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Urologic Robotic Surgery Course

After completing this module, the learner should be able to:

  • Describe the surgical steps involved with the safe performance of robotic partial nephrectomy.
  • State the indications and contraindications for the robotic approach to urologic surgical procedures.
  • Identify errors that can occur with the system during robotic surgery conditions.
  • Describe steps to optimize coordination of bedside assistant
  • Describe the steps involved with safe operation of the daVinci Surgical System (Intuitive Surgery Inc, Sunnyvale, CA).
  • Describe complications that can occur during urologic robotic surgery and describe methods to avoid and manage the complications.

Authors

Firas Petros, MD
Clinical Fellow
Vattikuti Urology Institute
Henry Ford Hospital
Detroit, MI
Disclosures: Nothing to disclose

Craig Rogers, MD
Director of Renal Surgery
Henry Ford Hospital
Director of Urologic Oncology
Henry Ford West Bloomfield
Vattikuti Urology Institute
Henry Ford Hospital
Detroit, MI
Disclosures: Intuitive Surgical: Consultant or Advisor; Vascular Technology, Inc: Consultant or Advisor

UROLOGIC ROBOTIC SURGERY COURSE

Robotic Partial Nephrectomy

Contents:

  1. Abstract
  2. Introduction
  3. Indication and Contraindications
  4. Preoperative Work Up
  5. Patient Preoperative Preparation
  6. Instrumentation
  7. Surgical Steps
  8. Postoperative Care
  9. Management of Intraoperative Complications
  10. Management of Postoperative Complications
  11. Literature Review
  12. Tables
  13. Figures
  14. References

Abstract

Robotic assisted partial nephrectomy (RAPN) is a surgical technique that facilitates a minimally invasive approach to partial nephrectomy. There has been a recent paradigm shift in the management of localized renal tumors with an emphasis to more frequent utilization of partial nephrectomy over radical nephrectomy in order to preserve renal function, as well as decrease cardiovascular morbidity. This chapter describes techniques for transperitoneal RAPN using a 3 or 4-arm approach. RAPN may facilitate technical challenges of minimally invasive partial nephrectomy, such as tumor excision and renal reconstruction under warm ischemia. Surgeons should be familiar with strategies for avoiding and managing bleeding and other complications.

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Introduction

Surgical resection is the standard treatment of renal cell carcinoma. Partial nephrectomy (PN) is a standard treatment for small renal cortical neoplasms, although other potential treatment options include active surveillance, ablation, and radical surgery.1 Robotic assisted partial nephrectomy (RAPN) may facilitate technical challenges of minimally invasive partial nephrectomy, particularly with intracorporeal suturing under the time constraints of warm ischemia. Several institutions have reported their experience with RAPN.2-9 15-16 In this chapter, we describe techniques for RAPN using a transperitoneal approach and discuss prevention and management of complications.

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Indication and Contraindications

Indications for PN include patients with a solitary functioning kidney, bilateral tumors or renal insufficiency as well as elective indications in patients with localized kidney tumors and a normally functioning contralateral kidney. For small renal masses, recurrence rates are similar to those for radical nephrectomy and thus a minimally invasive PN offers preservation of renal function while minimizing patient morbidity. In general, any patient who would be considered for a LPN may also be considered for RPN. Experience with RAPN may expand indications of RAPN to include select patients with complex renal tumors (hilar 12, endophytic, or multiple) 3 and larger tumors over 4 cm in size. However these are advanced procedures and should be done on select patients by a surgeon with considerable experience. Relative contraindications to a minimally invasive approach include extensive prior abdominal surgery, uncorrected coagulopathy and patients with renal insufficiency in which an open approach with cold ischemia is preferred 14.

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Preoperative Work Up

Patients being considered for RAPN should undergo a staging workup including axial imaging with an abdominal CT or MRI, and a chest X-ray. Additional imaging such as a chest CT, head CT, and bone scan may be ordered for high risk disease or clinical evidence of metastasis. Preoperative blood tests include serum electrolytes, a complete blood count, coagulation studies, and liver function tests.

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Patient Pre-operative Preparation

Patients should discontinue anticoagulants (i.e. NSAIDS, warfarin, etc) at least 5-7 days before surgery if medically indicated. A bowel preparation, such as Magnesium Citrate, is given the day before surgery. Patients are instructed not to eat or drink anything after midnight on the night before surgery. The physician should offer the patient a full discussion of available treatment options (i.e. Active surveillance, ablation, radical surgery) and potential complications of RPN (i.e. Urine leak, hemorrhage, injury to surrounding structures, potential radical, total nephrectomy etc).

