Awake Da Vinci robotic partial nephrectomy: First case report ever in a situation of need.

A 63-year-old women presented with a 5.5-cm cystic right renal tumor (Bosniak IV, PADUA score 9) showing a significant growth (+1 cm/year). Partial nephrectomy was feasible ( Fig. 1 A) and recommended (eGFR 80 ml/min); active surveillance was abandoned due further growth risk and patient preference. She was heavy smoker, mildly obese (BMI 30), having a history of right pneumonectomy for lung cancer (2012) and subsequent severe restrictive respiratory syndrome. At admittance, vital signs and routine lab exams were normal. Ejection fraction (EF) was 60% with no signs of pulmonary hypertension. Lung function tests revealed a forced expiratory volume over 1 second (FEV1) of 0.86 L (40% predicted), a forced vital capacity (FVC) of 0.98 L (38% predicted) and diffusion lung carbon monoxide (DLCO) (36% predicted). The American Society of Anesthesiologists (ASA) score was grade 4. The risk associated with GA was deemed too high and only partially evaluable through standard risk scales and the patient had been refused surgery in other tertiary cancer centers. After multidisciplinary meeting, we opted for a robot-assisted surgery under continuous spinal anesthesia (CSA): the reasons are reported in the discussion. After a thorough informed consent, the patient accepted to undergo surgery. Fig. 1 A: Preoperative CT-scan; B: Port placement; C: 3D reconstruction of the right kidney and of the tumor mass; D: Awake patient during the procedure (left decubitus position). Fig. 1 A: Preoperative CT-scan; B: Port placement; C: 3D reconstruction of the right kidney and of the tumor mass; D: Awake patient during the procedure (left decubitus position). On arrival in the operating room, vital signs were normal. Peripheral venous, central venous, and arterial lines were obtained. With the patient in lateral decubitus, aided by a spine ultrasound, the subarachnoid space was identified in the T8-T9 interspace with a 20-G Tuohy needle (SpinoLong Tuohy 20-G x 90 mm,Temena). A 24-G spinal catheter (SpinoLong Tuohy Kit, Temena) was positioned with the 10 cm mark at the skin. A subarachnoid T4-T5 sensory and motor block was achieved with 1 mL 0.5% isobaric levobupivacaine within 15 minutes. Target-controlled conscious sedation (Bispectral Index value between 70 and 85) was achieved through propofol, remifentanil and ketamine infusions. Hypotension required intravenous noradrenaline (0,1 mcg/kg/min) for the first 30 minutes; hemodynamics remained then stable. Anesthetic boluses and vital signs during the operation are recorded in Table 1 . Table 1 Intraoperative parameters and timing of spinal boluses of isobaric levobupivacaine. Table 1 Time after spinal block SBD/DBP (mmHg) HR (beats/min) SpO 2 (%) PaO 2 (mmHg) PaCO 2 (mmHg) Levobupivacaine 0.5% (mg) 10 min 100/50 51 97 30 min 120/61 52 97 115 46 2.5 60 min 130/65 50 96 157 42 2.5 70 min 143/70 53 97 2.5 + 15 mcg fentanyl 90 min 130/72 56 97 139 52 2.5 120 min 142/65 54 96 123 55 2.5 150 min 123/75 57 96 135 53 180 min 140/75 63 98 90 48 At ICU 133/60 62 98 93 42 DBP diastolic blood pressure, HR heart rate, ICU intensive care unit, PaCO2 partial pressure of carbon dioxide in arterial blood, PaO2 partial pressure of oxygen in arterial blood, SpO2 oxigen saturation, SBP systolic blood pressure. Intraoperative parameters and timing of spinal boluses of isobaric levobupivacaine. DBP diastolic blood pressure, HR heart rate, ICU intensive care unit, PaCO2 partial pressure of carbon dioxide in arterial blood, PaO2 partial pressure of oxygen in arterial blood, SpO2 oxigen saturation, SBP systolic blood pressure. Patient was placed in left decubitus position, with a mild scissoring. The retroperitoneum was accessed at the apex of the XII rib and developed with a dedicated balloon. Trocars disposition is shown in Fig. 1 B. Pneumo-retroperitoneum of 8 mmHg was achieved with Air Seal (ConMed, Milford, Connecticut, USA). Da Vinci Xi robot was then docked. Surgery was guided by 3D reconstructions of the kidney (Medics Srl, Moncalieri, Italy, Fig. 1 C), displayed by the Tile-Pro function. After renal artery clamping, partial nephrectomy of the renal mass was performed. Warm ischemia time was 25 minutes. The patient remained perfectly still during the entire procedure, which lasted 2h45 ( Fig. 1 D). During Intensive Care Unit (ICU) monitoring, analgesia was provided by paracetamol 1 g every 8 hours in addition to 0.16% levobupivacaine at 0.5 mL/h through the spinal catheter. The Visual Analogue Scale score for pain was never higher than 1. On post-operative day 3, the spinal catheter and surgical drain were removed. A mild airway infection was treated with piperacilline/tazobactam and respiratory physiotherapy. The patient was discharged on day 9 in stable conditions, with blood creatinine of 0.64. Pathologic examination revealed a pT1bG1R0 clear cell renal carcinoma.

