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Year : 2014  |  Volume : 30  |  Issue : 3  |  Page : 275-282

Robotic nephron-sparing surgery for renal tumors: Current status

1 Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Urology, King Abdulaziz University, Jeddah, Saudi Arabia
2 Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

Date of Web Publication1-Jul-2014

Correspondence Address:
Monish Aron
USC Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, California 90089, USA

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-1591.135667

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There have been a number of advances in robotic partial nephrectomy (RPN) for renal masses. We reviewed these advances with emphasis on the evolution of technique and outcomes as well as the expanding indications for RPN. Literature in the English language was reviewed using the National Library of Medicine database. Relevant articles were extracted, and their citations were utilized to broaden our search. The identified articles were reviewed and summarized with a focus on novel developments. RPN is an evolving procedure and is an emerging viable alternative to laparoscopic partial nephrectomy and open partial nephrectomy with favorable outcomes. The contemporary techniques used for RPN demonstrate excellent perioperative outcomes. The short-term oncologic outcomes are comparable to those of laparoscopic and open surgical approaches. Further studies are needed to assess long-term oncologic control.

Keywords: Outcomes, partial nephrectomy, renal cell carcinoma, robotic surgery

How to cite this article:
Azhar RA, Gill IS, Aron M. Robotic nephron-sparing surgery for renal tumors: Current status. Indian J Urol 2014;30:275-82

How to cite this URL:
Azhar RA, Gill IS, Aron M. Robotic nephron-sparing surgery for renal tumors: Current status. Indian J Urol [serial online] 2014 [cited 2023 Mar 29];30:275-82. Available from:

   Introduction Top

Over the last two decades, the incidence of renal cell carcinoma (RCC) has increased annually by 2% in North America and Europe, [1],[2] primarily reflecting an increase in the incidental detection of small renal masses (SRMs) by abdominal imaging. [3],[4] Approximately, 75% of newly diagnosed renal masses are asymptomatic, incidentally detected and <4 cm in size. [5]

The current treatment options for SRMs include active surveillance, partial nephrectomy (PN), ablative techniques and rarely, radical nephrectomy (RN). [6] The decisions regarding the optimal treatment of incidentally diagnosed SRMs are complex and depend on tumor characteristics, including size, location and local or distant spread, and on patient factors, including age, comorbidities, renal-function, and preference.

Active surveillance is reserved for SRMs in patients with limited life expectancy and multiple comorbidities. [6],[7],[8] Thermal ablation (TA) techniques, including cryoablation and radiofrequency ablation, have emerged as alternative nephron-sparing treatments for SRMs. [9],[10] However, the long-term efficacy of TA is unknown, and a recent worldwide analysis suggests that the local SRM recurrence rate may be higher than those of PN and RN. [11] Historically, clinically stage I renal masses have often been treated with RN. [12] However, the increased recognition of chronic kidney disease (CKD) as a worldwide public health problem and an independent risk factor for cardiovascular events, hospitalization and death [13] has led to the increased use of nephron-sparing surgery, which is performed with the ultimate goal of achieving the PN "trifecta" that is, negative surgical margins, functional preservation and complication-free recovery.

The recently published prospective randomized phase three trial from the European Organization for Research and Treatment of Cancer and several other large retrospective nonrandomized studies have shown comparable oncologic efficacy for PN and RN in the treatment of low-stage renal tumors. [14],[15],[16],[17] Nephron-sparing surgery is now accepted as a standard of care for most stage T1a renal masses. [6]

Although open PN (OPN) remains the reference standard for clinically localized cases, [18] laparoscopic PN (LPN) has recently emerged as a viable, minimally invasive approach that provides similar intermediate oncologic outcomes and faster postoperative recovery compared with open surgery. [19] Recently, robotic PN (RPN) has emerged as an alternative to LPN. Given the enhanced dexterity and three-dimensional vision afforded by the robotic platform and the relatively shorter learning curve compared with LPN, [20] a rapidly increasing number of PNs are being performed robotically. Worldwide, in 2008, RPN was the fastest growing robotic procedure among all surgical specialties. [21] Subject to the availability of the technology and expertise, it is also becoming the technique of choice for treating most stage T1a tumors. In addition, its feasibility has been demonstrated for highly complex renal masses. [22] This review summarizes the current status of RPN, focusing on the evolving indications, technical advancements, and current outcomes data.

   Indications for partial nephrectomy Top

Although the traditional absolute indications for PN include bilateral tumors, renal insufficiency, and a solitary functional kidney, extensive data indicate equivalent cancer-specific and metastasis-free survival between patients treated with PN and RN for T1a lesions. [23],[24]

The indications for nephron-sparing surgery now encompass most tumors <4 cm in patients with a normal contralateral kidney. Furthermore, Leibovich et al. demonstrated the oncological equivalency of treating T1b tumors with PN, which provided a 5-year cancer-specific survival (CSS) of 98% for tumors 4-7 cm in size. [25]

Partial nephrectomy has also been endorsed by the American Urological Association as the treatment of choice for clinical stage T1a and selects T1b renal tumors. [6]

Patients considered for PN should be evaluated with high-quality cross-sectional triphasic abdominal computed tomography (CT) or contrast-enhanced magnetic resonance imaging (MRI), chest radiography, and serum chemistries including electrolytes, renal-function and liver-function tests, and coagulation studies.