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Instrumentation

RAPN is performed using the da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA). Robotic instruments used by the console surgeon include the Hot Shears™ monopolar curved scissors or Monopolar Cautery Hook in the dominant hand and the Fenestrated Bipolar Grasper, ProGrasp™, or PK™ Dissecting Forceps in the non-dominant hand. Robotic needle drivers are used for renal reconstruction 11. A Fenestrated Bipolar Grasper or ProGrasp™ instrument in the nondominant hand may also be used as a needle driver at the discretion of the surgeon. Robotic instruments available for the optional third instrument arm include the ProGrasp, Dual Blade Retractor, and the Double Fenestrated Grasper. Different instruments offer different relative advantages during RAPN. In the non-dominant hand, the broad smooth tips of the ProGrasp or Fenestrated Bipolar Grasper instruments can be used for atraumatic dissection of vessels and blunt retraction of the tumor during resection. The fine sharp tips of the Maryland Bipolar Forceps or PK Dissecting Forceps are useful for precise dissection and cauterization of small vessels, but the surgeon must be aware so the sharp tips don't the hilar vessels during hilar dissection or the tumor during tumor resection. The ProGrasp has no thermal energy but has a strong closing force, making it a robust grasping instrument. The ProGrasp is the only robotic instrument that can apply robotic bulldog clamps and also provides the best fit with the robotic ultrasound probe. The monopolar curved scissors is most commonly used as a dominant hand instrument as it can be used for tasks such as cauterization, blunt and sharp dissection, and tumor excision. The Monopolar Hook may occasionally be useful for blunt dissection of hilar vessels and tissue planes, but is not as well suited for tumor excision or cutting small vessels.

Laparoscopic instruments used by the bedside assistant include a laparoscopic grasper, needle driver, scissors, bulldog clamps and applier or Satinsky clamp, Hem-o-lok™ clips and appliers (Teleflex, Research Triangle Park, NC) and a specimen retrieval bag.

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Surgical Steps

Patient Positioning and Trocar Placement

Following induction of general endotracheal anesthesia, a Foley catheter and orogastric tube are placed. The patient is placed in flank position with the affected side up. Mild table flexion may be used to increase the space for ports, but the kidney rest is not used. All pressure points are carefully padded and the patient is secured to the operating table. After pneumoperitoneum is achieved, trocars are placed under direct vision. The port for the da Vinci camera is placed a few centimeters cranial to the umbilicus in a medial or lateral position per surgeon preference (Figure 1). Two da Vinci robotic ports are placed at least 5-6 cm on each side of the camera port to minimize collisions. With a medial camera position, ports are triangulated towards the renal hilum, offering a global view similar to conventional laparoscopy. Placement of the camera near the lateral border of the rectus can provide an optimal global view while leaving room medially for the assistant. With a lateral camera position, the ports are in a diamond configuration with the camera port closest to the kidney. This offers more room medially for the assistant but a less global view for the surgeon. We generally use a zero degree camera for most cases to minimize camera changes and to leave more room medially for the assistant. But a 30 degree down lens can offer improved vision in areas such as the posterior hilar dissection and upper pole dissection. An optional port for the third robotic instrument arm may be placed caudally away from the other ports. Assistant ports are placed medially. A 15 mm primary assistant port in a periumbilical midline position can help with tumor extraction and passage of instruments such as needles, hemostatic agents, and a robotic ultrasound probe. For right sided cases, a 5 mm subxiphoid port can be placed for liver retraction using a locking grasper secured to the abdominal side wall or diaphragm. A retractor is generally not needed for left sided cases, but release of lateral splenic attachments can improve hilar exposure. The robot is docked posteriorly at an angle over the shoulder.

Bowel Mobilization

The colon is mobilized to expose the kidney by incising sharply along the white line of Toldt (Figure 2). A combination of sharp and blunt dissection is used to develop a plane between the posterior mesocolon and anterior Gerota's fascia. Bowel mobilization includes a Kocher maneuver for right sided cases to reflect the duodenum for improved hilar exposure. Dissection is continued to the upper pole of the kidney to release attachments to the spleen or liver. Wide bowel mobilization is recommended for optimal exposure of the renal hilum and tumor. Lateral attachments to the kidney are generally not released prior to the completion of hilar dissection in order to improve hilar exposure.

