Abstract
Robotic partial nephrectomy is an emerging procedure. The Washington University Renorrhaphy involves robotic assistance, rapid closure of the collecting system, and renorrhaphy with sliding nonabsorbable clips. Bolsters are rarely used. Preliminary results have shown very short ischemic times with few complications. This communication offers a short video describing the renorrhaphy.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
Robotic partial nephrectomy is an emerging procedure which is an alternative to laparoscopic and open partial nephrectomy. The procedure has been noted as similar to laparoscopic partial nephrectomy in several different technical descriptions [1–3]. Renorrhaphy has classically been performed with surgical bolsters and weck (Teleflex, Research Triangle Park, NC) hem-o-lok clips or lapra-ty (Ethicon, Cincinnati, OH) clips placed directly on the kidney with pressure [4, 5]. Alternatively, knots can be tied on the renal parenchyma to complete the renorrhaphy.
In an effort to simplify renal reconstruction, and to shorten warm ischemia times, a modification of laparoscopic renorrhaphy was adapted to robotic partial nephrectomy. After performing this renorrhaphy in 40 robotic partial nephrectomy cases, and unveiling the renorrhaphy technique at the 2008 World Robotic Urologic Symposium, the goal of this communication is to describe the technique and provide an accompanied videographic atlas.
Materials and methods
Robotic renorrhaphy was performed with several modifications to previous descriptions of the laparoscopic technique. After tumor excision and possible usage of energy sources on the bed, the renorrhaphy is performed. Although surgical bolsters are not used, they can be used if deemed necessary by the surgeon.
-
Step 1 Collecting system is oversewn with 2-0 vicryl suture on an SH needle. The stitch may be tied, or a lapra-ty clip may be used to secure the stitch. Lapra-ty clips are absorbable, and hem-o-lok clips are not, so only lapra-ty clips are used on the collecting system.
-
Step 2 (video) The renal capsular stitches are placed, usually every 1 cm along the defect. A #1 vicryl stitch is used on a CT needle. On the end of the stitch there is a weck clip on the inner “renal side” of the stitch and a knot/lapra-ty on the distal aspect of the stitch (Fig. 1). The weck clip is useful to have on the side of the kidney so more surface area can be used when compressing the parenchyma.
-
Step 3 (video) After sewing both sides of the renorrhaphy, a weck clip is placed on the stitch. By holding the stitch tightly with the prograsp instrument, and using the needle driver to apply gentle pressure on the weck clip (Fig. 1), the clip will slide down onto the kidney and can be tightened to any degree. It is critical to hold the stitch with a powerful grasper such as the prograsp so the surgeon may apply the proper countertension.
-
Step 4 (video) After sliding down the clips, they can be tightened further with each subsequent stitch, as less pressure is on each individual clip. After retightening the clips, lapra-ty clips may be applied to secure the weck clips from sliding back during renal reperfusion. Further stitches are placed in between existing sutures and then the kidney is unclamped.
Results
The simplified bolsterless renorrhaphy with “weck sliders” has been completed in 40 patients. The renorrhaphy has been rapidly performed with mean ischemic time of ~20 min in the series. For smaller peripheral tumors, <3 cm in size, the ischemic time is routinely less than 15 min. There has been one delayed bleed requiring transfusion in the series, which occurred in a patient who was heparinized for a pulmonary embolism. There has been one urine leak. The descriptive details of the series are under separate review. These were the only two renorrhaphy-related complications.
Discussion
The Washington University Renorrhaphy differs from previous laparoscopic descriptions in that clips are used as “sliding” clips. Furthermore, bolsters have been largely eliminated, as the renorrhaphy can be adequately tightened. Other laparoscopic reports have also eliminated bolsters [6]. This technique is ideally suited to robotic partial nephrectomy as the clips can be retightened as needed, allowing an extra degree of safety when performing renorrhaphy. Furthermore, the robotic needle driver allows the surgeon to tighten the weck clip with precision and accuracy. This method has been successful in this series, which is the largest reported series in the literature of robotic partial nephrectomy.
References
Gettman MT, Blute ML, Chow GK et al (2004) Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology 64:914–8
Phillips CK, Taneja SS, Stifelman MD (2005) Robot-assisted laparoscopic partial nephrectomy: the NYU technique. J Endourol 19:441–5
Bhayani SB (2008) da Vinci partial nephrectomy: an atlas of the four arm technique. J Robotic Surg 1:279–285
Orvieto MA, Chien GW, Tolhurst SR et al (2005) Simplifying laparoscopic partial nephrectomy: technical considerations for reproducible outcomes. Urology 66:976–80
Canales BK, Lynch AC, Fernandes E et al (2007) Novel technique of knotless hemostatic renal parenchymal suture repair during laparoscopic partial nephrectomy. Urology 70:358–9
Weight CJ, Lane BR, Gill IS (2007) Laparoscopic partial nephrectomy for selected central tumours: omitting the bolster. BJU Int 100:375–8
Acknowledgments
This research was funded by the MSI Research Director’s Fund.
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Below is the link to the electronic supplementary material.
ESM1 (MOV 40.9 MB)
Rights and permissions
About this article
Cite this article
Bhayani, S.B., Figenshau, R.S. The Washington University Renorrhaphy for robotic partial nephrectomy: a detailed description of the technique displayed at the 2008 World Robotic Urologic Symposium. J Robotic Surg 2, 139–140 (2008). https://doi.org/10.1007/s11701-008-0096-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11701-008-0096-4