By Holly Fleming, senior brand copywriter at Intuitive
I was born with a mutant kidney: my left kidney had two ureters instead of one (for a total of three ureters). I had no knowledge of this in childhood.
Nevertheless, I started getting kidney infections in my 20s and 30s. When I was 35, I contracted a very severe kidney infection and was hospitalized for a week. It was 2005.
The hospital performed a CT scan and discovered my left kidney was not only a mutant with its two ureters, but had shriveled up; my right kidney had taken over its function. While in the hospital, my urologist told me I’d need to come back in a few months to have the kidney removed—otherwise it would continue to be a magnet for infection. They’d remove it laparoscopically, and he predicted I’d have no more of these infections.
And that’s what happened. I was diagnosed with “left renal dysplasia;” they eradicated the infection with antibiotics; and three months later, I underwent a radical laparoscopic nephrectomy. I had four access ports; morphine; a full recovery. The pain afterward was intense and I was again in the hospital, this time for four days.
But I’m lucky—my right kidney is robust. A “super kidney,” my urologist called it. I know he was just trying to make me feel better after the nephrectomy, but I’ll take it.
Nephrectomy—the removal of a kidney—can be partial or radical. Until recently, radical nephrectomies were far more common. In a partial nephrectomy, also called “kidney-sparing” surgery, surgeons remove the diseased tissue or tumor while leaving as much healthy kidney tissue as possible in order to attempt to preserve renal function. Partial nephrectomy is generally considered to be a more technically demanding surgery.
Surgeons can perform partial and radical nephrectomy through open surgery, laparoscopic surgery, or with robotic assistance using a da Vinci system. The modern era of kidney surgery was launched in 1869 when Gustav Simon, professor of surgery at Heidelberg, performed the first planned nephrectomy on a living person. Simon’s successor at Heidelberg, Vincenz Czerny, performed the first partial nephrectomy 18 years later. Full and partial nephrectomies are now performed with both laparoscopic and da Vinci robotic surgical systems.
Dr. Ketan Badani is a professor of urology at Icahn School of Medicine at Mount Sinai in New York. He uses da Vinci SP and da Vinci Xi in his procedures: partial nephrectomy, radical nephrectomy, prostatectomy, and many others.
Dr. Badani explains how a nephrectomy is not a reconstructive operation. It’s extirpative—a “take it out” operation. Procedures requiring reconstruction (such as prostatectomy) grew first and fastest for da Vinci robotics, due to the precision and control of the systems. And the more a surgeon does these procedures, he says, the more advantages are felt.
“What we found is the more we do robotic surgery, the better it is, the faster we are at it, the more efficient it is,” he said. “So even an extirpative operation like a nephrectomy has now become a mainstream robotic procedure because of all of these reasons.”
Dr. Badani did laparoscopic nephrectomies for many years. “I even did laparoscopic nephrectomies when I had access to a robot for many years,” he said. “But rarely will I do a lap nephrectomy now because I prefer to do it robotically for all the reasons I just mentioned.”
Many of the cases Dr. Badani deals with on a regular basis involve tumors and patients with kidney cancer. He spoke of the evolution where many radical nephrectomy cases became candidates for partial once surgeon skillsets increased.
“The truth is that robotic surgery has affected the way that we manage this disease, kidney cancer,” he said. “And I say it because you can do a total nephrectomy for a kidney tumor, you can do a partial nephrectomy for a kidney tumor—and there are reasons why you’d do one or the other. But in general, in the United States, a lot of tumors that should have had a partial nephrectomy were getting total nephrectomies because it’s an easier operation, and in general the skillset to do a partial was much more challenging.”
Dr. Badani trained with Dr. Mani Menon at Henry Ford Hospital in Detroit, where Dr. Menon was the chairman of urology. Dr. Menon performed the first robotic prostatectomy—a seminal moment in surgical robotics.
“It was an environment where nobody else was doing it at the time—not in the country, not at the meetings, not at the tradeshows, not anywhere,” Dr. Badani said. “I learned it right front and center—green, new, ready to tackle the world.”
Dr. Badani is using da Vinci SP in increasingly innovative ways. While still performing many surgeries with da Vinci Xi, Dr. Badani believes in a right platform, right patient approach, where many cases can benefit from the single-port robotic system.
“The thing about innovation is that you don’t want to reproduce what you’re already doing,” Dr. Badani said. “(da Vinci) Xi partial nephrectomy, or (da Vinci) Xi radical nephrectomy—we’re doing it well. It’s really a good system for doing kidney surgery.”
He explained that there are certain advantages that come with using the da Vinci SP for kidney surgery over multiport da Vinci systems.
Access sites: The surgeon can get to the kidney from areas of the body that are hidden. They can make an incision down low by the bikini line, or from an incision from a previous surgery so as to not make a new scar.
