Robotic-assisted Partial Nephrectomy
Key Points
Robotic-assisted partial nephrectomy (RAPN) is a minimally invasive surgical procedure used to remove a portion of the kidney (usually containing a suspected cancerous tumour) while preserving the healthy tissue.
Dr Ashrafi uses the latest da Vinci Xi robotic technology with very small, robotic instruments through small “keyhole” incisions to enhance the precision and dexterity of the surgery.
One of the keyhole incisions may need to be enlarged to remove the resected part of your kidney.
If successful, the procedure allows better preservation of kidney function than the complete removal of your kidney.
If partial removal is not considered feasible or is felt to be unsafe, we may decide to perform a complete removal of your kidney.
Bleeding, incomplete tumour clearance and urine leakage from the cut edge of the kidney are the major side-effects.
Dr Ashrafi uses a special enhanced recovery after surgery (ERAS) protocol to further improve your pain and recovery after surgery.
What does this procedure involve?
The robotic-assisted partial nephrectomy (RAPN) procedure involves several key steps. Here's an overview of what typically occurs during the procedure:
Anaesthesia: Before the surgery begins, the patient is given general anesthesia to ensure they are asleep and pain-free throughout the procedure.
Incisions: Dr Ashrafi will make several small incisions in the patient's abdomen. Typically, four to six small incisions are made, each about 8-12mm long. We use local anaesthetic to numb the keyhole incisions and minimise your discomfort when you wake up.
Trocar placement: Trocars, which are narrow tubes, are inserted through the incisions. These serve as access ports for the robotic instruments and the camera.
Robotic system setup: The da Vinci Surgical System is positioned near the patient. The surgeon sits at a console and manipulates the robotic arms and instruments. The robot does not perform any part of the procedure by itself. It is always under the direct control of the surgeon. Carbon dioxide gas is pumped into the abdomen. This helps the Dr Ashrafi see inside the abdomen. It also gives more room to work.
Camera insertion: A thin, high-definition camera is inserted through one of the trocars. The camera provides a magnified, three-dimensional view of the surgical site, allowing Dr. Ashrafi to visualise the kidney and surrounding structures in detail.
Robotic instrument insertion: Additional robotic instruments, including robotic arms with specialised tools, are inserted through the other trocars. These instruments are controlled by the surgeon from the console.
The bowel is dissected away from the surgical site.
The fat is removed from around the kidney tumour and the tumour is prepared for excision.
Renal artery clamping: To minimise bleeding and maintain optimal visualisation, Dr Ashrafi clamps the renal artery, temporarily stopping blood flow to the kidney.
Tumour excision: Using the robotic instruments, Dr Ashrrafi carefully removes the tumour or the affected part of the kidney while sparing healthy tissue. Precise dissection is performed to ensure complete removal of the tumour while preserving adequate healthy margins.
Renal reconstruction: After removing the tumour, Dr Ashrafi reconstructs the remaining kidney tissue to restore its normal function and maintain urine flow.
Haemostasis and inspection: Dr Ashrafi ensures that there is no bleeding from the surgical site and thoroughly inspects the area for any signs of bleeding or injury.
Trocar removal and closure: Once the procedure is completed, the robotic instruments and trocars are removed from the patient's abdomen. One of the keyhole incisions may need to be enlarged to remove the resected part of your kidney. The small incisions are typically closed with sutures.
Recovery and monitoring: The patient is moved to a recovery area where they are monitored closely. Pain management, antibiotics, and other post-operative care measures are provided as needed.
It's important to note that the specific details of the procedure may vary depending on the patient's condition and the tumour. Dr Ashrafi will assess each case individually and tailor the procedure accordingly.
What are the benefits of robotic-assisted partial nephrectomy?
Minimally invasive approach with reduced blood loss, less pain, shorter hospital stays, and faster recovery compared to traditional open surgery.
Robotic technology provides the surgeon with enhanced visualisation, dexterity, and control. T
Kidney preservation: The primary goal of RAPN is to remove the tumour or affected part of the kidney while preserving as much healthy kidney tissue as possible. This is particularly important for patients with a solitary kidney or pre-existing kidney disease.
Improved visualisation: The robotic system provides a three-dimensional, high-definition view of the surgical site, allowing the surgeon to see with greater clarity. It helps in identifying the tumour boundaries and critical structures, facilitating precise surgical maneuvers.
Precise dissection and suturing: The robotic instruments used in RAPN have articulating wrists that mimic the natural movement of the human hand. This enables Dr Ashrafi to perform precise dissection and suturing in a confined space, leading to improved surgical outcomes.
Reduced complications: RAPN has been associated with lower rates of complications, such as bleeding, infections, and damage to surrounding structures, compared to open surgery.
Shorter hospital stay and faster recovery: Due to the minimally invasive nature of RAPN, patients generally experience shorter hospital stays and quicker recovery times compared to traditional open surgery. This allows for a faster return to normal activities and a better quality of life.
