Effect and safety of fourth arm robot assisted partial nephrectomy via retroperitoneal approach / 中华泌尿外科杂志

ABSTRACT

Objective:To investigate the effect and safety of using the fourth arm in robot assisted partial nephrectomy via retroperitoneal approach.Methods:The clinical data of 480 patients with newly diagnosed renal tumors treated in the First Affiliated Hospital of Medical College of Zhejiang University from January 2016 to December 2018 were analyzed retrospectively. All patients underwent robot assisted partial nephrectomy with the fourth arm and were divided into two groups according to the surgical approaches. There were 312 cases in the retroperitoneal group, 198 males and 114 females, aged 18-82 years, with an average of 54.0 years. The tumors were located in the right kidney in 152 cases (48.7%), left kidney in 155 cases(49.7%), double kidney in 5 cases (1.6%), with tumor size of (3.5±2.7) cm, R.E.N.A.L. score of 4-5 in 105 cases (33.7%), 6-8 in 143 cases(45.8%), and 9-12 in 64 cases (20.5%). There were 168 cases in the transperitoneal group, 105 males and 63 females, the age ranged from 21 to 79 years, with an average of 53.2 years. The tumors were located in the right kidney in 85 cases (50.6%), left kidney in 78 cases (46.4%), double kidney in 3 cases (1.8%), with tumor size of (3.8±2.9) cm, R.E.N.A.L. score of 4-5 in 52 cases (31.0%), 6-8 in 81 cases (48.2%), and 9-12 in 35 cases (20.8%). In the retroperitoneal group, the patients were placed in the 90 ° lateral position on the healthy side, the lens hole cannula was placed 2-3 cm above the iliac crest, and one operation hole cannula was placed 8 cm away from the lens hole cannula on the ventral and dorsal sides respectively. The included angle between the two operation holes and the lens hole was 150°-180°. The fourth arm operation hole was established 8 cm away from the ventral operation hole, and the included angle between the connecting line and the horizontal line is ≤15°. The fourth arm operating hole was placed with ProGrasp forceps, which can be used to push away fat, peritoneum, traction and lift kidney, etc., so as to obtain satisfactory operating space and position. The perioperative conditions and surgical complications of the two groups were compared.Results:The operations were successfully completed in both groups, and there was no conversion to open surgery. The installation time of retroperitoneal group and transperitoneal group were (12.3±5.3)min and (7.8±3.8)min respectively, the console time was (70.5±17.1)min and (89.4±23.9)min respectively, the warm ischemia time was (17.3±8.2)min and (19.2±9.1)min respectively, the intraoperative bleeding volume was (115.2±47.3)ml and (125.8±52.1)ml respectively, and the intestinal recovery time was (1.5±1.8)d and (2.7±2.4)d respectively.The postoperative hospital stay was(6.3±1.8)d and (7.4±2.8)d, respectively ( P<0.05). The positive rates of incision margin in retroperitoneal group and transperitoneal group were 0(0 cases) and 0.6% (1 case). The time of indwelling drainage tube was (4.6±2.5)d and (4.9±2.8)d, respectively, and there was no significant difference ( P>0.05). The incidence of postoperative complications in the retroperitoneal group was lower than that in the transperitoneal group (67 cases, 21.5% vs. 51 cases, 30.3%, P=0.031). There was significant difference in the incidence of Clavien grade Ⅰ-Ⅱ complications (62 cases, 19.8% vs. 48 cases, 28.6%, P=0.030). There was no significant difference in the incidence of Clavien grade Ⅲ-Ⅳ complications (5 cases, 1.6% vs. 3 cases, 1.9%, P>0.05). Conclusions:Compared with the transperitoneal approach, the retroperitoneal approach with the fourth arm robot assisted partial nephrectomy is safe and effective, with shorter operation time, warm ischemia time, postoperative recovery time and fewer complications.