Surgical Techniques in the Management of Small Renal Masses

Robotic-assisted enucleation for renal masses: A comparison of on-clamp and off-clamp approach

INTRODUCTION

In surgically excising renal masses, studies have demonstrated that tumor enucleation is an effective option. However, there is limited literature comparing off-clamp to on-clamp tumor enucleation.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 189 patients who underwent robotic-assisted laparoscopic partial nephrectomy via tumor enucleation by a single surgeon from March 2012 and April 2022. Patients were stratified based on use of renal hilar clamping intraoperatively. Surgical, oncologic, and renal functional outcomes were captured. Variables were analyzed and compared between the two groups using Student's T-tests and Chi-square tests.

RESULTS

Of 189 procedures analyzed, 124 were performed on-clamp and 65 were performed off-clamp. There were no differences in patient demographics or average length of follow-up. There were no differences in estimated blood loss, complications, or hospital length of stay. Recurrence rates were similar for the two groups. The absolute difference in estimated glomerular filtration rate change between the two groups at time of first follow-up was not significant (p = 0.25).

CONCLUSIONS

There is no significant difference in perioperative outcomes such as surgical time, blood loss, or complications between the two groups. Furthermore, there was no significant difference in postoperative kidney function between the two techniques.

Robotic Partial Nephrectomy: Update on Techniques

Surgical techniques for robot-assisted partial nephrectomy are driven by the aims of simplifying the most challenging surgical steps, maximizing functional and oncologic outcomes, and consistently pushing the envelope on possibilities. Over the past several years, we have seen an emergence in not only innovation in surgical technique, and robotic platforms, but integration of a variety of imaging techniques. We believe with developing robotic expertise, practicing urologists will continue to push the envelope in nephron preservation and complication-free recovery.

Feasibility and necessity of the fourth arm of the da Vinci Si surgical system for robot-assisted partial nephrectomy

BACKGROUND

To investigate the feasibility of the fourth arm of the da Vinci Si system for robot-assisted partial nephrectomy (RAPN).

METHODS

Fifty-eight consecutive patients underwent RAPN with the same port placements. After reviewing the surgical videos and records, 38 patients showing usefulness of the fourth arm were categorized into Group A and those not showing usefulness into Group B. The background data, tumor characteristics, and perioperative outcomes were compared between the groups.

RESULTS

Group B had a larger proportion of tumors located on the inner side of the kidney, and the console time was significantly longer. Multivariable logistic regression analysis showed that tumors located on the inner side of the kidney were associated with the non-use of the fourth arm of the da Vinci Si system during RAPN.

CONCLUSIONS

Our findings suggested that use of fourth arm in RAPN by da Vinci Si should be considered for each tumor location.

Optimization of renal function preservation during robotic partial nephrectomy

Over the past few years, the role of robotic-assisted partial nephrectomy (RPN) has exponentially grown. Multiple recognized factors contribute to postoperative renal function in patients undergoing RPN. The aim of this review is to identify these potential factors, and to evaluate strategies that may help optimize the goal of renal function preservation. A nonsystematic literature review was performed to retrieve the most recent evidence on factors contributing to renal function post-RPN. Analyzed elements include baseline factors (tumor complexity and patient characteristics), intraoperative (surgical) factors (control of the renal hilum and type of ischemia, resection technique, renorrhaphy technique), and pharmacotherapeutics. In conclusion, the advantages of robotic surgery in the setting of partial nephrectomy (PN) are becoming well established. Maximal preservation of renal function remains a priority goal of the procedure, and it is influenced by a plethora of factors. Adequate patient selection using radiomics, control of comorbidities, utilization of evidence-based intraoperative techniques/strategies, and postoperative care are key components of postoperative preservation of renal function. Further investigations regarding these factors and their effects on long-term renal function are necessary and will continue to aid in guiding appropriate patient care.