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Introduction: We sought to compare surgical outcomes between transperitoneal and retroperitoneal robotic partial nephrectomy (RPN) for posterior tumors., Patients and Methods: Using our multi-institutional RPN database, we reviewed 610 consecutive cases for posterior renal masses treated between 2007 and 2015. Primary outcomes were complications, operative time, length of stay (LOS), surgical margin status, and estimated glomerular filtration rate (eGFR) preservation. Secondary outcomes were estimated blood loss, warm ischemia time (WIT), disease recurrence, and disease-specific mortality. Due to significant differences in treatment year and tumor size between approaches, retroperitoneal cases were matched 1:4 to transperitoneal cases based on propensity scores using the greedy algorithm. Outcomes were compared between approaches using the chi-square and Mann-Whitney U tests., Results: After matching, 296 transperitoneal and 74 retroperitoneal cases were available for analysis, and matched groups were well balanced in terms of treatment year, age, gender, race, American Society of Anesthesiologists physical status classification (ASA) score, body mass index, tumor laterality, tumor size, R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus, anterior/posterior, location relative to polar lines) score, and hilar location. Compared with transperitoneal, the retroperitoneal approach was associated with significantly shorter mean LOS (2.2 vs 2.6 days, p = 0.01), but longer mean WIT (21 vs 19 minutes, p = 0.01). Intraoperative (p = 0.35) and postoperative complications (p = 0.65), operative time (p = 0.93), positive margins (p = 1.0), and latest eGFR preservation (p = 0.25) were not significantly different between approaches. No differences were detected in the other outcomes., Conclusions: Among high-volume surgeons, transperitoneal and retroperitoneal RPN achieved similar outcomes for posterior renal masses, although with slight differences in LOS and WIT. Retroperitoneal RPN may be an effective option for the treatment of certain small posterior renal masses.

Purpose: To compare diameter as a continuous variable with categorical R.E.N.A.L. nephrometry score (RNS) in predicting surgical outcomes of robotic partial nephrectomy (RPN)., Methods: We retrospectively reviewed consecutive patients receiving RPN at our institution between July 2007 and June 2014 (n = 286). Three separate multivariate analyses were performed to assess the relationship between RNS components (R = radius, E = endophyticity, N = nearness to collecting system, L = location relative to polar lines), total RNS, and diameter as a continuous variable with operating time, warm ischemia time (WIT), and estimated blood loss (EBL). Each linear regression model's quality of fit to the data was assessed with coefficients of determination (R 2 )., Results: Continuous tumor diameter and total RNS were each significantly correlated to operative time, EBL, and WIT (p < 0.001). Categorical R related to operative time (R = 2 vs. R = 1, p = 0.001; R = 3 vs. R = 1, p = 0.001) and WIT (R = 2 vs. R = 1, p = 0.003; R = 3 vs. R = 1, p = 0.016), but not to EBL. For each of these outcomes, diameter outperformed both R and total RNS, as assessed by R 2 . Age, body mass index, Charlson Comorbidity Index, and anterior versus posterior location did not correlate with surgical outcomes., Conclusions: In this series of RPN from a high-volume center, surgical outcomes more closely related to tumor diameter than RNS. While RNS provides surgeons a standardized tool for preoperative planning of renal masses, tumor size may be employed as a more familiar measurement when counseling patients on potential outcomes.

The objective of this study was to evaluate surgical outcomes with respect to the experience level of the bedside assistant during robot-assisted partial nephrectomy. A retrospective review was conducted of a prospectively maintained database of 414 consecutive robot-assisted laparoscopic partial nephrectomies performed by experienced robotic surgeons at our institution from April 2011 to September 2014. A senior-level assistant was defined as a resident in his or her post-graduate year (PGY) 4 or 5, or a fellow. Junior-level assistants were considered to be PGY-2, PGY-3, or a nurse first assistant. Multivariate analyses were performed using linear, Poisson, and logistic regression models. There were 115 junior-level cases and 299 senior-level cases. On univariate analysis, the experience level of the assistant had no impact on operative time (168 for junior level vs. 163 min for senior level, p = 0.656). Likewise, there were no differences between the junior- and senior-level groups with regard to warm ischemia time (21.3 vs. 20.9 min, p = 0.843), negative margin status (111/115 (96.5 %) vs. 280/299 (93.6 %), p = 0.340), or postoperative complications (17/115 (14.8 %) vs. 35/299 (11.7 %), p = 0.408). After multivariate analysis, operative time was associated with increased body mass index and tumor size (both p < 0.001), but not with resident experience level (p = 0.051). Estimated blood loss and postoperative complications were also not associated with the PGY of the assistant (p = 0.488 and p = 0.916, respectively). Despite common concern, the PGY status of a physician trainee serving as the bedside assistant does not appear to influence the outcomes of robot-assisted partial nephrectomy at a high-volume center.

Objective: To identify specific comorbidities within the Charlson Comorbidity Index (CCI) that are associated with increased complication rates after robot-assisted partial nephrectomy (RAPN)., Patients and Methods: After institutional review board approval, a consecutive series of 641 patients undergoing RAPN were retrospectively identified. Perioperative complications were defined and classified using the Clavien grading system. Fisher's exact test or chi-square test was performed to evaluate the association of individual comorbidities with perioperative complications. Logistic regression was used for multivariable analysis to adjust for other non-CCI comorbidities and tumor-specific and patient-specific characteristics., Results: Of the 641 patients undergoing RAPN, complications occurred in 67 patients (10.5%), including 10 (14.9%), 28 (41.8%), 20 (29.9%), 5 (7.5%), and 4 (6.0%) patients with Clavien grade 1, 2, 3a, 3b, and 4 complications, respectively. Cerebrovascular disease [odds ratio 3.01 (95% confidence interval [CI] 1.10, 8.26) p = 0.03] and chronic obstructive pulmonary disease [COPD; 3.12 (1.24, 7.89) p = 0.02] predicted complications in multivariable analysis of clinicopathologic characteristics, including all CCI and non-CCI comorbidities. In additional modeling with only CCI comorbidities, similar results were observed, with cerebrovascular disease [2.93 (1.04, 7.56) p = 0.04] and COPD [2.69 (1.04, 6.28) p = 0.04] as the only two significant variables. No other variables reached statistical significance in either model, including nephrometry score or estimated blood loss (p >  .50 for both). COPD predicted major complications (Clavien grade 3 or 4) in multivariable analysis [3.19 (1.07, 9.48) p = 0.04]., Conclusions: Cerebrovascular disease and COPD predict perioperative RAPN complications after RAPN. Identification of patients with these comorbidities preoperatively may afford improved counseling and risk stratification.

