Posterior transperitoneal robot-assisted partial nephrectomy in the treatment of renal tumors: Feasibility of a hybrid approach

Robot-assisted partial nephrectomy (RAPN) for posterior renal tumors may be performed through anterior (transperitoneal) or posterior (retroperitoneal) approach depending on surgeon's expertise. We propose herein a surgical artifice using daVinci Xi system to combine advantages of both approaches. From November 2019 to November 2020, patients with posterior renal mass, candidate for RAPN were prospectively included after informed consent. After positioning patient in lateral position, daVinci Xi system was docked on tumor side, to initiate transperitoneal procedure. Posterolateral dissection of perinephric space along fascia retrorenalis was conducted until psoas major muscle was exposed. Three additional robotic ports were then inserted in lumbar space, and RAPN was resumed after rotating daVinci Xi boom. Demographics, tumor characteristics, perioperative outcomes, estimated glomerular filtration rate (eGFR) and follow-up data were analyzed. Ten consecutive patients underwent RAPN with the modified technique. All cases were performed robotically, without modification of port placement. Median (range) tumor diameter was 37 (21–48mm) with median RENAL score of 8 (4–10) Median operative time and warm ischemia time were respectively 128min (70–180min) and 19min (14–22). One patient had a Clavien-Dindo grade II complication. At median follow-up of 13 months (6–18), all patients had eGFR comparable to baseline. We report the feasibility and safety of a new hybrid posterior transperitoneal approach for RAPN using daVinci Xi system. Limitations include the absence of RENAL score>10 and pT2 tumors. Greater experience is needed to assess learning curve for surgeons untrained to robotic lomboscopy. Objectif La néphrectomie partielle robot-assistée (RAPN) pour le traitement des tumeurs rénales postérieures peut être réalisée par voie antérieure (transpéritonéale) ou postérieure (rétropéritonéale) selon l’expérience de l’opérateur. Nous proposons un artifice technique, utilisant la plateforme daVinci Xi afin de combiner les avantages des deux approches. De novembre 2019 à novembre 2020, les patients candidats à une RAPN avec tumeur postérieure ont été inclus prospectivement après information adaptée. Après une installation classique en décubitus latéral, la chirurgie était initiée par voie transpéritonéale à l’aide de 3 trocarts robotiques, et consistait en une dissection exclusive du bord externe du rein le long du fascia rétrorénal de Zuckerkandl jusqu’au muscle gra