Although most urologists and guideline committees currently support elective PN for T1a tumors, the expansion of PN to larger tumors (T1b/T2) has been increasingly advocated by many to optimize renal preservation. There are also lifelong concerns about tumor formation (2-5%) in the contralateral kidney. [26] The expansion of elective PN to T1b and T2 tumors is subject to important selection factors, including patient age and medical condition, tumor location and proximity to critical structures and the experience of the surgeon.

Over the last decade, PN has generally been favored, with many believing that PN should be performed whenever technically feasible, even for larger tumors in the presence of a normal contralateral kidney. For T1b renal masses, PN and RN result in equivalent cancer-specific outcomes. [25],[27-31] In the largest study to date, Badalato et al. analyzed a retrospective dataset that included 11,256 patients who underwent PN and RN for T1b masses, with 1047 who underwent PN, with a median follow-up of approximately 3 years. After controlling for several factors, no difference was found in CSS or overall survival between the PN and RN treatment groups. Stratification by tumor size and patient age did not affect the findings. [27] Lane and Gill reported the long-term oncological outcomes of LPN and OPN for T1 tumors; at 7-year, the CSS for T1a tumors was 95% in both cohorts. In addition, both procedures resulted in similar 7-year CSS for T1b tumors. [32]

We believe that RPN should be performed for carefully selected T1b or larger tumors that are technically amenable. The tumor size alone does not fully reflect its complexity. Furthermore, these procedures should be performed at a center of excellence by an experienced robotic surgeon.

   Robotic partial nephrectomy Top

Despite advances in LPN, it has not been universally embraced due to the technical demands it places on the surgeons. The limited degree of freedom of nonarticulating laparoscopic instruments makes tumor excision and reconstruction under the time constraints of warm ischemia demanding. RPN overcomes this technical deterrent and facilitates adoption of minimally invasive PN among urologists compared with LPN.

A number of published reports have demonstrated the safety and feasibility of RPN for hilar, completely endophytic and multiple tumors. [33],[34] Even in the setting of a solitary kidney, where the preservation of renal-function was previously thought to be best achieved by an open procedure, [35] novel techniques that minimize or completely eliminate warm ischemia time (WIT) have enabled RPN to be performed safely with excellent functional results. [36],[37]

A transperitoneal or retroperitoneal approach is chosen depending on the tumor location, patient surgical history and surgeon preference [Figure 1] and [Figure 2]. The transperitoneal approach is the most widely used for RPN. Although safe and effective when performed by an experienced surgeon, the retroperitoneal approach is potentially more challenging because of its confined workspace and relatively fewer anatomic landmarks. [38] In addition, this procedure is unforgiving in the event of bleeding and large amounts of sticky fat.
Figure 1: Right robotic transperitoneal partial nephrectomy port placement: AS, 12-mm or 5-mm assistant port; right RA, 8-mm right robotic arm; RC, 12-mm robotic camera port; U, umbilicus; AS, assistant port; 4th RA, fourth 8-mm robotic arm

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Figure 2: Left robotic retroperitoneal partial nephrectomy port placement (4-arm approach): 1, 8-mm robotic arm port is placed between the base of the 12th rib and the edge of the paraspinous muscle. 2, 12-mm camera port; 3, 12-mm assistant port; 4, 8-mm robotic arm port; 5, 8-mm robotic arm port

Click here to view

The retroperitoneal approach is best suited for posteromedial tumors and a hostile peritoneal cavity. It has several advantages over the transperitoneal technique. The retroperitoneal approach avoids bowel manipulation and allows direct exposure of the renal hilum. The relative contraindications of this approach include prior major retroperitoneal surgery, dense perirenal inflammation/fibrosis, musculoskeletal limitations that preclude proper positioning, large tumors with extensive collaterals and abundant perinephric fat with extensive stranding. [38],[39]

   Warm ischemia time Top

An important consideration in evaluating surgical options for RCC is WIT. Traditionally, during PN, the renal hilar vessels are clamped before tumor excision. In contrast to OPN, which is often performed under renal hypothermia to minimize ischemic insult to the clamped kidney, minimally invasive techniques for achieving renal hypothermia during renal hilar clamping have failed to achieve widespread application. [40]

Although the exact WIT threshold beyond, which irreversible kidney injury occurs is controversial, <30 min of WIT has long been postulated to provide acceptable postoperative kidney function, as demonstrated by the glomerular filtration rate (GFR). [41],[42] In a single-institution series of 102 patients who underwent LPN or RPN, Wang and Bhayani [43] reported a decreased WIT (19 vs. 25 min) and shorter hospital stay (2.5 vs. 2.9 days) for the RPN cohort, but no difference in complication rates between the two groups. A recent multicenter analysis that examined surgical outcomes for three experienced robotic surgeons showed significantly shorter WIT for RPN compared with LPN (19.7 vs. 28.4 min, P < 0.0001). [20] This study showed that RPN had a benefit with respect to WIT, even with complex tumors (25.9 min for RPN vs. 36.7 min for LPN). Furthermore, the authors demonstrated that in patients who required collecting system repair or had multiple tumors, the mean WIT was still <30 min. For tumors > 4 cm, the patients had a significantly longer WIT compared with patients with a tumor size <4 cm, but once again, both groups had <30 min of WIT. [44]