Equivalent oncological outcomes: Studies have shown that RAPN provides comparable oncological outcomes to open surgery, with similar rates of cancer control and long-term survival.
What are the alternatives to robotic-assisted partial nephrectomy?
There are alternative approaches to robotic-assisted partial nephrectomy for the treatment of kidney tumours. These alternatives include:
Open partial nephrectomy: This is the traditional surgical approach where a large open incision is made in the abdomen or side to access the kidney. The surgeon directly operates on the kidney to remove the tumour and reconstruct the remaining healthy tissue. Open surgery provides direct visualisation and tactile feedback but typically involves longer hospital stays, more postoperative pain, and slower recovery compared to minimally invasive approaches.
Laparoscopic partial nephrectomy: Laparoscopic partial nephrectomy is a minimally invasive procedure similar to RAPN but without the use of robotic technology. Instead of robotic arms, the surgeon uses long, thin but rigid instruments inserted through small incisions to remove the tumour and reconstruct the kidney. Laparoscopic surgery offers benefits such as reduced blood loss, shorter hospital stays, and faster recovery compared to open surgery. However, it may have certain limitations in terms of instrument articulation and visualisation compared to robotic surgery.
Radiofrequency ablation (RFA) or Cryoablation: These are image-guided procedures that use thermal energy (RFA) or extreme cold (cryoablation) to destroy the tumour without removing it surgically. These techniques are typically used for smaller tumours or in cases where surgical removal may not be feasible. RFA and cryoablation are less invasive than surgical procedures, but they may have higher recurrence rates compared to partial nephrectomy.
Active surveillance: Active surveillance involves closely monitoring small kidney tumours over time without immediate treatment. It is typically recommended for older or frail patients, those with multiple health issues, or when the tumour is low-risk and unlikely to progress rapidly. Active surveillance involves periodic imaging and assessments to monitor tumour growth or any signs of progression.
The choice of treatment depends on various factors, including the size and location of the tumour, the patient's overall health, kidney function, and the surgeon's expertise. Dr Ashrafi will evaluate each case individually and discuss the available options with the patient to determine the most suitable treatment approach.
What happens on the day of the procedure?
Dr. Ashrafi will briefly review your history and medications and will discuss the surgery again with you to confirm your consent. An anaesthetist will see you to discuss the general anaesthetic and pain relief after the procedure. We may provide you with a pair of TED stockings to wear, and we may give you a heparin injection to thin your blood. These help to prevent blood clots from developing and passing into your lungs.
What can I expect after the procedure?
We will place a drain (tube) in the surgery site to remove excess fluid from the abdomen.
We put a catheter (long thin tube) in your bladder to drain the urine
All the keyhole incisions are closed with absorbable stitches
The procedure usually takes two to four hours to perform
After the procedure, you often get some bruising and swelling around the keyhole incisions together with some swelling or puffiness in your scrotum.
You may feel some shoulder pain and bloating until your bowel starts working again (normally after 24 hours).
Most patients can go home after a day or two.
Are there any after-effects?
If partial removal is not considered feasible or is felt to be unsafe, Dr Ashrafi may decide to perform a complete removal of your kidney
Bleeding, incomplete tumour clearance and urine leakage from the cut edge of the kidney are the major side-effects to partial nephrectomy
Pain or discomfort at the incision site (almost all patients)
Shoulder tip pain due to irritation of your diaphragm by the carbon dioxide gas (almost all patients)
Temporary abdominal bloating (almost all patients)
Bleeding, infection, pain or hernia at the incision site requiring further treatment (2-10%)
Removal of the whole kidney may be needed if partial removal is not thought to be possible (2-10%)
Bleeding during or after surgery requiring transfusion, embolisation or conversion to open surgery (2-10%)
A positive surgical margin requiring close observation or re-operation at a later date (2-10%)
Recognised or unrecognised injury to organs/blood vessels requiring conversion to open surgery or deferred open surgery (0.4-2%)
Inadvertent entry into your lung cavity requiring insertion of a temporary drainage tube (0.4-2%)
Urinary leakage from the cut edge of the kidney requiring further treatment (0.4-2%)
Involvement or injury to nearby local structures (blood vessels, spleen, liver, lung, pancreas & bowel) requiring more extensive surgery (0.4-2%)
Anaesthetic or cardiovascular problems possibly requiring intensive care including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death (0.4-2%)
What can I expect when I get home?
You will get some swelling and bruising of the incisions which may last several days.
It may be several days before you have your bowels open and this is normal. Dr Ashrafi will prescribe your bowel medications to keep your bowel movements soft and regular.
You will usually be given a script for the following medications:
non-opiate pain killers
medications to help bowel activity
antibiotics for a few days
Any medication you may need will be arranged and dispensed from the hospital pharmacy
A follow-up appointment will be made for post-operative review in 2-4 weeks
Disclaimer
We have made every effort to give accurate information but there may still be errors or omissions on this information page. We cannot accept responsibility for any loss from action taken (or not taken) as a result of this information.