Objective: To develop an evidence-based approach to the diagnostic workup of suspicious upper urinary tract lesions., Methods: The PubMed database was searched using the following terms with a filter for English language: "upper tract urothelial carcinoma" and "upper tract transitional cell carcinoma," along with the following corresponding terms: "cost," "epidemiology," "diagnosis," "ureteroscopy," and "workup." A total of 404 articles were returned, and 33 were reviewed in full based on relevance., Results: Computed tomography urogram is both sensitive and specific (96% and 99%). Cytology is utilized for its specificity (89%-100%). Ureteroscopy and biopsy of an upper tract lesion can be helpful in equivocal cases but can pose challenges in terms of yield and eventual pathologic upstaging. Due to the high sensitivity and specificity of other noninvasive tests, ureteroscopy can be obviated in select cases. We assess the available evidence and devise an algorithm for the evaluation of an upper tract urothelial carcinoma lesion., Conclusion: Ureteroscopy can be omitted as part of the diagnostic workup in appropriately selected cases of upper tract urothelial carcinoma., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To evaluate the incidence of and risk factors for a urine leak in a large multicentre, prospective database of robot-assisted partial nephrectomy (RPN)., Patients and Methods: A database of 1 791 RPN from five USA centres was reviewed for urine leak as a complication of RPN. Patient and tumour characteristics were compared between patients with and those without postoperative urine leaks. Fisher's exact test was used for qualitative variables and Wilcoxon sum-rank tests were used for quantitative variables. A review of the literature on PN and urine leak was conducted., Results: Urine leak was noted in 14/1 791 (0.78%) patients who underwent RPN. The mean (sd) nephrometry score of the entire cohort was 7.2 (1.9), and 8.0 (1.9) in patients who developed urine leak. The median (range) postoperative day of presentation was 13 (3-32) days. Patients with urine leak presented in delayed fashion with fever (two of the 14 patients, 14%), gastrointestinal complaints (four patients, 29%), and pain (five patients, 36%). Eight of the 14 patients (57%) required admission, while eight (57%) and nine (64%) had a drain or stent placed, respectively. Drains and stents were removed after a median (range) of 8 (4-13) days and 21 (8-83) days, respectively. Variables associated with urine leak included tumour size (P = 0.021), hilar location (P = 0.025), operative time (P = 0.006), warm ischaemia time (P = 0.005), and pelvicalyceal repair (P = 0.018). Upon literature review, the historical incidence of urine leak ranged from 1.0% to 17.4% for open PN and 1.6-16.5% for laparoscopic PN., Conclusion: The incidence of urine leak after RPN is very low and may be predicted by some preoperative factors, affording better patient counselling of risks. The low urinary leak rate may be attributed to the enhanced visualisation and suturing technique that accompanies the robotic approach., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

Purpose: To compare perioperative outcomes, specifically hospital length of stay (LOS), after retroperitoneal and conventional transperitoneal robot-assisted partial nephrectomy (RAPN)., Patients and Methods: We retrospectively compared consecutive patients with a posterior renal mass undergoing retroperitoneal RAPN (n=116) versus transperitoneal RAPN (n=97) at our institution between July 2007 and March 2014. The surgical approach was based on patient and tumor characteristics, history of abdominal surgery, and surgeon preference. The primary outcome was postoperative LOS, and secondary outcomes included complication rate, inpatient narcotic pain medication use, and inpatient antiemetic use., Results: Baseline patient and tumor characteristics were similar between groups. A significantly great proportion of patients undergoing retroperitoneal RAPN had LOS equal to 1 day (57% vs 10%, P<0.01). Complication rates were similar between groups (P=0.37). Median pain medication use was also similar between groups (P=0.85). A significantly greater proportion of retroperitoneal RAPN patients, however, needed no antiemetics postoperatively (59% vs 43%, P=0.02). On multivariate analysis, transperitoneal RAPN was a significant predictor of LOS greater than 1 day (odds ratio=7.4, P<0.01), when controlling for age, sex, body mass index, patient comorbidity, previous abdominal surgery, baseline kidney function, nephrometry score, and tumor size., Conclusions: For patients with posterior renal masses, retroperitoneal RAPN significantly reduces their hospital LOS when compared with transperitoneal RAPN.

Introduction: Expert-reported outcomes and complications may not reflect the standardized coding that can be provided by independent, third-party evaluations. The goal of this article is to compare expert-reported complications with standardized coding by the National Surgical Quality Improvement Program (NSQIP). The procedures evaluated were laparoscopic radical nephrectomy (LRN), robot-assisted radical prostatectomy (RARP), and radical cystectomy (RC)., Methods: The 10 largest LRN, RARP, and RC series were reviewed for reported complications. An index patient was derived from each series using patient demographic data. Index patients were entered into the NSQIP surgical risk calculator (SRC), which provides 11 predicted outcomes based on inputted data. SRC-predicted outcomes were compared with available complication rates in each series., Results: Across the 30 studies, 172 out of 330 (52%) of NSQIP-provided outcome types were presented within expert manuscripts. Death and venous thromboembolism (VTE) were the most commonly reported (27 and 23 studies, respectively), whereas urinary tract infection (UTI) (9) and pneumonia (10) were the least commonly presented. Comorbidities and follow-up duration were reported in 8 out of 30 and 17 out of 30 studies, respectively. For LRN, the median number of reported outcomes was 3 (range 1-5). LRN experts demonstrated a shorter mean length of stay (LOS) (2.5 days, SD=1.7) (p<0.001). In RARP studies, a median of 7.5 (3-11) outcomes was reported. Experts outperformed NSQIP RARP predictions in serious complications (p<0.001), any complication (p<0.001), surgical site infection (p=0.025), UTI (p<0.001), and VTE (p=0.002). RC manuscripts reported a median of 7 (2-11) outcomes. RC experts had higher rates of serious complications (p<0.001), reoperation (p<0.001), and death (p<0.001) than predicted by SRC., Conclusion: The level of standardization in reporting of outcomes differs between expert series and NSQIP, thus making comparisons difficult.

Introduction/objective: Robotic-assisted partial nephrectomy (RPN) offers a mean length of stay (LOS) of 2 to 3 days. The purpose of this study is to determine the impact of modifiable and nonmodifiable risk factors on hospital LOS after RPN., Patients and Methods: We retrospectively reviewed our prospectively maintained database to identify all patients undergoing RPN for localized tumors at five US centers from 2007 to 2013. Patient and tumor characteristics were compared among hospital LOS groups. Associated factors were modeled using univariate and multivariate cumulative logistic regression to determine factors predictive of hospital LOS., Results: One thousand five hundred thirty-two patients were grouped into LOS 1 to 3 days (1298, 84.1%), LOS=4 days (133, 8.6%), and LOS >4 days (110, 7.2%). Patient demographics were similar between groups. Patients in the LOS=4 and LOS >4 day groups were more likely to have a higher Charlson comorbidity index score (mean 2.2, 3.1 and 3.8; p<0.001), higher nephrometry score (mean 7.1, 7.6, 7.8; p=0.0002), and larger tumors (mean 2.9, 3.6 and 3.5 cm; p<0.0001) than those in the LOS 1 to 3 day group. Significant differences in complication rates were observed when comparing LOS 1-3 (116, 8.9%), LOS=4 (40, 30%), and LOS >4 (59, 54%). According to the Clavien-Dindo classification of surgical complications, 11 grade 3 and 11 grade 4 complications occurred in patients with an LOS of 4 or more days (p<0.0001). Postoperative transfusion, deep vein thrombosis, pulmonary embolism, atrial fibrillation, dyspnea/atelectasis, ileus, and acute renal failure each significantly predicted a hospital LOS >4 days (p<0.001)., Conclusion: 15.8% of patients undergoing RPN have an LOS of 4 days or more. Longer LOS was independently associated with higher Charlson index, nephrometry score (nonmodifiable factors), and perioperative complications (potentially modifiable). These data may be useful in perioperative counseling and payer precertification.