With the recognition of the potential impact that even a short duration of WIT may have on renal-function, variations in surgical technique have been attempted to minimize or eliminate ischemic insult to the kidney. One such technique is early-unclamping, which involves releasing the hilar clamp after controlling the transected intrarenal blood vessels within the sinus fat. Thus, parenchymal reconstruction (cortical approximation) is performed off-clamp. The early-unclamping technique resulted in a 50% reduction in ischemia time (31 vs. 14 min). [45] Further pushing the envelope, a novel "zero-ischemia" technique has been developed to eliminate global renal ischemia. In this technique, the surgeon identifies and controls only the tertiary or higher-order arterial branches that feed the "tumor plus margin", and thus, no ischemia is experienced by the renal remnant. [46] After devascularizing the tumor in a highly selective manner, RPN is performed while maintaining an uninterrupted blood flow to the rest of the kidney. Neurosurgical micro bulldog clamps can be used if needed to control the specific arterial branches feeding the tumor. In a study of 100 patients who underwent anatomical zero-ischemia PN, the median operative time (OT) was 275 min, the estimated blood loss was 200 mL, and 20% of the kidney was excised; all the patients had negative tumor margins. These early data support the safety and feasibility of the zero-ischemia approach. [47]

Reports of zero-ischemia RPN from other institutions indicate that the technique is reproducible by surgeons with expertise in minimally invasive kidney surgery. [48],[49]

   Technical considerations Top

0Functional preservation

From a technical perspective, PN is among the most challenging procedures undertaken by urologists. PN outcomes are ultimately dictated by surgically modifiable and nonmodifiable factors. [50] Nonmodifiable factors refer to the quality and quantity of the nephrons, and the kidney quantity that can be preserved depends on tumor characteristics including size, location and depth. Surgically modifiable factors include the ischemia duration, surgical margin width, maximal preservation of vascularized parenchyma by eliminating deep sutures and technical imprecision leading to complications.

The volume of the preserved renal parenchyma fundamentally determines postoperative renal-function. [51],[52] Accordingly, it is important for surgeons to minimize the amount of kidney tissue excised during nephron-sparing surgery by adopting the "minimal margin" or even an "enucleation" approach. Renal tumor enucleation is a nephron-sparing technique in which the tumor is excised by dissection in the natural plane between the peritumor pseudocapsule and the renal parenchyma, without removing a visible rim of normal parenchyma. [53],[54],[55] Significant data support this approach as an oncologically sound procedure. [53],[54],[55] Preoperative assessment with high-quality cross-sectional CT is crucial for planning tumor excision. Real-time intraoperative ultrasonography is an important adjunct, as it can accurately delineate the tumor from the normal kidney. [46] The stereoscopic visualization and enhanced dexterity afforded by the robotic platform facilitate a tightly contoured tumor excision.

Super-selective arterial clamping in anatomic partial nephrectomy

The anatomic PN technique is built on the "artery first, tumor second" philosophy. This concept underlies seminal technical innovations such as vascular micro-dissection (VMD), in which the specific arterial branch(es) feeding the tumor is (are) identified. [37],[47] Using the patient's preoperative three-dimensional CT arteriogram as a roadmap, VMD is performed radially from the hilum outward to identify the specific arterial branch(es) supplying the tumor. A radial nephrotomy incision may be required to carry the dissection intrarenally; in these instances, defining the parenchymal surface where the vessels enter as the starting point is critically important. Mini vessel loops can be used to encircle higher-order vessels as dissection proceeds. Neurosurgical aneurysm micro bulldog clamps (Bear disposable vascular clamps) are applied to achieve tumor-specific devascularisation. The preservation of the perfusion of all the nontumor-bearing parenchyma is confirmed with color Doppler ultrasonography or intravenous indocyanine green when a robot with infrared visualization is employed. Tumor excision is performed with a combination of electrocautery and cold scissors. Hem-o-lok clips ® (Weck Surgical Instruments, Teleflex Medical, Durham, NC) are applied to small vessels projecting into the tumor from the resection bed, and these clips are ultimately under-sewn to prevent their migration into the pelvicalyceal system (PCS). Any PCS entry is repaired in a water-tight fashion. Recognizing that indiscriminate whip-stitching of the PN bed may induce ischemia in the underlying normal parenchyma, only point-specific hemostatic suturing is performed. Typically, no surgical bolster is required, thereby eliminating potential pressure ischemia on the renal remnant. Clearly, this anatomic approach lends itself well to complex, perihilar tumors. [56] However, tumors located at a significant transparenchymal distance from the hilum, particularly those with a large parenchymal contact surface area, are generally unsuitable for this technique.

Minimal margin partial nephrectomy

Super-selective arterial clamping, as described above, transforms hilar-unclamped, minimally invasive PN into a clean and controlled procedure. However, this technique maintains a controlled environment, even during the total elimination of vascular clamping and minimal volume loss. We recently adapted our technique with these features in mind, rendering both hilar preparation and VMD with micro bulldog application unnecessary in many cases. The technique is still grounded in anatomic concepts. Specifically, we propose the following: (1) The natural architecture of the kidney and its vasculature is radially oriented; (2) this architecture is largely preserved in the setting of neoplastic growth if the tumor is well-encapsulated; (3) the parenchyma immediately adjacent to the tumor is histologically altered, perhaps by compressive effects exerted by the tumor; [57] and (4) the vessels in this histologically altered zone are generally smaller in caliber. Therefore, the most amenable resection plane for a totally unclamped PN is very close to the pseudocapsule, which we termed the "minimal margin" plane. Notably, this term does not refer to the final pathologic margin width but rather to our intent to excise the tumor along the closest plane dictated by the natural kidney architecture.

