Off-clamp robotic partial nephrectomy: Points of technique

Objective

To present a stepwise approach to off-clamp robotic partial nephrectomy (RPN), focusing on tips and tricks.

Patients and surgical procedure

Two emblematic cases are presented to describe the technique. The first one refers to a 27 years-old guy diagnosed with a 5-cm – R.E.N.A.L. 7 – right-sided mass located at the lower pole. The second case presented refers to a 69 years-old gentleman diagnosed with a 5-cm – R.E.N.A.L. 9 – suspicious mediorenal right-sided mass. After accurate counseling, the patients underwent off-clamp RPN.

Results

In the first case, a mini-enucleo-resection technique was pursued (Surface-Intermediate-Base score = 1–2). Selective single-layer renorrhaphy was performed at the end due to bleeding foci. Final pathology revealed low-grade oncocytic tumor, pT1b, R0. In the second case, a pure enucleation resection technique was pursued (Surface-Intermediate-Base score = 0). No renorrhaphy was performed at the end of the anatomical resection given the absence of active bleeding. Pathology analysis revealed a clear cell renal cell carcinoma, pT1b, G3, with negative margins.

Conclusions

Off-clamp approach can represent a viable alternative during RPN. Tumor enucleation resection technique has the perfect synergistic effect in maximizing the perioperative vision notwithstanding the avoided renal artery clamping. Moreover, it sponsors a minimized “nephron sparing” renorrhaphy.