Robotic partial nephrectomy for hilar renal masses

Abstract

Background: : International urological guidelines recommend partial nephrectomy (PN) as the gold-standard treatment for clinical T1 renal tumors whenever technically feasible, given theimproved renal function preservation compared to radical nephrectomy andequivalent oncological safety. With the diffusion of robotic surgery, experience withrobot-assisted partial nephrectomy (RAPN) has exponentially grown over the last decade, and this has led to spread the indication of the procedure to more complex tumors.Initially, clinical stage or size cut-offs were used to define complexity, however, in the last decades, more accurate standardized nephrometry scores have been introduced aimed to define renal mass complexity, such as the R.E.N.A.L., the PADUA, ABC, Complexity Index and most recently the renal tumor contact surface area (CSA). Nonetheless, hilar masses are still regarded as a separate entity and many surgeons consider radical nephrectomy instead of partial nephrectomy the preferred approach for this type of renal cancer.Their physical contact with the renal vessels in the region of the renal hilum made many to consider laparoscopic techniques unfeasible until Gill et al. first described laparoscopic PN for hilar tumors in 2005 [1]. The robotic assistance has been shown to facilitate tumor resection, with the continued advantage of a minimally-invasive approach [2]. Notwithstanding the proved feasibility of RAPN for hilar masses, some authors still consider the open approach as the gold standard [3] for such complex lesions and Raman et al. showed how the hilar location as an independent predictor of preferred open approach [4]. Objective: We aimed to report our surgical approach to hilar masses, describing a step by step robotic-assisted partial nephrectomy and highlighting key aspects such as clampless and selective-suturing technique.