Not having to release scar: In patients who have had significant prior abdominal surgery with a lot of internal scarring, one of the challenges for robotic surgery is releasing the scar tissue in order to get the ports in. With da Vinci SP, scar tissue is released for just one port.
Working in small spaces: If there’s a tumor on the back side of a kidney and the surgeon wants to access it from the back, they use a retroperitoneal approach, as opposed to a transperitoneal (through the abdomen). This approach offers a smaller space and could be made easier with a single-port entry site.
When the single-port da Vinci SP originally came into market, Dr. Badani explained that trying to use it in the same way as multiport da Vinci Xi could be frustrating—until he realized there were specific ways in which the SP was advantageous.
“The lightbulb goes off: why am I trying to do the same thing with the SP? Why am I making it difficult on myself? And you start thinking about things you can do with the SP, like extraperitoneal for prostate, transvesical for prostate, retroperitoneal for kidney, lower McBurney’s, or bikini line incisions for kidney. All of a sudden now, it’s exciting, because you’re willing to learn it a little bit differently, doing something you wouldn’t be doing otherwise.”
The future of robotic surgery will be an evolution: increasingly advanced systems coupled with innovative surgeons to produce unimaginably new techniques—all in the service of reproducibly better outcomes.
“To me, it’s not one size fits all. I don’t view that one antibiotic is the right one to use for every infection. And I certainly don’t view one surgical tool as the right thing to treat everything with. And so I was always dreaming of the day when I had multiple robotic options to choose from to pick the right platform for the right disease in the right patient. And again, we’re not where we need to be, but I would prefer to have two options that do different things, than one that does everything.”
And what will the future of robotic surgery bring? Surgeons like Dr. Badani are at the forefront of this issue, and they are definitely contemplating the question.
“My personal thought on this is that minimally invasive surgery continues to become more minimally invasive. We used to think that doing a smaller incision in the flank to do a partial nephrectomy—even though we still had to take the 12th rib to get to the kidney—was a minimally invasive approach. ‘Go ahead! That’s half the size of an incision we used to use!’”
Dr. Badani sees a future with surgeons utilizing integrated intelligence to steer the course of surgery, attempting to provide reproducible outcomes for patients all over the globe.
“The most important thing for the future of surgery is to reproducibly and reliably offer the same operation with the same outcome, across the world.”
Nephrectomy recovery times have improved—as have recovery times for surgery in general as it has progressed from open to minimally invasive surgery.
After my laparoscopic nephrectomy, I was in the hospital for multiple days and in a lot of pain. Dr. Badani’s current expectations for his da Vinci system surgical outcomes are high.
“I expect the same outcome for the easiest of easy and hardest of hard. These patients should all go home either the same day, or by the next morning. They should all be up, walking, eating, drinking, feeling 85-90% back to normal within a week.”
Where innovative surgeons have access to robotic systems like the da Vinci SP, progress follows.
“It is very unique to robotic surgery: that literally a single technology has changed the way we surgically manage the disease of kidney cancer. The expectation, the bar, has been raised high.”
Important safety information
Nephrectomy (kidney removal) including Partial Nephrectomy (removing part of the kidney): negative outcomes, risks, and complications include but are not limited to poor kidney function often due to limited blood flow, leaking of urine, cut or tear in the spleen, pancreas or liver, bowel injury, trapped air between the chest wall and lung, injury to diaphragm (muscle separating the chest from the abdomen), urinary fistula (abnormal bond of an organ, intestine or vessel to another part of the body), abnormal pooling of urine, limited or cut off blood supply to kidney, abnormal pooling of lymph fluid.
Patients should talk to their doctor to decide if surgery with a da Vinci system is right for them. Patients and doctors should review all available information on nonsurgical and surgical options and associated risks in order to make an informed decision.
Serious complications may occur in any surgery, including surgery with a da Vinci system, up to and including death. Serious risks include, but are not limited to, injury to tissues and organs and conversion to other surgical techniques which could result in a longer operative time and/or increased complications.
For important safety information, including surgical risks and considerations, please also refer to www.intuitive.com/safety. For a product’s intended use and/or indications for use, risks, full cautions, and warnings, please refer to the associated user manual(s).
Individuals’ outcomes may depend on a number of factors—including but not limited to—patient characteristics, disease characteristics, and/or surgeon experience.
Da Vinci Xi/X System Precaution
The demonstration of safety and effectiveness for the representative specific procedures did not include evaluation of outcomes related to the treatment of cancer (overall survival, disease-free survival, local recurrence) or treatment of the patient’s underlying disease/condition. Device usage in all surgical procedures should be guided by the clinical judgment of an adequately trained surgeon.
Da Vinci SP system
The safety and effectiveness of this device for use in the performance of general laparoscopic surgery procedures have not been established. This device is only intended to be used for single port urological procedures and for transoral otolaryngology surgical procedures in the oropharynx for benign tumors and malignant tumors classified as T1 and T2 with the da Vinci EndoWrist SP instruments and the da Vinci SP surgical system (SP1098).