A Prospective Evaluation of the Utility of Laparoscopic Doppler Technology During Minimally Invasive Partial Nephrectomy

Current Application of Navigation Systems in Robotic-Assisted and Laparoscopic Partial Nephrectomy: Focus on the Improvement of Surgical Performance and Outcomes

Kidney cancer represents the third most prevalent malignancy among all types of genitourinary cancer worldwide. Currently, there is a growing trend of employing partial nephrectomy for the management of large and complex tumors. Surgical outcomes are associated with some amendable surgical factors, including warm ischemic time, pedicle clamping, preserved volume of renal parenchyma, appropriate surgical strategy, and precise resection of the tumor. Improving surgical performance is pivotal for achieving favorable surgical outcomes. Due to advancements in imaging visualization technology and the shift of the medical paradigm toward precision medicine, an increasing number of navigation systems have been implemented in partial nephrectomy procedures. The navigation system can assist surgeons in formulating optimal surgical strategies and enhance the safety, precision, and feasibility of resecting complex renal tumors. In this review, we provide an overview of currently available navigation systems and their feasible applications, with a focus on how they contribute to the improvement of surgical performance and outcomes during robotic-assisted and laparoscopic partial nephrectomy.

Intraoperative ultrasonography (IOUS)-guided vs conventional laparoscopic nephrectomy: a randomised control trial

OBJECTIVES

To assess the efficacy of routine use of intraoperative ultrasonography (IOUS) in improving perioperative outcomes in patients undergoing IOUS-guided laparoscopic nephrectomy (IOUS-LN) and conventional laparoscopic nephrectomy (C-LN).

PATIENTS AND METHODS

This was a parallel-arm, single-blinded, randomised controlled trial (CTRI/2021/12/038906). All patients undergoing LN, either for benign or malignant causes, were included. Patients undergoing partial/cytoreductive nephrectomy, with venous thrombus were excluded. In the study arm, IOUS-guided renal vascular assessment was performed after colon mobilisation and a standard LN was performed in the control arm. The primary outcome was intraoperative duration. The secondary outcomes were blood loss, need for open conversion, blood transfusion, perioperative complications, duration of Intensive Care Unit (ICU) stay and length of hospitalisation (LOH). The patients were followed for 3 months after surgery.

RESULTS

A total of 104 patients were included, with 52 in each arm. Demographic characteristics were comparable in both arms. A significant reduction in the operative duration (mean [sd] 181.69 [40.8] vs 199.7 [41.8] min, P = 0.02) was seen in the IOUS-LN group. The difference in blood loss showed no significant difference when compared between both groups (median [interquartile range] 84.55 [74-105.5] vs 99.95 [78.5-111] mL, P = 0.08). On subgroup analysis, the reduction in the operative duration was significant in patients who underwent laparoscopic simple nephrectomy (LSN; mean [sd] 194.4 [42.5] vs 221.2 [36.4] min, P = 0.01), whereas comparable operative durations were seen in patients undergoing laparoscopic radical nephrectomy (LRN; mean [sd] 168.96 [35.3] vs 178.3 [35.9] min, P = 0.34). Similar conversion rates were seen in both groups (P = 0.98) along with blood transfusions (P = 0.78). The LOH, ICU stay, and complications were similar in both groups. Significantly less blood loss (P = 0.03) was noted with IOUS in patients undergoing LSN. IOUS did not influence any outcomes in patients undergoing LRN.

CONCLUSION

Intraoperative ultrasonography significantly reduced the operative duration in LN, but with no significant reduction in the volume of blood loss. Significant reduction in intraoperative duration and blood loss was seen in patients who underwent LSN on subgroup analysis.

New imaging technologies for robotic kidney cancer surgery

Objective

Kidney cancers account for approximately 2% of all newly diagnosed cancer in 2020. Among the primary treatment options for kidney cancer, urologist may choose between radical or partial nephrectomy, or ablative therapies. Nowadays, robotic-assisted partial nephrectomy (RAPN) for the management of renal cancers has gained popularity, up to being considered the gold standard. However, RAPN is a challenging procedure with a steep learning curve.

Methods

In this narrative review, different imaging technologies used to guide and aid RAPN are discussed.

