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ever, this decision must be balanced with accompanying risks/ benefits on a case-by-case basis because there is no clear evi- dence that this type of surgical approach is superior to the current clamped RPN. Ranko Miocinovic, M.D., and Georges Pascal Haber, M.D., Ph.D., Glickman Urological and Kidney Institute, Center for Laparoscopic and Robotic Surgery, Cleveland, Ohio, USA References 1. White WM, Goel RK, Haber GP, et al. Robotic partial nephrectomy without renal hilar occlusion. BJU Int. 2010;105:1580-1584. 2. Thompson RH, Lane BR, Lohse CM, et al. Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol. 2010;58:340-345. 3. Song C, Park S, Jeong IG, et al. Followup of unilateral renal function after laparoscopic partial nephrectomy. J Urol. 2011;186:53-58. 4. Lane BR, Gill IS, Fergany AF, et al. Limited warm ischemia during elective partial nephrectomy has only a marginal impact on renal functional outcomes. J Urol. 2011;185:1598-1603. 5. Lane BR, Russo P, Uzzo RG, et al. Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant role of nonmodifiable factors in determining ultimate renal function. J Urol. 2011;185:421-427. 6. Simmons MN, Fergany AF, Campbell SC. Effect of parenchymal volume preservation on kidney function after partial nephrectomy. J Urol. 2011;186:405-410. doi:10.1016/j.urology.2012.01.066 UROLOGY 79: 1301–1302, 2012. © 2012 Elsevier Inc. REPLY Robotic technology continues to push the limits of minimally invasive nephron-sparing surgery. The initial report of 8 off- clamp robotic partial nephrectomies (RPNs) by White et al demonstrated the feasibility of RPN without arterial clamping 1 ; but by excluding hilar, endophytic, or multiple tumors and tumors 4 cm or in solitary kidneys, the full potential of robotic technology in performing off-clamp RPN was not explored. Although this initial report was appropriately judicious, we sought to build upon this work by reporting our further expe- rience, applying off-clamp RPN in all of these situations, in- cluding those in which off-clamp RPN might be most benefi- cial. Although most of our 28 cases were elective, patients with multiple tumors, solitary kidneys, or preexisting renal insuffi- ciency were not excluded and may be those who stand to gain the most from avoidance of warm ischemia. As our experience shows, off-clamp RPN can be applied in increasingly complex nephron-sparing procedures, but even though negative margins were achieved in all 28 cases, we reiterate our reservations regarding this technique and caution others before embarking upon their initial procedures. Our report demonstrates feasibility of off-clamp RPN for larger and more complex tumors, and with using cold-scissor excision rather than harmonic scalpel or other energy devices, but fea- sibility should not be equated with preference. Only with fur- ther experience and investigation will it become clear whether the potential benefit of avoiding ischemia with off-clamp RPN is worth the potential for additional bleeding and reduced visibility (with implications for parenchymal preservation) and whether our early experience is reproducible. Ryan Novak, M.D., Pharm.D., Daniel Mulligan, M.D., Ronney Abaza, M.D., F.A.C.S., Robotic Urologic Surgery, Department of Urology, The Ohio State University Medical Center & Arthur G. James Cancer Hospital, Columbus, Ohio, USA Reference 1. White WM, Goel RK, Haber GP, et al. Robotic partial nephrectomy without renal hilar occlusion. BJU Int. 2010;105:1580-1584. doi:10.1016/j.urology.2012.01.067 UROLOGY 79: 1302, 2012. © 2012 Elsevier Inc. 1302 UROLOGY 79 (6), 2012
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ever, this decision must be balanced with accompanying risks/benefits on a case-by-case basis because there is no clear evi-dence that this type of surgical approach is superior to thecurrent clamped RPN.
Ranko Miocinovic, M.D., and Georges Pascal Haber,M.D., Ph.D., Glickman Urological and Kidney Institute,Center for Laparoscopic and Robotic Surgery, Cleveland,Ohio, USA
References1. White WM, Goel RK, Haber GP, et al. Robotic partial nephrectomy
without renal hilar occlusion. BJU Int. 2010;105:1580-1584.2. Thompson RH, Lane BR, Lohse CM, et al. Every minute counts
when the renal hilum is clamped during partial nephrectomy. EurUrol. 2010;58:340-345.
. Song C, Park S, Jeong IG, et al. Followup of unilateral renal functionafter laparoscopic partial nephrectomy. J Urol. 2011;186:53-58.
. Lane BR, Gill IS, Fergany AF, et al. Limited warm ischemia duringelective partial nephrectomy has only a marginal impact on renalfunctional outcomes. J Urol. 2011;185:1598-1603.
. Lane BR, Russo P, Uzzo RG, et al. Comparison of cold and warmischemia during partial nephrectomy in 660 solitary kidneys revealspredominant role of nonmodifiable factors in determining ultimaterenal function. J Urol. 2011;185:421-427.
. Simmons MN, Fergany AF, Campbell SC. Effect of parenchymalvolume preservation on kidney function after partial nephrectomy.J Urol. 2011;186:405-410.
doi:10.1016/j.urology.2012.01.066UROLOGY 79: 1301–1302, 2012. © 2012 Elsevier Inc.
REPLYRobotic technology continues to push the limits of minimallyinvasive nephron-sparing surgery. The initial report of 8 off-clamp robotic partial nephrectomies (RPNs) by White et al
demonstrated the feasibility of RPN without arterial clamping1;1302
ut by excluding hilar, endophytic, or multiple tumors andumors �4 cm or in solitary kidneys, the full potential of roboticechnology in performing off-clamp RPN was not explored.lthough this initial report was appropriately judicious, we
ought to build upon this work by reporting our further expe-ience, applying off-clamp RPN in all of these situations, in-luding those in which off-clamp RPN might be most benefi-ial. Although most of our 28 cases were elective, patients withultiple tumors, solitary kidneys, or preexisting renal insuffi-
iency were not excluded and may be those who stand to gainhe most from avoidance of warm ischemia.
As our experience shows, off-clamp RPN can be applied inncreasingly complex nephron-sparing procedures, but evenhough negative margins were achieved in all 28 cases, weeiterate our reservations regarding this technique and cautionthers before embarking upon their initial procedures. Oureport demonstrates feasibility of off-clamp RPN for larger andore complex tumors, and with using cold-scissor excision
ather than harmonic scalpel or other energy devices, but fea-ibility should not be equated with preference. Only with fur-her experience and investigation will it become clear whetherhe potential benefit of avoiding ischemia with off-clamp RPNs worth the potential for additional bleeding and reducedisibility (with implications for parenchymal preservation) andhether our early experience is reproducible.
yan Novak, M.D., Pharm.D., Daniel Mulligan, M.D.,onney Abaza, M.D., F.A.C.S., Robotic Urologic Surgery,epartment of Urology, The Ohio State University Medicalenter & Arthur G. James Cancer Hospital, Columbus,hio, USA
Reference1. White WM, Goel RK, Haber GP, et al. Robotic partial nephrectomy
without renal hilar occlusion. BJU Int. 2010;105:1580-1584.
doi:10.1016/j.urology.2012.01.067
UROLOGY 79: 1302, 2012. © 2012 Elsevier Inc.UROLOGY 79 (6), 2012