Hilar Dissection

Continued dissection exposes the ureter and gonadal vein. The ureter is identified and retracted anteriorly and the lower pole of the kidney is elevated off the underlying psoas muscle by the assistant to place the renal hilum on stretch to facilitate hilar dissection. Anterior traction on the kidney may be provided by the surgeon or the assistant. Dissection then proceeds cranially toward the renal hilum. The third-arm robotic instrument can be placed under the ureter to help lift the kidney, allowing two-handed dissection of hilar structures (Figure 3). The renal vein is usually identified by tracing the gonadal vein to its insertion in the renal vein on the left side or the inferior vena cava on the right side just caudal to the renal vein. The renal artery is identified posterior to the renal vein. The renal hilum is then dissected for subsequent clamping (Figure 4). A flexible robotic doppler drop-in probe (Vascular Technology Inc, Nashua, NH) may help with identification of renal hilar vessels, particularly in cases involving multiple renal arteries or early branching. The probe may also be used to confirm adequate ischemia after clamping.5

Tumor Identification

Gerota's fascia is opened to expose the tumor and sufficient surrounding normal renal capsule to allow room for tumor excision and sutured reconstruction. The fat directly over the tumor is either left on the tumor or sent separately for pathologic analysis for staging purposes. Intraoperative ultrasonography is a valuable tool for the identification of tumor location, borders, and depth in order to ensure negative margins. The assistant controls a flexible laparoscopic ultrasound probe introduced through the assistant port. A new development is the use of a drop-in robotic ultrasound probe (Hitachi-Aloka, Tokyo, Japan or BK Medical, Peabody, MA)13. This probe has a flexible cable and drops in through the assistant port, allowing the surgeon to grasp the probe with the ProGrasp (or Fenestrated Bipolar Grasper) and utilize the articulation of the robotic instrument to navigate the probe in multiple directions for tumor identification, delineation of margins and proximity to the collecting system.5 The live intraoperative ultrasound image and/or preoperative CT images can be displayed on the console screen as a picture on picture display using the TilePro™ feature of the da Vinci S and Si system (Figure 5). The renal capsule is marked with cautery at the intended resection margin.

Hilar Clamping

Prior to clamping, ensure that all stitches and instruments are available for resection and renal reconstruction under warm ischemia. In addition, a test of the needle drivers prior to hilar clamping is recommended, as the instruments will not function after 10 cases. Mannitol and /or furosemide may be given before and after clamping for renal ischemic protection. Hilar clamping is performed using either bulldog clamps or a Satinsky clamp. If bulldog clamps are used, the renal artery is clamped first (Figure 6). Robotically-applied bulldog clamps are also available (Scanlan Inc, St. Paul, MN and Klein Surgical Inc., San Antonio, TX) that are reusable and allow for grasping and application using the articulation of the robotic ProGrasp instrument.5 Laparoscopic and robotic bulldog clamps are passed through the assistant trocar to the surgeon. For small or exophytic tumors, the renal artery alone may be clamped. For larger central tumors both the renal artery and renal vein are generally clamped to improve visualization during tumor resection. Use of the Satinsky clamp requires a dedicated port and care must be taken to avoid external or internal collisions with the Satinsky clamp that could cause injury to renal vessels. Off-clamp tumor excision may be initially attempted for small exophytic tumors but with experience more complex lesions may be approached with limited predissection of the renal hilum to allow for vascular control if needed.

Tumor Excision

The tumor is excised sharply taking care to maintain a negative surgical margin (Figure 7). A ureteral catheter may be preplaced for retrograde injection of methylene blue to help identify collecting system entry, but the magnification provided by the robotic camera is usually sufficient to identify collecting system entry with a ureteral catheter. During excision, the assistant uses the suction for exposure and counter traction. The surgeon can apply countertraction on the tumor with the nondominant hand either by grasping the overlying fat or with gentle blunt pressure on the tumor to avoid grasping the tumor. The resected tumor is placed aside for later retrieval.

