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Oncologic Safety of Robotic Partial Nephrectomy: Setting Tiles in the Mosaic of Evidence While Designing Future Research Projects

Published:November 22, 2017DOI:https://doi.org/10.1016/j.euf.2017.11.003
      The role of partial nephrectomy (PN) in the treatment of localized renal masses is an area of increasing interest, as confirmed by the growing body of evidence on this topic. Nonetheless, indications, approaches, and techniques for PN, as well as correct reporting of outcomes, are still a matter of great debate within the urology community [

      Lyunberg B, Albiges L, Bensalah K, et al. European Association of Urology guidelines on renal cell carcinoma. Version 2017. https://uroweb.org/guideline/renal-cell-carcinoma/

      ,
      • Campbell S.
      • Uzzo R.G.
      • Allaf M.E.
      • et al.
      Renal mass and localized renal cancer: AUA guideline.
      ,
      • Motzer R.J.
      • Jonasch E.
      • Agarwal N.
      • et al.
      Kidney cancer, version 2.2017, NCCN clinical practice guidelines in oncology.
      ,
      • Finelli A.
      • Ismaila N.
      • Bro B.
      • et al.
      Management of small renal masses: American Society of Clinical Oncology clinical practice guideline.
      ,
      • Minervini A.
      • Carini M.
      • Uzzo R.G.
      • et al.
      Standardized reporting of resection technique during nephron-sparing surgery: the surface-intermediate-base margin score.
      ]. Two interrelated aspects deserve attention: (1) the risk-benefit trade-offs between PN and radical nephrectomy (RN) for anatomically complex renal masses [
      • Kim S.P.
      • Campbell S.C.
      • Gill I.
      • et al.
      Collaborative review of risk benefit trade-offs between partial and radical nephrectomy in the management of anatomically complex renal masses.
      ]; and (2) the definition of evidence-based strategies to tailor the PN surgical approach (open vs laparoscopic vs robotic) and resection strategies and techniques according to the specific characteristics of the patient, tumor, and surgeon [
      • Kim S.P.
      • Campbell S.C.
      • Gill I.
      • et al.
      Collaborative review of risk benefit trade-offs between partial and radical nephrectomy in the management of anatomically complex renal masses.
      ]. Indeed, while there is little controversy regarding the role of PN for small, anatomically “simple” tumors, decisions on whether to perform PN or RN for large and/or complex renal masses are challenging and highly nuanced [
      • Minervini A.
      • Carini M.
      • Uzzo R.G.
      • et al.
      Standardized reporting of resection technique during nephron-sparing surgery: the surface-intermediate-base margin score.
      ]. This is true for old, frail, and comorbid patients with cardiovascular diseases, for whom the surgical complexity of PN might involve a higher risk of complications compared to RN. However, the same concept pertains to young healthy patients, for whom both oncologic safety and functional preservation are crucial given their long life expectancy. The competing trade-offs between the two approaches are even more complex in the robotic era, as the surgical approach is becoming an increasingly relevant variable in clinical decision-making, beyond surgeon experience and skills [
      • Kim S.P.
      • Campbell S.C.
      • Gill I.
      • et al.
      Collaborative review of risk benefit trade-offs between partial and radical nephrectomy in the management of anatomically complex renal masses.
      ]. In this regard, indications for robotic PN have been extended to the entire spectrum of anatomical tumor complexity, especially in high-volume centers.
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      References

      1. Lyunberg B, Albiges L, Bensalah K, et al. European Association of Urology guidelines on renal cell carcinoma. Version 2017. https://uroweb.org/guideline/renal-cell-carcinoma/

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