Purpose: To determine preoperative predictors associated with renal cell carcinoma (RCC) and unfavorable pathology in small renal masses treated with partial nephrectomy (PN)., Materials and Methods: PN records from 5 centers were retrospectively queried for patients with a clinically localized single tumor <4 cm on imaging (clinical T1a). Between 2007 and 2013, 1,009 patients met the inclusion criteria. Unfavorable pathology was defined as any grade III or IV RCC or tumors upstaged to pathologic T3a disease. Logistic regression models were used to determine preoperative characteristics associated with RCC and with unfavorable pathology., Results: A total of 771 (76.4%) patients were found to have RCC and 198 (19.6%) had unfavorable pathology. On multivariate, bootstrap-adjusted logistic regression analysis, factors associated with the presence of malignancy were imaging tumor size ≥ 3 cm (odds ratio [OR] = 1.46; P = 0.040), male sex (OR = 1.88; P<0.0001), and nephrometry score ≥ 8 (OR = 1.64; P = 0.005). These same factors were independently associated with risk of unfavorable pathology: size ≥ 3 cm (OR = 1.46; P = 0.021), male sex (OR = 2.35; P<0.0001), and nephrometry score ≥ 8 (OR = 1.49; P = 0.015). The c statistic was 0.62 for the predicting malignancy and 0.63 for unfavorable pathology., Conclusions: In this multi-institutional cohort, male sex, imaging tumor size ≥ 3 cm, and nephrometry score ≥ 8 were predictors of RCC and adverse pathology following PN. These factors may assist in risk stratification and selective renal mass biopsy before decision making. Further studies are necessary to validate these findings., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To determine if patients with pathological, medical renal disease, defined as evidence of pathological abnormalities indicative of renal damage in the non-neoplastic partial nephrectomy specimens, have worsened functional outcomes following robot-assisted partial nephrectomy (RPN)., Materials and Methods: Sixty patients with and 101 without pathologically proven renal disease on non-neoplastic renal specimens were evaluated for differences in postoperative outcomes following RPN. Multiple linear regression modeling assessed for factors influencing early and late declines in renal function., Results: The two groups were similar in all preoperative parameters. Both patients with and without pathological renal disease had similar lengths of hospitalization, transfusions, and complication rates. The percent change in the glomerular filtration rate was similar for patients with and without pathological renal disease (-8.8% vs -12.2%, p=0.194). Patients with pathological renal disease had less chronic kidney disease (CKD) upstaging than patients without renal disease (18.3% vs 39.6%, p=0.006). Increasing age (p=0.030) and higher preoperative glomerular filtration rates (p=0.044) predicted worse late percentage declines in renal function, while increased warm ischemia time predicted late CKD upstaging (p=0.043)., Conclusion: The presence of pathological renal disease in non-neoplastic renal tissue did not place patients at risk for worsened postoperative complications or renal function deterioration following RPN.

Background: Robot-assisted partial nephrectomy (RPN) in the setting of chronic kidney disease (CKD) presents additional challenges for the preservation of renal function., Objective: To evaluate functional outcomes of RPN in patients with CKD relative to patients undergoing RPN without baseline CKD., Design, Setting, and Participants: A total of 1197 consecutive patients who underwent RPN at five academic institutions between 2007 and 2012 were identified for this descriptive study. A total of 172 patients who underwent RPN with preexisting CKD (estimated glomerular filtration rate [eGFR] of 15-60 ml/min per 1.73 m(2)) were identified. Perioperative results of 121 patients were compared against propensity score-matched controls without CKD (eGFR ≥60 ml/min per 1.73 m(2))., Intervention: RPN in patients with or without baseline CKD., Outcome Measurements and Statistical Analysis: Descriptive statistics and propensity score-matched operative and functional outcomes., Results and Limitations: After propensity score matching, patients with baseline CKD had a lower percentage eGFR decrease at first follow-up (-5.1 vs -10.9), which remained significant at a mean follow-up of 12.6 mo (-2.8 vs -9.1, p<0.05), and they had less CKD upstaging (11.8% vs 33.1%). CKD patients were less likely to be discharged in the first two postoperative days (39.7% vs 56.2%, p=0.006) and had a higher rate of surgical complications (21.5% vs 10.7%, p=0.007). The retrospective analysis was the main limitation of this study., Conclusions: RPN in patients with baseline CKD is associated with a smaller decrease in renal function compared with patients without baseline CKD, but a higher risk of surgical complications and a longer hospital stay., (Copyright © 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background and Purpose: American Urological Association guidelines endorse partial nephrectomy as the preferred treatment for patients with small renal masses, while considering patients with significant comorbidities potential candidates for ablative therapy. We compared perioperative, renal functional, and oncologic outcomes of renal cryoablation and robot-assisted partial nephrectomy (RAPN) based on our long-term institutional experience., Patients and Methods: A retrospective review evaluated 267 patients who underwent laparoscopic or percutaneous cryoablation (July 2000-June 2011) and 233 patients who underwent RAPN (June 2007-September 2012) for enhancing renal masses at Washington University., Results: The perioperative complication rate was 8.6% in the cryoablation group vs 9.4% in the RAPN group (P = 0.75). There was no significant difference in complication risk between the two treatment modalities on multivariate analysis. Estimated glomerular filtration rate (eGFR) at last follow-up was 6% lower than preoperative eGFR in the cryoablation group and 13% lower in the RAPN group (P<0.01). The advantage of cryoablation in preserving renal function persisted on multivariate analysis (P = 0.02). In patients with pathologically proven renal-cell carcinoma, 5-year Kaplan-Meier disease-free survival (DFS), cancer-specific survival (CSS), and overall survival was 83.1%, 96.4%, and 77.1% in the cryoablation cohort vs 100%, 100%, and 91.7% in the RAPN group. Mean time to recurrence was 16.2 months (range 0.03-42.0 mos). Cryoablation was associated with increased recurrence risk (hazard ratio [HR] = 11.4, P = 0.01) on multivariate analysis., Conclusions: Cryoablation and RAPN are safe alternatives for managing renal masses amenable to nephron-sparing interventions, offering acceptable morbidity and excellent renal preservation. While RAPN offers improved DFS, for those willing to undergo close postoperative monitoring and accept the potential need for re-treatment of recurrent disease, cryoablation offers excellent long-term CSS.