Renorrhaphy

The renal defect is generally closed in two layers with suturing of the base of the resection bed to achieve hemostasis and repair any collecting system defects (Figure 8) and suturing of the outer capsular layer to approximate the capsular edges and close the defect. Suture characteristics vary per surgeon preference but often consist of a 3-0 or 4-0 sized monofilament or braided polyglactin suture on a RB-1, SH or CT-1 needle. Inner layer sutures can be anchored with clips to minimize knot tying and reduce warm ischemia time, either using absorbable Polyglactin clips (Lapra-Ty, Ethicon Inc., San Argelo, Tx) or Hem-o-lok clips passed through the renal capsule. The renal capsule is then closed with 2-0 polyglactin sutures on a CT-1 needle placed through the renal capsule across the defect about one cm apart (Figure 9). The sutures may be anchored with Hem-o-lok clips and tightened using the sliding clip technique for compressive hemostasis.4 Barbed absorbable suture (V-loc, Covidien, Mansfield, MA, or Quill, Angiotech Pharmaceuticals, Inc. Vancouver, BC or Stratafix, Ethicon Inc, Somerville, NJ) may also be used for renorrhaphy to minimize slippage of sutures or clips for efficiency.5 Bolsters and hemostatic agents may be placed in the renal defect, but are often not be necessary as the sliding clip technique can often provide complete closure of the defect. Following reconstruction of the renal defect, the hilar clamps are removed. An additional LapraTy clip may be placed on the last suture to prevent slippage of the suture. If bulldog clamps are used, the venous clamp is removed first followed by the arterial clamp.

Specimen Retrieval and Closure

The specimen is placed in an endoscopic retrieval bag and removed. A Jackson-Pratt drain may be placed through the most lateral robotic port site.

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Postoperative Care

Hemoglobin levels and vital signs are assessed postoperatively as clinically indicated. Intravenous fluids, analgesics, prophylaxis for deep vein thrombosis, and antibiotic prophylaxis are given per surgeon preference. The morning following surgery, the Foley catheter is removed, the diet is advanced, and patients are encouraged to ambulate. Patients usually stay about two days in the hospital. After the Foley catheter is removed, the abdominal drain may be observed for increased output and the drain fluid is sent for a creatinine level. If the drain creatinine is not elevated, the drain is removed.

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Management of Intraoperative Complications

Hemorrhage

Intraoperative hemorrhage can be prevented with meticulous dissection and being cognizant of the use of instruments and cautery near large vessels. Venous bleeding can usually be addressed with a combination of direct pressure, increased insufflation pressure, hemostatic agents, and patience. If a bleeding vessel is identified, cautery or clips may be used to control the bleeding. Injury to larger vessels may require sutured repair. Parenchymal bleeding during warm ischemia may occur due to unclamped arterial inflow to the kidney. A long bulldog clamp or Satinsky clamp may be placed en-block across the renal hilum to encompass all hilar branches. If the renal vein is clamped and unoccluded arterial inflow is suspected, the venous clamp may be removed to help alleviate renal congestion and improve vision. Bleeding may occur after unclamping the renal hilum from inadequate closure of the renal defect. The insufflation pressure may be temporarily increased and direct pressure applied while additional large compressing sutures and additional hemostatic agents are placed. If bleeding remains uncontrolled, there should be a low threshold for open conversion or radical nephrectomy to safely control bleeding.

Bowel Injury

Bowel injury during RPN can be a serious complication, particularly if unrecognized. Bowel injury can occur during insertion of ports or instruments or as a result of thermal injury. If a serosal injury or a small bowel laceration is noted, it should be repaired. There should be a low threshold to consult general surgery for intraoperative consultation. For larger injuries or contamination, bowel resection or diversion may be necessary.

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Management of Postoperative Complications

Urine Leak

If there is evidence of urine leakage (i.e. continued high drain output, elevated drain creatinine level), the drain is left in place and output is monitored. If a leak persists, a CT urogram may be performed to determine whether a urinoma is present that needs to be drained, and to rule out ureteral obstruction. If there is a significant undrained urinoma, percutanous drainage should be performed. Serial imaging can be performed to confirm improvement and resolution of the urinoma. If there is a persistent leak without urinoma, the drain may be taken off suction and gradually pulled back over several weeks to facilitate sealing of the collecting system. For a persistent urinary fistula, retrograde placement of a ureteral stent or percutaneous nephrostomy tube placement should be considered, particularly if there is persistent high output drainage or evidence of distal obstruction on CT urogram (i.e. secondary to blood clot). If a ureteral stent is placed, a urethral Foley catheter could be considered to ensure maximal drainage of the kidney without urine refluxing up the ureteral stent. Most urine leaks will resolve with maximal drainage of the urinary tract and patience. Re-exploration and repair of the collecting system versus nephrectomy are feasible, but rarely indicated.

