Robotic Surgery in Kidney Tumor Treatment
The gold standard in the treatment of localized kidney tumors is surgical resection.
In recent years, there has been a trend towards partial nephrectomy in cases. The reason for this trend is the fact that chronic renal failure is more common in patients who underwent radical nephrectomy, even if other renal functions are normal pre-operatively, and therefore, the desire and aim of preserving renal functions as much as possible.
The use of the da Vinci system (Intuitive Surgical Corporation, Sunnyvale, California, USA) is increasing, especially in radical prostatectomy. Possible advantages of robot-assisted laparoscopic surgery over laparoscopy; Robot-assisted laparoscopic radical and partial nephrectomy is laparoscopic and open nephrectomy.
Technique: Robot-assisted laparoscopic nephrectomy is performed under general anesthesia. The anesthesia team should be alert for the effects of CO2 insufflation and pneumopertonium, such as oliguria and hypercarbia. The basics of surgical dissection in robot-assisted laparoscopic nephrectomy are similar to the laparoscopic method. In the transperitoneal method, the patient is placed in the lateral position (45 -60°), and the pneumoperitoneum is created by entering with a Veress needle as in the laparoscopic method. Then, the robot-assisted laparoscopic arms and the necessary ports for the assistant are placed and the surgery is started.(17)
Robotic Surgery
(Robot Assisted Minimally Invasive Surgery):
The operation is performed over the robotic arms sent to the target anatomy through incisions made on the patient’s abdominal wall. One of the incisions is used for the camera that sends a 3D HD, real, simultaneous view of the operating field to the surgeon’s console. The surgeon manages the robotic instruments using his console. In this way, it reaches very narrow areas and has the chance to perform maneuvers that cannot be done by human hands. In addition, it eliminates the hand tremor problem experienced in laparoscopic surgery and can perform rotation maneuvers that laparoscopic instruments cannot. The 3D HD image quality provided to the surgeon is one of the features that distinguishes robotic surgery from laparoscopic surgery. In robotic radical nephrectomy surgery, it feeds the kidney and carries the dirty blood in the kidney.
After the vessels are identified and closed, the connection of the kidney with these vessels and the ureter is cut. The kidney, which is separated from the surrounding tissues, is removed from the body and the operation is terminated. In robotic partial nephrectomy surgery, after the tumor area is determined and marked with an instant ultrasound image during the operation, thanks to a feature offered by the da Vinci Robotic Surgery System, the vessels that feed the kidney and carry the dirty blood from the kidney are closed for a short time. After the tumor is separated from the kidney and the removed area is closed, the blood inlet and outlet in the veins are opened. The operation is terminated by removing the tumor from the body. The very small incisions made in robotic surgery allow the patient to return to his daily life faster after the surgery.
ROBOTIC SURGERY FOR TESTICULAR TUMOR
The use of the da-Vinci robotic system allowed laparoscopic surgery to mimic an open bilateral approach without repositioning the patient. The robot also enables easier and more complex dissections that may allow for further resection of post-chemotherapy masses and more complete dissection behind the great vessels.
The development of the supine approach to robotic RPLND allows surgeons to better mimic open techniques and perform a complete, bilateral dissection.
Initially, during robotic RPLND, patients are placed in the lateral decubitus position to facilitate modified template dissection. This approach allows for modified template-based dissection as previously published and is sufficient for early-stage disease, but may require repositioning if a complete bilateral dissection is attempted.
The use of the robotic system (Davinci Xi) allows for wider dissection. This technique is particularly useful when performing large postchemotherapy retroperitoneal dissections. Although the complication rates between open and R-RPLND are comparable, the rate of chylous ascites is reported to be <1% versus approximately 4% in the L-RPLND and R-RPLND series, respectively. Meticulous use of surgical clips around the left renal vein and lymphatic ducts can minimize the risk of chylous ascites. Anterograde loss of ejaculation is another frequently cited complication associated with RPLND. In R-RPLND, 100% of patients can maintain ejaculatory function, at least in the primary setting with modified templates.
