Robot Is Equal to Urological Challenges: Cleveland Clinic Surgeon Performs First Robotic Partial Nephrectomy on Transplanted Kidney
Saturday, February 04, 2012
With the introduction and FDA approval of robotics in 2000, urological surgeons gained a powerful new tool. Robotic assistance enhances the features of laparoscopic surgery with the advantage of increased precision and 3-D vision. These capabilities have proven to be especially valuable in treating kidney tumors located in difficult positions.
Jihad Kaouk, M.D., Director of the Center for Robotic and Image-Guided Surgery at Cleveland Clinic’s Glickman Urological & Kidney Institute, has utilized this technology to great advantage in recent years, achieving a number of the world’s “firsts” in robotic laparoscopy. Most recently, Dr. Kaouk and his team performed the world’s first robotic partial removal of a transplanted kidney tumor — a case that had a number of unique features.
The patient was a 35-year-old woman. She had a transplanted kidney, donated by her father 10 years earlier. A routine ultrasound revealed a large mass on the kidney. The patient had consulted with specialists at two other major medical centers before coming to Cleveland Clinic. Both had recommended total nephrectomy, which would have necessitated lifelong dialysis.
“The challenge here was the location of the transplanted kidney,” says Dr. Kaouk. “It was located in the pelvis, down from the native site.”
Partial nephrectomy is rare under these conditions. Dr. Kaouk found only 18 reported cases in the United States — none robotic. All were conventional surgeries with an open incision directly over the kidney.
“The tumor mass was 7cc,” says Dr. Kaouk. “It was mushrooming over the blood vessel that feeds the kidney. We would need to reach these vessels to control them and achieve warm ischemia for some time, to enable us to cut without bleeding. Then, we would need to suture the kidney back and reperfuse it.”
Despite the challenges, Dr. Kaouk and his team were confident. They have done more than 1,000 laparoscopic partial nephrectomies, 300 of them robotic — the largest wealth of experience in the world.
The unusual location of the transplanted organ forced Dr. Kaouk to devise a wholly novel approach.
“I had to modify where I put the port, the way I entered with the robot, because the usual techniques wouldn’t apply to a kidney in the pelvis,” says Dr. Kaouk. “I had to ‘sneak’ the scope and the instruments from under the kidney and the tumor to the vessels from an angle. Then I had to control the vessels and perform the partial nephrectomy. That worked well.”
There is some controversy over the safe duration of warm ischemia. The modified robotic approach allowed for more controlled surgery that minimized bleeding and allowed for a reasonable warm ischemia time.
The patient stayed in the hospital a few days for observation. One week later, she was doing well and was not experiencing any pain. Surgical margins were negative, and serum creatinine returned to baseline two weeks after surgery.
By preserving the transplanted kidney, the patient was spared losing the transplanted kidney and a lifetime of dialysis.
“I couldn’t be happier,” says Dr. Kaouk.
To contact Jihad Kaouk, M.D., please call (216) 444-2976 or e-mail kaoukj@ccf.org. To make a referral, please call 1-800-223-2273, extension 45600.
MD News February 2012