Robot-Assisted Partial Nephrectomy for Complex Renal Tumors

Abstract

Partial nephrectomy (PN), whether using open or robotic approach, is an oncologically safe alternative for radical nephrectomy (RN) in appropriately selected patients with renal cell cancer (RCC). As urologists become increasingly facile with the robotic platform, robot-assisted partial nephrectomy (RAPN) will be increasingly performed in patients with complex renal tumors. These include tumors that are completely endophytic or hilar in location, ≥cT1b, tumors with a high RENAL nephrometry score, multiple tumors, or tumors in patients with solitary kidney or significant chronic kidney disease (CKD). While the “trifecta” of negative surgical margins, minimal renal functional decline and no urologic complications remains the ideal goal for any PN, its attainment may pose unique surgical challenges in patients with complex renal tumors. In this chapter, we describe some of the approaches for such patients, tailored to the specific clinical presentation. General considerations to optimize outcomes in such cases include additional assistant ports, judicious use of the 4th robotic arm, and use of pre-clamp check lists. Specific technical maneuvers include use of intraoperative ultrasound probes (for endophytic tumors), tumor enucleation/enucleoresection and modified renorrhaphy techniques (for hilar tumors), cutting wide and deep without excess traction (in cases of cystic/≥cT1b tumors), and minimizing warm ischemia (‘on-demand’ ischemia and early unclamping of the main renal artery, selective clamping of tumor specific arteries, or regional hypothermia) in patients with multiple renal tumors, solitary kidney or pre-existing CKD.