Initial experience of laparoscopic radical nephrectomy using the Senhance^® robotic system for renal cell carcinoma

Abstract

The Senhance^® robotic system (TransEnterix, Morrisville, NC, USA), previously called the TELELAP Alf-X system, is a novel robotic system with a telesurgical concept. We herein describe our initial experience of Senhance^® assisted laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) with detailed figures and videos. Case 1: A left renal tumor was incidentally detected in a 52-year-old female on ultrasonography. Case 2: A right renal tumor was detected in a 67-year-old male with epigastric pain on computed tomography. They were referred for further examination and diagnosed with RCC (clinical T1bN0M0 and clinical T2aN0M0, respectively). Senhance^® assisted LRN was completed without conversion to conventional LRN or open surgery in both cases. The pneumoperitoneum time, console time and estimated blood loss in case 1 and case 2 were 173 min, 143 min and 3 mL, and 154 min, 122 min and 50 mL, respectively. The postoperative course was uneventful. Senhance^® assisted LRN for RCC was safely and precisely performed. Furthermore, the operator was comfortable during the surgery. Although further surgical experience and long-term follow-up are required to assess surgical and oncological outcomes, Senhance^® assisted LRN for RCC may be a promising procedure.

Supplementary information

The online version contains supplementary material available at 10.1007/s13691-021-00487-x.

Introduction

The Senhance^® robotic system (TransEnterix, Morrisville, NC, USA), previously called the TELELAP Alf-X system, was reported as a novel robotic system with a telesurgical concept in 2012 [1]. This robotic system is composed of up to four independently positionable and controllable robotic arms, which are controlled by the surgeon via a console with attached laparoscopic handles (Fig. 1) [2]. This system has several novel characteristics, such as an eye-tracking camera control system and haptic feedback, and operations can be performed in comfortable seated position without neck strain. These characteristics are different from the da Vinci^® surgical system (Intuitive Surgical, Sunnyvale, CA, USA), which is the most popular robotic system. Standard trocars used in conventional laparoscopy are able to be used with the Senhance^® system. Although the instruments are specific to that system, most are reusable without limited times. Therefore, the maintenance cost is lower than that for the da Vinci^® system. The Senhance^® system was approved for general surgery, gynecology, urology and thoracic surgery by European regulators and the Food and Drug Administration in USA in 2014 and 2017, respectively. This system was approved for use by the Japanese Ministry of Health, Labour and Welfare in 2019, and it can be used in 98 benign and malignant laparoscopic procedures across the general, colorectal, gynecologic, pediatric, and urological surgery fields, including laparoscopic radical nephrectomy, at reimbursement rates equivalent to traditional laparoscopy.

Fig. 1.

The Senhance^® robotic system featuring up to four manipulator arms (a) and cockpit (b)

Initial experiences with the Senhance^® system in general surgery and gynecology were recently published, and its feasibility and safety were reported [2–5]. Although several reports about the Senhance^® system in the urological field were published [2, 6, 7], they were mainly about radical prostatectomy. As of February, 2021, only one case of Senhance^® assisted laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) has been reported [2]; however, the details, such as trocar position, instruments and procedures, were not described. Thus, detailed descriptions are required for its popularization. We describe initial experience of Senhance^® assisted LRN for RCC with detailed figures and videos.

Case report

Case 1

A 52-year-old female (body mass index 21.4 kg/m²) with no medical history was found to have anemia (serum hemoglobin level 6.7 g/dL) in an annual health check-up and visited a neighboring hospital. Esophagogastroduodenoscopy and colonoscopy were performed, and gastritis was found. A left renal tumor of 52 mm in diameter was incidentally detected on abdominal ultrasonography and she was referred to our hospital for further examination. On computed tomography (CT), a cystic tumor, which was 48 mm in diameter, was detected at the upper pole of the left kidney (Fig. 2a, b). The septum of the tumor was enhanced by contrast medium in the early phase (Fig. 2c), and the enhancement of the septum gradually decreased in the portal and delayed phases (Fig. 2d, e). Under the diagnosis of left RCC (clinical T1bN0M0), Senhance^® assisted LRN was planned.

