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Page 2 of 11 Bianchi et al. Mini-invasive Surg 2021;5:37 https://dx.doi.org/10.20517/2574-1225.2021.64

Keywords: Renal cancer, robotic partial nephrectomy, nephron sparing surgery, retroperitoneal access

INTRODUCTION
Open partial nephrectomy (PN) has long been the gold standard for treatment of renal masses amenable to
nephron-sparing surgery. However, in the last decades, minimally invasive approaches have gained traction
in this field, due to improved postoperative recovery without compromised functional, perioperative, and
[1]
oncological outcomes .
Minimally invasive PN may be performed either with laparoscopy (LPN) or with robot-assisted laparoscopy
(RAPN); due to the highly advanced laparoscopic skills needed for LPN, RAPN is increasingly being
performed, with reports in the literature of shorter warm ischemia time, length of stay, blood loss, and
[2,3]
superior functional and oncological outcomes with the latter .

As with standard laparoscopic techniques, RAPN might be performed with either transperitoneal
(tRAPN) or retroperitoneal (rRAPN) approach .
[4]
[5,6]
No specific indication of in which candidates tRAPN or rRAPN should be used can be found in current
guidelines, and in the literature the two approaches have been shown to offer equivalent perioperative
morbidity, functional and pathological outcomes regardless of tumor location . However, the choice of
[7,8]
surgical approach is influenced by tumor location: tRAPN for medial and anterior masses and rRAPN for
posterior ones.

The three- and four-arm RAPN techniques are well described in the literature [9-12] . However, a
retroperitoneal robotic access technique is less standardised. Therefore, we describe our rRAPN access
technique step-by-step, showing all relevant details in the available video [Supplementary Video 1], focusing
on patient positioning, port placement, generating retroperitoneal space, and robot docking.

METHODS
Patient preparation
For retroperitoneal approaches, bowel preparation is not administered and fasting is indicated from
midnight. A type and screen is sent, and two packs of red blood cells are available in the operating room, as
for all renal surgeries performed in our department.

Patient positioning
After general anesthesia is established, the patient is positioned in a full flank position with the ipsilateral
side up relative to the renal tumor and the arms extended on supports to facilitate retroperitoneal access.
The bed is bent to widen maximally the distance between the iliac crest and the ribs and, eventually, flipped
to the anti-Trendelemburg position, in the case of a particularly prominent iliac crest (typically in women)
[Figure 1].

Next, after disinfection, surgical drapes are positioned along the paravertebral line laterally and the
parasternal line medially, just under the basisternal line cranially and the bisiliac line caudally, in order to
provide full access to the retroperitoneal space, as well as exposure of the whole abdomen in case of need to
convert to a transperitoneal approach.