Results

Three-dimensional visualization technology has been extensively discussed in RAPN, showing its value in enhancing robotic-surgery training, patient counseling, surgical planning, and intraoperative guidance. Intraoperative imaging technologies such as intracorporeal ultrasound, near-infrared fluorescent imaging, and intraoperative pathological examination can also be used to improve the outcomes following RAPN. Finally, artificial intelligence may play a role in the field of RAPN soon.

Conclusion

RAPN is a complex surgery; however, many imaging technologies may play an important role in facilitating it.

Laparoscopic and Robotic-Assisted Partial Nephrectomy: An Overview of Hot Issues

Laparoscopic partial nephrectomy and robot-assisted partial nephrectomy are attracting increased attention from urologists. They can achieve the same effect of oncology control as radical nephrectomy; moreover, they can offer better preservation of renal function, thus obtaining long-term living benefits. The indications are also expanding, making it possible for larger and more difficult tumors. Laparoscopic partial nephrectomy and robot-assisted partial nephrectomy can be performed by transperitoneal and retroperitoneal approaches, with their individual advantages and limitations. In addition, the renal tumor scoring systems have been widely used and studied in laparoscopic partial nephrectomy and robot-assisted partial nephrectomy. In -order to better preserve renal function, the zero-ischemia technique is widely used. The application of intraoperative imaging technology provides convenience and greater benefits. Besides, whether minimal invasive partial nephrectomy can be performed without stop antiplatelet treatment is still disputed. Clinicians perform substantial exploration and practice to achieve the "trifecta" of surgery: complete resection of the tumor, maximum protection of renal function, and no complications.

How well do software assistants for minimally invasive partial nephrectomy meet surgeon information needs? A cognitive task analysis and literature review study

INTRODUCTION

Intraoperative software assistance is gaining increasing importance in laparoscopic and robot-assisted surgery. Within the user-centred development process of such systems, the first question to be asked is: What information does the surgeon need and when does he or she need it? In this article, we present an approach to investigate these surgeon information needs for minimally invasive partial nephrectomy and compare these needs to the relevant surgical computer assistance literature.

MATERIALS AND METHODS

First, we conducted a literature-based hierarchical task analysis of the surgical procedure. This task analysis was taken as a basis for a qualitative in-depth interview study with nine experienced surgical urologists. The study employed a cognitive task analysis method to elicit surgeons' information needs during minimally invasive partial nephrectomy. Finally, a systematic literature search was conducted to review proposed software assistance solutions for minimally invasive partial nephrectomy. The review focused on what information the solutions present to the surgeon and what phase of the surgery they aim to support.

RESULTS

The task analysis yielded a workflow description for minimally invasive partial nephrectomy. During the subsequent interview study, we identified three challenging phases of the procedure, which may particularly benefit from software assistance. These phases are I. Hilar and vascular management, II. Tumour excision, and III. Repair of the renal defects. Between these phases, 25 individual challenges were found which define the surgeon information needs. The literature review identified 34 relevant publications, all of which aim to support the surgeon in hilar and vascular management (phase I) or tumour excision (phase II).

CONCLUSION

The work presented in this article identified unmet surgeon information needs in minimally invasive partial nephrectomy. Namely, our results suggest that future solutions should address the repair of renal defects (phase III) or put more focus on the renal collecting system as a critical anatomical structure.

Application of intraoperative ultrasonography in retroperitoneal laparoscopic partial nephrectomy: A single-center experience of recent 199 cases

Objectives:

To summarize the value and application experiences of intraoperative laparoscopic ultrasonography (ILUS) in retroperitoneal laparoscopic partial nephrectomy (RLPN).

Materials and Methods:

From January 2013 to December 2018, RLPN with ILUS was performed on the recent 199 patients in our center (two patients received bilateral RLPN due to suspected malignancy of both right and left sides), and the relevant clinical and follow-up data were retrospectively reviewed. Among them, 119 patients were male and 80 were female; the age of patients was 53.4 ± 12.3 years. Of all the renal tumors, 105 were located on the left side and 96 on the right side with a RENAL score of 6.6 ± 1.7. All the patients were diagnosed as or suspected of having a renal tumor by preoperative imaging examination. The ILUS was applied in all the operations to help locate the tumor, delineate the boundary, clarify the diagnosis, observe the blood supply, and so on.