Fig. 2.

a–f Computed tomography (CT) demonstrated a cystic tumor, which was 48 mm in diameter, at the upper pole of the left kidney in case 1 (a coronal section, b–e axial section, f three-dimensional image). b The renal tumor on CT without contrast medium, c the renal tumor in the early phase, d the tumor in the portal phase, e the tumor in the delayed phase, g–l CT demonstrated a solid tumor, which was 75 mm in diameter, at the lower pole of the right kidney in case 2 (g coronal section, h–k axial section, l three-dimensional image). h The renal tumor on CT without contrast medium, i the tumor in the early phase, j the tumor in the portal phase, k the tumor in the delayed phase. Yellow and red arrow indicates a septum of the tumor and a renal artery, respectively. Green arrowheads indicate a tumor

Case 2

A 67-year-old male (body mass index 27.6 kg/m²) visited a neighboring hospital because of epigastric pain and a right renal tumor was incidentally detected on CT. He was referred to our hospital for further examination. A renal tumor of 75 mm in diameter was found at the lower pole of the right kidney (Fig. 2g, h) on CT. The tumor was heterogeneously enhanced in the early phase (Fig. 2i), but the enhancement was washed out in the portal and delayed phases (Fig. 2j, k). Under the diagnosis of a right RCC (clinical T2aN0M0), Senhance^® assisted LRN was planned.

Surgical technique

Case 1

Under general anesthesia, the patient was placed in a right lateral position and a camera port was inserted at the exterior edge of the abdominal rectus muscle around the umbilicus (Fig. 3a). After establishing pneumoperitoneum, three trocars were inserted as shown in Fig. 3a. The distance between port A and a camera port was 9 cm, and the distance between port B and a camera port was 10 cm. A 10-mm rigid laparoscope (Conmed, Tokyo, Japan), 5-mm bipolar forceps and 5-mm monopolar scissors were inserted from a camera port, a 12-mm trocar (port A) and 5-mm trocar (port B), respectively, and they were docked to the Senhance^® system. All procedures were performed in a similar manner to conventional left LRN. Sharp dissection using a vessel-sealing device (Enseal, Ethicon), suction using a straight laparoscopic electrode (Opti 4, Covidien), and clamping of the renal artery and vein using clips were performed from port C by the assistant.

Fig. 3.

a Trocar position in Senhance^® assisted left laparoscopic radical nephrectomy. The camera port was made at the exterior edge of the abdominal rectus muscle around the umbilicus. A 12-mm port was made at the exterior edge of the abdominal rectus muscle caudal of the arcus costalis (A). A 5-mm trocar was inserted slightly lateral to the exterior edge of the abdominal rectus muscle caudal to the camera port (B). In addition, a 12-mm trocar was inserted around the umbilicus for the assistant (C). b Trocar positioning in Senhance^® assisted right laparoscopic radical nephrectomy. The trocar positioning mirrored that in Senhance^® assisted left laparoscopic radical nephrectomy (camera port and A–C). A 5-mm trocar was additionally inserted at the anterior axillary line caudal to the arcus costalis to lift the liver (D)

Case 2

Under general anesthesia, the patient was placed in a left lateral position, and the trocar positioning mirrored that in case 1 (Fig. 3b). A 5-mm trocar was additionally inserted to lift the liver (port D). A rigid laparoscope, 5-mm monopolar scissors and 5-mm bipolar forceps were inserted from a camera port, a 12-mm trocar (port A) and 5-mm trocar (port B), respectively, and they were docked to the Senhance^® system (Fig. 4). The assistant supported from a 12-mm port (port C). All procedures were performed in a similar manner to conventional right LRN.

Fig. 4.

Intraoperative setup in Senhance^® assisted right laparoscopic radical nephrectomy. A 5-mm trocar was additionally inserted to lift the liver later

Detailed intraoperative findings in cases 1 and 2 are shown in Supplemental Videos 1 and 2, respectively.

Peri- and postoperative results

In both cases, the procedure was safely completed without conversion to conventional LRN or open surgery. The pneumoperitoneum time, console time and estimated blood loss in cases 1 and 2 were 173 min, 143 min and 3 mL, and 154 min, 122 min and 50 mL, respectively. The postoperative course was uneventful. The histopathological diagnosis was clear cell RCC and the surgical margin was negative.

Discussion

We described our initial experience of Senhance^® assisted LRN for RCC with detailed figures and videos. It was safely performed and the surgical procedures were almost the same as those in conventional LRN. A three-dimensional camera with 16-fold magnification provides a high-quality visual field and precise assessment of thin tissue structures. The camera with “eye sensing control” was able to be precisely maneuvered by the eye movements of the surgeon. The high-quality visual field and precise maneuvering were particularly useful during dissection of the renal hilum. Furthermore, the operator performed the surgery in a comfortable seated position without neck strain.

