginner surgeon due its adjacency and similar appearance to adrenal gland. Surgeon must alert about abnormal drainage fluid. Serum and body amylase should be sent to confirm the diagnosis. Drainage tubes have to keep for a longer duration up to 3 months; most of the pancreatic leakage can be healed with conservative management. (3) Renal injuries: The adrenal gland is closely related to superior pole of kidney. Kidneys can be injured when dissecting the adrenal base. Bleeding from superficial renal injury usually can be secured with, hemostatic agent and bipolar electrocautery. Deep renal defect must be sutured to secure the bleeding. Nephectomy is indicated when adrenal tumor infiltrates to kidney. Possibility of nephrectomy should be included in preoperative consent taking. (4) Bowel injury: Prompt detection of bowel injury is critical. Small intestine injury can be primary sutured with 4-0 absorbable suture under sufficient bowel preparation. Colostomy is required for colon injury. Bowel injury can be prevented with anatomy familiarity and gentle mobilization. 5. Diaphragm and pleura injury: Diaphragm defect must be repaired and chest drained must be inserted. 6. Postoperative hormone-related complications: Functioning adrenal tumors contribute to most cases in

20

B. Fu et al.

adrenal surgery, about 1% of the patients may have postHowever retroperitoneal space is small and lack of idenoperative hormone-related complications. Patients with tifiable anatomical landmarks, this limitation may Cushing’s syndrome will be complicated with Addison’s increase the difficulty in blood vessels identification and crisis when corticosteroid supplement is insufficient. exposure. Retroperitoneal approach is more challenging 7. Other complications include wound infection, intra-­ in obese patients due to excess of adipose tissue within abdominal infection, pulmonary infection, incisional herthe retroperitoneal space. Bilateral lesions can be opernia and others. ated simultaneously in retroperitoneal posterior lumbar (1) Wound infection: Wound infection is managed with approach without changing of positions, selection of this regular dressing and orally antibiotic. Wound infecroutes is highly dependent on surgeons’ surgical experition can be prevented with strict intraoperative asepence [1, 6, 25]. tic technique. 2. Training: Anatomical laparoscopic adrenal surgeries had (2) Intra-abdominal infection: It is rare, but common in proven its reproducibility by following the standardize patients with previous history intra-abdominal infecsurgical steps. We had successfully trained over 100 tion; it may be aggravated during inadequate intraabtrainees to perform this operation in our center. Trainees dominal drainage or presence of residual blood clot. will be trained for basic laparoscopic skills through lapIt is managed with sufficient drainage and antibiotics; aroscopic simulator as initial step, followed by laparoperitoneal lavage should be performed as indicated. scopic animal model training. Finally, they will be (3) Pneumonia: It is common in patients with preexisting supervised to perform retroperitoneal laparoscopic adrepulmonary diseases. Preventive measures include nalectomy during clinical training. Our training showed incentive spyrometry, active expectorant, regular that junior doctors without experience in open surgery chest physiotherapy and early mobilization. Patient experience can master this surgery successfully after with low pulmonary reserve should have intensive formal training [26, 27]. care unit backup preoperatively. Chest physician 3. Adrenal-sparing surgery: Adrenal-sparing surgery was should be consulted for complicated pneumonia. traditionally performed for bilateral hereditary paragan (4) Incisional hernia: The incidence of incisional hernia glioma (multiple endocrine neoplasm type 2 and Von at the trocar insertion site is relatively low, accounted Hippel-Lindau syndrome), to preserve the adrenal cortifor 0.77~3%. Most of the hernias occur at the cal function, and avoid the lifelong hormone replaceextended abdominal incision for specimen retrieval. ment therapy. In recent years, some authors had applied Proper wound closure is the key prevention. Incisional it in other types of adrenal tumors such as aldosterhernia is managed according to the principle of incionoma. Technically, adrenal-sparing surgery can be sion hernia management. applied to single peripheral tumor less than 2  cm in diameter. Bleeding from the excisional adrenal surface can be secured by bipolar coagulation, ultrasonic appa8 Technical Status ratus and Hem-o-Lok clips. Larger tumors or potentially malignant tumors are absolute contraindications for 1. Selection of surgical approaches adrenal-sparing surgery due to risk of tumor seeding. At present there are four kinds of approaches for lapaLaparoscopic adrenal-sparing surgery has proven its roscopic adrenal surgery, that are transperitoneal antesafety and feasibility; however, it still associates with rior, transperitoneal lateral flank, retroperitoneal lateral minimal risk of tumor residual leading to postoperative flank and retroperitoneal posterior lumbar approaches. recurrence. Thus, preoperative imaging study for careful The transperitoneal approach was first introduced by case selection and intraoperative optimal tumor excision Gagner, and subsequently was widely utilized worldis crucial [28]. wide. Transperitoneal approach offer obvious anatomical 4. Laparoscopic surgery for pheochromocytoma landmarks and large operating space. For transperitoneal Pheochromocytoma once was a contraindication for anterior approach, patient is positioned in a supine posilaparoscopic surgery. The restriction factors of pheotion; this approach offer familiar intraoperative view chromocytoma for laparoscopic surgery include abunwhere intraabdomen structures remain at anatomical dant of vascular supply, potential malignancy, position. More trocars are required for mobilization and intraoperative blood pressure fluctuation, potential rupretraction of adjacent organs to expose the adrenal. ture of tumor’s capsule and tumor seeding. With accuRetroperitoneal lateral flank approach offers direct mulation of experience in laparoscopic adrenal surgery, access to the adrenal without interference of intraablaparoscopic excision pheochromocytoma had been dominal organs. This approach maybe not affected by widely performed. During excision of adrenal pheochroadhesion from previous intraabdominal surgery. mocytoma, tumor contact should be avoided to prevent

2  Retroperitoneoscopic Anatomical Adrenalectomy

blood pressure fluctuation due to release of catecholamines vasoactive substances into systemic circulation. Most western authors prefer transperitoneal approach to have early and easy access to suprarenal vein. However, base on our experiences, early access and ligation of suprarenal vein in excision of pheochromocytoma is not necessary. During adrenal gland dissection, surgical instruments are usually contact with periadrenal adipose tissue instead of adrenal gland itself, thus the tumor is less stimulated. After dissecting the three anatomical plane, the operating space will be sufficient enough for good exposure of suprarenal vein. When performing surgery for pheochromocytomy, it is important to recognize the pathological changes of feeding vessels to adrenal pheochromocytomas; there are mainly two type of pathologic changes in local vessels of large pheochromocytoma. Surface vessels of the tumor are abundant and dilated covering the tumor; these vessels are easily bled when contacted. Basilar vessels of the tumor are proliferated and dilated as well, these vessels enter the base of tumor in pyramid appearance (Figs.  2.23 and 2.24). It is important to identify these abnormal vessels and dissect them gently during pheochromocytoma surgery; these vessels bleed easily and the bleeding is tremendous. These vessels should be clipped instead of eletrocauterized. Most of the pheochromocytoma can be excised through laparoscopic retroperitoneal approach by dissecting the three anatomical plane and careful handling of the blood vessels. We had reported our experience in laparoscopic excision of a 13 cm pheochromocytoma retroperitoneally [3, 29]. *(Figures 2.20, 2.21, 2.22, 2.23, and 2.24 showed retroperitoneal laparoscopic excision of a 8  cm right pheochromocytoma.)

Fig. 2.20  Dissection of first anatomical plane which is the ventral surface of tumor

21

Fig. 2.21  Dissection of second anatomical plane

Fig. 2.22  Dissection of third anatomical plane dissection

Fig. 2.23  Basilar vessels dissection and ligation (The ‘Left corner’ of pyramid)

22

Fig. 2.24  Basilar vessels dissection and ligation (The ‘Right corner’ of pyramid)

5. Laparoscopic surgery of giant adrenal tumor Adrenal tumors bigger than 6  cm are traditionally operated in open approach. With the advancement of laparoscopic technology and accumulation of laparoscopic surgery experience, laparoscopic surgery for giant adrenal tumor is ventured. We had experience in performing retroperitoneal laparoscopic adrenalectomy for a 14  cm adrenal tumor. Some important principles must be complied when performing laparoscopic surgery for giant adrenal tumor. (a) Sufficient preoperative patient preparation: For giant pheochromocytoma, intravenous fluid should be given to expand intravenous volume preoperatively, phenoxybenzamine 10 mg tds to qid should be given for 2 weeks to control blood pressure. Dosage of phenoxybenzamine should be increased over a short period of time. Patients with suspected pheochromocytoma should be prepared with plasma volume expansor as well [25]. (b) Selection of routes: The author prefers retroperitoneal route to avoid mobilizing the intraperitoneal organs. However, retroperitoneal route has limitation in surgical space, worse for giant tumor. It is important to avoid peritoneal perforation; gas pressure from the peritoneal cavity can significantly reduce the retroperitoneal space. (c) Tumor dissection: Operating steps are similar as other adrenal surgeries where the three anatomical planes are dissected in order. Giant tumor should be seen once first anatomical plane was dissected. Bleeding is common due to abundant of dilated at the tumor surface and dense adhesion at the anatomical plane. If bleeding unable to be secured and the exposure is

B. Fu et al.

Fig. 2.25  Right suprarenal vein traveled vertically into the vena cava

affected, dissection should be stopped at bleeding area and continued at other area. It is not necessary to follow the regular dissection order once tumor is found [29]. (d) Exposure of suprarenal vein: Suprarenal vein is difficult to be exposed in giant adrenal tumor. Anatomical familiarity and maximum anatomical plane dissection are critical. Right suprarenal vein is shorter and travels vertically into the vena cava (Fig.  2.25). During dissection of third anatomical plane, the tumor base is retracted upward, dissection is progressed medially until the lateral border of vena cava and medially of adrenal to expose right suprarenal vein. Left suprarenal vein is longer and travels obliquely into the left renal vein. It usually can be exposed when dissection of third anatomical plane approaching medial border of adrenal [29]. 6. Laparoscopic adrenalectomy for adrenocortical carcinoma Most adrenocortical carcinoma is unresectable during diagnosis. Laparoscopic adrenalectomy is one of the treatment options for resectable adrenocortical carcinoma. Principle of resection is similar to open surgery, involved lymph nodes and infiltrated organs must be resected en bloc. The most important predictor for survival is complete tumor clearance. The five-year survival rate for patients with complete tumor clearance is 32~48%, however the average survival drops to less than 1 year for incomplete tumor clearance. 7. Laparoscopic surgery for recurrent or residual adrenal tumor Second operation is indicated for recurrence or postoperative residual adrenal tumors. Second adrenal surgery can be performed laparoscopically, however

2  Retroperitoneoscopic Anatomical Adrenalectomy

the surgeon must be experience in this surgery. Retroperitoneal route certainly offers more advantages in second operation especially for patient who was operated transperitoneally during first surgery. Dense adhesion should be anticipated for second surgery; surgery should be converted to open surgery when it is difficult to proceed [30]. 8. The laparoscopic treatment of metastatic adrenal carcinoma The incidence of metastatic adrenal carcinoma is low, Laparoscopic metastatectomy can be performed for isolated adrenal metastasis without infiltration to surrounding organ. Patient must be strictly selected with favorable prognosis of primary tumor. Principle of resection is to achieve complete tumor clearance [31]. 9. Single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery for adrenal Retroperitoneal SILS adrenalectomy is performed based on the principle of retroperitoneal laparoscopic anatomical adrenalectomy. Its learning curve and perioperative parameter are comparable to retroperitoneal laparoscopic anatomical adrenalectomy with additional cosmetic advantage. We are also exploring transperitoneal SILS adrenalectomy and vaginal assisted natural orifice transluminal endoscopic adrenal surgery, to confirm their feasibility and safety [32–36]. 10. Robot assisted adrenal surgery is discussed in Chap. 3.

References 1. Gagner M, Lacroix A, Bolte E.  Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med. 1992;327(14):1033. 2. Mercan S, Seven R, Ozarmagan S.  Endoscopic retroperitoneal adrenalectomy. Surgery. 1995;118(6):1071–5. 3. Ariyan C, Strong VE. The current status of laparoscopic adrenalectomy. Adv Surg. 2007;41:133–53. 4. Brunt LM.  Minimal access adrenal surgery. Surg Endosc. 2006;20:351–61. 5. Ishidoya S, Ito A, Sakai K, et  al. Laparoscopic partial versus total adrenalectomy for aldosterone producing adenoma. J Urol. 2005;174:40–3. 6. Zhang X, Fu B, Lang B, et  al. Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases. J Urol. 2007;177:1254–7. 7. Zhang X, Zheng T, Ma X, et al. Retroperitoneoscopic surgery for adrenal cysts: a single-center experience of 14 cases. J Endourol. 2007;21(2):177–9. 8. Zhang X, Lang B, Ouyang JZ, et al. Retroperitoneoscopic adrenalectomy without previous control of adrenal vein is feasible and safe for pheochromocytoma. Urology. 2007;69:849–53. 9. Zhang X, Lang B, OuYang J-Z, et al. Retrospective comparison of retroperitoneoscopic versus open adrenalectomy for pheochromocytoma. J Urol. 2008;179(1):57–60. 10. Zheng T, Zhang X, Ma X, et  al. Retroperitoneoscopic surgery for adrenal cysts: a report of 15 cases. Chin J Minim Inva Surg. 2005;5(6):431–2.

23 11. Zhang X. Anatomical retroperitoneoscopic adrenalectomy:operative technique and our experience. J Clin Urol. 2007;22(8):561–4. 12. Zhang X, Fu B, Lang B, et al. Technique of anatomical retroperitoneoscopic adrenalectomy. Chin J Urol. 2007;28(3):5–8. 13. Henry JF, Defechereux T, Raffaelli M, et al. Complications of laparoscopic adrenalectomy: results of 169 consecutive procedures. World J Surg. 2000;24:1342–6. 14. Permpongkosol S, Link RE, Su LM, et  al. Complications of 2,775 urological laparoscopic procedures: 1993 to 2005. J Urol. 2007;177(2):580–5. 15. Rosevear HM, Montgomery JS, Roberts WW, et al. Characterization and management of postoperative hemorrhage following upper retroperitoneal laparoscopic surgery. J Urol. 2006;176(4. Pt 1):1458–62. 16. Walz MK, Alesina PF, Wenger FA, et al. Posterior retroperitoneoscopic adrenalectomy—results of 560 procedures in 520 patients. Surgery. 2006;140(6):943–8. 17. Zhang X, Lang B, Ouyang JZ, et al. Retroperitoneoscopic adrenalectomy for pheochromocytoma (report of 56 cases). Chin J Urol. 2007;28(3):149–52. 18. Zhang X, He H, Chen Z, et al. Retroperitoneal laparoscopic management of primary aldosteronism with report of 130 cases. Chin J Surg. 2004;42(18):1093–5. 19. Zhang X, Zhu QG, Ma X, et al. Application of the harmonic scalpel for retroperitoneoscopic partial adrenalectomy. Jiangsu Med J. 2002;28(6):403–4. 20. Zhang X, Ye ZQ, Chen Z, et al. Laparoscopic adrenalectomy (report of 23 cases). J Clin Urol. 2000;15(12):541–2. 21. Lang B, Zhang X, Fu B, et al. A retrospective comparative study on retroperitoneoscopic and open adrenalectomy for adrenal pheochromocytoma. Chin J Minim Inva Surg. 2007;7(8):730–2. 22. Zhang X, Ye ZQ, Song XD, et  al. Laparoscopic and pos terior laparsocopic adrenalectomy as compared with open adrenalectomy(report of 93 cases). Chin J Urol. 2002;23(6): 332–4. 23. Wang BJ, Wu Z, Zhang X, et al. Staged laparoscopic training for performing the anatomic retroperitoneoscopic adrenalectomy. Chin J Urol. 2009;30(5):293–6. 24. Zhang X, Wang B, Zhang G, et al. Laparoscopic adrenalectomy for beginners without open counterpart experience: initial results under staged training. Urology. 2009;73(5):1061–5. 25. Baojun W, Xin M, Hong L, et  al. Anatomic retroperitoneoscopic adrenalectomy for selected adrenal tumors >5  cm: our technique and experience. Urology. 2011;78(2):348–52. 26. Fu B, Zhang X, Wang GX, et al. Long-term results of a prospective, randomized trial comparing retroperitoneoscopic partial versus total adrenalectomy for aldosterone producing adenoma. J Urol. 2011;185(5):1578–82. 27. Cai W, Guo G, Li HZ, et al. The application of new technique in retroperitoneal adrenalectomy based on the new acknowledge of morbid anatomy regarding feeding vessels in large pheochromocytoma. J Minim Inv Urol. 2013;2(2):88–91. 28. Li J, Lv WC, Tian Y, et al. Laparoscopic adrenalectomy for large adrenal tumors. J Clin Urol. 2011;26(3):200–2. 29. Liao WF, Ma LL, Lu J, et  al. Retroperitoneal laparoscopic re-operation in the nephron region. Chin J Minim Inva Surg. 2013;13(1):81–3. 30. Sturgeon C, Leong SP, Duh QY.  Laparoscopic surgery for melanoma metastases to the adrenal gland. Expert Rev Anticancer Ther. 2004;4(5):831–41. 31. Ma X, Li H, Zhang X, et al. Modified anatomical retroperitoneoscopic adrenalectomy for adrenal metastatic tumor: technique and survival analysis. Surg Endosc. 2013;27(3):992–9. 32. Fu B, Wang GX, Zhang X, et al. Single-port Transumbilical laparoscopic surgery in urology with report of 18 cases. J Clin Urol. 2009;24(11):805–8.

24 33. Zhang X, Ma X, Li HZ, et  al. Single-port anatomical retro peritoneoscopic adrenalectomy (report of 5 cases). J Clin Urol. 2009;24(9):647–50. 34. Zhang X, Shi TP, Li HZ, et al. Laparo-endoscopic single site anatomical retroperitoneoscopic adrenalectomy using conventional instruments: initial experience and short-term outcome. J Urol. 2011;185(2):401–6.

B. Fu et al. 35. Shi TP, Zhang X, Ma X, et  al. Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: a matched-pair comparison with the gold standard. Surg Endosc. 2011;25(7):2117–24. 36. Zou X, Zhang G, Xiao R, et  al. Transvaginal natural orifice transluminal endoscopic surgery (NOTES)-assisted laparoscopic adrenalectomy: first clinical experience. Surg Endosc. 2011;25(12):3767–72.

3

Robotic Adrenalectomy Bin Fu, Hongzhao Li, Xin Ma, and Xu Zhang

1

Overview

Laparoscopic adrenalectomy had become a preferred surgical method for adrenal tumors, and its applied range is broadening. For the experienced surgeons, surgeries for pheochromocytoma, giant or malignant adrenal tumor, and metastatic adrenal tumors can be finished under the laparoscope, and its advantages in safety, reliability and minimally invasive are obvious. With the widely use of robot surgery system all over the world, robot assisted adrenal surgeries had also proved to be an alternative treatment method, which have equal therapeutic effect with laparoscopic surgery [1, 2]. The advantages of robot assisted surgery are mainly manifested in following aspects: Three-dimensional and amplifying view, ergonomics and the activity range of endowrists. It’s reported recently that the therapeutic effect between robot assisted surgery and laparoscopic surgery are similar, and advantages of reconstructive surgery and intraperitoneal knotting are evident. Robot assisted surgeries have better comfortableness and short learning curve for surgeons, so wide range of applications and prospects are foreseeable. Comparing the retroperitoneal approach, the transperitoneal adrenal surgeries may have more injury risk to the adjacent organs like liver, spleen, pancreas and major vessels when exposing the adrenal gland. Especially for tiny adrenal tumors, the exposure is relatively more difficult [3–6]. According to the author’s experience, robot assisted surgeries may have its unique superiority for giant adrenal tumors or adrenal tumors which have complicated anatomic relationship.

