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Dr. Khater on troubleshooting robotic partial nephrectomy


"I emphasized the fact that the use of ultrasound is very important and should be done on every single case," says Nazih Paul Khater, MD, FACS.

In this video, Nazih Paul Khater, MD, FACS, summarizes his North American Robotic Urology Symposium discussion "Troubleshooting the RAPN.” Khater is an associate professor of urology and director of Urologic Research at LSU Health Shreveport.


Dr. Khater on his NARUS discussion "Troubleshooting the RAPN"

This is the North American Robotic Urology Symposium, which is NARUS. It began in 2017. The 2024 meeting was year number 8 for NARUS. It was held from February the 22nd to the 24th. The meeting is in Las Vegas each year, and on the first day, we started with the Young NARUS session that focuses more on topics of interest to recent graduates or fellows. The speakers are a mix of either young or senior level experts. I was invited to participate as a speaker and a moderator at this Young NARUS session and I joined esteemed faculty during the robotic partial nephrectomy block. The moderators for the session included Dr. Laura Bukavina, Dr. Alejandro Sanchez, Dr. Richard Link, and myself. Dr. Sanchez discussed closure of the kidney, Dr. Link spoke about the future of robotic surgery, and Dr. Bukavina gave us a state-of-the-art talk about patients with chronic kidney disease and how to manage them. My talk was more focused on how to troubleshoot partial nephrectomy. It was basically things that graduates and young urologists [can take away for] their careers. Partial nephrectomy is still a delicate procedure...The saying "see one, teach one, do one," is not always the case with this operation. I started by clarifying where the problems come from. There can be either a problem during a tumor excision and we can have a bleed, it can be a concern for positive surgical margins when we dissect the tumor, and third, I was able to discuss any injury to inadvertent vessels close to the hilum at the beginning of the dissection. Finally, I went over injuries of adjacent organs like the ureter and the diaphragm or the pleura in difficult cases. Basically, I focused on the fact that whether or not you're doing this operation on a multi-port robot or a single-port robot, I advise surgeons to do a full hilar dissection: expose everything, skeletonize the artery, the vessel, especially in large and central tumors that are either a T1b or a T2a. I emphasized the fact that the use of ultrasound is very important and should be done on every single case, whether or not it's a simple partial nephrectomy, or a more complicated one, because studies have shown that when we use intraoperative ultrasound, it can increase surgeon confidence, the fact that we know the depth of the tumor and the extent. It's a perfect tool that every surgeon should take into consideration during each case. I discussed bleeding first; if you have a venous problem, how to troubleshoot that. That means how to deal with your bulldog clamp, how to make sure your vein is clamped. Then I touched on the 2 remaining problems during tumor dissections: arterial [bleeding] that can be either an individual single bleed or a diffuse arterial bleed and how to troubleshoot that, because this is frequent. We have steps for this. I also offered the audience tips to minimize your warm ischemia time, because it's a concern when you dissect the tumor and you have a concern for positive surgical margin. I discussed the offclamp resection, selective clamping, and the fact that nowadays, we are in the era of 3D printing, artificial intelligence. Those are tools that are present in the armamentarium of the urologist. These are important points I clarified. Third, I emphasized bleeding from inadvertent vessels at the hilum of the kidney. Number one, when the assistant at the bedside is holding the suction, it's very important not to have a continuous suction when there's a bleed; on the contrary, we should apply pressure to have a tamponade effect and use intermittent suction to minimize the bleed and see the origin of the bleed. It is encouraged for young urologists and urologists in their early careers to consider having a Prolene stitch or if you want, we call it a rescue stitch, which is a 4.0 Prolene suture that is 6 inches in length. It is important to know how to have it on your table in case of bleeding to suture any puncture in the vein or any vessel at this step. And third, I of course discussed injuries to the ureter in the case of lower pole kidney tumors, and injuries to the diaphragm when the pleura is exposed in upper pole kidney tumors. I came up with this acronym "CURE." If we want to do a good job for our patients with partial nephrectomy, knowing how to control any bleeding, "U" is use of ultrasound, "R" is readjust; that means we readjust your resection deeper if need be, and "E" is evaluate your surroundings. That means minimizing excessive movement from your instrument.

This transcript was edited for clarity.

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