In technical terms, minimal margin PN begins with a radial nephrotomy tangential to the tumor. Being radially oriented, this initial incision should be relatively bloodless. Using a fine spreading motion with robotic forceps, the natural radial plane adjacent to the tumor is developed bluntly. The plane is extended superficially in a circumferential manner and then deepened with a combination of blunt dissection, in which the tumor is gently nudged off the parenchyma using the backside of the robotic forceps, and high power electrocautery (cautery setting at 100 W), which controls small vessels near the tumor. Larger vessels projecting into the tumor are defined and controlled with Hem-o-lok clips. If the tumor is not sufficiently mobilized off the parenchymal bed to dissect out these vessels, both clip placement and suture ligation will fail. In this instance, the vessel is transected to further release the tumor, and the bedside assistant's suction apparatus is used to compress the vessel until suturing is performed. As such, having two available suction apparatuses is prudent: One for judicious suction and irrigation and one for compression only. Once the tumor is completely excised, point-specific hemostatic suturing and PCS repair are performed as needed. Bolster application is rare. The minimal margin technique is most applicable to perihilar and polar exophytic tumors; treating peripheral tumors with large contact surface areas remains challenging with this approach.

   Renal function after partial nephrectomy Top

As discussed above multiple factors influence renal-function after PN, including baseline function, amount of parenchyma preserved, and WIT. [52] These factors have recently been the focus of debate as well as intense clinical and laboratory research.

Critics of segmental ischemia techniques note that post-PN functional outcomes are driven by remnant kidney volume and baseline kidney function, not WIT. [58] We agree that kidney volume and quality are the fundamental determinants of ultimate function. However, the following points merit attention. First, WIT is important; a multivariate analysis that adjusted for volume and quality factors showed that a WIT of 25 min was significantly associated with acute kidney injury and new-onset stage IV CKD (CKD; hazard ratio = 2.27; P =0.049). [52] Second, the kidney volume excised and WIT are inherently correlated: More complex tumors predict greater volumes of excised kidney and longer WITs. Third, kidney volume and quality are largely determined by tumor characteristics, patient characteristics, or both; therefore, they are surgically nonmodifiable to a large extent. [58] Conversely, WIT is definitely modifiable via surgery.

From our perspective, it is difficult to determine whether preserving more kidney parenchyma or minimizing ischemia is more important because each factor affects the other.

During larger kidney resections, a greater volume of parenchyma is removed and the ischemia time is longer. Currently, the ultimate goal is to both preserve more kidney parenchyma and minimize ischemia.

   Complications of robotic partial nephrectomy Top

As minimally invasive techniques in PN have evolved, procedural complications have decreased, and the complication rates in contemporary RPN series, even those including large, complex tumors, remain low (8.6-20.0%). [20],[43],[59]

In a single-institution series of 102 patients who underwent LPN or RPN, Wang and Bhayani [43] reported a decreased WIT (19 vs. 25 min) and shorter hospital stay (2.5 vs. 2.9 days) for the RPN cohort but no difference in complication rates between the two groups. A recent study comparing 118 patients who underwent LPN with 129 patients who underwent RPN also found similar rates of postoperative complications between study arms (10.2% vs. 8.6%). [20] In a multi-institutional study of 450 patients who underwent RPN, complications were stratified using the Clavien-Dindo classification system. [60],[61] Overall, 71 patients experienced a complication (16%), with 8 intraoperative and 65 postoperative complications; 54 complications were classified as Clavien Grade I or II (12%), which required conservative management only, whereas 17 were Clavien Grade III or IV (4%) and necessitated subsequent intervention.

The rates of postoperative hemorrhage after minimally invasive PN are relatively low (<5%) and are similar between laparoscopic and robotic series, with a rare need for angioembolization (0.4%). [62],[63] The majority of delayed postoperative hemorrhages arise from arterial pseudoaneurysms or the formation of arteriovenous fistulas. [64] As expected, with increasing tumor centrality and the involvement of major vascular structures during resection, the risk of vascular anomalies also increases. Angioembolization can readily control the source of postoperative PN hemorrhage if recognized quickly and can obviate the need for operative re-intervention, which carries a significant risk of RN. In any patient who presents with postoperative bright red hematuria, significant anemia or hemodynamic instability after PN, a high index of suspicion and a low threshold for angiointervention are necessary.

Several techniques have been used during LPN and RPN to improve hemostasis and reduce the risk of postoperative hemorrhage. These methods include the use of a deoxidized cellulose bolsters during renorrhaphy to provide compressive hemostasis; [65] the use of a gelatin matrix thrombin sealant, which has been reported to reduce postoperative hemorrhage from 11.8% to 3.2%; [66] the use of "sliding-clip" renorrhaphy, which involves the application of  Hem-o-lok ® clips) to the reconstruction sutures to provide the appropriate tension to the kidney repair; [67] and the use of barbed V-Loc sutures (Covidien, Mansfield, MA) during reconstruction, which allow the even distribution of tension across the surgical bed to control transected vessels and reduce the likelihood of postoperative bleeding. [67]

Anatomical zero-ischemia PN can minimize the bleeding risk because it permits the methodical identification of feeding vessels with individual, point-specific suture ligation. Because the kidney remains perfused during resection, there is no time constraint for ischemia. Tumor resection can proceed deliberately with the specific control of individual blood vessels as they are encountered, enabling continuous hemostasis assessment. By intentionally minimizing the amount of normal parenchyma resected, the entry into larger renal blood vessels is reduced.

