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Background: Robotic technology is being increasingly adopted in urologic surgery., Objective: To describe a contemporary surgical technique and report cumulative surgical outcomes of robot-assisted laparoscopic partial nephrectomy (RALPN) at our tertiary care institution., Design, Setting, and Participants: Medical charts of consecutive patients who underwent RALPN between June 2006 and November 2011 were reviewed from a prospectively maintained, institutional review board-approved database., Surgical Procedure: The main steps of our current surgical technique are described in this video tutorial: patient positioning and trocar placement; bowel mobilization; hilar dissection; tumor identification and demarcation; clamping of the hilum; tumor excision; renorraphy; hilar unclamping; and tumor retrieval., Outcome Measurements and Statistical Analysis: Patients' characteristics and main surgical outcomes were analyzed., Results and Limitations: A total of 400 patients (mean age: 58.5 yr, mean body mass index: 30.7 kg/m(2)) were included in this analysis. Mean renal tumor size was 3.17 cm (standard deviation [SD]: 1.64) and mean RENAL score was 7.2 (SD: 2). Six patients (1.5%) presented with a solitary kidney. Mean total operative time was 190.3 min (SD: 57), and mean warm ischemia time was 19.2 min (SD: 10.72). In 36 cases (9%), an unclamped hilum technique was used. After a mean follow-up of 12.4 mo (SD: 12.2), there was a decline of -9.2 ml/min per 1.73 m(2) (SD: 26.56) in estimated glomerular filtration rate. Most renal masses were malignant (74.5%), and the overall mean tumor size was 3.05 cm (SD: 1.66). Renal cell carcinoma with a clear cell histology represented the most frequent malignant diagnosis (64.4% of cases). A positive margin was observed in nine cases (2.25%). A total of 11 intraoperative complications (2.7%) occurred, and a conversion to open or laparoscopic PN was required in six cases (1.5%). A postoperative complication occurred in 61 cases (15.3%), the majority of them being low grade., Conclusions: The standardization of each surgical step has allowed for optimization of RALPN and ultimately improved its outcomes and expanded its indications., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Recent studies showed that robotic partial nephrectomy (RPN) offered outcomes at least comparable to those of laparoscopic partial nephrectomy (LPN). LPN can be particularly challenging for more complex tumors., Objective: To compare the perioperative outcomes of patients undergoing LPN or RPN for a single renal mass of moderate or high complexity., Design, Setting, and Participants: A retrospective analysis was performed for 381 consecutive patients who underwent either LPN (n = 182) or RPN (n = 199) between 2005 and 2011 for a complex renal mass (RENAL score ≥ 7). Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis., Intervention: LPN or RPN., Outcome Measurements and Statistical Analysis: Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis., Results and Limitations: There was no significant difference between the two groups with respect to patient age, gender, side, American Society of Anesthesiologists score, Charlson comorbidity index (CCI), or tumor size. Patients undergoing LPN had a slightly lower body mass index (29.2 kg/m(2) compared with 30.7 kg/m(2), p = 0.02) and preoperative estimated glomerular filtration rate (eGFR) (81.1 compared with 86.0 ml/min per 1.73 m(2), p = 0.02). LPN was associated with an increased rate of conversion to radical nephrectomy (RN) (11.5% compared with 1%, p<0.001) and a higher decrease in percentage of eGFR (-16.0% compared with -12.6%, p = 0.03). There were no significant differences with respect to warm ischemia time (WIT), estimated blood loss, transfusion rate, or postoperative complications. WIT, preoperative eGFR, and CCI were found to be predictors of postoperative eGFR in multivariable analysis. No difference in perioperative outcomes was found between moderate and high RENAL score subgroups. The retrospective study design was the main limitation of this study., Conclusions: RPN provides functional outcomes comparable to those of LPN for moderate- to high-complexity tumors, but with a significantly lower risk of conversion to RN. This situation is likely because of the technical advantages offered by the articulated robotic instruments. A prospective randomized study is needed to confirm these findings., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Recent reports have suggested that robotic laparoendoscopic single-site surgery (R-LESS) is feasible, yet comparative studies to conventional laparoscopy are lacking., Objective: To report our early experience with R-LESS radical nephrectomy (RN)., Design, Setting, and Participants: A retrospective review of R-LESS RN data was performed between May 2008 and November 2010. A total of 10 procedures were performed and subsequently matched to 10 conventional laparoscopic RN procedures (controls). The control group was matched with respect to patient age, body mass index (BMI), American Society of Anesthesiologists score, surgical indication, and tumor size., Surgical Procedure: R-LESS RN was performed using methods outlined in the manuscript and supplemental video material. All patients underwent R-LESS RN by a single surgeon. Single-port access was achieved via two commercially available multichannel ports, and robotic trocars were inserted either through separate fascial stabs or through the port, depending on the type used. The da Vinci S and da Vinci-Si Surgical Systems (Intuitive Surgical, Sunnyvale, CA, USA) with pediatric and standard instruments were used., Measurements: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed., Results and Limitations: The mean patient age was 64.0 yr of age for both groups, and BMI was 29.2 kg/m(2). There was no difference between R-LESS and conventional laparoscopy cases in median operative time, estimated blood loss, visual analogue scale, or complication rate. The R-LESS group had a lower median narcotic requirement during hospital admission (25.3 morphine equivalents vs 37.5 morphine equivalents; p=0.049) and a shorter length of stay (2.5 d vs 3.0 d; p=0.03). Study limitations include the small sample size, short follow-up period, and all the inherent biases introduced by a retrospective study design., Conclusions: R-LESS RN offers comparable perioperative outcomes to conventional laparoscopic RN. Prospective comparison is needed to definitively establish the position of R-LESS in minimally invasive urologic surgery., (Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.)