Robotic Assisted Partial Nephrectomy (RAPN)
Robotic assisted partial nephrectomy is a procedure involving surgical removal of a kidney tumour while leaving the remainder of that kidney inside. It is a treatment option for patients with small kidney tumours. This is Dr Threadgate’s preferred surgical approach for patients with kidney tumours less than four centimetres in diameter and an option for some tumours larger than this.
The procedure is done in hospital under a general anaesthetic. It takes two to four hours and patients usually stay in hospital for two nights.
The discovery of a small kidney tumour often comes as a surprise as they are often found by accident during a scan for other reasons. These tumours rarely cause any symptoms or have any physical signs. The treatment options include surveillance (monitoring), partial nephrectomy or radical nephrectomy (removal of the entire kidney). When surgical treatment is chosen Dr Threadgate has a strong preference for partial nephrectomy as it delivers equivalent cancer survival rates and quality of life scores as radical nephrectomy whilst preserving the function of the affected kidney.
If the decision is to proceed with a robotic assisted partial nephrectomy then preparations and planning commence straight away. A date for surgery will be selected and the necessary pre-operative blood, urine and heart tests organised.
A booking form is completed for the appropriate hospital and patients should expect a call from the hospital pre-admission clinic pre-operatively. The hospital will provide the patient with fasting and admission times. The hospital may also give advice regarding nearby accommodation should family members wish to stay closer during the admission.
A written estimate of Dr Threadgate’s (and the surgical assistants) fee are provided ahead of surgery. Patients should contact the anaesthetist, pathology provider (Douglas Hanly Moir) and their private health fund to obtain an estimate of their fees.
After a general anaesthetic is administered a urethral catheter is inserted in to the bladder. The patient is placed on their side and pressure area protected. A small incision is made above and to the side of the umbilicus and a telescope inserted in to the abdominal cavity. Carbon dioxide gas is pumped in to the abdominal cavity to create space to work in. An additional four to five small incisions are made in order to insert three robotic instruments and one to two instruments for use by the bed side surgical assistant.
The da Vinci robot is then positioned behind the patient and the robotic instruments inserted. Dr Threadgate then leaves to sterile field and moves to the da Vinci control console where he controls all movements of the robotic instruments.
The procedural steps can be summarised as:
- The large intestine, the small intestine (on the right) and the spleen (on the left) is moved away from the kidney
- The artery and vein to the kidney is identified
- Using an ultrasound probe the renal tumour is located and the fat adjacent to it is
- The artery and occasionally the vein to the kidney is clamped. If a ‘zero ischaemia’ procedure is planned then this step is omitted
- The tumour is then excised with a small margin of normal kidney
- Any sizable arteries or calyces in the base of the tumour excision site are sutured closed
- The defect in the kidney is then closed using a series of sutures
- Any clamps on the artery and vein are removed
- A drain is inserted through one of the small incisions and placed near the site of tumour excision
- The tumour is placed in a small plastic pouch and removed via a small incision near pelvic bone the umbilical incision
- The incisions are closed and local anaesthetic infiltrated
Post operative hospital stay
Patients wake up in recovery shortly after the procedure. When their condition is stable and pain under control they are transferred to the ward (normally 90 minutes). On the ward most patients will have a patient controlled analgesia (PCA) device, this allows the patient to press a button and have pain relief delivered via an intravenous drip when required. The PCA is usually not required the following day and tablet pain relief is used instead.
Whilst in bed patients are encouraged to complete breathing exercises and move their feet and legs. Compression stocking and or calf compression devices as well as blood thinning injections are used to reduce the risk of deep vein thrombosis (DVT). Early mobilisation is encouraged with patients sitting up out of bed on the evening of the procedure and walking around the ward the following morning.
Intake of fluids and light food is allowed after the procedure. Medication may be given to assist with nausea and constipation.
The urethral catheter and drain are usually removed on the morning of discharge. Wound dressing stay on for three days. Dissolving sutures are used and do not require removal.
Recovery at home
Patients should avoid heavy lifting (more than 5kg) or vigorous activity for four weeks following their procedure. Activities should resume gradually and if exertion causes pain then rest and retry in a day or two. Normal bowel function will take a few weeks to return, laxatives, fibre and adequate hydration will assist during this time.
Even though the incisions are small it can take time for patients to return to full activities. Help at home and time off work for four weeks after this procedure is recommended. Dr Threadgate recommends no driving for at least two weeks and only return to driving if the patient is certain they can operate the vehicle in all situations.
Post operative appointments
The following is a summary of the usual post op appointments:
- Two weeks review with Dr Threadgate for histopathology results and wound check
- Twelve weeks review with Dr Threadgate with a CT scan and blood test
- Ongoing three to six monthly reviews with scans and blood test dependant on the type of tumour