Urine leakage is a recognized PN complication, but its incidence remains low. In the largest series performed to date comparing LPN with OPN, urine leakage was comparable between the groups (3% and 2.3%, respectively). [19] Several RPN series with smaller cohorts have shown urine leakage rates of 1.6-2.3%, similar to those obtained with laparoscopic procedures. [20],[60] Predictors of postoperative urine leakage include tumor centrality, tumor size, collecting system entry, and a higher nephrometry score. [68],[69]

Several techniques can reduce the risk of urine leakage. A retrograde ureteral catheter can enable methylene blue injection to identify urine leakage and aid its visualization during water-tight repair. [70] This method is particularly useful for central tumors and those necessitating large resections, such as heminephrectomy. Alternatively, the collecting system can be closed by mechanical compression with a bolstered renorrhaphy, without a ureteral catheter. [65] If urine leakage occurs, most cases can be managed conservatively. Persistent or clinically symptomatic urine leakage can be addressed with ureteral stenting or percutaneous urinoma drainage. [71] A percutaneous nephrostomy tube may be required in recalcitrant cases for better proximal diversion.

   Limitations of robotic partial nephrectomy Top

Despite the many advantages of the robotic platform, some limitations remain. First, there is loss of tactile feedback, which might result in tissue trauma or suture breakage, an issue that is particularly pertinent for surgeons with limited experience. However, the loss of haptic feedback can be overcome using learned visual cues. Currently, efforts are underway to develop methods of providing feedback through grip force, potentially allowing haptic information integration in the future. [72]

Despite the widespread adoption of robotic surgery in the United States, there has been a more tempered acceptance of the robotic platform throughout the rest of the world. The higher costs associated with robotic surgical systems largely account for their limited adoption. However, the purported benefits of robotic surgery, including widespread applicability for surgeons, operative efficiency, decreased hospital stays and minimal complications, might translate into lower overall costs to the hospital. [73]

   Trifecta outcomes Top

The concept of a "trifecta" outcomes of robotic or LPN has been recently introduced. [74] These outcomes are negative tumor margins, functional preservation and no urologic complications. Trifecta outcomes were evaluated in 534 patients who underwent RPN or LPN for renal tumors over a 12-year period. [74] The patients were divided retrospectively into four chronological eras, referred to as the discovery era (September 1999 to December 2003; n = 139), the conventional hilar-clamping era (January 2004 to December 2006; n = 213), the early-unclamping era (January 2007 to November 2008; n = 104) and the zero-ischemia era (March 2010 to October 2011; n = 78).

Renal-functional decline was defined as a >10% estimated GFR reduction, as predicted after surgery based on the kidney percentage preserved, which was subjectively assessed by the surgeon during the procedure after tumor excision. Over the four eras, the tumors trended toward being larger (2.9, 2.8, 3.1 and 3.3 cm for the discovery, conventional hilar-clamping, early-unclamping and zero-ischemia eras, respectively; P = 0.08), but the estimated percentage of kidney preserved was similar (89%, 90%, 90%, and 88%, respectively; P = 0.3). More recent eras were associated with increasingly complex tumors than earlier eras, with tumors more likely to be >4 cm in size (P = 0.03), centrally located (P < 0.009) or hilar (P < 0.0001). Nevertheless, the WITs decreased serially at 36, 32, 15 and 0 min, for the discovery, conventional hilar-clamping, early-unclamping and zero-ischemia eras, respectively (P < 0.0001). The renal-function outcomes were superior in the contemporary eras, with fewer patients experiencing declines (P < 0.0001). The negative tumor margin rates were uniformly low (P = 0.7), and urological complications tended to be fewer in the more recent eras (P = 0.01). Trifecta outcomes were achieved more commonly in the recent eras and were 45%, 44%, 62%, and 68% for the discovery, conventional hilar-clamping, early-unclamping and zero-ischemia eras, respectively (P = 0.0002). The authors concluded that despite increasing tumor complexity, the trifecta outcomes of RPN and LPNs improved significantly over the past decade. Thus, the trifecta should be a routine goal during PN surgery. [75]

   Conclusions Top

Robotic partial nephrectomy is a welcome extension of LPN, and it represents a viable alternative to laparoscopic and open surgery. The use of robotic assistance can also aid surgeons with limited laparoscopic experience, given the shorter learning curve. Published series of RPN have demonstrated that it is safe and feasible, with perioperative outcomes comparable to laparoscopic and open surgical approaches. In addition, short-term analyses of functional and oncologic outcomes demonstrate comparable results. Further studies are needed to assess long-term oncologic control. The experience with RPN is likely to grow and mature with the aim of providing the trifecta outcomes of negative tumor margins, minimal renal-function decrease and no urologic complications.