Background: Ongoing efforts are focused on minimizing or eliminating renal ischemia during robot-assisted partial nephrectomy (RPN). Although various techniques allowing the elimination of renal hilar clamping have been described, large multi-institutional studies assessing perioperative and functional outcomes of this approach are lacking., Objective: To evaluate perioperative and functional outcomes of RPN without hilar clamping and to assess comparative effectiveness relative to clamped RPN., Design, Setting, and Participants: A multi-institutional data analysis of prospectively collected records of 886 RPNs performed by high-volume surgeons across five academic institutions between 2007 and 2011 was carried out. A total of 66 patients who underwent RPN without hilar clamping were identified. After the exclusion of 17 patients, perioperative results of 49 patients were compared against propensity score matched clamped controls., Intervention: RPN without hilar clamping., Outcome Measurements and Statistical Analysis: Descriptive statistics and propensity score matching., Results and Limitations: Patients undergoing off-clamp RPN had a mean tumor size of 2.5 cm (standard deviation [SD]: ± 2.1) and a mean RENAL nephrometry score of 5.3 (SD: ± 1.5). The mean preoperative estimated glomerular filtration rate (eGFR) was 81 (SD: ± 29). The mean estimated blood loss (EBL) was 210 ml (SD: ± 212), and the mean operative time was 155 min (SD: ± 46). No Clavien 3-5 complications were recorded. The mean postoperative change in eGFR was 3% at first follow-up (1-3 mo), and no patient required postoperative dialysis. The positive surgical margin rate was 3% (n=2), with no disease recurrence reported at a mean follow-up of 21 mo. In propensity score matched analyses, the off-clamp RPN patients had a significantly shorter mean operative time (156 min compared with 185 min, p<0.001), a higher EBL (228 ml compared with 157 ml, p=0.009), and a smaller decrease in eGFR (2% compared with -6%, p=0.008). The retrospective analysis was the main limitation of this study., Conclusions: With appropriately selected patients and adequate surgeon experience, off-clamp RPN is safe and feasible. Off-clamp RPN was associated with higher EBL, shorter operative times, and smaller decrease in renal function., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: We evaluated the early oncological end point of recurrence-free survival in patients with renal cell carcinoma up-staged from cT1 to pT3a after partial nephrectomy. We also aimed to establish preoperative factors associated with pathological tumor up-staging., Materials and Methods: A prospective database of robotic partial nephrectomy cases performed at 5 academic centers was queried for patients who underwent surgery for a solitary cT1 renal mass. Patients with pT1-2 renal cell carcinoma were compared to those with pT3a tumors to determine the difference in recurrence-free survival. Preoperative factors associated with cT1 to pT3a up-staging were studied using multivariate logistic regression analysis., Results: A total of 1,096 patients underwent robotic partial nephrectomy for a cT1 renal mass. At final pathological evaluation 855 tumors (78.0%) were found to be renal cell carcinoma, of which 41 (4.8%) were up-staged to pT3a. The 24-month recurrence-free survival estimates for pT1-2 and pT3a tumors were 99.2% and 91.8%, respectively (p=0.003). Multivariate analysis revealed that a high vs low R.E.N.A.L. (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior and location relative to polar lines) nephrometry score was associated with tumor up-staging (OR 2.97, 95% CI 1.20-7.35, p=0.02). On separate multivariate analysis increasing tumor diameter (OR 1.66, 95% CI 1.32-2.08, p<0.001) and hilar location (OR 2.83, 95% CI 1.43-5.61, p=0.003) were also associated with up-staging., Conclusions: At short-term followup patients with renal cell carcinoma up-staged from cT1 to pT3a have reasonable oncological outcomes after partial nephrectomy. Factors associated with tumor up-staging include high tumor complexity, increasing tumor diameter and hilar location. Further studies are needed to determine the comparative efficacy of partial vs radical nephrectomy for small pT3a tumors., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Unlabelled: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: For patients who are unfit for extirpative surgery, percutaneous cryoablation (PCA) presents a minimally-invasive alternative for the treatment of renal masses. PCA has been demonstrated to be safe, with complication rates <10% being reported consistently. Studies have suggested that a minimal and insignificant decline in renal function can occur after PCA. Finally, among studies with a follow-up >20 months, treatment success rates range from 75% to 96%. However, longer-term oncological and functional results for patients treated with PCA are relatively limited. The present study profiles one of the largest reported experiences with PCA for renal masses: 129 tumours in 124 patients. Our complication rate was comparable to that observed in other reported studies. At a mean follow-up of 30 months, treatment success was achieved in 87% of tumours, which is in line with published PCA success rates. On multivariable analysis, tumour size >3.0 cm was found to be significantly associated with treatment failure. A minimal but statistically significant renal functional decline was observed, with 20% of patients experiencing a progression in National Kidney Foundation-Chronic Kidney Disease stage. On multivariable analysis, age >70 years, hilar tumour location and postoperative day 1 estimated glomerular filtration rate <60 mL/min/1.73 m(2) were found to be significantly associated with renal functional decline. The present study confirms that PCA of renal masses represents a safe alternative to surgery in patients with substantial medical comorbidities. In the present cohort, baseline patient and tumour characteristics probably impact the risk of tumour recurrence, as well as renal disease progression, after PCA., Objective: To evaluate perioperative, oncological and functional outcomes after percutaneous cryoablation (PCA) for renal masses based on our single-centre experience., Patients and Methods: We retrospectively identified 124 patients who underwent PCA for 129 renal tumours between March 2005 and June 2011. Patient demographics and baseline clinical characteristics, tumour features, perioperative information, and postoperative outcomes were recorded. Oncological outcomes were defined by radiographic evidence of recurrence on follow-up computed tomography or magnetic resonance imaging. Renal disease progression was defined by a change in National Kidney Foundation-Chronic Kidney Disease stage., Results: Patients had mean (sd) age of 72.6 (10.2) years; mean (sd) tumour size and nephrometry score were 2.7 (1.1) cm and 6.5 (1.7), respectively. Our overall complication rate was 9% (11/124), whereas the major (greater than Clavien II) complication rate was 2% (2/124). Significant predictors of renal disease progression following PCA included age ≥ 70 years (odds ratio [OR], 4.31, P = 0.03), hilar tumour location (OR, 4.67, P = 0.04), and post operative day 1 estimated glomerular filteration rate ≤60 mL/min/1.73 m(2) (OR, 7.09, P = 0.02). Our treatment success rate was 87% (112/129) at a mean (sd) follow-up of 30.2 (18.8) months. Tumour size ≥3.0 cm was significantly associated with PCA failure (hazard ratio, 3.21, P = 0.03)., Conclusion: PCA provides a safe and oncologically effective alternative to extirpative surgery for renal masses in patients with significant medical comorbidities., (© 2012 BJU International.)

Objective: To review complications of robot-assisted partial nephrectomy (RAPN) at 5 centers, as classified by the Clavien system., Materials and Methods: A multi-institutional analysis of prospectively maintained databases assessed RAPN complications. From June 2007 to November 2011, 886 patients at 5 United States centers underwent RAPN. Patient demographics, perioperative outcomes, and complications data were collected. Complication severity was classified by Clavien grade., Results: Mean (standard deviation) data were patient age, 59.4 (11.4) years; age-adjusted Charlson Comorbidity Index, 3.0 (1.9); radiographic tumor size, 3.0 (1.6) cm; nephrometry score, 6.9 (2.0); and warm ischemia time, 18.8 (9.0) minutes. Median blood loss was 100 mL (interquartile range, 100-250 mL). Of the 886 patients, intraoperative complications occurred in 23 patients (2.6%) and 139 postoperative complications occurred in 115 patients (13.0%) for a total complication rate of 15.6%. Among the 139 postoperative complications, 43 (30.9%) were classified as Clavien 1, 64 (46.0%) were Clavien 2, 21 (15.1%) were Clavien 3, and 11 (7.9%) were Clavien 4. No complication-related deaths occurred. Intraoperative hemorrhage occurred in 9 patients (1.0%) and postoperative hemorrhage in 51 (5.8%). Forty-one patients (4.6%) required a perioperative blood transfusion, 10 (1.1%) required angioembolization, and 2 (0.2%) required surgical reexploration for postoperative hemorrhage. Urine leaks developed in 10 patients (1.1%): 3 (0.3%) required ureteral stenting, and 2 (0.2%) required percutaneous drainage. Acute postoperative renal insufficiency or renal failure developed in 7 patients (0.8%), 2 of whom required hemodialysis. The RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor and the location relative to polar lines) nephrometry scoring system accurately predicted RAPN complication rates., Conclusion: Complication rates in this large multicenter series of RAPN appear to be acceptable and comparable with other nephron-sparing modalities. Most complications (77.0%) are Clavien 1 and 2 and can be managed conservatively., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Robot-assisted partial nephrectomy (RAPN) has been established as a viable alternative to open and laparoscopic partial nephrectomy for small renal tumors. Multiple variations in surgical technique have been described to reduce warm ischemia time (WIT). We present our off-clamp technique for RAPN. From August 2007 to January 2012, off-clamp RAPN was performed on 47 tumors in 39 patients. WIT was 0 minutes in all cases. The mean operative time was 147 minutes (SD=58); the mean and median estimated blood loss were 219 mL (SD=253) and 150 mL (range 50-1500), respectively; the mean length of stay was 1.9 days (SD=1.1). There were no intraoperative complications, and results for all surgical margins were negative. In experienced hands, our off-clamp technique for RAPN is a safe and feasible technique that eliminates WIT.

