Robot-assisted partial nephrectomy: current status, techniques, and future directions

Abstract

Open partial nephrectomy for the treatment of small renal masses (SRMs) concerning for renal cell carcinoma has been increasingly utilized with the increased incidental detection of SRMs and the growing recognition of the benefits of renal preservation. Laparoscopic partial nephrectomy (LPN) is a minimally invasive technique that achieves comparable oncologic and improved morbidity outcomes when compared to the open procedure. However, LPN is a technically demanding procedure resulting in a long learning curve and a lack of widespread adoption. Robot-assisted partial nephrectomy (RAPN) overcomes many of the technical hurdles of the LPN and is now coming to the forefront for the minimally invasive surgical management of SRMs. To date, the short-term oncologic outcomes of RAPN have been comparable to the open operation while providing the improved morbidity outcomes of LPN. Although encouraging, we await the long-term oncologic results of this new and promising procedure. The current bottleneck is an issue of cost and reliance on a patient-side surgeon. Future developments in instrumentation, newer robots, cost reduction, more streamlined training, increased robotic experience, and adoption by more centers will lead to greater benefit for patients with SRMs requiring nephron-sparing surgery. This review will discuss techniques for RAPN and then delve into the current status of RAPN using parameters such as warm ischemia time, blood loss, hospital stay, oncological outcomes, complications, learning curve, and quality of life. There will be an exploration of potential disadvantages associated with RAPN followed by a look at evolving techniques in regard to this groundbreaking procedure.

The Emergence of Surgeon-Controlled Robotic Surgery in Urologic Oncology

“…In the Unites States, particularly, the 5 year survival rate of patients diagnosed with kidney cancer jumped from 51% in the 1970s to 69% in the last decade [17]. One of the contributing factors for developed nations witnessing increased incidence and improved survival from kidney cancer stems largely from the liberal use of computed tomography (CT) and other imaging modalities in the last decade [33]. Patients with incidental renal malignancy found on imaging were often at a lower pathologic stage and grade at diagnosis, which unsurprisingly resulted in improved overall survival post-treatment [33,34].…”

“…The standard treatment for localized renal cancer has long been to simply remove the entire kidney, otherwise known as a radical nephrectomy (RN) [33]. There has been, however, a growing trend toward nephron-sparing surgery.…”

“…Initial steps are the same as described earlier [33]. The hilar vessels are dissected and proximally positioned vessel loops are secured with Hem-o-lok clip [33].…”

“…The hilar vessels are dissected and proximally positioned vessel loops are secured with Hem-o-lok clip [33]. The kidney is dissected free of its surrounding fatty tissue with attention on keeping fatty tissue surround the tumor intact [33].…”

“…The renal capsule encompassing the tumor is circumferentially marked with monopolar scissors. [33] 50 min prior to clamping the renal artery, an intravenous injection of 12.5 g Mannitol is administered [33]. Laparoscopic bulldog clamps are used to clamp the renal artery or hilar vessels [33].…”