   References Top

1.Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin 2010;60:277-300.  Back to cited text no. 1
2.Mathew A, Devesa SS, Fraumeni JF Jr, Chow WH. Global increases in kidney cancer incidence, 1973-1992. Eur J Cancer Prev 2002;11:171-8.  Back to cited text no. 2
3.Chow WH, Devesa SS, Warren JL, Fraumeni JF Jr. Rising incidence of renal cell cancer in the United States. JAMA 1999;281:1628-31.  Back to cited text no. 3
4.Chow WH, Devesa SS. Contemporary epidemiology of renal cell cancer. Cancer J 2008;14:288-301.  Back to cited text no. 4
5.Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK. Rising incidence of small renal masses: A need to reassess treatment effect. J Natl Cancer Inst 2006;98:1331-4.  Back to cited text no. 5
6.Campbell SC, Novick AC, Belldegrun A, Blute ML, Chow GK, Derweesh IH, et al. Guideline for management of the clinical T1 renal mass. J Urol 2009;182:1271-9.  Back to cited text no. 6
7.Chawla SN, Crispen PL, Hanlon AL, Greenberg RE, Chen DY, Uzzo RG. The natural history of observed enhancing renal masses: Meta-analysis and review of the world literature. J Urol 2006;175:425-31.  Back to cited text no. 7
8.Crispen PL, Viterbo R, Boorjian SA, Greenberg RE, Chen DY, Uzzo RG. Natural history, growth kinetics, and outcomes of untreated clinically localized renal tumors under active surveillance. Cancer 2009;115:2844-52.  Back to cited text no. 8
9.Berger A, Kamoi K, Gill IS, Aron M. Cryoablation for renal tumors: Current status. Curr Opin Urol 2009;19:138-42.  Back to cited text no. 9
10.Sterrett SP, Nakada SY, Wingo MS, Williams SK, Leveillee RJ. Renal thermal ablative therapy. Urol Clin North Am 2008;35:397-414, viii.  Back to cited text no. 10
11.Kunkle DA, Uzzo RG. Cryoablation or radiofrequency ablation of the small renal mass: A meta-analysis. Cancer 2008;113:2671-80.  Back to cited text no. 11
12.Hollenbeck BK, Taub DA, Miller DC, Dunn RL, Wei JT. National utilization trends of partial nephrectomy for renal cell carcinoma: A case of underutilization? Urology 2006;67:254-9.  Back to cited text no. 12
13.Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351:1296-305.  Back to cited text no. 13
14.Van Poppel H, Da Pozzo L, Albrecht W, Matveev V, Bono A, Borkowski A, et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2011;59:543-52.  Back to cited text no. 14
15.Becker F, Siemer S, Humke U, Hack M, Ziegler M, Stöckle M. Elective nephron sparing surgery should become standard treatment for small unilateral renal cell carcinoma: Long-term survival data of 216 patients. Eur Urol 2006;49:308-13.  Back to cited text no. 15
16.Patard JJ, Shvarts O, Lam JS, Pantuck AJ, Kim HL, Ficarra V, et al. Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience. J Urol 2004;171:2181-5.  Back to cited text no. 16
17.Matin SF, Gill IS, Worley S, Novick AC. Outcome of laparoscopic radical and open partial nephrectomy for the sporadic 4 cm. or less renal tumor with a normal contralateral kidney. J Urol 2002;168:1356-9.  Back to cited text no. 17
18.Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup. J Urol 2000;163:442-5.  Back to cited text no. 18
19.Gill IS, Kavoussi LR, Lane BR, Blute ML, Babineau D, Colombo JR Jr, et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol 2007;178:41-6.  Back to cited text no. 19
20.Benway BM, Bhayani SB, Rogers CG, Dulabon LM, Patel MN, Lipkin M, et al. Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: A multi-institutional analysis of perioperative outcomes. J Urol 2009;182:866-72.  Back to cited text no. 20
21.Gautam G, Benway BM, Bhayani SB, Zorn KC. Robot-assisted partial nephrectomy: Current perspectives and future prospects. Urology 2009;74:735-40.  Back to cited text no. 21
22.Dulabon LM, Kaouk JH, Haber GP, Berkman DS, Rogers CG, Petros F, et al. Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446 consecutive cases. Eur Urol 2011;59:325-30.  Back to cited text no. 22
23.Lau WK, Blute ML, Weaver AL, Torres VE, Zincke H. Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc 2000;75:1236-42.  Back to cited text no. 23
24.Lee CT, Katz J, Shi W, Thaler HT, Reuter VE, Russo P. Surgical management of renal tumors 4 cm. or less in a contemporary cohort. J Urol 2000;163:730-6.  Back to cited text no. 24
25.Leibovich BC, Blute M, Cheville JC, Lohse CM, Weaver AL, Zincke H. Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol 2004;171:1066-70.  Back to cited text no. 25
26.Bani-Hani AH, Leibovich BC, Lohse CM, Cheville JC, Zincke H, Blute ML. Associations with contralateral recurrence following nephrectomy for renal cell carcinoma using a cohort of 2,352 patients. J Urol 2005;173:391-4.  Back to cited text no. 26
27.Badalato GM, Kates M, Wisnivesky JP, Choudhury AR, McKiernan JM. Survival after partial and radical nephrectomy for the treatment of stage T1bN0M0 renal cell carcinoma (RCC) in the USA: A propensity scoring approach. BJU Int 2012;109:1457-62.  Back to cited text no. 27
