Robotic zero ischemia partial nephrectomy: step by step surgical technique with tips and tricks

Abstract

Currently, most renal cell carcinoma cases are detected incidentally as small renal masses during radiologic imaging, such as abdominal ultrasound or computed tomography, and partial nephrectomy is being increasingly performed for these lesions. There has been a worldwide increase in minimally invasive surgical approaches, and robotic partial nephrectomy (RPN) in particular has the advantages of more rapid tissue dissection, reconstruction, intracorporeal suturing, three-dimensional optical magnification, dexterity in motion, and ability to perform tremor-free and delicate movements with three independent robotic arms. Renal hilar clamping during RPN decreases bleeding, but warm ischemia might negatively impact renal function. However, with sufficient surgical experience in robotic kidney surgery, zero ischemic or off-clamp RPN might be a safe and feasible minimally invasive surgical approach that has the advantage of avoiding complete renal ischemia, thus avoiding a decrease in renal function particularly in small, less complex, peripherally located, exophytic renal masses less than 3 cm in size. Currently available absorbable barbed sutures could further facilitate performing internal and external renorraphy, as could fibrin and tissue sealants that may also be used for hemostasis. This approach might be particularly important in patients with underlying kidney disease.