As described above, initial experiences of Senhance^® assisted extraperitoneal radical prostatectomy for prostate cancer were previously reported [2, 6, 7]. Samalavicius et al. reported excellent functional outcomes and urinary continence in 27 initial cases [2]. Kastelan et al. also reported that the Senhance^® system was safe and feasible for prostate cancer in 40 initial cases [7]. However, further surgical experience, establishment of surgical procedures, and long-term oncological and functional outcomes are required for popularization of Senhance^® assisted radical prostatectomy.

LRN is the gold standard for clinical T2 RCC and localized masses not treatable by partial nephrectomy [8]. LRN is one of the surgical procedures used in the urological laparoscopic skills qualification system called the Endoscopic Surgical Skill Qualification System in Urological Laparoscopy, which was established by the Japanese Urological Association and Japanese Society of Endourology [9]. The difficulty of LRN is considered to be relatively low among urological laparoscopic procedures; therefore, we selected LRN as an introductory surgical procedure using the Senhance^® system. Although Senhance^® assisted LRN for RCC could be safely and precisely performed even in introductory cases, the pneumoperitoneum time was relatively longer compared with conventional LRN. Additional time required to dock robot arms was one of the reasons of longer pneumoperitoneum time, however, it may be shortened by accumulating experiences. Furthermore, a limitation on the types of usable devices might be also the reason. Usually, a kidney is efficiently dissected from a surrounding tissue using vessel sealing devices or laparoscopic coagulation shears in conventional LRN. In the present cases, only monopolar scissors and bipolar forceps were used, therefore, repeated coagulation with bipolar forceps and transection by scissors were required during the precise dissection of tissues, including small vessels and relatively thick tissue, such as Gerota’s fat. However, high quality ultrasonic instrument was approved on October 2020 in Japan. Transection without bleeding is possible using only the ultrasonic instrument of the Senhance^® system; therefore, the precise dissection of tissues described above may become more efficient. The ultrasonic instrument is expected to help shorten the console time. After the accumulation of surgical experience and establishment of surgical procedures, surgical and oncological outcomes of Senhance^® assisted LRN should be compared with conventional LRN for its popularization.

The procedure of Senhance^® assisted LRN should be further improved. The Senhance^® robotic system is composed of four robotic arms and a console, as described above. In the present cases, we only used three robotic arms and the so-called “the third arm” was not used. If an additional robotic arm is inserted through port D, as shown in Fig. 3b, in right radical nephrectomy, it may be useful to lift the liver or kidney. We plan on performing Senhance^® assisted right laparoscopic radical nephrectomy using all four robotic arms. In the present cases, a 10-mm rigid laparoscope was used and a 12-mm trocar was inserted into port A, as shown in Fig. 3a, b. When retrieving the specimen into the bag that was inserted from the camera port, a 10-mm rigid laparoscope was inserted from port A; therefore, a 12-mm trocar was needed. If a 5-mm laparoscope is used, a 5-mm trocar is sufficient for port A, which may lead to a better cosmetic result.

Most of the instruments used in the Senhance^® system is 5 mm in diameter. As they are thinner than the instruments usually used in the da Vinci system, cosmesis may be better. Furthermore, forceps of 3 mm in diameter and 5-mm articulating instruments are also available for the Senhance^® system [10, 11], thus reduced port surgery (RPS) and laparoendoscopic single-site surgery (LESS) are able to be performed. Hirano et al. previously reported RPS using the Senhance^® system for sigmoid colon cancer [12]. We actively perform LESS and RPS for RCC [13, 14]. After accumulating experience with multichannel Senhance^® assisted LRN, we will introduce LESS and RPS to Senhance^® assisted LRN.

In conclusion, Senhance^® assisted LRN for RCC was safely and precisely performed. Furthermore, the operator was comfortable during the surgery. Although further surgical experience and long-term follow-up are required to assess surgical and oncological outcomes, Senhance^® assisted LRN for RCC may be a promising procedure.

Supplementary information

Below is the link to the electronic supplementary material.

Funding

There is no funding to disclose.

Declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed herein involving patients were in accordance with the ethical standards of the Institutional and/or National Research Committees and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent for the usage of clinical data, including laboratory data, images, and operative videos was obtained from the patients.