28.Antonelli A, Ficarra V, Bertini R, Carini M, Carmignani G, Corti S, et al. Elective partial nephrectomy is equivalent to radical nephrectomy in patients with clinical T1 renal cell carcinoma: Results of a retrospective, comparative, multi-institutional study. BJU Int 2012;109:1013-8.  Back to cited text no. 28
29.Crépel M, Jeldres C, Sun M, Lughezzani G, Isbarn H, Alasker A, et al. A population-based comparison of cancer-control rates between radical and partial nephrectomy for T1A renal cell carcinoma. Urology 2010;76:883-8.  Back to cited text no. 29
30.Deklaj T, Lifshitz DA, Shikanov SA, Katz MH, Zorn KC, Shalhav AL. Laparoscopic radical versus laparoscopic partial nephrectomy for clinical T1bN0M0 renal tumors: Comparison of perioperative, pathological, and functional outcomes. J Endourol 2010;24:1603-7.  Back to cited text no. 30
31.Simmons MN, Weight CJ, Gill IS. Laparoscopic radical versus partial nephrectomy for tumors >4 cm: Intermediate-term oncologic and functional outcomes. Urology 2009;73:1077-82.  Back to cited text no. 31
32.Lane BR, Gill IS. 7-year oncological outcomes after laparoscopic and open partial nephrectomy. J Urol 2010;183:473-9.  Back to cited text no. 32
33.Rogers CG, Metwalli A, Blatt AM, Bratslavsky G, Menon M, Linehan WM, et al. Robotic partial nephrectomy for renal hilar tumors: A multi-institutional analysis. J Urol 2008;180:2353-6.  Back to cited text no. 33
34.Boris R, Proano M, Linehan WM, Pinto PA, Bratslavsky G. Initial experience with robot assisted partial nephrectomy for multiple renal masses. J Urol 2009;182:1280-6.  Back to cited text no. 34
35.Lane BR, Novick AC, Babineau D, Fergany AF, Kaouk JH, Gill IS. Comparison of laparoscopic and open partial nephrectomy for tumor in a solitary kidney. J Urol 2008;179:847-51.  Back to cited text no. 35
36.Haber GP, Lee MC, Crouzet S, Kamoi K, Gill IS. Tumour in solitary kidney: Laparoscopic partial nephrectomy vs laparoscopic cryoablation. BJU Int 2012;109:118-24.  Back to cited text no. 36
37.Gill IS, Patil MB, Abreu AL, Ng C, Cai J, Berger A, et al. Zero ischemia anatomical partial nephrectomy: A novel approach. J Urol 2012;187:807-14.  Back to cited text no. 37
38.Weizer AZ, Palella GV, Montgomery JS, Miller DC, Hafez KS. Robot-assisted retroperitoneal partial nephrectomy: Technique and perioperative results. J Endourol 2011;25:553-7.  Back to cited text no. 38
39.Ng CS, Gill IS, Ramani AP, Steinberg AP, Spaliviero M, Abreu SC, et al. Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: Patient selection and perioperative outcomes. J Urol 2005;174:846-9.  Back to cited text no. 39
40.Gill IS, Abreu SC, Desai MM, Steinberg AP, Ramani AP, Ng C, et al. Laparoscopic ice slush renal hypothermia for partial nephrectomy: The initial experience. J Urol 2003;170:52-6.  Back to cited text no. 40
41.Becker F, Van Poppel H, Hakenberg OW, Stief C, Gill I, Guazzoni G, et al. Assessing the impact of ischaemia time during partial nephrectomy. Eur Urol 2009;56:625-34.  Back to cited text no. 41
42.Thompson RH, Lane BR, Lohse CM, Leibovich BC, Fergany A, Frank I, et al. Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol 2010;58:340-5.  Back to cited text no. 42
43.Wang AJ, Bhayani SB. Robotic partial nephrectomy versus laparoscopic partial nephrectomy for renal cell carcinoma: Single-surgeon analysis of >100 consecutive procedures. Urology 2009;73:306-10.  Back to cited text no. 43
44.Patel MN, Krane LS, Bhandari A, Laungani RG, Shrivastava A, Siddiqui SA, et al. Robotic partial nephrectomy for renal tumors larger than 4 cm. Eur Urol 2010;57:310-6.  Back to cited text no. 44
45.Nguyen MM, Gill IS. Halving ischemia time during laparoscopic partial nephrectomy. J Urol 2008;179:627-32.  Back to cited text no. 45
46.Gill IS, Eisenberg MS, Aron M, Berger A, Ukimura O, Patil MB, et al. "Zero ischemia" partial nephrectomy: Novel laparoscopic and robotic technique. Eur Urol 2011;59:128-34.  Back to cited text no. 46
47.Ng CK, Gill IS, Patil MB, Hung AJ, Berger AK, de Castro Abreu AL, et al. Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy. Eur Urol 2012;61:67-74.  Back to cited text no. 47
48.Papalia R, Simone G, Ferriero M, Costantini M, Guaglianone S, Forastiere E, et al. Laparoscopic and robotic partial nephrectomy with controlled hypotensive anesthesia to avoid hilar clamping: Feasibility, safety and perioperative functional outcomes. J Urol 2012;187:1190-4.  Back to cited text no. 48
49.Shao P, Qin C, Yin C, Meng X, Ju X, Li J, et al. Laparoscopic partial nephrectomy with segmental renal artery clamping: Technique and clinical outcomes. Eur Urol 2011;59:849-55.  Back to cited text no. 49
50.Aron M, Gill IS, Campbell SC. A nonischemic approach to partial nephrectomy is optimal. Yes. J Urol 2012;187:387-8.  Back to cited text no. 50
