Sammy Elsamra, MD, Associate Professor of Surgery (Urology) and Chief, Section of General Urology at Robert Wood Johnson University Hospital and Rutgers, is using the most advanced minimally invasive robotic surgery techniques to treat patients with complex diagnoses and conditions. In this video see how Dr. Elsamra uses single-port robotic surgery to perform a left partial nephrectomy. This localized, retroperitoneal approach minimizes pain and reduces hospital stay.
My name is Sammy L. Sara. I'm a urologic surgeon here at Rutgers Robert Wood Johnson Medical School and Robert Wood Johnson University Hospital in New Brunswick. Today we present a case of a 3 centimeter left lower pole renal mass treated with a single port robotic retroperitoneal partial nephrectomy. The patient is a 40 year old man with an incidentally detected 3 centimeter left lower pole renal mass noted on recent screening for cardiac risk evaluation. The patient is noted to have a large hepatic hemangioma, which is ultimately deemed benign. Patient is referred for partial nephrectomy. Patient's past medical history is unremarkable, except that he is a former smoker and his BMI is 25. An MRI of the abdomen and pelvis with and without contrast revealed. A 3 centimeter lower pole renal mass. Emanating from the lateral aspect of the kidney. Coronal view demonstrates the location of the mass. After obtaining informed consent, the patient agreed to proceed with a single port retroperitoneal partial nephrectomy. We performed the 4 centimeter incision in the lower anterior robotic access site just 2 finger breadths off of the anterior superiliac spine. We then. Added a sidecart 12 millimeter port to allow for a system to aid with passage of instruments and suctioning. The retroperitoneal space was entered behind the kidney, and the space between the kidney and the psoas muscle was developed. Naturally, we're in the camera below position and the #2 arm is utilized to elevate the kidney anteriorly. As we dissect on the medial aspect, we identify the ureter and then ultimately trace this up to the hilum as deemed by the pulsatile motions. The renal artery is skeletonized. Care is taken to ensure we have a proper window behind the renal artery. To allow for sunscreen bulldog placement. Once the renal artery is prepared, we then turn our attention to the kidney. We angle the camera. Upward in a cobra-like fashion, and we look up towards the kidney and defat the kidney and mobilize it within Groda's fascia. The kidney is mobilized sufficiently to allow for facile manipulation of the kidney and facile renorphy once the mass is removed. It is important for the surgeon to be able to toggle between the arms to maximize efficiency of motion. We then utilize the Fuji Areta drop in ultrasound probe to identify the mass. And ascertain its depth, we also appreciated the parapelvic renal cysts. The mass was scored along its uh interface with the capsule based on its external appearance and the appearance on ultrasound. At this point, the vascular bulldog clamp was introduced into the retroperitoneum, and it was applied using the force bipolar in the strong mode on the renal artery. We then proceeded with excision of the mass. We utilized the rosy to aspirate any blood from the partial nephrectomy as we proceeded. Sharp cautery was utilized along with some resection and nucleation. Toggling again between arms 1 and 2 and arms 1 and 3 allowed for retraction of the mass to allow for better access to the. Underside of this mess. We could see the parapelvic cyst that has entered in this area. The mess is completely resected. And the reory ensued. We utilize a 30 V lock suture in a running fashion to perform the deep renography, focusing on any sites of venous bleeding, and focusing on the corticomedullary junction, where most of the arterials will be entering. Once we near the end of the suture, we pass the suture through the capsule and secure it in place with a wet clip applied robotically. Suture is broken off at its interface with the needle, and an additional suture is brought in. The remainder of the deeper north is completed. This time the assistant utilized the wet clip. And again, suture is broken off from the needle. A 2OV lock suture is used to perform the capsular renography. Any a running, sliding, wet clip technique. Our bedside assistant is able to pass. The white clips. To bolster the suture and create tension across the capsular renorphy. Once the renorphy is complete. Utilize the force bipolargrasper in the strong mode to remove the bulldog vascular clamp. Clamp is removed from the body. The renal mass is also removed from the body and placed into the globe. Tisal hemostatic product is placed into the renorphy. And since we have a Groda's fascia that can be re-approximated, we re-approximate it. We place fibular into. The space below Groda's fascia on top of the reori. The case was unremarkable. Mom ischemia time was 19 minutes. Operative time was 1.5 hours, and the patient was discharged home from PACU without incident. We did not use a drain. Patient had no postoperative issues. And his pathology revealed grade 2 PT1A clear cell renal cell carcinoma with negative margins. Paisha had an excellent cosmetic effect. Single port robotic portion nephrectomy utilizes a small incision which allows for less pain, shorter length of stay, and regionalization of the operation. This regionalization allows for facile access to the retroperitoneum, a more direct route to the kidney and the mass, and favorable approach for posterior masses in an easier fashion. Thank you very much.
