This article lays an emphasis on the Role of Robotic Partial Nephrectomy in the treatment of renal cell carcinoma. The increasing radiological detection of histological low-grade low-stage renal masses has presented a challenging task to the practising urologist. Nephron sparing surgery (NSS) not only preserves the kidney but also allows safe removal of tumour of unknown malignant potential without removing the kidney. Advent of robotic technology and evolution of surgical technique together have offered to serve patients with these tumours, yet a large number of which are asymptomatic at the time of diagnosis. Centres which have the facility for robotic surgery have been offering partial nephrectomy to patients with more and more challenging nephrometric scores. On the other hand, radical nephrectomy is being offered to a large proportion of patients with tumours otherwise suitable for NSS. Advances in technology like firefly and intra operative real time ultrasound have further refined the technique of Robotic Partial Nephrectomy.

1. Role of Robotic Partial Nephrectomy in the
treatment of renal cell carcinoma

2. Review Article
Role of Robotic Partial Nephrectomy in the
treatment of renal cell carcinoma
Rajesh Taneja a,
*, Ishfaq A. Geelani b
a
Senior Consultant, Urology and Robotic Surgery, India
b
DNB Urology, Attending Consultant, Indraprastha Apollo Hospitals, New Delhi, India
Renal cell carcinoma (RCC) is the commonest malignant
neoplasm of the kidney and almost 200,000 new cases are
detected annually, and half of this number succumb to this
disease. The advent of ultrasound screening for unrelated
abdominal symptoms has shifted the stage of diagnosis from a
delayed stage to early, asymptomatic, localized disease, in
which the treatment can be safely directed towards nephron
sparing surgery (NSS).Ithas beenamplywelldocumented inthe
last decade and a half that the oncological outcome of NSS or
Partial Nephrectomy (PN) is equal to the earlier gold standard of
Radical Nephrectomy for localized small volume disease, stage
T1.1
This approach has been shown to be superior to radical
nephrectomy in terms of long-term development of renal
impairment, cardiovascular morbidity and premature death in
addition to psychological rehabilitation of patient with the
thought that part of the kidney could be saved.2
1. NSS
NSS was initially popularised by Andrew C Novick. In the
beginning, it was a tedious operation through a large
abdominal incision with or without intracorporeal cooling.
As the experience advanced, the cooling was given up with
equally good results of NSS. This was the time when
laparoscopy was beginning to gain popularity among urolo-
gists, and the pioneers in the field introduced the concept of
NSS through laparoscopic approach, thus reporting successful
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x
a r t i c l e i n f o
Article history:
Received 8 July 2015
Accepted 17 July 2015
Available online xxx
Keywords:
Renal cell carcinoma
Nephron sparing surgery
Robotic Partial Nephrectomy
Uro oncology
Intraoperative renorrhaphy
a b s t r a c t
This article lays an emphasis on the Role of Robotic Partial Nephrectomy in the treatment of
renal cell carcinoma. The increasing radiological detection of histological low-grade low-
stage renal masses has presented a challenging task to the practising urologist. Nephron
sparing surgery (NSS) not only preserves the kidney but also allows safe removal of tumour
of unknown malignant potential without removing the kidney. Advent of robotic technology
and evolution of surgical technique together have offered to serve patients with these
tumours, yet a large number of which are asymptomatic at the time of diagnosis. Centres
which have the facility for robotic surgery have been offering partial nephrectomy to
patients with more and more challenging nephrometric scores. On the other hand, radical
nephrectomy is being offered to a large proportion of patients with tumours otherwise
suitable for NSS. Advances in technology like firefly and intra operative real time ultrasound
have further refined the technique of Robotic Partial Nephrectomy.
# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights
reserved.
* Corresponding author.
E-mail address: rajeshtanejadr@rediffmail.com (R. Taneja).
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Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
http://dx.doi.org/10.1016/j.apme.2015.07.004
0976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.