B. Fu Department of Urology, The First Hospital Affiliated to Nanchang University, Nanchang, China H. Li · X. Ma · X. Zhang (*) Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China e-mail: [email protected], [email protected]

2

Indications and Contraindications

The same as the laparoscopic adrenalectomy. On account of the flexibility and easy mastering of the robot operating system, it has more advantages when treating giant and complexed adrenal tumors, so indications can be appropriately loosened for experienced surgeons [5, 7].

3

Perioperative Treatments

The same as the laparoscopic adrenalectomy.

4

Operating Procedure

(1) Anaesthesia and patient position, the constructions of pneumoperitoneum, distribution of trocars and the docking of robotic operation system refer to Sect. 3, Chap. 2, Part 2. (2) Robot assisted left adrenal surgery 1. Cut off the side peritoneum Separate the adhesion of the greater omentum and the side peritoneum (Fig. 3.1). Cut off the side peritoneum between the Toldt’s line and the descending colon (Fig. 3.2). Then move the descending colon to inner side by sharp dissection into the space between the Gerota fascia and the fusion fascia of colon. This space is a relatively avascular. The incision scope of the side peritoneum: from fossa iliaca (Fig. 3.3) to the inferior margin of spleen (Fig. 3.4). 2. The exposure of the adrenal tumor Cut off the splenocolic ligament (Fig.  3.5), and continue to droop the colon towards the ventral side. Left adrenal grand or tumor are mostly positioned behind the tail of pancreas (Fig. 3.6). Dissociate and retract the tail of pancreas towards the ventral side with the combination of sharp and blunt dissection, then separate the space between the anterior layer of

© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 X. Zhang (ed.), Laparoscopic and Robotic Surgery in Urology, https://doi.org/10.1007/978-981-13-3738-3_3

25

26

B. Fu et al.

Fig. 3.1  Separate the adhesion of the greater omentum and the side peritoneum

Fig. 3.4  Incise the side peritoneum upward to the inferior margin of spleen

Fig. 3.2  Cut off the side peritoneum between the Toldt’s line and the ascending colon

Fig. 3.5  Cut off the splenocolic ligament

Fig. 3.3  Incise the side peritoneum downward to the fossa iliaca

Fig. 3.6  Retract the tail of pancreas towards the ventral side

3  Robotic Adrenalectomy

27

Fig. 3.7  The golden adrenal tumor can be seen through the Gerota fascia

Fig. 3.9  Dissociate and expose the ventral surface of the adrenal grand

Fig. 3.8  Cut off the Gerota fascia on the surface of the adrenal tumor

Fig. 3.10  Expose the left renal vein

the Gerota fascia and the fusion fascia of colon, until the golden adrenal grand or tumor can be seen through the Gerota fascia (Fig. 3.7). If the exposure of the spleen is insufficient, let the assistant to lift it upwards, then expose and open the connection of spleen and kidney. Dissociate the spleen towards the inner and upper side. Cut off the Gerota fascia on the surface of the adrenal tumor (Fig. 3.8) and expose the ventral surface of the adrenal grand (Fig. 3.9). 3 . Expose and control the adrenal central vein The left renal vein can be found underneath the left adrenal tumor (was light blue under the endoscope), open the left vein sheath, and expose the left renal vein (Fig.  3.10). Dissociate between the left renal vein and left adrenal tumor carefully, and expose the left adrenal central vein (Fig. 3.11), confirm its infusion into the left renal vein then use one

Fig. 3.11  Expose the left adrenal central vein and confirm its infusion into the left renal vein

28

B. Fu et al.

Fig. 3.12  Ligate and cut the left adrenal central vein

Fig. 3.13  Continue to dissect the upper pole of the adrenal tumor below the spleen

Hem-o-lok for clamping the distal end, then cut the adrenal central vein (Fig. 3.12). 4. Continue to dissect the adrenal tumor. Generally, at first, dissociate the upper pole of the tumor below the inferior margin of spleen. The blood vessels on the tumor’s surface can be electrocoagulated by bipolar or mutilated by Hem-o-Lok (Fig. 3.13). 5. Dissociate the dorsal surface of the adrenal tumor along the surface of the psoas major (Fig. 3.14). Then incise the Gerota’s fascia which covers the upper pole of the kidney, dissociate the lower pole of the adrenal tumor in this level (Fig. 3.15), and remove the tumor completely. Clamp the normal adrenal grand between the tumor and the normal side of it with Hem-o-Lok, mutilate and remove the tumor completely (Fig. 3.16). 6. Lower the pressure of pneumoperitoneum, check out if there is hemorrhagic spot then stop it carefully.

Fig. 3.14  Dissociate along the surface of the psoas major and dissociate the dorsal surface of the adrenal tumor

Fig. 3.15  Dissociate the lower pole of the adrenal tumor in the upper pole of the kidney

Fig. 3.16  Remove the adrenal tumor and clamp the normal adrenal grand by Hem-o-Lok

3  Robotic Adrenalectomy

29

7. Put the adrenal tumor into specimen bag and take out through a certain expanded incision of cannula. 8. Indwelling drainage tubes or not depends on actual surgical circumstances. 9. Close the incision. (3) Robot assisted right adrenal surgery 1. Anaesthesia and patient position, the constructions of pneumoperitoneum, distribution of trocars and the docking of robotic operation system refer to Part 2 Unit 2 Chap. 3 of the book. 2. Cut off the falciform ligament, lift up the liver towards the head side. Cut off the falciform ligament (Fig.  3.19), control the cannula through the subxiphoid approach by the assistant, place in the fan-­ shaped retractor to retract the liver, or lift up the right lobe of liver by self-locked needle holder, pick up the Fig. 3.19  Cut off the side peritoneum between the Toldt’s line and the liver towards the head side (Figs.  3.17, 3.18, and ascending colon 3.19).

Fig. 3.17  Cut off the falciform ligament

Fig. 3.18  Lift up the liver towards the head side

Fig. 3.20  Cut off the side peritoneum down to the fossa iliaca

3. Cut off the side peritoneum to show up the right adrenal. Separate the adhesion of the greater omentum and the side peritoneum. If the ascending colon and the duodenum do not interrupt the exposure of the right adrenal grand, skip this step. Cut off the side peritoneum between the Toldt’s line and the ascending colon. Move the ascending colon and the duodenum to inner side, by sharp dissection into the space between the Gerota fascia and the fusion fascia of colon. This space is a relatively avascular. The incision scope of the side peritoneum: from fossa iliaca (Fig. 3.20) to the inferior border of liver and the lateral of the inferior vena cava (Fig. 3.21). As for slim-­ shape patients, the adrenal grand or the tumor can be seen easily through the anterior layer of the Gerota fascia.

30

B. Fu et al.

Fig. 3.21  Cut off the side peritoneum up to the inferior border of liver and the lateral of the inferior vena cava

Fig. 3.22  The relationship between the right adrenal tumor, the right renal vein and the vena cava

4. Expose the right adrenal tumor then find and expose the right renal vein below the liver, and IVC (light blue under the endoscope). Right adrenal tumors are mostly located in the outer upper quadrant of the intersection angle between the right renal vein and the IVC (Fig. 3.22). Sharp dissection of the fascia and the adipose tissue on the surface of the tumor, then revealing the ventral surface of the adrenal tumor (Figs. 3.23 and 3.24). 5. Expose the adrenal central vein completely. Dissociate sufficiently between the wall of inferior vena cava and the adrenal grand, mutilate the nutrient vessels of the tumor, until the right adrenal central vein was exposed (Fig.  3.25). Two Hem-o-lok was used for double cross-clamping the proximal part of the adrenal central vein, one Hem-o-lok for clamping

Fig. 3.23  Dissociate the ventral surface of the tumor

Fig. 3.24  Dissociate sufficiently between inferior vena cava and the adrenal grand

Fig. 3.25  Expose the right adrenal central vein

3  Robotic Adrenalectomy

Fig. 3.26  ligate and cut the right adrenal central vein

Fig. 3.27  Dissociate along the surface of the psoas major and dorsal surface of the adrenal gland

the distal end (optional), then mutilate the adrenal central vein (Fig. 3.26). 6. After the medial border of the adrenal grand was dissociated, dissociate along the surface of the psoas major, and dissociate the margo dorsalis of the adrenal grand completely (Fig. 3.27). Next, separate the lower pole of the adrenal on the upper pole of the right kidney (Fig. 3.28). Pick up the lower limb of the tumor, dissociate it upwards gradually, and cut off between the tumor and the normal adrenal grand. Clamp the normal side of the adrenal grand with Hem-o-Lok to reduce bleeding, then remove the tumor completely (Fig. 3.29). 7. Lower the pressure of pneumoperitoneum, to check out if there is hemorrhagic spot. Put the adrenal grand into specimen bag and take out through a certain expanded incision of cannula. Indwell drainage tubes.

31

Fig. 3.28  Separate the lower pole of the adrenal tumor on the upper pole of the kidney

Fig. 3.29  Remove the tumor, clamp the normal side of the adrenal grand by the Hem-o-Lok

5

Precautions

1 . Experienced assistant is important for the robotic surgery. 2. The distance between the cameral hole and arm hole should be more than 8 cm. The assistant hole should be located between the two arm holes with proper distance to reducing the conflict. 3. Tear of the right adrenal vein is a major risk factor for transition to open surgery. During robotic right adrenal gland surgery, close attention must be taken to reveal and control the central vein. The needle holder and the vascular suture should be on prepared for use as possible. 4. The central vein of the left adrenal gland can be easily revealed and treated after exposing the left renal vein. Safe controlling the adrenal vein is a critical step in adrenalectomy for reducing the complication of bleeding.

32

B. Fu et al.

5. The conclusion above of the three separate levels of retroperitoneal laparoscopic adrenalectomy are of guiding significance for robotic adrenalectomy, and understanding the anatomical levels is important for the rapid completion of the operation [1].

6

Postoperative Management

Similar with the laparoscopic adrenal surgery, see Chap. 2 for details. Gastric tubes are normally indwelled before the robot assisted adrenal surgery, and can be removed on the first days after the surgery.

7

Complications and Treatments

The complications of robot assisted adrenal surgery and transabdominal laparoscopic adrenal surgery are similar. Intraoperative and postoperative bleeding are common complications [3].

8

Technical Status

1. Increasing indications The first case of robotic adrenalectomy was reported by Horgan and Vanuno in 2001. After years of development, its safety and feasibility has been confirmed. With the increasing number of cases and the accumulation of experience, robot adrenal surgery has been widely used at home and abroad. Compared with traditional ­laparoscopic surgery, robot adrenal surgery has some advantages. First, the robotic arm automatically eliminates tremor, operates accurately and is easy to perform partial adrenalectomy. Also, the operation is fine, the tumor is less stimulated, and the excision of pheochromocytoma is safer [8]. Second, for huge adrenal tumors, obesity, and other special cases of extra adrenal pheochromocytoma, and need to reserve the adrenal cases, its precise operation and the three-dimensional view provide the incomparable advantages of traditional laparoscopic surgery [9]. Third, the robotic arm is flexible and reduces the chance of open surgery when dealing with complications such as vascular injuries. In addition, the learning curve of robot operating system is obviously shorter than that of traditional laparoscope, which is beneficial to teaching [10]. For the time being, laparoscopic surgery is still the standard treatment for adrenal tumors in our country. Given its unique advantages, robotic adrenal surgery is the main direction for future development. 2. Selection of approaches

The robot adrenal surgery is optional via the abdominal route and also via the retroperitoneal route. In the early phase, abdominal approach was generally chosen for robotic adrenal surgery for the space of abdominal route is larger and better able to avoid fights between mechanical arms. However, in the abdominal approach, the free adrenal gland must be free from surrounding organs, such as the liver, spleen, pancreas, etc. so it is not good for the revelation of adrenal tumors less than 1.5 cm. As a result, in the abdominal approach, adrenal gland tumors larger than 1.5 cm are usually selected for adrenal surgery. Along with the improvement of robot equipment and the development of retroperitoneal robot surgery, there are some reports about adrenal surgery in some retroperitoneal approaches. On the basis of a large number of retroperitoneal laparoscopic adrenalectomy, we performed a retroperitoneal approach to robotic adrenal surgery with familiar access and microscopic anatomy, enabling the appearance of adrenal tumors (Fig. 3.30) and the dissociation and ligation of the central adrenal vein (Fig. 3.31) [11, 12]. Our experience shows that retroperitoneal robotic adrenal surgery is superior to treating adrenal tumors larger than 5 cm, as well as adrenal tumors treated with 2-3 cm. However, due to space limitations, treatment of adrenal tumors larger than 10  cm still has some difficulties. 3. The comparative study of laparoscopic adrenalectomy and robot assisted adrenalectomy (1) Research by Bruhn AM et al. suggests that for appropriate patients, robot assisted adrenal surgery and laparoscopic adrenal surgery have similar outcomes, while robot assisted surgeries can have more delicate operations and a better visual effect [5].

Fig. 3.30  Dissecting the adrenal tumor in the robot assisted retroperitoneal right adrenal surgery

3  Robotic Adrenalectomy

33

References

Fig. 3.31  Mutilating the adrenal central vein in the robot assisted retroperitoneal right adrenal surgery

(2) You JY et  al. had compared robot assisted/laparoscopic adrenal surgery from the same surgeon, the results suggest that robot assisted adrenal surgery is the ideal choice for adrenal surgical diseases, and is one of optional surgeries in addition to traditional laparoscopic adrenal surgery [13]. (3) Brandao LF et  al. had a meta-analysis over 600 cases of adrenal minimally invasive surgeries (including 277 cases of robot assisted adrenal surgery and 323 cases of laparoscopic adrenal surgery), the results suggest that the operation time and the incidence of converse to open surgery between them are similar. However, robot assisted adrenal surgeries have advantages of short period in hospital, less bleeding and fewer postoperative complications, etc [14, 15].

1. Qiu JG. 腹腔镜肾上腺手术应用解剖与手术入路. Chin J Endourol. 2009;3:162–7. 2. Young JA, Chapman WH, Kim VB, et  al. Robotic-assisted adrenalectomy for adrenal incidentaloma: case and review of the technique. Surg Laparosc Endosc Percutan Tech. 2002;12:126–30. 3. Kumar R, Hemal AK, Menon M.  Robotic renal and adrenal surgery: present and future. BJU Int. 2005;96:244–9. 4. Winter JM, Talamini MA, Stanfield CL, et  al. Thirty robotic adrenalectomies: a single institution’s experience. Surg Endosc. 2006;20:119–24. 5. Rogers CG, Blatt AM, Miles GE, et al. Concurrent robotic partial adrenalectomy and extra-adrenal pheochromocytoma resection in a pediatric patient with von Hippel-Lindau disease. J Endourol. 2008;22:1501–3. 6. Shen ZJ, Wang XJ, Xu TY, et al. Current application status of robot-­ assisted laparoscopic adrenalectomy. J Clin Urol. 2015;30:381–4. 7. Shen ZJ, Xia LL, He W, et  al. Da Vinci robot-assisted laparoscopic adrenalectomy for complex adrenal tumor. J Mod Urol. 2014;19:71–4. 8. Park JS, Lee KY, Kim JK, et al. The first laparoscopic resection of extra-adrenal pheochromocytoma using the da Vinci robotic system. J Laparoendosc Adv Surg Tech A. 2009;19:63–5. 9. Bruhn AM, Hyams ES, Stifelman MD. Laparoscopic and robotic assisted adrenal surgery. Minerva Urol Nefrol. 2010;62:305–18. 10. Galvani C, Gorodner MV, Joseph Espat N. Robotic-assisted resection of adrenal aldosteronoma. Ann Surg Oncol. 2011;18:479–81. 11. Agcaoglu O, Aliyev S, Karabulut K, et  al. Robotic versus laparoscopic resection of large adrenal tumors. Ann Surg Oncol. 2012;19:2288–94. 12. You JY, Lee HY, Son GS, et  al. Comparison of robotic adrenalectomy with traditional laparoscopic adrenalectomy with a lateral transperitoneal approach: a single-surgeon experience. Int J Med Robot. 2013;9:345–50. 13. Brandao LF, Autorino R, Zargar H, et  al. Robot-assisted laparoscopic adrenalectomy: step-by-step technique and comparative outcomes. Eur Urol. 2014;66:898–905. 14. Brandao LF, Autorino R, Laydner H, et al. Robotic versus laparoscopic adrenalectomy: a systematic review and meta-analysis. Eur Urol. 2014;65:1154–61. 15. Crisan N, Neiculescu C, Matei DV, et  al. Robotic retroperitoneal approach - a new technique for the upper urinary tract and adrenal gland. Int J Med Robot. 2013;9:492–6.

4

Retroperitoneal Laparoscopic Simple Nephrectomy Songliang Du, Xin Ma, Tao Zheng, and Xu Zhang

1

Introduction

In 1991, Clayman successfully performed the first laparoscopic nephrectomy [1]. Later, Gaur introduced the balloon technique to create retroperitoneal working space and performed nephrectomy through retroperitoneal approach [2]. Up to date, laparoscopic simple nephrectomy for benign disease on non-functioning kidney has become the standard of care. Different from radical nephrectomy, removal of perirenal fat capsule is not required for simple nephrectomy. Otherwise, the remaining surgical steps including pedicle control are similar to radical nephrectomy. Laparoscopic procedure offers significant advantages as compared to open surgery, including less postoperative pain, lower complication rates, shorter hospital stay and faster recovery. Retroperitoneal approach for renal and adrenal surgeries offers direct access to the targeted organs without interference to intraperitoneal organs, Retroperitoneal nephrectomy gained its popularity due to these advantages. Furthermore, retroperitonal nephrectomy compartmentalized contamination within the retroperitoneal space for complicated infection diseases such as tuberculosis, xanthogranulomatous pyelonephritis and severe perirenal infections. Selection between transperitoneal and retroperitoneal approaches mainly depend on the patient’s condition and surgeon’s experience. Laparoscopic nephrectomy can be very challenging in recurrent infected kidney necessitating advanced laparoscopic experience.

S. Du · X. Ma · X. Zhang (*) Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China e-mail: [email protected], [email protected] T. Zheng Department of Urology, Wuhan Fourth Hospital, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

2

Indications and Contraindications

2.1

Indications

Retroperitoneal laparoscopic simple nephrectomy is mainly performed for non-functioning kidney resultant from benign renal disease, with presence of a normal contralateral kidney. The indications include: 1. Chronic inflammatory/infection conditions such as chronic pyelonephritis, tuberculosis and xanthogranulomatous pyelonephritis 2. Obstructive nephropathy 3. Reflux nephropathy 4. Renovascular hypertension 5. Symptomatic congenital or acquired cystic kidney disease (such as autosomal dominant polycystic kidney disease (ADPKD) or maldeveloped polycystic kidney) 6. Large or complex kidney stones causing renal atrophy 7. Post-transplantation hypertension

2.2

Contraindications

Absolute contraindications include patient medical unfit for general anesthesia, uncorrected coagulopathy and acute infectious diseases. Morbid obesity and non-functioning kidney with severe infection are relative contraindications.

3

 reoperative Evaluations and Patient P Preparation

3.1

Preoperative Evaluations

Preoperative evaluation includes full history, physical examination, electrocardiogram, chest X-ray, laboratory tests and imaging examinations.

© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 X. Zhang (ed.), Laparoscopic and Robotic Surgery in Urology, https://doi.org/10.1007/978-981-13-3738-3_4

35

36

S. Du et al.

Laboratory tests include full blood count, renal profile, liver function test, coagulation profile, serum blood glucose, blood cross match and, urine FEME. Urine culture and sensitivity is required for infectious cases. Imaging examinations consist of kidney ultrasound, intravenous urography (IVU), renal nuclear scan, and computed tomography (CT). CT renal 4 phases is essential to evaluate both the affected and contralateral kidney, to provide information regarding morphology of kidney, vasculature anatomy, surrounding organs, presence of stones or inflammation. For patients with suspected tuberculosis, investigations can be sent to assist diagnosis include erythrocyte sedimentation rate (ESR), Mantoux tuberculin skin test (PPD test), morning urine sample for Zeihl-Neelsen staining, Urine PCR and biopsy of lesions within the urinary tract. Nephrectomy for renal tuberculosis is recommended at least 3-weeks after initiation of anti-Tubeculosis treatment and normalization of ESR. Nephrostomy drainage prior to surgery is advisable for pyonephrosis or infected hydronephrosis to prevent perioperative sepsis. Patient should be treated with antibiotic according to sensitivity preoperatively.

3.2

Patient Preparation

Informed consent should be obtained with a discussion of possible complications. Patients must be consented for conversion to open surgery. Anticoagulant medications must be discontinued in advance to surgery. Patient is fasted for 6 h before surgery. Bowel preparation is not necessary for retroperitoneal surgery. Prophylactic antibiotics are administered during induction of general aneasthesia. IV Cefazolin 1  g usually provides adequate coverage in non-allergic patient. Pneumatic compression stockings are applied preoperatively for deep vein thrombosis prevention.

4

Step-by-Step Operative Technique (Left Nephrectomy for Renal Tuberculosis)

4.1

Anesthesia and Patient Positioning

approach for adrenal gland and upper urinary tract laparoscopic surgery.

4.3

Mobilization of Retroperitoneal Adipose Tissue

The retroperitoneal adipose tissue is mobilized from the indentation, which is the meeting of peritoneal reflection and psoas muscle superiorly to iliac fossa inferiorly; from peritoneal reflection medially to psoas muscle laterally. The dissected adipose tissue can be placed into the iliac fossa to avoid interruption to subsequent surgery. This topic is described in detail in Chap. 1: Establishment of retroperitoneal approach for adrenal gland and upper urinary tract laparoscopic surgery.

4.4

 ongitudinal Incision of Gerota’s Fascia L and Perirenal Fat

The Gerota’s fascia (Fig. 4.1) and adipose capsule of the kidney (Fig.  4.2) are longitudinally incised, just posterior to peritoneal refection.

4.5

Mobilization of the Kidney

The kidney is mobilized from perirenal adipose tissue along the kidney surface with combination of sharp and blunt ­dissection. White and loose areolar tissue and vertical septa are landmarks for correct dissection plane. Kidney dissection is started at anterior surface (Fig. 4.3), followed by posterior surface with exposure of renal pedicle (Figs.  4.4 and 4.5). Subsequently lower pole is dissected, ureter will be exposed and transected, and finally upper pole dissection is performed.

Anesthesia and patient positioning are described in Chap. 1: Establishment of retroperitoneal approach for adrenal gland and upper urinary tract laparoscopic surgery.

4.2

Creation of Retroperitoneal Working Space and Trocar Placement

Creation of retroperitoneal working space and trocar placement is described in Chap. 1: Establishment of retroperitoneal

Fig. 4.1  Longitudinal incision of Gerota’s fascia (GF Gerota’s fascia)

4  Retroperitoneal Laparoscopic Simple Nephrectomy

37

Fig. 4.2  Longitudinal incision of adipose capsule (K kidney, AC adipose capsule)

Fig. 4.5  Dissection at the posterior surface of the kidney (upper pole)

Fig. 4.3  Dissection at anterior surface of the kidney (K kidney)

Fig. 4.6  The renal artery is clipped by Hem-o-lok (RA renal artery)

4.6

Fig. 4.4  Dissection at the posterior surface of the kidney (lower pole) (K kidney)

Control of the Renal Pedicle

After posterior surface dissection, the kidney is retracted anteriorly. The renal artery is localized based on the sharp and well-defined pulsation. Perihilar adipose tissue is carefully dissected with suction apparatus and harmonic scalpel. Sufficient length of renal artery needs to be skeletonized for ligation. The renal artery is clipped with three Hem-o-lok clips; two clips are placed at the vascular stump, one clip are placed at the kidney side, then divided (Fig. 4.6). The renal vein is exposed anterior to the renal artery and skeletonized. Renal vein is clipped and transected in similar manner as renal artery (Fig. 4.7). A distended renal vein is better to be transected with Endo-GIA (Fig. 4.8).

38

S. Du et al.

Fig. 4.7  The renal vein is clipped by Hem-o-lok (RA renal artery, RV renal vein)

Fig. 4.9  Ureter is clipped by Hem-o-lok (U ureter)

tube is inserted via camera trocar incision, skin incisions are sutured.

5

Postoperative Management

The urinary catheter and gastric tube are removed after patient regains full consciousness. Antibiotic is continued postoperatively. Anti-tuberculosis treatment is continued according to the plan of infective disease physician. Drainage tube can be removed when drainage is minimal.

Fig. 4.8  Endo-GIA stapler is applied to simultaneously ligate and transect the renal vessels (RA renal artery, RV renal vein)

4.7

Transection of the Ureter

Ureter will be exposed during mobilization of lower pole. Ureter is skeletonized, clipped with Hem-o-lok clips, and divided (Fig.  4.9). Ureter is clipped at both ends for renal tuberculosis to prevent the leakage of infected urine.

4.8

I nspection of Hemostasis and Kidney Extraction

The pneumoperitoneum pressure is lowered to 3–5 mmHg, operative field is inspected for active bleeding. Hemostasis is secured with bipolar coagulation, metal clips or Hem-olok clips. Specimen is extracted through extended the skin incision of first trocar within a specimen bag. Drainage

6

Complications and Management

6.1

Intraoperative Complications

6.1.1 Vascular Injury and Bleeding Major vessels and organs injury are rare, but can result in fatal complication [3]. Superior mesenteric artery is within 1 cm distance from the left renal artery. Twelve cases of the superior mesenteric artery injury during the left nephrectomy had been reported since 1973 [4]. The risk of superior mesenteric artery injury is higher as the dissection of renal pedicle and adrenal gland is more proximal. Aorta injury is rare, surgery need to be converted to open surgery immediately once it happens. The incidence of inferior vena cava injury is low. As the pneumoperitoneal pressure is much higher than the inferior vena cava pressure, bleeding might not obvious to be identified. Minor IVC injury can be repaired with intracorporeal laparoscopic suturing. Conversion to open surgery is advisable if surgeon is inexperienced with laparoscopic suturing or IVC injury is major. Renal vein or its branches injuries can be secured with Metal clips or Hem-o-lok. Conversion to open surgery is recommended when necessary [5, 6].

4  Retroperitoneal Laparoscopic Simple Nephrectomy

6.1.2 Visceral Injury Visceral injuries include liver, spleen, pancreas and duodenum, usually occur in cases with severe adhesion. Conversion to open surgery is recommended when necessary. Peritoneum must be closed to ensure compartmentalization of retroperitoneal space especially in infective cases and renal tuberculosis when the peritoneal is breached.

6.2

Postoperative Complications

Postoperative complications include retroperitoneal hematoma or abscess, wound infection, pneumothorax and incisional hernia, requiring timely detection and symptomatic treatment. Collection at the surgical site required drainage and antibiotic treatment. Chest tube is inserted to manage pneumothorax, and incision hernia requires surgery repair.

6.3

Prevention and Treatment of Complications

It is critical to identified surrounding structures during dissection to avoid potential vital complications. Dissection of the renal artery. It is advisable to dissection and transect renal artery at its root. Distal dissection of renal artery requires dissection for the branches and may miss some of the branches. Renal hilum needs to be dissected meticulously to avoid bleeding from the small branches. Thermal injury of bowel. Colon and duodenum adhere at the anterior kidney surface. Electrocautery dissection at this area may result in immediate or delayed enteric perforation. Bowel needs to be mobilized sharply with scissor. Transection of the renal vein. Distended renal vein can be transected with stapler device instead of Hem-o-lock. Malfunction of stapler device including failure of closure and triggering is one of the reasons for conversion to open surgery. Surgeon must familiar with the operation of stapler device and ensure appropriate stapler size to be used. If failure of triggering is encountered, another stapler can be introduced proximally to salvage the situation when there is sufficient length for another stapler.

7

Special Considerations

7.1

Selection of Cases

It is advisable for beginner surgeon to gain experience from simple cases at initial stage. Kidney with gross hydronephrosis and recurrent infection is not suitable for beginner surgeon.

39

7.2

The Sequence of Kidney Mobilization

It is easier to mobilize the kidney from the anterior aspect first in view of limited space at the posterior aspect. If the posterior surface is mobilized first, kidney will be pushed and pressed against the peritoneum under air pressure. This will increase the difficulty of anterior dissection and risk of peritoneum and bowel injury. Upper pole dissection should be kept for last, upper pole attachment maintains kidney in a superior retracted position for dissection of other aspects.

7.3

Control of the Renal Pedicle

The renal pedicle control for simple nephrectomy is similar to radical nephrectomy. Renal vein should be remained patent after ligation of renal artery to allow venous return of the residual blood from the kidney, hence kidney will less congested. The renal vein should appear flatten after the ligation of renal artery; if the renal vein remains filling; it indicates that there is still artery supplying the kidney. The ligated renal artery may be just a branch or there is presence of aberrant artery. Since the right renal vein is short, it will be safer to expose and identify the anatomic relationship between the renal vein and inferior vena cava before transection of the renal vein. For the left renal vein, it is crucial to avoid injury to its branches. When dense adhesions around the renal pedicle is encountered, complete skeletonization of the vessels is not necessary, the renal vessels and its surrounding adipose connective tissue can be clipped together with Hem-o-­ lok or transected with stapler.

7.4

Treatment of the Giant Hydronephrosis

Renal pedicles should be dissected and controlled first before decompression and fully mobilization of the kidney. Renal hilum will be difficult to be maintained in tension for dissection in a floppy and mobile kidney. Nevertheless, the kidney can be decompressed first if the hydronephrosis is massive and impedes the retraction and exposure of the renal hilum. The renal artery may be atrophy, thin and transposition in some cases. Renal artery may proliferates into plexiform appearance along the renal pelvis. Attention of detail must be given to these cord-like structures during dissection; these structures need to be ligated to avoid bleeding.

7.5

Management of Infected Nonfunctioning Kidneys

Chronic infection often results in different degree of perirenal fibrosis and adhesion. The plane between the renal

40

S. Du et al.

surface and perirenal fat may still be identified if adhesion is not severe. Dense adhesion should be sharply incised. Blunt dissection of dense adhesion can result in tearing of kidney parenchyma or bleeding from the vessels within the adhesion. The nephrectomy can be preceded as subcapsular nephrectomy when perirenal adhesion is dense and extensive. Adhesions between renal capsule and parenchyma are usually loose as compared to perirenal adhesion. The kidney is mobilized intracapsularly and the perirenal adhesion will be left untreated. Although the excision perirenal fat is not required in simple nephrectomy, kidney can be mobilized together with Gerota’s fascia when dense and extensive perirenal adhesion is encountered. Adhesion of the Gerota’s fascia is usually loose and mobilization along this plane is easier. Renal tuberculosis is usually associated with significant hydronephrosis due to obstruction. The surgical field will be contaminated when the hydronephrotic kidney is accidentally ruptured. Mobilization along the Gerota’s fascia can reduce manipulation of the kidney, hence risk of kidney injury. There will be dense adhesion, fibrous cord and enlarge lymph node around the renal hilum in kidney with recurrent infection and tuberculosis, resulting in difficult dissection and identification of renal vessels. Thick fiber cord around the renal hilum that cannot be excluded as blood vessels should be clipped with Hem-o-lok and transected to prevent bleeding. The fibrotic renal pedicle is carefully dissected until the thickness that can be clamped by staple device; skeletonization of renal vessels should not be performed to avoid injury to renal vessels. Conversion to open surgery is recommended to ensure safe operation for cases with dense adhesions that are enormously difficult for dissection.

7.6

Management of Atrophic Kidneys

The blood supply to the atrophic kidney is usually subtle, the renal artery is atrophy and thin. Renal vessels proliferate to small branches, which are difficult to be identified. Preoperative computed tomography angiography (CTA) can be performed for assessment of the vasculature anatomy.

If renal pedicles are difficult to be identified intraoperatively, the upper and lower pole of kidney are mobilized first, before dissection of renal hilum. Renal hilum can be localized through extending the upper and lower pole dissection along the medial aspect. In another approach, the lower pole is mobilized to expose the ureter and IVC. Ureter and IVC will be dissected proximally to localize the renal hilum.

7.7

 anagement of Combined Renal M Disease with Ureteral Lesions

It is important to ensure the status of ureter before simple nephrectomy. The ureter should be excised if presence of concurrent ureteral lesion. During the surgery, ureter will be mobilized and ligated as distal as possible. Ureteral stones should be cleared to avoid residual infection. Mobilization of ureter in renal tuberculosis is challenging because the ureter is thickening and stiff. Adipose and fibrous tissues around the ureter are dissected as much as possible to reduce thickness of ureter. The thickened ureteral wall which containing focus of residual tuberculosis should be completely excised. Lower abdomen incision may be required for excision of distal ureter.

References 1. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrectomy: initial case report. J Urol. 1991;146(2):278–82. 2. Gaur DD, Agarwal DK, Purohit KC. Retroperitoneal laparoscopic nephrectomy: initial case report. J Urol. 1993;149(1):103–5. 3. Siqueira TM Jr, Kuo RL, Gardner TA, et al. Major complications in 213 laparoscopic nephrectomy cases: the Indianapolis experience. J Urol. 2002;168(4 Pt 1):1361–5. 4. Nevoux P, Zini L, Villers A, et  al. Celiac axis and superior mesenteric artery: danger zone for left nephrectomy. J Endourol. 2008;22(11):2571–4. 5. Gill IS, Kavoussi LR, Clayman RV, et al. Complications of laparoscopic nephrectomy in 185 patients: a multi-institutional review. J Urol. 1995;154(2. Pt 1):479–83. 6. Simon SD, Castle EP, Ferrigni RG, et  al. Complications of laparoscopic nephrectomy: the Mayo clinic experience. J Urol. 2004;171(4):1447–50.

5

Retroperitoneal Laparoscopic Radical Nephrectomy Chao Wang, Hongzhao Li, Baojun Wang, and Xu Zhang

1

1

Introduction

Laparoscopic renal surgery has emerged as an equally efficacious with minimally morbidity alternative to open radical nephrectomy for selected kidney tumors [1, 2]. Classical radical nephrectomy as described by Robson [3] consists of several principles; the most fundamental principle is en-bloc dissection of the tumorous kidney outside the renal fascia. Laparoscopic radical nephrectomy (LRN) aims to replicate established open surgical procedures using the transperitoneal or retroperitoneal approach. In comparison to the transperitoneal approach, the retroperitoneal approach allows the surgeon to achieve rapid and straightforward access to the renal hilum. Approach for retroperitoneal laparoscopic radical nephrectomy (RRN) is not standardized; it is performed according to center and surgeon preference. Intimate knowledge of the renal anatomy as well as the surrounding retroperitoneal structures is required in order to safely and effectively dissects along the proper surgical planes. The retroperitoneum lies between the posterior parietal peritoneum anteriorly and the transversalis fascia posteriorly. Since Gerota described the fascia layer around the kidney in 1895, anatomists and radiologists had studied this fascia for many years. Currently, Meyers and other authors in a series of articles [4–7] proposed the generally accepted viewpoints. There are at least three fasciae structures presented around the kidney: the anterior renal fascia (Gerotas fascia), the posterior renal fascia (Zuckerkandl fascia), and the lateroconal fascia. The retroperitoneum is divided into three distinct compartments by perirenal fascia (Fig. 5.1). The anterior pararenal space is located between the parietal peritoneum and the C. Wang Department of Urology, The First People’s Hospital of Jining, Jining, China

3

2

4

5 10

kidney 6

7 9

8

Fig. 5.1  Cross-section of kidney and perirenal fascial structures at the level of the renal pedicle (schematic diagram). The green arrow and dotted lines demonstrated the area of incision for the lateroconal fascia, and the anterior dissection in the anterior perirenal space. The blue arrow and dotted lines indicated the posterior plane of dissection in the anterior psoas space. (1) Pararenal fat. (2) Lateroconal fascia. (3) Parietal peritoneum. (4) Transversalis fascia. (5) Fusion fascia. (6) Anterior renal fascia. (7) Outer layer of the posterior renal fascia. (8) Inner layer of the posterior renal fascia. (9) Quadratus lumborum muscle. (10) Psoas major muscle. The outer layer of the posterior renal fascia was fused with the fasciae of the quadratus lumboru muscle and psoas muscles

H. Li · B. Wang · X. Zhang (*) Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China e-mail: [email protected], [email protected] © Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 X. Zhang (ed.), Laparoscopic and Robotic Surgery in Urology, https://doi.org/10.1007/978-981-13-3738-3_5

41

42

C. Wang et al.

anterior renal fascia. Superiorly it extends to the dome of the diaphragm, inferiorly it communicates with the pelvis. The perirenal space is located between the anterior and posterior renal fasciae. The posterior pararenal space is located between the posterior renal fascia and the transversalis fascia containing only fat. It extends toward the pelvic cavity inferiorly but is limited medially by fusion of the posterior renal fascia with the fascia of the quadratus lumborum and psoas muscles. Accurate anatomical recognition of the perirenal space and the fascia enveloping the kidney are the keys to perform radical nephrectomy.

cose, urine FEME, blood cross-matched electrocardiogram, chest radiograph 3. Special imaging examination: 4 phase contrasted computed tomography (CT) urogram (assessing the tumor size and location, local and regional extension), CT angiography or MRA(defining and quantifying the possible vascular invasion and aberrant vessels), nuclear medicine renal scan or bone scan (if indicated), 3D computed tomography reconstruction imaging

2

Informed consent should be obtained together with a discussion of possible complications. Patients must be consented for conversion to open surgery. Anticoagulant medications must be discontinued before surgery. The patient must fast starting at midnight on the night before surgery. Bowel preparation is optional. Prophylactic antibiotics are administered during induction of general aneasthesia. IV Cefazolin 1  g usually provides adequate coverage in non-allergic patient. Pneumatic compression stockings are applied preoperatively for deep vein thrombosis prevention. Foley catheter is routinely used while nasogastric tube is optional.

Indications and Contraindications

The indications for retroperitoneal laparoscopic radical nephrectomy are similar to the indications for open radical nephrectomy. RRN can be expended to more challenging cases after gaining more experience. Indications for RRN are as below: 1. Organ-confined T1-T2 malignant renal tumors, not amenable to a partial nephrectomy 2. T3a and even T3b renal tumors, depending on the surgeon’s expertise 3. Upper tract urothelial carcinoma, requiring removal of the ipilateral ureter and ureteral orifice The usual contraindications for RRN: 1 . Patient with uncorrected coagulopathy 2. Patient who are medically unfit for general anesthesia. 3. Patient with past history of retroperitoneal lumbar surgery Excessively large tumor size, and locally advanced renal cell carcinomas that has invaded adjacent structures or to the inferior vena cava thrombus are relative contraindications, depending on the surgeon’s experience and the characteristics of the individual tumor.

