In this video, Mount Sinai surgeon Ketan K. Badani, MD, FRCS (Hon.), demonstrates the initial incision and access for the single port low anterior approach in the supine position, including details of anatomy and creating the space for SP robot docking.
For more than two decades, Mount Sinai surgeon Ketan K. Badani, MD, FRCS (Hon.), has consistently pushed the boundaries of robot-assisted partial nephrectomy, first using multiport systems and more recently single-port technology. Now, he has made a significant discovery that has resulted in a new paradigm for how this procedure can be performed.
Dr. Badani has determined that it is possible to perform a purely single-port partial nephrectomy retroperitoneally for virtually any kidney tumor regardless of location through a low anterior incision with the patient laid flat instead of in a flank position on their side.
“In working with the single-port system, we realized it is not only very good for working in a small space such as the retro-peritoneum, but also that we could go much further in terms of distances, which opened up possibilities that could not be attempted with multiport surgeries,” explains Dr. Badani, Vice Chair of Urology and Robotic Operations and Director of the Comprehensive Kidney Cancer Center and Reconstructive Urology at the Mount Sinai Health System.
Ketan K. Badani, MD, FRCS (Hon.), Professor of Urology and Director of the Kidney Cancer Center at the Icahn School of Medicine at Mount Sinai
“My access to the kidney in the retroperitoneal space is much more versatile through this approach,” he says. “I can reach any part of the kidney from this one incision without having to make any changes.” Watch the video here.
Dr. Badani estimates he is using this low-anterior, single-port approach for partial nephrectomy in approximately 95 percent of retroperitoneal cases, whereas he estimates that he used the retroperitoneal multiport approach in less than 5 percent of cases. He notes that it has several benefits for patients. It involves a smaller, more hidden incision that results in better aesthetic outcomes but, more importantly, uses a muscle-sparing approach to decrease pain and promote faster recovery.
“Because we can perform the procedure using the same access point each time, our patients are spending less time under anesthesia and achieving faster recovery times,” says Dr. Badani, who is also Professor of Urology at the Icahn School of Medicine at Mount Sinai . “Most of the patients we treat feel comfortable enough to voluntarily opt for same-day discharge.”
A retrospective study led by Dr. Badani comparing outcomes among 70 patients who underwent single-port robotic partial nephrectomy between 2018 and 2023 as part of a large multi-institution collaboration known as SPARC reinforces these observations.
In the study, 44 patients were treated using the low anterior approach (LAA), and 36 were treated using the lateral flank approach. Dr. Badani noted that the LAA group exhibited significantly lower median RENAL scores (8 vs. 5, p < 0.001) and more varied tumor locations (p = 0.002). He also found that in the bivariate analysis, there were no statistically significant differences in ischemia time, estimated blood loss, or complication rates between the groups. Although operative times were longer in the LAA group (101 vs. 134 minutes, p < 0.001), these patients were more likely to be discharged the same day (p < 0.001). When controlling for other variables, he found that LAA was associated with shorter ischemia time (p = 0.005), but noted no significant difference in operative time (p = 0.348) and length of stay (p = 0.122).
“These early data suggest that LAA is more versatile for varying tumor locations,” Dr. Badani says. “However, larger cohort studies are needed to ascertain whether there is an overall difference in patient recovery.”
The study, “Comparison of Lateral Flank Approach and Low Anterior Access for Single Port (SP) Retroperitoneal Partial Nephrectomy: An Analysis From the Single Port Advanced Research Consortium (SPARC),” was published in the May 2024 edition of the Journal of Urology.
Dr. Badani has launched a program to share the LAA approach with surgeons worldwide. There are now six centers nationwide that have adopted this technique, and they are sharing data with him so he can further investigate the impact on patient outcomes.
As Dr. Badani continues to push the boundaries of minimally invasive robot-assisted partial nephrectomy, he is also looking at treatment options that do not involve surgery, such as histotripsy. Histotripsy uses focused ultrasound waves to break apart tissue and was approved in 2023 by the U.S. Food and Drug Administration for the treatment of liver tumors.
“We are looking at the potential of histotripsy—which would enable us to destroy kidney tumors without even inserting a needle in the body,” Dr. Badani says. “As far as we have come in terms of minimally invasive approaches to partial nephrectomy, there is always something more we can do to improve patient outcomes.”