This article provides an overview of extirpative laparoscopic and robotic procedures used in the management of renal cell carcinoma, including laparoscopic radical nephrectomy, laparoscopic partial nephrectomy, and robotic-assisted partial nephrectomy. The clinical indications and principles of surgical technique for each of these procedures are discussed. The oncologic, renal functional, and perioperative outcomes of these procedures are also assessed and compared, as are complication rates., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To evaluate the outcomes of robotic partial nephrectomy (RPN) for solitary kidney in a large multicenter series., Materials and Methods: Medical records of 886 consecutive patients who underwent RPN at 5 academic institutions from May 2007 to May 2012 were retrospectively analyzed. Data were prospectively collected in an Investigational Review Board-approved protocol. Experienced robotic surgeons performed all operations. Patient demographics, functional, perioperative, and early oncologic outcomes were analyzed., Results: A total of 26 patients with a solitary kidney were identified and included in the analysis; of these, 16 (62%) had solitary kidneys secondary to a previous malignancy. Perioperative outcomes included a median warm ischemia time of 17 minutes (interquartile range, 12, 28 minutes). Only 2 intraoperative complications occurred. One was a renal vein injury and one an aortic vessel tear, and both patients required intraoperative blood transfusions. No conversions to laparoscopy or open surgery occurred. There were 3 postoperative complications (11.5%). Median follow-up was 6 months (interquartile range, 5, 9.7 months). Postoperative renal function did not change significantly as measure by estimated glomerular filtration rate (-15.8%; P=.13). None of the patients required dialysis. Positive margins occurred in 1 patient, with 73% of patients having a renal cell carcinoma., Conclusion: We report a multi-institutional series of RPN in patients with solitary kidney presenting with small renal masses. Our findings suggest that RPN represents a feasible treatment option in this specific population by offering reliable preservation of renal function, low surgical morbidity, and early oncologic safety in the hands of experienced robotic surgeons., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To evaluate the potential benefit of performing off-clamp robot-assisted partial nephrectomy as it relates to renal functional outcomes, while assessing the safety profile of this unconventional surgical approach., Methods: Twenty-nine patients who underwent off-clamp robot-assisted partial nephrectomy for suspected renal cell carcinoma at Washington University between March 2008 and September 2011 (group 1) were matched to 29 patients with identical nephrometry scores and comparable baseline renal function who underwent robot-assisted partial nephrectomy with hilar clamping during the same period (group 2). The matched cohorts' perioperative and renal functional outcomes were compared at a mean 9-month follow-up., Results: Mean estimated blood loss was 146.4 mL in group 1, versus 103.9 mL in group 2 (P = .039). Mean hilar clamp time was 0 minutes in group 1 and 14.7 minutes in group 2. No perioperative complications were encountered in group 1; 1 Clavien-2 complication (3.4%) occurred in group 2 (P = 1.000). At 9-month follow-up, mean estimated glomerular filtration rate in group 1 was 79.9 versus 84.8 mL/min/1.73 m(2) preoperatively (P = .013); mean estimated glomerular filtration rate in group 2 was 74.1 versus 85.8 mL/min/1.73 m(2) preoperatively (P < .001). Hence, estimated glomerular filtration rate declined by a mean of 4.9 mL/min/1.73 m(2) in group 1 versus 11.7 mL/min/1.73 m(2) in group 2 (P = .033)., Conclusion: Off-clamp robot-assisted partial nephrectomy is associated with a favorable morbidity profile and relatively greater renal functional preservation compared to clamped robot-assisted partial nephrectomy. Nevertheless, the benefit is small in renal functional terms and may have very limited clinical relevance., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background and Purpose: Because of the impact warm ischemia time may have on renal function, various surgical techniques have been proposed to minimize or eliminate warm ischemia. The purpose of this study is to evaluate our initial renal functional outcomes of off-clamp robot-assisted partial nephrectomy (RAPN), while assessing the safety profile of this unconventional surgical approach., Patients and Methods: We performed a retrospective review of our off-clamp RAPN experience between August 2007 and January 2012. All patients with baseline and postoperative serum creatinine determinations were included. Patient demographics, operative information, perioperative outcomes, and renal functional outcomes were evaluated for this cohort., Results: Forty-two patients with a mean age of 59.9 years (standard deviation [SD]=12) had a median follow-up of 100 days (range 1-1007 days). In all cases, warm ischemia time was 0 minutes. Mean operative time was 143 minutes (SD=59), and median estimated blood loss was 138 mL (range 50-1500 mL). No intraoperative complications were encountered, and all surgical margins were negative. Our postoperative complication rate was 14.3%. At the most recent follow-up, the mean estimated glomerular filtration rate (eGFR) was 76.2 mL/min/1.73 m(2) (SD=27.6), compared with 78.5 mL/min/1.73 m(2) (SD=28.9) preoperatively (P=0.11). Therefore, the mean eGFR decline of 2.3 mL/min/1.73 m(2) (SD=9.1) was not significant., Conclusions: Off-clamp RAPN is associated with minimal morbidity and minimal decline in renal function on short-term follow-up. Further studies and continued monitoring of renal function are needed to determine if off-clamp RAPN provides any advantage in renal function preservation relative to the traditional RAPN with vascular clamping.

Background and Purpose: Considering the potential impact of warm ischemia time (WIT) on renal functional outcomes after robot-assisted partial nephrectomy (RAPN), many techniques that reduce or eliminate WIT have been studied. We present our institutional experience and progression using one such technique-off-clamp RAPN-as well as the results of this technique in the management of complex cases., Patients and Methods: A retrospective chart review of 65 patients undergoing off-clamp RAPN was performed, 15 of whom underwent off-clamp RAPN for 26 complex tumors. Complex features included hilar location, completely endophytic growth, and ipsilateral multifocality. In all cases, hilar vessels were dissected but not clamped., Results: Mean tumor size was 2.5 cm (standard deviation; [SD]=1.4), while mean nephrometry score was 8.7 (SD=1.5). One (7%) intraoperative complication occurred. Mean estimated blood loss was 403 mL (SD=381), mean operative time was 190 minutes (SD=68), and WIT was 0 minutes in all cases. Mean length of stay was 1.8 days (SD=0.9), with one patient needing a postoperative blood transfusion (Clavien II complication). Final pathology results demonstrated clear-cell carcinoma (n=16), papillary carcinoma (n=4), angiomyolipoma (n=1), oncocytoma (n=2), and cystic nephroma (n=3). Margins were negative for tumor for 96% (25/26) of resected masses. Estimated glomerular filtration rate (eGFR) decreased by an average of 3.1 mL/min/1.73 m(2) (SD=9.8, P=0.24), at a mean follow-up of 177 days (SD=296). Five patients with radiographic follow-up of at least 6 months have no evidence of disease recurrence., Conclusions: Off-clamp RAPN can be safely and effectively performed even in the case of complex tumors, but occurs with higher estimated blood loss. Minimal changes in eGFR were experienced by patients undergoing off-clamp RAPN at an average follow-up of roughly 6 months. Longer follow-up and direct comparison with conventional clamped RAPN technique are needed to establish the efficacy of off-clamp RAPN in complex cases.