3

 reoperative Evaluation and Patient P Preparation

3.1

Preoperative Evaluation

The preoperative evaluations for retroperitoneal laparoscopic radical nephrectomy are same as an open procedure: 1 . History taking and physical examination 2. Basic laboratory studies: full blood count, coagulation profile, liver function test, renal profile, fasting blood glu-

3.2

4

Patient Preparation

Step-by-Step Operative Technique

Based on anatomical features of the renal area, we summarized the entire surgical procedure to be carried out along “two spaces” and “two poles”. Anterior dissection of the kidney is performed within the anterior pararenal space involving mobilization of anterior renal fascia from fusion fascia. Posterior dissection is performed within the anterior psoas space (part of the posterior pararenal space; Fig.  5.1). The superior dissection is performed up to the subdiaphragmatic level and the distal dissection is performed until the iliac fossa. Tissue dissection and hemostasis from small vessels were achieved using a harmonic scalpel (Ethicon Endo-­ Surgery, Johnson and Johnson, Cincinnati, OH, USA). Patient positioning and trocar placement are described Chap. 1: Establishment of retroperitoneal approach for laparoscopic adrenal gland and upper urinary tract surgery. We prefer the retroperitoneal approach with the three-port technique as previously described (see Sect. 1: Chap. 1) (Fig. 5.2). A 2-cm skin incision is made under the 12th rib on the posterior axillary line anterior to the sacrospinal muscle. The muscular layer and lumbodorsal fascia were bluntly divided with a long hemostatic forcep. Index finger is inserted into the retroperitoneal space (posterior pararenal space), and bluntly dissects the adipose tissue from superior to inferior and from posterior to anterior, at same time pushes the peritoneum anteriorly. The space is subsequently

5  Retroperitoneal Laparoscopic Radical Nephrectomy

expanded with a balloon expander (Fig. 5.3). Six hundered to eight hundred milliliters of air is insufflated into the balloon for an average-sized adult. Subsequent insertion of trocars will be guided by index finger from the retroperitoneal space. A 10  mm camera trocar (Trocar B) is inserted two fingers breadths above the iliac crest on midaxillary line; trocar C is inserted at the subcostal margin on anterior axillary line; trocar A is inserted via the initial skin incision and the skin incision is sutured to fix the trocar. Twelve millimeters trocar will be inserted on the side of dominant hand. Pneumoretroperitoneum is created by CO2 insufflation via camera trocar (pressure range, 10–12 mmHg). Surgeon operates at the backside of the patient (using Trocar A and C).

43

The assistant (camera operator) works at the abdominal side (using Trocar B).

4.1

Mobilization of Retroperitoneal Adipose Tissue and Exposure of the Deeper Fascial Structures

Retroperitoneal adispose tissue is mobilized from the infraphrenic fossa superiorly to iliac fossa inferiorly, from peritoneal reflection anteriorly to psoas major posteriorly. The lateral conical fascia is exposed (Fig. 5.4) and is subsequently longitudinally incised posterior to the retroperitoneal fold (Fig. 5.5).

Fig. 5.2  Trocars configuration for left retroperitoneal laparoscopic nephrectomy Fig. 5.4  The lateral conical fascia is exposed Fig. 5.3  Home-made balloon expander

44

C. Wang et al.

Fig. 5.5  The lateral conical fascia longitudinally incised posterior to the retroperitoneal fold

Fig.5.7  A cave-like gap is created in anterior pararenal space

Fig. 5.6  Anterior pararenal space is exposed

Fig. 5.8  Dissection is performed in the dorsal side of the posterior renal fascia and the psoas major is exposed (PM psoas major)

4.2

 nterior Dissection of the Kidney and A Entering the Anterior Pararenal Space

Different from the usual RRN procedure where posterior dissection is the first step in kidney mobilization [8, 9], we prefer to dissect anterior plane first. Dissection is progressed meticulously between the fusion fascia (the fascia posterior to mesocolon) and the anterior renal fascia on the inferomedial pole of the kidney, entering the first avascular plane (anterior pararenal space) (Fig. 5.6). The white loose areolar tissue is identified as the landmarks for the correct avascular plane [10]. This dissection is complete until a cave-like gap is created (we named this created space as “bird’s nest”; Fig. 5.7).

4.3

 osterior Dissection of the Kidney: P Entering the Anterior Psoas Space (Part of the Posterior Pararenal Space)

Dissection is performed outside the fascia between the posterior renal fascia and the psoas major. As the renal fascia fused with the quadratus lumborum fascia, these two fascias are always dissected together to expose the muscle fibers of deeper psoas (Fig.  5.8). This plane is extended superiorly to the diaphragm and inferiorly to the iliac fossa. The inferior vena cava will be interior to the psoas major (Fig. 5.9).

5  Retroperitoneal Laparoscopic Radical Nephrectomy

45

Fig. 5.9  The inferior vena cava will be interior to the psoas major (IVC Inferior vena cava)

Fig. 5.10  Dissection is performed on the dorsal kidney along the psoas major extended up to infraphrenic space (PM psoas major)

4.4

Fig. 5.11  Dissection is performed on the dorsal kidney along the psoas major extended down to iliac fossa (PM Psoas major)

Exposure of the Renal Hilum

Dissection is performed on the dorsal kidney along the psoas major with the extend from the infraphrenic space to the iliac fossa (Figs. 5.10 and 5.11). The kidney is retracted ventrally, renal vessels can be identified based on the characteristic of the pulsations. Sharp, well-defined pulsations reveal the location of fat-covered arteries (Fig. 5.12). Right angle forceps is applied to expose the renal hilum (Fig. 5.13). Hem-o-­ Lok is used in clipping the renal artery (Fig.  5.14). The inferior vena cava and renal vein can be observed after ligating renal artery (Fig. 5.15). The renal vein is subsequently clipped and transected with two Hem-o-lok clips at the vascular stump and one at the renal side (Fig. 5.16). An engorged renal vein after ligation of artery indicates that there is still artery supplying the kidney. The ligated renal artery may be Fig. 5.12  Anatomy recognition in renal hilum (RH renal hilum, MAL just a branch or there is presence of aberrant artery that medial arcuate ligament, IVC inferior vena cava)

46

Fig. 5.13  Right angle forceps is applied to expose the renal hilum (RA renal artery)

C. Wang et al.

Fig. 5.16  The renal vein is subsequently clipped and transected with two Hem-o-lok clips at the vascular stump and one at the renal side (RV renal vein)

Fig. 5.14  Right renal artery is clipped Fig. 5.17  The anterior pararenal space is continuously extended (P peritoneum)

which needs to be identified. The gonadal, lumbar, adrenal veins can be mobilized and secured with clips separately, especially for left-sided nephrectomy.

4.5

Fig. 5.15  The inferior vena cava and renal vein can be observed after ligating renal artery (RV renal vein, IVC inferior vena cava)

Redirection Towards the Previous Dissected Anterior Space

Continuous expand the space of the previously dissected cave-like gap (bird nest) (Fig. 5.17). Ultimately, the anterior space and the posterior space are extended until they join together superiorly just below the diaphragm, and inferiorly at the iliac fossa.

5  Retroperitoneal Laparoscopic Radical Nephrectomy

47

Fig. 5.18  Expand the space of the lower pole of ventral side of kidney (LPK lower pole of kidney, D duodenum)

Fig. 5.20  The ureter and gonadal vein are mobilized and clipped (D duodenum)

Fig. 5.19  The ureter and gonadal vein are covered by renal fascia and the remnant of the lower poles

Fig. 5.21  The plane of dissection is between the upper pole of kidney and the adrenal gland (AG adrenal gland)

4.6

 obilization of the Upper and Lower M Poles of the Kidney

Expand the space of the lower pole of ventral side of kidney (Fig. 5.18). The ureter and gonadal vein are covered by renal fascia and the remnant of the lower poles (Fig. 5.19). They are mobilized, clipped and divided (Fig.  5.20). If adrenal gland is to be preserved, the plane of dissection is between the upper pole of kidney and the adrenal gland (Figs. 5.21 and 5.22).

4.7

Specimen Entrapment and Extraction

The specimen is excised en bloc covered by renal fascia (Fig.  5.23) and manually extracted intact in an EndoCatch

Fig. 5.22  The adrenal gland is preserved

48

C. Wang et al.

with insufflation-related complications including subcutaneous emphysema and gas embolism. Diaphragm injury is rare, surgeon need alert aware about it to avoid pneumothorax. Precise knowledge of the renal anatomy and surrounding retroperitoneal structures, meticulous dissection are important to prevent these complications.

6.1

Fig. 5.23  The specimen is en bloc excised (PM psoas major, K kidney)

entrapment sac (US.  Surgical, Norwalk, CT, USA). The specimen was extracted via extended skin incision between the second and the third trocar site to 5–7 cm (Trocar A and B, depending on the tumor size). After removal of the specimen, the pressure of the retroperitoneum is reduced to 5 mmHg to check for possible bleeding. Once hemostasis is secured, a drain tube is inserted via the second trocar (camera trocar), and the surgical incision is closed with 2/0 polyglycolic acid sutures.

5

Postoperative Management

Patient can be allowed for oral intake generally 1 day after surgery, started with clear fluids and stepped up as tolerated. Indeed, most patients do not have active bowel movement and flatus until postoperative day 2 or 3. Parenteral antibiotic is continued postoperatively. The Foley catheter is usually removed day after the surgery, and the drain is removed once the drainage is minimal. Patient is encouraged for mobilization day one post-operatively. Mean duration of hospital stay (including the day before the surgery and the day of the nephrectomy) is 5–7  days. Patients can gradually resume normal activities after hospital discharge, vigorous activities are limited for at least 1 month after surgery.

6

Complications and Management

Common complications of retroperitoneal laparoscopic radical nephrectomy are similar to those associated with open surgery, including injury to adjacent organs, bleeding, infection. In addition, laparoscopic nephrectomy is associated

Peritoneum Injury

The most common intraoperative minor complication is peritoneum injury. In our experiences, peritoneum injury will not cause significant problems, and the procedure can still be completed with retroperitoneum approach. If the peritoneal injury is small, pneumoperitonium pressure is decreased and injury is occluded with the Hem-o-lok. When operative exposure is compromised, especially in obese patients, an additional 5-mm trocar can be inserted into the abdominal cavity to drain the CO2.

6.2

Bleeding

Bleeding may occur during the dissection of the renal hilum or renal mobilization. The vascular injuries are generally due to venous bleeding. These injuries may involve the main renal vein and its tributaries, (especially on the left side), the vena cava, inferior phrenic vessels, occasionally the aberrant vessels. Bleeding from the small vessels can usually be controlled it by bipolar coagulation. Otherwise, when the bleeding is troublesome, pneumoperitoneum pressure can be increased to 15–25  mmHg to provide tamponade effect. Subsequently, bleeders can be identified by using suction apparatus and guaze, and secured with clips or sutures. Bleeding from the renal hilum may need to controlled with stapler device. The surgeon should decide promptly for conversion to open procedure, once the bleeding is anticipated cannot be controlled.

6.3

Injuries of the Adjacent Organs

After ligation of renal pedicles, the kidney is sequentially mobilized using blunt and sharp dissection. We usually prefer to dissect the anterior aspect first. If dense adhesion or bleeding is encountered, dissection need to be performed in great care to avoid injury to the adjacent organs. On the right side, the duodenum, right colon and liver are the adjacent organ; whereas on the left side, the spleen, the left colon, and the tail of the pancreas are the adjacent organ. Electrocautery should not be used near to the peritoneum, to avoid potential thermal injury to intra-abdominal viscera.

5  Retroperitoneal Laparoscopic Radical Nephrectomy

7

Special Considerations

7.1

Kidney Mobilization

49

7.2

Concomitant Adrenalectomy

Adrenalectomy as part of radical nephrectomy is one of the most controversial areas in urooncology. Up to today, there is The general principle of surgical oncology is to excise the no universal accepted recommendation. The decision to perentire tumor with an adequate surgical margin. In radical form simultaneous adrenalectomy is individualized based on nephrectomy, the basic surgical oncological principle is en-­ radiological and intraoperative findings [16]. In our practice, bloc resection of the diseased kidney at the renal fasciae, concomitant adrenalectomy is recommended if any abnorincluding perinephric fat and ipsilateral adrenal fat3 achieve mity of the adrenal gland has been found on preoperative CT a better oncological outcome. scan. In additional, an upper pole or large tumor invading the In 1993, Gaur [11] reported the first retroperitoneal lap- adrenal gland mandates adrenalectomy. aroscopic nephrectomy. Since then, several techniques for retroperitoneal laparoscopic radical nephrectomy had been described [12–15]. These techniques involved renal fascia 7.3 Specimen Extraction: Intact or Morcellation incision at renal hilum near the parietal peritoneum reflexion, perirenal fat was exposed and part of the renal fascia was left over; which did not apply to the principle of radi- In earlier studies, most surgeons and medical institutions cal nephrectomy. Based on laparoscopic anatomical stud- advocated morcellation of the specimen in a specimen “bag” ies, we observed two potential relatively bloodless planes to minimize the risk of tumor cell spillage and seeding. external to the renal fascia; which were the plane between Recently the most author preferred intact specimen extracthe fusion fascia and the anterior renal fascia at the anterior tion as it allows precise pathologic staging [17–19]. aspect and the plane between the posterior renal fascia and the lumbar muscles at the posterior aspect. Posterior renal fascia was fused with the fascia of the quadratus lumborum 7.4 Lumbar Tributaries of the Left Renal Vein (Fig. 5.24) and psoas muscles and would be dissected together as one fascia. Identification of the correct anterior and posterior ana- Injury to the posterior lumbar tributaries of the left renal tomical planes at the renal fascia is the main factor for a good vein may result in significant complications [20–22]. The radical nephrectomy. Recognition of the lateroconal fascia lumbar tributaries of the left renal vein are variably sized, and peritoneum reflexion is crucial for anterior dissection. thin walled vessels that usually enter the left renal vein from We proposed incision of lateroconal fascia near the perito- a posterior location [23]. Lewis et al. [24] found that posteneum reflexion and dissection between the fusion fascia and rior lumbar tributaries have the most intra-individual variathe anterior renal fascia until creation of a cave-like space. tion, they stated that these vessels are “the most difficult to This technique complies to the oncological principle of min- display and control at laparoscopic donor nephrectomy.” imum manipulation of a tumorous kidney. Subsequently, Thus understanding the detail anatomy of the posterior lummobilization the dorsal side of the kidney and dissection the bar tributaries will help the surgeon (especially the novice) renal pedicle are performed. This technique offers a distinct to avoid the potential risk of vascular injuries during renal advantage. If posterior aspect is dissected first, the entire kid- surgery. ney would be pressed and pushed anteriorly under air pressure, resulting tight adherence of the anterior renal fascia to the peritoneal and a higher risk of peritoneal injury. In our 8 Future Perspectives experience, this complication can occur even with an experience surgeon. Since retroperitoneal laparoscopic radical nephrectomy was Some authors routinely incise the renal fascia near the first introduced to the urological community in the early psoas muscles during posterior dissection. We do not carry 1990s, this operation had constantly evolved. With the growout this conventional practice as we mobilize the kidney at ing of surgeon expertise and emerging of new instrumentathe posterior renal fascia. In view of the posterior renal fas- tion, laparoscopic radical nephrectomy has expended to cia is fused together with the fasciae of the quadratus lum- more challenging cases. Renal tumour with renal vein and borum and psoas muscles, these fasciae ware always subhepatic inferior vena caval tumor thrombus be managed dissected together, without incising the renal fascia. There laparoscopically [25–29]. The da Vinci Surgical System that was no negative impact on the lumbar muscles from our is equipped with 3D vision and dexterous “EndoWrists”, experience. enable nephrectomy for advance tumour with IVC tumor

50

C. Wang et al.

Fig. 5.24  Lumbar tributaries of the left renal vein (LRA left renal artery, LRV left renal vein, AZV reno-hemi-azygo-lumbar trunk, ALV left ascending lumbar vein, GV gonadal vein, LV lumbar vein, IVC inferior vena cava, A aorta, LK left kidney, U ureter)

thrombus can be performed this procedure can be performed easily and safely, especially for the patients with vena caval tumor thrombus [30–32]. We believe that Robotic-assisted approach will become the new standard treatment for challenging renal cell carcinoma in the future.

References 1. Ono Y, Hattori R, Gotoh M, et  al. Laparoscopic radical nephrectomy for renal cell carcinoma: the standard of care already? Curr Opin Urol. 2005;15(2):75–8. 2. Saranchuk JW, Savage SJ. Laparoscopic radical nephrectomy: current status. BJU Int. 2005;95(Suppl 2):21–6. 3. Robson CJ, Churchill BM, Anderson W.  The results of radical nephrectomy for renal cell carcinoma. J Urol. 1969;101(3):297–301. 4. Meyers MA, Whalen JP, Peelle K, et  al. Radiologic features of extraperitoneal effusions. An anatomic approach. Radiology. 1972;104(2):249–57. 5. Raptopoulos V, Kleinman PK, Marks S Jr, et al. Renal fascial pathway: posterior extension of pancreatic effusions within the anterior pararenal space. Radiology. 1986;158(2):367–74. 6. Marks SC Jr, Raptopoulos V, Kleinman P, et  al. The anatomical basis for retrorenal extensions of pancreatic effusions: the role of the renal fasciae. Surg Radiol Anat. 1986;8(2):89–97. 7. Chesbrough RM, Burkhard TK, Martinez AJ, et  al. Gerota versus Zuckerkandl: the renal fascia revisited. Radiology. 1989;173(3):845–6. 8. Gill IS, Schweizer D, Hobart MG, et  al. Retroperitoneal laparoscopic radical nephrectomy: the Cleveland clinic experience. J Urol. 2000;163(6):1665–70. 9. Rassweiler JJ, Seemann O, Frede T, et  al. Retroperitoneoscopy: experience with 200 cases. J Urol. 1998;160(4):1265–9. 10. Zhang X, Fu B, Lang B, et  al. Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases. J Urol. 2007;177(4):1254–7. 11. Gaur DD, Agarwal DK, Purohit KC. Retroperitoneal laparoscopic nephrectomy: initial case report. J Urol. 1993;149(1):103–5. 12. Gill IS, Rassweiler JJ.  Retroperitoneoscopic renal surgery: our approach. Urology. 1999;54(4):734–8.

13. Hsu TH, Sung GT, Gill IS.  Retroperitoneoscopic approach to nephrectomy. J Endourol. 1999;13(10):713–8; discussion 718–20. Review 14. Larre S, Kanso C, De La Taille A, et  al. Retroperitoneal laparoscopic radical nephrectomy: intermediate oncological results. World J Urol. 2008;26(6):611–5. 15. Cicco A, Salomon L, Hoznek A, et  al. Results of retroperitoneal laparoscopic radical nephrectomy. J Endourol. 2001;15(4):355–9; discussion 375–6 16. O’Malley RL, Godoy G, Kanofsky JA, et al. The necessity of adrenalectomy at the time of radical nephrectomy: a systematic review. J Urol. 2009;181(5):2009–17. 17. Gill IS.  Laparoscopic radical nephrectomy for cancer. Urol Clin North Am. 2000;27(4):707–19. 18. Gettman MT, Napper C, Corwin TS, Cadeddu JA.  Laparoscopic radical nephrectomy: prospective assessment of impact of intact versus fragmented specimen removal on postoperative quality of life. J Endourol. 2002;16(1):23–6. 19. Savage SJ, Gill IS. Intact specimen extraction during renal laparoscopy: muscle-splitting versus muscle-cutting incision. J Endourol. 2001;15(2):165–9. 20. Leventhal JR, Deeik RK, Joehl RJ, et al. Laparoscopic live donor nephrectomy—is it safe? Transplantation. 2000;70(4):602–6. 21. Martay K, Dembo G, Vater Y, et al. Unexpected surgical difficulties leading to hemorrhage and gas embolus during laparoscopic donor nephrectomy: a case report. Can J Anaesth. 2003;50(9):891–4. 22. Leventhal JR, Kocak B, Salvalaggio PR, et al. Laparoscopic donor nephrectomy 1997 to 2003: lessons learned with 500 cases at a single institution. Surgery. 2004;136(4):881–90. 23. Li G, Dong J, Lu JS, et  al. Anatomical variation of the posterior lumbar tributaries of the left renal vein in retroperitoneoscopic left living donor nephrectomy. Int J Urol. 2011;18(7):503–9. 24. Lewis GR, Mulcahy K, Brook NR, et  al. A prospective study of the predictive power of spiral computed tomographic angiography for defining renal vascular anatomy before live-donor nephrectomy. BJU Int. 2004;94(7):1077–81. 25. Wang M, Zhang J, Niu Y, Xing N. Feasibility of pure conventional retroperitoneal laparoscopic radical nephrectomy with level II vena Caval tumor thrombectomy. Urology. 2016;90:101–4. 26. Shao P, Li J, Qin C, et al. Laparoscopic radical nephrectomy and inferior vena cava thrombectomy in the treatment of renal cell carcinoma. Eur Urol. 2015;68(1):115–22.

