Current controversies and challenges in robotic-assisted, laparoscopic, and open partial nephrectomies.
BACKGROUND
Recent studies demonstrate that partial versus radical nephrectomy confers a survival advantage while lowering the risk of severe chronic kidney disease. Open partial nephrectomy remains the gold standard, but the use of minimally invasive approaches is expanding.


METHODS
Using a MEDLINE literature search, we reviewed all relevant literature between 2000 and 2014. Fifty-one articles were left for review after filtering for inclusion of trends, learning curve, perioperative outcomes, warm ischemia time, and costs.


RESULTS
Partial nephrectomy use has increased over the past decade accounting for 24.7 % of all surgeries performed for the treatment of organ-confined renal masses in 2008. The introduction of robotic technology has continued to alter the landscape accounting for 47 % of all partial nephrectomies at academic US centers in 2011, though a center bias and publication bias likely exist. A slower adoption rate has been seen at non-academic centers and those in low-income areas. The learning curve for robotic-assisted laparoscopic nephrectomy has been shorter than for laparoscopic partial nephrectomy, explaining, in part, why the rate of partial nephrectomy remained relatively stagnant before the robotic-assisted laparoscopic nephrectomy, despite an increase in the detection of small renal masses. Operative and warm ischemia time remain shortest for open partial nephrectomy, though it is associated with the highest blood loss and longest hospital stay. Finally, open partial nephrectomy remains the least costly modality.


CONCLUSIONS
Each approach to partial nephrectomy has its advantages and disadvantages, and continued effort must be applied to comparative effectiveness research for nephron-sparing treatments for renal cell carcinoma.
Department of Urology, David Geffen School of Medicine at UCLA, 924 Westwood Bl, Ste 1000, Los Angeles, CA, 90095, USA, alaviana@mednet.ucla.edu.
Aaron A
AA
Laviana
Jim C
JC
Hu
D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D009392:Nephrectomy / Q000379:methods*; D051436:Renal Insufficiency, Chronic / Q000601:surgery*; D012371:Robotics