Virtual surgical planning: A novel aid to robot-assisted laparoscopic partial nephrectomy

Background and Purpose: Incidental detection of small renal masses has significantly increased over the last two decades with the advent of cross-sectional imaging. The shift in stage has been met with a shift in treatment modality because the preservation of renal parenchyma can prevent adverse outcomes. Robot-assisted laparoscopic partial nephrectomy (RALPN) needs significant surgeon expertise, and preoperative planning is imperative. Patients and Methods: Between December 2010 and September 2011, virtual surgical planning (VSP) was used in consecutive patients with renal tumors that were suspicious for renal-cell carcinoma who were undergoing RALPN by a single surgeon. Three-dimensional (3D) reconstructions were examined and manipulated preoperatively, and an operative plan formulated. Intraoperative anatomy and preoperative 3D reconstructions were compared in real time. Results: A total of 10 patients underwent RALPN with preoperative VSP. Average patient age at intervention was 54.6 years and average tumor size was 4.3cm (range 1.7-7.5cm). Tumor laterality was evenly distributed. Nephrometry score ranged from 5A to 10P, and final tumor pathology results revealed malignancy in 80%. No complications occurred intraoperatively, and an excellent correlation was noted between preoperative 3D reconstruction and intraoperative anatomy. All patients underwent a successful partial nephrectomy with no positive margins on final pathology results. Mean length of surgery was 232.9 minutes (range 156-435min), and mean estimated blood loss was 370mL (range 75-1800mL). Warm ischemia time ranged from 20 to 50 minutes (mean 33.9min). Data regarding postoperative renal function were available for six patients with an average loss of function of 9.5% (range 2%-17%). Conclusions: The implementation of this novel technology has significantly improved our ability to plan RALPN preoperatively. Tumor depth and complexity of tumor resection are assessed and the appropriate operative intervention and approach planned. Tumor proximity to vascular structures and collecting system were reliably predicted and therefore anticipated. Overall, these advantages created a safer surgical endeavor.