Robotic retroperitoneal partial nephrectomy: A step by step approach

Abstract

Objectives: The early adoption of robotic partial nephrectomy was mainly via the transperitoneal approach [1] due to increased working space, familiar landmarks and ease of access. However, the retroperitoneal approach for robotic partial nephrectomy has been shown to decrease operative time, blood loss, and length of stay [2–4], without an increase in perioperative complications [5, 6]. There are, however, technical nuances in creating the retroperitoneal space and completing this approach safely. We describe our technique for gaining access to the retroperitoneum for robotic retroperitoneal partial nephrectomy. Methods: The patient is completely anesthetized and placed in the full flank (90 degree) position. The table is flexed at the level of the umbilicus to increase the space between the iliac crest and 12th rib to allow enough space for access. Initial access to the retroperitoneum is gained through an incision in the mid-axillary line just above the iliac crest and the oblique muscles and lumbodorsal fascia are separate bluntly. This allows access to the retroperitoneal space which is finger dissected to allow placement of a dilating balloon. The retroperitoneal space is expanded under direct vision with the aid of the robotic endoscope and this allows the retroperitoneal landmarks to be seen without obstructing fat or bleeding vessels. Once the space is developed a 3 or 4 robotic ports with one assistant port are placed under direct vision. If 4 ports are used, the anterior reflection of the peritoneum is bluntly pushed medially off of the transversus abdominus muscle to create enough space for the additional port to be placed anteriorly. The robot is then docked and robotic partial nephrectomy is performed using the same principles as the transperitoneal approach. Results: Robotic retroperitoneal partial nephrectomy was performed using a 4 robotic port configuration and one 12 mm assistant port. The steps of the technique that are highlighted include: 1) placing patient in the full flank position, 2) access and balloon dilation of the retroperitoneal space, 3) peritoneal mobilization to allow space for 4 robotic ports, 4) port placement under direct vision, 5) docking, 6) management of paranephric fat, 4) incision of Gerota's fascia above the psoas muscle and exposure of renal artery. Conclusion: Retroperitoneal approach for robotic partial nephrectomy is safe and reproducible. The access technique is standardized and reproducible.