Hemorrhage

Post-operative hemorrhage may be identified by hemodynamic instability and a decreasing hematocrit. Hemoglobin levels can be evaluated postoperatively as clinically indicated. Immediate post-operative hemorrhage can usually be managed conservatively initially with close monitoring of vital signs, blood count, and transfusions as indicated. Delayed postoperative hemorrhage is usually due to formation of a pseudoaneurysm, arteriovenous (AV) fistula, or arteriocalyceal fistula. Communication of a pseudoaneurysm or AV fistula with the collecting system can result in significant hematuria. Hematuria is the most common presentation of delayed hemorrhage after RAPN and any degree of hematuria should be carefully evaluated. It is important to have a low threshold to evaluate post-operative hematuria as rapid diagnosis and treatment of vascular complications is important to avoid more serious morbidity. When significant evidence of bleeding is present (i.e. gross hematuria requiring clot evacuation, decreasing hematorcrit despite transfusion, etc), patients should be taken directly for renal angiography with potential embolization by interventional radiology. If angio-embolization fails to control the bleeding or hemodynamic instability precludes interventional radiology management, operative re-exploration is indicated. If bleeding still cannot be controlled, nephrectomy may be necessary.

Bowel Injury

Early recognition of bowel injury is critical, as a delay in treatment may result in progression to sepsis. Early signs of unrecognized bowel injury include trocar site pain, abdominal distention, nausea/vomiting, fever and leukopenia or leukocytosis, and enteric output from the drain. Immediate surgical exploration and repair is indicated if suspicion of bowel injury is high. A CT scan with oral and IV contrast may be performed to identify the injury or associated abscess if the patient is stable and the clinical picture is less clear. A small subset of these patients may be able to be managed conservatively with TPN.

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Literature Review

A summary of select major published series of RAPN is shown in Table 1. The feasibility of RAPN has been demonstrated in these and multiple other studies.2-9 Early reports of RAPN did not demonstrate a clear advantage of a robotic approach, but these were small studies with few patients and relatively small, exophytic tumors.3 Later reports demonstrated the applicability of RAPN to more complex tumors.4 Large multi-institutional studies have demonstrated the safety and efficacy of RAPN for management of renal tumors.7,8 Recent reports comparing RAPN and laparoscopic partial nephrectomy have demonstrated comparable cancer control with RAPN providing significant reduction in blood loss, hospital stay, and warm ischemia times.9,10

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Tables

Table 1 – Summary of select major published RAPN series

Variable1

Aron 2

Rogers 3

Ho 6

Spana 7

Benway 8

Benway 9

Wang 10

Number of cases

12

14

20

450

183

129

40

Mean Tumor Size (cm)

2.4

2.4

3.5

2.9

2.9

2.9

2.5

Mean OR time

242

192

82.8

188

210

189

140

Mean EBL (ml)

329

230

189

213

131.5

155

136

Mean WIT (min)

23

31

21.7

20.2

23.9

19.7

19

Mean LOS (days)

4.7

2.6

4.8

NR

NR

2.4

2.5

Complications
(%)

4

0

0

71 (15.8)

15 (8.2)

11 (8.5)

8 (20)

Positive Margin (%)

none

0

0

NR

7 (3.8)

5 (3.9)

1

Mean follow-up (months)

7.4

3

NR

NR

16

NR

NR

OR time=Operative Time, EBL= Estimated Blood Loss, WIT=Warm Ischemia Time, LOS=Length of Stay, NR=Not Reported

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Figures

Figure 1. Port placement for left robotic assisted partial nephrectomy (RAPN). A. Medial camera position; B. Lateral camera position.

Port placement for left robotic assisted partial nephrectomy (RAPN). A. Medial camera position; B. Lateral camera position.

Figure 2. Bowel mobilization during left RAPN C-Colon.

Bowel mobilization during left RAPN C-Colon.

Figure 3. Use of third robotic arm for kidney retraction during left RAPN. Arrow denotes third-arm robotic instrument lifting lower pole of kidney to place renal hilum on stretch. K-kidney, RV-renal vein.

Use of third robotic arm for kidney retraction during left RAPN.

Figure 4. Hilar Dissection during left RAPN. RV-renal vein, RA-renal artery.

Hilar Dissection during left RAPN. RV-renal vein, RA-renal artery.

Figure 5. Overlay of radiographic images during RAPN using TilePro™. Note preoperative CT scan image (lower left) and live intraoperative ultrasound image (lower right) with arrow pointing to tumor. P-intraoperative ultrasound probe, T-tumor, K-kidney.