5  Retroperitoneal Laparoscopic Radical Nephrectomy 27. Bansal RK, Tu HY, Drachenberg D, et al. Laparoscopic management of advanced renal cell carcinoma with renal vein and inferior vena cava thrombus. Urology. 2014;83(4):812–6. 28. Słojewski M, Gołab A, Petrasz P, Sikorski A.  Laparoscopic radical nephrectomy for T3b tumor. J Laparoendosc Adv Surg Tech A. 2010;20(1):47–9. 29. Disanto V, Pansadoro V, Portoghese F, et al. Retroperitoneal laparoscopic radical nephrectomy for renal cell carcinoma with infrahepatic vena caval thrombus. Eur Urol. 2005;47(3):352–6.

51 30. Sun Y, de Castro Abreu AL, Gill IS. Robotic inferior vena cava thrombus surgery: novel strategies. Curr Opin Urol. 2014;24(2):140–7. 31. Abaza R.  Technical considerations in robotic nephrectomy with vena caval tumour thrombectomy. Indian J Urol. 2014;30(3):283–6. 32. Wang B, Li H, Ma X, et  al. Robot-assisted laparoscopic inferior vena cava thrombectomy: different sides require different techniques. Eur Urol. 2016;69(6):1112–9.

6

Robotic Inferior Vena Cava Thrombectomy Baojun Wang, Xin Ma, Hongzhao Li, and Xu Zhang

1

Introduction

Renal cell carcinoma (RCC) has a natural tendency of progression from the kidney along its route of venous drainage, into the inferior vena cava (IVC) in 4–10% of patients. Radical nephrectomy (RN) with tumor thrombectomy is the standard of care for these difficult cases. Even such complex operative procedures were conducted in an open fashion, potential fatal complications caused by bleeding or embolism may occur. Open surgery requires a big abdomen incision associated with slow recovery. With the development of laparoscopy and robotic technology in recent years, several centers had reported successful experience in laparoscopic IVC thrombectomy (IVCT). However, laparoscopic IVCT is extremely challenging and technically demanding, even for experienced laparoscopic surgeons. Surgical robotic equipment has been increasingly used in intricate laparoscopic procedures and might facilitate application of minimally invasive surgical techniques in such challenging surgeries. We performed robotic IVC thrombectomy (R-IVCT) since 2013. Detailed techniques for R-IVCT of different sides (left or right RCC) are compared and described below.

2

Indications and Contraindications

2.1

Indications

1. According to the Mayo classification, level I thrombus (thrombus extending ≤2 cm above the renal vein) 2. Level II thrombus (thrombus extending >2 cm above the renal vein, but below the hepatic veins)

2.2

Contraindications

1 . Patient with uncorrected coagulopathy 2. Patient who are medically unfit for general anesthesia. 3. Level III thrombus is relative contraindication For cases of level III IVC thrombi, robotic techniques need to be explored in future work.

3

Preoperative Preparation

3.1

General Patient Preparation

Preoperative patient preparations are similar as those for transperitoneal robotic surgery, including preoperative skin preparation, bowel preparation, prophylactic antibiotics, etc.

3.2

Special Patient Preparation

1. Low molecular heparin (if indicated), is given to decrease the risk of pulmonary embolism. 2. Preoperative renal artery embolization on the affected side is recommended. Preoperative embolization is helpful in reducing intraoperative bleeding, dissecting IVC and renal vein, extracting tumor thrombus 3. Temporary IVC filter is not recommended due to the risk of thrombogenesis of contralateral renal vein and hepatic vein, which may affect tumor thrombus dissection during the operation. 4. Preoperative color Doppler ultrasound re-examination for IVC is recommended especially for level II–IV thrombus to ensure the latest status of tumor thrombus.

B. Wang · X. Ma · H. Li · X. Zhang (*) Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China e-mail: [email protected], [email protected] © Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 X. Zhang (ed.), Laparoscopic and Robotic Surgery in Urology, https://doi.org/10.1007/978-981-13-3738-3_6

53

54

B. Wang et al.

4

Step-by-Step Operative Technique

4.1

Anesthesia and Patient Position

After general anesthesia and Foley catheter insertion, patient is positioned to 60–70 degree left lateral recumbent position with flank extension supported by gel cushion. Other than respiration and ECG monitoring, blood pressure monitoring via jugular vein and radial artery are required for all cases. Multichannel venous assess should be established, which is helpful for medication and fluid infusion. For right RCC, R-IVCT and RN can be both completed with this position. For the left RCC, R-IVCT can be completed with this position. After R-IVCT, left RN will be performed in 60–70° right lateral decubitus position.

4.2

the abdominal cavity under direct vision. During the operation, the instruments on second and third can be exchange as indicated (Fig. 6.2).

4.2.2 D  issection of Inferior Vena Cava, Left Renal Vein and Right Renal Vein Hepatocolic ligament, hepatorenal ligament are divided (Figs. 6.3 and 6.4). Liver is retracted upward with a needle holder (Fig. 6.5), and the retraction is secured by clamping the needle holder at lateral abdominal wall, for exposure of operating field. Ascending colon is medialized to expose the retroperitoneum space (Fig. 6.6). Duodenum is mobilized until the IVC is fully exposed (Figs.  6.7 and 6.8). Perivascular fascia is dissected to skeletonize the IVC, right renal vein and left renal vein (Figs.  6.9 and 6.10).

 ight Radical Nephrectomy and Inferior R Vena Cava Thrombectomy

4.2.1 Patient Position and Port Placement Establishment of pneumoperitoneum, port placement, and operation of robotic surgical system are almost similar to transperitoneal approach for upper urinary tract robotic which are described in Chap. 1 “Establishment of transperitoneal approach for adrenal gland and upper urinary tract robotic surgery”, with the different of three assistant trocars are inserted (Fig.  6.1). First assistant trocar is inserted at 6 cm above the umbilical for insertion of suction device. The second assistant trocar is inserted at the subumbilical for insertion of Hem-o-lok clips, and the third assistant trocar is placed near the xiphoid under the costal margin for liver retraction. A monopolar curved scissor, bipolar Maryland clamp and Prograsp grasper are inserted as first, second and third arms respectively. All the instruments are inserted in to

Fig. 6.2  Port placement

Fig. 6.1  Patient position and port placement

Fig. 6.3  Hepatocolic ligament is divided (L liver)

6  Robotic Inferior Vena Cava Thrombectomy

55

Fig. 6.4  Hepatorenal ligament is divided (L liver)

Fig. 6.7  Duodenum is mobilized medially (D duodenum)

Fig. 6.5  Liver is retracted upward with a needle holder (L liver, LAW lateral abdominal wall)

Fig. 6.8  IVC exposure (IVC inferior vena cava)

Fig. 6.6  Peritoneum is incised and the retreoperitoneum space is exposed (LP lateral peritoneum)

Fig. 6.9  Right renal vein exposure (IVC inferior vena cava, RRV right renal vein)

56

Fig. 6.10  Left renal vein exposure (IVC inferior vena cava, LRV left renal vein)

Fig. 6.11  The accessory hepatic vein is divided and clipped with Hem-­ o-­loks (L liver, AHV accessory hepatic vein, IVC inferior vena cava)

B. Wang et al.

Fig. 6.12  The left renal vein is isolated (IVC inferior vena cava, LRV left renal vein)

Fig. 6.13  The lumbar veins are divided and then clipped (IVC inferior vena cava, LV lumbar vein)

4.2.3 D  issection of Inferior Vena Cava at the Thrombus Level, Left Renal Vein and Part Lumbar Vein The ventral surface of the IVC is exposed. For level II IVC thrombus, the short hepatic vein, right suprarenal vein are clipped and divided for cross clamping of IVC (Fig. 6.11). The left renal vein was dissected circumferentially at the interaortocaval space (Fig. 6.12). Then dorsal surface of IVC is mobilized, and the affected lumbar vein was clipped and divided (Figs. 6.13 and 6.14). 4.2.4 S  equential Occlusion of Distal IVC, Left Renal Vein, and Proximal IVC IVC proximal and distal to the thrombus and the left renal vein are double looped with vessel loop and secured with Hem-olok clip for surgeon control (Figs.  6.15, 6.16, and 6.17).

Fig. 6.14  Complete exposure of the IVC, left and right renal veins (IVC inferior vena cava, LRV left renal vein, RRV right renal vein)

6  Robotic Inferior Vena Cava Thrombectomy

57

The distal IVC, left renal vein, and proximal IVC were sequentially occluded (Fig. 6.18).

4.2.5 Extraction of Thrombus After the sequential occlusion, the IVC wall is incised, and the thrombus is removed (Figs. 6.19 and 6.20). After irrigation of IVC lumen with heparinized saline, IVC is closed with 5-0 polypropylene suture (Fig.  6.21). Occlusion at proximal IVC, left renal vein, and distal IVC are released in order. Hemostasis is secured. The thrombus is inserted into a specimen bag to avoid tumor dissemination.

Fig. 6.15  The vessel loops were wrapped twice around the cephalic IVC

4.2.6 Right Radical Nephrectomy In the same position, right renal artery is isolated, clipped with Hem-o-lok clips and divided (Fig.  6.22). Right kidney and adrenal gland are mobilized as described in Chap. 5. Right

Fig. 6.16  The vessel loops were wrapped twice around the left renal vein (LRV left renal vein)

Fig. 6.18  The caudal IVC, left renal vein and cephalic IVC were sequentially clamped (IVC inferior vena cava, LRV left renal vein)

Fig. 6.17  The vessel loops were wrapped twice around the proximal IVC (IVC inferior vena cava)

Fig. 6.19  The IVC thrombus is exposed and excised (TT tumor thrombus)

58

B. Wang et al.

renal artery embolization is recommended 1–2 h before operation. In cases which renal artery embolization is not performed, modified technique can be used. Right renal artery is dissected and ligated in the interaortocaval space before IVC clamping. The right kidney is removed together with the IVC thrombus if possible. If they can’t be removed together, the right renal vein will be transected with Endo-­GIA before clamping the IVC.

4.3

Fig. 6.20  The IVC thrombus was completely removed (IVC inferior vena cava)

 eft Radical Nephrectomy and Inferior L Vena Cava Thrombectomy

4.3.1 Patient Position and Port Placement Patient position and trocars placement are the similar as for the right RCC. Left renal artery embolization must be performed 1–2 h before operation. 4.3.2 Dissection of Inferior Vena Cava Hepatocolic ligament and hepatorenal ligament were incised (Fig.  6.23), and the liver is retracted upward (Fig.  6.24). Ascending colon is medialized (Fig. 6.25). Perirenal fascia is dissected (Fig. 6.26), Duodenum is medialized to expose the IVC (Fig. 6.27). 4.3.3 Isolation of Right and Left Renal Vein The right renal vein (Fig. 6.28) and left renal vein (Fig. 6.29) are skeletonized. Left renal vein, including the thrombus were transected with Endo-GIA (Figs. 6.30 and 6.31).

Fig. 6.21  The IVC is closed by a running suture (IVC inferior vena cava)

Fig. 6.22  The right renal artery is clipped with Hem-o-loks and then divided (RRA right renal artery)

4.3.4 D  issection of Right Renal Artery and Inferior Vena Cava at the Thrombus Level Right renal artery is dissected at interaortocaval space (Fig. 6.32). IVC is dissected circumferentially proximal and

Fig. 6.23  Hepatocolic ligament is divided (GB gall bladder, L liver)

6  Robotic Inferior Vena Cava Thrombectomy

59

Fig. 6.24  Liver is retracted upward with a needle holder (L liver)

Fig. 6.27  IVC exposure (IVC inferior vena cava)

Fig. 6.25  Peritoneum is incised and ascending colon is medialized (C colon)

Fig. 6.28  The right renal vein is dissected (RRV right renal vein)

Fig. 6.26  Perirenal fascia is dissected (L liver, IVC inferior vena cava)

Fig. 6.29  The left renal vein is dissected (LRV left renal vein, IVC inferior vena cava)

60

B. Wang et al.

Fig. 6.30  The left renal vein is transected with Endo-GIA stapler (LRV left renal vein)

Fig. 6.33  Cephalic IVC is dissected circumferentially (IVC inferior vena cava)

Fig. 6.31  The left renal vein is divided (LRV left renal vein, IVC inferior vena cava)

Fig. 6.34  The vessel loops were wrapped twice around the IVC (IVC inferior vena cava)

distal to the thrombus level, and double looped with vessel loops. The vessel loops, are secured with Hem-o-Locks for surgeon control (Figs. 6.33, 6.34, and 6.35). The ventral surface of the IVC is exposed. For level II IVC thrombus, the short hepatic vein, right suprarenal vein are clipped and divided for cross clamping of IVC (Fig. 6.36). Then dorsal surface of IVC is mobilized, and the affected lumbar vein was clipped and divided (Fig. 6.37).

Fig. 6.32  The right renal artery is dissected at intreraortovaval space (IVC inferior vena cava, RRA right renal vein)

4.3.5 S  equential Occlusion of Distal IVC, Right Renal Artery, Right Renal Vein, and Proximal IVC The vessel loop is tightened and fixed with a Hem-o-lok clip to occlude the distal IVC (Fig. 6.38). Right renal artery and right renal vein are both occluded with “bulldog” clamps (Figs. 6.39 and 6.40). The vessel loop at the proximal IVC is

6  Robotic Inferior Vena Cava Thrombectomy

61

Fig. 6.35  The vessel loops were wrapped twice around the proximal IVC (IVC inferior vena cava)

Fig. 6.38  The vessel loop is tightened and fixed with a Hem-o-lok clip to occlude the distal IVC (IVC inferior vena cava)

Fig. 6.36  The accessory hepatic vein is divided and clipped with Hem-­ o-­loks (IVC inferior vena cava, SHV short hepatic vein)

Fig. 6.39  Right renal artery is occluded with bulldog clamp (RRA right renal artery)

Fig. 6.37  The lumbar veins are divided and then clipped (LV lumbar vein)

Fig. 6.40  Right renal vein is occluded with bulldog clamp (IVC inferior vena cava, RRV right renal vein)

62

B. Wang et al.

Fig. 6.41  The vessel loop is tightened and fixed with a Hem-o-lok clip to occlude the proximal IVC (IVC inferior vena cava)

Fig. 6.43  The IVC thrombus is removed (IVC inferior vena cava, TT tumor thrombus, RRV right renal vein, L liver)

Fig. 6.42  IVC is incised, and the thrombus is exposed (TT tumor thrombus)

Fig. 6.44  The tumor thrombus involving IVC wall is excised (IVC inferior vena cava, TT tumor thrombus)

tightened and fixed with a Hem-o-lok clip to occlude the proximal IVC (Fig. 6.41).

4.3.6 Extraction of Thrombus After sequential occlusion, IVC is incised, and the thrombus is removed (Fig. 6.42). For the thrombus that partial invades the IVC wall, the affected IVC wall can be resected en-bloc (Figs. 6.43 and 6.44). The IVC tumor thrombus is inserted into a small endobag to prevent contamination of the peritoneal space (Fig.  6.45). After irrigation of IVC lumen with heparinized saline, IVC is closed with 5-0 polypropylene suture (Fig.  6.46). Occlusion at proximal IVC, right renal vein, right renal artery, and the distal IVC are released in order (Figs.  6.47, 6.48, 6.49, and 6.50). Hemostasis is ensured after pneumoperitoneum pressure is reduced (Fig. 6.51).

Fig. 6.45  The IVC thrombus is placed into specimen bag

6  Robotic Inferior Vena Cava Thrombectomy

63

Fig. 6.46  The IVC is closed by a running suture (IVC inferior vena cava)

Fig. 6.49  The right renal artery is declamped (IVC inferior vena cava)

Fig. 6.47  The proximal IVC is released (IVC inferior vena cava)

Fig. 6.50  The cephalic IVC is released (IVC inferior vena cava)

Fig. 6.48  The Bulldog clamp is removed and the right renal vein is declamped (IVC inferior vena cava)

Fig. 6.51  The blood circulation of the IVC is reestablished (IVC inferior vena cava, RRV right renal vein, RRA right renal artery)

64

B. Wang et al.

4.3.7 Left Radical Nephrectomy The patient’s position was converted to a right 60–70° lateral decubitus position with extended flank. The trocars and instruments are configured according to robotic left RN. The left renal artery is dissected, clipped and divided with Hem-­ o-­lok clips. The left renal vein is dissected medially until transected stump. Left kidney and adrenal gland are mobilized according to the principle of RN.

5

Complications and Management

5.1

Tumor Thrombus Detachment

This fatal complication rarely occurs. Once happen, it can result in pulmonary embolism or myocardial infarction.

5.2

Fig. 6.53  The IVC defect is closed by a running suture

Vascular Injury and Bleeding

During the operation, blood vessels are skeletonized, and exposed to risk of injury. Vascular injury usually happened during dissection of IVC and renal vein, especially lumbar vein dissection (Fig. 6.52). Familiarity of the anatomy and gentle dissection are the key components of primary prevention. Once bleeding, gauzes can be placed and pneumoperitoneum pressure can be increased to tamponade the bleeding. The injured vessel wall can be repaired continuously with absorbable suture (Fig. 6.53). IVC looping proximal and distal to the thrombus is associated with high risk of bleeding as well. IVC tributaries are clipped with Hem-o-lok clips and left in situ; vessel loops might dislodge the Hem-o-lok clips and cause bleeding (Fig.  6.54). IVC tributaries adjacent to cross-clamping location should be sutured; Hem-o-lok clips may be dislodged during looping of vessel loops. (Fig. 6.55).

Fig. 6.54  Vessel loops dislodge the Hem-o-lok clips and cause bleeding (IVC Inferior vena cava)

Fig. 6.52  Bleeding from an injured tributary of the IVC

Fig. 6.55  Preventive suturing to avoid bleeding

6  Robotic Inferior Vena Cava Thrombectomy

Once bleeding occurs, a good mastering of robotic suture technique is required to repair the damaged vessel wall and stop the bleeding. Surgery should be converted to open surgery as indicated.

5.3

Organ Injury

Organ injuries such as liver, kidney, spleen, pancreas and intestinal injury rarely occur. Familiarity of the anatomy and gentle dissection again are the key components of primary prevention. Once the organ injury occurs, management should be conducted according to principle of corresponding organ.

5.4

Surgical Site Infection

Surgical site infection is managed with regular dressing. Colligated drain can be inserted as indicated, to drain the exudate. Antibiotic should be started according to sensitivity when patient is fever.

5.5

Peritonitis

It rarely occurs, however it can occurs in patients with primary intraperitoneal infection. Postoperative intraperitoneal collection and hematoma can aggravate the infection. Optimal drainage is crucial in addition to appropriate antibiotic prescription. Intraperitoneal lavage can be performed as indicated.

5.6

Pneumonia

It usually occurs in patients with primary lung diseases. Preoperative lung function test and blood gas analysis are important for this kind of patient during preoperative evaluation. Post operatively, patient should be rest in 45 degree prompt up position whenever possible. Chest physiotherapy should be initiated as soon as possible, patient is encouraged for early ambulation. Good inhalation and exhalation techniques are emphasized to patient, Patient need to be ensure for performing incentive spyrometry regularly. If patient is complicated with pneumonia, chest physician can be, consulted.