Reference: 1.Werntz, et al. Indications, evolving technique, and early outcomes with robotic retroperitoneal lymph node dissection, Current Opinion in Urology: September 2018 – Volume 28 – Issue 5 – p 461-468
ROBOTIC SURGERY (ROBOT ASSISTED LAPAROSCOPIC CYSTECTOMY MINIMALLY INVASIVE SURGERY)
Bladder cancer surgeries (cystectomy) involve removing the bladder, part of the ureter, and surrounding lymph nodes. When necessary, prostate and semen sacs in men; in women, it may also involve removing the uterus, ovaries, and vagina. In robotic bladder cancer surgeries, 1 cm incisions are made in the lower part of the patient’s abdomen. The surgeon performs the surgery by simultaneously managing the robotic instruments sent through these incisions from the console in the operating room. At the same time, a camera is sent from one of the incisions to the surgeon’s console, which simultaneously transmits a real 3-dimensional image. In bladder cancer surgery, after the bladder and necessary surrounding tissues are removed, a new outlet for urine is created and the surgery is terminated. One of the advantages of robotic surgery for bladder cancer surgeries is to ensure that the surrounding tissues are not damaged by performing smaller maneuvers in very narrow areas. This advantage is of great importance in the protection of the vascular and nerve structures that provide sexual function, especially in men. The very small incisions made in robotic surgery allow the patient to return to his daily life faster after the surgery.
ROBOTIC SURGERY IN PROSTATE CANCER (RADICAL PROSTATECTOMY-LYMPHADENECTOMY)
Robotic Surgery
(Robot-Assisted Laparoscopic Radical Prostatectomy
Minimally Invasive Surgery):
The camera, which transmits the 3D HD real image of the instruments and the operation area to the surgeon console, is sent to the patient’s operating area through small incisions. By controlling these instruments, which can rotate 540 degrees from the console in the operating room, the surgeon performs the operation in very narrow spaces with maneuvers that human hands cannot do.
The biggest advantage of robotic surgery to prostate cancer surgery is that instruments can be moved freely in very narrow spaces. The prostate is found only in men, and the pelvic area of men is much narrower than that of women. During the operation, the prostate is separated from the bladder and urethra, and the bladder is brought closer to the urethra and joined together. Thus, the urinary tract is restored. This method, which helps to protect the nerves, minimizes the risks of urinary incontinence and sexual insufficiency after surgery. In addition, the small incisions made during the surgery allow the patient to return to his daily life faster after the surgery.
ROBOTIC SURGERY OF BENIGN PROSTATE HYPERPLASIA (BPH)
(MILLIN ADENEMECTOMY)
Adenomectomy surgery is the most effective treatment in the treatment of patients with large prostates. In recent years, it has come to the fore with the development of robotic surgery.
In addition, it may be preferred in the presence of a large bladder stone with BPH or when there are orthopedic problems that may prevent positioning for closed surgeries. Mild to moderate pain may occur after the operation. The urinary catheter is usually withdrawn in 4-7 days and a hospital stay may be required during this time.
The fact that patients consult the doctor earlier and the diagnosis is made in the early period, and that the endoscopic methods have shown great improvement, have enabled the majority of surgical treatments to turn into closed interventions. Closed surgeries are interventions that are performed using special instruments under direct observation through the camera view through the urinary tract.
The common method used for prostates over 100Gr was open prostatectomy and was first described and applied by Millin in 1947. With the development of technology, the laparoscopic technique, which was first applied and described by Mariano et al., started to be used in 2002. With the use of laparoscopic prostatectomy, it was observed that there was a greater improvement in the quality of life with a greater improvement in complaints compared to open surgery, and also less blood loss, shorter hospital stay, and less urethral catheterization time.
With the developments in the last 20 years, we started to use the robotic method in surgery. Robotic surgery has emerged as a more effective surgical method than laparoscopic surgery because it provides a three-dimensional image, surgical sutures are applied more precisely, and its mobility is better. Robotic surgery is the most common method I use for prostates over 100 grams. It is also an important advantage that stone surgery can be done easily.
We applied a new method in our robotic prostatectomy (adenomectomy) series and achieved more success compared to the surgical methods performed so far.
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