How robotic surgery is transforming kidney cancer treatment

A Mediclinic specialist explains the benefits of robotic partial nephrectomy over traditional open surgery and laparoscopic surgery. 

Partial nephrectomy is a kidney-sparing surgery performed primarily to remove small, localised tumours while preserving healthy kidney function. It’s the preferred treatment for early-stage kidney cancer, reducing long-term risks of chronic kidney disease, and in patients with a single or damaged kidney.

Dr Jos Myburgh, a urologist at Mediclinic Bloemfontein who recently performed his first partial nephrectomy using the Da Vinci robot, explains why robotic partial nephrectomy is preferable to traditional open surgery and laparoscopic surgery.

Downsides of open nephrectomy surgery

“Traditional open surgery is done via large upper abdominal incisions and is extremely painful, creating a significant burden on recovery,” he says. “The risk of wound infection is increased, and because of the pain, difficulty with breathing, and coughing to clear secretions from the lungs, the risk of lung infections becomes a lot higher. Patients also don’t get out of bed and start walking as soon as they would after laparoscopic or robotic surgery, increasing the risk for deep vein thrombosis or lung embolism. Bleeding is also significantly higher with open surgery.” However, it is sometimes necessary when there are risks associated with removing only the tumour.

The challenges of partial nephrectomy laparoscopic surgery

Laparoscopic and robotic surgery share the advantage of being minimally invasive but laparoscopic surgery can be more challenging. “With both types of surgery, small incisions are made, and a camera and instruments are inserted into the abdomen through special ports (tubes),” explains Dr Myburgh. “Vision inside the abdomen is better as the camera and light are always in the operating field. Laparoscopic surgery also allows for some enlargement of the image – on average up to four times.

The technical challenge with laparoscopic surgery is that the surgeon must depend on their assistant to hold the camera and show them the operating field. The surgeon also must work with straight instruments, which makes dissecting around “corners” and suturing more challenging. “Laparoscopic partial nephrectomy remains a good operation but requires significant skill and experience because of these technical difficulties,” says Dr Myburgh. 

Why partial nephrectomy robotic surgery is preferable

“Partial nephrectomy robotic surgery shares the advantages of laparoscopic surgery, but it helps us overcome the technical difficulties in several ways. Visibility is improved even more – up to 10x enlarged and in 3D – which gives us valuable depth perception in the surgical field. The instruments are wristed and have a range of motion larger than our hands, which makes dissection and suturing a lot easier. To the surgeon it feels like the kidney is right in front of you on a table instead of deep down in someone’s abdomen where it’s difficult to reach and to see.”

The Da Vinci robotic system also boasts advanced technological features that improve surgeons’ ability to perform partial nephrectomy more successfully. Being able to connect a special ultrasound probe that fits into the abdomen through one of the ports and sends the image to the surgeon’s console helps to:

• Clearly identify the tumour – which van be very difficult
• Identify the margins of the tumour 
• Evaluate the blood flow of the tumour.

In addition, Da Vinci has a “firefly” mode that can detect an intravenous-injected dye, showing surgeons where blood vessels run within the tissues, and whether the kidney has been clamped properly before starting with tumour dissection. It can even help delineate the tumour margin from healthy kidney tissue. 

“Overall, these advantages make a partial nephrectomy feasible for cases where it wouldn’t have been possible in the past,” Dr Myburgh says. “It remains a minimally invasive operation with excellent postoperative recovery and a low complication rate.”

Radical versus partial nephrectomy

Radical nephrectomy is the removal of the entire kidney with the surrounding fatty tissue and lymph nodes. Sometimes the adrenal gland is included in the removal as well. In contrast, partial nephrectomy removes the tumour from the kidney, while preserving the rest of the healthy kidney. “The defect in the kidney then needs to be reconstructed to control and prevent bleeding or possible urine leakage,” Dr Myburgh explains.

He adds that partial nephrectomy can be done either as an elective procedure or when necessary. “Mandatory indications include patients with a kidney tumour who have a single kidney, impaired kidney function, tumours in both kidneys, or when we suspect a genetic syndrome that would predispose them to recurring tumours over their lifetime.”

However, research shows that patients with a suitable tumour (usually but not necessarily exclusively stage 1 tumours, smaller than 7cm) can benefit from partial nephrectomy even if they have two healthy kidneys. “If the case is well selected then the long-term cancer outcome is the same as doing a radical nephrectomy, but overall survival seems to be a bit better with partial nephrectomy because kidney function preservation over the long term is better,” says Dr Myburgh. “This in turn results in better overall health, especially from a cardiovascular perspective.”  

The primary priority remains effective cancer control. Because kidney cancers typically respond poorly to chemotherapy and radiation therapy, complete surgical removal is still essential whenever possible. As a result, there are cases where radical nephrectomy remains the most appropriate treatment option.