5.7

Other Complications

Other complication Postoperative renal failure, lymphatic leakage, lower limb deep venous thrombosis, etc.

65

6

Future Perspectives

In 2002, Fergany developed a laparoscopic technique for IVC thrombectomy on a porcine model. In the same year, Sundaram described hand-assisted laparoscopic thrombectomy for a short IVC thrombi, that could be removed using a Satinsky clamp. This method is not a complete minimal invasive approach, with narrow indication and the poor reproducibility. In 2006, Romero firstly described a laparoscopic IVC tumor thrombectomy on short thrombus with 3 cm length. The thrombectomy was performed with Satinsky clamping part of the IVC wall without IVC cross-clamping. Recently, many laparoscopic IVC thrombectomies have been reported. Most of the cases were level I or short level II IVC thrombus. The thrombectomies were performed by either pushing back the thrombus to renal vein or clamping part IVC wall with a Satinsky clamp without cross-clamping of the IVC. For level II or III IVC thrombus, hand-assisted laparoscopic thrombectomy or laparoscopy-assisted open thrombectomy was performed. There are also case report of complete laparoscopic approach. For level II IVC thrombus, laparoscopic IVC thromectomy can be performed via both transperitoneal or retroperitoneal approach for right RCC. However, for left RCC, only transperitoneal laparoscopic surgery is suitable. In 2011, Abaza reported the first successful robotic IVC thrombectomy R-IVCT.  However, among the five cases described by Abaza, cross-clamping of the IVC was applied in only two cases. In literature, only nine cases of R-IVCT have been reported. Detailed techniques for left R-IVCT in management of level II IVC thrombus has not been described in literature. This chapter provided a detailed description of the IVC thrombectomy techniques performing in Chinese PLA General Hospital. Currently, this operation is still in the exploratory stage, popularization of this operation remains challenging. In view of its unique advantages, R-IVCT is the direction of future development.

References 1. Zhang X, Wang B, Ma X, et al. Clinical research of robot assisted

laparoscopic nephrectomy with inferior vena caval thrombectomy. Chin J Urol. 2015;36:321–4. 2. Wang B, Li H, Ma X, et  al. Robot-assisted laparoscopic inferior vena cava thrombectomy: different sides require different techniques. Eur Urol. 2016;69(6):1112–9. 3. Neves RJ, Zincke H. Surgical treatment of renal cancer with vena cava extension. Br J Urol. 1987;59:390–951. 4. Pouliot F, Shuch B, LaRochelle JC, et  al. Contemporary management of renal tumors with venous tumor thrombus. J Urol. 2010;184:833–41. 5. Han Z, Yin C, Meng X, et al. Modified liver mobilization technique in the management of renal cell carcinoma with intrahepatic inferior vena cava thrombosis. Chin J Urol. 2012;33:492–4.

66 6. Skinner DG, Pfister RF, Colvin R.  Extension of renal cell carcinoma into the vena cava: the rational for aggressive surgical management. J Urol. 1972;107:711–6. 7. Zheng S, He Z, et al. Advanced renal cell carcinoma with inferior vena cava invasion: a case report and literature review. J Clin Urol. 1988;3:217. 8. Fergany AF, Gill IS, Schweizer DK, et  al. Laparoscopic radical nephrectomy with level II vena caval thrombectomy: survival porcine study. J Urol. 2002;168:2629–31. 9. Sundaram CP, Rehman J, Landman J, et al. Hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with inferior vena caval thrombus. J Urol. 2002;168:176–9. 10. Romero FR, Muntener M, Bagga HS, et al. Pure laparoscopic radical nephrectomy with level II vena caval thrombectomy. Urology. 2006;68:1112–4. 11. Martin GL, Castle EP, Martin AD, et al. Outcomes of laparoscopic radical nephrectomy in the setting of vena caval and renal vein thrombus: seven-year experience. J Endourol. 2008;22:1681–5. 12. Wang W, Xu J, Adams TS, et al. Pure retroperitoneal laparoscopic radical nephrectomy for left renal cell carcinoma with differential extensions of level I renal vein tumor thrombus. J Endourol. 2014;28:312–7. 13. Wang W, Wang L, Xu J, et  al. Pure retroperitoneal laparoscopic radical nephrectomy for right renal masses with renal vein and inferior vena cava thrombus. J Endourol. 2014;28:819–24.

B. Wang et al. 14. Xu B, Zhao Q, Jin J, et al. Laparoscopic versus open surgery for renal masses with infrahepatic tumor thrombus: the largest series of retroperitoneal experience from China. J Endourol. 2014;28: 201–7. 15. Kovac JR, Luke PP.  Hand-assisted laparoscopic radical nephrectomy in the treatment of a renal cell carcinoma with a level II vena cava thrombus. Int Braz J Urol. 2010;36:327–31. 16. Hoang AN, Vaporcyian AA, Matin SF. Laparoscopy-assisted radical nephrectomy with inferior vena caval thrombectomy for level II to III tumor thrombus: a single-institution experience and review of the literature. J Endourol. 2010;24:1005–112. 17. Wang M, Ping H, Niu Y, et al. Pure conventional laparoscopic radical nephrectomy with level II vena cava tumor thrombectomy. Int Braz J Urol. 2014;40:266–73. 18. Abaza R.  Initial series of robotic radical nephrectomy with vena caval tumor thrombectomy. Eur Urol. 2011;59:652–6. 19. Lee JY, Mucksavage P.  Robotic radical nephrectomy with vena caval tumor thrombectomy: experience of novice robotic surgeons. Korean J Urol. 2012;53:879–82. 20. Gu L, Ma X, Zhang X, et al. Surgical therapy for renal cell carcinoma with tumor embolism of the inferior vena cava and its prognostic factors. Chin J Urol. 2014;35:87–90. 21. Sun Y, de Castro Abreu AL, Gill IS.  Robotic inferior vena cava thrombus surgery: novel strategies. Curr Opin Urol. 2014;24: 140–7.

7

Retroperitoneal Laparoscopic Nephroureterectomy Dan Shen, Xin Ma, Hongzhao Li, and Xu Zhang

1

Introduction

Radical nephroureterectomy with excision of bladder cuff is the standard treatment for upper tract urothelial carcinoma. This operation is suitable to be performed laparoscopically. Long term follow-up for patient with upper tract urothelial carcinoma who had undergone laparoscopic nephroureterectomy showed a favorable outcome. Laparoscopic nephroureterectomy can be performed via transperitoneal, retroperitoneal; since both approaches have their own advantages and disadvantages, selection of approaches is mainly depending on surgeon’s preference.

2

Indications and Contraindications

The indications for retroperitoneal laparoscopic nephroureterectomy are urethelial carcinomas arising from renal pelvis or ureter. Contraindications include patients who are medically unfit for surgery and patients with uncorrected coagulopathy. Intraperitoneal adhesion due to history of intraperitoneal surgery or chronic infection are relative contraindications.

3

 reoperative Evaluation and Patient P Preparation

3.1

Preoperative Evaluation

The preoperative evaluations for retroperitoneal laparoscopic nephroureterectomy are as follows: 1 . History taking and physical examination 2. Laboratory tests include full blood count, renal profile, liver function test, coagulation profile, serum blood gluD. Shen · X. Ma · H. Li · X. Zhang (*) Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China e-mail: [email protected], [email protected]

cose, blood cross match and, urine FEME,. Urine culture and sensitivity is required for infectious cases. 3. Electrocardiogram, chest radiograph 4. Special imaging examinations are requested according to indication: (a) Intravenous urogram (b) CT renal 4 phases is essential to evaluate both the affected and contralateral kidney, to provide information regarding morphology of kidney, morphology of the tumor, vasculature anatomy, surrounding organs invasion and possible lymph node metastasis. (c) CT thorax, abdomen, pelvic for distant organ metastasis staging. (d) MRI is requested when CT scan finding is equivocal (e) Retrograde pyelography, ureteroscopes and biopsy. 5. Urine cytology. This test is high specificity, low sensitivity. Early detection is possible when positive result is combined with ureteroscopes and narrow band imaging.

3.2

Patient Preparation

Informed consent should be obtained with a discussion of possible complications. Patients must be consented for conversion to open surgery. Anticoagulant medications must be discontinued in advance to surgery. Patient is fasted for 6 h before surgery. Bowel preparation is not necessary for retroperitoneal surgery. Prophylactic antibiotics are administered during induction of general aneasthesia. IV Cefazolin 1  g usually provides adequate coverage in non-allergic patient. Pneumatic compression stockings are applied preoperatively for deep vein thrombosis prevention.

4

Step-by-Step Operative Technique

Surgery is performed under general anesthesia with endotracheal intubation, and divided into two parts:

© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 X. Zhang (ed.), Laparoscopic and Robotic Surgery in Urology, https://doi.org/10.1007/978-981-13-3738-3_7

67

68

D. Shen et al.

1. Transurethral circumferential excision of the ureteral orifice. (a) The patient placed in the lithotomy position, cystoscopic examination is performed to detect intravesical lesion. TURBT should be performed for intravesical lesion. (b) A 5F ureteral catheter could be inserted into the affected ureter (Fig. 7.1). Circumferential incision of the ureter orifice and intramural ureter are performed with Colin’s knife until the perivesical fat tissue is visualized (Fig. 7.2). (c) The incision is started at medial wall (Fig. 7.3), followed by lateral wall, inferior wall and superior wall. (d) The excised ureteric orifice is pushed outward (Fig. 7.4), ureteral catheter is kept within the ureter while withdrawing the resectoscope. The ureteral catheter is fixed to the Foley catheter.

2. Retroperitoneal laparoscopic nephroureterectomy. (a) Patient is repositioned from lithotomy position to lateral decubitus position, and followed by sterilization and drapping in the usual fashion. (b) The retroperitioneal approach is usually performed with three trocars. Trocars configuration and establishment of pneumoperitoneum are described in detail in Chap. 1: Establishment of retroperitoneal approach for adrenal gland and upper urinary tract laparoscopic surgery. (c) The ureter can be found on the peritoneum covered by the posterior renal fascia in the posterior pararenal space. The ureter need to be isolated and ligated Hemo-lok clips or titanium clips distally to the tumor. (d) Removal of the diseased kidney is similar as retroperitoneal laparoscopic radical nephrectomy as described in detail in Chap. 5.

Fig. 7.1  5F ureteral catheter is inserted into the affected ureter (UO ureteral orifice)

Fig. 7.3  Circumferential incision of ureteral orifice

Fig. 7.2  Incision was proceeded until fatty tissue was visualized

Fig. 7.4  The incised intramural ureter was pushed outward

7  Retroperitoneal Laparoscopic Nephroureterectomy

69

needs to be dissected with care to avoid injury to iliac vessels, superior vesical artery, and the uterine artery in female patients.

6

Fig. 7.5  Full length dissection of ureter (U ureter)

Patient can be allowed for oral intake generally 1 day after surgery, started with clear fluids and stepped up according to bowel function recovery. Indeed, most patients do not have active bowel movement and flatus until postoperative day 2 or 3. Parenteral antibiotic is continued postoperatively. The drain is removed once the drainage is minimal. Patient is encouraged for mobilization on day one post-operatively. Patients can gradually resume normal activities after hospital discharge, vigorous activities are limited for at least 1 month after surgery. The foley catheter is usually removed a week after the surgery. Urine leakage may happen in some patients due to unsuture bladder wall defect after removal of the distal bladder cuff. When there is decreased in urine output or presence of hematuria, catheter blockage should be suspected. Catheter should be flushed with saline to ensure good urine drainage. Drainage tube may be kept for longer duration in this situation.

7

Fig. 7.6  The ureter was pulled mobilized the intramural segment and bladder cuff (IMSU intramural segment of ureter)

(e) A 5-mm trocar can be inserted at iliac fossa if necessary. The ureter is retracted upward, dissected distally until the excised segment of distal ureter is visualized (Fig. 7.5). The ureter is pulled to mobilized the intramural segment and bladder cuff (Fig. 7.6). (f) The specimen was manually extracted intact within a specimen bag through an extended the skin incision at second trocar incision. A drain tube is through first trocar incision (camera trocar), and the surgical incision is sutured.

5

Cautions

Oncological principle should be complied intraoperatively. The ureter should be ligated below the tumor with a Hem-o-­ lok clip or a titanium clip before further mobilization and removal to avoid urine leakage in surgical field. Pelvic ureter

Postoperative Management

Long-Term Results

Most of upper tract urothelial carcinoma cases were treated with open radical nephroureterectomy before 2001, while laparoscopic surgery was not popularized. Comparative analyses by Favaretto [1] showed that disease recurrence was not significantly related to surgical approach. Up to date, there is no consensus for approaches of distal bladder cuff removal, among transvesical, extravesical and endoscopic approach. Xylinas et  al. [2] compared the oncologic effectiveness among different approaches for bladder cuff excision in his retrospective analysis of 2681 patients. No differences in nonbladder recurrence and survival between these approaches were found; however a higher intravesical urothelial carcinoma recurrence was noted in endoscopic approach. We believe that the retroperitoneal laparoscopic nephroureterectomy will probably become the gold standard for management of upper tract urothelial carcinoma in furture.

References 1. Favaretto RL, Shariat SF, Chade DC, et  al. Comparison between laparoscopic and open radical nephroureterectomy in a contemporary group of patients: are recurrence and disease-specific survival associated with surgical technique. Eur Urol. 2010;58(5):645–51. 2. Xylinas E, Rink M, Cha EK, Clozel T, Lee RK, Fajkovic H, Comploj E, Novara G, Margulis V, Raman JD. Impact of distal ureter management on oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma. Eur Urol. 2014;65:210–7.

8

Robotic Nephroureterectomy Dan Shen, Xin Ma, Hongzhao Li, and Xu Zhang

1

Introduction

Since the initial application of the robotic system in urological surgeries in 2001, robotic-assisted laparoscopic nephroureterectomy (RALNU) had become an alternative option to open or laparoscopic surgery for upper tract urothelial carcinoma(UTUC). Robotic surgical platform with its multiangle articulating endowrist system provides potential advantage in this surgery, especially for the distal ureter isolation and bladder closure. Varieties of RALNU techniques were described in the literature, which some of the techniques involved repositioning of patient and redocking of the robot. With the improvement and modification of da Vinci Xi system, RALNU may be more feasible as compared to the previous version.

2

Indications and Contraindications

The indications and contraindications are similar to laparoscopic nephroureterectomy as described in Chap. 7.

3

 reoperative Evaluation and Patient P Preparation

3.1

Preoperative Evaluation

Preoperative evaluation and patient preparation are similar as laparoscopic nephroureterectomy as described in Chap. 7.

D. Shen · X. Ma · H. Li · X. Zhang (*) Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China e-mail: [email protected], [email protected]

4

Step-by-Step Operative Technique

4.1

Endouroligical Manipulations

After induction of general anesthesia, patient is positioned to lithotomy position. Cystoscopic examination is performed. A 5F ureteral catheter is inserted into the affected ureter. Circumferential incision of the ureter orifice and intramural ureter are performed with Colin’s knife until the perivesical fat tissue is visualized. A Foley catheter is inserted and fixed with the ureteral stent (Chap. 7).

4.2

Patient Positioning and Port Placement

Trocars placement is almost similar as transperitoneal robotic assisted radical nephrectomy, with minor adjustment to accommodate distal ureter dissection. Patient is repositioned to 60–70 degree lateral recumbent position with flank extension supported by gel cushion. Pneumoperitoneum is established via a transumbilical Veress needle. Camera trocar is inserted at semilunalis lateral to the umbilical. Other trochars are inserted under direct vision. First 8-mm robotic trocar is inserted a palm width distance above the camera trocar, second 8-mm robotic trocar is inserted a palm width distance inferolateral to the camera trocar, to create a 100 degree angle between the axis from first robotic trocar to camera trocar, and the axis from camera trocar to second robotic trocar. This angle is not created as 120 degree to avoid collision between robotic arms in second and third robotic trocar during distal ureter dissection. Third robotic was inserted a palm width distance below the camera trocar. First assistant trocar for radical nephrectomy is inserted at midpoint between the camera trocar and first robotic trocar above the umbilical. Second assistant trocar for distal ureter dissection is inserted at midpoint between the camera trocar and third robotic trocar below umbilical. For right sided tumors, an additional 5-mm port is inserted just below the xiphoid for liver retraction.

© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 X. Zhang (ed.), Laparoscopic and Robotic Surgery in Urology, https://doi.org/10.1007/978-981-13-3738-3_8

71

72

4.3

D. Shen et al.

Kidney Dissection

Kidney dissection is almost the similar as transperitoneal robotic nephrectomy. Peritoneum reflection is incised and colon is medialized (Fig. 8.1). For left sided tumor, the linocolic and phrenicocolic ligaments are incised to medialize the left colon together with the pancreas. For right-sided tumor, the duodenum is mobilized until the exposure of inferior vena cava. The lower pole of the kidney is identified and dissected. Upward retraction of the lower pole allows identification of the gonadal vein, ureter, and psoas muscle. The ureter is dissected proximally to the lower pole of kidney until identification of the renal hilum. The ureter is ligated distally below the level of the tumor with Hem-o-lock clips (Fig. 8.2). The renal artery and vein are identified, dissected, ligated with Hem-o-locks and divided (Fig. 8.3). The Kidney is mobilized from the surrounding attachment.

Fig. 8.3  The renal artery and vein were clipped with Hem-o-lock clips and divided

Fig. 8.4  Distal ureter dissection

Fig. 8.1  Line of Toldts was incised and the colon was medialized

4.4

Distal Ureterectomy

Robotic system will be redocked. Imaginary line from camera trocar to midpoint between second and third trocar will be the axis of reference for docking of robotic system. First robotic arm is inserted via second robotic trocar; second robotic arm is inserted via third robotic trocar. Third robotic arm is not used. The distal ureter is gently dissected to prevent injury to iliac vessels. Ureteral is dissected distally until the excised segment of distal ureter is visualized; superior vesicle pedicles are preserved during the dissection. The ureter is pulled to mobilized the intramural segment and bladder cuff (Fig. 8.4). If the ureteral orifice is not incised through endourological approach, the bladder is distended with sterFig. 8.2  The ureter was ligated below the level of the tumor with Hem-­ ile water; the intramural segment of ureter is dissected ciro-­lock clips cumferentially from the detrusor muscle, and followed by

8  Robotic Nephroureterectomy

circumferentially incision of mucosa around the ureteral orifice. The bladder defect is closed with absorbable continuous suture. Bladder is distended with sterile water to assess the integrity of the defeat closure. The nephroureterectomy specimen is inserted into a retrieval bag. A drain is placed and the robot is undocked. The specimen may be extracted through the most distal trocar.

73

7

Special Considerations

It is similar to the robotic-assisted laparoscopic radical nephrectomy. Other than that, Pelvic ureter needs to be dissected with care from iliac vessel and pelvic organs.

Extravesical excision of distal ureter and ureteral orifice are the most challenging aspect in RALNU.  Trocar configuration and robotic docking for radical nephrectomy may not be optimal in excision distal ureter ureteral orifice dissection. Additional trocars and redocking of robotic system may be necessary. In comparison to Si system, Xi system equipped with overhead instrument arm architecture to facilitate anatomical access from virtually any position. Furthermore, the camera can be placed into any of the robotic trocars. However, the longer shaft arms of the robotic instrumentation in Xi system may result in the assistant assisting further away from patient [1]. Besides, there is a reported technique named Single-docking robotic RALNU.  This technique offers the advantage of shorter operative duration as compared to redocking technique and it was reported safe [2]. Preemptive ureter ligation below the tumor with a clip is recommended to decrease the risk of distal migration of UTUC. This is maneuver is important in view of intravesical chemotherapy cannot be administered immediately after surgery [3]. In recent years, Utilization RALNU had been doubled. RALNU offered higher odds of lymphadenectomy and lower odds of positive surgical margins. RALNU showed superior perioperative outcomes and comparable long term oncological outcome in comparison to open nephroureterectomy. However, data from RALNU is still limited, which leads to inconclusive results.

