We present two cases of robotic partial nephrectomy.
The first case involves a 55-year-old woman with a right renal tumor. The second is a more complex case, involving a 5-cm lower pole renal mass.
We typically use three robotic ports and two assistant ports. The camera port is positioned on the pararectal line at the level of the umbilicus, while the other two robotic ports are placed along the midclavicular and anterior axillary lines. The assistant ports (12 mm and 5 mm) are positioned along the midline, between the camera and robotic ports, creating a "U-shaped" configuration centered on the tumor location.
The line of Toldt is incised and the colon is medialized. In most cases, as demonstrated in these two procedures, direct access to the tumor is achieved without the need for prior identification or preparation of the renal hilum. For polar tumors, Gerota's fascia is opened close to the tumor site, and the kidney is not fully mobilized. Extended kidney mobilization is reserved for posterior tumors, allowing direct visualization and improved access to the neoplastic mass. When feasible, the adipose tissue overlying the tumor is preserved to facilitate accurate pathological staging.
Tumor margins are circumferentially marked and incised using robotic scissors, and the lesion is progressively separated from the healthy parenchyma along an avascular plane. When bleeding vessels are encountered, forced monopolar scissors are used for pinpoint coagulation. After tumor excision, repeated forced monopolar coagulation of the resection bed is performed until complete hemostasis is achieved. Maximal coagulation with high-energy settings is applied during this phase and continued until adequate tissue firmness is obtained. To prevent eschar adhesion to the monopolar scissors, energy is delivered in near-contact mode, occasionally accompanied by gentle irrigation.
In cases of incidental calyceal entry, the defect is closed with a running 4-0 absorbable monofilament suture. Following complete coagulation of the tumor bed, the surgical field is routinely inspected for two minutes to confirm hemostasis. A hemostatic agent (Floseal® or SURGIFLO™) is then applied to the resection bed. The excised tumor is retrieved using a 10-mm EndoCatch™ specimen bag (Ethicon, Somerville, NJ, USA). Gerota's fascia and the peritoneum may be closed using a running barbed suture. A drain is usually left in the renal fossa for at least 24 hours.
Regarding perioperative outcomes, in our experience only 2% of patients developed Clavien–Dindo grade ≥III complications. Specifically, one patient hada urinoma, which was successfully managed with ureteral stenting. No cases of postoperative hemorrhage were observed.