Purpose: Despite the explicit endorsement of the American Urological Association guidelines of partial nephrectomy as the treatment of choice for T1a renal cell carcinoma, a considerable underuse of nephron sparing surgery characterizes general practice patterns in the United States. We explored possible financial disincentives associated with partial nephrectomy that may contribute to this important quality of care deficit., Materials and Methods: A PubMed® query on perioperative outcomes identified 10 series on open or laparoscopic radical nephrectomy and 16 on open, laparoscopic or robot-assisted partial nephrectomy. Mean operative time and hospital length of stay were calculated for each group. Using these data in conjunction with Health Care Financing Administration data on physician work time, which guides the current Resource-Based Relative Value Scale Medicare fee schedule, we calculated global physician time expenditure and hourly Medicare reimbursement rates for each of these 5 surgical services., Results: Mean±SD operative time for open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy was 180.7±24.7 minutes (95% CI 119.3-242.0) in 3 studies, 178.8±16.5 (95% CI 163.5-194.1) in 7, 226.0±36.9 (95% CI 187.2-264.8) in 6, 227.9±40.2 (95% CI 185.8-270.1) in 6 and 227.9±37.8 (95% CI 167.7-288.1) in 4, respectively (p=0.028). Mean length of stay (days) after open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy was 5.8±0.7 days (95% CI 4.0-7.7) in 3 studies, 2.5±1.1 (95% CI 1.4-3.6) in 6, 5.8±0.4 (95% CI 5.3-6.2) in 5, 2.9±0.3 (95% CI 2.6-3.3) in 6 and 2.8±1.0 (95% CI 1.2-4.4) in 4, respectively (p<0.001). The hourly reimbursement rate was calculated at $200.61, $242.03, $185.66, $231.27 and $231.97 for open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy, respectively. Hence, open partial nephrectomy emerged as the lowest paying of these procedures., Conclusions: Inferior compensation for open partial nephrectomy relative to that of laparoscopic or open radical nephrectomy may impede the dissemination of nephron sparing surgery for small renal masses. This may occur particularly in a general practice setting, where the expertise required for laparoscopic or robot-assisted partial nephrectomy may be lacking. We propose rectifying this inequity to facilitate wider use of nephron sparing surgery in the clinically appropriate setting., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Partial nephrectomy has been increasingly recommended over radical nephrectomy for the management of small renal masses based on improved renal functional outcomes without sacrifice of oncologic effectiveness. Robot-assisted partial nephrectomy (RAPN) has been introduced in an effort to offer another minimally invasive option for nephron-sparing surgery. However, reports of RAPN have been limited to short-term perioperative outcomes. The goal of this study is to report and evaluate the initial oncologic outcomes of RAPN. Utilizing prospectively obtained data on RAPN performed by four surgeons at four separate tertiary care centers, we selected patients with unilateral, localized, non-familial, pathologically-confirmed pT1 renal cell carcinoma and a minimum post-operative follow-up of 12 months., Methods: Utilizing prospectively obtained data on RAPN performed by four surgeons at four separate tertiary care centers, we selected patients with unilateral, localized, non-familial, pathologically-confirmed pT1 renal cell carcinoma and a minimum post-operative follow-up of 12 months. Survival analysis (disease-free, cancer-specific, and overall survival) was performed, and Kaplan-Meier curves were generated., Results: RAPN was performed in 124 patients with a median tumor size of 3.0 cm (IQR 2.2-4.2 cm). Median follow-up was 29 months (range 12-46 months). Positive parenchymal surgical margins occurred in two patients (1.6 %), both of whom were recurrence-free at 30 and 34 months after surgery. The three-year Kaplan-Meier estimated disease-free survival was 94.9 %, cancer-specific survival was 99.1%, and overall survival was 97.3 %., Conclusions: In our cohort of patients with small renal carcinomas who were followed for a median of 29 months, recurrence and survival outcomes were similar to those reported for open and laparoscopic partial nephrectomy. Further long-term outcomes will be needed to definitively claim that RAPN is oncologically equivalent to other surgical approaches.

• Robot-assisted partial nephrectomy (RAPN) has emerged as a viable technique for nephron-sparing surgery. • In this article, we review the outcomes of RAPN in its current iteration, with attention to operative, oncological, and functional outcomes. In addition, we highlight techniques that may serve to enhance outcomes., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Purpose: We evaluated the incidence of perioperative complications after robotic partial nephrectomy., Materials and Methods: We retrospectively reviewed the records of patients treated with robotic assisted partial nephrectomy across the 4 participating institutions. Demographic, blood loss, warm ischemia time, and intraoperative and postoperative complication data were collected. All complications were graded according to the Clavien classification system., Results: A total of 450 consecutive robotic assisted partial nephrectomies were done between June 2006 and May 2009. Overall 71 patients (15.8%) had a complication, including intraoperative and postoperative complications in 8 (1.8%) and 65 (14.4%), respectively. Hemorrhage developed in 2 patients (0.2%) intraoperatively and in 22 (4.9%) postoperatively. Seven patients (1.6%) had urine leakage. As classified by the Clavien system, complications were grade I-II in 76.1% of cases and grade III-IV in 23.9%. Robotic assisted partial nephrectomy was converted to open or conventional laparoscopic surgery in 3 patients (0.7%) and to radical nephrectomy in 7 (1.6%). There were no deaths., Conclusions: Current data indicate that robotic assisted partial nephrectomy is safe. Most postoperative complications are Clavien grade I or II, or can be managed conservatively., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the outcomes of patients with a positive surgical margin by gross and/or frozen examination during partial nephrectomy, in whom a re-resection of the margin or a completion nephrectomy was performed., Methods: Patients with renal cancer who underwent partial nephrectomy were considered. If the patient had a positive margin and underwent completion nephrectomy or re-excision of the margin, they were included. Patients with planned enucleation were excluded from the study. Clinical and pathologic information were reviewed to examine for residual cancer in the additionally resected tissue., Results: In the final cohort, 29 patients with a positive margin and subsequent complete parenchymal re-resection or completion nephrectomy were identified. Eight patients underwent nephrectomy, after which no residual cancer was found in the renal remnant. Twenty-one patients underwent total re-resection of the margin, of which two were found to have carcinoma. Renal functional outcomes revealed a decrease in estimated glomerular filtration rate of 25 mL/min/1.73 m(2) in patients who underwent radical nephrectomy, and 4 mL/min/1.73 m(2) in patients who underwent re-resection of the margin with preservation of the renal unit., Conclusions: A positive surgical margin does not necessarily mean that cancer remains in the renal remnant in most cases. Therefore, radical nephrectomy or re-resection of the margin is overtreatment in many cases, but a small percentage of patients will harbor residual malignancy. Clinical correlation is recommended before reexcision or completion nephrectomy after a positive surgical margin, with careful consideration of the impact on subsequent renal function weighed against the possibility of residual disease., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Minimally invasive approaches to partial nephrectomy have been rapidly gaining popularity but require advanced laparoscopic surgical skills. Renal hilar tumors, due to their anatomic location, pose additional technical challenges to the operating surgeon., Objective: We compared the outcomes of robot-assisted partial nephrectomy (RPN) for hilar and nonhilar tumors in our large multicenter contemporary series of patients., Design, Setting, and Participants: We retrospectively reviewed prospectively collected data on 446 consecutive patients who underwent RPN by renal surgeons experienced in minimally invasive techniques at four academic institutions from June 2006 to March 2010. Patients were stratified into two groups: those with hilar lesions and those with nonhilar lesions., Measurements: Patient demographics, operative outcomes, and postoperative outcomes, including oncologic outcomes, were recorded., Results and Limitations: Forty-one patients (9%) had hilar renal masses; 405 patients (91%) had nonhilar masses. There was no statistical differences in patient demographics except for larger median tumor size in the hilar cohort (3.2 cm vs 2.6 cm; p=0.001). The only significant difference in operative outcomes was an increase in warm ischemia times for the hilar group versus the nonhilar group (26.3±7.4 min vs 19.6±10.0 min; p=<0.0001). There were no differences in postoperative outcomes; however, there was a trend for increased risk of malignancy and higher stage tumors in the hilar lesion group. Final pathologic margin status was similar in both groups. Only one patient in the nonhilar group had evidence of recurrence at 21 mo. The study was limited by the lack of standard anatomic classification of renal tumors and the potential influence of the surgeons' prior robotic experience., Conclusions: The data represent the largest series of its kind and strongly suggest that RPN is a safe, effective, and feasible option for the minimally invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared with nonhilar tumors in the hands of experienced robotic surgeons., (Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Robot-assisted partial nephrectomy (RAPN) is emerging as a viable approach for nephron-sparing surgery (NSS), though many reports to date have been limited by evaluation of a relatively small number of patients., Objective: We present the largest multicenter RAPN experience to date, culling data from four high-volume centers, with focus upon functional and oncologic outcomes., Design, Setting, and Participants: A retrospective chart review was performed for 183 patients who underwent RAPN at four centers between 2006 and 2008., Surgical Procedure: RAPN was performed using methods outlined in the supplemental video material. Though operative technique was similar across all institutions, there were minor variations in trocar placement and hilar control., Measurements: Perioperative parameters, including operative time, warm ischemic time, blood loss, and perioperative complications were recorded. In addition, we reviewed functional and oncologic outcomes., Results and Limitations: Mean age at treatment was 59.3 yr. Mean tumor size was 2.87 cm. Mean total operative time was 210 min while mean ischemic time was 23.9 min. Calyceal repair was required in 52.1% of procedures. Mean estimated blood loss was 131.5 ml. Sixty-nine percent of excised tumors were malignant, of which 2.7% exhibited positive surgical margins. The incidence of major complications was 8.2%. At up to 26 mo follow-up, there have been no documented recurrences and no significant change in serum creatinine (1.03 vs 1.04 mg/dl, p=0.84) or estimated glomerular filtration rate (eGFR) from baseline (82.2 vs 79.4 mg/ml per square meter, p=0.74). The study is limited by its retrospective nature, and the outcomes are likely influenced by the robust prior laparoscopic renal experience of each of the surgeons included in this study., Conclusions: RAPN is a safe and efficacious approach for NSS, offering short ischemic times, as well as perioperative morbidity equivalent to other standard approaches. Moreover, RAPN is capable of providing patients with excellent functional and oncologic outcomes., (Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: Recently, our institution refined a technique for robot-assisted renorrhaphy utilizing sliding Weck Hem-O-Lock clips, which are tightened by the surgeon seated at the console and locked into place with a LapraTy clip. In addition to the relative ease of implementation, we believe that our technique also provides a superior strength of closure over other commonly used techniques., Methods: An in vivo porcine model was used to compare a sliding-clip technique against an assistant-placed LapraTy-only closure, and a surgeon-placed simple suture closure. A force gauge was used to record the maximum tension that could be applied during each closure method before the suture ripped through the renal parenchyma, thus illustrating the relative strength of each closure., Results: The simple suture closure performed relatively poorly, ripping through parenchyma at a mean force of 11.3 N. The LapraTy-only method allowed a maximum applicable mean force of 16.7 N. The sliding Weck clip with a LapraTy bolster provided the tightest closure, allowing for a mean force of 32.7 N before ripping through parenchyma. Statistical analysis reveals that a sliding-clip technique provides a significantly tighter closure than both of the other tested methods., Conclusion: A sliding-clip technique allows for more tension to be safely applied to the closure of a partial nephrectomy defect than other commonly used methods. We believe that this is primarily attributable to the larger footprint of the Hem-O-Lock clip, which allows for the tension to be distributed over a greater surface area. The LapraTy then ensures the security of the closure by holding the Weck clip in place. Further studies are necessary to determine if this increased tension translates into appreciably better hemostasis.