6.2

References

5

Postoperative Management

Patient can be allowed for oral intake generally 1 day after surgery, started with clear fluids and stepped up as tolerated. Indeed, most patients do not have active bowel movement and flatus until postoperative day 2 or 3. Parenteral antibiotic is continued postoperatively. The drain is removed once the drainage is minimal. Patient is encouraged for mobilization day one post-operatively. Continues bladder irrigation is not required. Catheter should be maintained unobstructed and removed after a week.

6

Complications and Management

6.1

Bleeding

Urine Leakage

Urine leakage is more common in patient who has undergone transurethral resection of ureteral orifice without closure of bladder defeat. It usually resolves with conservative management. Urine output needs to be monitored closely. When presence of hematuria or catheter obstruction, catheter should be flushed with saline, blood clot should be evacuated. Good urine drainage should always be ensured. Drainage tube can be kept for a longer duration.

1. Darwiche F, Swain S, Kallingal G, Punnen S, Manoharan M, Parekh DJ, et  al. Operative technique and early experience for robotic-­ assisted laparoscopic nephroureterectomy (RALNU) using da Vinci Xi. Springerplus. 2015;4:298. 2. Ho C-Y, Lin Y-C, Tsai T-F, Yeh C-H, Juang G-D, Cheng Y-H, et al. Single-docking robotic radical nephroureterectomy with bladder cuff excision in a single institution. Urol Sci. 2016;27(2):S38. 3. Lai WR, Lee BR. Techniques to resect the distal ureter in robotic/ laparoscopic nephroureterectomy. Asian J Urol. 2016;3(3):120–5.

9

Retroperitoneal Laparoscopic Donor Nephrectomy Jianwen Chen, Xin Ma, Tao Zheng, and Xu Zhang

1

Introduction

Up to date, kidney transplantation remains the best treatment of end-stage renal failure. Shortage of cadaveric donor results in extended waiting time for transplantation. Living donor renal transplantation offers an effective way to alleviate the kidney shortage status. Living donor renal transplantation was increasingly performed to fulfill huge demand of donor kidneys. The first living donor laparoscopy nephrectomy was performed in 1995. Laparoscopic surgery offers the advantages of minimal invasive surgery, including small skin incision, minimal postoperative pain, early recovery, and low morbidity, while maintaining comparable surgical outcomes [1]. Laparoscopic approach has extended into the realm of live donor nephrectomy that has become the standard of care at most major academic centers. Long-term studies had confirmed that allograft outcomes and complication rates after laparoscopic donor nephrectomy (LDN) are equivalent to those of the open approach [2]. There are mainly two approaches for laparoscopic donor nephrectomy, which are peritoneal approach and retroperitoneal approach. Our experiences showed that retroperitoneal approach offered more advantages as compared to peritoneal approach, including rapid access into the retroperitoneum, rapid and safe control of the renal pedicle, less postoperative accumulation of lymphatic fluid and blood, less bowel related complications, and potentially earlier return of bowel function and hospital discharge [3, 4]. However, limited working J. Chen Department of Nephrology, The First Medical Center, Chinese PLA General Hospital, Beijing, China X. Ma · X. Zhang (*) Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China e-mail: [email protected], [email protected] T. Zheng Department of Urology, Wuhan Fourth Hospital, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

space of the retroperitoneum, lack of familiarity of retroperitoneal anatomy, long learning curve resulted in retroperitoneal laparoscopic donor nephrectomy a challenging surgery. In this chapter, we will introduce retroperitoneal laparoscopic left nephrectomy for kidney harvesting in details.

2

Indications and Contraindications

2.1

Indications

The donor must be healthy adult above 18 years old. Careful selection for donors older than 65 years old. Must abide by the relevant laws and regulations, such as human organ transplant act and related regulations.

2.2

Contraindications

Donors with severe lung disease, hypertension, diabetes, hepatitis, proteinuria(>250  mg/24  h), HIV carriers, creatinine clearance is less than 80 mL/min, obesity (BMI > 30), complicated renal malformations, coagulation dysfunction, malignant tumor, tuberculosis, kidney disease and renal insufficiency, mental disorder, mental dysplasia, physical disabilities, etc.

3

 reoperative Evaluation and Patient P Preparation

3.1

Preoperative Evaluation

Preoperative evaluation includes full history, physical and psychological examination. Preoperative laboratory and imaging tests include ABO blood type compatibility test, HLA crossmatch test, group reactive antibodies, lymphocyte cell toxicity test, routine blood investigations, and coagulation profile, renal profile, liver function test, virus serology tests (CMV,

© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 X. Zhang (ed.), Laparoscopic and Robotic Surgery in Urology, https://doi.org/10.1007/978-981-13-3738-3_9

75

76

J. Chen et al.

EBV, HBV, HCV, syphilis), urine FEME, radionuclear renogram, renal vascular imaging and kidney 3D reconstruction by CT or MRI to provide detailed anatomical data for renal vascular, renal parenchyma and collecting system.

3.2

Patient Preparation

Preoperative patient preparation is the similar as simple nephrectomy described in Chap. 4. Bowel preparation is performed at the night before surgery. Patient is given intravenous fluid infusion to ensure good kidney perfusion. Prophylactic antibiotic is prescribed. Deep venous thrombosis prophylaxis is implemented with good hydration, application of compressive elastic stockings on the lower extremities, and low-molecular-weight heparin.

4

Step-by-Step Operative Technique (Retroperitoneal Laparoscopic Left Donor Nephrectomy)

The principle of renal selection is keeping the best kidney for the donor. Left kidney will be the first choice when both kidney functions are equal, due to longer left renal vein that can facilitate renal implantation to the recipient.

4.1

Anesthesia and Patient Positioning

After induction of general anesthesia and endotracheal intubation is applied, foley catheter is inserted. The patient is placed in a lateral decubitus position with extended flank and firmly secured on the operating table.

4.2

4.3

Mobilization of Retroperitoneal Adipose Tissue

The retroperitoneal adipose tissue is routinely mobilized by using harmonic scalpel, from the indentation, which is the meeting of peritoneal reflection and psoas muscle superiorly to iliac fossa inferiorly, to provide a good retroperitoneal working space and identification of retroperitoneal anatomical landmarks such as diaphragm, psoas muscle, peritoneum reflection, and Gerota’s fascia.

4.4

Free of the Kidney and Ureter

The Gerota’s fascia (Fig. 9.1) and perirenal fat tissue (Fig. 9.2) are longitudinally incised, just posterior to the peritoneum reflection. The kidney is mobilized with combination of sharp and blunt dissection along the surface of the renal cortex by following the avascular plane between perirenal fat and renal capsule. The kidney is dissected according to the sequence of anterior surface (Fig.  9.3), posterior surface (Fig.  9.4), and lower pole (Fig. 9.5). The upper pole is not dissection to prevent kidney prolapse. Ureter (Fig. 9.6) can be identified along lower pole dissection. Periureteric tissue need to be preserve as blood supply of blood supply of ureter.

4.5

Renal Pedicles Dissection

Kidney is retracted anteriorly; renal artery can be identified through its pulsation around the midpole along the posterior surface. The renal artery (Fig. 9.7) and renal vein

Creation of Retroperitoneal Working Space and Trocar Placement

A three-trocar technique is performed as previously described in details in Chap. 1. Briefly, a 2  cm skin incision is made below the edge of 12th rib on the posterior axillary line, the peritoneum is pushed forward by the index finger and balloon expander is introduced and inflated with 800 mL air to expand the retroperitoneal working space. Under the guidance of index finger, A 10 mm camera trocar is inserted two fingers breadths above the iliac crest on midaxillary line; second trocar is inserted at the just below the subcostal margin on anterior axillary line; third trocar is inserted via the initial skin incision and the skin incision is sutured to fix the trocar. 12 mm trocar will be inserted on the side of ­dominant hand.

Fig. 9.1 Incision of Gerota’s fascia longitudinally (GF Gerota’s fascia)

9  Retroperitoneal Laparoscopic Donor Nephrectomy

77

Fig. 9.2  Incision of perirenal fat tissue longitudinally (K kidney)

Fig. 9.5  Dissection of lower pole of kidney (K kidney)

Fig. 9.3  Dissection of anterior surface of kidney (K kidney)

Fig. 9.6  Dissection and reveal of ureter (U ureter)

(Fig. 9.8) is skeletonized by dissecting the perivascular tissue. Gonadal vein (Fig. 9.9) is clipped with Hem-o-Lock and divided after identified by following the renal vein. Occasionally, renal vein- half azygos vein  - lumbar vein complex (Reno—hemi—azygo—lumar trunk, AZV) and other renal vein branches may interfere the exposure of renal artery (Fig. 9.10). All these branches should be separately ligated and divided to expose the root of left renal artery (Fig.  9.11). Upper pole of the kidney is dissected from the adrenal gland, subsequently mobilized medially until the hilum (Fig.  9.12). Left suprarenal vein is carefully identified (Fig. 9.13) during the upper pole dissection along the anterior surface; it is, clipped with Hem-o-Lok and divided. Fig. 9.4  Dissection of posterior surface of kidney (K kidney)

78

J. Chen et al.

Fig. 9.7  Dissection of renal artery (RA renal artery)

Fig. 9.10  AZV and its branches (LK left kidney, U ureter, GV gonadal vein, LRV left renal vein, LRA left renal artery, AZV Reno—hemi— azygo—lumar—trunk, ALV ascending lumbar vein, LV lumbar vein)

Fig. 9.8  Dissection of renal vein (RV renal vein)

Fig. 9.11  Ligation of AZV and revealing the root of left renal artery (A aorta)

Fig. 9.9  Dissection of Gonadal vein (GV gonadal vein)

Fig. 9.12  Dissection of upper pole of kidney (K kidney)

9  Retroperitoneal Laparoscopic Donor Nephrectomy

79

Fig. 9.13  Dissection of adrenal vein (AV adrenal vein)

Fig. 9.15  Renal artery is clipped at the root with two Hem-o-lok clips (RA renal artery)

Fig. 9.14  Dissection and transection of the ureter at the level of iliac fossa (U ureter)

Fig. 9.16  Renal vein is clipped at the root with two Hem-o-lok clips (RV renal vein)

4.6

4.8

Transection of the Ureter

Ureter will be identified along the dissection of lower pole, and transected at the level of the iliac fossa (Fig. 9.14).

4.7

 urgical Incision for Extraction S of Donor Kidney

A 7 cm length oblique incision is extended from skin incision of second trocar(skin incision at subcostal margin on the anterior axillary line). Layers of incision include the skin, subcutaneous tissue, the external oblique muscle, and the internal oblique muscle, the transverse abdominis muscle is kept intact.

Transecion of the Renal Pedicle

Renal artery is clipped at the root with two Hem-o-lok clips (Fig. 9.15), and subsequently transected distal the two Hem-­o-­ lok clips (Fig. 9.17). The renal vein is transected in the similar manner (Figs.  9.16, 9.17, and 9.18). These Hem-o-­lok clips are retained at proximal the stumps of renal artery and vein. Distal stumps at the donor kidney should not be clipped and remain open. Linear cutting stapler is also commonly used to transect the renal artery (Fig. 9.19) and renal vein (Fig. 9.20).

4.9

Kidney Extraction

The transverse abdominal muscle is bluntly separated through the preparatory incision. Left hand is inserted into

80

J. Chen et al.

Fig. 9.17  Renal artery is transected by scissor

Fig. 9.20  Renal vein is transected by linear cutting stapler (RV renal vein)

Fig. 9.18  Renal vein is transected by scissor

Fig. 9.21  Taking out the kidney through the preparatory incision

retroperitoneal space to take out the kidney (Fig. 9.21). The donor kidney is kept in salted ice water immediately, and transferred quickly to the recipient team for further trimming and preparation for implantation.

4.10

Fig. 9.19  Renal artery is transected by linear cutting stapler (RA renal artery, RV renal vein)

Single Hand Assisted Technique

After complete retroperitoneal mobilization of the kidney, a 7 cm length oblique incision is extended from skin incision of second trocar (skin incision at subcostal margin on the anterior axillary line), and opened by layer until entering the retroperitoneal space. The surgeon’s left hand is introduced into the retroperitoneal space through this incision without using a hand port device, to facilitate handling and evacuation of donor kidney in the final stage. The kidney is retracted with this hand during final dissection and division of the

9  Retroperitoneal Laparoscopic Donor Nephrectomy

81

5

Postoperative Management

Prophylactic antibiotic is continued postoperatively. Orally intake is allowed and stepped up according to bowel function recovery. Patient is allowed for ambulation day one postoperative, and urinary catheter can be removed. Drainage tube is usually removed day 2–3 postoperative when the drainage is minimal.

6

Fig. 9.22  Carefully screening for minor bleeding

renal pedicles, and extracted after transection of renal pedicles.

4.11

Inspection of Hemostasis

The pneumoperitoneum pressure is lowered to 3–5 mmHg. Hemostasis is ensured at the surgical field especially the renal hilum. Bipolar forceps, metal clips and Hem-o-lok clips can be used to secure bleeder. A closed suction drain is inserted via the camera trocar incision, All surgical incisions are sutured (Fig. 9.22).

4.12

The Matters Needing Attention

Gentle dissection is important to avoid donor kidney injury and renal artery spasm. All the tributaries from renal vein, including left suprarenal vein, gonadal vein, AVZ should be divided to provide optimal length for renal vein. Renal artery is dissected until its root at abdominal aorta. Renal pedicles should not be transected across the distal Hem-o-Lock clip. A short length of vascular stump should be kept from the distal Hem-o-Lock to prevent retraction of the vasculature across the clips. Incision for extraction of donor kidney is prepared in advance to transection of renal pedicles, in to reduce the warm ischemia time. The incision is made after the renal pedicles are sufficiently skeletonized and the donor kidney is fully mobilized.

Complications and Management

The complications of retroperitoneal laparoscopic donor nephrectomy is almost similar to retroperitoneal laparoscopic simple nephrectomy. Its special complications include:

6.1

I njury of the Renal Capsule and Renal Parenchyma

This complication is very common at early stage of the surgery, usually caused by excessive compression of instruments to the kidney. It can be prevented by gentle and soft dissection, and abandonment of malfunction instruments. Minor capsular tear needs not be repaired intraoperatively; which can be suture in figure of 8 with absorbable suture after kidney extraction.

6.2

The Renal Blood Vessels Are Too Short

Implantation to the recipient will be difficult to be performed when the renal pedicles are very short. To avoid this problem, all the tributaries from renal vein should be identified, ligated and divided. The renal vein should be transection as near to the IVC as possible. The renal artery is dissected until its root at the abdominal aorta to ensure optimal length.

6.3

Hem-o-Lock clip Dislodgement

Dislodgement of Hem-o-Lock clips will result in massive haemorrhage, and even death. Its occurrence is mainly due to inappropriate placement of the clips and accidentally dislodgement during kidney extraction. In order to prevent Hem-o-Lock clip dislodgement, the renal vessels should be fully skeletonized, Hem-o-Lock should not be clipped at ­tissue or vessel wall, renal pedicles should be transected at a short distance

82

from the Hem-o-Lock, 2 Hem-o-Lock clips should be placed with a small gap in between.

References 1. Jacobs SC, Cho E, Foster C, et  al. Laparoscopic donor nephrectomy: the University of Maryland 6-year experience. J Urol. 2004;171(1):47–51.

J. Chen et al. 2. Levey HR, Rais-Bahrami S, Richstone L, et  al. Laparoscopic live donor nephrectomy: a technical road map. J Endourol. 2011;25(2):201–8. 3. Dong J, Lu J, Zu Q, et al. Retroperitoneal laparoscopic live-donor nephrectomy: introduction of simple hand-assisted technique (without hand port). Transplant Proc. 2011;43(5):1415–7. 4. Dong J, Lu J, Zu Q, et al. Retroperitoneal laparoscopic live donor nephrectomy: report of 105 cases. J Huazhong Univ Sci Technol Med Sci. 2011;31(1):100–2.

Robotic Donor Nephrectomy

10

Jianwen Chen, Xin Ma, and Xu Zhang

1

Introduction

In 1956, Merril et al. described the first open donor nephrectomy. Up to date, kidney transplantation remains the best treatment for end-stage renal failure. As previously described in Chap. 9, living donor renal transplantation as an effective way to alleviate the kidney shortage status. The laparoscopic approach had become the standard approach for donor renal transplantation at most major academic centers [1]. However, this approach has its inherent limitations, including two-­ dimension view, non-articulating instruments, difficulty in suturing and knotting, and poor ergonomic for surgeon [2]. Since FDA approval of robotic technology for clinical usage in 2000, this technology had gained its popularity and widely applied in clinical practice. The da Vinci system offers the advantages of three-dimensional view, instruments with an articulating wrist and seven degrees of freedom, tremor filtering, and motion scaling that significantly improves the performance of complex surgeries. Therefore, the da Vinci system can be a useful adjunct in performing laparoscopic donor nephrectomy [3]. In this chapter, we will introduce transperitoneal roboticassisted laparoscopic left donor nephrectomy for kidney harvesting in details.

J. Chen Department of Nephrology, The First Medical Center, Chinese PLA General Hospital, Beijing, China X. Ma · X. Zhang (*) Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China e-mail: [email protected], [email protected]

2

Step-by-Step Operative Technique (Transperitoneal Robotic-Assisted Laparoscopic Left Donor Nephrectomy)

2.1

 nesthesia, Patient Positioning A and Trocar Placement

After induction of general anesthesia and endotracheal ­intubation, Foley catheter is inserted. Patient positioning and trocar placement are performed as previously described in details in Chap. 1.

2.2

 edialization of the Descending Colon M and Retraction of Spleen

Open the left paracolic sulcus lateral peritoneum (Fig. 10.1), Lienorenal and lienocolic ligaments are divided (Fig. 10.2). Descending colon is medialized, together with tail of pancreas and spleen to fully expose the kidney by dissecting the avascular plane between anterior Gerota’s fascia and mesocolon.

2.3

Skeletonization of the Renal Vessels

Lower pole is dissected to expose gonadal vessels (Fig. 10.3) and ureter (Fig.  10.4). The gonadal vein is usually first encountered, dissection lateral to gonadal vein will expose the ureter. Both structures are mobilized proximally toward the renal hilum. Gonadal vein is dissected until its insertion to renal vein. Renal vein is skeletonized until sufficient length for subsequent implantation. Suprarenal vein and

© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 X. Zhang (ed.), Laparoscopic and Robotic Surgery in Urology, https://doi.org/10.1007/978-981-13-3738-3_10

83

84

J. Chen et al.

Fig. 10.1  Open the left paracolic sulcus lateral peritoneum

Fig. 10.4  Expose the left renal vein (RV renal vein)

Fig. 10.2  Lienorenal and lienocolic ligaments are divided (S spleen)

Fig. 10.5  Expose the left gonadal vein (GV gonadal vein)

gonadal vein are ligated and divided near their insertion at renal vein (Figs. 10.5, 10.6, 10.7, and 10.8). The lumbar vein can be visualized after division of gonadal vein; it will be ligated and divided. Renal artery located posterior to renal vein, it needs to be skeletonized until its root at abdominal aorta (Fig. 10.9).

2.4

Moblization of the Ureter

Ureter is mobilized distally until sufficient length for implantation. Periureteric tissue need to be preserve as blood supply of blood supply of ureter (Fig. 10.10).

