Robotic Assisted Partial Nephrectomy
What is a Partial Nephrectomy?
A partial nephrectomy is an operation to remove part of your kidney that has disease or tumour with in it (See Fig.1.). This enables you to have disease removed but also preserve your kidney and its function (See Fig.2). Surrounding fatty tissue and lymph nodes, adrenal gland and upper end of your ureter are not removed as they in a radical or “total” nephrectomy procedure. It is usually the standard of care for tumours <4cm in diameter (Stage T1a)
Fig.1 Tumour or disease removed from kidney (dotted lines)
The Kidney is then repaired. In robotic-assisted laparoscopic surgery this is done without the use of a hand or large incisions.
What is an Open Partial Nephrectomy?
Open partial nephrectomy is the traditional operation for removing a particular part of the kidney. The surgeon makes a flank incision approximately 15-20cm (6-8 inches) long allowing enough room to remove the disease from a kidney. This is required if it is not technically possible or considered too difficult to remove part of the kidney using keyhole techniques.
What is laparoscopic surgery?
Laparoscopic surgery is key-hole surgery that is performed without having to make a large cut (incision). Instead surgery is carried out through small key-hole instruments inserted into the abdomen via small incisions. Carbon dioxide gas fills the abdomen to enable vision of the internal organs.
What is robotic assisted surgery?
This is laparoscopic surgery using robotic assistance through the small key-hole incisions. In this is technique a robotic system is placed beside you. Attached to this are 3 or 4 robotic arms; two/three for instrument attachments and the other arm for a high magnification 3D camera to allow the surgeon to see within you abdomen (tummy). The instruments are approximately 8 mm in diameter and permit very delicate and precise movements including suturing/stitching within the abdomen. .
Guys Hospital was one of the first U.K trusts to offer robotic-assisted surgery for urological procedures. At present there are 27 Da Vinci® robotic systems available in the U.K and around 7 are offering partial nephrectomy. The da Vinci® system is used extensively throughout the U.S. and Europe; it is being used currently in many different areas of surgery. Other procedures performed at Guy’s Hospital include radical prostatectomy or radical cystectomy for the removal of the prostate and bladder due to cancer.
What is a Robot assisted laparoscopic Partial Nephrectomy?
Robot assisted laparoscopic partial nephrectomy is key-hole surgery to remove a diseased part from a kidney using the da Vinci robotic system. The da Vinci® robot has several advantages that may make it useful for partial nephrectomy in the treatment of kidney cancer.
The da Vinci® robot has an excellent optical system that provides high-definition imaging and a three dimensional (3D) view for the surgeon. Guy’s Hospital has the latest da Vinci robot, the Si Dual console, and is the most experienced robotic centre in the UK, The da Vinci system also offers the surgeon improved dexterity as it uses intuitive operative controls to move instruments with greater a capability than standard laparoscopy would normally allow. These controls may allow for greater operative precision during the tumour removal and subsequent reconstruction (rebuilding) of the kidney during the laparoscopic partial nephrectomy procedure.
Robotic Urological Surgery
Figure 2: The surgeon console, patient-side cart and high definition video system are the key components of the da Vinci Si robot
1. Avoids open surgery and the resulting large scar and muscle damage. Smaller scars from the ports will be visible
2. Shorter hospital stay of usually 3-4 days
3. Less pain after the operation.
4. Quicker full recovery and earlier return to work
5. Quicker and more precise suturing than is possible with standard laparoscopy.
Risks of the Procedure
As in any complex surgery there are a few risks of which the common ones are:
1. Bleeding and blood transfusion (<5%). Occasionally a bleeding blood vessel can be stopped in the x-ray department by blocking the bleeding vessel using angiography (blood vessel imaging).
2. Damage to structures around the kidney: spleen, colon, liver, pancreas, bowel (2%)
3. Urinary leak around the kidney or bleeding into the ureter tube, if removing the tumour causes entry into the kidney’s urine collecting system (3-5%). This may require a prolonged hospital stay, insertion of a ureteric stent (internal drainage tube into the ureter) or re-insertion of a drainage tube through the skin.