Results:

RLPN with ILUS in these 199 patients was successfully performed without conversion to open surgery. All surgeries were completed in 90.2 ± 21.7 min, with 73.6 ± 89.2 mL for estimated blood loss, and 19.3 ± 5.6 min for warm ischemia time. The tumor size was 3.6 ± 1.5 cm, and all the surgical margins were negative. The drainage days and postoperative hospital days were 4.7 ± 2.3 and 6.1 ± 2.3, respectively. The preoperative creatinine was 69.7 ± 19.4 μmol/L compared with 61.6 ± 12.7 μmol/L measured 1 month postoperatively. There were 17 cases of renal cell carcinoma no more than 1 cm, and they were resected without artery clamp or a large amount of blood loss. Satellite tumors were confirmed in 12 cases, of which 8 were not detected by preoperative examinations and finally found by ILUS during surgeries.

Conclusion:

ILUS can alleviate the difficulty of preoperative diagnosis, facilitate surgical dissection, and improve the effect of nephron-sparing surgeries. Due to its great advantage, ILUS should further be promoted and applied.

Laparoscopic ultrasonography: The wave of the future in renal cell carcinoma?

Laparoscopic or robotic surgery is the main method of treating renal cell carcinoma (RCC). Laparoscopic surgery can accurately target lesions and shorten patient recovery time. Renal endogenous tumors or inferior vena cava tumor thrombi are very difficult to remove using the laparoscopic approach. The emergence of laparoscopic ultrasonography (LUS) has solved this problem. LUS can assist in the detection of tumor boundaries and the extent of tumor thrombi. The lack of tactile feedback may hinder the development of laparoscopic surgery for the treatment of renal cancer. LUS has become an important tool that has improved the rates of successful surgery. LUS is applied in not only early and locally advanced RCC treatment but also in monitoring ablation therapy, testing renal blood perfusion, and exposing renal pedicles. Sonographic techniques used for LUS include initial B-mode, Doppler, and contrast-enhanced ultrasound (CEUS). Contrast agents applied for CEUS do not induce nephrotoxicity and can display renal perfusion more accurately than the regular color Doppler ultrasound. According to current literature, LUS is a promising technique for the treatment of RCC, especially for endogenous RCC or RCC with thrombosis, and for monitoring the effectiveness of radiofrequency ablation, although further well-designed studies are warranted.

Clinical impact of intraoperative navigation using a Doppler ultrasonographic guided vessel tracking technique for pancreaticoduodenectomy

During pancreaticoduodenectomy (PD), early ligation of critical vessels such as the inferior pancreaticoduodenal artery (IPDA) has been reported to reduce blood loss. Color Doppler flow imaging has become the useful diagnostic methods for the delineation of the anatomy. In this study, we assessed the utility of the intraoperative Doppler ultrasonography (Dop-US) guided vessel detection and tracking technique (Dop-Navi) for identifying critical arteries in order to reduce operative bleeding. Ninety patients who received PD for periampullary or pancreatic disease were enrolled. After 14 patients were excluded because of combined resection of portal vein or other organs, the remaining were assigned to 1 of 2 groups: patients for whom Dop-Navi was used (n = 37) and those for whom Dop-Navi was not used (n = 39; controls). We compared the ability of Dop-Navi to identify critical vessels to that of preoperative multi-detector computed tomography (MD-CT), using MD-CT data, as well as compared the perioperative status and postoperative outcome between the 2 patient groups. Intraoperative Dop-US was significantly superior to MD-CT in terms of identifying number of vessels and the ability to discriminate the IPDA from the superior mesenteric artery (SMA) based on blood flow velocity. The Dop-Navi patients had shorter operation times (531 min versus 577 min; no significance) and smaller bleeding volumes (1120 mL versus 1590 mL; P < 0.01) than the control patients without increasing postoperative complications. Intraoperative Dop-Navi method allows surgeons to clearly identify the IPDA during PD and to avoid injuries to major arteries.