51.Simmons MN, Fergany AF, Campbell SC. Effect of parenchymal volume preservation on kidney function after partial nephrectomy. J Urol 2011;186:405-10.  Back to cited text no. 51
52.Thompson RH, Lane BR, Lohse CM, Leibovich BC, Fergany A, Frank I, et al. Renal function after partial nephrectomy: Effect of warm ischemia relative to quantity and quality of preserved kidney. Urology 2012;79:356-60.  Back to cited text no. 52
53.Carini M, Minervini A, Masieri L, Lapini A, Serni S. Simple enucleation for the treatment of PT1a renal cell carcinoma: Our 20-year experience. Eur Urol 2006;50:1263-8.  Back to cited text no. 53
54.Carini M, Minervini A, Lapini A, Masieri L, Serni S. Simple enucleation for the treatment of renal cell carcinoma between 4 and 7 cm in greatest dimension: Progression and long-term survival. J Urol 2006;175:2022-6.  Back to cited text no. 54
55.Minervini A, Serni S, Tuccio A, Siena G, Vittori G, Masieri L, et al. Simple enucleation versus radical nephrectomy in the treatment of pT1a and pT1b renal cell carcinoma. Ann Surg Oncol 2012;19:694-700.  Back to cited text no. 55
56.Abreu AL, Gill IS, Desai MM. Zero-ischaemia robotic partial nephrectomy (RPN) for hilar tumours. BJU Int 2011;108:948-54.  Back to cited text no. 56
57.Minervini A, di Cristofano C, Lapini A, Marchi M, Lanzi F, Giubilei G, et al. Histopathologic analysis of peritumoral pseudocapsule and surgical margin status after tumor enucleation for renal cell carcinoma. Eur Urol 2009;55:1410-8.  Back to cited text no. 57
58.Lane BR, Russo P, Uzzo RG, Hernandez AV, Boorjian SA, Thompson RH, et al. Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant role of nonmodifiable factors in determining ultimate renal function. J Urol 2011;185:421-7.  Back to cited text no. 58
59.Haber GP, White WM, Crouzet S, White MA, Forest S, Autorino R, et al. Robotic versus laparoscopic partial nephrectomy: Single-surgeon matched cohort study of 150 patients. Urology 2010;76:754-8.  Back to cited text no. 59
60.Spana G, Haber GP, Dulabon LM, Petros F, Rogers CG, Bhayani SB, et al. Complications after robotic partial nephrectomy at centers of excellence: Multi-institutional analysis of 450 cases. J Urol 2011;186:417-21.  Back to cited text no. 60
61.Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: Five-year experience. Ann Surg 2009;250:187-96.  Back to cited text no. 61
62.Simmons MN, Gill IS. Decreased complications of contemporary laparoscopic partial nephrectomy: Use of a standardized reporting system. J Urol 2007;177:2067-73.  Back to cited text no. 62
63.Ukimura O, Nakamoto M, Gill IS. Three-dimensional reconstruction of renovascular-tumor anatomy to facilitate zero-ischemia partial nephrectomy. Eur Urol 2012;61:211-7.  Back to cited text no. 63
64.Montag S, Rais-Bahrami S, Seideman CA, Rastinehad AR, Vira MA, Kavoussi LR, et al. Delayed haemorrhage after laparoscopic partial nephrectomy: Frequency and angiographic findings. BJU Int 2011;107:1460-6.  Back to cited text no. 64
65.Haber GP, Gill IS. Laparoscopic partial nephrectomy: Contemporary technique and outcomes. Eur Urol 2006;49:660-5.  Back to cited text no. 65
66.Gill IS, Ramani AP, Spaliviero M, Xu M, Finelli A, Kaouk JH, et al. Improved hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin sealant. Urology 2005;65:463-6.  Back to cited text no. 66
67.Benway BM, Wang AJ, Cabello JM, Bhayani SB. Robotic partial nephrectomy with sliding-clip renorrhaphy: Technique and outcomes. Eur Urol 2009;55:592-9.  Back to cited text no. 67
68.Meeks JJ, Zhao LC, Navai N, Perry KT Jr, Nadler RB, Smith ND. Risk factors and management of urine leaks after partial nephrectomy. J Urol 2008;180:2375-8.  Back to cited text no. 68
69.Mayer WA, Godoy G, Choi JM, Goh AC, Bian SX, Link RE. Higher RENAL Nephrometry Score is predictive of longer warm ischemia time and collecting system entry during laparoscopic and robotic-assisted partial nephrectomy. Urology 2012;79:1052-6.  Back to cited text no. 69
70.Bove P, Bhayani SB, Rha KH, Allaf ME, Jarrett TW, Kavoussi LR. Necessity of ureteral catheter during laparoscopic partial nephrectomy. J Urol 2004;172:458-60.  Back to cited text no. 70
71.Ramani AP, Desai MM, Steinberg AP, Ng CS, Abreu SC, Kaouk JH, et al. Complications of laparoscopic partial nephrectomy in 200 cases. J Urol 2005;173:42-7.  Back to cited text no. 71
72.Okamura AM. Haptic feedback in robot-assisted minimally invasive surgery. Curr Opin Urol 2009;19:102-7.  Back to cited text no. 72
73.Ahmed K, Ibrahim A, Wang TT, Khan N, Challacombe B, Khan MS, et al. Assessing the cost effectiveness of robotics in urological surgery - A systematic review. BJU Int 2012;110:1544-56.  Back to cited text no. 73
74.Hung AJ, Cai J, Simmons MN, Gill IS. "Trifecta" in partial nephrectomy. J Urol 2013;189:36-42.  Back to cited text no. 74
75.Gill IS. Towards the ideal partial nephrectomy. Eur Urol 2012;62:1009-10.  Back to cited text no. 75


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