Fig. 10.3  Gonadal vein and ureter are exposed (GV gonadal vein)

10  Robotic Donor Nephrectomy

85

Fig. 10.6  Gonadal vein is ligated

Fig. 10.9  The left renal artery is dissected (RA renal artery)

Fig. 10.7  Gonadal vein is divided (RV renal vein)

Fig. 10.10  The ureter is mobilized (U ureter)

2.5

Mobilization of the Upper Pole Kidney

Perirenal adipose tissue is incised at the anterior surface around the hilum (Fig. 10.11), and is dissected along the kidney surface toward the upper pole to expose the adrenal gland. Attention of detail is given to identify the presence of aberrant artery during upper pole dissection. Preoperative CT or MRI angiogram is helpful in illustrating the renal artery branches.

2.6

Fig. 10.8  The adrenal vein is ligated (AV adrenal vein)

 ateral and Posterior Dissection L of the Kidney

Kidney is mobilized along the lateral surface and posterior surface. Posterior mobilization needs to perform with care when approaching to the renal hilum to avoid injury to

86

J. Chen et al.

renal pedicles. Kidney should be always ensure untwisted during the mobilization. Kidney will be completely mobilized with renal artery, renal vein and ureter remain intact (Fig.10.12).

2.7

Surgical Incision for Kidney Extraction

A 7  cm skin incision is made at the left iliac fossa, and opened in layer until entering the peritoneum. Assistant’s left hand is introduced into the peritoneal cavity through the incision without using of a hand port device, to facilitate handling and evacuation of donor kidney in the final stage.

Fig. 10.11  Perirenal adipose tissue is dissected along the kidney surface and the kidney is mobilized (K kidney)

Fig. 10.12  Kidney will be completely mobilized with renal artery, renal vein and ureter remain intact (K kidney, RV renal vein)

2.8

Transection of the Ureter

Recipient team must be ready with salted ice water and renal perfusion fluid. Ureter that is identified during lower pole dissection is transected at the level of the iliac fossa (Fig. 10.13).

2.9

Treatment of the Renal Pedicle

Renal artery is clipped at the root with two Hem-o-lok clips (Fig.  10.14), and subsequently transected distal the two Hem-o-lok clips. The renal vein is transected in the similar manner (Figs. 10.15 and 10.16). These Hem-o-lok clips are retained at proximal the stumps of renal artery and vein.

Fig. 10.13  Hand-assisted ligation of ureter

Fig. 10.14  Hand-assisted ligation and shearing of renal artery

10  Robotic Donor Nephrectomy

87

Fig. 10.15  Ligation of renal vein

Fig. 10.16  Clipping renal vein

Distal stumps at the donor kidney should not be clipped and remain open.

References

2.10

Kidney Extraction

Donor kidney is extracted with the left hand, kept in salted ice water immediately, and transferred quickly to the recipient team for further trimming and preparation for implantation.

1. Levey AS, Danovitch G, Hou S. Living donor kidney transplantation in the United States—looking back, looking forward. Am J Kidney Dis. 2011;58:343–8. 2. Lechevallier E. Laparoscopic living-donor nephrectomy: is it really better? Eur Urol. 2010;58:510–1; discussion 512–3. 3. Horgan S, Vanuno D, Benedetti E. Early experience with robotically assisted laparoscopic donor nephrectomy. Surg Laparosc Endosc Percutan Tech. 2002;12:64–70.

Retroperitoneal Laparoscopic Partial Nephrectomy

11

Songliang Du, Hongzhao Li, Xin Ma, and Xu Zhang

1

Introduction

n­ ephrectomy (PN) has achieved the same oncological outcome as compared to radical nephrectomy in patients with Renal cell carcinoma (RCC) accounts for about 2–3% of small renal mass [1, 2]. adult malignancies, and 80–90% of adult renal malignancies. Winfield and Gill reported the first case of laparoscopic Incidence of RCC in China increases over years. In recent partial nephrectomy (LPN) and retroperitoneal laparoscopic years, the majority of patients with RCC are asymptomatic partial nephrectomy (RLPN) in the treatment of benign renal and detected by health screening, which accounts for 50–60% disorders in 1993 and 1994 [3, 4], respectively. In 1993, of patients with renal cancer. McDougall reported the first case of LPN to treat renal canUltrasonography examination is a simple and non-­ cer. Progression of LPN was slow that time, mainly due to invasive examination method. As renal cancer is a solid technical difficulty to resect the tumor accurately and reconmass, it appears hypoechoic in ultrasound assessment, heter- struct the parenchyma with the limitation of ischemia time. oechoicity may result from central hemorrhage, necrosis, Over the past decade, LPN has developed into a mature surand cystic change. Information can be gathered from ultra- gery as the advancement of laparoscopic equipment and the sound is limited and unable to distinguish RCC from other continuous improvement of surgical techniques [5]. renal lesions such as renal cyst and angiomyolipoma in some circumstances. Computed Tomography (CT) renal 4 phases can diagnose most of the RCC and provide sufficient infor- 2 Indications and Contraindications mation as preoperative assessment. Magnetic resonance imaging (MRI), as compared to CT, can provide more define 2.1 Indications information and have advantages in the detection and diagnosis of small RCC, and more accurate in renal cystic lesions The indications for laparoscopic partial nephrectomy (LPN) assessment. MRI can accurate show intrarenal tumor margin are similar with open partial nephrectomy (OPN). and, invasion of the adjacent tissues, It is very useful to Absolute indications for LPN include tumor in solitary assess renal vein or inferior vena cava thrombus and the kidney, synchronous bilateral renal tumor, or unilateral lymph node metastasis. tumor with poorly/nonfunctioning contralateral kidney. The accuracy of imaging to diagnose renal malignancy is Relative indications for LPN include hereditary renal canmore than 90%, hence, renal biopsy has limited role in man- cer, syndromic renal tumor, or patient with high risk of future agement of renal tumor. Small renal mass that is equivocal in renal impairment due to diabetes, hypertension, or renovasimaging assessment, partial nephrectomy or regular follow- cular disease. ­up examination (1–3 month) is recommended. Renal biopsy Patients with a single, small (4 but4 cm: intermediate-term oncologic and functional outcomes. Urology. 2009;73(5):1077–82. 12. Dash A, Vickers AJ, Schachter LR, et al. Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4–7 cm. BJU Int. 2006;97(5):939–45. 13. Butler BP, Novick AC, Miller DP, et al. Management of small unilateral renal cell carcinomas: radical versus nephron-sparing surgery. Urology. 1995;45(1):34–40. 14. Scoll BJ, Uzzo RG, Chen DY, et  al. Robot-assisted partial nephrectomy: a large single-institutional experience. Urology. 2010;75(6):1328–34. 15. Hinata N, Fujisawa M.  Current status of robotic partial nephrectomy in Japan. Investig Clin Urol. 2016;57(Suppl 2):S121–9. 16. Dube H, Bahler CD, Sundaram CP.  The learning curve and factors affecting warm ischemia time during robot-assisted partial nephrectomy. Indian J Urol. 2015;31(3):223–8. 17. Haseebuddin M, Benway BM, Cabello JM, Bhayani SB.  Robot-­ assisted partial nephrectomy: evaluation of learning curve for an experienced renal surgeon. J Endourol. 2010;24(1):57–61. 18. Haber GP, White WM, Crouzet S, White MA, Forest S, Autorino R, et  al. Robotic versus laparoscopic partial nephrectomy: single-­ surgeon matched cohort study of 150 patients. Urology. 2010;76:754–8. 19. Kutikov A, Uzzo RG. The R.E.N.a.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol. 2009;182:844–53. 20. Lee JH, You CH, Min GE, et al. Comparison of the surgical outcome and renal function between radical and nephron-sparing surgery for renal cell carcinomas. Korean J Urol. 2007;48:671–6. 21. Aboumarzouk OM, Stein RJ, Eyraud R, et  al. Robotic versus laparoscopic partial nephrectomy: a systematic review and meta-­ analysis. Eur Urol. 2012;62(6):1023–33. 22. Bi L, Zhang C, Li K, et al. Robotic partial nephrectomy for renal tumors larger than 4 cm: a systematic review and meta-analysis. PLoS One. 2013;8(10):e75050. 23. Choi JE, You JH, Kim DK, Rha KH, Lee SH.  Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol. 2015;67:891–901. 24. Long JA, Yakoubi R, Lee B, et al. Robotic versus laparoscopic partial nephrectomy for complex tumors: comparison of perioperative outcomes. Eur Urol. 2012;61:1257–62. 25. Desai MM, Strzempkowski B, Matin SF, et al. Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy. J Urol. 2005;173(1):38–41. 26. Nambirajan T, Jeschke S, Al-Zahrani H, et  al. Prospective, randomized controlled study: transperitoneal laparoscopic

X. Lyu et al. versus retroperitoneoscopic radical nephrectomy. Urology. 2004;64(5):919–24. 27. Nadler RB, Loeb S, Clemens JQ, et  al. A prospective study of laparoscopic radical nephrectomy for T1 tumors—is transperitoneal, retroperitoneal or hand assisted the best approach? J Urol. 2006;175(4):1230–3. 28. Masson-Lecomte A, Bensalah K, Seringe E, et  al. A prospective comparison of surgical and pathological outcomes obtained after robot-assisted or pure laparoscopic partial nephrectomy in moderate to complex renal tumours: results from a French multicentre collaborative study. BJU Int. 2013 Feb;111(2):256–63. 29. Wahafu W, Ma X, Li HZ, et al. Evolving renorrhaphy technique for retroperitoneal laparoscopic partial nephrectomy: single-surgeon series. Int J Urol. 2014;21:865–73. 30. Patel M, Porter J.  Robotic retroperitoneal partial nephrectomy. World J Urol. 2013;31:1377–82. 31. Hughes-Hallett A, Patki P, Patel N, Barber NJ, Sullivan M, Thilagarajah R. Robot-assisted partial nephrectomy: a comparison of the transperitoneal and retroperitoneal approaches. J Endourol. 2013;27:869–74. 32. Hu JC, Treat E, Filson CP, et al. Technique and outcomes of robot-­ assisted retroperitoneoscopic partial nephrectomy: a multicenter study. Eur Urol. 2014;66:542–9. 33. Choo SH, Lee SY, Sung HH, et al. Transperitoneal versus retroperitoneal robotic partial nephrectomy: matched-pair comparisons by nephrometry scores. World J Urol. 2014;32:1523–9. 34. Kim EH, Larson JA, Potretzke AM, Hulsey NK, Bhayani SB, Figenshau RS. Retroperitoneal robot-assisted partial nephrectomy for posterior renal masses is associated with earlier hospital discharge: a single-institution retrospective comparison. J Endourol. 2015;29:1137–42. 35. Becker F, Van Poppel H, Hakenberg OW, Stief C, Gill I, Guazzoni G, et  al. Assessing the impact of ischaemia time during partial nephrectomy. Eur Urol. 2009;56:625–34. 36. Thompson RH, Frank I, Lohse CM, Saad IR, Fergany A, Zincke H, et al. The impact of ischemia time during open nephron s­ paring surgery on solitary kidneys: a multi-institutional study. J Urol. 2007;177:471–6. 37. Hruby S, Lusuardi L, Jeschke S, Janetschek G.  Cooling mechanisms in laparoscopic partial nephrectomy: are they really necessary? Arch Esp Urol. 2013;66:139–45. 38. Ward JP.  Determination of the optimum temperature for regional renal hypothermia during temporary renal ischaemia. Br J Urol. 1975;47:17–24. 39. Gill IS, Abreu SC, Desai MM, Steinberg AP, Ramani AP, Ng C, et al. Laparoscopic ice slush renal hypothermia for partial nephrectomy: the initial experience. J Urol. 2003;170:52–6. 40. Schoeppler GM, Klippstein E, Hell J, Hacker A, Trojan L, Alken P, et  al. Prolonged cold ischemia time for laparoscopic partial nephrectomy with a new cooling material: Freka-Gelice-a comparison of four cooling methods. J Endourol. 2010;24:1151–4. 41. Saitz TR, Dorsey PJ, Colli J, Lee BR.  Induction of cold ischemia in patients with solitary kidney using retrograde intrarenal cooling: 2-year functional outcomes. Int Urol Nephrol. 2013;45:313–20. 42. Landman J, Venkatesh R, Lee D, Vanlangendonck R, Morissey K, Andriole GL, et al. Renal hypothermia achieved by retrograde endoscopic cold saline perfusion: technique and initial clinical application. Urology. 2003;61:1023–5. 43. Janetschek G, Abdelmaksoud A, Bagheri F, Al-Zahrani H, Leeb K, Gschwendtner M. Laparoscopic partial nephrectomy in cold ischemia: renal artery perfusion. J Urol. 2004;171:68–71.

Retroperitoneal Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction

13

Guoxi Zhang, Taoping Shi, Hongzhao Li, and Xu Zhang

1

Introduction

Ureteropelvic junction obstruction (UPJO) is one of the common cause of hydronephrosis, occurring in one per 1500 live births [1]. UPJO may obstruct the flow of urine from the renal pelvis to the proximal ureter resulting a dilated of renal collective system. At the initial stage, the renal pelvic smooth muscle proliferates to enhance the peristalsis of renal pelvis, However, failure of peristalsis to overcome the obstruction will result in backpressure within the renal pelvis, and may lead to the atrophy of renal parenchyma and renal damage. The causes of UPJO remain largely unknown. Possible etiologies include the following. • Intrinsic obstruction Intrinsic obstruction may result from the congenital stenosis of UPJ, UPJ valve, UPJ polyp and high insertion of the ureter into the renal pelvis. The congenital stenosis of UPJ is the most common cause for UPJO, demonstrating muscularis hypertrophy and fibrous hyperplasia in UPJ. The stenosis is usually not longer than 2 cm, and the diameter of lumen is about 1–2 mm. UPJ valve is a congenital plica of muscle. The UPJ polyp has a sunflower appearance. The congenital stenosis of UPJ is usually accompanied by a high insertion of the ureter, which may be caused by congenital or secondary diseases usually accompanied by malrotation of kidney. • Extrinsic obstruction Extrinsic obstruction is often caused by crossing lower pole renal vessel(s) or entrapment of the ureter by a vessel or fiber rope, preventing the urine from flowing down the ureter. However, some authors believed that the ­“aberrant” G. Zhang Department of Urology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China T. Shi · H. Li · X. Zhang (*) Department of Urology, The First Medical Center, Chinese PLA General Hospital, Beijing, China e-mail: [email protected], [email protected]

vessel alone did not cause the primary obstruction, but an intrinsic lesion at the UPJ or proximal ureter [2, 3]. In contrast, some authors considered that not all the patients with a crossing vessel have intrinsic defect [4]. In our opinion, crossing lower-pole renal vessel(s) and intrinsic defect maybe co-exist or independently present. • Functional obstruction Functional obstruction is often caused by asymmetry of ureteral wall musculature or increased collagen deposition without intrinsic or extrinsic obstruction in UPJ. Functional obstruction may result in abnormal peristalsis through the UPJ, elevated intrarenal back pressure, dilatation of the collecting system, and hydronephrosis. Abnormal intramuscular nervous distribution and developmental defect of smooth muscle in the ureter may also lead to functional obstruction. The clinical presentation of UPJO is different according to the age of patients. Children may present with intermittent flank pain, hematuria, urinary tract infection, a flank mass. Adults with UPJO can present with various symptoms, including back and flank pain, urinary tract infection, and/or pyelonephritis. Other clinical presentations of UPJO include renal colic, abdominal pain due to the rupture of renal pelvis, hypertension caused by increased renin secretion due to the compression of the renal artery by the collective system, and the symptoms of renal insufficiency. Laboratory examination: • Routine urine test may show gross or microscopic hematuria, pyuria and bacteriuria. Urine culture may grow bacteria. • Serum creatinine and urea nitrogen level will increase gradually with the loss of kidney functions. Imaging examination: • Ultrasonography Ultrasonography is the first choice in the imaging examinations for diagnosis of UPJO, which can show the degree of hydronephrosis and the level of obstruction.

© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House 2020 X. Zhang (ed.), Laparoscopic and Robotic Surgery in Urology, https://doi.org/10.1007/978-981-13-3738-3_13

127

128

• Radiography Intravenous urography (IVU) can show the dilated renal pelvis and the stenosis, and determine the split renal function. If the contrast does not excrete well into the renal pelvis, delayed images may be required. KUB radiograph can be obtained 60 or 120 min, even 180 min after the administration of contrast material. The retrograde pyelography, percutaneous antegrade pyelography or magnetic resonance urography (MRU) may be required when IVU images are not clear. Retrograde pyelography is important for confirmation of the diagnosis and demonstration of the exact site and nature of obstruction before surgery. In most cases, retrograde pyelography is performed preoperatively to avoid the risk of introducing infection. Percutaneous antegrade pyelography and MRU are alternative to retrograde pyelography if the finding is not satisfactory. • Nephrogram Nephrogram is the most common method for evaluating renal excretory function. It can assess the glomerular filtration function and confirm the obstruction in upper urinary tract. Diuretic nephrogram is the standard practice in most of the center. Diuretic renogram can differentiate most of the equivocal result by inducing physiological diuresis to the dilated pelvic system. Result of diuretic nephrogram will be plotted in O’rally curve. Differential renal function and degree of hydronephrosis are the two most important parameters to be referred for the indication of surgical repair [5]. Both parameters are even more important for kidney selection to undergo surgery in bilateral PUJO. • Magnetic resonance imaging Magnetic resonance urography (MRU), is widely used in diagnosis of hydronephrosis. MRU can provide good quality to show the etiology level and degree of obstruction and hydronephrosis. MRU is superior to demonstrate both malignant and benign causes of obstruction due to its multi planar capability and superior soft tissue differentiation. MRU can be the imaging examination of choice in patients who are high risk to radiation and contract exposure such as children, pregnant women and patients with renal insufficiency [6]. • Computed tomography (CT) CT scan is usually obtained for the patients with hydronephrosis. Contrast-enhanced CT scan can provide detailed anatomical and functional information for the diagnosis of UPJO.  CT angiography (CTA) with threedimensional (3D) reconstructed images can help identify crossing vessels. The sensitivity and specificity of CTA in determining crossing vessels at UPJ is 91–100% and 96–100%, respectively. Management of UPJO is aimed to relieve the obstruction of the renal pelvis and protect the renal function. The

G. Zhang et al.

gold standard of UPJO management is dismembered Anderson Hyne’s pyeloplasty over decades with the success rate of more than 90%. This approach is suitable for different clinical scenarios. Precautions should be taken to preserve the vascularity of the upper ureter and pelvis, anastomosis should be tension free and watertight, crossing vessel need to be identified and transposed. The first laparoscopic pyeloplasty was reported by Schuessler [7] in 1993. In his case series, five patients with symptomatic UPJO underwent dismembered Anderson Hyne’s pyeloplasty. Operating time ranged from 3 to 7 h, with the majority of surgery time devoted to laparoscopic suturing (1–3 h). Complete resolution of symptoms was noted in all patients in average 12 months follow up (range 9–17  months). Laparoscopic dismembered pyeloplasty achieves the similar success rates as open surgery, with the addition advantages of minimal invasiveness [8, 9]. Laparoscopic dismembered pyeloplasty provides a higher success rate for UPJO as compared to endopyelotomy [10]. There are two approaches for laparoscopic pyeloplasties which are transperitoneal and retroperitoneal approaches [11]. Both transperitoneal and retroperitoneal approaches have high success rate. Retroperitoneal approach has better results in operative time, duration of hospital stay, recovery of intestinal function and resumption of oral feeding. In retroperitoneal approach, the crossing vessels are easier to be identified by elevation of the lower pole of the kidney, and transposition and reconstruction are not difficult to ­perform [12, 13]. From year 2000, we had performed more than 300 retroperitoneal laparoscopic pyeloplasties, majority were dismembered pyeloplasty. We improved and modified some key steps of this surgery based on our experience.

2

Indications and Contraindications

2.1

Indications

• Presence of one of the following for the patient with primarily UPJO: glomerular filtration rate (GFR) of the affected side kidney