Renal ischemia and approach to the renal hilum: Tips and tricks

The advent of robotic partial nephrectomy (RPN) may help overcome some of the limitations encountered during laparoscopic partial nephrectomy (LPN), namely, the longer warm ischemia time and higher rate of urologic complications. RPN is an advanced surgical technique that should be performed by experienced surgeons on select patients, and with an adequately prepared assistant bedside surgeon. A 3- or 4-arm approach may be utilized, although a 3-arm approach is recommended for those early in their experience. Surgeons should be familiar with strategies for avoiding hemorrhage and other complications, and if encountered, strategies for controlling bleeding, including suturing, additional clamping of unidentified arterial inflow, or venous unclamping. Surgeons should also be familiar with strategies that minimize warm ischemia time, namely preemptive selective ligation of involved arterioles and early unclamping. Strategies for achieving renal hypothermia primarily include retrograde injection of ice-cold saline. Surgeons performing RPN need to be comfortable with laparoscopic dissection of the renal hilum. Anticipating and preventing hemorrhage during hilar dissection, during warm ischemia time (WIT), and after hilar unclamping is a fundamental technical skill that should be mastered to safely and consistently perform RPN in a quality fashion.