3. laparoscopic partial nephrectomy (LPN).3
Various techniques
of renorrhaphy were described and the surgeons continued to
follow the one they were most comfortable with. Laparoscopic
NSS offered distinct advantage of reduced peri-operative pain,
hospital stay and estimated blood loss.4
The main problems
with LPN were the steep learning curve even for the urologists
familiar with laparoscopic skills, and a need to curtail warm
ischaemia time to 20 min.
Although literature was abound with evidence in favour of
NSS, not many suitable tumours were being treated by partial
nephrectomy due to disadvantages of both laparoscopic and
open NSS as mentioned. Robotic technology has given a thrust
towards NSS by offering the advantages of minimally invasive
procedure with a shorter and less steep learning curve
compared to laparoscopic operation and the oncologic benefit
of open partial nephrectomy. The learning curve for RPN is
shorter than laparoscopic procedure.5
The three-dimensional
high definition camera, wristed small calibre instruments, wide
range of movements and scaling of surgeons' movements offer
definite advantages over conventional laparoscopy. Evolution
of technology such as 'Tile Pro', i.e. image in image technology
for intra operative imaging, Indocyanin Green, the illuminating
vascular contrast using 'Firefly' technology, and barbed sutures
have changed the technique of Partial Nephrectomy. The
technique of renorrhaphy done robotically offers to reduce
warm ischaemia time when compared to laparoscopic proce-
dure.6
Warm ischaemia time for remnant kidney should ideally
belessthan20 min.However,electronmicroscopicstudieshave
shown that the up to 60 min of warm ischaemic time can result
inreturnoffunctionwithoutdiscernibledamagetotheremnant
kidney. Indocyanin green when injected intravenously by
'Firefly' technology can help to identify the arterial supply to
tumour. In some cases, this can help in selectively clamping the
segmental artery, resulting in reduced ischaemia to rest of the
kidney.7
2. Feasibility of Robotic Partial Nephrectomy
(RPN)
The centres which acquired Robotic technology are doing
more and more partial nephrectomies as compared to those
in which open or laparoscopic procedures are being carried
out. Studies have shown that the incidence of conversion to
radical nephrectomy or open surgery is much more with
laparoscopic procedure when compared with robotic.8
Vari-
ous nephrometric scoring systems have been evolved which
attempt to predict the feasibility of (RPN), one such popular
score is R.E.N.A.L. Pictorial description of this system has been
provided in box.9
However, this is only a guiding system and
does not set any rules. All that can be predicted by these
scoring systems is the ease or difficulty that might be
encountered during RPN. As the experience is mounting,
more and more surgeons are attempting to perform RPN,
which were once thought to be difficult. Entirely endophytic
tumours have been shown to be amenable to RPN.10
Advocates of partial Nephrectomy in tumours lager than7 cm
diameter argue that one must still offer partial nephrectomy,
because the foot prints of metastasis would already have
occurred, and therefore whether a partial or radical nephr-
ectomy is performed, the overall outcome is unlikely to
be different.11
Hence giving the benefit to the patient, one
should offer partial nephrectomy to such patients (Fig. 1 and
Table 1).
3. Oncological clearance – surgical margin
RCC is resistant to both radiotherapy and chemotherapy.
Therefore one should strive to achieve a complete oncological
clearance while performing partial nephrectomy. Robotics
adds to the advantage of dynamic imaging like intracorporeal
ultrasound imaging. The 'tile pro' function in robotic console is
a real boon to reduce the tumour positivity of resected margin.
However, tumour positive margin as reported in an excised
specimen has to be viewed in light of the intraoperative
findings. All margin positive cases should be discussed at
length with their family members and an option of radical
nephrectomy must be offered. Various studies have included
patients with positive surgical margins, who have been
followed over years and remained recurrence and metastasis
free, thus providing evidence in favour of safety in not being
treated as radical nephrectomy12
in some of the selected cases
(Picture 1).
Fig. 1 – Diagrammatic representation of RENAL nephrometric score.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2
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4. 4. Vascular control
It is generally wise to clamp both renal artery and vein, but
lately, it has been shown that only arterial clamping offers
reasonable haemostasis and the kidney remains perfused with
venous blood which is better than total ischaemia.13
If both
artery and vein have been clamped, and while excision of
tumour bleeding is encountered then it is wise to unclamp the
vein, which may drain blood from renal parenchyma, which
might be engorged due to an unclamped arterial twig.
One of the troublesome problems that can occur if the
calyceal system is not closed meticulously is a persistent
urinary leakage and a pyelocutaneous fistula. Intraoperative
retrograde ureteric cannulation is usually not required, but is
still practised in certain centres to delineate the collecting
system. The pelvicalyceal anatomy is quite clearly visible
using the high definition three-dimensional vision of Robotic
camera. Pyelocutaneous fistula can present itself during the
early post-operative period, usually within the first week.
Various methods of diversion of urine from the renal remnant
can be tried ranging from retrograde double J stenting to
percutaneous nephrostomy. Application of various sealing
agents through percutaneous and retrograde routes has been
attempted with different results.14
Frustrating persistent
urinary leaks have ended in delayed radical nephrectomy.
Patience has been found to be rewarding in many cases
(Picture 2).
5. Intraoperative renorrhaphy
Intraoperative renorrhaphy must be done meticulously. It is
better to put an additional suture at the time of medullary
Table 1 – RENAL nephrometry score.
1 pt 2 pts 3 pts
(R)adius (maximal diameter in cm) ≤4 >4 but <7 ≥7
(E)xophytic/endophytic properties ≥50% <50% Entirely endophytic
(N)earness of the tumour to the
collecting system or sinus (mm)
≥7 >4 but <7 ≤4
(A)nterior/Posterior No points given. Mass assigned
a description of a, p, or x
(L)ocation relative to the polar lines*
*suffix ‘‘h’’ assigned if the tumour
touches the main renal artery or vein
Entirely above the upper or below
the lower polar line
Lesion crosses
polar line
>50% of mass is across
polar line (a) or mass
crosses the axial renal
midline (b) or mass is
entirely between the
polar lines (c)
Picture 1 – CT scan picture of a large upper polar mass in a 14-year-old girl.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 3
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5. closure than to rely on sealing agents as haemostatic supports.
Renal artery is a direct branch of Aorta, and the pressure in its
branches is high enough to defy sealing ability of haemostatic
agents. Sealing agents such as 'floseal' are useful in controlling
cortical ooze that can escape closure by cortical interrupted
sutures. Therefore it is considered wise to unclamp the renal
artery after closure of medulla as it would not only reduce the
warm ischaemia time, but also allow the surgeon to ensure
proper haemostasis of the vital vessels. Cortical vessels are
smaller and can be controlled by interrupted cortical pressure
sutures. It is difficult to control a medullary bleeding once
cortical sutures have been tied (Picture 3).
6. Scope of RPN
American Urology Association Guidelines 2009 clearly men-
tion the procedure of choice for T1a and possible T1b tumours
is partial nephrectomy, and yet PN is poorly utilized technique
in community practice.15
Robotic technology has revolution-
ized the treatment of RCC, and this has primarily resulted in
shift from radical nephrectomy to partial nephrectomy. This is
an evolving science and is subject to criticism and scrutiny like
any other evolutionary process. Currently published literature
is full of evidence in favour of RPN and the evolution is in
progress even further.16
Future directions include develop-
ment of augmented reality like haptic feedback and single port
partial nephrectomy.17,18
In present circumstances, where
robotic technology and due experience are available, anything
other than a partial nephrectomy should be discouraged in a
suitable case.
Conflicts of interest
The authors have none to declare.
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