61
Laparoscopic and Robotic Surgery of
the Kidney
Michael J. Schwartz; Soroush Rais-Bahrami; Louis R. Kavoussi
Questions
1.A 22-year-old woman presents with severe intermittent, positional left flank pain. Her medical and surgical histories are unremarkable, and her body mass index (BMI) is 19 kg/m2. Renal ultrasound shows no evidence of stones or hydronephrosis. What is the best next step in evaluation?
a.Cystoscopy and retrograde pyelogram
b.Computed tomography (CT) urogram
c.Flat and upright intravenous pyelogram
d.Nuclear renal scan
e.Observation
2.A laparoscopic renal biopsy is performed for a 53-year-old man with chronic renal insufficiency of unclear etiology and a BMI of 47 kg/m2. A prior percutaneous approach did not obtain adequate tissue. Using a two-port retroperitoneal approach, copious retroperitoneal fat is encountered and there is difficulty with orientation and localizing the kidney. The best next step is to:
a.abort the procedure. Recommend a repeat percutaneous image-guided approach to the nephrology service.
b.advance a biopsy needle under laparoscopic guidance through the fat to the presumed location of the kidney.
c.convert to an open retroperitoneal procedure using a mini flank incision.
d.intraoperative renal ultrasound to localize the kidney.
e.place a third port to aid in dissection.
3.The following are preferred methods of renal hilar ligation during
laparoscopic/robotic nephrectomy EXCEPT:
a.en bloc stapling of the renal artery together with the renal vein.
b.stapling the renal artery and vein separately.
c.multiple titanium clips on the artery, stapler ligation of the vein.
d.multiple Hem-o-lok clips on the artery, stapler ligation of the vein.
e.all of the above are preferred methods of renal hilar ligation.
4.Absolute contraindications to laparoscopic partial nephrectomy include:
a.aspirin therapy for cardiac stents.
b.multiple prior abdominal surgeries.
c.prior ipsilateral renal surgery.
d.untreated infection.
e.body mass index greater than 50 kg/m2.
5.On postoperative day 3 following robotic-assisted laparoscopic right partial nephrectomy, a 54-year-old man presents to the emergency room with nausea, low-grade fever, right-sided abdominal pain, and foul-smelling discharge from a right lateral trocar site. CT scan with oral contrast demonstrates extravasation of contrast from the ascending colon with an adjacent fluid collection. The most likely etiology of the injury is:
a.trocar injury.
b.blunt dissection.
c.sharp dissection.
d.bowel ischemia.
e.electrocautery scatter.
6.A 65-year-old man underwent an uncomplicated robot-assisted left laparoscopic partial nephrectomy and was discharged home on postoperative day 2, voiding clear yellow urine. He presents to the emergency room a week later with new-onset gross hematuria and flank pain. He is mildly tachycardic and hypotensive. Hematocrit is 22%. One hour after fluid resuscitation, his vital signs have normalized, but the hematuria persists and he is requiring continuous bladder irrigation (CBI). The best next step is:
a.CT scan with intravenous (IV) contrast.
b.intensive care unit (ICU) admission, blood transfusion, and serial hematocrits.
c.echocardiogram.
d.renal angiography with angioembolization.
e.cystoscopy, placement of left ureteral stent.
7.A 53-year-old woman who underwent a laparoscopic heminephrectomy for a
5-cm central kidney tumor continues to have drain output greater than
150 mL per day on postoperative day 3. Drain fluid assessment demonstrates a creatinine level of 19 mg/dL while the patient's serum creatinine is within normal limits (1.1 mg/dL). The best way to resolve the leakage is to:
a.continue the drain and observe.
b.insert an indwelling ureteral stent.
c.insert an indwelling ureteral stent and Foley catheter.
d.insert a percutaneous nephrostomy tube.
e.consider a completion nephrectomy.
8.A 50-year-old man presents with 4 + proteinuria and intermittent milky-white urine after recent travel. Retrograde pyelogram demonstrates a lymphorenal fistula. Complete blood count (CBC) demonstrates eosinophilia, and urine culture is positive for Wuchereria bancrofti. Treatment options recommended prior to laparoscopic nephrolysis include all of the following EXCEPT:
a.treatment course of diethylcarbamazine.
b.low-fat diet.
c.nonsteroidal anti-inflammatory drug (NSAID) administration.
d.observation.
e.retrograde instillation of silver nitrate into the collecting system.
