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Media Gallery

Positioning in the Upside Arm Adducted (UAA) position. This position maximizes access to the abdomen while avoiding robotic interference with the patient's arm.
This illustrates port placement with the second assist port placed above the umbilicus and slightly lateral of midline. The lower assistant port is in the lower midline. Final positions are always determined after abdominal access, insufflation and camera port placement.
Direct insertion trocar placement. The trocar is placed directly into the decompressed abdomen and connected to CO2 insufflation. Once the peritoneal cavity develops the port may be pushed further in to the abdomen. (ENDOPATH® XCEL™ Bladeless Trocar, Ethicon Endosurgery)
The 5-mm subxiphoid port is used to place a blunt grasper under the liver for this right-sided case and elevate it.
The colon is released from the lateral abdominal wall.
The anterior pararenal space is defined. Gerota fascia is not entered at this point.
The renal artery is freed from periarterial tissue.
The tumor is free of Gerota fascia with a generous margin of clear capsule surrounding it. Overlying fat is left attached.
The assistant places two "Bulldog" vascular clamps on the renal artery.
The initial phase of the resection is performed. Knowledge of the intrarenal anatomy of the tumor allows incision near the base; initial scissor orientation is straight down with tips away.
After reaching an appropriate depth, the scissors are turned and the base of the resection developed beneath the tumor.
A running suture, begun outside the resection bed, is placed to oversew collecting system and vascular structures. The authors prefer V-Lok suture, which is cut without tying.
Hemostatic agent and Surgicel are placed in the renal defect and 0 polyglactin on a CT-1 used to begin capsular closure.
Further capsular sutures are placed and tensioned with Hem-o-lok clips. Lapra-tys are then used to complete this "sliding-clip" renorrhaphy.

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Table 1. Overall Demographics of Robotic-Assisted Laparoscopic Partial Nephrectomy

Series	Number of Patients	Total Number of Masses	Follow-up Time, Months	Operative Time, Minutes	Mean Length of Stay	Estimated Blood Loss, mL	Tumor Size, cm	Cancer (%)
Gettman et al (2004)^[45]	13	13	7	215	4.3	170	3.5	10 (76.9)
Kaul et al (2007)^[37]	10	10	15	155	1.5	92	2.3	8 (80)
Rogers et al (2008)^[34]	8	14	3	192	2.6	230	3.6	8 (60)
Rogers et al (2008)^[46]	11	11	NR	202	2.6	220	3.8	11 (100)
Benway et al (2009)^[47]	50	50	NR	145.3	2.5	140	2.7	28 (56)
Wang et al (2009)^[48]	40	40	NR	140	2.5	136	2.5	25 (62)
White et al (2009)^[49]	20	20	NR	197	4.05	220	2.72	NR
Patel et al (2010)^[41]	71	71	6.8	245.9	2	100	2.71	51 (72)
Gong et al (2010)^[50]	29	29	15	197	2.5	220	3	21 (72)
Petros et al (2011)^[51]	95	95	NR	248.3	2	122	2.39	68 (72)
Laydner et al (2011)^[52]	8	19	14	199	4.75	250	2.2	16 (84)
Abreu et al (2011)^[53]	7	7	NR	237	4	229	3.4	6 (86)
Dulabon et al (2011)^[42]	446	446	NR	188.1	2.88	213	3.02	333 (75)
Spana et al (2011)^[54]	450	NR	NR	188	NR	206	2.91	NR
Kaouk et al (2011)^[55]	187	NR	6	181.4	3.64	248	3.15	171 (69)
Guillotreau et al (2012)^[56]	210	212	4.8	180	3	200	2.4	156 (74)
NR = not recorded

Table 2. Warm Ischemia Time Associated With Renal Arterial Clamping and Positive Margin Rate

Series	Arterial clamping (%)	Clamp Time, Minutes	Positive Margin (%)
Gettman et al (2004)^[45]	5 (38.5)	22	1 (7.7)
Kaul et al (2007)^[37]	7 (70)	21	0 (0)
Rogers et al (2008)^[34]	NR	31	0 (0)
Rogers et al (2008)^[46]	11 (100)	28.9	0 (0)
Benway et al (2009)^[47]	NR	17.8	1 (2)
Wang et al (2009)^[48]	40 (100)	19	1 (2)
White et al (2009)^[49]	20 (100)	23.8	NR
Patel et al (2010)^[41]	57 (80)	21.1	3 (4)
Gong et al (2010)^[50]	29 (100)	25	0 (0)
Petros et al (2011)^[51]	NR	17.7	NR
Laydner et al (2011)^[52]	13 (68)	21	0 (0)
Abreu et al (2011)^[53]	0 (0)	NA	0 (0)
Dulabon et al (2011)^[42]	NR	20.22	7 (1)
Spana et al (2011)^[54]	NR	20.2	NR
Kaouk et al (2011)^[55]	NR	18	NR
Guillotreau et al (2012)^[56]	NR	17	3 (1)
NR = not recorded; NA = not applicable

Table 3. Postoperative Complications as Classified With the Clavien-Dindo system.

