What is the preferred surgical approach for central tumors, robotic partial nephrectomy (RPN) or laparoscopic partial nephrectomy (LPN)?

Robotic vs Laparoscopic Partial Nephrectomy for Central Tumors

Robotic partial nephrectomy (RPN) is the preferred surgical approach for central renal tumors due to significantly shorter warm ischemia times and lower risk of conversion to radical nephrectomy compared to laparoscopic partial nephrectomy (LPN). 1

Advantages of Robotic Approach for Central Tumors

• RPN provides equivalent perioperative outcomes to LPN but with significantly shorter warm ischemia time, which is crucial for preserving renal function in patients with central tumors 1
• RPN is associated with a significantly lower risk of conversion to radical nephrectomy (1% vs 11.5%) when dealing with complex renal tumors 2
• The articulated robotic instruments offer technical advantages that make managing complex central tumors more feasible 2
• For hilar, endophytic, and multiple renal tumors, RPN has demonstrated safety and feasibility with negative surgical margins 3

Surgical Planning and Patient Selection

• Nephrometry scoring systems (R.E.N.A.L. and PADUA) should be used to assess tumor complexity and guide surgical approach selection 1
• For small central tumors (≤4 cm) with low-to-intermediate complexity, either RPN or LPN may be appropriate, with RPN preferred when available 1
• For extremely complex central tumors not amenable to minimally invasive approaches, open partial nephrectomy may be considered 1
• Transperitoneal approach is generally preferred for central tumors due to larger working space and better angles for suturing 1

Technical Considerations

• Warm ischemia time should ideally be kept under 30 minutes to preserve renal function, which is more consistently achievable with RPN for central tumors 1, 4
• Careful preoperative planning using 3D imaging is essential to map the vascular anatomy and plan the resection strategy for central tumors 1
• Technical advances in RPN include the first-assistant sparing technique, sliding clip technique, early unclamping, and selective arterial clamping, which have contributed to improved outcomes 5

Perioperative Outcomes

• RPN is associated with shorter warm ischemia time compared to LPN, which is particularly important for central tumors 5, 2
• Hospital length of stay tends to be shorter with RPN compared to LPN 5, 6
• Estimated blood loss may be higher with RPN in some studies, but transfusion rates remain similar between the two approaches 7
• Postoperative complication rates are either similar or favor RPN compared to LPN 5

Functional and Oncological Outcomes

• Both approaches demonstrate comparable preservation of renal function when performed by experienced surgeons 7, 2
• Positive surgical margin rates are similar between RPN and LPN 7, 2
• Long-term oncological outcomes, including recurrence-free survival, appear comparable between the two approaches 7, 6

Important Caveats and Pitfalls

• Surgeon experience significantly impacts outcomes for both approaches, particularly for complex central tumors 1
• The learning curve for both procedures is substantial, with optimal results typically seen after 200+ cases 7
• Conversion rates to open or radical nephrectomy are higher with complex central tumors, particularly with the laparoscopic approach 2
• While RPN offers technical advantages, it may have higher direct costs compared to other approaches 6
• Nephron-sparing surgery (partial nephrectomy) should be prioritized over radical nephrectomy whenever technically feasible to preserve renal function and reduce cardiovascular morbidity and mortality 4