Purpose of Review: Robot-assisted partial nephrectomy (RAPN) is emerging as a viable complement to traditional laparoscopic and open partial nephrectomy. As a relatively new technique, the techniques and technologies employed during RAPN continue to evolve. In the present article, we provide an overview of the evolution of robot-assisted renal surgery, and highlight the recent advances that have helped to bring RAPN to the fore., Recent Findings: The learning curve for RAPN appears to be slight, and technical proficiency may be quickly achieved, even for those with limited laparoscopic experience. Recent advances include improvements in ergonomics of the robotic system itself, as well as the introduction of sliding-clip renorrhaphy, early unclamping techniques, and off-clamp techniques. Early-to-intermediate outcomes are very promising, demonstrating short warm ischemic times, and a low rate of complication and recurrence. Disadvantages to the approach include substantial cost, as well as increased reliance upon the assistant to perform critical maneuvers., Summary: Robot-assisted partial nephrectomy appears to be a safe and efficacious technique for the surgical management of localized renal malignancy. Recent developments have focused upon reducing ischemic insult, as well as decreasing reliance upon the assistant.

Purpose: The learning curve for robot-assisted partial nephrectomy (RAPN) has not been extensively studied. We therefore evaluated the learning curve of RAPN for a fellowship-trained laparoscopic surgeon with extensive prior experience with laparoscopic partial nephrectomy (LPN). We also examined the potential effect of tumor size on the learning curve., Patients and Methods: We prospectively evaluated 38 consecutive patients undergoing RAPN by a single surgeon (S.B.B.). Sixteen patients had tumors <2 cm, and 22 patients had tumors >2 cm. Warm ischemia times and overall operative times were recorded as indices of learning progression., Results: Average operative time for tumors <2 cm was 131.9 minutes (115.3-148.5 minutes) and for tumors >2 cm was 145.8 minutes (131.1-160.5 minutes). The difference between the operative times for tumors <2 and >2 cm was not statistically significant (p = 0.23). Average warm ischemia time for tumors <2 cm was 21 minutes (16.9-25.1 minutes) and for tumors >2 cm was 24.7 minutes (21.3-28.1 minutes). This difference was also not statistically significant (p = 0.20). Defined by the overall operative time, the learning curve for RAPN was 16 cases, and by ischemic time, the learning curve was 26 cases. Tumor size did not have an effect on the learning curve., Conclusions: The learning curve for RAPN is short for surgeons already experienced with LPN. The learning curve for portions performed under warm ischemia is slightly longer, implying that the critical portions of the procedure require more experience to become facile. Tumor size does not appear to have a significant impact on the learning curve for surgeons experienced with LPN.

The widespread adoption of laparoscopic partial nephrectomy (LPN) has been curtailed by its technical complexity. With the introduction of robotic technology, there is a potential for a shorter learning curve for minimally invasive nephron-sparing surgery (NSS). Initial published data on robot-assisted partial nephrectomy show promising perioperative outcomes comparable to large LPN series performed by highly experienced laparoscopic surgeons. Intraoperative parameters (operating room time, warm ischemia time, and blood loss) and short-term oncologic results demonstrate that this technique, unlike LPN, has a relatively short learning curve. Economic factors, as well as the necessity of an experienced bedside assistant, present the potential shortcomings of the procedure.

Purpose: Robot assisted partial nephrectomy is rapidly emerging as an alternative to laparoscopic partial nephrectomy for the treatment of renal malignancy. We present the largest multi-institution comparison of the 2 approaches to date, describing outcomes from 3 experienced minimally invasive surgeons., Materials and Methods: We performed a retrospective chart review, evaluating 118 consecutive laparoscopic partial nephrectomies and 129 consecutive robot assisted partial nephrectomies performed between 2004 and 2008 by 3 experienced minimally invasive surgeons at 3 academic centers. Perioperative data were recorded along with clinical and pathological outcomes., Results: The robot assisted and laparoscopic partial nephrectomy groups were equivalent in terms of age, gender, body mass index, American Society of Anesthesiologists classification (2.3 vs 2.4) and radiographic tumor size (2.9 vs 2.6 cm), respectively. Comparison of operative data revealed no significant differences in terms of overall operative time (189 vs 174 minutes), collecting system entry (47% vs 54%), pathological tumor size (2.8 vs 2.5 cm) and positive margin rate (3.9% vs 1%) for robot assisted and laparoscopic partial nephrectomy, respectively. Intraoperative blood loss was less for robot assisted vs laparoscopic partial nephrectomy (155 vs 196 ml, p = 0.03) as was length of hospital stay (2.4 vs 2.7 days, p <0.0001). Warm ischemia times were significantly shorter in the robot assisted partial nephrectomy series (19.7 vs 28.4 minutes, p <0.0001). Subset analysis based on complexity revealed that tumor complexity had no effect on operative time or estimated blood loss for robot assisted partial nephrectomy, although complexity did affect these factors for laparoscopic partial nephrectomy. In addition, for simple and complex tumors robot assisted partial nephrectomy provided significantly shorter warm ischemic time than laparoscopic partial nephrectomy (15.3 vs 25.2 minutes for simple, p <0.0001; 25.9 vs 36.7 minutes for complex, p = 0.0002). There were no intraoperative complications during robot assisted partial nephrectomy vs 1 complication during laparoscopic partial nephrectomy. Postoperative complication rates were similar for robot assisted and laparoscopic partial nephrectomy (8.6% vs 10.2%)., Conclusions: Robot assisted partial nephrectomy is a safe and viable alternative to laparoscopic partial nephrectomy, providing equivalent early oncological outcomes and comparable morbidity to a traditional laparoscopic approach. Moreover robot assisted partial nephrectomy appears to offer the advantages of decreased hospital stay as well as significantly less intraoperative blood loss and shorter warm ischemia time, the latter of which may help to provide maximal preservation of renal reserve. In addition, operative parameters for robot assisted partial nephrectomy appear to be less affected by tumor complexity compared to laparoscopic partial nephrectomy. Interestingly while the advantages of robotic surgery have historically been believed to aid laparoscopic naïve surgeons, these data indicate that robot assisted partial nephrectomy may also benefit experienced laparoscopic surgeons.

