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The benefits of robotic kidney cancer surgery

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Robotic-assisted surgery is increasing in popularity in many surgical areas including kidney cancer surgery. Researchers from UCLA’s Jonsson Comprehensive Cancer Center led the largest multicenter study to date on a surgical procedure known as a retroperitoneoscopic robot-assisted technique for removal of small kidney cancers. They published their findings online on July 7 in the journal European Urology.

The study authors note that approximately 50,000 Americans are diagnosed with kidney cancer each year. The majority of these malignancies are small tumors that are often found during screening for other medical problems. These tumors require surgical removal; however, the surgery is often technically difficult, especially if they are located on the posterior (rear) side of the kidney. Another surgical challenge that occurs is among patients who have had previous abdominal surgery; these patients may scar tissue that hampers the identification of normal anatomy.

Study leader Dr. Jim Hu and his colleagues at UCLA’s Jonsson Comprehensive Cancer Center have shown that robot-assisted retroperitoneoscopic partial nephrectomy (RARPN) is an ideal approach for patients with posterior kidney tumors or previous abdominal surgery. RARPN is a type of minimally invasive laparoscopic surgery in which the operation is performed with precise robotic arms and magnified, high-definition 3-D cameras that are controlled by the surgeon. The five-year study comprised 227 patients who were an average age of 60 years.

The researchers note that, at present, many medical centers use a procedure known as thermal ablation for the removal of small, difficult-to-reach kidney tumors; it entails using a heat-producing probe. However, this technique requires an eight times higher need for computed tomography (CT) scanning after surgery to monitor the possible regrowth of the tumor; these CT scans expose the patients to radiation.

Another significant finding of the study was that there was that a significant variability was found between different surgeons in the amount of time the main blood supply to the kidney (renal artery) was blocked off during surgery. This time is called the warm ischemia time (WIT), which differed up to five minutes depending on the surgeon; this occurred even though all the surgeons involved in the study were fellowship-trained, high-volume surgeons at tertiary referral centers. Robotic surgery has a steep learning curve; thus, more experienced surgeon had shorter WITs. This is relevant because longer WITs are associated with more complications, such as acute kidney failure and long-term chronic kidney disease.

The researchers also found significant differences in the number of complications between surgeons; the surgeons with the most complications had three times as many complication as those with the fewest. Despite that finding, major complications were infrequent. For example, only three patients required a blood transfusion. A positive finding of the study was that only 1% of the patients suffered a cancer recurrence during follow-up.

“These differences in WIT may be attributable to slight variations in surgical technique,” explained Dr. Hu, who is also Director and Henry Singleton Chair in Robotic and Minimally Invasive Surgery. He added, “But we showed center-specific variations in the RARPN approach and we present a video on surgical technique to highlight our approach.” In addition to UCLA, participating centers included the University of Michigan and Swedish Medical Center in Seattle, Washington.

Take home message:

Robotic surgery has many advantages in many surgical fields including gynecology, urology, and bariatric surgery. The surgeon sits comfortably at a console rather than hunching over the operating table. The magnification and 3-D imaging facilitate meticulous examination of the surgical area; thus, it reduces the risk of residual tumor. Because of the steep learning curve, it is prudent to locate a highly experienced surgeon. Fortunately for Angelenos, Ronald Reagan UCLA Medical Center has many highly skilled surgeons on its staff.