4. Conversion to open surgery due to robot failure, bleeding, or other complications.
5. Total/radical nephrectomy if partial nephrectomy is not technically possible
6. Anaesthetic complications: including irregular heartbeat, chest infection, blood clots in the legs/lungs.
7. 10-20% chance that the tumour removed is not cancerous and is a relatively harmless benign growth.
8. Late complications: port site hernia, scaring, cancer recurrence.
9. The risk of dying from laparoscopic urologic surgery is extremely low and is roughly between 0.03-0.08%
Please ask any questions that you wish prior to consenting for your operation.
Preparing for your surgery
Your consultant should discuss the details of the procedure with you in outpatients outlining the procedure as part of your consent.
You should have attended a pre-assessment clinic prior to your admission to hospital to assess your suitability for this procedure and fitness to undergo general anaesthesia and surgery.
Prior to your surgery you will need to sign a consent form and have your skin marked at the site of the surgery. This consent gives the consultant permission to operate on you. Before you sign this, please ensure that you fully understand the procedure you are about to undergo. If you do have any questions, concerns please ask your consulting team to clarify them for you.
The day of your surgery
You may eat and drink, as you desire the evening prior to surgery however a minimum of 6 hours prior to your surgery you will need to be Nil By Mouth (NBM), which is to have nothing at all by mouth prior to surgery. A full general anaesthetic is required for robotic partial nephrectomy.
After Robotic Assisted Laparoscopic Partial Nephrectomy?
You will wake up with a catheter into your bladder, a wound drain from your tummy, and have 4-5 small wounds from where the robotic arm port sites have been made.
Once your procedure is completed you will be taken to the recovery department to be monitored by the staff before transfer back to the ward.
Once you are stable then you will be transferred back to the ward. We do ask that while immobile and bed bound post operatively that you move your feet, wiggle your toes to help promote circulation in your legs.
Your catheter will remain in for approximately 24 hours, the drain will also come out generally after 48 hours. You will have blood tests on the first 2 days.
Your average length of stay for this procedure is 3-4days.
You will be discharged when you have passed wind (flatus), you are mobilising safely, you are passing urine well, and your pain is well controlled on appropriate oral analgesics.
You will need to return for an outpatient appointment at the Wednesday renal cancer clinic with your consulting team to get the results from your surgery.
What can I expect after getting home?
You should not forget that although you may feel well and have no large scar, you still have had major surgery.
You will need a period of time to recover fully before returning to normal activities. You should be active within your home and build up to returning to your usual tasks.
You may have some pain associated with the surgery and also occasional bouts of lethargy are not uncommon after major surgery. You may need to rest/sleep more than usual in the first 2 weeks after the operation.
What are the disadvantages of me having a Robotic Assisted Laparoscopic Nephrectomy as opposed to open Nephrectomy?
This operation needs specialised training, as the surgeon is unable to “feel” your tissues or organs unlike open surgery. It is only suitable for certain kidney tumours and your surgeon will tell you if you are suitable.
Some commonly asked questions?
Does the robot do the surgery?
No, the surgeon does the operation. The robot is an instrument that allows the surgeon to operate in small spaces in the body. It essentially makes the surgeon's hands two seven-millimeter instruments. The robot is controlled by the surgeon and does not work on its own.
How much pain will I be in?
Since the surgery is done through a small incision, most patients experience much less post procedure pain then with open surgery. You will have regular pain killers by mouth or injection for the first few days. Patients tend to need much less pain medication. After one week, most are feeling no pain at all.
When can I exercise?
Light walking is encouraged right after the procedure. After 2 weeks brisk walking is recommended. After four weeks, jogging, aerobic exercise and heavy lifting can resume.
Can I shower or bath?
Yes, the stitches in your tummy are either dissolvable or waterproof clips, we just asked that you rinse thoroughly the soap from your body as this may irritate the wounds and that you pat yourself completely dry.
When can I drive?
When you are comfortable to do so; and when able to make an emergency stop. Please also check with your insurance company before returning to drive.
When can I resume sexual activity?
This will depend on when both you and your partner feel comfortable but is safe after the first week.
When can I return to work?
Please allow a couple of weeks’ recuperation before returning to work, if you work entails lifting please speak to your consultant prior to leaving hospital.