9.A robotic-assisted laparoscopic left partial nephrectomy is performed to resect a local recurrence following laparoscopic radiofrequency ablation of an anterior renal tumor. During exposure of the left renal vessels, dense adhesions and scar tissue are encountered and a deep injury to the pancreatic tail is identified. This scenario is best managed by:
a.application of biologic glue or sealant over the tail of the pancreas.
b.distal pancreatectomy with an endoscopic GIA stapler.
c.routine completion of the case, drain placement, and postoperative bowel rest.
d.routine completion of the case with administration of somatostatin postoperatively.
e.routine completion of the case with postoperative bowel rest and parenteral nutrition.
.Standard trocar placement for renal surgery may need to be adjusted based on which of the following patient characteristics?
a.Obese body habitus
b.Prior abdominal surgery
c.Renal tumor size
d.Robotic assistance
e.All of the above
.Laparoscopic unilateral simple nephrectomy is indicated in all of the following clinical scenarios EXCEPT:
a.40-year-old woman with renovascular hypertension refractory to medical and angiographic repair.
b.58-year-old man with left-sided xanthogranulomatous pyelonephritis and differential renal function of 8%.
c.69-year-old man with 7-cm endophytic right renal mass with 25 Hounsfield unit enhancement on abdominal CT.
d.63-year-old man with left renal tuberculosis recalcitrant to medical management.
e.34-year-old woman with chronic right flank pain, right hydronephrosis not amenable to surgical repair, and dramatic thinning of the right renal parenchyma.
.When obtaining access for laparoscopic renal surgery, which of the following technique(s) is/are employed to minimize the risk of bowel injury?
a.Insertion of a Veress needle (Ethicon US, LLC) away from prior surgical scars
b.Hasson technique of open trocar placement
c.Retroperitoneal approach
d.a and b.
e.a, b, and c
.During laparoscopic renal cyst decortication for a large, symptomatic left perihilar cyst, a major portion of the cyst wall is noted to be adjacent to the vessels and collecting system. The best next step in management to prevent cyst recurrence is:
a.complete the removal of the cyst wall. Repair any vascular or collecting system injuries as necessary.
b.place a pedicle of autologous fat in the defect.
c.fill the cystic space with talc.
d.plan to leave a drain in the defect for 6 to 8 weeks, periodically instilling a sclerosis agent.
e.all of the above are equally viable options.
.Routine lymphadenectomy when performing laparoscopic radical nephrectomy for node-negative patients by preoperative imaging has been shown to yield:
a. increased overall survival.
b.higher complication rates.
c.10% rate of lymph node metastasis.
d.increased cancer-specific survival.
e.none of the above.
.A patient clinically suited to undergo cytoreductive nephrectomy may benefit from the laparoscopic approach to cytoreductive nephrectomy over open cytoreductive nephrectomy in regard to all of the following EXCEPT:
a.decreased blood loss.
b.shorter perioperative hospitalization.
c.shortened convalescence with similar survival.
d.shorter time interval to commencing systemic therapy.
e.improved overall survival.
.A mesenteric defect is recognized during medial reflection of the descending colon in a laparoscopic left partial nephrectomy. Before completion of the case, the mesenteric defect should be repaired to prevent:
a.internal hernia.
b.formation of adhesions.
c.postoperative hemorrhage.
d.colonic injury.
e.none of the above.
.An area of serosal denudation is noticed by the bedside assistant while performing colonic mobilization bluntly with a suction-irrigation device during a robotic-assisted laparoscopic left nephrectomy. The best choice in management of this injury is:
a.routine completion of the case with postoperative bowel rest and parenteral nutrition
b.placement of imbricating stiches to repair the area of serosal disruption.
c.segmental colon resection and primary reanastomosis.
d.end colostomy.
e.diverting loop ileostomy.
.Laparoscopy is now the preferred method for addressing most surgical renal pathology based on widely reproducible findings in comparative studies with open approaches showing:
a.equivalent outcomes.
b.superior cosmesis.
c.reduced analgesic requirement.