Robotic microsurgery optimization

The increased application of the da Vinci robotic platform (Intuitive Surgical Inc.) for microsurgery has led to the development of new adjunctive surgical instrumentation. In microsurgery, the robotic platform can provide high definition 12×-15× digital magnification, broader range of motion, fine instrument handling with decreased tremor, reduced surgeon fatigue, and improved surgical productivity. This paper presents novel adjunctive tools that provide enhanced optical magnification, micro-Doppler sensing of vessels down to a 1-mm size, vein mapping capabilities, hydro-dissection, micro-ablation technology (with minimal thermal spread-CO₂ laser technology), and confocal microscopy to provide imaging at a cellular level. Microsurgical outcomes from the use of these tools in the management of patients with infertility and chronic groin and testicular pain are reviewed. All these instruments have been adapted for the robotic console and enhance the robot-assisted microsurgery experience. As the popularity of robot-assisted microsurgery grows, so will its breadth of instrumentation.

A Pilot Study of Laparoscopic Doppler Ultrasound Probe to Map Arterial Vascular Flow within the Neurovascular Bundle during Robot-Assisted Radical Prostatectomy

Purpose. To report on the feasibility of a new Laparoscopic Doppler ultrasound (LDU) technology to aid in identifying and preserving arterial blood flow within the neurovascular bundle (NVB) during robotic prostatectomy (RARP). Materials and Methods. Nine patients with normal preoperative potency and scheduled for a bilateral nerve-sparing procedure were prospectively enrolled. LDU was used to measure arterial flow at 6 anatomic locations alongside the prostate, and signal intensity was evaluated by 4 independent reviewers. Measurements were made before and after NVB dissection. Modifications in nerve-sparing procedure due to LDU use were recorded. Postoperative erectile function was assessed. Fleiss Kappa statistic was used to evaluate inter-rater agreement for each of the 12 measurements. Results. Analysis of Doppler signal intensity showed maintenance of flow in 80% of points assessed, a decrease in 16%, and an increase in 4%. Plane of NVB dissection was altered in 5 patients (56%) on the left and in 4 patients (44%) on the right. There was good inter-rater reliability for the 4 reviewers. Use of the probe did not significantly increase operative time or result in any complications. Seven (78%) patients had recovery of erections at time of the 8-month follow-up visit. Conclusions. LDU is a safe, easy to use, and effective method to identify local vasculature and anatomic landmarks during RARP, and can potentially be used to achieve greater nerve preservation.

Advancements in laparoscopic partial nephrectomy: expanding the feasibility of nephron-sparing

Partial nephrectomy (PN) offers equivalent oncologic outcomes to radical nephrectomy (RN) but has greater preservation of renal function and less risk of chronic kidney disease and cardiovascular disease. Laparoscopic PN remains underutilized likely because it is a technically challenging operation with higher rates of perioperative complications compared to open PN and laparoscopic RN. A review of the latest PN literature demonstrates that recent advancements in laparoscopic approaches, imaging modalities, ischemic mitigating strategies, renorrhaphy techniques, and hemostatic agents will likely allow greater utilization of LPN and expand its usage to increasingly more complex tumors.

Description of a multicenter safety checklist for intraoperative hemorrhage control while clamped during robotic partial nephrectomy

Background

The adoption of robotic assistance has contributed to the increased utilization of partial nephrectomy for the management of renal tumors. However, partial nephrectomy can be technically challenging because of intraoperative hemorrhage, which limits the ability to identify the tumor margin and may necessitate the conversion to open surgery or radical nephrectomy. To our knowledge, a comprehensive safety checklist does not exist to guide surgeons on the management of hemorrhage during robotic partial nephrectomy. We developed such an safety checklist based on the cumulative experiences of high volume robotic surgeons.

Methods

A treatment safety checklist for the management of hemorrhage during robotic partial nephrectomy was collaboratively developed based on prior experiences with intraoperative hemorrhage during robotic partial nephrectomy.

Results

Reducing the risk of hemorrhage during robotic partial nephrectomy begins with reviewing the preoperative imaging for renal vasculature and tumor anatomy, with a focus on accessory vessels and renal tumor proximity to the renal hilum. During hilar exposure, an attempt is made to identify additional accessory renal arteries. The decision is then made on whether to clamp the hilum (artery +/- vein). If bleeding is encountered during resection, management is based on whether the bleeding is suspected to be arterial or from venous backbleeding. Operative maneuvers that may increase the chance of success are highlighted in safety checklists for arterial and venous bleeding.

Conclusions

Safely performing robotic partial nephrectomy is dependent on attention to prevention of hemorrhage and rapid response to the challenge of intraoperative bleeding. Preparation is essential for maximizing the chance of success during robotic partial nephrectomy.