Series	Intraoperative Complications (%)	Clavien-Grade 1 and 2 (%)	Clavien-Grade 3 and 4 (%)	Transfusion (%)	Recurrences (%)
Gettman et al (2004)^[45]	0 (0)	1 (7.7)	0 (0)	0 (0)	0 (0)
Kaul et al (2007)^[37]	0 (0)	2 (20)	1 (10)	1 (10)	0 (0)
Rogers et al (2008)^[34]	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)
Rogers et al (2008)^[46]	0 (0)	0 (0)	2 (18)	0 (0)	NR
Benway et al (2009)^[47]	3 (6)	4 (8)	1 (2)	2 (4)	0 (0)*
Wang et al (2009)^[48]	2 (5)	7 (18)	1 (2)	2 (5)	NR
White et al (2009)^[49]	0 (0)	4 (20)	1 (5)	3 (15)	NR
Patel et al (2010)^[41]	1 (1)	4 (6)	3 (4)	2 (3)	0 (0)*
Gong et al (2010)^[50]	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)
Petros et al (2011)^[51]	2 (2)	4 (4)	3 (3)	2 (2)	NR
Laydner et al (2011)^[52]	0 (0)	1 (5)	0 (0)	0 (0)	NR
Abreu et al (2011)^[53]	0 (0)	2 (29)	0 (0)	1 (14)	NR
Dulabon et al (2011)^[42]	10 (2)	16 (4)	1 (0.2)	18 (4)	1 (0.2)
Spana et al (2011)^[54]	1 (0.2)	54 (12)	17 (4)	18 (4)	NR
Kaouk et al (2011)^[55]	3 (1)	42 (17)	6 (2)	17 (9)	NR
Guillotreau et al (2012)^[56]	7 (3)	36 (17)	6 (3)	NR	0 (0)
NR = not recorded *None at 12 months follow-up

Table 4. Assessment of Renal Function

Series	Preoperative Serum Creatinine level, mg/dL	Preoperative eGFR, mL/min/1.73 m²	Postoperative Serum Creatinine level, mg/dL	Postoperative eGFR, mL/min/1.73 m²	Increased Postoperative Serum Creatinine level, mg/dL	Decreased Postoperative eGFR, mL/min/1.73 m²
Rogers et al (2008)^[34]	0.9	84.9	0.93	79.3	0.03	5.6
Rogers et al (2008)^[46]	NR	82.7	NR	74.7	NR	8
Benway et al (2009)^[47]	1.12	NR	1.12	NR	0	NR
White et al (2009)^[49]	0.86	NR	1.02	NR	0.16	NR
Patel et al (2010)^[41]	NR	76.2	NR	73.9	NR	2.3
Gong et al (2010)^[50]	NR	NR	NR	NR	NR	4.5
Laydner et al (2011)^[52]	1.08	74	1.2	70.25	0.12	3.75
Abreu et al (2011)^[53]	1.1	65.6	1.3	67	0.2	-1.4
Kaouk et al (2011)^[55]	0.89	86.3	86.35	82.08	0.05	4.22
Guillotreau et al (2012)^[56]	0.94	86.3	NR	76	NR	10.3
NR = not recorded

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Author

E Jason Abel, MD Associate Professor of Urologic Oncology, Department of Urology, Associate Professor of Radiology (Affiliate Appointment), Department of Radiology, University of Wisconsin School of Medicine and Public Health; Attending Urologist, William S Middleton Memorial Veterans Hospital

E Jason Abel, MD is a member of the following medical societies: American Medical Association, American Society of Clinical Oncology, American Urological Association, Harris County Medical Society, Kidney Cancer Association, Society for Basic Urologic Research, Society of Urologic Oncology, Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Granville L Lloyd, MD Associate Professor, Associate Program Director, Department of Surgery, Division of Urology, University of Colorado School of Medicine, Anschutz Medical Campus; Director of Robotic Surgery, Rocky Mountain Regional VA Medical Center

Disclosure: Nothing to disclose.

Sri Sivalingam, MD, MSc, FRCSC Fellow in Endourology and Minimally Invasive Surgery, Department of Urology, University of Wisconsin School of Medicine and Public Health

Sri Sivalingam, MD, MSc, FRCSC is a member of the following medical societies: American Urological Association, Canadian Medical Association, Canadian Urological Association

Disclosure: Nothing to disclose.

Michael B Williams, MD, MS Assistant Professor, Department of Urology, Leroy T Canoles, Jr, Cancer Research Center, Eastern Virginia Medical School

Michael B Williams, MD, MS is a member of the following medical societies: American Association for Cancer Research, American Urological Association, Society of Urologic Oncology, Texas Medical Association, American Society of Clinical Oncology, American Association of Clinical Urologists

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Urology, Department of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Antares.

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