Introduction: Laparoscopic partial nephrectomy has emerged as a standard of care for small renal masses. Nevertheless, there remains concern over the potential for irreversible insult to the kidney as a result of exposure to warm ischemia. We aim to investigate the utility of selective segmental arterial clamping as a means to reduce the potential for ischemic damage to a solitary kidney during laparoscopic partial nephrectomy utilizing a porcine model., Materials and Methods: A total of 20 domestic swine were randomized into four equal groups. Each subject underwent laparoscopic radical nephrectomy to create the condition of a solitary kidney. On the contralateral side, a laparoscopic lower pole partial nephrectomy was performed, employing either selective or nonselective vascular clamping for either 60 or 90 minutes. Postoperatively, clinical status and serial serum studies were closely monitored for 1 week., Results: There were no intraoperative complications. The 90-minute nonselective clamping produced devastating effects, resulting in rapid deterioration into florid renal failure within 72 hours. The 60-minute nonselective clamping group experienced modest but significant rises in both blood urea nitrogen and creatinine. Both 60- and 90-minute selective clamping groups performed well, with no significant rises in creatinine over a 7-day period, and no instances of renal failure., Conclusions: Selective arterial clamping is a safe and feasible means of vascular control during laparoscopic partial nephrectomy. In the porcine model, selective clamping appears to improve functional outcomes during prolonged periods of warm ischemic insult. Prospective evaluation of the technique in humans is necessary to determine if selective arterial control confers long-term functional benefits in patients with limited renal reserve.

Introduction: For the treatment of renal tumors, minimally invasive nephron-sparing surgery has become increasingly performed due to proven efficiency and excellent functional and oncological outcomes. The introduction of robotics into urologic laparoscopic surgery has allowed surgeons to perform challenging procedures in a reliable and reproducible manner. We present our surgical technique for robotic assisted partial nephrectomy (RPN) using a 3-arm approach, including a sliding-clip renorrhaphy., Materials and Methods: Our RPN technique is presented which describes the trocar positioning, hilar dissection, tumor identification using intraoperative ultrasound for margin determination, selective vascular clamping, tumor resection, and reconstruction using a sliding-clip technique., Conclusion: RPN using a sliding-clip renorrhaphy is a valid and reproducible surgical technique that reduces the challenge of the procedure by taking advantage of the enhanced visualization and control afforded by the robot. The renorrhaphy described is performed under complete control of the console surgeon, and has demonstrated a reduction in the warm ischemia times in our series.

Background: Robotic partial nephrectomy (RPN) is emerging as an alternative to traditional laparoscopic partial nephrectomy (LPN). Despite the potential advantages of the robotic approach, renorrhaphy remains a challenging portion of the procedure., Objective: To present our technique and outcomes for RPN, including sliding-clip renorrhaphy., Design, Setting, and Participants: Between 2007 and 2008, 50 patients underwent RPN performed by a single attending surgeon., Surgical Procedure: In this paper, we describe our technique for RPN, including a sliding-clip renorrhaphy, which is distinguished by the use of Weck Hem-O-Lock clips that are slid into place under complete control of the surgeon seated at the console and secured with a LapraTy clip. For the first 13 procedures, traditional tied-suture or assistant-placed clip closures were performed; sliding-clip renorrhaphy was performed in the remaining 37 cases., Results and Limitations: Mean tumor size was 2.5 cm. Mean operative time was 145.3 min, and mean overall warm ischemia time was 17.8 min. Mean estimated blood loss was 140.3 ml. The learning curve for overall operative time was 19 cases; the learning curve for portions of the case performed under warm ischemia (including tumor resection and renorrhaphy) was 26 cases. The introduction of a sliding-clip renorrhaphy produced significant reductions in overall operative time and warm ischemia time, while blood loss and hospital stay remained stable over our experience. Limitations of RPN include cost and increased reliance on the bedside assistant., Conclusions: Sliding-clip renorrhaphy provides an efficient and effective repair that is under nearly complete control of the surgeon. This technique appears to contribute to significantly shorter overall operative times and, perhaps most critically, to shorter warm ischemia times. The learning curve for RPN using this technique appears to be foreshortened compared with LPN.

Objectives: To compare a single-surgeon experience of laparoscopic partial nephrectomy (LPN) and robotic-assisted partial nephrectomy (RPN) in 102 consecutive patients., Methods: The clinical, pathologic, and follow-up information from 102 consecutive procedures (40 RPNs and 62 LPNs) was reviewed., Results: No statistically significant differences were found between the groups with regard to age, body mass index, or American Society of Anesthesiologists score. No significant difference was found between the estimated blood loss (136 vs 173 mL), tumor size (2.5 vs 2.4 cm), need for pelvicaliceal repair (56% for both), and positive margin rate (1 vs 1 patient) between RPN and LPN, respectively. The mean total number of trocars in the robotic group was greater than the laparoscopic group (4.6 vs 3.2, P = .01). The mean total operative time (140 vs 156 minutes, P = .04), warm ischemia time (19 vs 25 minutes, P = .03), and length of stay (2.5 vs 2.9 days, P = .03) were significantly shorter for RPN than for LPN, respectively., Conclusions: RPN can produce results comparable to LPN but has disadvantages, such as cost and assistant control of the renal hilum. Additional randomized trials are needed.

Purpose of Review: Robotic-assisted partial nephrectomy is an emerging technique for the treatment of renal malignancy. Our aim is to review the initial reported experience with robotic partial nephrectomy, evaluating techniques, early outcomes, and potential advantages of the robotic approach over the traditional laparoscopic approach., Recent Findings: Early experience with robotic partial nephrectomy demonstrates good oncologic outcomes. Other parameters, such as operative time, blood loss, postoperative renal function, and hospital stay, appear to be at least equivalent to laparoscopic partial nephrectomy. New techniques, including refined methods for renorrhaphy, have also been introduced which aim to simplify critical portions of the procedure, although vascular clamping still remains a challenging aspect of the procedure. The learning curve appears to be slight, even for surgeons without extensive laparoscopic experience., Summary: Although long-term outcome data is presently lacking, the early experience with robotic partial nephrectomy shows promise. The technique should continue to evolve as it gains acceptance as an alternative to the traditional laparoscopic approach.

Background: A standard of care for the treatment of small renal masses is partial nephrectomy. The open and laparoscopic approaches have been well described in the literature. Robotic assistance may augment partial nephrectomy by aiding in dissection and renal reconstruction. In this communication we describe the surgical outcomes of 35 patients undergoing robotic partial nephrectomy., Methods: Patient records and databases were reviewed for 35 consecutive patients undergoing RPN. Clinical, pathological, and radiographic data were obtained. The data was deidentified., Results: Thirty five patients successfully underwent RPN. An additional 2 patients were converted to other nephron sparing procedures. Mean tumor size was 2.8 cm, and mean OR time was 142 minutes. Mean warm ischemia time was 20 minutes. All margins were negative. There were 4 complications, and no patients required reoperation., Conclusion: Robotic partial nephrectomy can produce excellent initial results. Further studies should be performed to compare the outcomes to laparoscopic and open operations.