The procedures performed in this report were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

A full written consent for publication of this case report was obtained from the patient.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

PG and FG conceived the medical procedure; MO and FG wrote the manuscript with support of GC and PG; all the Authors discussed the results, contributed to the discussion and approved the final manuscript.

Several recent reports suggest that regional anesthesia may be an alternative to GA for laparoscopic surgery, entailing reduced surgical stress, avoidance of airway instrumentation, less emesis, early ambulation and faster recovery with possibly shorter hospital stay. On the other hand, there are risks of hypotension due to sympathetic blockade, hyperesthesia, pain, and also increased surgical time due to the limitation of intra-abdominal pressure. 1 The awake laparoscopy has been used in minor surgeries, such as diagnostic procedures in case of penetrating abdominal wounds, gynecological surgeries including endometriosis ablation, salpingo-oophorectomy, hysterectomy or sleeve gastrectomies 2 , 4 In our case, the choice of a regional anesthesia was imperative, given the very high risk linked to the use of GA. In our opinion, a pure laparoscopic approach would have been unsuitable, due to the high PADUA score and the risk of rupture of the cystic mass, with possible tumor seeding. Open surgery via lumbotomy was unfeasible under regional anesthesia. Therefore, after careful multidisciplinary evaluation and hospital Risk Management permission, we chose to use multiport Da Vinci Xi. To our knowledge, no previous report of a robotic Da Vinci procedure under spinal anesthesia exists and this was confirmed by the manufacturer. 3D kidney reconstructions were adopted to guide excision. The constant communication between anesthesiologists and surgeons was paramount. The retroperitoneal approach was preferred firstly due to posterior, lower pole location of the tumor and also to minimize the peritoneal stretching and the phrenic nerve irritation. The choice of CSA was due to the predicted duration of surgery. Compared to single-shot spinal anesthesia and continuous epidural anesthesia, CSA allows to use small incremental and titrated doses of local anesthetics, avoiding the hemodynamic effects of a lasting block. Many complications of CSA have been reported, including post-dural puncture headache, bleeding and epidural hematoma, infection, inadvertent catheterization of the subdural space, inadequate anesthesia and catheter breakage during removal. 5 In our case, none of these complications occurred. We acknowledge that the choice of an awake robotic surgery is hardly generalizable.

Supporting data and further information can be requested to the corresponding author ( [email protected] ).

The present case is the first report showing that the use of CSA allows the use of the Da Vinci robot on an awake patient with sufficient safety during a complex procedure like a partial nephrectomy.

Major laparoscopic procedures are commonly performed under general anesthesia (GA). In the last years, regional anesthesia has been proposed as an alternative in selected patients for diagnostic microlaparoscopy or for minor gynecologic surgeries, to avoid airway manipulation and to enhance recovery. 1 , 2 Robotic surgery has almost replaced laparoscopy for major urological procedures such as radical prostatectomy and complex partial nephrectomies. GA is typically required for robotic surgeries given that robotic arms are docked to the patient. 3 We present the first case of awake robotic partial nephrectomy performed on a patient unfit for GA, harboring a complex cystic kidney tumor.

The authors declare that they have no competing interests.