Overlay of radiographic images during RAPN using TileProâ„¢

Figure 6. Renal hilar clamping during left RAPN. Arrow denotes renal artery being clamped by laparsoscopic bulldog clamp. RV-renal vein, LV-lumbar vein.

Renal hilar clamping during left RAPN

Figure 7. Tumor excision during RAPN. K-kidney, T-tumor, C-collecting system.

Tumor excision during RAPN. K-kidney, T-tumor, C-collecting system.

Figure 8. Sutured repair of collecting system and deep layer of renorrhaphy during left RAPN using SH needle.

Sutured repair of collecting system and deep layer of renorrhaphy during left RAPN using SH needle

Figure 9. Renal capsular reconstruction during left RAPN using a CT-1 needle.

Renal capsular reconstruction during left RAPN using a CT-1 needle.

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References

  1. AUA clinical guidelines: guideline for management of the clinical stage 1 renal mass;1-76, 2009.
  2. Aron, M., Koenig, P., Kaouk, J. H. et al.: Robotic and laparoscopic partial nephrectomy: a matched-pair comparison from a high-volume centre. BJU Int, 102: 86, 2008.
  3. Rogers, C. G., Singh, A., Blatt, A. M. et al.: Robotic Partial Nephrectomy for Complex Renal Tumors: Surgical Technique. Eur Urol, 53: 514, 2008.
  4. Benway, B. M., Wang, A. J., Cabello, J. M. et al.: Robotic partial nephrectomy with sliding-clip renorrhaphy: technique and outcomes. Eur Urol, 55: 592, 2009.
  5. Sukumar S, Rogers CG. Robot-assisted partial nephretomy. J Endourology, 25(2):151, 2011.
  6. Ho, H., Schwentner, C., Neururer, R. et al.: Robotic-assisted laparoscopic partial nephrectomy: surgical technique and clinical outcomes at 1 year. BJU Int, 103: 663, 2009.
  7. Spana G, Haber GP, Dulabon LM, Petros F, Rogers CG, Bhayani SB, Stifelman MD, Kaou,k JH. Complications after robotic partial nephrectomy at centers of excellence: Multi-institutional analysis of 450 cases. J Urol, 186: 417, 2011.
  8. Benway, B. M., Bhayani, S. B., Rogers, C. G. et al.: Robot-Assisted Partial Nephrectomy: An International Experience. Eur Urol, 2010.
  9. Benway, B. M., Bhayani, S. B., Rogers, C. G. et al.: Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes. J Urol, 182: 866, 2009.
  10. Wang, A. J., Bhayani, S. B.: Robotic partial nephrectomy versus laparoscopic partial nephrectomy for renal cell carcinoma: single-surgeon analysis of >100 consecutive procedures. Urology, 73: 306, 2009.
  11. Robotic partial nephrectomy: Current technique and outcomes. Wang L, Lee BR.Int J Urol. 2013 May 2.
  12. Robot-assisted Partial Nephrectomy for Hilar Tumors: Perioperative Outcomes. Eyraud R, Long JA, Snow-Lisy D, Autorino R, Hillyer S, Klink J, Rizkala E, Stein RJ, Kaouk JH, Haber GP. Urology. 2013 Apr 1.
  13. Comparison of Robotic and Laparoscopic Ultrasound Probes for Robotic Partial Nephrectomy. Kaczmarek BF, Sukumar S, Kumar RK, Desa N, Jost K, Insua M, Menon M, Rogers CG. J Endourol. 2013 Mar 19.
  14. A comparison of robotic, laparoscopic and open partial nephrectomy. Lucas SM, Mellon MJ, Erntsberger L, Sundaram CP. JSLS. 2012 Oct-Dec;16(4):581-7.
  15. Evaluation of robotic and laparoscopic partial nephrectomy for small renal tumours (T1a). Froghi S, Ahmed K, Khan MS, Dasgupta P, Challacombe B. BJU Int. 2013 Mar 11.
  16. Perioperative complications of robot-assisted partial nephrectomy: analysis of 886 patients at 5 United States centers. Tanagho YS, Kaouk JH, Allaf ME, Rogers CG, Stifelman MD, Kaczmarek BF, Hillyer SP, Mullins JK, Chiu Y, Bhayani SB. Urology. 2013 Mar;81(3):573-9.

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Status
Module 3 Partial Nephrectomy Posttest Available 1.50 credits/hours

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